Labia Majora Research Articles

Aesthetic reconstruction of localized periurethral cancer defects: a case report

Although several techniques of vulvar reconstruction have been reported, the aesthetic repair of localized periurethral defects has not been investigated yet. A 60-year-old woman presented with a neoplasm located on the right side 1–2 mm from the urethral meatus. A radical wide local excision was performed with the resection of the distal part of the urethra. The urethral meatus was reconstructed by the mobilization of the anterior and lateral vaginal mucosa. The vulvar defect was repaired by the advancement of the two bilateral V-shaped local flaps harvested at the level of labia majora. The present case emphasizes the importance of tailoring reconstructive options for vulvar reconstruction to provide aesthetically appealing results, to prevent or restore organ function and to reduce disease and treatment-related morbidity. Level of evidence: Level V, therapeutic study.

Male-to-Female Gender-Affirming Surgery Using Nile Tilapia Fish Skin as a Biocompatible Graft

Insufficient penile skin is common during vaginoplasty for male-to-female transition. This issue may be compensated by a scrotal skin flap, with the drawback of hair growth [1]. In recent studies, Nile tilapia skin was successfully used for the surgical management of Mayer-Rokitansky-Küster-Hauser syndrome [2,3] and vaginal stenosis [4,5]. This study aims to describe a novel technique for primary vaginoplasty in male-to-female gender-affirming surgery using Nile tilapia skin as a biocompatible graft to ensure adequate vaginal depth. Stepwise demonstration of the procedure with narrated video footage. Transgender health clinic. A 29-year-old patient with gender dysphoria was referred to our office because of a desire for gender-affirming surgery. A physical examination revealed normal male genitalia with a 14-cm-long penis. Before surgery, approval from the institutional review board and written permission from the patient were obtained. After orchiectomy, penile disassembly, perineal dissection, and urethroplasty were performed, and a hollow Nile tilapia skin mold was prepared and sutured to the distal edge of the remaining penile skin. This structure was inverted, covering the newly created canal. The neocavity was then filled with a handmade inflatable vaginal mold, held in place by sutures in the labia majora. Finally, labiaplasty and clitoroplasty were conducted. After 7 days, the inflatable mold was removed, and the use of progressively larger dilators was initiated. After 3 weeks, a neovagina that was 16 cm long and able to accommodate the width of 2 fingers was detected. At that time, the Nile tilapia skin was completely reabsorbed into the neovaginal mucosa. There were no complications in the early postsurgical period. Nile tilapia skin, a safe, low-cost, and easy-to-use biocompatible material, may be an alternative option to scrotal skin grafts for neovaginal augmentation in primary vaginoplasty for male-to-female gender transition. However, further studies are needed to confirm this assertive.

Prenatal Diagnosis of a Cyst of the Canal of Nuck Associated With an Ovarian Cyst and Acute Polyhydramnios

In the female, the canal of Nuck is a tubular fold of parietal peritoneum that travels along with the round ligament through the inguinal canal to its attachment on the labia majora. The canal of Nuck is analogous to the processus vaginalis in the male. In embryonic development, this pathway typically obliterates early in life; however, in some cases, it may partially or completely fail to close. This failure to obliterate can lead to complications ranging from a cyst of the canal of Nuck (also known as a female hydrocele) to herniation and incarceration of abdominal and pelvic organs. There is little information available in the medical literature concerning this rare condition; therefore, it is important for sonographers, physicians, and surgeons to be familiar with this developmental abnormality. This report represents the first prenatal case of a cyst of the canal of Nuck, along with the unique combination of a large left fetal ovarian cyst and acute polyhydramnios. The embryology, incidence, differential diagnosis, management, and treatment of these female conditions are discussed.

