Service de Gynécologie-Obstétrique, CHI Créteil, 40 avenue de Verdun, 94010 Créteil, France
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Abstract |
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Key words: blind hemivagina/pregnancy outcome/renal agenesis/uterine malformation
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Introduction |
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Materials and methods |
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Symptoms at time of referral are outlined in Table I. Right blind hemivagina was found in 52% of patients. All patients underwent ultrasound examination of the kidneys or intravenous pyelography: an ipsilateral renal agenesis was found in all cases except for one patient who had normal kidneys and a didelphic uterus.
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Patients were examined 3 months later. Morphological results were obtained from medical records. To assess long-term reproductive performance the patients were asked by phone to complete a questionnaire; this occurred an average of 6.5 years after surgical procedure (range: 123 years). The questionnaire concerned dysmenorrhoea, vaginal discharge, dyspareunia and pregnancies, including their number and results (live birth, early termination, early spontaneous abortion and ectopic pregnancy), gestational age at delivery, mode of delivery and whether the pregnancy was ipsi- or contralateral to the obstructed hemivagina.
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Results |
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Thirty-eight patients (90%) answered the questionnaire. Dysmenorrhoea and abdominal pain were resolved in 87% (27/31) and 100% of cases, respectively. Vaginal discharge was noted in 16% of cases. Dyspareunia was resolved in both patients (Table I), and no new cases were noted after surgery.
With regard to reproductive performance, eight patients had not attempted intercourse, 19 did not wish to become pregnant, two had been trying for 6 and 12 months respectively to achieve pregnancy. Nine women who had undergone vaginal septum excision experienced 20 pregnancies after surgical procedure and the results are outlined in Table IV. Four women had 4 ipsilateral pregnancies after resection of vaginal septum. Two of them (with a didelphic and complete septate uterus) had vaginal deliveries after 37 weeks and two others (with didelphic uterus) had an early spontaneous abortion and an ectopic pregnancy. The five patients who underwent hemihysterectomy and ipsilateral hemicolpectomy did not achieve pregnancy.
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Discussion |
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Ipsilateral renal agenesis is prevalent since the development of the urinary system parallels that of the genital tract (Muller et al., 1967; Acien, 1992
). However, the presence of normal kidneys has been reported (Johnson and Hillman, 1986
) and we found a case of a normal urinary tract in our series. It has been reported that the right one is predominantly involved, occurring in 66% of cases (Rock and Jones, 1980
; Morgan et al., 1987
). However, our results did not confirm this, right and left sides being equally involved.
Clinical management of blind hemivagina must include renal imaging by ultrasonography or intravenous pyelography, both to confirm the absence of a normal kidney in the affected side and to detect abnormalities in the contralateral urinary tract (Stassart et al., 1992). Our series included a case of contralateral vesico-ureteral reflux with a normal kidney which necessitated surgical treatment. Assessment of uterine malformation by hysterosalpingography may not be beneficial (Acien, 1997
), though it may permit a communicating uterus to be diagnosed especially in patients with haematic vaginal discharge. Abdominal and endovaginal ultrasonography (Nasri et al., 1990
) and more recently three-dimensional ultrasound (Jurkovic et al., 1995
; Raga et al., 1996
) may contribute to the analysis of the external uterine shape. Magnetic resonance imaging may also be helpful to detect uterine anomalies (Mintz et al., 1987
; Pellerito et al., 1992
; Sardanelli et al., 1995
). However, these two latter techniques are expensive and do not change radically the management of this malformation. Laparoscopic exploration has the ability to assess the type of uterine malformation and reveal other complications in the upper genital tract which may require appropriate surgery. Early correct diagnosis will allow the appropriate surgical treatment to be performed in a single procedure, including laparoscopic exploration and resection of the vaginal septum. Incision of the septum followed by resection 23 months later (Morgan et al., 1987
) should be avoided as incision alone may lead to the development of haematocolpos or pyocolpos after a spontaneous closure. However, to avoid resection of normal vaginal tissue, particularly when the obstructed hemivagina reaches the hymeneal ring, a limited resectionmarsupialization (3 cm diameter) may be performed during an initial surgical procedure, allowing the remaining vaginal septum to be removed 1 month later. This was performed three times in this study, twice for haematocolpos and once for pyoclopos. In the second case of pycolpos, resection of vaginal septum was performed in one surgical procedure and was not affected by infected menstrual retention (Candiani et al., 1997
).
The obstetric outcome in our series was similar to other studies (Acien, 1993; Raga, 1997
). Pregnancies occurred mainly in the contralateral cavity (80%), although four patients had pregnancies in the affected side after surgical procedure. These latter findings confirm that, once the obstruction has been relieved, both the dilated uterus and its corresponding tube recover their normal function.
In conclusion, our results confirm that diagnosis of blind hemivagina should be made as early as possible to avoid genital complications which may necessitate aggressive surgical treatment. Resection of the vaginal septum preceded by laparoscopic exploration of the upper genital tract allows uterine anatomy and function to recover. Obstetric outcome after surgical treatment depends on the type of uterine malformation present.
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Notes |
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References |
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Submitted on December 30, 1998; accepted on April 9, 1999.