Laparoscopic Removal of Nonseparated Cavitated Horn in Unicornuate Uterus: Surgical Aspects and Long-Term follow-up.

BACKGROUND: In unicornuate uterus cases, when the rudimentary horn is very close to the uterus and is firmly attached, laparoscopic surgery can be very challenging due to the danger of massive bleeding and the possiblity of damaging the healthy hemiuterus. The aim of study is to verify if the laparoscopic resection of the horn site of hematometra, when solidly attached to the unicornuate uterus, is safe and effective. MATERIALS AND METHODS: This is a retrospective analysis of prospectively collected data in a tertiary referral centre. From 2005 to 2021, a total of 19 women were diagnosed with unicornuate uterus with cavitated noncommunicating horn (class II B). We reviewed the original documentations of the patients and created a database. The follow-up results were assessed by questionnaires answered by the patients. In all cases, the chosen treatment was: laparoscopic removal of the rudimentary horn together with the ipsilateral salpinx and reconstruction of the myometrium of the hemiuterus. Statistical Package for Social Science (SPSS) version 21.0 was used to perform data analysis. We decided to calculate continuous variables in terms of mean and standard deviation (SD) or as median and interquartile range (IQR), as appropriate. Instead, categorical variables were expressed in terms of percentage. RESULTS: Five patients (12-18 years old) with unicornuate uterus and rudimentary horn with hematometra and broadly connected to the hemiuterus were operated laparoscopically. The surgical procedure was successfull in all cases. No major complications were recorded. Postoperative course was uneventfull. In the follow-up in all cases dysmenorrhea and pelvic pain disappeared. Three patients sought to become pregnant and have children. They had in total 4 pregnancies with 2 abortions in the 1st trimester and two pregnancies with premature births at the 34th and 36th weeks. No serious gestational complications were recorded and the pregnancies ended with caesarean sections due to breech presentation. CONCLUSION: Overall, for the rudimentary horn solidly attached to the unicornuate uterus, the laparoscopic resection of the horn site of hematometra seems to be safe and effective.

Conservative surgical repair in cervical atresia associated with partial or complete absence of the vagina.

OBJECTIVE: To describe the surgical technique of laparoscopically assisted uterovaginal/vestibular anastomosis in patients with cervical atresia associated with partial or complete absence of the vagina. DESIGN: Surgical video article. Local institutional review board approval and written permission from the patients were obtained. SETTING: Tertiary referral center. PATIENT(S): The surgical video presents surgical correction in 3 different patients with cervical agenesis. The first patient, aged 14 years, had a normoconformed uterus and total absence of the vagina. The second patient, aged 12 years, demonstrated a left unicornuate uterus and partial absence of the vagina. The third patient, aged 13 years, displayed a right unicornuate uterus and total absence of the vagina. INTERVENTION(S): Laparoscopic time and perineal time. During laparoscopy, the entire abdominopelvic cavity was assessed to evaluate the uterine morphology and size to exclude anomalies such as hematometra. The adnexa and adhesions were evaluated and any endometrial flare-ups were treated appropriately. A laparoscopic ultrasound probe was used to evaluate the size and location of the endometrial cavity. In cases with total absence of vaginas, an H-shaped incision in the hymenal dimple allowed a larger area of available tissue for the anastomosis. A tunnel was then created by blunt finger dissection between the bladder and rectum. Simultaneously, the uterus was pushed caudally by an assistant while the operator grasped it from below using an internal probe. A circular myometrial incision at the uterine caudal body allowed to reach the endometrial cavity and open it. The edges of the uterine cavity were then anastomized with the edges of the hymenal incision. In cases with partial absence of vaginas, the creation of the tunnel between the vagina and rectum was not necessary and the open uterus was anastomosed with the margins of the vaginal dome, engraved on the guide of a metal dilator. All patients received broad-spectrum antibiotics (i.e., cephalosporins of the last available generation) on the day before surgery and on the day of surgery. MAIN OUTCOME MEASURE(S): Intraoperative anatomic and ultrasound data, neovaginal length, and recovery of menstrual function 180 days after surgery. RESULT(S): The surgical procedure was successful in all cases. No major complications were recorded, and in particular, no bladder or rectal injuries occurred. No stenosis of the neocervix was recorded. The main hospital stay of the patients was 3.5 ± 1.5 days. In each case, the neovagina developed gradually over time after surgery because of the upward traction action exerted by the uterus through its natural ligament apparatus (cardinal ligaments and ovarian vessels). This fact eliminated the requirement for the use of a mold after surgery. At the 15-week follow-up, vaginoscopy was performed, with mucus observed at the site of uterovaginal anastomosis in all cases. None of the patients developed infection after surgery because of the avoidance of molds or pessaries and the natural mucus production. Six months after surgery, the length of the neovagina was >4 cm in all 3 cases. CONCLUSION(S): Laparoscopic-assisted uterovaginal/vestibular anastomosis may be considered the treatment of choice for patients with cervical atresia associated with partial or complete absence of the vagina.

Creation of a neovagina in Rokitansky syndrome: comparison between two laparoscopic techniques.

