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Successful Conservative Treatment in a Rare Case of Type 2 Congenital Cervical Dysgenesis: Case Report and Systematic Literature Review

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Successful Conservative Treatment in a Rare Case of Type 2 Congenital Cervical Dysgenesis: Case Report and Systematic Literature Review Obstet Gynecol Res 2020; 3 (2): 119-131 DOI: 10.26502/ogr036 Research Article Successful Conservative Treatment in a Rare Case of Type 2 Congenital Cervical Dysgenesis: Case Report and Systematic Literature Review Ursula Catena1,2, Ilaria Romito1,2*, Maria Cristina Moruzzi1,2, Ilaria De Blasis1,2, Antonia Carla Testa1,2, Giovanni Scambia1,2 1Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, Rome, Italy 2Catholic University of Sacred Heart, Rome, Italy *Corresponding Author: Dr. Romito Ilaria, Division of Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli, Catholic University of Sacred Heart, IRCCS, Rome 00168, Italy, Tel: +393924151114; E-mail: [email protected] Received: 12 April 2020; Accepted: 20 April 2020; Published: 29 April 2020 Citation: Ursula Catena, Ilaria Romito, Maria Cristina Moruzzi, Ilaria De Blasis, Antonia Carla Testa, Giovanni Scambia. Successful Conservative Treatment in a Rare Case of Type 2 Congenital Cervical Dysgenesis: Case Report and Systematic Literature Review. Obstetrics and Gynecology Research 3 (2020): 119-131. Abstract Objective: Providing a systematic review of type 2 articles published at the time we began our review up cervical dysgenesis (CD) by taking into consideration from inception to July 2019. an interesting and rare case of genital anomaly which was treated with the use of laparoscopic ultrasound Results: Three hundred thirty-four articles were guidance. identified, three hundred fifteen other articles were excluded for various reasons. Overall, nineteen articles Materials and Methods: A research of MEDLINE, were incorporated for further assessment. Three surgical EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, techniques were used to treat type 2 cervical dysgenesis: OVID and Cochrane Library was done. We analysed all drilling and coring technique (CDT), utero-vaginal types of study including case reports. We identified anastomosis (UVA) and hysterectomy (HRT) or hemi- hysterectomy (H-HRT). Recurrences (38%) were Obstetrics and Gynecology Research - Vol. 3 No. 2 – June 2020. 119 Obstet Gynecol Res 2020; 3 (2): 119-131 DOI: 10.26502/ogr036 described only with CDT. Five successful pregnancies it generally affects women during their childbearing were reported with the same technique. age, impairing fertility [2]. In the new ESHRE/ESGE classification, cervical anomaly is classified into 5 Conclusions: Type 2 cervical dysgenesis is a rare groups or classes: C0 (normal cervix), C1 (septate congenital malformation. Data about recurrence and cervix), C2 (double normal cervix), C3 (unilateral pregnancy rate are too sparse to recommend one cervical aplasia), and C4 (cervical aplasia) [3]. In technique rather than another. As shown in our another type of classification [4], this condition is comprehensive review, ultrasound-guided laparoscopy divided into 4 categories according to both the could represent a valid new surgical treatment approach. anatomical variants and the type of surgical treatment: type 1 cervical agenesis (CA) (characterized by the Keywords: CDT; UVA; Type 2 Cervical Dysgenesis complete absence of the cervix and no endocervical canal); type 2 cervical dysgenesis (CD) (characterized 1. Introduction by cervical obstruction with the cervix being well Cervical uterine anomalies are among the rarest uterine formed, but lacking an endocervical canal); type 3 congenital anomalies which can be observed in the cervical dysgenesis (characterized by cervical fibrous absence of the cervical canal or concomitantly with its cord whose diameter as well as the stroma nature may obstruction. Although the prevalence counts only vary); type 4 cervical dysgenesis (characterized by accounts for 3% of all uterine malformations and for cervical fragmentation with separation of the segments) 0.1% of the overall population [1], it is relevant because (Figure1) [5]. Legend: (1) Cervical agenesis type 1; (2) Cervical dysgenesis type 2; (3) Cervical dysgenesis type 3; (4) Cervical dysgenesis type 4 Figure 1: Cervical uterine anomalies [5]. Obstetrics and Gynecology Research - Vol. 3 No. 2– June 2020. 