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Outcomes in patients undergoing robotic reconstructive uterovaginal anastomosis of congenital cervical and vaginal atresia

Abstract Objective To introduce our experience of robotic surgery of reconstructive uterovaginal anastomosis and operative outcomes in congenital cervical and vaginal atresia patients. Methods Clinical observation and follow‐up of four patients with congenital cervical and vaginal atresia who underwent robotic reconstruction of cervix and vagina by SIS (small intestinal submucosa, SIS) graft. Results Average patient age was 13.8 ± 2.2. Patients complained of severe periodic abdominal pain. Diagnosis was made according to clinical characteristics, physical examination, MRI and classified by ESHRE/ESGE system. All patients underwent reconstruction of cervix and vagina by uterovaginal anastomosis by SIS graft. Average operation time was 232.5 ± 89.2 min, average blood loss was 225.0 ± 95.7 mL. After surgery, all patients have regular menstruation without pain. Average follow up was 12 months, average vagina length was 8.9 ± 0.3 cm, average vagina width was 2.9 ± 0.1 cm. Conclusion Robotic assisted reconstruction of cervix and vagina is feasible from our experience, enlarged cases and additional studies are required.


| INTRODUCTION
Congenital cervical atresia including cervical agenesis and cervical dysgenesis 1 is a rare Mullerian abnormality of the female reproductive tract, first reported by Ludwig in 1900. 2 The incidence is about one in every 80 000 to 100 000 births. 3 It is known to be associated with both partial and complete vaginal aplasia and renal anomalies. 4 It is defined as absent or aplasia of the cervix and characterized either by the absolute absence of any cervical tissue or by the presence of severely defected cervical tissue such as cervical cord or cervical fragmentation. 5 It will cause significant morbidity and mortality, if not diagnosed and definitively treated early.
The diagnosis was made according to clinical symptom and sign, such as amenorrhea, cyclical abdominal pain and pelvic hematometra.
Ultrasound and MRI (magnetic resonance imaging) are the two most important examinations for diagnosis. Different diagnosis include high transverse vaginal septum and imperforate hymen.
There are several classifications of cervical atresia, including the Buttram classification, 6 the American Fertility Society Classification of Mullerian Anomalies, 7 Rock. Congenital uterine cervical anomalies, 8 and ESHRE/ESGE classification. 5 The etiology of the disease is not very clear. have been reported for some uterine anomalies, it is generally accepted that uterine anomalies result from a polygenic mechanism. 9 The management of cervical atresia remains controversial because there are no guideline nor carefully designed cohort or randomized trials to support a best surgical practice. Until today, total hysterectomy still offers numerous benefits and is supported as a treatment option by several authors. Uterovaginal anastomosis is the restoration of the genital tract by direct suturing of the isthmus uteri to the vagina. It offers an alternative for patients to maintain menstruation. However, the experience from reconstructive uterovaginal anastomosis is limited. Here, we report four cases of cervical atresia of ESHRE/ESGE classification C4V4 who underwent reconstructive uterovaginal anastomosis with SIS (small intestinal submucosa, SIS) graft by robotic surgery. The purpose of this particular paper is to review the surgical approach in four patients with cervical-vaginal agenesis, and to analyze their operative outcomes after 12 months.   established with a closed Veress needle insertion, just above the umbilicus. A 12 mm port was placed 4 cm above the umbilicus for insertion of the robotic videolaparoscope. Two 8 mm robotic trocars were placed bilaterally on the anterior line axillary, 2 cm above the umbilicus. An ancillary 5 mm trocar was placed in the left 8 cm away from the videolaparoscope trocars and the other 12 mm trocar was placed 1 cm above the anterior superior spine point, these two trocars were used by the assistant surgeon. A 30-degree camera was used for the entire procedure.

| Surgical procedures
After docking, the primary surgeon controlled the robot from the console. We use monopolar scissors with Arm 1 on the right side of the patient and bipolar forceps with Arm 2 on the left side. Power setting of about 30 w with either cutting or cautery was used. Vessels smaller than 3 mm were coagulated using monopalar scissors, and bipolar forceps were used with larger vessels.
First, we check out the whole pelvis, because of the obstacle of the low segment of the uterus, all four patients had adhesion and endometriosis. We used the monopolar scissor and bipolar forceps to separate the adhesion and exposed the uterus, ovaries and fallopians.

| RESULTS
All four patients recovered well and reserved their uterus after robotic surgery without any complication. Average operation time was 232.5 AE 89.2 min, average blood loss was 225.0 AE 95.7 mL (Table 1).
Hospital days after surgery were 10 AE 1.4. After surgery, all patients have regular menstruation without periodic pain. Average follow-up was 12 months, average vagina length was 8.9 AE 0.3 cm, vagina width was 2.9 AE 0.1 cm (Table 2). There was no re-admission. is the diagnostic gold standard. 10 Here, we agree the decision to include all variants of cervical dysgenesis in sub-class C4 as was made by the ESHRE/ESGE classification 5 to avoid an extremely extensive sub-classification, which does not seem to be user friendly.
We recommend early operation as the management of the disease. As early diagnosis and surgery is necessary to prevent endometriosis among patients with congenital cervical atresia 11  Uterovaginal anastomosis can be performed by laparotomy, laparoscopy and robotics. As minimally invasive surgery is important for patients, especially for younger patients, laparoscopic or robotic surgery may be more favorable. The disadvantages of the laparoscopic approach include two-dimensional vision, dependence on assistance skill, decreased range of motion and the degrees of freedom of the instruments. The incorporation of robotics brings unique benefits to surgery, including intraoperative wrist-like motion of the robotic arms, which provides finer and more dexterous movements to perform a delicate dissection and suture. 15 We recommend moving the trocars up in order to make a spacious cavity to perform surgery as most patients were teenagers. surgery. 17 After that, favorable pregnancy outcomes were described   18,19 The surgery of cervico-vaginal anastomosis can provide patients with chances of spontaneous pregnancies. And before pregnancy and delivery, there are some potential obstetric complications patients must be counseled on, such as abortion, preterm delivery, cesarean section, uterine rupture, etc. In our study, all four patients were teenagers and we still need to follow-up their pregnancy outcomes.

| CONCLUSIONS
Our study found that cervical atresia might be successfully treated by uterovaginal anastomosis under robotics. We recommend the ESHRE/ESGE classification of cervical-vaginal abnormalities.
With appropriate evaluation and individualized management, we believe that a successful treatment and pregnancy outcome might be achieved.

CONFLICT OF INTEREST
None.