女性外阴慢性单纯性苔藓的临床研究

Objective To investigate clinical features of vulvar lichen simplex chronicus (VLSC) . Methods Clinical data were collected from 137 VLSC patients who visited a Vulvar Clinic in the Department of Dermatology, Beijing Hospital from 2017 to 2018, and analyzed retrospectively. Non-normally distributed measurement data (age and disease duration) were described as median (P25, P75) , and analyzed by using rank sum test, and enumeration data were compared by using chi-square test. Results Among the 137 patients with VLSC, the age at onset was 32.0 (25.5, 40.0) years, and the disease duration was 36.0 (15.0, 72.0) months. Thirty-two (23.4%) patients had a history of atopic diseases, and the age at onset of VLSC was significantly lower in these patients with a history of atopic diseases (29.5[25.0, 35.8] years) than in those without a history of atopic diseases (33.0[27.0, 41.0] years, Z = 2.03, P = 0.042) . The most frequently involved site was the labia majora (130/137, 94.9%) , and the labia minora was rarely involved (13/137, 9.5%) . Bilateral lesions were observed in 103 (75.2%) patients, and hypopigmentation occurred in 8 (5.8%) patients. All the patients experienced itching to different extents, including moderate itching in 44 (32.1%) cases and severe itching in 80 (58.4%) . The ratio of patients with severe itching to those with disease duration > 2 years (68.1%) was significantly higher than that of patients with severe itching to those with disease duration < 2 years (47.7%, χ2 = 5.830, P = 0.016) . Patients reported that local wetness and sweating (55 cases, 40.1%) , spicy diet (41 cases, 29.9%) and mental stress (36 cases, 26.3%) could aggravate itching. Conclusions VLSC commonly occurs in patients aged 20 - 39 years, and atopic predisposition may be an important factor for VLSC. VLSC mostly involves bilateral labia majora, and the longer the disease duration, the more severe the itching. Key words: Neurodermatitis; Vulvar diseases; Pruritus; Femininity; Hypopigmentation; Local wetness

Retrospective analysis of surgically treated cases of squamous cell carcinoma vulva.

Vulvar carcinoma accounts for 3%-5% of gynecologic malignancies. The past three decades has observed changes in the trends of clinical characteristics and treatment modalities used in managing this disease. The aim of the present study is to analyze the clinic-pathological characteristics and survival of women with squamous cell carcinoma vulva who underwent primary surgical management. This was a retrospective observational study. Case records of 30 consecutive patients with squamous cell carcinoma of vulva during the period of 2010-2016 were retrospectively reviewed and their clinical profile, treatment details, complications, and survival were analyzed. Kaplan-Meier survival analysis, followed by logrank test, was used for survival outcome, and Cox proportional hazard model was used to assess significant risk factors. The mean age of patients was 58 ± 12.9 years. The most common symptom was growth over vulva (73.3%), itching (63.3%), and nonhealing vulval ulcer (26.6%). The most common site for disease was labia majora. The surgical treatments ranged from wide local excision to radical vulvectomy. Postoperative adjuvant therapy was required for 16 patients. The median (95% confidence interval [CI]) overall survival was 27 (21.7-32.2) months. Five-year survival probability for early-stage disease (I + II) was 49% (95% CI: 12.9, 78.4) and for advanced disease (III + IV) was 24.8% (95% CI: 4.8, 42.6). Lymph node-positive status was found to have a significant impact on survival (hazard ratio of 4.9 [95% CI: 1.15-21.02, P = 0.02]). Despite advances in detection and management modalities, the survival for vulval malignancies has not improved.

Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty

IntroductionPoor genital self-image is a common phenomenon leading to an increasing interest in female genital surgery over the last years. AimThe aim was to correlate objective measurements of the labia minora with the individual subjective perception of the labial size. MethodsIn a cross-sectional study with 200 premenopausal women (median age 33.5 years) presenting for gynecological issues other than vulvar diseases, labial width and length were measured, and psychological and physical complaints were assessed. Multivariable logistic regression analyses were performed to identify factors that influenced self-reported complaints and subjective perception of labia size. Main Outcome MeasureThe main outcome measure was labial appearance (width and length in mm, color), subjective perception of the labial size, and complaints. ResultsThe median width of the labia minora was 19.0 mm (interquartile range = 12.6–27.5), and the median length was 35.5 mm (interquartile range = 27.8–48.9). The objective size of the labia was significantly associated with womens' subjective perception of the labial size, but not with self-reported complaints. Nearly one-third of the women (n = 53, 27%) reported complaints of their labia minora which were mainly physical (n = 41, 77%) or a combination of physical and psychological problems (n = 9, 17%), while only a small group reported experiencing only psychological complaints (n = 3, 6%). Predictors of complaints were previous cosmetic surgery and the subjective perception of the labia size. The latter was significantly associated with discomfort during intercourse and when visiting a sauna and by labia minora that protruded over the labia majora. Clinical ImplicationsCutoff values to define labial hypertrophy and to justify labial reduction surgery should be avoided. Strength & LimitationsThis is a large sample of labial measurements in women not seeking labiaplasty. Standardized and validated questions regarding quality of life, sexuality, and body image could have provided more insight into psychological aspects. ConclusionThese data demonstrate the variability of labial anatomy and its perception.Widschwendter A, Riedl D, Freidhager K, et al. Perception of Labial Size and Objective Measurements-Is There a Correlation? A Cross-Sectional Study in a Cohort Not Seeking Labiaplasty. J Sex Med 2020;17:461–469.

