Complete Eversion Research Articles

Eversão completa de bexiga no pré-parto em vaca Nelore - relato de caso

ABSTRACT Partial or complete bladder eversion is a rare condition of poor prognosis in cows, commonly associated with intense tenesmus observed in the peripartum period. A 14-year-old obese Nellore cow at 280 days of gestation was referred with 24-hour bladder prolapse. The bladder was complete eversion through the vulvar vestibule showing a thick congested wall and small residual urine volume. After clinical examination, the cow received scopolamine butylbromide and intercoccygeal epidural anesthesia, and the externalized bladder segment was partially reduced, remaining only 10 cm externalized. The cow was maintained with an intravesical human gastric tube number 16 and constant monitoring. The eversion was fully reduced after 12 hours of local treatment, and as the cow presented subclinical ketosis, hypocalcemia and cystitis, antibiotic, glucose, calcium and propylene glycol therapy were performed. We opted for induction of parturition, and after 24 hours, a healthy 52kg calf was born and the placenta was delivered 16 hours after calving. The cow and calf were discharged on the sixth day of hospitalization, with no recurrences or secondary complications after treatment.

Anterior plate osteosynthesis for multifragmentary patella fracture with additive stabilization of the distal pole using suture cerclage

The aims of the surgical treatment are the anatomical reduction of the articular surface and stabilization of amultifragmentary patella fracture with a distal pole fragment using plate osteosynthesis and additive suture tape cerclage to secure the distal fragment. Demonstration of the surgical procedure for amultifragmentary patella fracture in the knee joint of a male cadaver. Start with a median prepatellar skin incision and splitting of the bursa and surrounding fascia. Lateral arthrotomy with proximal and distal extension for complete eversion and articular exposure of the multifragmentary fracture. The fracture is then reduced from the articular side using temporary K‑wire fixation and reduction clamps, followed by screw osteosynthesis of the large fragments (e.g., distal and proximal poles). After selection of the plate it is fixed with locking screws. In addition, asuture cerclage according to Krakow and/or McLaughlin is applied distally and transosseously through the tibial tuberosity and proximally through the quadriceps tendon. The knotting of the McLaughlin suture cerclage should be done in 90° flexion of the knee joint. Functional postoperative treatment with hard shell orthesis with movement limitation (30°, 60° and 90° for 2weeks each) and partial weight bearing of 15-20 kg for 6weeks is recommended. Full weight-bearing is only allowed in full extension. Plate osteosynthesis is biomechanically superior in comparison to the widely used tension band osteosynthesis. In multifragmentary fractures, additional augmentation with asuture tape cerclage seems to be appropriate. Due to the lack of study results there is currently no clinical evidence for this.

Scrotal approach for tunica expansion procedure (TEP) for penile girth and length restoration during penile prosthesis implantation in patients with penile angulation due to Peyronie's disease and erectile dysfunction: technique and outcomes.

Peyronie's disease is often comorbid with erectile dysfunction and can cause significant penile shortening. We describe our modified tunica expansion procedure (TEP) technique of penile length preservation and girth enhancement with correction of penile angulation in patients with mild Peyronie's disease (<30 degree angulation, or hourglass deformity, no hinging) and erectile dysfunction presenting for inflatable penile prosthesis (IPP) surgery. A retrospective review of IPP placement from one high volume surgeon was performed. A total of 474 patients' charts from June 2017 to June 2021 were reviewed and those charts of patients undergoing modified TEP in the setting of Peyronie's disease were analyzed. Average increase in length and girth were measured and means with standard deviations calculated. The modified TEP is performed through a scrotal approach and involves complete eversion of the penis with dissection of Buck's fascia off the underlying tunica. Subsequently, staggered scorings of the underlying tunica are performed allowing for circumferential girth enhancement and length preservation. In men with Peyronie's disease, these scorings are preferentially concentrated on the side of the plaque to allow straightening without loss of length. A total of 32 patients with Peyronie's disease from the larger cohort underwent the modified TEP. Mean increase in length of distal corpora was 2.8 ± 0.8 cm (range 2.0-3.4 cm) (measured using Furlow before and after penile eversion with TEP), while mean increase in girth (measured at midphallus prior to prosthesis insertion and after IPP inflation) was 1.6 ± 0.4 cm (range 1.2-2.2 cm). There were no reported complications. A scrotal approach to TEP is an easy to perform technique that can be used to restore length and enhance girth in men with Peyronie's disease undergoing insertion of IPP. Additionally, it is a customizable approach that can also be used to correct mild penile angulation.

