先天性宫颈闭锁分型手术治疗方法

<正>子宫以解剖学内口为界分为子宫体和宫颈两部分,宫颈又以组织学内口为界分为子宫峡部和宫颈管。根据发生学原理,在排除了由于副中肾管发育不良形成Mayer-Rokitansky-Kunster-Hauser(MRKH)综合征中伴有痕迹子宫发育而形成的无宫颈病例,我们把宫颈发育异常分为宫颈闭锁与宫颈功能不全两种类型。本文结合对宫颈闭锁畸形特征的研究,讨论其手术治疗方法。     

先天性阴道闭锁3例分型分析

有学者将先天性阴道闭锁分为两型:Ⅰ型系阴道下段闭锁,其阴道上段及子宫正常;Ⅱ型系阴道完全闭锁,多合并宫颈发育不良,子宫体正常或畸形,子宫内膜可有正常分泌功能[1,2].1984年3月至2009年3月我院收治29例先天性宫颈闭锁患者中,26例合并阴道完全闭锁,1例合并阴道上段闭锁,2例合并阴道顶端闭锁,后两种3例皆属未分型的阴道闭锁.现将阴道上段闭锁续作为Ⅲ型阴道闭锁、阴道顶端闭锁续作为Ⅳ型阴道闭锁,报告分析如下.     

Ⅱ型阴道闭锁一例并文献复习

先天性阴道闭锁（congenital atresia of vagina）是由泌尿生殖窦及苗勒管末端发育异常而未形成贯通的阴道所致,发病率较低。阴道完全闭锁也称为Ⅱ型阴道闭锁,多合并宫颈的发育不良,子宫体发育不良或子宫畸形,在临床上更为罕见。本文对2018年10月吉林大学第二医院妇产科收治后又转诊至北京协和医院的1例Ⅱ型阴道闭锁病例进行临床分析并复习相关文献,总结目前国内外诊断、分型和治疗的进展,以期医生能更好地认识这种生殖道畸形,患者得到个体化治疗,实现更佳预后。     

宫颈发育异常的手术处理原则及方法

<正>宫颈发育异常是较罕见的苗勒管畸形,是苗勒管垂直融合异常的一种畸形,宫颈发育异常分为宫颈发育不良(dysgenisis or atresia,即宫颈闭锁)和先天性无宫颈(agenisis)两大类。宫颈闭锁分成3种亚型,即宫颈残迹、宫颈纤维索、宫颈管口闭塞。宫颈残迹是仅有部分宫颈组织发育,但并不形成圆柱体形的宫颈,也没有宫颈管和宫颈腺体;宫颈纤维索是在子宫下方     

子宫局部解剖与剖宫产术

子宫是个肌性的空腔器官,其大小与年龄及孕次有关。青春期及绝经期子宫较小,生育期则较大;未产妇子宫较小、经产妇子宫较大。正常子宫腔长约7～9cm。一、子宫的解剖子宫分为体部与颈部。子宫颈以阴道附着部为界分成三个部分:包绕阴道穹窿部位的子宫颈为子宫颈阴道部;位于盆腔内的子宫颈部分为子宫颈阴道上部;二者中间部分为子宫颈中部。子宫颈阴道上部之上即为子宫峡部,也就是解剖学内口与组织学内口之间,子宫峡部之上为子宫体(图1)。     

应用脱细胞猪小肠黏膜下层移植物经腹腔镜联合阴式子宫阴道吻合术

<正>宫颈发育异常分为先天性无宫颈和宫颈闭锁两大类。宫颈闭锁包括宫颈残迹、宫颈纤维索、宫颈管口闭塞3种亚型。对宫颈闭锁特别是合并阴道发育异常的处理一直是临床上非常棘手的问题。考虑到宫颈成型术后的宫颈粘连、逆行性感染等情况,以往观念认为,宫颈发育异常的首选手术治疗方法是全子宫切除术。近年来随着新型材料和手术方法的发展,应用移植上皮作为支撑材料敷于成型的宫颈管腔,防     