Minimal invasive procedures for the treatment of genitourinary syndrome of menopause (GSM). Un update

Genitourinary syndrome of menopause (GSM) is a new term for a condition more renowned as atrophic vaginitis. It is used to describe a variety of menopausal symptoms and signs that are related to the physical changes of the vulva, vagina and lower urinary tract. The etiology of GSM is secondary to decreased levels of endogenous estrogens and represents a common but underreported condition. In this update we present novel minimal invasive procedures that may benefit GSM symptoms making particular focus on platelet-rich plasma (PRP) treatment, hyaluronic acid (HA) treatment and energy-based devices (CO2 laser, YAG laser, radiofrequency device and high intensity focused ultrasounds). Currently, PRP has becoming popular as a non-operative treatment option for GSM symptoms. The principle underlying PRP treatment has to do with its ability to reproduce natural mechanisms of cell regeneration through the sequential secretion of numerous growth factors. Moreover, HA has been widely used as an important ingredient in topical hydrating and lubricating gels or injected for conditions such as dyspareunia. Lately, it has also been used as a new tool to treat age-related fat lysis of the female genitalia and especially the labia majora. Τhe Energy based devices have been recently suggested for the management of GSM. They utilize technologies such as laser, electromagnetic waves and high intensity focused ultrasounds to focus energy in the vaginal wall heating the targeted tissue at various depths without causing any pain or needing a recovery time. These minimal invasive procedures appear to be promising options for the treatment of GSM symptoms. However, further studies are necessary to evaluate more thoroughly the effectiveness and safety of these procedure and assess medium and long term results.

Large vulvar mass in young adult female

A 24-year-old African-American woman with no significant medical history presented with an enlarging mass on her right labium for two years. It had grown more rapidly in the past few months and occasionally bled. A gelatinous 5.5 × 6.5 cm polyp with surface ulceration on a 4 cm stalk was on the right labium majus (Figure 1). The patient was scheduled for surgical removal. Two clamps could be placed on the stalk before removing the lesion and using interrupted hemostatic sutures. Pathology report demonstrated a fibroepithelial stromal polyp (FSP) with surface ulceration and reactive atypia including koilocytic type changes (Figure 2). Human papillomavirus (HPV) testing on follow-up pap smear was negative. Fibroepithelial stromal polyp or “pseudosarcoma botryoides” were associated with elevated hormone levels and chronic inflammation. Due to the large size of this presentation, histologic evaluation was required to rule out angiomyxomas or other malignant conditions. There has been no recurrence to date.

Martius graft transposition: a successful procedure for the ultimate repair of the anovaginal/rectovaginal fistula

Background Recto/ano-vaginal fistula (RAVF) is one of the worst medical conditions that could lead a lady to suffer in her life. It represents a horrendous experience that might put the lady suffering that ailment not only on the brink of abandoning her social life, but even disrupting her marital life and breaking the integrity of her family. There are various operative methods implemented all over the past decades aiming to cure such medical condition. Of those, interposing a vascularized tissue flap is suggested as an operative solution to guarantee long term successful healing. Of which the most commonly tried is the bulbocavernous flap technique. Patients and methods Eighteen patients with both low and mid recto/ano-vaginal fistula,were repaired using martius graft transposition technique. And all fistulas were at least 8 months old. All patients were followed up for around one year postoperative for assessment of fistula healing and any associated persistent complications and side effects. Results All of the 18 patients included in the current study, were fully cured with no recurrence of fistula on one year follow up term, with 13 patients complaining mild dyspareunia that didn't hamper them resuming their sexual life. Out of eight patients with low fistula, of whom four had an old complete perineal tear with severed sphincter. five patients almost regained full control over flatus and stools. While two patients reported appreciably partial control over flatus and liquid stools. Conclusion Dissection and mobilization of fibrofatty graft (Martius graft) from the labia majora with intact blood supply for enforcing and supporting the site of repaired fistula is better than gracilis and gluteus grafts in surgical repair of recto/ano-vaginal fistula.