S367 Endoscopic Eversion and Stent-Assisted Strangulation for the Management of an Intraductal Papillary Neoplasm of the Bile Duct: A Minimally Invasive Technique for Non-Surgical Candidates

Introduction: Intraductal papillary neoplasms of the bile duct (IPNB) are uncommon lesions that may accompany risk for malignancy. Management is often surgical and may be associated with significant postoperative morbidity and mortality. Case Description/Methods: An 80-year-old female with a history of hepatocellular carcinoma (HCC) presented for management of jaundice and sepsis after microwave ablation of HCC. Computed tomography (CT) imaging demonstrated intra and extrahepatic biliary ductal dilation with a 19 mm soft tissue density in the distal common bile duct (CBD). Index labs depicted leukocytosis, hyperbilirubinemia, and elevated lactate. Endoscopic ultrasound (EUS) delineated a round, hypoechoic intraductal CBD lesion. The pancreas and ampulla were normal. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed a distal CBD filling defect. Biliary sphincterotomy was performed and balloon sweeping revealed a frond-like partially protruding polypoid lesion suggestive of an IPNB. Due to non-surgical candidacy, we decided to perform a complete eversion with subsequent full prolapse of the lesion by using a biliary extraction balloon. This was followed by the placement of a biliary plastic stent to assist with strangulation of the base of the lesion. Biopsies were consistent with a papillary neoplasm with intestinal differentiation, confirming our findings of an IPNB, without accompanying high-grade dysplasia or carcinoma. Interval surveillance ERCP 3 months later revealed no protruding lesion from the major papilla, no residual filling defects on cholangiogram, and sweeping of the biliary tree uncovered no contents. Cholangioscopy demonstrated segmental mucosal irregularity with mild granular tissue in the mid/distal bile duct wall; however, cholangioscopy-guided intraductal biopsies and brushings showed benign reactive tissue and no recurrent IPNB. At 5 months of follow-up, the patient continues to do well. Discussion: IPNB is a rare biliary lesion. Radical surgical resection has been the mainstay of curative treatment. However, a few recent cases have described endoluminal radiofrequency ablation as an alternative therapy. To the best of our knowledge, this is the first reported case of balloon-assisted eversion combined with stent-assisted strangulation of an IPNB leading to spontaneous removal. In non-surgical candidates, this technique may be advantageous to minimize adverse operative outcomes, improve patient tolerance, and decrease cost. Watch the video at https://tinyurl.com/ACGAbstractS367

An Unusual Cause of Vulvar Hemorrhage: About 12 Cases

Vulvar or genital hemorrhage is an alarming reason for consultation that worries parents a lot. Several etiologies of vulvar bleeding have been reported, including sexual abuse (common in our socioeconomic context) or urethral prolapse. Urethral prolapse is the complete eversion of the distal congestive urethral mucosa through the urinary sphincter. It is a benign condition that is uncommon in children and occurs in girls with a peak in frequency between the ages of four and six, mainly in the black population. The clinical presentation is dominated by vulvar bleeding, which therefore poses a medico-legal issue and a differential diagnosis with other causes of genital hemorrhage. The diagnosis is purely clinical, presenting as a more or less voluminous pink or purplish edematous circumferential pseudotumor bulge that bleeds spontaneously. No paraclinical examination is necessary. We retrospectively analyzed the records of 12 prepubertal patients aged between 5 and 12 years who consulted for genital hemorrhage either post-traumatic or spontaneous with urethral prolapse in the Pediatric Surgical Emergency urethral prolapse department, over a period of 18 years (1998 - 2020). In our series, the age of diagnosis ranged from 5 to 12 years with a median age of 08 years. Eleven patients were Caucasian and only one patient was from Senegal. Other causes of vaginal hemorrhage were ruled out, including sexual abuse or post-traumatic bleeding. The treatment of this affection is subject to great controversy, between surgical and conservative treatment, all our patients benefited from surgical treatment except one patient who benefited from medical treatment. The risk of complications, in particular urethral stenosis and recurrence, is not negligible in the face of poorly conducted medical treatment or surgery. In our series, the clinical outcome was favorable in all patients. The duration of hospitalization could be shortened by an early removal of the urinary catheter, .......

