{"paper_id":"2234168d-a76f-4c37-a223-f386fb200dde","body_text":"Laparoscopically assisted uterovaginal canalization and vaginoplasty for patients with congenital cervical and vaginal atresia: a step-by-step guide and long-term outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Laparoscopically assisted uterovaginal canalization and vaginoplasty for patients with congenital cervical and vaginal atresia: a step-by-step guide and long-term outcomes Jia Kang, Na Chen, Ye Zhang, Congcong Ma, Yidi Ma, Yuan Wang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-59387/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jun, 2021 Read the published version in Journal of Minimally Invasive Gynecology → Version 1 posted You are reading this latest preprint version Abstract Objective: To study the long-term outcomes of laparoscopically assisted uterovaginal canalization and vaginoplasty in patients with congenital cervical and vaginal atresia and to introduce the surgery step-by-step. Methods: A prospective observational study was conducted including 10 patients diagnosed with congenital cervical and vaginal atresia underwent laparoscopically assisted cervicovaginal canalization between January 2016 and Jun 2020 in a tertiary teaching hospital. Clinical characteristics and perioperative data were recorded. Patients were followed up in outpatient clinic at 3, 6 and 12 months postoperatively, and once a year thereafter. Menstruation cycles and degree of dysmenorrhea were recorded. Gynecological examination was performed to measure vaginal length and to examine whether there was restenosis. Results: All procedures went smoothly, with no case requiring conversion to laparotomy or no intraoperative complications occurred. Postoperative febrile morbidity occurred in one patient (1/10, 10%). The median (quartile) follow-up time was 26.0 (21.3, 48.3) months. All patients resumed menstruation, including nine patients (9/10, 90%) with regular monthly menstruation. Eight patients (8/10, 80%) experienced mild-to-moderate dysmenorrhea; the remaining 2 patients (2/10, 20%) had no dysmenorrhea. Cervical restenosis occurred in one patient (1/10,10%) 12 months postoperatively, and cervical dilation was performed. So far, eight months after the second surgery, no restenosis has been found. The mean postoperative vaginal length was 7.9 ± 1.3 cm by the time of last follow up. Only one patient prepared for pregnancy for two years, but she had not conceived yet. Conclusion: Laparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe and promising management option for correcting congenital cervical and vaginal atresia. Obstetrics & Gynecology Cervical anomalies Congenital cervical atresia Laparoscopic cervical canalization Figures Figure 1 Figure 2 Introduction Congenital cervical atresia is a rare Müllerian anomaly and is associated with vaginal aplasia in 50% of cases 1 . The true incidence of congenital cervical atresia is somewhat difficult to determine. Patients with congenital cervical atresia usually have a normal or deformed but functional uterus and present with cyclic abdominal pain with no menstruation. A timely surgical correction is necessary to relieve obstruction and to prevent the onset of endometriosis or hematometra. Hysterectomy had been advocated by some clinicians for these patients due to risks of reoperation and potential death from reconstructive surgery 2 , 3 . While hysterectomy resulted in irreversible physical and psychological damage for these teenager girls. With the development of new techniques and assisted reproductive techniques, fertility-sparing strategies, including uterovaginal or uterovestibular anastomosis, cervicovaginal canalization, cervicoplasty and cervical end-to-end anastomosis, had yielded encouraging outcomes, as well as successful pregnancies 4 – 6 . But most of them were case reports and only in a short term follow up. In our center, we applied laparoscopically assisted cervical canalization and vaginoplasty for patients with congenital cervical and vaginal atresia from Jan 2016. In this prospective observational study, we aimed to report the surgical procedure step by step and long-term outcomes of laparoscopically assisted cervical canalization and vaginoplasty for congenital cervical and vaginal atresia. Materials And Methods Setting and patients Between January 2016 to July 2020, we carried out a prospective observational study of patients with congenital cervical anomalies who had received surgical treatment at the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH). The inclusion criteria were as follows. 1. Patients diagnosed with congenital cervical anomaly with a functional uterus, with or without vaginal atresia. The diagnosis of cervical atresia was suggested by clinical manifestation, gynecological examination, and results from pelvic Magnetic Resonance Imaging (MRI). In all cases, the diagnosis was confirmed during laparoscopy. 2. Patients had undergone laparoscopically assisted cervical canalization and vaginoplasty by the same experienced gynecologist (Dr. Lan Zhu). 3. Patients had undergone pelvic MRI examinations preoperatively. The exclusion criteria were as follows: 1. The patient was diagnosed with distal vaginal atresia or transverse vaginal septum although the hematoma was present; 2. The canalizations were not assisted by laparoscopy; 3. Patients with congenital cervical atresia were performed hysterectomy. Data Collection Clinical characteristics, including onset age, course of disease, malformations and lesions of the reproductive system, complicated malformations of other systems, and perioperative data, including operating time, estimated bleeding volume, intraoperative complications and postoperative febrile morbidity, were reviewed and recorded in detail. There is no widely accepted standard definition of febrile morbidity. We chose a level of 38℃, which has been used previously in a number of studies assessing postoperative infectious morbidity. Postoperative febrile morbidity was defined by a body temperature of at least 38 °C on two consecutive occasions at least 6 h apart, excluding the first 24 h 7 , 8 . Patients were followed up in outpatient clinic at 3, 6 and 12 months postoperatively, and once a year thereafter. Regarding menstruation, each patient was asked about her cycles and degree of dysmenorrhea. Gynecological examination was performed to measure vaginal length and to examine whether there was restenosis. Sexual satisfaction was assessed with the female sexual function index (FSFI), the most commonly applied and valid tool for measuring sexual satisfaction 9 . Chinese version of the FSFI has been validated to be a reliable and valid questionnaire in Chinese women 10 . Based on epidemiological research of Chinese women, the cutoff score for the FSFI total score was 23.45 11 . Higher scores indicate better sexual function. Outcome variables Success rate of laparoscopically assisted cervical canalization and vaginoplasty, which was defined as no restenosis. Surgery The surgical procedures were performed during menstruation. 1. Briefly, the patient was placed in the lithotomy position under general anesthesia. 2. Laparoscopy was performed to explore the abdominopelvic cavity to identify evidence of endometriosis, pelvic adhesions, and uterine anomalies, especially cervical anomalies and the amount of cervical remnants (Fig. 1 A). If necessary, appropriate surgery, such as ovarian cystectomy, adhesiolysis, salpingostomy or excision of pelvic endometriosis, was performed. 3. The procedure was switched to vaginal surgery. To perform vaginoplasty, an 8-cm-long, two-finger-wide canal was created by blunt dissection between the bladder and the rectum along the anatomical vaginal route. To protect the bladder and rectum from injury, a metal urinary drainage tube was inserted into the urethra and the bladder, and an index finger was placed into the anus and rectum. 4. Laparoscopically, we dissected the uterine fundus by using a monopolar needle to access the uterine cavity. After suctioning the hematocele, a metal guide was placed in the uterine cavity to push the uterus inferiorly (Fig. 1 B). 