阴道闭锁16例临床分析

目的　分析阴道闭锁的临床特点 ,探讨其分型在诊断与治疗中的意义。方法　回顾分析我院近 16年收治的 16例阴道闭锁患者的临床资料。阴道闭锁按解剖学特点分为两型 :Ⅰ型指阴道下段闭锁 ,10例 ;Ⅱ型指阴道完全闭锁 ,6例。结果　Ⅰ、Ⅱ型阴道闭锁平均发病年龄分别为(13 0± 1 1)岁及 (15 5± 3 4 )岁 ,盆腔包块直径分别为 (7 7± 3 0 )cm及 (5 3± 1 0 )cm ,两者比较 ,差异有极显著性 (P <0 0 1) ;平均病程分别为 (3 5± 2 4 )个月及 2 4 0个月 (中位数 )。Ⅰ型阴道闭锁者盆腔包块位置较低 ,而Ⅱ型阴道闭锁者盆腔包块较高或位于盆腔一侧。Ⅰ型阴道闭锁者均行切开术 ,术后置阴道模型 ,随诊 1～ 16 8个月 ,中位数为 2 1 0个月 ,月经均正常 ,其中 4例出现阴道狭窄行阴道扩张术。已婚的 2例中 ,1例足月妊娠剖宫产分娩。Ⅱ型阴道闭锁合并子宫内膜异位症 (内异症 )、输卵管积血、双子宫者各 1例 ,合并双子宫及内异症者 1例 ;3例行子宫切除术 ,3例行保守性手术即阴道成形、宫颈成形及阴道子宫接通术 ,仅 1例术后有月经但伴痛经 ,于术后 6年因内异症手术治疗。结论　Ⅰ型阴道闭锁手术效果好 ;Ⅱ型阴道闭锁多合并内异症或子宫畸形 ,保守性手术治疗效果较差。     

妊娠晚期子宫动脉和子宫下段解剖关系的初步探讨

目的探讨妊娠晚期子宫动脉及其分支与子宫下段的关系,为凶险性前置胎盘止血方案设计提供解剖学依据。方法选择2012年1月至2019年10月13例剖宫产患者,在完成手术的同时,对子宫动脉上、下行支与宫颈组织学内口的关系进行临床解剖学研究。结果 13例患者均清晰地显露宫颈组织学内口、子宫动脉主干及其上行支、输尿管盆腔段以及子宫动脉横跨输尿管处,仅2例显露子宫动脉下行支。13例中,4例子宫动脉于子宫侧缘宫颈组织学内口水平分为上、下行支;9例于宫颈组织学内口以下水平分为上、下行支。结论妊娠晚期子宫动脉在组织学内口或以下水平分为上行支和下行支,在组织学内口水平结扎双侧子宫动脉上行支为主的综合外科手术措施是治疗凶险性前置胎盘的有效方法。     

22卷1期疑难病案讨论选登

1诊断及诊断依据1.1诊断①中隔子宫;②左侧宫颈口闭锁,颈管及周围积液合并感染;③左肾缺如。1.2诊断依据根据子宫正常大小、宫底较宽,B超提示子宫横切有两个宫腔及两个宫颈管腔,左侧宫颈管下方囊性内有隔样回声与阴道壁囊肿相通考虑子宫不完全性中隔,左侧宫颈管口与阴道不通,其侧壁与右侧宫颈管相通开口位置偏离,使左侧宫腔的经血排出不畅,积聚在开口下方的宫颈管内,使颈管扩张形成侧穹隆顶部的囊肿,因囊肿内容物引流不畅合并感染破溃于阴道内,出现咖啡色及脓性分泌物。副中肾管发育异常造成生殖器官畸形,常合并有泌尿系统异常,临床常需影…     

