Unification and orificing of two functional non-communicating uterine horns through the created neovagina using peritoneum


Uncu G., Aslan M. K., Kasapoğlu I.

ESGE 32nd Annual Congress, Brussels, Belgium, 1 - 04 October 2023, pp.22

  • Publication Type: Conference Paper / Summary Text
  • City: Brussels
  • Country: Belgium
  • Page Numbers: pp.22
  • Bursa Uludag University Affiliated: Yes

Abstract

Background The incidence of Mullerian abnormalities is extremely rare. There is no exact surgical method to make the anatomy functional.  The present case demonstrates the surgical approach for Mullerian agenesis with bilateral uterine remnant with functional endometrium. Methods An 18-year-old adolescent was admitted to a tertiary university hospital with primary amenorrhea and cyclic pelvic pain complaints. The physical examination and MRI scans suggested a complex Mullerian abnormality. The patient had uterine remnants with bilateral functional endometrium and cervicovaginal agenesis. An operation was planned to reconstruct her anatomy by providing a neovagina and anastomosis of uterine remnants. GnRH analogues were prescribed to suppress her menstruation until the process. The operation was performed in the third month of the first diagnosis. She underwent a laparoscopy. There were approximately 5x6 cm bilateral uterine horns with healthy adnexa. As the first step, neovagina was created using a modified peritoneal pull-down technique, a standard approach in that clinic. A vaginal incision was applied, and a blind vaginal dissection was performed to reach the peritoneum vaginally. Then, an acrylic vaginal mold was inserted. The vaginal orifice was laparoscopically incised by ultrasonic energy with the guidance of inserted vaginal acrylic mold. The orifice was gradually dilated with larger molds. The whole pelvic peritoneum was circularly dissected, and the distal part of the dissected peritoneum was pulled down with four 2.0 vicryl sutures at 0, 90, 180, and 270 degrees of opened vaginal orifice. The uterine cavities of bilateral remnants were incised, and two separate Foley catheters were replaced in both cavities. A mold with a hole was used to insert the catheters through the vagina. Both catheters were fixated in cavities with prolene sutures pulled up from the anterior abdominal wall. The next step was uterine anastomosis. The uterine remnants were unified by continued saturation. Therefore, a normally shaped uterus was consisted of. As the last step, the created uterus and neovagina were anastomosed. The patient was educated about how to apply mold exercises and follow-ups. Results The postoperative 1-month MRI scan showed the healed unified uterine cavities and vagina. She had spontaneous menstruation in the second month after surgery. Now she has regular menses with approximately 910 cm functional vagina. Conclusions Mullerian abnormalities are extremely uncommon, and their broad spectrum makes it challenging to identify an exact surgical method to restore functional anatomy. Therefore, a customized surgical approach should be designed for each patient based on their unique condition.