Use Of Vaginal Dilators Research Articles

Association Between the Regular Use of Vaginal Dilators and/or Sexual Activity and Vaginal Morbidity in Locally Advanced Cervical Cancer Survivors: An EMBRACE-I Study Report

PurposeTo provide risk estimations for vaginal morbidity with regard to vaginal dilation (summarizing the use of dilators and/or sexual activity) in locally advanced cervical cancer patients (LACC) treated with definitive radiochemotherapy and image-guided adaptive brachytherapy (IGABT) within the prospective, multi-institutional EMBRACE-I study. Material/MethodsPhysician-assessed vaginal morbidity (CTCAEv3.0), use of vaginal dilators and patient-reported sexual activity (EORTC-CX24) were prospectively assessed at baseline and during regular follow-up.Frequency analysis for vaginal dilation was performed in a sub-cohort of patients with ≥3 follow-ups. Regular dilation was defined if reported in ≥50% of follow-ups, no/infrequent dilation if reported in <50%. Actuarial estimates were calculated with Kaplan-Meier method; comparisons evaluated with the log-rank test. Univariate and multivariable Cox proportional hazard regression were used to evaluate risk factors for vaginal stenosis G≥2. ResultsThe EMBRACE-I study included a total of 1416 patients (2008-2015); 882 were evaluated in the present report with a median follow-up of 60 months. Of those, 565 (64%) reported regular dilation. This was associated with a significantly lower 5-year risk of vaginal stenosis G≥2 compared to no/infrequent dilation (23% vs. 37%, p≤0.001). This univariate finding was confirmed by multivariable analysis, after adjusting for other risk factors (HR=0.630, p=0.001).Regular vaginal dilation was also associated with a significantly higher risk for vaginal dryness G≥1 (72% vs. 67%, p=0.028) and bleeding G≥1 (61% vs. 34%, p≤0.001). ConclusionVaginal stenosis represents irreversible fibrotic changes that can cause pain during gynecological examination and dyspareunia in LACC survivors. Regular vaginal dilation (defined as the use of dilators and/or sexual activity) is associated with a significantly lower risk for G≥2 vaginal stenosis, suggesting a potential improvement of vaginal patency. It is also associated with a significantly higher risk for mild G≥1 dryness and bleeding (no higher risk for G≥2), which both can be clinically managed.

The Impact of Vaginal Dilator Use on the Quality of Life in Women Treated with Adjuvant Radiotherapy for Cervical Cancer

The Impact of Vaginal Dilator Use on the Quality of Life in Women Treated with Adjuvant Radiotherapy for Cervical Cancer

Impact of Vaginal Dilator Use and 68 Gy EQD2(α/β=3) Dose Constraint on Vaginal Complications in External Beam Irradiation Followed by Brachytherapy in Post-Operative Endometrial Cancer.

This study evaluated the clinical outcomes of applying a 68 Gy EQD2(α/β=3) dose constraint to the most exposed 2 cm3 area of the vagina in post-operative endometrial cancer patients treated with vaginal-cuff brachytherapy after external beam irradiation and the impact of vaginal dilator use on late vaginal complications. We analyzed 131 patients treated with vaginal-cuff brachytherapy after external beam irradiation. Group-1 (65 patients) received one fraction of 7 Gy, and Group-2 (66 patients) received one fraction of between 5.5 and 7.0 Gy after applying a 68 Gy EQD2(α/β=3) dose constraint. Vaginal-cuff relapse, late toxicity, clinical target volume, vaginal dilator use, D90, and EQD2(α/β=3) at 2 cm3 of the most exposed part of the clinical target volume were evaluated. Descriptive analysis, the chi-squared test, Student's t-test, and the Cox proportional and Kaplan-Meier models were used for the statistical analysis. With a median follow-up of 60 months, the vaginal-cuff relapse rate was 1/131 (0.8%). Late vaginal complications appeared in 36/65 (55.4%) Group-1 patients and 17/66 (25.8%) Group-2 patients (p = 0.003). Multivariate analysis showed that belonging to Group-1 and vaginal dilator use of <9 months were independent prognostic factors of late vaginal complications with hazard ratios of 1.99 (p = 0.021) and 3.07 (p = 0.010), respectively. A 68 Gy EQD2(α/β=3) constraint at 2 cm3 of clinical target volume and vaginal dilator use of ≥9 months were independent prognostic factors, having protective effects on late vaginal complications.