5. The uterus was pushed inferiorly by the guide. In the meantime, a thick needle was punctured carefully through the neovaginal region toward the mass until the metal lever was reached. After ensuring no damage, an incision was made at the puncture site. The metal guide was pulled out (Fig. 1 C). 6. A rubber cervical catheter, cut from a Pezzer catheter, was dragged from the vaginal vault to the uterine cavity. The mushroom-like end of the Pezzer catheter was inserted into the cervix (Fig. 1 D). Excising the anterior uterine wall (Fig. 1 E) and dragging the mushroom-like end of the catheter into uterine cavity (Fig. 1 F). 7. The anterior uterine wall was closed using 2 − 0 agnail stitches (Fig. 1 G). 8. Switching to vaginal surgery, circular suturing of the cervix to form the vaginal portion of the cervix and interrupted sutures were placed to secure the cervical catheter to the cervix (Fig. 1 H). 9. A metal urinary drainage tube was inserted into the urethra and bladder, and methylene blue was injected into the bladder to check any outflow of the blue dye to reexamine for damage to the urethra or bladder. 10. Finally, after surgery, a soft mold made of two sterile condoms filled with sterile gauze was placed in the neovaginal cavity for the first 7–14 days (Fig. 1 I). Later, the soft mold was removed, and the patient started vaginal dilation with a silicone dilator (length: 10 cm, diameter: 3 cm), which was advised to be daily, with 24 hours of continuous wear for the first 6 postoperative months to prevent contraction of the neovagina. Six months after surgery, the patient was advised to wear the mold intermittently and to gradually shorten their time wearing mold. There is no guideline for how long cervical stents should be placed. In our patients, cervical stents were not removed until the patient intended to be pregnant. If cervical stenosis occurred, a new cervical stent would be placed during reoperation. The schemas of surgical maneuver are presented in Fig. 2 . Statistical analysis Statistical analysis was performed using SPSS (version 20.0 for Windows). The mean ± SD or median (quartile) is presented for quantitative variables, and frequencies (%) are presented for qualitative variables. Ethics approval This study was approved by the Ethics Committee of the PUMCH (project: S-452). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Results From January 2016 to June 2019, a total of ten patients with congenital cervical and vaginal atresia who underwent laparoscopically assisted cervicovaginal canalization in the Peking Union Medical College Hospital were recruited in our study. Clinical characteristics of the patients The mean (± SD) symptom onset age was 14.5 ± 3.0 years. The median (quartile) duration of symptom onset to canalization was 15.5 (5.7, 28.0) months. Uterine corpus and cervical malformations were delineated by a combination of pelvic MRI and laparoscopic exploration. Cervical obstruction anomalies were observed in 6 (60%) patients, cervical agenesis was found in 3 (31.6%) patients, and cervical fragmentation was noted in 1 (10%) patients. All patients had total vaginal atresia. A total of 20% of the patients (2/10) had uterine malformations, including one with complete septate uterus (U2bC4V4) and one with a partial bicorporeal uterus (U3aC4V4) according to the European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynecological Endoscopy (ESGE) classification 12 . The other 8 were all U0C4V4. Urinary ultrasound and/or intravenous pyelography examinations were performed in all 10 patients. None of them was found to have urinary anomaly. Plain-film X-ray exams of the spine were also performed in these 10 patients, one of them (1/10, 10%) was verified scoliosis (Table I). Pelvic endometriosis was confirmed by pathological examination and stage of endometriosis was diagnosed by laparoscopy according to revised American Society for Reproductive Medicine classification of endometriosis 13 . 20% of the patients had no endometriosis, 20% of the patients were diagnosed as stage I endometriosis, 30% of the patients were stage II and the remaining 30% were staged IV (Table I). Surgical outcomes and follow-ups of the patients All patients underwent laparoscopically assisted canalization smoothly, with no case requiring conversion to laparotomy and no intraoperative complications occurred. The mean operation time was 105.0 ± 34.4 min, and the median (quartile) estimated blood loss was 100.0 (87.5, 100.0)ml. The mean length of the neo-vagina was 8.3 ± 0.7 cm intraoperatively. The postoperative course was uneventful; only one case had a postoperative temperature of 38–39℃ for 2 days after surgery. The median (quartile) follow-up time was 26.0 (21.3, 48.3) months. All patients experienced relief of abdominal pain and resumed menstruation, including 9 patients with regular monthly menstruation. Eight patients experienced mild-to-moderate dysmenorrhea; the remaining 2 patients had no dysmenorrhea. During the follow-up period, cervical reobstruction occurred in one patient 12 months postoperatively, and ultrasound-guided transvaginal cervical dilation was performed. So far, eight months after the second surgery, no restenosis has been found. The mean postoperative vaginal length was 7.9 ± 1.3 cm by the time of last follow up. 8 patients wore vaginal mold almost every day except for menstruation and 1 patient kept the length and width of vagina by regular sexual intercourse. The remaining 1 patient stopped dilating vagina 3 months after surgery. She had no vaginal restenosis and the vagina was about 7 cm long, but the vagina was only about 2 cm wide. Only one patient had intercourse sexual life. She was satisfied with sexual life subjectively. In addition, the scores of desire, arousal, orgasm, lubrication, satisfaction and pain were 6, 15, 16, 10, 12 and 11 respectively. After the weighted, the total FSFI score was 26.1. Moreover, this was the only patient prepared for pregnancy for two years, but she had not conceived yet (Table II). The patient is going to seek assisted reproductive technology for help. Discussion Congenital cervical atresia is a very uncommon Müllerian duct malformation 1 . 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 complications 1 , 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 atresia 1 . 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 effective 15 . 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 midterm 16 , 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 uterus 14 , 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 endometrium 19 – 23 . Carefully outlining the anatomical variations of congenital cervical anomalies before performing any reconstructive procedure is recommended and crucial for prognosis 24 . 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 os 24 . 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 cases 25 – 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. Conclusion In summary, in this prospective observational study, we reported that laparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe and effective management option for relieving obstructions in patients with congenital cervical and vaginal atresia. However, more studies and longer follow-up are needed. Declarations Ethics approval and consent to participate: This study was approved by the Ethics Committee of the PUMCH (project: S-452). Consent for publication: Written informed consent for publication was obtained. Availability of data and materials: All data generated or analyzed during this study are included in this published article. Competing interests: The authors declare that they have no competing interests. Funding: The work was supported by the Chinese Academy of Medical Sciences (CAMS) Initiative for Innovative Medicine (grant number: CAMS-2017-I2M-1-002) and National Science Foundation for Youth (grant number: 81801401). Authors' contributions: J.K. participated in the design of the study, conducted the data acquisition, interpreted and analyzed the data, and drafted and revised the manuscript. C.N. pointed out deficiencies and ameliorated the manuscript. Y.Z participated in videoing the surgery and selecting of photographs. C.C.M., Y.D.M., Y.W. and W.J.T contributed to the data collection. L.Z. was responsible for design of the work and final approval of the version to be published. Acknowledgements: We acknowledge Mr. Xue Liu for the wonderful surgical diagram he drew in this work. References Fujimoto VY, Miller JH, Klein NA, Soules MR. Congenital cervical atresia: report of seven cases and review of the literature. Am J Obstet Gynecol. 