Gupta AS
Cervical atresia is
fortunately a rare congenital Mullerian anomaly with poor results after
surgical corrections. Vaginal aplasia is associated in 50% of these cases. Young,
adolescent girls with a functional uterus above an atretic or a dystretic
cervix underwent repeated unsuccessful attempts at reconstruction of the cervix
which eventually led to a hysterectomy. This was the fate of most of these
teenagers almost a decade or two back. The problem was of constructing a patent
cervical canal and maintaining its patency permanently. The reconstructed
cervix would close down despite use of intracervical stents like Foley
catheters as the cervical mucosa would not regenerate or could not be created.
Over the last 2 decades many
successful attempts have been made to establish permanent patency of the
functional uterus to the exterior. These reconstructive plastic procedures include
excision of the atretic part of the cervix and directly anastomosing the uterus
to the vagina, use of bio medical grafts like amniotic membrane, vaginal
mucosa, porcine small intestine submucosa, patients' own colon and even full
thickness skin graft. Stents used were Foley catheters, silicone stents and
polytetrafluroethylene Gore-Tex stents.
Some patients have isolated cervical atresias but a patent vagina. The
other category which poses greater management challenge is that of an
adolescent with cervical atresia and vaginal aplasia. In such cases there is a
need to not only establish patency of the uterus to the exterior but also
perform a vaginoplasty to establish a functional vagina.
The various methods attempted to restore functional and reproductive
capability of these individuals include cervical drilling and canalization
procedures, uterovaginal anastomosis, uterovestibular anastomosis,
uterocolonocovaginoplasty performed either through a standard laparotomy or
laparoscopically. Anastomosis are preferred over canalization procedures even though they are easy to perform as the
incidence of re-stenosis is very high (40-60 % ) with drilling and canalization
procedures. This results in multiple repeat surgeries, increased morbidity and
eventually leads to a hysterectomy.
In patients with only cervical atresia, or associated vaginal aplasia successful
restoration of menstrual, sexual and reproductive function have been reported
in numerous studies by various authors by performing uterovaginal anastomosis
or uterovestibular anastomosis. Restenosis, infections are real morbidities
which still require hysterectomy.
These procedures are usually
performed in a semi-lithotomy position to allow concurrent abdominal and
vaginal procedure. After these procedures patients have good vaginal depth for
sexual function and pregnancies have been reported naturally or after use of assisted
reproductive techniques. All
patients who have delivered have delivered by elective cesarean section. No
vaginal births have been reported. Since the procedure of uterovaginal
anastomosis or uterovestibular anastomosis involves incising the uterine fundus
elective prelabor cesarean section is safer for childbirth.
Reviewing the literature, studying the treatment
options and noting the success rate of the uterovaginal anastomosis procedures it
is heartening to see that an option for conservative treatment is a reality for
the adolescent girl with cervical atresia. Early diagnosis, desire to save the uterus,
restore menstrual, sexual and reproductive function either spontaneous or with
assisted reproductive techniques, opting for uterovaginal anastomosis as the 1st
line of treatment can change the grim outlook for these adolescent girls who
are standing at the brink of their womanhood and save them from a hysterectomy.