The uterus was divided into two parts, the uterine body and the cervix, by the anatomical internal opening, and the cervix was further divided into the isthmus and the cervical canal by the histological internal opening. According to the principles of genesis, after excluding cases of absence of cervix formed due to paramedian duct hypoplasia with traces of uterine development in Mayer-Rokitansky-Kunster-Hauser (MRKH) syndrome, cervical developmental abnormalities are divided into two types: cervical atresia and cervical insufficiency. This article discusses the surgical treatment of cervical atresia malformations in the context of a study of their characteristics.
I. Characteristics of cervical atresia malformation and surgical treatment options.
Based on the systematic study of the anatomical and pathological features of congenital cervical atresia cases, we proposed the diagnostic criteria for cervical atresia typing based on the theory of embryonic development and the experimentally confirmed hypothesis of female reproductive tract development, combined with the international classification of cervical developmental anomalies, namely: Type I is normal isthmus type: atresia at the histological endoplasm of the uterus, above which the isthmus and the anatomical endoplasm of the uterus develop Type II is atresia of the isthmus: atresia of the isthmus between the anatomical and histological endografts of the uterus, absence of the cervical canal, mostly accompanied by hypoplasia of the uterine body; Type III is complete atresia of the cervix: atresia of the isthmus and cervical canal below the anatomical endografts of the uterus, with different lengths, diameters and shapes of the atretic cervix, mostly accompanied by hypoplasia of the uterine body; Type IV is atresia of the uterus Absent type: the lower end of the uterine body is directly connected to the cervical canal which is blinded, the anatomical internal opening of the uterus is not obvious, and the isthmus is absent.
According to the diagnostic criteria for cervical atresia, the surgical treatment plan for cervical atresia is as follows: for type I cervical atresia, the isthmus of the atretic uterus is an enlarged cystic cavity with blood accumulation, and the wall of the cyst is myxomatous tissue about 6 mm thick. Intermittent sutures are placed on the epithelial margin of the vaginal wall, so that the cervical canal wall is smooth after shaping, and no uterine tube is needed to prevent adhesions after surgery. In type II and III patients, it is difficult to open the atretic segment of the cervix because it is long and tough, and even if it is opened, it will be re-atretic, so the uterus should be removed and vaginoplasty should be performed before marriage. In type IV patients, since there is no isthmus, the lower part of the uterus cannot be formed during pregnancy, resulting in infertility, whether or not to preserve the uterus can be based on the opinion of the affected party; if the uterus is preserved, all the traumatic surfaces from the built-in tube of the cervical canal to the ectocervix must be epithelialized, and attention should be paid to contraception in the future.
The relationship between cervical atresia and vaginal atresia.
A pair of paramedian tubes develops into the fallopian tubes, the body of the uterus, the cervix and the upper part of the vagina, and the urogenital sinuses develop to form the lower part of the vagina and the external genitalia. Vaginal atresia is closely related to the developmental disorder of bilateral fusion of the paramedian ducts, mostly accompanied by cervical atresia, where the endometrium may have normal secretory function, and cervical atresia is caused by defects in the developmental process of vertical or lateral fusion and resorption of the paramedian ducts. To solve the problem of cervical atresia treatment, it is necessary to clarify the malformed features of vaginal atresia and its relationship with cervical atresia. In 2002, Peking Union Medical College Hospital classified congenital vaginal atresia into two types: Type I: vaginal atresia in the lower part of the vagina with normal development of the upper part of the vagina and uterus; Type II: vaginal atresia in combination with cervical atresia, with normal or malformed development of the uterine body and normal endometrial secretion. In clinical work, cases of superior vaginal atresia and apical vaginal atresia have been found, which are untyped cases of vaginal atresia. Based on the study of these new cases, we have added and improved the above typing, and further clarified the relationship between cervical atresia and vaginal atresia: all cases of cervical atresia are combined with vaginal atresia; all cases of vaginal atresia, except type I, are also combined with cervical atresia. Among the cases identified so far: type II vaginal atresia, combined with each type of cervical atresia; type III vaginal atresia, combined with type III cervical atresia; type IV vaginal atresia, combined with type I and IV cervical atresia or combined with primordial uterus. In cases of type II, III, and IV vaginal atresia combined with cervical atresia, the decision of uterus removal and timing of vaginoplasty can be made based on the fractal diagnosis of cervical atresia.
