Cervical atresia- Is there a simple approach

Cervical atresia- Is there a simple approach. Dr. Uday Bhaskar , Dr.Vidhya T, Dr.Rajiv Padankatti , Dr. R K Satheesan , Dr.Sripathi V Apollo Childrens Hospital, Chennai.

Introduction. Cervical atresia is a relatively rare mullerian anomaly which poses diagnostic and management challenges We report a case which was managed by canalisation with good short term outcome..

Case details. 9Y/F Complex urogenital anomaly Presents with cyclical abdominal pain of 3 months duration Evaluation with CECT abdomen- Bicornuate uterus with well formed right horn and atrophic left horn with hematometra and distension of right horn and cervix. Right hydrosalpinx with small sized right ovary and normal sized left ovary ESHRE Class- U4a, C4, V0 Proceeded with Laparotomy.

Surgery. Cervicotomy on lower most aspect of distended cervix , hematometra and hematosalpinx drained Atresia of external os confirmed Under cystoscopic guidance, neocervical opening created followed by Graded dilatation upto 22 Ch urethral dilator 18 fr Silastic placed across neocervical canal.

cervicotomy.

18Fr silastic foleys as stent.

Follow up. She had 3 painless mensturations after the procedure Repeat cystogenitoscopy showed patent and epitheliased neocervical canal through which uterine cavity could be entered.

Cervical atresia- Discussion. Very rare with about 200 cases reported in literature Mostly present with primary amenorrhoea with or without cyclic pelvic pain Lack of uniformity in classification and management Associated with vaginal aplasia in 52% Uterine and Renal anomalies in 20%.

Embryology. . . Defect in elongation of mullerian ducts (associated with vaginal aplasia ) Defect in canalisation of cervix.

shre Name Diagnostic Method: Main class ESHRE/ESGE classification Female genital tract anomalies Birth Date: Uterine anoma CervicaVVaginal anomaly CQ-existent class Class UO/Normal uterus Class IJ2/Septate uterus b. Canplete a. Patial Class U4/Hemi uterus Class Ul/Dysmorphic uterus a. T.shaped b. ln'Mtllts Class IJ3/Bicorporeal uterus c. Others Ul 1.12 IJ3 1.14 115 1.16 Normal uterus Dysmorphic uterus Septate uterus Bicorporeal uterus Hemi-uterus Aplastic Sub-class a. b. Infantilis c. Others a. Partial b, Complete a. Partial b. Complete c. Bicorporeal septate a. With rudimentary cavity (communicating or horn) b. Without rudimentary cavity (horn without cavity/no horn) a. With rudimentary cavity (bi- or unilateral horn) b. Without rudimentary cavity (bi• or unilateral uterine remnants/aplasia) co C2 vo V' Normal ærvix Septate cervix Dout*e •nomar cervix Unilateral cerveal aplasia Cervical aplasia Normal vagina Longitudinal vaginal septum Longitudinal '*Etructing va - septum Transverse vaginal septum and/or te Vaginal aplasia a. PartGI b, Complete c. Bimweal septate Class U5/Aplastic uterus Unclassified malformations a. With b. Without cavity b. Witho•..Jt Associated anomalies of non-Müllerian origin: Class U6/Unclassified cases.

Evaluation. Speculum examination USG pelvis- Transabdominal or transvaginal route USG KUB MRI/ CECT Pelvis.

Treatment. Dilatation procedures Vaginoplasty Hysterectomy.

Dilatation procedures. Described by Ludwig in 1900 Laparoscopic approach published by El salman in 2010 using nelaton catheter Successful in around 70% of cases.

Dilatation procedures. Advantages. Relatively Simple procedure- Short learning curve, reproducible and can be done in resource limited settings Preserves native uterus thus making pregnancy possible (natural or IVF) Minimal pelvic dissection preventing adhesions.

Conclusion. Cervical atresia should be treated with dilatation rather than hysterectomy or uterovaginal anastomosis Minimal pelvic dissection, careful guided dilatation and creation of neocervical canal with stenting for reasonable amount may provide optimal result. Case is being presented for its rarity and dilemma in management.

References. Darwish AM. Balloon cervicoplasty : a simplified technique for correction of isolated cervical atresia. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2013 Jan 1;166(1):86-9. El Saman AM. Endoscopically monitored canalization for treatment of congenital cervical atresia: the least invasive approach. Fertility and sterility. 2010 Jun 1;94(1):313-6. Fujimoto VY, Miller JH, Klein NA, Soules MR. Congenital cervical atresia: report of seven cases and review of the literature. American journal of obstetrics and gynecology . 1997 Dec 1;177(6):1419-25..

Thank you.