Reddish Smooth Nodule on the Labia Majora: A Quiz.

Reddish Smooth Nodule on the Labia Majora: A Quiz.

Fractured peripheral venous catheter: a rare incident

Although placement of peripheral venous catheters (PVC) for the purposes of administration of drugs and fluids during anesthesia, is seen as a benign part of the daily practice, such simplest procedure process risks. A written informed consent was obtained from the patient to report this case. A 29-year-old woman was admitted to the obstetric emergency ward for an excision of a large abscess of the right labia majora under spinal anesthesia. Venous access was assured with a 20 G cannula inserted in the median cubital vein. During the surgical procedure, the patient was free to move her arms. At the end of the surgery, the anesthesist nurse removed the device with some resistance but it was immediately recognized that a large piece of the catheter was missing. A venous tourniquet was immediately placed proximal to the insertion point. Following palpation of a distinct cord-like object under the skin, it was decided to remove off the broken piece surgically by performing a venotomy under local anesthesia (A,B). PVC fracture is an unlikely and under-reported complication. Fragment of the catheter can break off and travel through the venous circulation into the heart and pulmonary circulation, causing abnormal heart rhythms or potentially leading to pulmonary embolism and even death.

The use of high-frequency ultrasonography in the assessment of selected female reproductive structures: the vulva, vagina and cervix.

IntroductionHigh-frequency ultrasonography enables visualization the layered structure of the skin and shows the epidermis, dermis, subcutaneous tissue and skin appendages: hair follicles, sebaceous glands, sweat glands and blood vessels. The aim of this study was to apply high-frequency ultrasonography to evaluate the structure of the vulva, vagina and cervix, and to describe their anatomy in ultrasound.Material and methodThe examinations were conducted with the use of high-frequency probes: DermaView 48 MHz and Episcan 50 MHz, by three operators experienced in performing classical ultrasound scans (with 30-, 10- and 9-year experience). The study involved 50 women aged 20–80 years who reported for a periodical gynecological check-up and presented no symptoms within the reproductive system.ResultsIn this study, the individual layers of the skin in the area of the mons pubis, labia majora (together with hair follicles and sweat glands) and labia minora were successfully visualized in all the patients. The subepidermal low-echogenicity band was seen in the area of the mons pubic and labia majora in 40 cases. This concerned 100% of women who underwent cosmetic skin treatments. In all the patients, HFUS demonstrated the layered structure of the anterior and posterior vaginal walls, the walls of the urinary bladder and rectum, layers of the vaginal portion of the cervix and the external opening of the cervix.ConclusionsHigh-frequency ultrasonography offers new quality of vulvar, vaginal and cervical imaging. It can be used for evaluation of the vulva and vagina, and confirms their layered structure. It also enables accurate measurements of the thickness of the vulvar epidermis and dermis as well as the thickness of the vaginal walls.

Eruption on the vulva and groin

A 30-year-old woman presented with a spreading papular eruption on the vulva, inguinal, and perianal skin of 9 years' duration. A prior course of prednisone provided temporary resolution. Treatment of recent flares with desonide, mupirocin, and topical tacrolimus were ineffective. Medical history was relevant for herpes simplex labialis treated with acyclovir. A similar eruption was observed in her father and paternal grandmother. Physical examination found agminated papules forming plaques on the labia majora and multiple 2- to 5-mm skin-colored exophytic papules on the inner thighs (Fig 1) and perianal skin.

Assessment of clitoral anatomy in human fetuses.