Association between bladder cancer treatment and female sexual function.

Bladder cancer ranks 17th in prevalence of cancer types among women, and the trend is rising. The increased risk of female sexual dysfunction (FSD) after radical cystectomy (RC) underscores the need for greater focus on preserving and mitigating FSD. To place greater emphasis on the importance of female sexual function (FSF) in the treatment of bladder cancer and stimulate additional research to discover more effective solutions for enhancing the overall quality of life. This review used a narrative approach. Previous reviews on FSF after RC have provided limited and 1-sided solutions due to the lack of research. What makes this review unique is its innovative approach: it includes all available measures curing FSD as well as comparative analyses based on experimental data, thus making the findings more comprehensive. A detailed perspective of treatments for female bladder cancer is provided, including nerve- and organ-sparing RC, robot-assisted RC, and radiotherapy. We also analyze the impact of treatments for female bladder cancer on postoperative FSD. Additionally, solutions for addressing or alleviating postoperative FSD are summarized, such as urinary diversion, vaginal reconstruction, and drug and nondrug treatment. Research has suggested that robot-assisted nerve- and organ-sparing RC is promising. Moreover, orthotopic neobladder among urinary diversions without a stoma helps to maintain a positive female body image. If part of the anterior vaginal wall must be removed during RC, vaginal reconstruction can restore the dimensions with synthetic grafts and biologic scaffolds. Additionally, postoperative measures, such as vaginal laser and hormone therapy, and use of vaginal dilators and lubricants have a significant role in reducing distress caused by FSD to provide maximum relief. To support FSF after RC, various interventions are needed, and urologists must focus on patient recovery while minimizing treatment impact on FSF as much as possible.

Mayer–Rokitansky–Küster–Hauser syndrome managed with McIndoe’s vaginoplasty: a case series and literature review

Introduction: Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome is a congenital anomaly characterized by the absence of the uterus and the upper two-thirds of the vagina. It is a rare congenital anomaly with an incidence of 1 in 5000 female live births. Case series: The authors describe three cases of females presenting with primary amenorrhoea who were diagnosed with MRKH syndrome. The patients were managed with McIndoe’s vaginoplasty with neovagina creation with an amnion graft. Discussion: Management of MRKH syndrome involves vaginoplasty with neovagina creation. The approach to neovagina creation can be done surgically or non-surgically. Non-surgical creation of the vaginal cavity involves serial use of vaginal dilators, while there are several ways for surgical creation of neovagina. The modified Abbe-McIndoe procedure using amnion to create neovagina is a minimally invasive, rapid, and simple procedure with no risk of immune rejection because the amnion membrane lacks histocompatibility antigens. In addition, the graft is also readily available, storable, and inexpensive. Conclusion: Diagnosis of MRKH syndrome can be made when a young female with primary amenorrhoea and normal secondary sexual characteristics has agenesis of the uterus, and upper two-thirds of the vagina revealed on ultrasonography or magnetic resonance imaging. The patient can be offered treatment with vaginoplasty with neovagina creation.

New neovagina-creating technique on the basis of a fasciocutaneous flap for Müllerian agenesis

To present a new surgical technique on the basis of an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of the external genitalia. Video demonstration of the surgical steps. An 18-year-old woman with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counseling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve the external genitalia with the chance to have a sensitive vagina guided the choice. The cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm-long canal bounded anteriorly by the bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying the vascular-from the pudendal artery-and nervous pedicles. A tunnel between the flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching the vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. The inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. During the postoperative period, no special positioning or ambulation restrictions were used. Compliance and sensitivity of the neovagina, esthetic result, and perioperative and long-term complications. The postoperative course was uneventful, with early mobilization. The length of hospital stay was 16 days to allow proper vaginal dilator use; initial daily followed by intermittent use was planned. At a 2-year follow-up, the neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and esthetic result. The new surgical technique was feasible and effective, preserving the external genitalia and avoiding graft healing and bowel secretion drawbacks without an intra-abdominal surgical step and related risks. However, more cases-2 cases performed to date with similar results-and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and the connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.

Figure it out on your own: a mixed-method study on pelvic health survivorship care after gynecologic cancer treatments.

