EP25.24: Intraoperative ultrasound in the characterization of cervical agenesis with upper third vaginal atresia: a case report

The prevalence of cervical agenesis and dysgenesis is estimated to be 1/90.000. In 10% of the cases it is associated with upper third vaginal atresia. Both are manifested by cyclical pelvic pain and its frequent association with endometriosis. We present the case of a 20-year-old patient with cervical agenesis with upper third vaginal atresia who required hysterectomy and vaginal reconstruction. The patient had been previously diagnosed with partial vaginal atresia after presenting with cyclical pelvic pain, and was treated with hormonal suppression of menstruation. After beginning sexual activity, definitive surgical management was planned. Preoperative imaging showed an upper third transverse vaginal septum 5mm thick, a partial septate uterus, a rounded hematocolpos approximately 65mL in volume with hematometra, and an image suggestive of the presence of uterine cervix, with no renal abnormalities or endometriosis. After resecting the intervening tissue between the blind vaginal pouch and the assumed cervix, a Foley catheter was introduced, and its pathway tracked using intraoperative ultrasound imaging. This revealed a completely obstructed uterine outflow tract, with the catheter tip located in the posterior cul-de-sac, not inside the endometrial cavity, thus confirming absence of the cervix. This was a U2aC4V4 anomaly by ESHRE, and given the low chance of pregnancy associated with this entity and the high risks of a canalization procedure, a laparoscopic hysterectomy with bilateral salpingectomy was performed. Other findings included pelvic adhesions and distended hematosalpinx. After closing the vaginal vault, followed by the use of vaginal dilators and local estrogens to avoid collapse and restenosis of the vaginal reconstruction. The intraoperative classification was confirmed by histopathology study. Intraoperative ultrasound is a valuable tool that can improve the characterization of complex congenital abnormalities and redirect treatment accordingly.