Congenital cervical atresia is a very uncommon Müllerian duct malformation1. Timely surgical correction is necessary to prevent the development of endometriosis or hematosalpinx. The presence of vaginal atresia increases the difficulty of the surgical technique and leads to a higher rate of complications1,14. Hence, the fertility-sparing procedure is a huge challenge for gynecologists when addressing these patients. Fujimoto et al. reported that the chance of success for canalization was approximately 40%-70% with or without vaginal atresia1. In this prospective observational study, we showed an easy, safe and promising laparoscopically approach to cervical canalization in patients with congenital cervical and vaginal atresia. After 16–51 months of follow-up, the success rate of laparoscopic assisted cervicovaginal canalization was 90%.
Laparoscopic cervicovaginal canalization for congenital cervical malformations had been reported by many authors, most of them were case reports. Less invasive way for management of cervicovaginal aplasia, such as combined retropubic balloon vaginoplasty and laparoscopic canalization, had been reported in 4 cases with middle-term effective15. While the complicated manipulation and risk of puncture made it difficult to be commanded. Laparoscopic cervicovaginal canalization with graft, such as full thickness skin graft and acellular porcine small intestinal submucosa graft, had also been reported to be effective in the midterm16,17. In our cohort, we didn’t use any graft to avoid additional damage or great expense.
There are some differences between our surgical technique and those proposed by the other authors. Our encouraging outcomes benefited from our attachment of great importance to protecting the bladder and rectum from injury, which we assumed would favor the success of the surgery. First, a metal drainage tube and finger were inserted into the bladder and rectum to indicate and protect these organs from being punctured or incised. Second, unlike previous reports, we didn't puncture from the fundus of uterus14,18, we placed a metal guide laparoscopically into the uterine cavity and then punctured from the vaginal vault to the uterus only when a mass was touched from the neovaginal vault, which avoided injuries caused by blind puncture. Third, unlike uterovaginal anastomosis, extensive dissection between the bladder and rectum was not necessary in our surgery, which therefore dramatically decreased the risk of injuries and pelvic adhesion and the risk of retrograde infection due to direct anastomosis with the endometrium19–23.
Carefully outlining the anatomical variations of congenital cervical anomalies before performing any reconstructive procedure is recommended and crucial for prognosis24. Cervical anomalies are classified into the following four types: 1) cervical agenesis: absence of the cervix; 2) cervical fibrous cord: a cervical body consisting of a fibrous band or cord; 3) cervical fragmentation: portions of the cervix are noted with no connection to the uterine body; and 4) cervical obstruction: an intact cervical body with obstruction of the cervical os24. While no standards have been recommended for specific cervical anomalies. In our study, we attached great importance to preoperative and intraoperative evaluation of cervical malformations. But due to the small sample size, we couldn’t figure out which cervical anomaly was good candidate for laparoscopically cervicovaginal canalization. Future studies are needed to address this problem.
A cervical stent seems to be necessary to drainage and to avoid cervical reobstruction. While retrograde infection should not be overlooked due to two cases of deadly peritonitis had been reported. According to our experience, Pezzer catheter should be given priority as cervical stent. Perforated, bulged “mushroom head” of Pezzer can drain menstrual blood and protect the stent from falling off.
Reproductive capacity and sexual satisfaction are useful detailed clinical information on treatment outcomes. Very few studies focused on that. Because in most cases, the congenital cervical atresia happened at the onset of puberty. Even after ten years of follow-up, the patients were only in their early 20 s. During this period, some patients underwent hysterectomies due to recurrent atresia or severe complications; the remaining patients were too young to be pregnant. Successful pregnancy after assisted reproductive techniques had been reported in several cases25–29. In our cohort, only one patient had intercourse sexual life. Encouragingly, she felt satisfied with sexual life and got along with her partner. But she hadn’t been conceived after two-year preparation. The strictured cervix, pelvic inflammatory environment and other factors could result in the infertility. Future studies are needed to discuss the pregnant rate because of its important clinical meaning and practical value.
Strengths and limitations
In this study, we described the surgical procedure step by step and used surgical photos and schematic to show the surgical procedure more intuitively. In addition, our cohort had a long follow-up term, with a median follow-up duration of 26 months. The small sample size was the primary limitation of our study, more patients need to be enrolled in a future study.