P179 DYSFUNCTION OF A MITRAL VALVE BIOPROTESIS FROM FLAIL OF A LEAFLET

Abstract Introduction The degeneration of biological valve prostheses is an irreversible process determined by intrinsic factors (calcification, thickening, fibrosis of the leaflets) or extrinsic (prosthesis–patient mismatch, malapposition, prosthetic detachment, thrombosis, endocarditis) that determine hemodynamic dysfunction with frequent need for surgical re–intervention . The average life span of a valve bioprosthesis is around ten years but in some cases premature dysfunction can occur. Clinical Case In September 2021, an 83–year–old woman who was symptomatic of progressively worsening dyspnea entered the emergency care unit of our hospital. In medical history: mitral valve replacement surgery using bioprosthesis in 2016, hypothyroidism in medical therapy. At the entrance, the patient appeared alert, attentive and oriented. Tachypnoic and dyspnoic at rest. Objectively ss 3/6 was appreciated on mitral focus, ss 2/6 on tricuspid focus. Signs of pulmonary congestion. PA 120/80 mmHg. HR 100 bpm, SpO2 88%. Laboratory tests showed increased NTproBNP values. On the ECG: sinus rhythm, HR 96 / min, atrioventricular conduction within limits, narrow QRS, widespread alterations in repolarization as from overload. The echocardiogram performed during the cardiological consultation showed normal biventricular size and contractility. The mitral biological prosthesis appeared in place with an increased transprosthetic gradient (mean Gp 7mmHg) and evidence of severe intraprosthetic regurgitation. There was also moderate to severe tricuspid insufficiency with PAPs estimated at 38 mmHg; the VCI was dilated and non–collapsing. Admitted to cardiac intensive care unit, trans–esophageal echocardiogram was performed which confirmed the finding of bioprosthesis dysfunction caused by severe mitral valve insufficiency in relation to eversion of the posterior leaflet. The patient remained in conditions of haemodynamic instability despite medical therapy with respiratory failure therefore after consulting cardiac surgery she was intubated and transferred for trans–catheter intervention of valve–in valve in emergency. Conclusions Transesophageal echocardiography represents the reference method in the evaluation of valve bioprostheses: in this case it allowed to highlight an unusual mechanism of mitral bioprosthesis dysfunction due to complete eversion of a leaflet.

Surgical Treatment of Femoral Artery Bifurcation Without Material: Technique and Follow-Up

Complete eversion of the femoral tripod is interesting to reduce clinical consequences of wound infection, in particular for patients at a high risk (e.g., obese, diabetics, cancer). Experience and follow-up of this technique are scarce. The different technical possibilities and results are reported here. A single-center prospective study including patients operated on for femoral occlusive lesions using eversion of the common femoral artery and its bifurcation. Clinical and imaging preoperative data, surgical technique, and follow-up are detailed. Thirty five patients (37 limbs) have been included between June 2014 and April 2016. The mean Rutherford index was 3.6 and 65% of the patients were claudicants. Lesions were limited to the common femoral artery in 14 (38%) of the cases and spread to the superficial femoral artery in 2 (7%) and to the 3 branches in 21 (57%) of the cases, respectively. Postoperatively, one death, one major amputation, and 3 reinterventions were noted, resulting in an 8% rate of major complications. The mean follow-up was 37months. At this time, 11 major adverse cardiovascular events, 9 deaths, and no additional major amputation were noted. The mean Rutherford index was 1.7 (P<0.001) and 3 reinterventions were necessary (one for septic occlusion at 3months and 2 for restenosis at 12 and 42months), translating into primary and secondary patency rates of 93.3% and 96.1%, respectively. This work further confirms that eversion of the femoral tripod is safe and effective. This experience adds to the existing body of the literature and describes alternative techniques of eversion. The technique should be considered when treating patients at a high risk of postoperative infection.