1997;177:1419–25. Fliegner JR, Pepperell RJ. Management of vaginal agenesis with a functioning uterus. Is hysterectomy advisable? Aust N Z J Obstet Gynaecol. 1994;34:467–470. Niver DH, Barrette G, Jewelewicz R. Congenital atresia of the uterine cervix and vagina: three cases. Fertil Steril. 1980;33:25–9. Liu Y, Wang YF. Successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia: A rare case report. J Obstet Gynaecol Res. 2017;43:1217–21. Shen F, Zhang XY, Yin CY, Ding JX, Hua KQ. 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Tables Table I Clinical characteristics of the 10 patients Patient No. 1 2 3 4 5 6 7 8 9 10 Age at diagnosis 13 14 17 14 19 13 19 10 14 12 Delay in diagnosis (month) 24 16 24 15 72 12 40 5 6 1 Uterine anomaly Complete septate uterus N Partial bicorporeal uterus N N N N N N N Cervical anomaly Cervical obstruction Cervical obstruction Cervical absence Cervical obstruction Cervical Fragmentation Cervical absence Cervical absence Cervical obstruction Cervical obstruction Cervical obstruction Preoperative vaginal length(cm) 0 0 1 0 0 0 2 0 0 0 Renal anomaly N N N N N N N N N N Spinal anomaly N N N N N Scoliosis N N N N Preoperative AFS stage* 0 I IV II II IV II IV I 0 Previous surgery 0 0 1 0 0 0 0 0 1 0 N: normal; *: Diagnosed by laparoscopy. Table II Surgical outcomes of the 10 patients Patient No. 1 2 3 4 5 6 7 8 9 10 Surgical time (min) 80 90 80 120 120 180 60 120 80 120 Estimated blood loss(ml) 50 100 100 100 100 300 100 100 10 100 Intraoperative complications NO NO NO NO NO NO NO NO NO NO Vaginal length at surgery 8 8 8 8 8 8 10 8 9 8 Postoperative morbidity NO NO NO NO NO NO NO Yes NO NO Follow-ups (Months) 22 19 27 49 30 48 16 22 25 51 Stricture of the cervix NO Yes NO NO NO NO NO NO NO NO Menstruation Regular, 2-3/23 Regular, 7/28-29 Regular, 5-7/30 Regular, 3/23-24 Irregular Regular, 5-6/30 Regular, 4-8/30 Regular, 10/23-30 Regular, 7/35-37 Regular, 4-5/30 Dysmenorrhea Mild Moderate NO Mild Mild NO Moderate Moderate Mild Mild Vaginal length at the last follow-up(cm) 7 7 8 10 8 8 10 6 8 7 Vaginal dilation By mold, every day By mold, every day Regular sexual intercourse By mold, every day By mold, every day By mold, every day By mold, intermittently By mold, every day By mold, every day Stop dilating 3 months after surgery Sexual satisfaction NK* NK Yes NK NK NK NK NK NK NK Pregnancy NO NO Prepared for 2 years, haven’t pregnant NO NO NO NO NO NO NO *NK: Not known, because of no intercourse sexual life. Cite Share Download PDF Status: Published Journal Publication published 01 Jun, 2021 Read the published version in Journal of Minimally Invasive Gynecology → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-59387\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research\",\"associatedPublications\":[],\"authors\":[{\"id\":1445228,\"identity\":\"59b748d1-1a8c-4237-ad5b-1e7e1cbc4b81\",\"order_by\":0,\"name\":\"Jia Kang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jia\",\"middleName\":\"\",\"lastName\":\"Kang\",\"suffix\":\"\"},{\"id\":1445229,\"identity\":\"408fd1b3-b62d-4ddf-b8d3-6441b04d9c33\",\"order_by\":1,\"name\":\"Na Chen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Na\",\"middleName\":\"\",\"lastName\":\"Chen\",\"suffix\":\"\"},{\"id\":1445230,\"identity\":\"cf62a6a5-794e-4ab6-b7e7-51ba1dc84d37\",\"order_by\":2,\"name\":\"Ye Zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ye\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":1445231,\"identity\":\"c7b8c1ce-9e21-432e-93a4-2808baa2f483\",\"order_by\":3,\"name\":\"Congcong Ma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Congcong\",\"middleName\":\"\",\"lastName\":\"Ma\",\"suffix\":\"\"},{\"id\":1445232,\"identity\":\"8817532f-4a44-430c-8a41-4de3651e78e6\",\"order_by\":4,\"name\":\"Yidi Ma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yidi\",\"middleName\":\"\",\"lastName\":\"Ma\",\"suffix\":\"\"},{\"id\":1445233,\"identity\":\"f6206625-3890-4e5c-a397-7ba83e7d81dc\",\"order_by\":5,\"name\":\"Yuan Wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yuan\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"},{\"id\":1445234,\"identity\":\"e3b54018-d23c-4947-9c5c-674129954a29\",\"order_by\":6,\"name\":\"Weijie Tian\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":false,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Weijie\",\"middleName\":\"\",\"lastName\":\"Tian\",\"suffix\":\"\"},{\"id\":1445235,\"identity\":\"d970228f-02ad-4d8f-a5ba-4d0f1c5c293f\",\"order_by\":7,\"name\":\"Lan Zhu\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIie3QIQvCQBTA8TcOXHlifQPBr/BMKgj7KoPB0sKSmIYgaPEDTPRDmMwnB6ahVbFoN0yMFudEk57aDPeH2y7cj3cbgMn0j1Gxmgh2D2S+x28JIaD8hRRP8r68V20yYmgNqFpxjnUVQVxt2NLKTuF7Yk1TBmdA6ExCVgkobI084Yzn74mg8E54F3gKQSJLryTKGlJ6EHe7vJEYeb3XE3xOISFzIpA3H6YQBRHQipBSX6qEVU4Ofe231BJ/JqjTdivDRf8cdWOX1/4iO2lInn2hx78Avr2snvZ8cSR7EpPJZDK96ApfpkLz2HTljgAAAABJRU5ErkJggg==\",\"orcid\":\"https://orcid.org/0000-0001-5753-5426\",\"institution\":\"Peking Union Medical College Hospital\",\"correspondingAuthor\":true,\"submittingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Lan\",\"middleName\":\"\",\"lastName\":\"Zhu\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2020-08-14 10:27:03\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-59387/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-59387/v1\",\"draftVersion\":[],\"editorialEvents\":[{\"content\":\"https://doi.org/10.1016/j.jmig.2020.12.011\",\"type\":\"published\",\"date\":\"2021-06-01T18:40:33+00:00\"}],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":1980906,\"identity\":\"6ad9617b-9180-497f-88ed-0d35336887c8\",\"added_by\":\"auto\",\"created_at\":\"2020-08-18 21:58:19\",\"extension\":\"png\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":8980763,\"visible\":true,\"origin\":\"\",\"legend\":\"Intraoperative images of laparoscopically uterovaginal canalization. (A) Laparoscopically images of pelvic cavity. The uterus was enlarged with no anomaly. No evidence of pelvic endometriosis or adhesion was found in this patient. (B) A metal guide was placed in the uterine cavity to push the uterus inferiorly. (C) The metal guide was pulled out from uterine cavity to the neovagina. (D) The mushroom-like end of the Pezzer catheter was inserted into the cervix. (E) Excising the anterior uterine wall. (F) Dragging the mushroom-like end of the catheter into uterine cavity. (G) Closing the anterior uterine wall. (H) Interruptedly suturing the cervical catheter to the cervix. (I) A soft mold made of two sterile condoms filled with sterile gauze was placed in the neovaginal cavity.\",\"description\":\"\",\"filename\":\"Figure10.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-59387/v1/Figure10.png\"},{\"id\":1980907,\"identity\":\"8fbda52e-fecb-4efe-8dfc-7335a2e27a17\",\"added_by\":\"auto\",\"created_at\":\"2020-08-18 21:58:20\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":498918,\"visible\":true,\"origin\":\"\",\"legend\":\"Surgical maneuver schemas. (A) Prior to the operation, the uterine cavity was enlarged due to hematoma, the uterine cervix was absent and the vagina was unobservable. (B) The neovagina was manually constructed between the bladder and the rectum and toward the uterus. To protect the bladder and rectum from injury, a metal urinary drainage tube was inserted into the urethra and the bladder, and an index finger was placed into the anus and rectum. (C) The uterus was pushed inferiorly by the metal guide. (D) The cervix was sutured with the neovagina, and the cervical catheter was interrupted sutured to the cervix.\",\"description\":\"\",\"filename\":\"Figure20.