III. Surgical treatment plan for cervical atresia.
Because cervical atresia is combined with vaginal atresia, treatment must first open the atretic vagina and then the blind end of the atretic cervix, and then anastomose the two. There are three cases of vaginal atresia combined with cervical atresia, which require separate surgical treatment plans: (1) complete vaginal atresia: for type I cervical atresia, an artificial vagina and cervicoplasty should be performed via the perineal route; for type II and III cervical atresia, a hysterectomy should be performed first, followed by an artificial vaginoplasty 3-6 months before marriage; for type IV cervical atresia, an artificial vaginoplasty can be performed according to the affected party’s In cases of combined type IV cervical atresia, either a combined vaginal and cervicoplasty with abdominal perineum or a hysterectomy should be performed first, followed by vaginoplasty 3-6 months before marriage. (2) Superior vaginal atresia: In combination with type III cervical atresia, hysterectomy and superior vaginoplasty should be performed. (3) Apical vaginal atresia: Transvaginal cervicoplasty should be performed for combined type I cervical atresia; for combined type IV cervical atresia, transvaginal cervicoplasty or hysterectomy should be performed according to the patient’s opinion. Therefore, patients with impaired menstrual discharge and backflow of menstrual blood should be operated for a limited period of time, and laparoscopic exploration should be performed to deal with pelvic lesions.
IV. Artificial vagina and cervicoplasty.
For type I with complete vaginal atresia and type IV with cervical atresia that requires preservation of the uterus, a more difficult procedure, vaginal and cervicoplasty, is required. The artificial vagina and cervicoplasty are distinguished by the artificial vaginal wall graft material. In 25 cases of type I cervical atresia combined with type II vaginal atresia, we designed and successfully performed local flap mesh grafting of the vulva and peritoneal grafting of the vagina and cervicoplasty according to their pelvic conditions and vulvar anatomy. All of them were dysmenorrhea-free within six months after surgery, and 18 cases were followed up for more than six months. 6 of the 8 married cases had 9 spontaneous pregnancies, 3 female and 4 male babies were delivered by cesarean section, and 1 case had 2 spontaneous abortions in early pregnancy. A brief description is as follows.
For patients with obvious hymen expansion, choose the vaginal vestibular mucosa advancement grafting method; for patients with hymen expansion but the free flap cannot form a certain depth of vagina, choose the vaginal vestibular mucosa combined with local pubic-femoral flap rotation grafting method; for patients with small vaginal vestibular development and no hymen expansion, choose the local pubic-femoral flap rotation grafting method; for patients with better labia minora development, choose the For those who have a hymen with bulging hymen and well-developed labia minora, the vaginal vestibule mucosa combined with partial labia minora flap grafting; for those who have well-developed labia minora but still cannot form a certain depth of vagina with free flap, the partial labia minora flap combined with partial labia femoral flap rotational grafting; for those who have pelvic lesions requiring abdominal dissection, the free wall layer at the abdominal incision can be chosen Peritoneal mesh grafting method.
2.Introduction of surgical style.
(1) Vaginal vestibular mucosa advancement grafting method: a shallow inverted arc incision 4~125px long is made in the center of the hymenal bulge, and the vaginal vestibular mucosa is freed, reaching the suburethral groove in front, the base of the labia minora laterally, and about 1 cm below the labial tether posteriorly, and several small longitudinal incisions 0.5~25px long are made on it (reticuloplasty). The vaginostomy reaches the blind end of the uterine cervix, and a puncture needle is used to guide the stoma from the middle of the vagina (a 1-finger loosening is sufficient) and drain the accumulated blood, and the mucosal margin of the vestibule is interrupted with 5-8 stitches corresponding to the mucosal margin of the uterine cervix. The free vestibular mucosa is slid inward along the wall of the vaginal cavity by applying pressure on the cervix, and a vaginal model with a central hole covered with petroleum jelly gauze is inserted. A catheter is left in place, covered with vulva gauze and secured with a “d” tape. Postoperatively, it is supplemented with top pressure.
(2) Vaginal vestibular mucosa combined with local pubic-femoral flap rotation grafting method: an inverted curved incision is made from 25px below the level of the urethra, along the medial base of the labia minora down to the labial ligament, and the mucosa between them is freed and reticuloplasty is performed. The vaginal cavity is created and the blind end of the cervix is opened to drain the accumulated blood. From the middle of the external vaginal opening, the flaps are curved upward and then downward, and each of the bilateral pubofemoral flaps is freed at approximately 125 px × 75 px (the lower external incision is not cut at approximately 37.5 px from the external vaginal opening to maintain the blood supply), and the medial edges of the flaps are closed with interrupted sutures and reticuloplasty. The vestibular mucosal flap and the pubofemoral flap were grafted onto the anterior and lateral posterior vaginal walls, respectively, with the apical wound edges sutured to the cervical wound edges, and the wound edges on both sides of the vaginal wall graft were intermittently sutured to form a cylinder and placed into the vaginal model. The pubofemoral skin wound is sutured, and the exposed wound edge of the pubofemoral flap is intermittently sutured to the wound edge of the vaginal opening.