Emergency glomus-saving autotransplantation of the internal carotid artery in the acute period of ischemic stroke

Purpose.Analysis of the immediate results of emergency glomus-sparing auto-transplantation of the internal carotid artery (ICA) in the acute period of ischemic stroke, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg.Material and methods.In this prospective, single-center study from January 2017 to August 2020. 49 patients were included in the acute period of ischemic stroke with hemodynamically significant extended atherosclerotic lesions of the ICA. All patients underwent glomus-sparing ICA autotransplantation, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg (Kazantsev A. N., Zarkua N. E., Chernykh K. P. et al. Аrteries with extended atherosclerotic lesions of the internal carotid artery. Patent application No. 202.013.4151/14 (062595), filing date 10/16/2020). Glomus-sparing ICA autotransplantation, developed on the basis of the City Alexandrovskaya Hospital, St. Petersburg, was performed as follows. On the inner edge of the external carotid artery (ECA), adjacent to the carotid sinus, 2–3 cm above the orifice, depending on the spread of atherosclerotic plaque (ASB), arteriotomy was performed with the transition to the common carotid artery (CCA) (also 2–3 see below the mouth of the NSA). The ICA was cut off at the site formed by the sections of the wall of the NSA and the CCA. Then the ICA was cut off as distally as possible in front of the hypoglossal nerve, so that the artery was completely resected. In view of the presence of an intact carotid glomus on the resected area of the ICA, which connects it to the wound, endarterectomy from the ICA was performed inside the operating field by its complete eversion. Then, open endarterectomy from ECA and CCA was performed. At the next stage, the ICA was implanted in its previous place with the creation of proximal and distal end-to-end anastomoses, so that the continuing ASB above the endarterectomy zone was fixed with a circular vascular suture.Results.There were no complications in the postoperative period. No cases of restenosis / thrombosis of the reconstruction zone were identified in all the sample according to the color duplex scanning data. On the 7th day after the operation, all patients were diagnosed with regression of neurological symptoms according to the National Institute of Health Stroke Scale: on admission, the mean score was 10.5±3.5; at the moment of the control point — 6.5±1.5; p=0.001. This reflects the effectiveness of the chosen treatment strategy. According to the data on the dynamics of systolic blood pressure, stable systolic parameters were observed in the postoperative period against the background of antihypertensive therapy taken before the operation.Conclusion.Carotid endarterectomy in the acute period of ischemic stroke is safe in the presence of mild neurological deficits (up to 25 points on the National Institute of Health Stroke Scale) and the diameter of the ischemic focus in the brain not exceeding 2.5 cm according to the computer data. tomography. Glomussparing ICA autotransplantation, developed on the basis of the Aleksandrovskaya Hospital, St. Petersburg, does not require the use of a patch and is not characterized by the risk of developing ICA thrombosis as a result of intimal detachment behind the endarterectomy zone. Preservation of the carotid glomus during reconstructive intervention on the ICA prevents the development of labile arterial hypertension and hemorrhagic transformation in the postoperative period.