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-59387/v1/Figure20.png\"},{\"id\":13578685,\"identity\":\"3f00aa4a-717e-4688-801f-d25aaae882e3\",\"added_by\":\"auto\",\"created_at\":\"2021-09-17 04:16:45\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":3339611,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-59387/v1/8f4e9196-8d75-4cbd-906a-bd0155e27045.pdf\"}],\"financialInterests\":\"\",\"formattedTitle\":\"\\u003cp\\u003eLaparoscopically assisted uterovaginal canalization and vaginoplasty for patients with congenital cervical and vaginal atresia: a step-by-step guide and long-term outcomes\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\" \\u003cp\\u003eCongenital cervical atresia is a rare M\\u0026uuml;llerian anomaly and is associated with vaginal aplasia in 50% of cases\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e. The true incidence of congenital cervical atresia is somewhat difficult to determine. Patients with congenital cervical atresia usually have a normal or deformed but functional uterus and present with cyclic abdominal pain with no menstruation. A timely surgical correction is necessary to relieve obstruction and to prevent the onset of endometriosis or hematometra.\\u003c/p\\u003e \\u003cp\\u003eHysterectomy had been advocated by some clinicians for these patients due to risks of reoperation and potential death from reconstructive surgery\\u003csup\\u003e\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e\\u003c/sup\\u003e. While hysterectomy resulted in irreversible physical and psychological damage for these teenager girls. With the development of new techniques and assisted reproductive techniques, fertility-sparing strategies, including uterovaginal or uterovestibular anastomosis, cervicovaginal canalization, cervicoplasty and cervical end-to-end anastomosis, had yielded encouraging outcomes, as well as successful pregnancies \\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR5\\\" citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e\\u003c/sup\\u003e. But most of them were case reports and only in a short term follow up.\\u003c/p\\u003e \\u003cp\\u003eIn our center, we applied laparoscopically assisted cervical canalization and vaginoplasty for patients with congenital cervical and vaginal atresia from Jan 2016. In this prospective observational study, we aimed to report the surgical procedure step by step and long-term outcomes of laparoscopically assisted cervical canalization and vaginoplasty for congenital cervical and vaginal atresia.\\u003c/p\\u003e \"},{\"header\":\"Materials And Methods\",\"content\":\" \\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eSetting and patients\\u003c/h2\\u003e \\u003cp\\u003eBetween January 2016 to July 2020, we carried out a prospective observational study of patients with congenital cervical anomalies who had received surgical treatment at the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital (PUMCH).\\u003c/p\\u003e \\u003cp\\u003eThe inclusion criteria were as follows. 1. Patients diagnosed with congenital cervical anomaly with a functional uterus, with or without vaginal atresia. The diagnosis of cervical atresia was suggested by clinical manifestation, gynecological examination, and results from pelvic Magnetic Resonance Imaging (MRI). In all cases, the diagnosis was confirmed during laparoscopy. 2. Patients had undergone laparoscopically assisted cervical canalization and vaginoplasty by the same experienced gynecologist (Dr. Lan Zhu). 3. Patients had undergone pelvic MRI examinations preoperatively.\\u003c/p\\u003e \\u003cp\\u003eThe exclusion criteria were as follows: 1. The patient was diagnosed with distal vaginal atresia or transverse vaginal septum although the hematoma was present; 2. The canalizations were not assisted by laparoscopy; 3. Patients with congenital cervical atresia were performed hysterectomy.\\u003c/p\\u003e \\u003c/div\\u003e \\n\\n\\u003ch2\\u003eData Collection\\u003c/h2\\u003e \\u003cp\\u003eClinical characteristics, including onset age, course of disease, malformations and lesions of the reproductive system, complicated malformations of other systems, and perioperative data, including operating time, estimated bleeding volume, intraoperative complications and postoperative febrile morbidity, were reviewed and recorded in detail. There is no widely accepted standard definition of febrile morbidity. We chose a level of 38℃, which has been used previously in a number of studies assessing postoperative infectious morbidity. Postoperative febrile morbidity was defined by a body temperature of at least 38\\u0026nbsp;\\u0026deg;C on two consecutive occasions at least 6\\u0026nbsp;h apart, excluding the first 24 h\\u003csup\\u003e\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003ePatients were followed up in outpatient clinic at 3, 6 and 12\\u0026nbsp;months postoperatively, and once a year thereafter. Regarding menstruation, each patient was asked about her cycles and degree of dysmenorrhea. Gynecological examination was performed to measure vaginal length and to examine whether there was restenosis.\\u003c/p\\u003e \\u003cp\\u003eSexual satisfaction was assessed with the female sexual function index (FSFI), the most commonly applied and valid tool for measuring sexual satisfaction\\u003csup\\u003e\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e\\u003c/sup\\u003e. Chinese version of the FSFI has been validated to be a reliable and valid questionnaire in Chinese women\\u003csup\\u003e\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u003c/sup\\u003e. Based on epidemiological research of Chinese women, the cutoff score for the FSFI total score was 23.45\\u003csup\\u003e11\\u003c/sup\\u003e. Higher scores indicate better sexual function.\\u003c/p\\u003e \\n\\n\\n\\u003ch2\\u003eOutcome variables\\u003c/h2\\u003e \\u003cp\\u003eSuccess rate of laparoscopically assisted cervical canalization and vaginoplasty, which was defined as no restenosis.\\u003c/p\\u003e \\n\\n\\u003ch2\\u003eSurgery\\u003c/h2\\u003e \\u003cp\\u003eThe surgical procedures were performed during menstruation. 1. Briefly, the patient was placed in the lithotomy position under general anesthesia. 2. Laparoscopy was performed to explore the abdominopelvic cavity to identify evidence of endometriosis, pelvic adhesions, and uterine anomalies, especially cervical anomalies and the amount of cervical remnants (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eA). If necessary, appropriate surgery, such as ovarian cystectomy, adhesiolysis, salpingostomy or excision of pelvic endometriosis, was performed. 3. The procedure was switched to vaginal surgery. To perform vaginoplasty, an 8-cm-long, two-finger-wide canal was created by blunt dissection between the bladder and the rectum along the anatomical vaginal route. To protect the bladder and rectum from injury, a metal urinary drainage tube was inserted into the urethra and the bladder, and an index finger was placed into the anus and rectum. 4. Laparoscopically, we dissected the uterine fundus by using a monopolar needle to access the uterine cavity. After suctioning the hematocele, a metal guide was placed in the uterine cavity to push the uterus inferiorly (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eB). 5. The uterus was pushed inferiorly by the guide. In the meantime, a thick needle was punctured carefully through the neovaginal region toward the mass until the metal lever was reached. After ensuring no damage, an incision was made at the puncture site. The metal guide was pulled out (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eC). 6. A rubber cervical catheter, cut from a Pezzer catheter, was dragged from the vaginal vault to the uterine cavity. The mushroom-like end of the Pezzer catheter was inserted into the cervix (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eD). Excising the anterior uterine wall (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eE) and dragging the mushroom-like end of the catheter into uterine cavity (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eF). 7. The anterior uterine wall was closed using 2\\u0026thinsp;\\u0026minus;\\u0026thinsp;0 agnail stitches (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eG). 