Uterus-preserving reconstruction for müllerian duct anomalies: Five-year experience and outcomes of a novel low-cost cervico-vaginoplasty technique in a resource-limited setting.

Abstract

Objective: To evaluate the feasibility and outcomes of three tailored surgical approaches for restoring menstrual outflow and fertility. Study Design: Prospective Cross-sectional. Setting: Bahawal Victoria Hospital, Bahawalpur, Pakistan. Period: January 2020 to December 2024. Methods: Thirty patients with congenital cervical and/or vaginal outflow tract obstruction (cervical agenesis, cervico-vaginal agenesis, and OHVIRA syndrome) were included. Three surgical strategies were used according to anatomy: (1) an abdominoperineal cervico-vaginoplasty with McIndoe neovagina and finger-guided uterovaginal anastomosis, (2) ultrasound-guided transvaginal creation of a neo-cervical canal, and (3) a purely vaginal septal excision approach for OHVIRA syndrome. A silicone intrauterine catheter and a low-cost syringe-based vaginal mould were used to maintain patency. Primary outcomes included restoration of menstruation, canal patency, complications, and fertility outcomes. Results: Complete cervical agenesis was identified in 40%, partial cervical agenesis in 20%, and combined partial cervical and partial vaginal agenesis in 23.3%. Twenty-three patients underwent abdominoperineal cervico-vaginoplasty, three underwent ultrasound-guided canal creation, and four underwent vaginal septal resection for OHVIRA. Of the 20 patients undergoing primary reconstruction, two (10%) developed restenosis, which was corrected successfully in both cases. Among the ten patients with prior failed surgeries, two required a hysterectomy. Menstrual restoration occurred in 27 patients (90%). Four patients had OHVIRA syndrome; three conceived spontaneously, including one remarkable case of twin gestation with one fetus in each uterus delivered by elective cesarean after dual cerclage. Four patients achieved spontaneous conception, with healthy live births. Conclusion: Tailored uterus-preserving reconstructive surgery using abdominoperineal, ultrasound-guided, and vaginal approaches, supported by a low-cost stenting (silicone catheter) and mould system, is safe and effective for complex Müllerian anomalies, even in resource-limited settings.