Obstructive Reproductive Tract Anomalies: A Review of Surgical Management

Hysteroscopic Transillumination as a Guide for Laparoscopic Excision of Rudimentary Uterine Horn: A Winning Duo

STUDY OBJECTIVE

Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination.

DESIGN

A step-by-step explanation of surgical technique with narrated video footage.

SETTING

Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy.

INTERVENTIONS

A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed.

CONCLUSION

Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism.

Long-term effects of surgically corrected menstrual outflow obstruction: A case-control study

OBJECTIVE

To enhance evidence-based knowledge on long-term sequalae in patients with surgically corrected obstructing Müllerian anomalies.

METHODS

This long-term case-control study included patients with menstrual outflow obstruction due to congenital anomalies of the uterus or vagina, who were at least 18 years old, and for whom 2 years had elapsed since the first surgery at the start of this study. The control group consisted of women without current gynecological problems. Patients underwent a surgical correction at the Radboud University Medical Center Nijmegen between 1980 and 2013. Of 78 patients approached, 38 (49%) were included in this study. The control group consisted of 54 females. The main outcome measures were pain and health state. The following questionnaires were used: Visual Analogue Scale pain scores, European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L) and the adapted Endometriosis Health Profile questionnaire (EHP-30).

RESULTS

Patients had higher actual and maximum abdominal pain scores compared with controls (11 vs 0 [P = 0.007] and 48 vs 21 [P = 0.035], respectively). Based on the EQ-5D-3L scores, patients had more pain and discomfort (P = 0.005), more mood problems (P = 0.023), and a poorer subjective health state (P = 0.002) and self-rated health state (P = 0.031). Based on the EHP-30, patients had a significant poorer self-rated health state on four out of five subscales.

CONCLUSION

In this study, following surgically corrected menstrual obstruction, patients had statistically significant higher abdominal pain scores and a poorer self-rated health state compared with controls.

Obstructed Hemi-Vagina with Ipsilateral Renal Agenesis Syndrome in Adulthood: A Diagnostic Challenge

A patient in her early 20s presented with constant and progressive lower abdominal and back pain, mainly on the right side of the abdomen, purulent vaginal discharge and pyrexia. A radiological assessment revealed a possible tubo-ovarian abscess and the incidental diagnosis of ipsilateral renal agenesis. The patient was treated for pelvic inflammatory disease (PID); however, after antibiotic administration and since the symptoms did not resolve, an abdominal MRI was requested, which revealed uterus didelphys with two cervices, an obstructed haemivagina and evidence of haematocolpos. The diagnosis of Obstructed Hemi-Vagina with Ipsilateral Renal Agenesis (OHVIRA) syndrome was confirmed, and the patient underwent the excision of the vaginal septum, the drainage of the haematopyocolpos and the laparoscopic drainage of the tubo-ovarian abscess. She achieved a good recovery.

Comparison of two different methods for cervicovaginal reconstruction: a long-term follow-up

INTRODUCTION AND HYPOTHESIS

As a consequence of the evolution of surgery in reconstructive techniques, cervicovaginal reconstruction has become an option for patients diagnosed with congenital cervical and vaginal atresia. This study was aimed at comparing long-term clinical and anatomical results in patients who had cervicovaginal reconstruction with either a small intestinal submucosa (SIS) graft or a split-thickness skin (STS) graft.

METHODS

This was a retrospective study of 34 patients who underwent cervicovaginal reconstruction using SIS or STS grafts between January 2012 and August 2017. The patients' postoperative resumption of menstruation, vaginal length, body image satisfaction, and sexual satisfaction were assessed. Quantitative and categorical variables were compared using Student's t test and Chi-squared test respectively.