8. Switching to vaginal surgery, circular suturing of the cervix to form the vaginal portion of the cervix and interrupted sutures were placed to secure the cervical catheter to the cervix (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eH). 9. A metal urinary drainage tube was inserted into the urethra and bladder, and methylene blue was injected into the bladder to check any outflow of the blue dye to reexamine for damage to the urethra or bladder. 10. Finally, after surgery, a soft mold made of two sterile condoms filled with sterile gauze was placed in the neovaginal cavity for the first 7\\u0026ndash;14 days (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003eI). Later, the soft mold was removed, and the patient started vaginal dilation with a silicone dilator (length: 10\\u0026nbsp;cm, diameter: 3\\u0026nbsp;cm), which was advised to be daily, with 24 hours of continuous wear for the first 6 postoperative months to prevent contraction of the neovagina. Six months after surgery, the patient was advised to wear the mold intermittently and to gradually shorten their time wearing mold. There is no guideline for how long cervical stents should be placed. In our patients, cervical stents were not removed until the patient intended to be pregnant. If cervical stenosis occurred, a new cervical stent would be placed during reoperation. The schemas of surgical maneuver are presented in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cdiv id=\\\"Sec7\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eStatistical analysis was performed using SPSS (version 20.0 for Windows). The mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD or median (quartile) is presented for quantitative variables, and frequencies (%) are presented for qualitative variables.\\u003c/p\\u003e \\u003c/div\\u003e \\n\\n\\u003ch2\\u003eEthics approval\\u003c/h2\\u003e \\u003cp\\u003eThis study was approved by the Ethics Committee of the PUMCH (project: S-452). All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.\\u003c/p\\u003e \"},{\"header\":\"Results\",\"content\":\" \\u003cp\\u003eFrom January 2016 to June 2019, a total of ten patients with congenital cervical and vaginal atresia who underwent laparoscopically assisted cervicovaginal canalization in the Peking Union Medical College Hospital were recruited in our study.\\u003c/p\\u003e \\n\\n\\u003ch2\\u003eClinical characteristics of the patients\\u003c/h2\\u003e \\u003cp\\u003eThe mean (\\u0026plusmn;\\u0026thinsp;SD) symptom onset age was 14.5\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.0\\u0026nbsp;years. The median (quartile) duration of symptom onset to canalization was 15.5 (5.7, 28.0) months. Uterine corpus and cervical malformations were delineated by a combination of pelvic MRI and laparoscopic exploration. Cervical obstruction anomalies were observed in 6 (60%) patients, cervical agenesis was found in 3 (31.6%) patients, and cervical fragmentation was noted in 1 (10%) patients. All patients had total vaginal atresia. A total of 20% of the patients (2/10) had uterine malformations, including one with complete septate uterus (U2bC4V4) and one with a partial bicorporeal uterus (U3aC4V4) according to the European Society of Human Reproduction and Embryology (ESHRE) and the European Society for Gynecological Endoscopy (ESGE) classification\\u003csup\\u003e\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u003c/sup\\u003e. The other 8 were all U0C4V4. Urinary ultrasound and/or intravenous pyelography examinations were performed in all 10 patients. None of them was found to have urinary anomaly. Plain-film X-ray exams of the spine were also performed in these 10 patients, one of them (1/10, 10%) was verified scoliosis (Table I).\\u003c/p\\u003e \\u003cp\\u003ePelvic endometriosis was confirmed by pathological examination and stage of endometriosis was diagnosed by laparoscopy according to revised American Society for Reproductive Medicine classification of endometriosis\\u003csup\\u003e\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e\\u003c/sup\\u003e. 20% of the patients had no endometriosis, 20% of the patients were diagnosed as stage I endometriosis, 30% of the patients were stage II and the remaining 30% were staged IV (Table I).\\u003c/p\\u003e \\n\\n\\u003ch2\\u003eSurgical outcomes and follow-ups of the patients\\u003c/h2\\u003e \\u003cp\\u003eAll patients underwent laparoscopically assisted canalization smoothly, with no case requiring conversion to laparotomy and no intraoperative complications occurred. The mean operation time was 105.0\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;34.4\\u0026nbsp;min, and the median (quartile) estimated blood loss was 100.0 (87.5, 100.0)ml. The mean length of the neo-vagina was 8.3\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.7\\u0026nbsp;cm intraoperatively. The postoperative course was uneventful; only one case had a postoperative temperature of 38\\u0026ndash;39℃ for 2 days after surgery.\\u003c/p\\u003e \\u003cp\\u003eThe median (quartile) follow-up time was 26.0 (21.3, 48.3) months. All patients experienced relief of abdominal pain and resumed menstruation, including 9 patients with regular monthly menstruation. Eight patients experienced mild-to-moderate dysmenorrhea; the remaining 2 patients had no dysmenorrhea. During the follow-up period, cervical reobstruction occurred in one patient 12 months postoperatively, and ultrasound-guided transvaginal cervical dilation was performed. So far, eight months after the second surgery, no restenosis has been found.\\u003c/p\\u003e \\u003cp\\u003eThe mean postoperative vaginal length was 7.9\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.3\\u0026nbsp;cm by the time of last follow up. 8 patients wore vaginal mold almost every day except for menstruation and 1 patient kept the length and width of vagina by regular sexual intercourse. The remaining 1 patient stopped dilating vagina 3 months after surgery. She had no vaginal restenosis and the vagina was about 7\\u0026nbsp;cm long, but the vagina was only about 2\\u0026nbsp;cm wide.\\u003c/p\\u003e \\u003cp\\u003eOnly one patient had intercourse sexual life. She was satisfied with sexual life subjectively. In addition, the scores of desire, arousal, orgasm, lubrication, satisfaction and pain were 6, 15, 16, 10, 12 and 11 respectively. After the weighted, the total FSFI score was 26.1. Moreover, this was the only patient prepared for pregnancy for two years, but she had not conceived yet (Table II). The patient is going to seek assisted reproductive technology for help.\\u003c/p\\u003e \"},{\"header\":\"Discussion\",\"content\":\" \\u003cp\\u003eCongenital cervical atresia is a very uncommon M\\u0026uuml;llerian duct malformation\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e. 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 complications\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e\\u003c/sup\\u003e. 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 atresia\\u003csup\\u003e\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u003c/sup\\u003e. 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\\u0026ndash;51 months of follow-up, the success rate of laparoscopic assisted cervicovaginal canalization was 90%.\\u003c/p\\u003e \\u003cp\\u003eLaparoscopic 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 effective\\u003csup\\u003e\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u003c/sup\\u003e. 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 midterm\\u003csup\\u003e\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e\\u003c/sup\\u003e. In our cohort, we didn\\u0026rsquo;t use any graft to avoid additional damage or great expense.\\u003c/p\\u003e \\u003cp\\u003eThere 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 uterus\\u003csup\\u003e\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e,\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e\\u003c/sup\\u003e, 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 endometrium\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR20 CR21 CR22\\\" citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e\\u003c/sup\\u003e.