Mitraclip for high risk patients with barlow mitral valve disease

Abstract Background No data have been published to now about the outcomes of MitraClip in inoperable patients with Barlow's Mitral Valve Disease. Despite the technical advantages of the new generation of MitraClips, the length and the thickness of the mitral leaflets and presence of flails with complete eversion and pseudo-cleft are challenging MitraClip procedure. Purpose To analyse the results of MitraClip in inoperable patients with Barlow's disease of Mitral valve. Methods We retrospectively collected the cases of MR in Barlow's disease treated with MitraClip in our institution from 2012 to 2018. The case were included in the analysis in presence of the following characteristics: bileaflet billowing or prolapse [or both], excessive leaflet tissue, and annular dilatation with or without calcification. Results We included in this analysis 59 patients (mean age 78±8 years, STS mortality score 4±2.9%). Echo data at baseline showed normal left ventricle ejection fraction and diastolic volume and increased left atrial volume index. Half of the included patients had a chordal rupture (n=27, 47%) and in 14 patients (23%) calcification of annulus and/or leaflet was diagnosed. The mean procedural time was 92±41min with a technical success (M-VARC) of 100% and more than 80% of patients requiring more than 1 clip. At 30 days follow-up the device success and the procedural success were respectively 59% and 56%. The mean diastolic mitral valve gradient was 3.1±1.5mmHg. At 30 days follow-up, 91% of the patients were NYHA class II stable patients; no death and no hospitalization occurred. During a median follow-up time of 412 days (IQR: 209–992 days) death for any cause occurred in 23% of the patients (n=14) and 16% of the patients (n=10) died because of a cardiovascular cause; 10 patients were re-hospitalized for heart failure and 5% of the patients (n=3) underwent an open-heart surgery at follow-up time. At univariate cox regression analysis the 1-Y composite end-point (death for any cause, HF re-hospitalization, MV surgery) was predicted by LV dimensions and 30 days procedural success. Conclusions To our knowledge, this is the first analysis of outcomes of Barlow's disease treated with MitraClip. Despite a high incidence of MR recurrence, we observed a good clinical response in term of NYHA class and mortality rate. Left ventricle size and 30-day procedural success predict outcomes. Funding Acknowledgement Type of funding source: None

Inverted Nipple Treatment and Poliglecaprone Spacer.

Nipple inversion is defined as a non-projectile nipple. It is a frequent pathologic condition, in which the whole nipple, or a portion of its, is buried inward towards the lactiferous duct and lies below the plane of the areola. Numerous strategies have been described to correct nipple inversion. All the procedures have the purpose to give a good shape to the nipple, preserving its function and sensitivity, when it is possible. To avoid recurrences and to obtain good aesthetic results, we present a modified percutaneous technique. We performed a retrospective study between 2011 and 2016 and included all the cases of inverted nipples treated in our department. Our modified percutaneous technique consists of a minimal incision supported by a percutaneous suture as a temporary spacer to fill the defect caused by releasing the fibro-ductal bands. A total of 41 cases of inverted nipples were corrected in 32 patients. After 1year of follow-up, no recurrence was observed and all nipples maintained complete eversion. There was only one case of partial unilateral necrosis in a patient who underwent tumorectomy and radiotherapy. All patients were satisfied with the aesthetic outcomes. This is a simple, safe and cheap technique that should be considered as a reliable method for long-term correction of nipple inversion. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Postpartum Uterine Prolapse in a Jaffarabadi Buffalo - A Case Report

The actual cause of prolapse of uterus is not clear, but there is no doubt that it occurs during the third stage of labour within a few hours of the expulsion of the calf and at a time when some of the foetal cotyledons have separated from the maternal carbuncles (Arthur, 2001). Prolapse of the uterus is a common complication of the third stage of labour in the buffaloes (Joseph et al., 2001). In ruminants, uterine prolapse is generally a complete eversion of the gravid uterus, wherein multigravidas (dairy bovines) are more often involved than the heifers, while in the sow and the bitch eversion is generally partial and comprises of one cornua only (Arthur,2001; Jackson, 2004). The condition is predisposed by genetic as well as managemental factors and precipitated by straining, parturition and dystocia (Odegaard, 1977). The incidence of vaginal prolapse was observed to be maximum as prepartum prolapse (56.30%), followed by postpartum vaginal prolapse (12.90 %) and vaginal prolapse in non-pregnant (5.70 %) buffaloes (Pandit et al ., 1982). The present paper deals with a case of postpartum complete uterine prolapse and its successful management in a Jaffarabadi buffalo.

