Robotic-assisted laparoscopic cervicouterine anastomosis in a patient with agenesis of the uterine isthmus

Abstract

Objective: To demonstrate the surgical management of agenesis of the uterine isthmus.

Design: Stepwise description of robotic-assisted laparoscopic cervicouterine anastomosis.

Setting: 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.

Keywords: Müllerian anomalies; isthmus agenesis; minimally invasive surgery; robotic surgery; uterine malformations.