To determine fetal clitoral dimensions in antenatal period and to provide a contribution to external genital morphology determination in premature infants. Thirty-one formalin fixed female fetuses aged between 18 and 40weeks (17 fetuses aged 21.53 ± 1.88weeks in the second trimester and 14 fetuses aged 31.00 ± 4.90weeks in the third trimester) were evaluated. 20 (64.5%) fetuses were between 3 and 97% percentile range and within normal limits. Clitoris appearance (completely covered by labium majus/partially showing/prominent), length and width of clitoris, labium minus length, length, and width of labium majus were assessed. Clitoris length during the second trimester was 4.84 ± 1.09mm, whereas it was 5.43 ± 1.07 in the third trimester. Clitoris width was as 3.35 ± 0.88mm in the second trimester and as 4.55 ± 0.96mm in the third trimester. A statistically significant increase was seen in width of clitoris, length, and width of labium majus and length of labium minus with gestational age in the second and third trimesters (p < 0.05). No significant difference was found between the second and third trimesters in terms of clitoris length (p = 0.146). A homogenous spread in clitoris appearance was obtained between the second and third trimesters without any significant difference (p = 0.912). In addition, fetus percentiles showed a homogenous spread without any significant differences between completely covered, partially covered and prominent groups (p = 0.452). The anatomical data can be beneficial to the development of fetal radiological screening procedures in females and also in morphological assessment criteria in premature infants, effectively assisting in diagnosing anomalies during the early term.

Giant primary lymphedema of the vulva in a young female

A 21-year-old single female with a large swelling of the vulva’s left labia majora was diagnosed with a case of primary lymphedema of the left lower limb and external genitalia. The giant labial swelling was excised, and the patient experiences no complications or recurrence for 7 months postoperatively. Following the surgical excision of the swelling, the left labia majora and minora were reconstructed successfully. The excised mass weighed 6.3 kg and measured 40 cm x 35 cm x 30 cm. There were no complications postoperatively, and the patient has not experienced recurrence during the 7-month follow-up period. The patient returned to her normal life. Level of evidence: Level V, therapeutic study.

Evaluation of the Efficacy and Safety of Hyaluronic Acid Injection in Labia Majora for Volume Restoration

Evaluation of the Efficacy and Safety of Hyaluronic Acid Injection in Labia Majora for Volume Restoration

Martius Labial Fat Pad Graft (use in RVF Repair)

Video Objective To demonstrate the utility of the Martius Labial Fat Pad Graft in pelvic fistula repair. Setting We present a minimally invasive surgical approach for a patient with recurrent rectovaginal fistula. Interventions An incision is made over the labium majus exposing the yellow fibrofatty graft. This graft is first retracted medially where a natural tissue plane facilitates dissection from the adjacent labium majus. It is then retracted laterally where a plane between it and the bulbocavernosus muscle is developed. To avoid devascularization of adjacent skin, a thin fatty layer is left attached at its undersurface. The division of the flap is begun in this case, at its anterior pedicle. It is important to develop a flap that easily covers the defect with a good degree of overlap. Once the flap has been sufficiently mobilized, a shellcross is used to create the subepithelial defect to enable passage of the flap through the levator plate. This defect is widened enough to prevent compression on the pedicled blood supply. After appropriate positioning, the flap is sewn into place by attaching it to the adjacent, underlying rectovaginal fascia with interrupted 2-0 Vicryl suture. It is important to note that no tensioning of the flap is required to approximate it to the adjacent tissue. The posterior vaginal wall is next closed over the graft in two layers followed by closure of the labial defect. Conclusion The Martius flap has multiple minimally invasive advantages in fistula repair to include low morbidity, lack of a cosmetic defect and the need for only a single surgical field. Its’ abundant blood supply promotes rapid neovascularization of the transplanted graft and lends itself well to a variety of surgical modifications that can be utilized in the repair of even the most difficult of fistulas.

Дослідження діагностичної інформативності якісного тесту циклооксигенази-2 при пухлинах зовнішніх статевих органів у жінок