经腹联合腔内三维超声对阴道斜隔综合征的诊断价值

目的探讨阴道斜隔综合征(OVSS)经腹联合腔内三维超声的特征,提高超声对OVSS的诊断准确率。方法回顾性分析42例手术证实OVSS患者的临床资料,并与手术结果对照分析。结果 42例OVSS患者中,左侧斜隔18例,右侧斜隔24例;Ⅰ型(无孔斜隔)12例、Ⅱ型(有孔斜隔)23例和Ⅲ型(无孔斜隔合并宫颈瘘管)7例。超声显示,42例患者均合并子宫畸形和斜隔侧肾脏缺如,其中双子宫37例,纵隔子宫4例,双角子宫1例;隔后腔积液39例,斜隔侧宫腔和宫颈管积液11例,斜隔侧输卵管积液7例,斜隔侧卵巢子宫内膜异位囊肿3例。经腹联合腔内三维超声诊断与手术结果符合率为100%(28/28),高于二维超声83.3%(35/42)。结论子宫畸形伴隔后腔积液及斜隔侧肾缺如为OVSS的声像图特征,经腹联合腔内三维超声对OVSS的诊断具有重要的临床价值。     

MRI features and differential diagnoses of congenital vaginal atresia

Objective: To investigate the MRI manifestations of congenital vaginal atresia, analyze its imaging features, and improve the understanding of the disease.

Methods: MRI findings and clinical data of 12 patients with congenital vaginal atresia confirmed by hysteroscopy and laparoscopic surgery were retrospectively analyzed. Vaginal atresia was classified according to vaginal dysplasia in AFS female genital malformation classification system.

Results: In this study, 12 cases of congenital vaginal atresia were diagnosed by combined preoperative MRI with operative diagnosis. Among them, 10 patients all had type-I congenital vaginal atresia, and their uterus and cervix were normal (1 patient had ectopic renal malformation combined with left ovarian endometriosis cyst and 1 patient with uterine empyema). The other two cases were diagnosed congenital vaginal atresia type II (1 case merged with residual uterus, 1 case with cervical dysplasia). MRI mainly manifested as dilatation and hemorrhage in the uterine cavity, cervical canal and vaginal upper segment. T1WI showed high signal, T2WI showed slightly lower and slightly higher signal. The dilated vagina was above the perineal level.

Conclusion: MRI features of congenital vaginal atresia have certain characteristics. MRI cannot only accurately assess the type of vaginal dysplasia and its associated complications, but also make objective evaluation and diagnosis, so it can be used as the best effective preoperative image evaluation.     

Uterine Avulsion: A Rare Cause of Cryptomenorrhea

BackgroundCryptomenorrhea at menarche is commonly due to mullerian duct anomalies. Uterine avulsion due to blunt pelvic trauma is a very rare cause of cryptomenorrhea. But so far no case of uterine avulsion has been reported due to a childhood trauma without pelvic fracture.CaseA 15-year-old young girl was evaluated for delayed menarche and the diagnosis of hematometra with obstruction at the level of internal cervical os was made on radiological examination. Detailed history revealed significant childhood blunt pelvic trauma when at the age of 3 years she was run over by a tractor. But the presence or absence of pelvic fracture was never documented as no radiographs were obtained. On abdominopelvic exploration cervix was well formed. Uterine body was found to be separated from the supravaginal cervix and there was a peritoneal window in between. During surgery hematometra was drained and the continuity of the uterine outflow tract was restored. Post surgery patient started having normal periods.Summary and ConclusionsThough very rare, uterine avulsion during pelvic trauma may cause cryptomenorrhea. Therefore such history should be sought in all cases of obstruction of the cervical canal because cryptomenorrhea has a much better prognosis than cervical congenital dysgenesis.     

Diagnosis and Surgical Treatment of Uterine Isthmus Atresia: A Case Report and Review of the Literature

Uterine isthmus atresia is a rare Müllerian duct anomaly occasionally diagnosed in adolescents with primary amenorrhea and cyclic abdominal pain. A case is presented of a 14-year-old female with monthly cyclic lower abdominal pain of a 2-year duration. Magnetic resonance imaging and 3-dimensional ultrasound showed separation of a 10-mm fibrotic tissue between the cervical canal and the endometrial cavity. In an attempt to preserve reproductive ability, an end-to-end anastomosis was laparoscopically performed between the cervical canal and uterine cavity. A platinol stent (WallFlex Biliary RX; Boston Scientific, Boston, MA) was placed by hysteroscopy to avoid stenosis after surgery. Laparoscopic end-to-end anastomosis is proposed to treat congenital uterine isthmus atresia.     