Laparoscopic Sacrocolpopexy for Treatment of Neovaginal Prolapse Following Gender Reassignment Surgery

Abstract Background: Prolapse of the neovagina is a rarely reported complication of male-to-female transgender surgery and is not commonly encountered by gynecologists. Documented management of such cases is scarce in the literature and includes a few case reports or abstracts. This article reports the current authors' experience treating complete eversion of the neovagina successfully with laparoscopic sacrocolpopexy. Case: A 55-year-old transgender female had complete eversion of her neovagina and symptoms of obstructive defecation syndrome (ODS). Use of a ring pessary was unsuccessful. A magnetic resonance imaging proctogram revealed anismus, and paradoxical contraction of the anal canal and puborectalis muscle. At a pelvic-floor multidisciplinary meeting, biofeedback treatment was recommended for her ODS symptoms as well as laparoscopic sacrocolpopexy. The procedure posed various technical difficulties for this patient, compared to an XX female, including lack of a distinct rectovaginal septum, a narr...

USING MULTI-FORAMINIFERAL-PROXIES TO RESOLVE THE PALEOGEOGRAPHIC HISTORY OF A LOWER MIOCENE, SUBDUCTION-RELATED, SEDIMENTARY BASIN (WAITEMATA BASIN, NEW ZEALAND)

A combination of five techniques was used to infer the paleobathymetry and paleoecology of 103 foraminiferal faunas (>63μm, census counts of 384 benthic species) from throughout the lower Miocene Waitemata Basin, Auckland, northern New Zealand. A canonical correspondence analysis ordination showed that environmental factors related to paleo-bathymetry were the main drivers of benthic foraminiferal composition and samples were sorted in approximate paleo-depth order using increasing planktic percentage and species diversity proxies. Cluster analysis recognised seven associations (A–G) and eight subassociations, which were interpreted in terms of paleo-bathymetry and paleoproductivity by qualitative comparison with modern faunas. Planktic-percentage-based regression (with benthic stress-indicator taxa removed) and a Modern Analogue Technique comparison (at generic level) of fossil benthic assemblages with a modern dataset (626 faunas from 0–5000 m) were both used to provide quantitative paleo-bathymetry estimates for each Miocene fauna. These paleo-depth estimates were refined using the upper- and lower-depth limits of some of the less common benthics present. No one technique appears to be better than others. All can provide anomalous paleo-bathymetric estimates that need to be explained. Paleo-depth estimates are most consistent and precise for inner–mid shelf faunas and become less precise and more frequently inconsistent with increasing depth. A number of faunas with inconsistent paleo-bathymetric estimates contain both shallow- and deep-water-restricted benthic tests. These are interpreted as resulting from the inclusion of reworked deep-water fossil tests into shallow faunas, or mixing of contemporaneous tests as sediment flowing from shelf depths down into the basin in turbidity currents and debris flows. The eight bathyal–abyssal associations and subassociations have overlapping depth ranges but only 3–4 of them were present in the basin at any one time. Their geographic distribution reflects a crude depth-related zonation, whereas their stratigraphic succession is inferred to have resulted from a period of increased carbon flux and decreased bottom oxygen sandwiched between periods of lower carbon flux and more oxic bottom conditions. The recognised associations are: A, Elphidium , intertidal–subtidal beach; B, Nonionella-Notorotalia , sheltered inner shelf; C, Amphistegina-Cibicides , exposed inner–outer shelf; D, Astrononion-Gyroidina , ≥mid-bathyal; E, Bolivina , mid–lower bathyal; F, Cibicides-Bolivina , bathyal; G, Oridorsalis-Neugeborina-Pullenia , ≥lower bathyal. The inferred paleoenvironment of the faunas is used to help resolve the paleogeographic history of the Waitemata Basin. Thin basal transgressive sequences of lensing conglomerate, shelly sandstone and limestone containing shelf faunas (Assocs A–C) record initiation of basin subsidence over a wide area (300 × 100 km), ~21 Ma. Continued subsidence (estimated from foraminiferal data at ~1 mm/yr) was accompanied by sediment starvation with little or no sediment accumulating until the basin reached lower bathyal depths (F, G). This created sufficient slope for turbidity currents from the north to flow down submarine canyons and deposit three interfingering submarine fans of sandstone (800–1000 m thick). Displaced Cretaceous–Oligocene nappes and melange (Northland Allochthon) moved part way into the basin from the north and large sub-seafloor slides of mixed basinal sediment and allochthon slid off its advancing toe. These slides were triggered by uplift of the northern part of the basin, which created land fringed by a wide shelf (C). A large submarine stratovolcano built up on the west side of the basin and shed volcaniclastic sediment (C, D, F) down its eastern slopes with some debris flows transporting mixed shallow water faunas up to 30 km into the basin. The ~4 million-year-life of this subduction-related basin came to an end with complete eversion before the end of the early Miocene.