RESULTS

The mean follow-up time was 81.29 ± 20.69 months. The SIS group had a shorter surgery time, an earlier return to work, and a higher cost (p < 0.05). All patients resumed menstruation, but 4 patients were diagnosed with cervical stricture. There was no significant difference in the length of the neovagina, and the satisfaction score of the sexual life of patients and their sexual partners was similar in both groups. Patients in the SIS group showed greater satisfaction with their bodies (p < 0.001). One patient in the SIS group got pregnant via assisted-reproduction techniques.

CONCLUSIONS

Cervicovaginal reconstruction using SIS or STS grafts is an effective treatment for patients diagnosed with congenital cervical and vaginal atresia. The method of SIS graft is simpler, with less surgical injury and greater body satisfaction, but it is more expensive.

OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly or Herlyn-Werner-Wunderlich syndrome): Is it time for age-specific management?

BACKGROUND

OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly or Herlyn-Werner-Wunderlich syndrome) is a rare Müllerian malformation. Usually, symptoms begin with worsening dysmenorrhea in post-menarche adolescents. The management in pre-menarche period is controversial and has only recently been subject of study.

AIMS

To review the experience of a pediatric tertiary center and to propose an age-specific management protocol for patients diagnosed before menarche.

METHODS

A retrospective cohort study (review of medical records - period 2009-2021).

RESULTS

Twenty-eight patients were diagnosed (mean age 11.9 years), seven (25%) before menarche, one (3%) perinatally. One patient had Floating-Harbor syndrome. Twenty-three patients had ipsilateral renal agenesis, while five had a multicystic-dysplastic kidney. The contralateral kidney showed hypertrophy in 25 patients, pelvicalyceal ectasia in 8 and dysplasia in 1. Twenty-four patients were symptomatic. Three of the seven diagnosed prior to menarche had symptoms. All post-menarche diagnosed patients were symptomatic. Twenty-six patients underwent surgery (one-stage drainage, vaginal septal resection, and vaginoplasty). Asymptomatic pre-menarche patients were followed-up until surgery after menarche onset. No patient underwent surgery prior to menarche solely for OHVIRA diagnosis. At follow-up (median 3.5 years, 3 lost to follow-up), eighteen patients were asymptomatic, one developed endometriosis, one had impaired renal function, two needed reoperations.

CONCLUSIONS

Pre-menarche OHVIRA patients, without symptoms, should undergo regular follow-up until the onset of menarche. Surgery must be considered in post-menarche or symptomatic patients. Post-operative, long-term follow-up is required, evaluating both renal and gynecological issues.

LEVEL-OF-EVIDENCE

IV.

Modified balloon vaginoplasty for high position vaginal atresia

INTRODUCTION

The first-line approach for the management of distal vaginal atresia involves a pull-through vaginoplasty. If the proximal vagina is 3 cm or more from the introitus, the risk of stenosis is high, and an interposition graft may be necessary. We describe a safe, low-cost, and accessible approach for distal vaginal atresia ≥ 3 cm that we call the "modified balloon vaginoplasty" and validate the technical feasibility and anatomical outcomes.

METHODS

Ten patients who underwent modified balloon vaginoplasty were retrospectively evaluated. Age, symptoms at presentation, length of atresia, operation time, and postoperative complications were analyzed.

RESULTS

All the cases were successfully performed without any intraoperative morbidity. The postoperative complications included one case of stenosis ring in the distal vagina because not right used vagina model. All the girls had regular menstruation and were satisfied with the surgical outcome.

CONCLUSION

Modified balloon vaginoplasty allows further distention of the distal vagina or thinning of the septum, which may decrease the risk of stenosis, is a beneficial choice for patients with distal vaginal atresia ≥ 3 cm.