Complete uterine septum involving cervix with unilateral external cervical os stenosis: diagnosis and management

BackgroundCongenital external cervical os stenosis is a form of Mullerian duct abnormality which is rare in virginal adolescents.CasePre-operatively, two non-sexually active adolescents of 12 and 14 years of age, with history of light menses and severe lower abdominal pain for 2 and 4 months respectively, were diagnosed with an obstructed, oblique vaginal septum syndrome. However, at operative vaginoscopy, a single cervix with a duplicated cervical os and unilateral cervical stenosis was discovered, confirming the diagnosis of a complete uterine septum involving the cervix and unilateral cervical stenosis. They were treated by expanding the affected external cervical os while leaving the hymen intact. A year following the treatment, follow up results found no recurrence of symptoms.Summary and conclusionOperative vaginoscopy using a hysteroscope is crucial and recommended for the diagnosis and treatment of congenital external cervical os stenosis in virginal adolescents.     

Pitfalls in ultrasonic cervical length measurement for predicting preterm birth

OBJECTIVE: To describe the anatomic and technical difficulties encountered with transvaginal ultrasound imaging of the cervix in a consecutive series of women at risk for preterm delivery. METHODS: Three groups of women had cervical ultrasound examinations: those with histories of preterm birth, those with incompetent cervices, and those admitted for preterm labor that did not progress. Standardized ultrasound examinations of the cervix involved measuring the length of the endocervical canal, funneling length, and internal os dilation with and without fundal pressure. RESULTS: Sixty consecutive women had transvaginal ultrasound examinations for assessment of the cervix. Forty-six had histories of preterm birth, five had incompetent cervices, and nine had arrested preterm labor. Six types of problems arose, which can be divided into anatomic or technical considerations, with an overall frequency of 27% (95% confidence interval 16%, 40%). Anatomic pitfalls that hampered identification of the internal os included an undeveloped lower uterine segment (n = 5), a focal myometrial contraction (n = 1), rapid and spontaneous cervical change (n = 1), and an endocervical polyp (n = 1). Technical pitfalls included incorrect interpretation of internal os dilation because of vaginal probe orientation (n = 7) and artificial lengthening of the endocervical canal because of distortion of the cervix by the transducer (n = 1). CONCLUSION: We caution those who perform cervical length examinations to be wary of falsely reassuring findings due to potential anatomic and technical pitfalls.     

Congenital incompetence of the cervical os: reduction of bulging membranes with a modified Foley catheter.

A case is described of congenital incompetence of the cervix associated with pronounced bulging of the fetal membranes through the cervical os. The patient, a primigravida, presented at 25 weeks' gestation without any evidence of uterine activity. She had no past history of cervical surgery or disease. The tip beyond the bulb of a size 22 Foley catheter was removed. We inflated the bulb progressively while applying sustained, gentle pressure to the bag of forewaters. Upon reducing the membranes to within the uterine cavity, we inflated the bulb of the catheter further with saline to a total volume of 25 cc. This procedure maintained the catheter within the uterine cavity and facilitated the insertion of a MacDonald cerclage in the region of the internal cervical os.     

The clinical management of congenital absence of the uterine cervix

Eight women with cervical atresia were evaluated and treated for symptoms of pelvic pain. Two distinct anatomic variations of cervical atresia were observed among these patients. A fibrous cord, with islands of endocervical glands, was noted in two patients surgically treated with the creation of a cervico-vaginal fistula through the fibrous cord. Alternatively, a complete absence of the cervical stroma required a uterovaginal anastomosis in two women. One of the two women with the cervicovaginal fistula continues to menstruate. Both women, after the anastomosis, required additional surgery to maintain menstrual flow and ultimately received hysterectomy. Subsequently, four women with complete congenital absence of the cervical stroma were treated primarily with the removal of the uterine fundus. Although menstrual function may be maintained in patients with some cervical stroma, no pregnancies have occurred. Thus, removal of the uterine fundus remains the treatment of choice, relieving symptoms and avoiding additional surgery to maintain uterovaginal patency.     