Pelvic health issues after treatment for gynecological cancer are common. Due to challenges in accessing physiotherapy services, exploring virtual pelvic healthcare is essential. This study aims to understand needs, preferences, barriers, and facilitators for a virtual pelvic healthcare program for gynecological cancer survivors. A multi-center, sequential mixed-methods study was conducted. An anonymous online survey (N=50) gathered quantitative data on pelvic health knowledge, opportunities, and motivation. Focus groups (N=14) explored patient experiences and consensus on pelvic health interventions and virtual delivery. Quantitative data used descriptive statistics, and focus group analyses employed inductive thematic analysis. Findings were mapped to the capability, opportunity, and motivation (COM-B) behavior change model. Participants reported lacking knowledge about pelvic health interventions and capability related to the use of vaginal dilators and continence care. Barriers to opportunity included lack of healthcare provider-initiated pelvic health discussions, limited time in clinic with healthcare providers, finding reliable information, and cost of physical therapy pelvic health services. Virtual delivery was seen favorably and may help to address motivational barriers related to embarrassment and frustration with care. Awareness of pelvic healthcare is lacking among people treated for gynecological cancer. Virtual delivery of pelvic health interventions is perceived as a solution to enhance access while minimizing travel, cost, embarrassment, and exposure risks. A better understanding of the pelvic health needs of individuals following gynecological cancer treatments enables the development of tailored virtual pelvic health rehabilitation interventions which may improve access to pelvic health survivorship care.

Vaginal stenosis and dilator use after pelvic brachytherapy

Introduction: To prevent vaginal stenosis, the use of a vaginal dilator is recommended. Objective: To analyze sociodemographic data, gynecological conditions and the use of vaginal dilator after pelvic brachytherapy. Materials and Methods: Cross-sectional, retrospective study, period 2016-2020, collected between October/2020 and February /2021, from records of women with gynecological cancer treated with brachytherapy at the Centro de Pesquisa Oncológicas (Brazil). The variables included sociodemographic data and gynecological conditions in following the treatment. In the analysis, descriptive statistics, chi-squaretest, Fisher's exact test and Mann-Whitney test were applied. Results: 519 patients records were included in the investigation; the analyzes showed significant associations between the topography and staging (p&lt;0.001), education (p=0.004) and age (p&lt;0.001); the comparison between the distribution of the ionizing radiation dose showed a difference with the continued sexual relationship category (p=0.006); the comparison between the proportions of continued sexual relationship and using a vaginal dilator was significant (p&lt;0.001); 49.10% (131) adhered to the use of vaginal dilator; 24.50% (127) are not sexually active and do not adhere to the use of the dilator. Discussion: It is evident that social and gynecological conditions interfere with the presence of vaginal stenosis and the use of a vaginal dilator after pelvic brachytherapy. Conclusions: The adherence found in the use of dilator affirms the contributions and the need for health education by nurses and physicaltherapists during and following the treatment.

Daily Vaginal Dilator Use During Radiation for Women With Squamous Cell Carcinoma of the Anus: Vaginal Wall Dosimetry and Patient-Reported Sexual Function

Background: At our institution, we treat patients with a daily vaginal dilator (VD) during chemoradiation (CRT) for squamous cell carcinoma of the anus (SCCA). We evaluated compliance with daily VD use, radiation dose to the vaginal wall (VW) and anterior vaginal wall (AVW), and patient-reported long-term sexual function. Methods: We included women with SCCA who received definitive, intensity-modulated radiotherapy-based CRT. Women who were alive without evidence of disease received a patient-reported outcome survey, which included the Female Sexual Function Index (FSFI). We identified factors associated with FSFI such as radiation dose to the VW and AVW using linear regression models and used Youden index analysis to estimate a dose cutoff to predict sexual dysfunction. Results: Three hundred thirty-nine consecutively treated women were included in the analysis; 285 (84.1%) were treated with a daily VD. Of 184 women alive without disease, ninety patients (49%) completed the FSFI, and 51 (56.7%) were sexually active with valid FSFI scores. All received therapy with a daily VD. Forty-one women (80%) had sexual dysfunction. Univariate analysis showed higher dose to 50% (D50%) of the AVW correlated with worse FSFI (β -0.262; p=.043), worse desire FSFI subscore (β -.056; p=.003) and worse pain FSFI subscore (β -.084; p=.009). Younger age correlated with worse pain FSFI subscale (β .067; p=.026). Age (β 0.070; p=.013) and AVW D50% (β -0.087; p=.009) were significant on multivariable analysis. AVW D50% >48Gy predicted increased risk of sexual dysfunction. Conclusion: Daily VD use is safe and well tolerated during CRT for SCCA. Using a VD during treatment to displace the AVW may reduce the risk for sexual dysfunction. Limiting the AVW D50% <48Gy may further reduce the risk but additional data are needed to validate this constraint.