(3) Local femoral flap rotation grafting method: An inverted arc-shaped incision is made in the vestibule at the level of the middle of the hymen, along the base of the labia minora, and the bottom of the arc reaches the labial ligament, and the vaginal cavity is created and the blind end of the cervix is opened to drain the accumulated blood. A partial pubofemoral flap of approximately 175px×4cm was freed and reticulated, and the medial edges of both flaps were sutured intermittently. The top of the pubofemoral flap was interrupted with the cervical margin, and the lateral edges of the flap were interrupted with sutures to form a cylinder and placed in the vaginal mold. The outer flap margin is interrupted and sutured to the vaginal opening margin.
(4) Partial labia minora flap grafting method: The vaginal cavity is created and the blind end of the cervix is opened to drain the accumulated blood. The folded part of the free labia minora is dissected and reticulated, and the medial edge is intermittently sutured at about 175 px, and the upper traumatic edge of the flap is intermittently sutured with the traumatic edge of the cervix. The labia minora flap was then interrupted and sutured into a cylinder and placed into the vaginal model. The outer flap margin was interrupted with the vaginal opening margin. The top of the residual labia minora was pulled down and sutured to both sides of the vaginal opening.
(5) Vaginal vestibular mucosa combined with partial labia minora flap grafting: the vestibular mucosa flap and labia minora flap are freed, the vaginal cavity is created and the blind end of the cervix is opened to drain the accumulated blood, the labia minora flap is grafted on the lateral posterior wall and part of the anterior wall of the vagina, the vestibular mucosa flap is grafted on the lower part of the anterior wall of the vagina, the apical trabecular edge of the flap is sutured to the trabecular edge of the cervix, and then the flap is sutured into a tube shape and placed in the vaginal model. The labia minora formation was completed by the same method as above.
(6) Partial labia minora flap combined with local pubic-femoral flap rotation grafting method: vaginal cavity creation and opening the blind end of the cervix to drain the accumulated blood. The partial labia minora flap and femoral flap were free in the same way as before, and after mesh shaping, they were intermittently sutured into a cylinder shape and transplanted into the vaginal cavity wall, and the apical wound edge was intermittently sutured with the cervical wound edge and placed into the vaginal model.
(7) Free peritoneal mesh grafting method: After vaginal cavity creation, the peritoneum is freed from the wall at the incision of the dissection, and the vaginal cavity wall is grafted after mesh shaping, with the apical end anastomosed to the cervical incision and placed in the vaginal model, and the end sutured to the vaginal vestibule mucosal margin.
The advantages of this type of surgery are: (1) the blood supply and nerves of the grafted epithelium are preserved, which is easy to transplant successfully and has good sensory function (except for the peritoneal method); (2) the grafted epithelium is reticuloplasty, i.e., some small openings of 0.5-1 cm in length are cut on the grafted flap, and the area is enlarged by pulling open the fissures before transplantation, so that the limited tissue can be utilized to the maximum. The flap can cover the whole artificial vaginal cavity wall with a depth of more than 225px and a capacity of 2 fingers, and the vaginal formation is completed at once. If the flap still cannot reach a certain depth through mesh shaping, the postoperative period will be supplemented by compression method to make the vagina reach a satisfactory depth before entering the scar contracture period (about 15 d after surgery); (3), the mesh after epithelial mesh shaping is conducive to the drainage of exudate from the traumatized surface of the recipient skin on the one hand, and the implantation of mucosal epithelium shed from the vestibule on the other hand, which can complete the epithelialization of the vagina earlier and has good moistening. (4) The epithelium and the wound can heal and grow faster, and the time for the first change of the vaginal model can be shortened to 3 days after surgery, so that the catheter can be removed and the patient can get out of bed earlier and recover quickly (the vaginal model must be changed for the first time 8~9 days after surgery for the peritoneal method). The disadvantage is that individual patients must apply the compression method in time after surgery and need to wear a vaginal model until they have a normal sexual life after marriage. In addition, for those who take local pubofemoral flap rotation graft, there is a scar on the vulva, but the damage to the patient and the postoperative scar are significantly smaller than the traditional pubofemoral flap grafting method.