Innovative Laparoscopic Uterus-Preserving Surgery for Cervicovaginal Agenesis with Functional Uterine Remnants

Highlight

• A novel uterus-preserving laparoscopic technique integrates peritoneal pull-down neovaginoplasty with catheter-guided uterovaginal anastomosis for cervicovaginal agenesis with functional uterine remnants.
• Menstrual drainage was successfully restored in all seven patients, with patency confirmed by hysteroscopy and no major intraoperative complications.
• Long-term functional uterine capabilities, such as fertility and safe pregnancy outcomes, remain uncertain due to limited data and occurrences of pelvic inflammatory disease.

Study Background

Cervicovaginal agenesis is a rare congenital Müllerian anomaly characterized by the absence of the cervix and vagina, often with functional uterine remnants. This condition results in obstructed menstrual outflow, leading to complications like haematometra, haematosalpinx, severe pelvic pain, and endometriosis. The rarity and anatomical complexity of this anomaly pose significant surgical and clinical challenges, particularly regarding uterine drainage and maintenance of fertility potential.

Traditional management ranges from hysterectomy to complex reconstructive surgeries aimed at creating a functional neovagina and establishing uterine drainage. However, uterus-preserving approaches remain controversial due to technical difficulty and uncertain reproductive outcomes. This study seeks to advance surgical management by describing a laparoscopic technique that aims to preserve the uterus while effectively relieving obstruction.

Study Design

This was a prospective case series involving seven patients diagnosed with cervicovaginal agenesis possessing functional uterine remnants, treated between 2019 and 2024. The intervention involved a uterus-preserving laparoscopic reconstruction, consisting of:

• Careful laparoscopic vesicorectal dissection to delineate anatomy.
• Peritoneal pull-down technique to create a neovagina using peritoneal tissue.
• Opening and drainage of the obstructed uterine remnants.
• Insertion of an intrauterine Foley catheter to maintain intrauterine patency.
• Circumferential laparoscopic-guided uterovaginal anastomosis to establish continuity.

For patients with bilateral uterine remnants, unification of the cavities was performed prior to anastomosis. Postoperative management included the use of vaginal moulds and continued intrauterine catheterization to prevent stenosis during healing.

Key Findings

All seven patients achieved restoration of menstrual drainage, confirmed both clinically and by office hysteroscopy, which demonstrated patent uterovaginal anastomoses and accessible endometrial cavities in each case. No significant intraoperative complications were reported, including injuries to the bladder, rectum, ureters, or major vascular structures.

Despite anatomic success, reproductive outcomes were variable and limited in scope. One patient underwent two frozen embryo transfer attempts without success. Another required hysterectomy due to recurrent pelvic inflammatory disease, although the neovagina was preserved. Importantly, no cases of late stenosis affecting anatomical patency were observed during available follow-up.

The study emphasizes that anatomical patency and menstrual restoration do not necessarily translate to normal uterine biological function, fertility capacity, or pregnancy safety. These outcomes warrant cautious interpretation given the small sample size and relatively short reproductive follow-up.

Expert Commentary

This innovative laparoscopic technique represents a meaningful advance in the management of a very challenging congenital anomaly. By combining peritoneal neovaginoplasty with catheter-guided uterovaginal anastomosis under minimally invasive guidance, it addresses two critical needs: durable vaginal creation and effective uterine drainage.

However, preserving the uterus anatomically is only one facet of care. The uterine environment’s ability to sustain embryo implantation, carry pregnancies to term safely, and avoid infectious or inflammatory complications remains largely unproven. The report of pelvic inflammatory disease culminating in hysterectomy underscores ongoing clinical challenges.

Current guidelines do not standardize management for cervicovaginal agenesis due to its rarity and heterogeneity. Thus, this approach may be suitable only for highly selected patients in specialized centers with multidisciplinary expertise. Larger, multicenter studies with rigorous imaging, hysteroscopic surveillance, and long-term reproductive outcome data will be essential to clarify the true fertility potential and safety profile.

Conclusion

The described uterus-preserving laparoscopic approach using peritoneal pull-down neovaginoplasty combined with catheter-guided uterovaginal anastomosis provides a feasible reconstructive strategy for cervicovaginal agenesis with functional uterine remnants. It successfully restores menstrual flow and maintains anatomical patency with minimal intraoperative risk.

Nevertheless, substantial knowledge gaps remain regarding subsequent fertility potential, pregnancy safety, and long-term functional durability. Continued accumulation of experience through multicenter collaboration and systematic follow-up is imperative to optimize patient selection, refine surgical technique, and ensure comprehensive reproductive care.

Funding and Clinical Trials

No specific funding information was provided in the source study. There were no clinical trial registrations reported.

References

• Aslan K, Kasapoglu I, Kosan B, Uncu G. A Uterus-Preserving Laparoscopic Technique for Cervicovaginal Agenesis With Functional Uterine Remnants. BJOG. 2026 Sep 2; PMID: 42684013.
• Rock JA, Singer A. Surgery for congenital absence of the vagina. The Obstetrician & Gynaecologist. 2007;9(3):178-183.
• Oppelt P, Renner SP, Brucker S, et al. Clinical aspects of Mayer-Rokitansky-Küster-Hauser syndrome: recommendations for clinical diagnosis and staging. Human Reproduction. 2006 Jul;21(3):792-7.