Technique of extraperitoneal uterosacral ligament suspension for apical suspension.

Vaginal vault prolapse can occur alone or in combination with anterior or posterior compartment prolapse. Apical prolapse has shown a strong correlation with anterior wall prolapse and a moderate correlation with posterior wall prolapse. The McCall culdoplasty uses the extraperitoneal vaginal approach to support the vault at the time of hysterectomy. Sacrospinous fixation and ileococcygeus suspension with or without mesh have also been used for the treatment of vaginal vault prolapse. The uterosacral ligaments can also be used to re-suspend the vaginal vault using the extraperitoneal or transperitoneal approach. With the extraperitoneal approach, the peritoneal sac, which can be difficult to access at times, especially when there are dense pelvic adhesions, does not need to be opened. The extraperitoneal approach also carries a lower risk of ureteric injury, as the ureters and the bladder can be retracted from the field using a Breisky-Navratil retractor. This video, which documents the surgical treatment of a woman with a complete vaginal eversion and grade 3 pelvic organ prolapse (POP), was recorded in a live workshop during the 2015 Urogynaecology and Reconstructive Pelvic Surgery Conference, held in Chennai, India, in January 2015. It is aimed at educating interested surgeons in the technique of extraperitoneal uterosacral suspension. This video demonstrates the extraperitoneal approach to uterosacral ligament suspension for apical support in women with vaginal vault prolapse.

Spontaneous postmenopausal urethral prolapse treated surgically and successfully.

Urethral prolapse (UP) is a circular complete eversion of the distal urethral mucosa through the external meatus. It is a rare condition seen mostly in African-American premenarcheal girls. Both a medical and a surgical approach to this condition have been described. We present a case of a spontaneous urethral prolapse in a 60-year-old postmenopausal Caucasian woman, who failed medical management and underwent successful surgical management. The patient is asymptomatic 18 months following the procedure.

Congenital upper lid eversion and severe chemosis in a new born

The purpose of this study is to report a case of bilateral congenital eversion of the upper eyelid in an 8 h- old male baby. JD is an 8 h-old male baby born by normal vaginal delivery after prolonged labor, to a 24-year-old primigravida. Pregnancy was said to be term but was complicated by pregnancy-induced hypertension. A midwife delivered the baby and it was by spontaneous vertex delivery. He was said to have cried immediately after birth, but shortly afterward parents noticed a reddish fleshy swelling over the eyes and this made it difficult for them to see the eyeballs. The reddish swelling steadily increased in size necessitating their prompt referral to our center. On examination, a full term baby was seen with complete eversion of both upper eyelids and marked conjunctival chemosis. Ocular examination revealed normal globes with healthy cornea and briskly reactive pupils. The child was admitted and started on 3-hourly chloramphenicol ointment, ciloxan eye drop (ciprofloxacin hydrochloride United States Pharmacopeia equivalent to ciprofloxacin 0.3% w/v) - 8 times daily and 5% hypertonic saline patch over the chemosed conjunctiva. The pediatrician was also invited to co-manage the patient. After 9-days of treatment, the conjunctival chemosis fully resolved and lids reverted back to normal position. At 4-week follow-up, the lids continued to maintain their normal position and child could now open eyelids spontaneously. Congenital upper eyelid eversion is a rare clinical entity even though it is said to be commoner in blacks. Knowledge of its complete resolution with conservative management will help in future management of such cases thereby preventing complications that may arise from poorly treated cases.