\\u003c/p\\u003e \\u003cp\\u003eCarefully outlining the anatomical variations of congenital cervical anomalies before performing any reconstructive procedure is recommended and crucial for prognosis\\u003csup\\u003e\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e. 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 os\\u003csup\\u003e\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e\\u003c/sup\\u003e. 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\\u0026rsquo;t figure out which cervical anomaly was good candidate for laparoscopically cervicovaginal canalization. Future studies are needed to address this problem.\\u003c/p\\u003e \\u003cp\\u003eA 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 \\u0026ldquo;mushroom head\\u0026rdquo; of Pezzer can drain menstrual blood and protect the stent from falling off.\\u003c/p\\u003e \\u003cp\\u003eReproductive 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\\u0026nbsp;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 cases\\u003csup\\u003e\\u003cspan additionalcitationids=\\\"CR26 CR27 CR28\\\" citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e\\u003c/sup\\u003e. 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\\u0026rsquo;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.\\u003c/p\\u003e \\n\\n\\u003ch2\\u003eStrengths and limitations\\u003c/h2\\u003e \\u003cp\\u003eIn 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.\\u003c/p\\u003e \"},{\"header\":\"Conclusion\",\"content\":\" \\u003cp\\u003eIn summary, in this prospective observational study, we reported that laparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe and effective management option for relieving obstructions in patients with congenital cervical and vaginal atresia. However, more studies and longer follow-up are needed.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\" \\u003ch2\\u003eEthics approval and consent to participate:\\u003c/h2\\u003e \\u003cp\\u003eThis study was approved by the Ethics Committee of the PUMCH (project: S-452).\\u003c/p\\u003e \\u003ch2\\u003eConsent for publication:\\u003c/h2\\u003e \\u003cp\\u003eWritten informed consent for publication was obtained.\\u003c/p\\u003e \\u003ch2\\u003eAvailability of data and materials:\\u003c/h2\\u003e \\u003cp\\u003eAll data generated or analyzed during this study are included in this published article.\\u003c/p\\u003e \\u003ch2\\u003eCompeting interests:\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare that they have no competing interests.\\u003c/p\\u003e \\u003ch2\\u003eFunding:\\u003c/h2\\u003e \\u003cp\\u003eThe work was supported by the Chinese Academy of Medical Sciences (CAMS) Initiative for Innovative Medicine (grant number: CAMS-2017-I2M-1-002) and National Science Foundation for Youth (grant number: 81801401).\\u003c/p\\u003e \\u003ch2\\u003eAuthors' contributions:\\u003c/h2\\u003e \\u003cp\\u003eJ.K. participated in the design of the study, conducted the data acquisition, interpreted and analyzed the data, and drafted and revised the manuscript. C.N. pointed out deficiencies and ameliorated the manuscript. Y.Z participated in videoing the surgery and selecting of photographs. C.C.M., Y.D.M., Y.W. and W.J.T contributed to the data collection. L.Z. was responsible for design of the work and final approval of the version to be published.\\u003c/p\\u003e \\u003ch2\\u003eAcknowledgements:\\u003c/h2\\u003e \\u003cp\\u003eWe acknowledge Mr. Xue Liu for the wonderful surgical diagram he drew in this work.\\u003c/p\\u003e \"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e \\u003cspan\\u003eFujimoto VY, Miller JH, Klein NA, Soules MR. Congenital cervical atresia: report of seven cases and review of the literature. Am J Obstet Gynecol. 1997;177:1419\\u0026ndash;25.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eFliegner JR, Pepperell RJ. Management of vaginal agenesis with a functioning uterus. Is hysterectomy advisable? Aust N Z J Obstet Gynaecol. 1994;34:467\\u0026ndash;470.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eNiver DH, Barrette G, Jewelewicz R. Congenital atresia of the uterine cervix and vagina: three cases. Fertil Steril. 1980;33:25\\u0026ndash;9.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLiu Y, Wang YF. Successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia: A rare case report. J Obstet Gynaecol Res. 2017;43:1217\\u0026ndash;21.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eShen F, Zhang XY, Yin CY, Ding JX, Hua KQ. Comparison of small intestinal submucosa graft with split-thickness skin graft for cervicovaginal reconstruction of congenital vaginal and cervical aplasia. Hum Reprod. 2016;31:2499\\u0026ndash;505.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAcien P, Acien MI, Quereda F, Santoyo T. Cervicovaginal agenesis: spontaneous gestation at term after previous reimplantation of the uterine corpus in a neovagina: Case Report. Hum Reprod. 2008;23:548\\u0026ndash;53.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eKolben M, Mandoki E, Ulm K, Freitag K. Randomized trial of cefotiam prophylaxis in the prevention of postoperative infectious morbidity after elective cesarean section. Eur J Clin Microbiol Infect Dis. 2001;20:40\\u0026ndash;2.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDavid-Montefiore E, Rouzier R, Chapron C, Darai E. Collegiale d'Obstetrique et Gynecologie de Paris-Ile de F. Surgical routes and complications of hysterectomy for benign disorders: a prospective observational study in French university hospitals. Hum Reprod. 2007;22:260\\u0026ndash;5.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDabaghi S, Zandi M, Ilkhani M. Sexual satisfaction in patients with Mayer-Rokitansky-Kuster-Hauser syndrome after surgical and non-surgical techniques: a systematic review. Int Urogynecol J. 2019;30:353\\u0026ndash;62.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eSun X, Li C, Jin L, Fan Y, Wang D. Development and validation of Chinese version of female sexual function index in a Chinese population-a pilot study. J Sex Med. 2011;8:1101\\u0026ndash;11.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eMa J, Pan L, Lei Y, Zhang A, Kan Y. Prevalence of female sexual dysfunction in urban chinese women based on cutoff scores of the Chinese version of the female sexual function index: a preliminary study. J Sex Med. 2014;11:909\\u0026ndash;19.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eGrimbizis GF, Gordts S, Di Spiezio Sardo A, et al. The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies. Hum Reprod. 2013;28:2032\\u0026ndash;44.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eRevised American Society for Reproductive Medicine classification of endometriosis. 1996. Fertil Steril. 1997;67:817\\u0026ndash;821.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eEl Saman AM. Endoscopically monitored canalization for treatment of congenital cervical atresia: the least invasive approach. Fertil Steril. 2010;94:313\\u0026ndash;6.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eEl Saman AM. Combined retropubic balloon vaginoplasty and laparoscopic canalization: a novel blend of techniques provides a minimally invasive treatment for cervicovaginal aplasia. Am J Obstet Gynecol. 2009;201:333 e331\\u0026ndash;5.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDing JX, Chen XJ, Zhang XY, Zhang Y, Hua KQ. Acellular porcine small intestinal submucosa graft for cervicovaginal reconstruction in eight patients with malformation of the uterine cervix. Hum Reprod. 2014;29:677\\u0026ndash;82.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLee CL, Wang CJ, Liu YH, Yen CF, Lai YL, Soong YK. Laparoscopically assisted full thickness skin graft for reconstruction in congenital agenesis of vagina and uterine cervix. Hum Reprod. 1999;14:928\\u0026ndash;30.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eKobayashi A, Fukui A, Funamizu A, Ito A, Fukuhara R, Mizunuma H. Laparoscopically assisted cervical canalization and neovaginoplasty in a woman with cervical atresia and vaginal aplasia. Gynecol Minim Invasive Ther. 2017;6:31\\u0026ndash;3.