The article presents the results of diagnostic value the qualitative test of cyclooxygenase-2 (COX-2) in tumors of the external genital organs in women. The objective: to evaluate the expression of the molecular marker COX-2 depending on the clinical, topographic, histological and morphological features of tumors of the external genital organs. Materials and methods. A prospective follow-up of 131 women with external genital tumors was conducted. In all clinical cases, a qualitative COX-2 test was performed. Results. When determining the diagnostic value of a qualitative COX-2 test for FIGO clinical staging, the «chances» (OR) of detecting COX-2 positive in patients increased at stages III (OR – 2.41) and IV (OR – 3.88). During TNM-staging, the reliable value of the qualitative analysis of COX-2 was verified at the T3 stage (78.6%), T4 stage (100.0%), as well as in the presence of Tx (100.0%). In the presence of metastases in the lymph nodes, the number of COX-2-positive clinical cases, depending on the degree of damage to the lymph nodes, increased to 44.4% with N1 (an increase of 1.92 times) compared with 29.3% with N0, reaching 50, 0% at N2 (the probability of metastasis increased by 2.41 times). It was proved that in the absence of distant metastases (M0), the proportion of COX-2-positive cases was 33.1%, and in the presence of (M1) it was 50.0%. The «chances» of distant metastases increased from 1.97 at M0 to 4.0 at M1. Reliable diagnostic value of a qualitative COX-2 test from the degree of differentiation of primary tumors of the external genital organs was established: in the presence of a high degree of differentiation, the detection rate reached 24.5% (OR – 1.0), with a moderate degree – 35.4% (OR – 1.68), in the presence of a low degree of differentiation – 44.0% (OR – 2.60), with undifferentiated tumors – 100.0% (OR – 10.0). When assessing the morphological features of the tumor, the diagnostic informativeness of the qualitative test was confirmed in the presence of undifferentiated cancer in 100.0% of cases (OR – 5.0), adenocarcinomas – in 60.0% of cases (OR – 2.83), malignant melanoma – 40, 0% of cases (OR – 1.25), as well as squamous keratinizing – 32.0% (OR – 1.0) and squamous non-keratinizing cancer – 36.0% (OR – 1.07). Conclusion. For the assessment of localization of the primary tumor, the greatest diagnostic value of the qualitative test was established for total lesion (100.0%, OR-2.0), labia majora pudendi (40.0%, OR-1.29) and vulva (34, 1%, OR – 1.0). Key words: cyclooxygenase-2, qualitative test, diagnostic value, tumors of external genital organs, women.

胰腺癌大阴唇皮肤转移一例

胰腺癌大阴唇皮肤转移一例

Prospective randomized comparison of repairing vesicovaginal fistula with or without the interposition flap: Result from a tertiary care Institute in Northern India.

Assessment of results of repairing vesicovaginal fistula (VVF) with or without the use of interposition flaps. This prospective randomized study was conducted between January 2012 to December 2017 in the Department of Urology, King George's Medical University, Lucknow, India. Obstetric and gynecological simple fistula of ≤4 cm were included for evaluation. Those with complex or complicated fistula or fistula due to malignancy were excluded. Patients were divided into two groups (group 1 and group 2) depending upon route of repair i.e., transvaginal or transabdominal, respectively, as per the characteristics and location of the fistula. These two groups of patients were randomized into two subgroups (1A, 1B and 2A, 2B) based on the inclusion or omission of the interposition flap during fistula repair. Perioperative and postoperative parameters (blood loss, mean operating time, hospital stay, and requirement of analgesics) and success rates of fistula repair were compared. All complications that occurred in the postoperative period till the last follow-up appointment were recorded. The Clavien-Dindo Classification was used to stratify the complications. Fifty-seven patients underwent transvaginal repair in group 1 (29 with Martius flap: group 1A; 28 without Martius flap: group 1B), while 69 patients underwent transabdominal repair in group 2 (35 with interposition flap: group 2A; 34 without flap: group 2B). Blood loss, mean operating time, hospital stay, and the requirement of analgesics were comparable between each subgroup-1A versus 1B and 2A versus 2B, respectively. The overall success rate of repair across all groups was 96.04% (121/126). The success rate was 93.1% in transvaginal repair with Martius flap versus 96.43% in transvaginal repair with no flap (p=1.0). Success rate was 97.1% in transabdominal repair with an omental flap versus 97.06% in without an omental flap (p=1.0). Mean follow-up period was 39.6 months (range: 6-68 months). Out of 29 patients with Martius flap interposition, 9 (31.03%) of them reported a significantly reduced sensation on the labia majora. Of these 9 patients, 5 reported numbness while the remaining 4 experienced pain as compared to the patients in subgroup IB, who did not report any altered sensation in the labia. (p=0.0019). The success rates are similar in simple VVF repair (fistula size less than 4 cm) irrespective of the use of interposition flaps. However, overall morbidities following repair with the interposition flap are higher when compared with repair without interposition flap, either by the transvaginal or by the transabdominal route.