Access to Cancer Care in LMIC - Navigating Current Challenges

At the Summit on Cancer Health Disparities held in 2023, the session on Access to Cancer Care in Low- and middle- income countries (LMIC) highlighted several efforts globally. The collaborative efforts of Dana Farber Cancer Institute and the Ministry of Health in spearheading the Butaro Cancer Center of Excellence (BCCOE) in Rwanda was one such initiative. They were able to set up the BCCOE to address the unmet need of cancer care in this area and have trained nurses in East Africa to help establish other similar centers. They also serve as the single radiotherapy center for the entire of the country. Another such collaborative effort between Massachusetts General Hospital and the cancer center in Botswana in setting up sexual health education initiatives for women undergoing pelvic radiation was highlighted. They started with a quality improvement project to demonstrate the benefit of sexual health education and proper vaginal dilator use amongst women in this demographic. They were able to demonstrate that 90% of patients were able to complete an in-person 6-week workshop with clear benefits noted on a long-term basis. To highlight examples of best practice examples of equitable partnerships, examples of partnerships between Instituto Nacional de Cancerologia in Mexico City and UCSF was described. It was emphasized that for successful collaborations, equitable bidirectional partnerships are key. The thought leaders in this field also highlighted challenges associated with global oncology and the need for inclusion of minorities in clinical trials to improve cancer care for all globally.

Association between Regular Vaginal Dilation and/or Sexual Activity and Long-Term Vaginal Morbidity in Cervical Cancer Survivors

To evaluate the association between regular vaginal dilation and/or sexual activity and vaginal morbidity in locally advanced cervical cancer patients after definitive radiochemotherapy and image-guided adaptive brachytherapy from the EMBRACE I study. Physician-assessed vaginal morbidity (CTCAE v.3), vaginal dilation and patient-reported sexual activity (EORTC QLQ CX24) were assessed at baseline, every 3 months in the 1st year, every 6 months in the 2nd and 3rd year and yearly thereafter. For this longitudinal analysis, a subgroup of patients was selected with at least 3 follow-ups with information on vaginal dilation and/or sexual activity. Vaginal penetration summarized either the use of vaginal dilators or sexual activity or both. Regular vaginal penetration was defined if reported in ≥50%, infrequent if reported in <50% and absent if reported in 0% of follow-ups. Actuarial estimates of vaginal morbidity were calculated with Kaplan-Meier method and included the individual symptoms: vaginal dryness, stenosis, mucositis and bleeding. Group comparisons were evaluated with the log-rank test. The EMBRACE I study included 1416 patients overall (2008-2015); the subgroup of patients for this longitudinal evaluation consists of 882 patients, with a median follow-up of 60 months (IQR 47-77). Of those, 565 (64%) reported regular, 205 (23%) infrequent and 112 (13%) no penetration. Reporting regular penetration was associated with a significantly lower risk of vaginal stenosis G≥2 of 23% at 5 years, compared to reporting of infrequent (37%) and no penetration (36%, p≤0.001). However, reporting regular penetration was associated with a significantly higher risk for vaginal dryness G≥1 (72% vs. 69% vs. 62%, respectively, p = 0.038) and bleeding G≥1 (61% vs. 40% vs. 25%, respectively, p≤0.001). No associations were seen for G≥1 vaginal stenosis, G≥2 dryness, G≥2 bleeding and G≥1/G≥2 mucositis. Regular penetration (defined as vaginal dilation and/or sexual activity) was associated with lower risk for vaginal stenosis G≥2, but higher risk for vaginal dryness G≥1 and bleeding G≥1. Mild vaginal dryness seems to become apparent in particular for patients experiencing vaginal penetration. Minor vaginal blood loss during dilation and/or sexual activity is commonly reported by patients, resulting from atrophy of the vaginal mucosa and/or telangiectasia. While both of these G≥1 symptoms can be managed with lubricants, moisturizer and/or hormonal replacement therapy, G≥2 vaginal stenosis represents an irreversible fibrotic adverse event that can cause dyspareunia in many cancer patients. These long-term data support clinical recommendations for dilation and/or sexual activity after radiotherapy.