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eZayed M, Fouad R, Elsetohy KA, Hashem AT, AbdAllah AA, Fathi AI. Uterovaginal Anastomosis for Cases of Cryptomenorrhea Due to Cervical Atresia with Vaginal Aplasia: Benefits and Risks. J Pediatr Adolesc Gynecol. 2017;30:641\\u0026ndash;5.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003ePadmawar A, Syed R, Naval S. Laparoscopic Uterovaginal Anastomosis for Cervical Agenesis: A Case Report. J Minim Invasive Gynecol. 2018;25:334\\u0026ndash;5.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eHe H, Guo H, Han J, Wu Y, Zhu F. An atresia cervix removal, lower uterine segment substitute for cervix and uterovaginal anastomosis: a case report and literature review. Arch Gynecol Obstet. 2015;291:93\\u0026ndash;7.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eKriplani A, Kachhawa G, Awasthi D, Kulshrestha V. Laparoscopic-assisted uterovaginal anastomosis in congenital atresia of uterine cervix: follow-up study. J Minim Invasive Gynecol. 2012;19:477\\u0026ndash;84.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eDeffarges JV, Haddad B, Musset R, Paniel BJ. Utero-vaginal anastomosis in women with uterine cervix atresia: long-term follow-up and reproductive performance. A study of 18 cases. Hum Reprod. 2001;16:1722\\u0026ndash;5.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eRock JA, Roberts CP, Jones HW. Jr. Congenital anomalies of the uterine cervix: lessons from 30 cases managed clinically by a common protocol. Fertil Steril. 2010;94:1858\\u0026ndash;63.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLin TK, Lin YR, Lai TH, Lee FK, Su JT, Lo HC. Transmyometrial blastocyst transfer in a patient with congenital cervical atresia. Taiwan J Obstet Gynecol. 2010;49:366\\u0026ndash;9.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eXu C, Xu J, Gao H, Huang H. Triplet pregnancy and successful twin delivery in a patient with congenital cervical atresia who underwent transmyometrial embryo transfer and multifetal pregnancy reduction. Fertil Steril. 2009;91:1958 e1951-1953..\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eLai TH, Wu MH, Hung KH, Cheng YC, Chang FM. Successful pregnancy by transmyometrial and transtubal embryo transfer after IVF in a patient with congenital cervical atresia who underwent uterovaginal canalization during Caesarean section: case report. Hum Reprod. 2001;16:268\\u0026ndash;71.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eAnttila L, Penttila TA, Suikkari AM. Successful pregnancy after in-vitro fertilization and transmyometrial embryo transfer in a patient with congenital atresia of cervix: case report. Hum Reprod. 1999;14:1647\\u0026ndash;9.\\u003c/span\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cspan\\u003eThijssen RF, Hollanders JM, Willemsen WN, van der Heyden PM, van Dongen PW, Rolland R. Successful pregnancy after ZIFT in a patient with congenital cervical atresia. Obstet Gynecol. 1990;76:902\\u0026ndash;4.\\u003c/span\\u003e \\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003ctable border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cp\\u003eTable I\\u003c/p\\u003e\\n\\u003cp\\u003eClinical characteristics of the 10 patients\\u003c/p\\u003e\\n\\u003c/caption\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePatient No.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e6\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e7\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e8\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e9\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e10\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAge at diagnosis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e13\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e14\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e17\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e14\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003e19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003e13\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003e19\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e14\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eDelay in diagnosis (month)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e24\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e16\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e24\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e15\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003e72\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003e12\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003e40\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e5\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e6\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eUterine anomaly\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003eComplete septate uterus\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003ePartial bicorporeal uterus\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCervical anomaly\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eCervical absence\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003eCervical Fragmentation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003eCervical absence\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003eCervical absence\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eCervical obstruction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePreoperative vaginal length(cm)\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003e2\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eRenal anomaly\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eSpinal anomaly\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003eScoliosis\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eN\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePreoperative AFS stage*\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eI\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eIV\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003eII\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003eII\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003eIV\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003eII\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eIV\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003eI\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"110\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePrevious surgery\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"86\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"85\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"104\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"66\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"76\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e1\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"82\\\"\\u003e\\n\\u003cp\\u003e0\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eN: normal;\\u003c/p\\u003e\\n\\u003cp\\u003e*: Diagnosed by laparoscopy.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\"\\u003e\\u003ccaption\\u003e\\n\\u003cp\\u003eTable II\\u003c/p\\u003e\\n\\u003cp\\u003eSurgical outcomes of the 10 patients\\u003c/p\\u003e\\n\\u003c/caption\\u003e\\n\\u003ctbody\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003ePatient No.