Advanced utero-vaginal prolapse and vaginal vault suspension: synthetic mesh vs native tissue repair

To compare prosthetic and ligament vaginal vault suspension at vaginal hysterectomy in patients, with utero-vaginal stage III-IV pelvic organ prolapse quantification. A retrospective case-control study was designed to compare 61 patients who had undergone Posterior intravaginal slingplasty (PIVS) with 61 patients in a matched control group who had undergone uterosacral ligament suspension (ULS). The primary outcome was to compare anatomic vaginal vault failure rate. The secondary outcomes were subjective cure and cure without adverse events. Follow-up mean duration for the PIVS and ULS groups was 56.2 and 57.7 months, respectively. Recurrent vault prolapse was observed more frequently in the ULS group with pre-intervention stage IV prolapse (0 vs 14.8 %; p = 0.04), while there was no difference in prolapse recurrence at any vaginal site. Although the subjective cure of PIVS and ULS was superimposable (91.8 vs 86.9 %; p = 0.25), there was a significantly higher cure rate, without adverse events, in the ULS group (90.2 vs 100 %; p = 0.01). Non-mesh vaginal vault repair should be considered the first-line measure at vaginal hysterectomy; prosthetic repair should be used for therapeutic purposes in patients with vaginal vault recurrence and considered at vaginal hysterectomy only in selected subjects with complete utero-vaginal eversion.

Benefits of primary surgical resection for symptomatic urethral prolapse in children

ObjectiveUrethral prolapse (UP) is a complete eversion of the distal urethral mucosa through the external meatus. UP must be distinguished by examination from trauma, prolapsed ureterocele, tumors or sexual abuse. Its management remains controversial. The aim of the study was to promote the benefits of primary surgical management for UP. MethodsA retrospective multicenter review of children who received surgery for UP between 1991 and 2011 was carried out. Non-complicated UP was primarily treated conservatively. A total of 19 patients were referred for complicated UP and underwent resection of the prolapsed urethral mucosa. ResultsThe mean delay in diagnosis was 2.2 days (range 1–6) and the most common symptoms were vaginal spotting and bleeding. No predisposing factor was found, but most patients had a mean weight, height and BMI greater than the 50th percentile. All patients underwent surgery successfully. One patient experienced a complication, i.e., dysuria. There was no case of recurrence after a mean 28 months of follow-up. ConclusionEarly detection is based on bedside examination. The first-line treatment strategy for uncomplicated UP should be conservative management. Surgical resection is safe and effective for patients with significant symptoms.

Hémorragie génitale de la petite fille : penser au prolapsus urétral

Urethral prolapse is a complete eversion of the distal urethral mucosa through the external meatus. It occurs primarily in prepubertal, primarly Black girls. Its pathophysiology has not been clearly identified. We report a case of a 5-year-old girl who came to the Emergency Department with a 1-day history of genital pain and “vaginal bleeding”. Early recognition makes differential diagnosis with sexual abuse and staging allows prompt management under general anesthesic like prolapse reduction or surgical excision.

Chronic treatment of female tammar wallabies with deslorelin implants during pouch life: effects on reproductive maturation

The present study reports on attempts to delay puberty in a model marsupial species using the gonadotrophin-releasing hormone (GnRH) agonist deslorelin. Female tammar wallaby pouch young received deslorelin (5 mg) or placebo implants (n=8/group) when they were 193±2 days old. Sexual maturity was significantly delayed in deslorelin-treated animals, with the first successful production of offspring in treated and control animals occurring at 813±62 and 430±42 days of age, respectively. This delay was associated with a period of retarded pouch and teat development. Progesterone concentrations remained at basal levels throughout the first breeding season, indicating the absence of luteal cycles in treated females. Recovery and maturation of the hypothalamic-pituitary axis was a gradual process. Treated animals failed to respond to GnRH challenge at 12 months of age and had a reduced LH response at 18 months of age, before attaining full responsiveness by 24 months of age. Despite this apparent pituitary recovery by 24 months of age, as evidenced by complete teat eversion and LH responsiveness to GnRH, the time to first parturition was significantly delayed beyond this time in three females. This suggests that there may be longer-lasting effects at the level of the ovary and/or on FSH secretion. The significant delay in the onset of sexual maturation in response to chronic GnRH agonist treatment in this model marsupial species may be of practical significance to the management of fertility in captive and semi-free range marsupial populations.