Restore the Continuity of Uterus-Cervix-Vagina for Cervical Restenosis after Cervicovaginal Reconstruction: A Case Report.

The girl was 20 years old. The preoperative diagnosis of the patient was U0C4V4, according to ESHER/ESGE classification.[ 1 ] She had cervicovaginal reconstruction due to cervicovaginal atresia in our hospital in 2015. The surgical process has been reported.[ 3 ] A cervical catheter was used to keep the newly created cervix patent postoperatively, and her menstruation was regular with no dysmenorrhea. However, the patient complained that the menstrual volume was significantly decreased with severe dysmenorrhea after the cervical catheter fell off 7 years after the operation. The B-ultrasound showed that the uterus was normal, the hematocele was in the uterine cavity, and the endometrial cyst was detected in the bilateral ovary. This patient was diagnosed with cervical restenosis after cervicovaginal reconstruction. Due to the cervical restenosis, we operated on the patient to restore the continuity of uterus-cervix-vagina, and the details are as follows. Vaginal exploration found that the vagina is 6 cm long, and the tail of the intrauterine device was out of the cervix [ Figure 1a ]. Under the guidance of the B-ultrasound, the original cervical catheter was removed through the vagina. The Hegar dilators showed that the cervical canal was blocked, and the smallest Hegar dilator could not find the obvious cervical canal [ Figure 1b ]. The blind end of the cervical canal was found by hysteroscopy, and the uterine cavity could not be reached [ Figure 1c ]. Hence, we decided to perform laparoscopic cervicovaginal reconstruction. Cervical restenosis after cervicovaginal reconstruction. (a) The tail of the intrauterine device was out of the cervix. (b) The Hegar dilator could not find the cervical canal. (c) The blind end of the cervical canal was found by hysteroscopy The first step was to explore the pelvic cavity, where we found severe adhesions and endometriosis caused by retrograde menstruation because of obstruction [ Figure 2a ]. The uterus, ovaries, and fallopian tubes were exposed, and the endometrial cyst was removed after the adhesion was released by the ultrasonic scalpel. To ensure the accuracy of the incision, an oval forceps was inserted into the vagina to guide the procedure, and then, the ultrasonic scalpel opened the top of the front wall of the vagina until it entered the vagina [ Figure 2b ]. Vasopressin with physiologic saline solution was injected into the uterine myometrium, and the position of the endometrium was guided by transrectal ultrasound. Under the guidance of B-ultrasound, the ultrasonic scalpel incised the middle and lower sections of the anterior wall of the uterus and reached the endometrium [ Figure 2c ]. The hematocele was drained from the uterus [ Figure 2d ]. We continued to cut the anterior wall of the uterus to the top of the vagina to ensure the vagina communicated with the uterine cavity. Prepared a T-shaped intrauterine device (IUD), connected the T-shaped IUD to the catheter scissoring from a 14-Fr Foley catheter, and then inserted this frame into the uterus [ Figure 2e ]. The arms of the frame hold the IUD in place near the top of the uterus. The catheter was left outside the vagina and trimmed to keep the newly created cervical canal patent. Unification was completed by placing continuous sutures vertically in the anterior walls of the uterus with absorbable barbed threads, then gradually suturing the vesical peritoneal reflection [ Figure 2f ]. The operation was successful. After six cycles of gonadotropin-releasing hormone agonist treatment postoperatively, sequential therapy with estradiol and dydrogesterone was administered owing to endometrial cyst. This patient is relieved of pain and experiences regular menstruation now. The process of laparoscopic cervicovaginal reconstruction. (a) The pelvic cavity had severe adhesions and endometriosis. (b) Opened the top of the front wall of the vagina. (c) Incised the middle and lower sections of the anterior wall of the uterus. (d) Hematocele was drained from the uterus. (e) Inserted the T-shaped intrauterine device with the catheter into the uterus. (f) Placed continuous sutures vertically in the anterior walls of the uterus

Congenital cervical and vaginal atresia in the presence of a functioning endometrium is an extremely rare Millerian anomaly that is associated with an obstructive phenomenon after menarche that leads to cyclic abdominal pain and pelvic masses.[ 1 2 ] For many decades, the main treatment for this disease was hysterectomy.[ 3 ] As a consequence of the evolution of surgery and the advances in heterologous biological grafts, conservative surgical management has become an option, such as cervicovaginal reconstruction.[ 4 5 6 ] In this article, we report a case that involves laparoscopic cervical reconstruction for cervical restenosis after cervicovaginal reconstruction in a patient with congenital cervical and vaginal aplasia.

Cervicovaginal reconstruction is the main operation for congenital cervical and vaginal aplasia.[ 7 8 ] After cervicovaginal reconstruction, the placement time of the cervical catheter should be extended appropriately because a short duration increases the risk of cervical restenosis due to incomplete epithelization.[ 9 ] Ding et al . reported that two patients (5.26%) experienced cervical obstruction and two patients (5.26%) experienced cervical stricture in long time follow-up (the median follow-up time was 52.05 months).[ 10 ] Kang et al . reported that four cases had pelvic abscesses owing to the long duration of cervical catheter placement and underwent hysterectomy; of these, two patients applied a mushroom-like cervical catheter to maintain drainage.[ 11 ] However, we used the T-shaped IUD, which can be used for contraception in ordinary women. During our long-term follow-up, there were no complications such as uterine infection caused by the placement of cervical catheter.[ 9 ] Hence, we recommended continuous wearing of the cervical catheter before pregnancy. Hysterectomy may be performed for surgical failures after initial restoration of the continuity of uterus-cervix-vagina.[ 12 ] Some patients have a strong desire to preserve the uterus because feeling far from normal in the areas of sexual activity and reproduction contributes to high levels of distress,[ 13 14 ] so restoring the continuity of uterus-cervix-vagina for cervical restenosis after cervicovaginal reconstruction is essential. Some reports had confirmed that the incidence and severity of endometriosis were higher in obstructive reproductive tract anomalies.[ 15 16 ] One retrospective study reported that the recurrence rate for endometriosis after surgical in adolescence is 41.6%.[ 17 ] Therefore, for patients with obstructive reproductive tract anomalies combined with endometriosis, long-term medication management is still needed to control the progression of endometriosis after surgical treatment of obstruction. We have confirmed that for patients with cervical restenosis requiring secondary surgery, transvaginal surgery has a high probability of risk and failure, so laparoscopic cervicovaginal reconstruction may be the best choice. This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent form. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Xiaotong Liu collected the data and wrote the paper. Xuyin Zhang collected the data and wrote the paper. Keqin Hua designed the study and reviewed the manuscript. All authors have read and agreed to the final version of the manuscript. The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request. There are no conflicts of interest.