Traumatic hypomenorrhea-amenorrhea (Asherman's syndrome)

Traumatic damage to the endometrium (corporeal adhesions) and/or to the cervical internal os (cervical stenosis or atresia) may cause hypomenorrhea-amenorrhea, the only sign of Asherman's syndrome. We demonstrated a close correlation between severity of menstrual insufficiency and extent of corporeal adhesions. Minor adhesions in the lower part of the uterine cavity, however, may cause severe hypomenorrhea, frequently complicated by dysmenorrhea. Secondary amenorrhea may be due either to complete obliteration of the uterine cavity or to stenosis or atresia of the internal os, as proved by radiologic studies. When amenorrhea is due to stenosis or atresia of the internal os, the ovarian cycle continues but the endometrium becomes refractory to horomonal stimuli, and hematometra does not occur. Simple cervical dilatation restores menstruation within 4 to 5 weeks. The menstrual insufficiency of Asherman's syndrome, therefore, may be explained by two pathophysiology mechanisms: (1) reduction of the endometrial bleeding area and (2) trophic changes and unresponsiveness of the endometrium, perhaps caused by a visceral reflex originating in the area of the internal os.     

Incidence of cyclical bleeding after laparoscopic supracervical hysterectomy

STUDY OBJECTIVE: The aim of the study was to estimate the incidence of cyclical bleeding after laparoscopic supracervical hysterectomy (LSH) when the uterus is amputated at or below the level of internal cervical os. DESIGN: Prospective series of consecutive patients (Canadian Task Force classification II-3). SETTING: Single surgery team, independent surgery center. PATIENTS: Women with symptomatic uterine leiomyomata, abnormal uterine bleeding, dysmenorrhea, or chronic pelvic pain. INTERVENTION: Laparoscopic supracervical hysterectomy (with concurrent bilateral salpingo-oophorectomy if required), along with laparoscopic biopsy sampling of the cervical stump. MEASUREMENTS AND MAIN RESULTS: From October 2002 through February 2004, we performed 67 consecutive LSH procedures. At the completion of uterine amputation, two biopsies were obtained from the cervix at 12 o'clock and 6 o'clock positions and submitted for histologic evaluation to identify the tissue type. We assumed the presence of endocervical tissue on cervical biopsy would indicate the uterine amputation took place at or below the level of internal os. All 67 patients were contacted 3- to 15-months postoperatively to inquire about bleeding status, and 64 (96%) responded. The overall bleeding incidence was 12/64 (19%). Among the subgroup with endocervical tissue on biopsy, 7/41 (17%) experienced cyclical bleeding. The continuous variables (i.e., age, body mass index [BMI], parity, uterine weight) and categorical variables (i.e., indications for surgery, status of endometriosis, adenomyosis, endocervical fulguration, cervical biopsy, history of cesarean section) were not statistically significant in association with the bleeding time. CONCLUSION: Our data suggest the overall incidence of post-LSH cyclical bleeding is 19%. When the uterus is amputated at or below the level of internal os, the incidence is 17%. To our knowledge, this is the first study in the medical literature to report on cyclical bleeding after LSH when the uterine amputation is demonstrated to have occurred at or below the level of internal cervical os.     

Verhinderung von Spätaborten und Frühgeburten

Operations at the uterine cervix to prevent miscarriages and preterm deliveries are based on two premises: (1) a cerclage can prevent premature opening of the cervix due to cervical incompetence and (2) operative occlusion of the cervical canal can prevent transcervical infections following incomplete narrowing of the internal os, insufficient mucous sealing of the cervix, or as a consequence of cervical lacerations. Cervical incompetence in the classic sense is an extremely rare finding. In women deemed to be at increased risk of cervical incompetence, cerclage was not found to prolong pregnancy significantly. It is still unclear whether cervical cerclage can improve outcomes of pregnancies in women with decreased cervical length or dilation of the internal os as detected by vaginal ultrasound. Indications and outcomes of the rare cervix occlusion operations have not as yet been studied in prospective randomized trials. In spite of this, some results suggest that women with a history of repeated miscarriages caused by ascending infections due to sealing deficits of the cervix may profit from an operation.