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e1\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e2\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e3\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e4\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e5\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e6\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e7\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e8\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e9\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e10\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eSurgical time (min)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e80\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e90\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e80\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e120\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e120\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e180\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003e60\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e120\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003e80\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003e120\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eEstimated blood loss(ml)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e50\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e300\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003e10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003e100\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eIntraoperative\\u003c/p\\u003e\\n\\u003cp\\u003ecomplications\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eVaginal length at surgery\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd 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width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e30\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e48\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003e16\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e22\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003e25\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003e51\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eStricture of the cervix\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eMenstruation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eRegular,\\u003c/p\\u003e\\n\\u003cp\\u003e2-3/23\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eRegular, 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4-5/30\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eDysmenorrhea\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eMild\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eModerate\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eMild\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eMild\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eModerate\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eModerate\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eMild\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eMild\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eVaginal length at the last follow-up(cm)\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e7\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e7\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003e10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003e10\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003e6\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003e8\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003e7\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eVaginal dilation\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eRegular sexual intercourse\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eBy mold, intermittently\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eBy mold, every day\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eStop dilating 3 months after surgery\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003eSexual satisfaction\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNK*\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eYes\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eNK\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003ctr\\u003e\\n\\u003ctd width=\\\"98\\\"\\u003e\\n\\u003cp\\u003ePregnancy\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"84\\\"\\u003e\\n\\u003cp\\u003ePrepared for 2 years, haven\\u0026rsquo;t pregnant\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"81\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"80\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"93\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"83\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"69\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003ctd width=\\\"94\\\"\\u003e\\n\\u003cp\\u003eNO\\u003c/p\\u003e\\n\\u003c/td\\u003e\\n\\u003c/tr\\u003e\\n\\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e*NK: Not known, because of no intercourse sexual life.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":true,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Cervical anomalies, Congenital cervical atresia, Laparoscopic cervical canalization\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-59387/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-59387/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eObjective: \\u003c/strong\\u003eTo study the long-term outcomes of laparoscopically assisted uterovaginal canalization and vaginoplasty in patients with congenital cervical and vaginal atresia and to introduce the surgery step-by-step.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eA prospective observational study was conducted including 10 patients diagnosed with congenital cervical and vaginal atresia underwent laparoscopically assisted cervicovaginal canalization between January 2016 and Jun 2020 in a tertiary teaching hospital. Clinical characteristics and perioperative data were recorded. Patients were followed up in outpatient clinic at 3, 6 and 12\\u0026nbsp;months postoperatively, and once a year thereafter. Menstruation cycles and degree of dysmenorrhea were recorded. Gynecological examination was performed to measure vaginal length and to examine whether there was restenosis.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eAll procedures went smoothly, with no case requiring conversion to laparotomy or no intraoperative complications occurred. Postoperative febrile morbidity occurred in one patient (1/10, 10%). The median (quartile) follow-up time was 26.0 (21.3, 48.3) months. All patients resumed menstruation, including nine patients (9/10, 90%) with regular monthly menstruation. Eight patients (8/10, 80%) experienced mild-to-moderate dysmenorrhea; the remaining 2 patients (2/10, 20%) had no dysmenorrhea. Cervical restenosis occurred in one patient (1/10,10%) 12\\u0026nbsp;months postoperatively, and cervical dilation was performed. So far, eight months after the second surgery, no restenosis has been found. The mean postoperative vaginal length was 7.9 ± 1.3\\u0026nbsp;cm by the time of last follow up. Only one patient prepared for pregnancy for two years, but she had not conceived yet.\\u003c/p\\u003e\\u003cp\\u003e\\u003cstrong\\u003eConclusion: \\u003c/strong\\u003eLaparoscopically assisted uterovaginal canalization and vaginoplasty is an easy, safe and promising management option for correcting congenital cervical and vaginal atresia.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Laparoscopically assisted uterovaginal canalization and vaginoplasty for patients with congenital cervical and vaginal atresia: a step-by-step guide and long-term outcomes\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2020-08-18 21:58:19\",\"doi\":\"10.21203/rs.3.rs-59387/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"66d54a78-8379-441b-9678-8deffa712516\",\"owner\":[],\"postedDate\":\"August 18th, 2020\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"published-in-journal\",\"subjectAreas\":[{\"id\":321324,\"name\":\"Obstetrics \\u0026 Gynecology\"}],\"tags\":[],\"updatedAt\":\"2021-07-22T18:40:33+00:00\",\"versionOfRecord\":{\"articleIdentity\":\"rs-59387\",\"link\":\"https://doi.org/10.1016/j.jmig.2020.12.011\",\"journal\":{\"identity\":\"journal-of-minimally-invasive-gynecology\",\"isVorOnly\":true,\"title\":\"Journal of Minimally Invasive Gynecology\"},\"publishedOn\":\"2021-06-01 18:40:33\",\"publishedOnDateReadable\":\"June 1st, 2021\"},\"versionCreatedAt\":\"2020-08-18 21:58:19\",\"video\":\"\",\"vorDoi\":\"10.1016/j.jmig.2020.12.011\",\"vorDoiUrl\":\"https://doi.org/10.1016/j.jmig.2020.12.011\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-59387\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-59387\",\"identity\":\"rs-59387\",\"version\":[\"v1\"]},\"buildId\":\"-HB7Z8yhvgn0wM9Nzuekk\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}