Are 7.5 Gy×2 fractions more efficient than 6 Gy×3 in exclusive postoperative endometrial cancer brachytherapy? A clinical and dosimetrical analysis

PurposeTo compare two vaginal brachytherapy (VBT) schedules in postoperative endometrial carcinoma (PEC) patients considering vaginal-cuff relapses (VCR), late toxicities, dosimetry analysis and vaginal dilator use. Material and methods110 PEC patients were treated with exclusive high-dose-rate VBT using two schedules. Group-1:44-patients received 6 Gy×3fractions (September-2011-April-2014); Group-2:66-patients were treated with 7.5 Gy×2fractions with a dose limit of equivalent total doses in 2-Gy fr (EQD2(α/β=3)) of 68 Gy in the most exposed 2 cm3 of clinical target volume (CTV) (July-2015-November-2021). The dose was prescribed at 5 mm from the applicator surface. Were evaluated the overall radiation dose delivered to 90% of the CTV (D90), the CTV receiving 100% of the prescription dose (V100) and the EQD2(α/β=3) received in the most exposed 2 cm3 to dose in CTV. Late toxicity was prospectively assessed using RTOG scores for bladder and rectum and objective LENT-SOMA criteria for late vaginal toxicity (LVT). Statistics: Descriptive analysis, Chi-square, Student’s t-tests and Kaplan and Meier method. ResultsThe median follow-up was 60 months (15.9–60). There were no VCR or late toxicities in bladder or rectum. LVT ≥ G1 appeared in 26/44 (59.1%) in Group-1 and 25/66 (37.9%) in Group-2. The mean EQD2(α/β=3) received by the most exposed 2 cm3 of CTV was 63.7 Gy ± 10.0 in Group-1 and 60.5 Gy ± 3.8 in Group-2 (p = 0.063). There were no differences in adherence to vaginal dilator use ≥9 months, overall D90 and V100. ConclusionConsidering the lack of vaginal relapses and similar LVT over time, 7.5 Gy×2fractions seem more efficient in terms of patient comfort, workload, and cost. This is the first study using dosimetry parameters to compare effectivity of schedules. Larger series are needed to confirm the present results.

717 Management of Gynecologic Involvement in Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS)

Abstract Introduction Stevens-Johnson Syndrome (SJS)/ Toxic Epidermal Necrolysis Syndrome (TENS) are rare and potentially life-threatening dermatologic conditions that require interdisciplinary management (Shanbhag et al., 2020). One of the most painful and traumatic is vaginal mucosal involvement. Gynecologic complications have been historically undermanaged, and lack of acute intervention can lead to dyspareunia, adhesion formation, and increased risk for vaginal cancers (Kaser et al., 2011). Unfortunately, treatment is variable but typically involves use of vaginal dilators, which can be painful, and often traumatic for both patient and provider. The purpose of this study was to analyze the utilization of these treatments and to observe any sequelae from gynecological involvement. Methods Retrospective chart review was completed for all female patients with a diagnosis of SJS/TENS who were admitted to a single center burn unit from 2015-2022. Trends in age, gynecologic involvement, wound care strategies, and outcomes were assessed. Results Twenty-nine patients met inclusion criteria. These patients ranged from 9-82 years of age with a mean of 43 (STD 21). Ten percent died in the hospital, 14% were transferred to another hospital, and the remaining patients were discharged to home or a rehabilitation facility. Of these 29 SJS/TENS patients, 59% had gynecologic involvement of which 52% received gynecologic interventions. Gynecologic interventions included use of vaginal dilators (67%), topical steroids (60%), antifungal ointment (33%), and menstrual suppression (13%). For pediatric populations, patient discomfort and family concerns limited pelvic exam and vaginal interventions. Accommodations for pediatric patients included completion of examination and treatment under anesthesia and education of parents about the treatment process. While 2 patients were confirmed to have no vaginal adhesions in follow up appointments, documentation of future vaginal complaints was not available for most patients. Conclusions Gynecologic management is an important part of SJS/TENS treatment with wide variability in practice patterns not only nationally but at a single setting institution. Outcomes from treatment versus non treatment with steroids +/- dilation is equivocal. Providers must be better at screening for symptoms in outpatient follow up. When forming new algorithms, special consideration among pediatric populations and invasive management needs to be considered. Applicability of Research to Practice There is wide practice variability on the gynecological management of SJS/TENS patients with variable outcomes. Longitudinal studies on outpatients would better help create algorithms for patient management.