Adenomyosis in a uterine horn of a patient with Mayer-Rokitansky-Kuster-Hauser syndrome

A 37-year-old woman with a previous diagnosis of Mayer-Rokitansky-Kuster-Hauser syndrome at 18 years of age was referred from a primary healthcare physician to a gynaecology appointment in our centre. She presented with a 2-year worsening pelvic pain and dyspareunia, symptoms that were previously absent and, at the time, with inadequate relief with oral analgesia. Physical examination showed absent uterine cervix and hypoplastic superior vagina. Transvaginal ultrasound and MRI suggested the presence of an hypoplasic uterus in left rotation. Laparoscopically, two asymmetric rudimentary horns were found, united by a fibrous central band, with an enlarged and congestive left horn. The three structures were removed as a whole. Histopathological examination reported the presence of multiple adenomyotic foci along the full thickness of the left rudimentary horn. The patient had an uneventful postoperative recovery and full remission of her symptoms.

Unicornuate uterus with noncommunicating functional horn: diagnostic workup and laparoscopic horn amputation

OBJECTIVE

To describe the diagnosis and the management of hematometra in a patient with unicornuate uterus with noncommunicating functional horn (hemi uterus and rudimentary uterine hemicavity).

DESIGN

Video case report.

SETTING

Minimally invasive gynaecology unit.

PATIENT(S)

Sixteen-year-old nulliparous woman admitted to the gynaecologic emergency department with pelvic pain during menses.

INTERVENTION(S)

Two-dimensional transvaginal ultrasound, magnetic resonance imaging, and laparoscopic rudimentary horn resection.

MAIN OUTCOME MEASURE(S)

Description of a case of anomaly of the female reproductive tract treated by laparoscopy.

RESULT(S)

After pain reduction and stabilization of clinical condition, ultrasound and magnetic resonance were performed, which detected a hemi uterus with a right rudimentary uterine hemicavity and a hematosalpinx. The removal of the right rudimentary uterine horn was successfully performed. The patient was in good health at the 3-month follow-up visit.

CONCLUSION(S)

Laparoscopic amputation of a functional rudimentary horn is considered the basic and traditional surgical option for women with hemiuterus. A detailed diagnostic evaluation should be performed to avoid misdiagnoses of other anomalies with blind hemicavity, which may be treated by hysteroscopy. Laparoscopic surgery with minimally invasive approach could be an essential tool to treat these cases, achieving optimal results with low postsurgical pain and a short hospital stay.

Management of partial vaginal agenesis according to the Wharton-Sheares-George technique - a long-term follow-up

The purpose of this study was to explore the long-term follow-up of treatment of congenital partial vaginal agenesis using the Wharton-Sheares-George technique. The technique was performed on 52 patients with congenital partial vaginal atresia from January 2009 to December 2017. As a result, the mean operating time of the Wharton-Sheares-George technique procedure was 25.6 ± 2.2 min. The mean estimated blood loss was 16.7 ± 4.7 mL. The average length of stay in hospital for the patients was 2.3 ± 0.2 days. There were no intraoperative and postoperative complications. The median duration of follow-up was 58 months. All of the patients experienced a resumption of menses. The mean vaginal length at 3 months was 7.3 ± 0.8 cm. Vaginal stenosis and adhesion did not occur in any cases during the follow-up. Twenty patients had sexual activities and the mean value of the FSFI questionnaire was 31.2 ± 4.0. Six cases became pregnant. There were four cases who each delivered one child and two cases who both delivered two children.IMPACT STATEMENTWhat is already known on this subject? It has been reported that the Wharton-Sheares-George technique provides, functionally and anatomically, very satisfactory results for the patients with Mayer-Rokitansky-Küster-Hauser syndrome. However, a study of the Wharton-Sheares-George technique in patients with congenital partial vaginal agenesis has not been reported previously in the medical literature.What the results of this study add? Our results have indicated that the Wharton-Sheares-George technique provides short operation time and length of stay, little blood loss intraoperatively, a satisfactory vaginal length and sexual activity in patients with congenital partial vaginal agenesis.What the implications are of these findings for clinical practice and/or further research? The study suggests that the Wharton-Sheares-George technique provides very satisfactory results in function and anatomy for congenital partial vaginal agenesis.