Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Catania, Italy.
Department of General Surgery and Medical Surgical Specialties, Gynecological Clinic, University of Catania, Catania, Italy.
Fertil Steril. 2022 Feb;117(2):463-465. doi: 10.1016/j.fertnstert.2021.10.001. Epub 2021 Nov 19.
To demonstrate the surgical management of agenesis of the uterine isthmus.
Stepwise description of robotic-assisted laparoscopic cervicouterine anastomosis.
Academic medical center.
PATIENT(S): A 27-year-old nulligravida with primary amenorrhea and cyclic pelvic pain.
INTERVENTION(S): The patient underwent a robot-assisted cervicouterine anastomosis using the following surgical steps: adhesiolysis of the right ovary from the rudimentary uterine horn; vesicouterine peritoneal fold dissection and mobilization of the cervical canal; the opening of the cervical canal and dilatation with Hegar dilators; longitudinal incision of the lower third of the anterior uterine wall up to the endometrial cavity; insertion of a 14 Ch Foley catheter, not inflated, fixed to the cervix with a suture and removed after 7 days; and closure of the cervicouterine breach with a double-layer Vicryl suture. Informed consent was obtained from the patient for the use of video and images.
MAIN OUTCOME MEASURE(S): After 3 months, the patency of the anastomosis site was assessed via hysteroscopy. Subsequent follow-up was performed by referring physicians.
RESULT(S): Postoperatively, anatomic continuity was restored and the patient was menstruating with regular monthly cycles; furthermore, cyclic pelvic pain was relieved. Few cases of this condition have been reported in the literature and, currently, surgical treatment of agenesis of the uterine isthmus is controversial, with some treatments including laparoscopic-assisted uterocervical anastomosis using a stent to prevent restenosis, primary cervicouterine anastomosis by laparotomy performed with a Foley catheter in the cervical canal, and anastomosis of the uterine isthmus agenesis. However, to our knowledge, we are the first to use a robotic approach. Preservation of reproductive function and symptom relief represent the goals of the surgery. Therefore, hysterectomy cannot be considered as a treatment option. However, after a cervicouterine anastomosis procedure, the normal uterine morphology cannot be achieved; cyclic abdominal pain may remain after surgical treatment. In this case, an alternative surgical approach, such as hysterectomy, can be considered.
CONCLUSION(S): Robotic-assisted treatment of this uncommon müllerian anomaly is feasible and may be an alternative to hysterectomy in individuals who wish to preserve fertility. Follow-up is needed to evaluate fertility and reproductive function.
展示先天性子宫峡部发育不全的手术治疗方法。
机器人辅助腹腔镜宫颈-子宫吻合术的分步描述。
学术医疗中心。
一位 27 岁的初产妇，原发性闭经，周期性盆腔疼痛。
患者接受了机器人辅助宫颈-子宫吻合术，手术步骤如下：从残角子宫松解右侧卵巢与子宫的粘连；分离膀胱子宫腹膜皱襞并牵开宫颈管；切开宫颈管并用 Hegar 扩张器扩张；从前壁下 1/3 处作一纵向切口直达子宫内膜腔；插入 14Ch Foley 导管，不充气，用缝线固定于宫颈，7 天后取出；用双层 Vicryl 缝线缝合宫颈-子宫裂孔。患者同意使用视频和图像。
术后 3 个月，通过宫腔镜检查评估吻合口通畅情况。后续随访由主治医生进行。
术后解剖连续性恢复，患者开始有规律的月经周期；周期性盆腔疼痛缓解。目前文献中仅少数病例报道了这种情况，且先天性子宫峡部发育不全的治疗方法存在争议，一些治疗方法包括腹腔镜辅助使用支架预防再狭窄的子宫颈-子宫吻合术、经阴道放置 Foley 导管行剖腹术式的原发性宫颈-子宫吻合术，以及先天性子宫峡部发育不全的吻合术。但据我们所知，我们是第一个使用机器人技术的。保留生育功能和缓解症状是手术的目标。因此，不能考虑子宫切除术作为治疗方法。但是，宫颈-子宫吻合术后，正常的子宫形态无法恢复；手术后周期性腹痛可能仍然存在。在这种情况下，可以考虑其他手术方法，如子宫切除术。
机器人辅助治疗这种罕见的米勒管畸形是可行的，对于希望保留生育能力的患者，可能是子宫切除术的替代方法。需要随访以评估生育能力和生殖功能。