V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT

You have accessJournal of UrologyCME1 Apr 2023V04-03 COMBINED ROBOTIC TRANSPERITONEAL AND TRANSVAGINAL PULL-THROUGH FOR REPAIR OF DISTAL VAGINAL ATRESIA: A VIDEO CASE REPORT Jeremiah Dallmer, Peris Castaneda, Andrew Freedman, and Paul Kokorowski Jeremiah DallmerJeremiah Dallmer More articles by this author , Peris CastanedaPeris Castaneda More articles by this author , Andrew FreedmanAndrew Freedman More articles by this author , and Paul KokorowskiPaul Kokorowski More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.03AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Distal vaginal atresia is a unique Mullerian pathology where the urogenital sinus, responsible for the lower 1/3 of the vagina, fails to cannulate during development. Unlike Meyer-Rokitansky-Kuster-Hauser syndrome, which is characterized by agenesis of the upper vagina and uterus, patients with distal vaginal atresia have normal Mullerian development including the uterus and proximal vagina. METHODS: We present the case of a 12 yo female with a three month history of cyclical abdominal pain. Upon outside workup, she was found to have a short, blind ending vagina. MRI showed a 9 cm x 8 cm dilated uterus, open cervix and proximal vagina filled with blood products. She was taken to the operating room for combined perineal and robotic transperitoneal pull-through. RESULTS: An 8.5 mm camera port was placed in the umbilicus and three 8.5 mm working ports were placed using a hidden incision approach below the belt line. We incised the peritoneum and dissected as distally as feasible along the rectovaginal space. At the blind-ending introitus, a U-shaped incision was made to create an anterior flap. This space was dissected proximally, monitoring the correct plane via a finger in the rectum and with direct visualization with the robotic camera. The two planes were connected. A 0-silk was robotically placed to manipulate the vagina. As the vagina was severely dilated from menstrual products, mobility was insufficient to reach the introitus. A small posterior incision on the proximal vagina was made and blood products were partially evacuated. The vesicovaginal space was then dissected robotically, maintaining the lateral attachments as blood supply and avoiding ureteral injury. The vaginal apex was then pulled to the introitus and anastomosed to the anteriorly based flap from the introitus. The patient remained hospitalized for two days with vaginal packing in place. She was trained in the use of vaginal dilators and has been progressively increasing the size without difficulty. CONCLUSIONS: Robotic dissection of the proximal vagina in the setting of distal vaginal atresia using a hidden incision approach allows for orthotopic reconstruction, and superior aesthetics as compared to traditional port placement. This approach obviated the need for the use of tissue grafting or more extensive open dissection. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e338 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jeremiah Dallmer More articles by this author Peris Castaneda More articles by this author Andrew Freedman More articles by this author Paul Kokorowski More articles by this author Expand All Advertisement PDF downloadLoading ...

Management of Hematometra and Hematocolpos in Obstructive Mullerian Anomalies by Image-Guided Drainage with Interventional Radiology: A Multi-Institutional Case Series

Study ObjectiveTo describe cases of image-guided drainage of symptomatic hematometrocolpos from obstructive Müllerian anomalies as a temporizing measure to manage acute pain symptoms and delay definitive management of the obstructive Müllerian anomalies that require complex reconstruction MethodsInstitutional Review Board exemption from all included institutions was obtained. A retrospective case series from 3 academic children's hospitals of 8 females under the age of 21 with symptomatic hematometrocolpos due to obstructive Müllerian anomalies drained by image-guided percutaneous transabdominal vaginal or uterine drainage with interventional radiology was reviewed and described. ResultsEight pubertal patients with obstructive Müllerian anomalies (6 patients with distal vaginal agenesis, 1 patient with an obstructed uterine horn, and 1 patient with a high obstructed hemi-vagina) and symptomatic hematometrocolpos are reported. All patients with distal vaginal agenesis had greater than 3 cm lower vaginal agenesis, which would usually require complex vaginoplasty and use of postoperative stents. Given their immaturity and inability to use stents or dilators postoperatively or medical complexity, they subsequently underwent ultrasound-guided drainage of hematometrocolpos with interventional radiology to relieve pain symptoms, followed by menstrual suppression. The patients with obstructed uterine horns had complex medical and surgical histories requiring perioperative planning; they also underwent ultrasound-guided drainage of hematometra as a temporizing measure to manage acute symptoms. ConclusionPatients presenting with symptomatic hematometrocolpos due to obstructive Müllerian anomalies might not be psychologically mature enough to undergo definitive complex reconstruction, which requires vaginal stent or dilator use postoperatively to prevent stenosis and other complications. Image-guided percutaneous drainage of symptomatic hematometrocolpos serves as a temporizing measure by offering pain relief until patients are ready to undergo surgical management and/or to allow time for complex surgical planning.

