Management of Cervical Elongation in the Setting of Uterine Preservation by Carson Kaeser and Mickey Cram at the Christ Hospital in Cincinnati, Ohio. One year ago, a 35-year-old with two previous full-term vaginal deliveries presented for symptoms of prolapse. Her heaviest baby was 8 pounds. Her most recent delivery was three years ago. Upon her initial evaluation a year ago, the patient reported bothersome uterine prolapse and desired future fertility. She is currently just over a year status post sacrohystopexy with rectocele here. The patient did well for the first year after her index surgery, but while recently on vacation felt a pop and noticed the recurrent protrusion of tissue from her vagina. Upon re-examination, the patient's cervix was seen at the level of the hymen, yet preservation of her apical support. The patient was also found to have a cystocele and recurrence of her rectocele. With a diagnosis of cervical elongation, cystocele, and rectocele, she was counseled and consented for partial trachelectomy with anterior and posterior repair. Here you can see the cervix protruding to the level of the hymen. You can see that the length from the hymen to the posterior fornix is 7 centimeters with good apical support, yet cervical elongation. The partial trachelectomy is begun by marking the cervix with a marking pen. This will be the area of incision, circumferentially. Injection is used with a combination of lidocaine and epinephrine, as well as saline, for hydrodissection as well as hemostasis. Here the inner tube of a pool suction is used as a guide through the cervical canal. Cautery device set to COAG is used to make the initial incision circumferentially. Curved Mayo scissors are then used to circumferentially dissect the portion of the cervix that shall be removed, similar to a vaginal hysterectomy. Cautery is then used to completely remove the cervix circumferentially around the inner tubing of the pool suction device. 3-0 delayed absorbable sutures are then used to re-approximate the cervical canal to the outer tissues previously dissected from the vaginal epithelium. This is continued in an interrupted figure-of-eight fashion circumferentially. Once completed, note that the vaginal epithelium is still not re-approximated to the endocervical canal. The Cystoseal is then addressed by way of an anterior repair. An injection is done, then a scalpel is used. Curved Mayo scissors are then used to dissect the vaginal epithelium from the underlying tissue. The anterior repair placation stitches are then placed using a delayed absorbable 3-0 suture. The final stitch of the Cystoseal repair is now being tied down. Redundant vaginal epithelium is now trimmed. The anterior repair is now closed using a 3-0 delayed absorbable suture. The closure of the anterior repair will now be continuous with the closure of the vaginal epithelium with the endocervical canal. The re-approximation of the vaginal epithelium with the endocervical canal via continuation of a 3-0 delayed absorbable suture in a running, locked fashion circumferentially. The partial trachelectomy and the anterior repair are now complete. To prevent cervical stenosis, we used a 12 French 5cc balloon Foley catheter inserted through the endocervical canal into the uterus. This was removed on post-operative day two. A cystoscopy was then performed. Here you can see the rectocele as well as a widened genital hiatus. A posterior repair will now be performed. A posterior repair has now been completed.

cervical elongation

future fertility

partial trachelectomy

anterior repair

posterior repair