OBJECTIVE: To compare Vecchietti's and Davydov's laparoscopic techniques for creation of a neovagina in patients with Rokitansky syndrome. DESIGN: Comparative retrospective study. SETTING: Tertiary referral center for the treatment of Rokitansky syndrome. PATIENT(S): Eighty patients with Rokitansky syndrome. INTERVENTION(S): Patients underwent surgical creation of a neovagina. Fifteen patients who underwent the Vecchietti procedure from October 2003 to December 2004 and 30 patients who underwent the Davydov procedure from June 2005 to August 2008 were also included from two previously published studies. Follow-up lasted at least 12 months. MAIN OUTCOME MEASURE(S): Intraoperative parameters and anatomic results were compared. Functional results were compared through the Female Sexual Function Index. Epithelization of the neovagina was assessed in both groups through vaginoscopy and Schiller's test. RESULT(S): No major intraoperative complications were encountered in either group. Mean (±SD) duration of surgery was 30 ± 9.6 and 134 ± 24 minutes in Vecchietti's and Davydov's approach, respectively. At 12 postoperative months, length and width of the neovagina in the two groups were 7.5 ± 1.1 and 2.8 ± 0.6 cm, and 8.5 ± 1.6 and 2.8 ± 0.65, respectively. Epithelization of the neovagina at 6-month follow-up was 60% and 80%, respectively, and 100% in both groups at 12 postoperative months. CONCLUSION(S): Anatomic and functional outcomes of the two approaches tend to be comparable at 12-month follow-up; the only significant difference seems to be in greater length for the neovagina obtained by Davydov's approach.

Creation of a neovagina by Davydov's laparoscopic modified technique in patients with Rokitansky syndrome.

OBJECTIVE: The purpose of this study was to assess anatomic and functional results after the laparoscopic Davydov procedure for the creation of a neovagina in Rokitansky syndrome. STUDY DESIGN: Thirty patients with Rokitansky syndrome underwent the laparoscopic Davydov technique from June 2005-August 2008. Mean follow-up time lasted 30 months (range, 6-44 months) and included clinical examinations and evaluation of the quality of sexual intercourse; vaginoscopy, Schiller's test, and neovaginal biopsies were performed after 6 and 12 months. Functional results were assessed with the use of Rosen's Female Sexual Function Index and were compared with age-matched normal control subjects. RESULTS: No perioperative complications occurred. At 6 months, anatomic success was achieved in 97% of the patients (n = 29); functional success and optimal results for the Female Sexual Function Index questionnaire were obtained in 96% of patients. Vaginoscopy and biopsy results showed a normal iodine-positive vaginal epithelium. CONCLUSION: The Davydov technique seems to be a safe and effective treatment for vaginal agenesis in patients with Rokitansky syndrome.

Umbilical endometriosis: a radical excision with laparoscopic assistance.

BACKGROUND: Umbilical endometriosis represents the most common site of cutaneous endometriosis. Although its treatment is typically surgical, in literature the approach used is variable and extends from diathermocoagulation to omphalectomy. Such superficial treatments for umbilical endometriosis can predispose the patient to a relapse of the disease. We here present seven cases of umbilical endometriosis treated with radical surgery with a laparoscopically-assisted approach, with a complete and long-term disease-free follow-up. CASES: Seven cases of umbilical endometriosis, four of which relapsing from a prior superficial treatment, were treated radically with a laparoscopically-assisted approach, with a long-term disease-free follow-up. CONCLUSION: Although a medical treatment can be considered, the treatment of choice in these patients should be that of excisional surgery so as to avoid lesion relapse and the risk of oncogenic transformation. Despite umbilical endometriosis is a rare finding, this relatively small case series treated by laparoscopically-assisted omphalectomy shows a complete resolution of the lesion and symptoms along with good aesthetic results at a long-term follow-up.

The unicornuate uterus with an occult adenomyotic rudimentary horn.

We report 2 case of an atypical variant of unicornuate uterus in 2 adolescent patients with severe dysmenorrhea. Pelvic ultrasonography and magnetic resonance imaging identified a normal uterine contour. On the right side within the uterine fundus, a nodule was detected with a small hypoechogenic content. At laparoscopy the uterus and adnexae appeared to be normal. No endometriotic lesions were identified. Hysteroscopy identified a single regular cervical canal and a uterine cavity resembling that of a left unicornuate uterus, with a single regular left tubal ostium. Complete resection of the right uterine nodule along with an ipsilateral salpingectomy was performed. The nodule contained a small endometrial cavity and hematometra. Histologic study showed a cavitated adenomyotic uterine rudiment. The patients were discharged on the second postoperative day. No intraoperative or postoperative complications or recurrence of pelvic pain occurred.

Laparoscopic findings and pelvic anatomy in Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To describe analytically the anatomic variety and laparoscopic findings observed in patients with Rokitansky syndrome throughout an 11-year span. METHODS: We analyzed the laparoscopic and chart records of 106 consecutive patients who underwent surgery for the creation of a neovagina, according to the modified laparoscopic Vecchietti procedure. RESULTS: A hypoplastic vagina was observed in 61 women. Müllerian remnants, laterally displaced in the pelvis, were identified in 92 cases; 42 (25.9%, 95% confidence interval [CI] 19.2-33.3) of 162 müllerian remnants were cavitated and contained endometrial mucosa. Ovaries were extrapelvic in 17 (16.0%, 95% CI 9.6-24.4) cases. Anomalies of the urinary tract were identified in 32 (30.2%, 95% CI 21.7-39.9) patients; unilateral renal agenesis was the most frequent finding (18 cases; 18%, 95%CI 10.4-25.5). CONCLUSION: Rokitansky syndrome has a wide variability of anatomic presentations, and, as the do other congenital anomalies of the female genital tract, it represents a continuum of embryonic malformations, which occur at different stages of development.