120 Obstet Gynecol Res 2020; 3 (2): 119-131 DOI: 10.26502/ogr036 The treatment remains controversial and depends on the 2. Case Report: CDT under Laparoscopic symptoms as well as on the type of malformation. Ultrasound Guidance in a Patient with Particularly, for type 2 CD, three different surgical Bicorporeal Uterus and Type 2 Right Cervical techniques have been proposed: first, coring and drilling Dysgenesis technique (CDT), consisting in opening the cervical We described a case of a 30-year-old nulligravida canal and draining the content; second, utero-vaginal woman, with irregular menstrual cycles. She was anastomosis (UVA), consisting in the anastomosis of referred to our gynaecological department for chronic the section between the vagina and the endometrium; pelvic pain and dysmenorrhea. The patient had a third, hysterectomy (HRT) or hemi-hysterectomy (H- bicorporeal uterus with unilateral type 2 CD. Pre- HRT) [5]. Although the first two techniques try to operative ultrasonographic evaluation revealed a restore and preserve the patient’s fertility, a consensus bicorporeal uterus, with double cervical canal, on which technique is the best has not yet been reached, hematotrachelos content in the right cervical canal, also because of the rarity of the condition and the consisting in an imperforated right cervix (Figure 2). difficulties in RCT setting. Indeed, only case reports Laparoscopy was performed in lithotomic position, after have been published until now, with a high rate of a 10-mm trocar insertion in the umbilicus. Two 5-mm complications, recurrence of the symptoms after the first ancillary trocars were introduced in the lower abdomen. treatment, and often without any reference on the Continuous CO2 pneumoperitoneum was induced reproductive outcome [6-8]. In the last few decades, a keeping an intra-abdominal pressure below 12 mmHg. new approach for the treatment of uterine pathologies A 0° optic was introduced in the umbilical 10-mm has started to be used which consists in the use of a trocar. Laparoscopy showed a IV stage endometriosis laparoscopic ultrasound probe (IUOS) to guide with nodules on the diaphragmatic peritoneum. In the gynaecological conservative procedures. The probe, pelvis, two hemi-uteruses were attached posteriorly to within the abdominal cavity, is in direct contact with the the rectum. The right ovary and fallopian tube were sections to be treated thus avoiding the potential source adherent and entrapped in a peritoneal pseudocyst. The of interference as abdominal wall or vaginal wall [9]. pseudocyst contained fluid, which was removed. The This new innovative method was applied for endoscopic right fallopian tube appeared swollen and hydropic and surgery in different conditions (myomas, uterine was therefore removed. A second 10mm-suprapubic septum, cervical cancer) and seemed to be promising trocar was positioned to enter with a Canon Aplio i800 and accurate in the treatment of other gynaecological ultrasound machine, and a laparoscopic probe covered diseases [10, 11]. For this reason, it could be used for with a sterile cover. The probe was inserted in the 10 the treatment of cervical uterine anomalies where a mm suprapubic trocar, angled 90° and positioned in more meticulous approach needs be employed [12]. direct contact with the peritoneum between the bladder Therefore, this systematic review sets out to analyse the and the uterus (Figure 3). The surgeon used efficacy and the fertility outcomes of different surgical vaginoscopic approach, with a 5-mm diameter techniques in the treatment of type 2 CD as well as to continuous-flow oval profile hysteroscope, a 30° fore- show the treatment of the rare type 2 CD case with the oblique telescope and a 5 Fr operating channel (Office use of IUOS. Continuous Flow Operative Hysteroscopy ‘size 5’; Karl Obstetrics and Gynecology Research - Vol. 3 No. 2– June 2020. 121 Obstet Gynecol Res 2020; 3 (2): 119-131 DOI: 10.26502/ogr036 Storz, Tuttlingen, Germany). Saline solution (NaCl drain the hematotrachelos (Figure 5). The right uterine 0.9%) was used as a means of distension infused by way hemi-cavity was entered from this right cervical canal of an electronic irrigation and aspiration system and a single tubal ostium was visualized (Figure 5). (Endomat; Karl Storz, Tuttlingen, Germany). A stable Cervical canal biopsy showed the presence of intrauterine pressure of about 40 mmHg was obtained. endocervical mucosa. No ectocervical mucosa was The hysteroscopic view showed a single external identified. A 10 Fr catheter was placed in the right cervical os with a regular cervix on the left side. A left hemi-cavity to keep the walls outstretched thus avoiding hemi-cavity with a single fallopian tube ostium was postoperative adhesions and possible right cervical found during the left cervical canal examination (Figure canal reclosure. The Foley catheter was maintained 4). The right external cervical os was not visible. inside the right hemi-cavity for 30 days. At day 31, Therefore, we used the laparoscopic ultrasound probe during post-operative follow-up, transvaginal that revealed a right uterine cavity connected to a ultrasonographic evaluation revealed a bicorporeal cervical canal filled with haemorrhagic material. The uterus with double normal endometrial cavity and two surgeon used a Collins speculum to open the walls of normal cervical canals (Figure 6).
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