Change in vaginal length and sexual function in women who undergo surgery ± radiation therapy for endometrial cancer

PURPOSEEndometrial Cancer (EC) is the most common gynecologic malignancy in the United States. Standard treatment is TAH/BSO with radiation therapy (RT) and chemotherapy given based on risk. Treatment can cause significant vaginal changes, including shortening, narrowing, loss of elasticity, atrophy, and dryness. These are not life threatening, but affect a woman's physical, psychological, and social functioning. Adjuvant vaginal dilator use is often advised, but there are inconsistent recommendations on use. This prospective study compared vaginal length changes and sexual function in women compliant with dilation versus not after surgery and RT. METHODS AND MATERIALSEnrolled patients underwent surgery for Stage I-IIIC EC ±RT. Vaginal dilator use was recommended for women receiving RT (external beam or brachytherapy). Vaginal length was measured with a vaginal sound and the Female Sexual Function Index (FSFI) was used to assess sexual function. RESULTSForty-one enrolled patients had sufficient data for analysis. Dilation significantly increased FSFI scores (p = 0.02) while RT without dilation showed a significant decrease (p = 0.04). Dilation helped maintain vaginal length for all patients (0 cm vs. 1.8 cm loss (p = 0.03)). Individual arms did not show statistically significant changes in length with dilation, though the trend showed RT without dilation had an average loss of 2.3 cm as compared to only 0.2 cm for regular dilation. Notably, there was no difference in length change with dilation for surgery alone versus surgery and RT (p = 0.14). CONCLUSIONThis data provides novel, prospective evidence of the benefit of vaginal dilation for maintaining vaginal length and improving sexual health after any pelvic treatment for EC. This evidence also supports that the addition of RT after surgery does not appear to significantly worsen vaginal shortening. This study has important implications for providing a strong foundation for future studies and helping to establish solid clinical management criteria for the prevention of vaginal stenosis and promotion of female sexual health.

A literature review on vaginal dilator use

Dilator stretching is often a frequent part of treatment for multiple disorders involving the pelvic floor muscles and it is unknown what the time and duration of dilator use is until patient goals are achieved. This paper looks at studies involving patient use of vaginal dilators with the diagnoses of vaginismus, dyspareunia, and pelvic pain to begin to answer the question. It was determined the recommendations given to UIHC physical therapy patients with these diagnoses change to increase the daily time and frequency of dilator usage.

Vaginal dilator use more than 9 months is a main prognostic factor for reducing G2‑late vaginal complications in 3D‑vaginal‑cuff brachytherapy (interventional radiotherapy)?

PurposeAnalyse the impact of different prognostic factors on G2-late vaginal complications after vaginal brachytherapy (VBT) ± external beam radiotherapy (EBRT) in postoperative endometrial cancer (PEC).MethodsOne hundred and twenty-six PEC patients treated with VBT ± EBRT were retrospectively analysed considering age, body mass index, applicator diameter, clinical target volume (CTV), use of dilators, chemotherapy and EQD2(α/β=3) at the most exposed 2 cm3 of the CTV as prognostic factors for vaginal complications. Late vaginal complications were evaluated using objective LENT-SOMA criteria. Statistics: descriptive analysis, Chi-square, Fisher and Student tests were applied. Univariate and multivariate analyses were performed with the Baptista–Pike exact method and multiple logistic regression.ResultsMean age was 65 years (SD ± 10), and median follow-up was 66 months (8–104). 19/126 patients (15%) showed G2-late vaginal complications, and 107/126 (85%) G0–G1. Univariate analysis showed: CTV ≤ 9 cm3 (p = 0.036), use of dilators < 9 months (p = 0.015), and total ≥ 68 Gy EQD2 received by 2 cm3 of CTV (p = 0.039) were associated with G2-late vaginal toxicity. Multivariate analysis showed the use of dilators < 9 months as an independent prognostic factor for G2-late vaginal toxicity (p = 0.043, OR 8.59, CI 1.59–159.9).ConclusionThe use of dilators < 9 months in VBT ± EBRT for PEC was an independent prognostic factor for G2-late vaginal toxicity. The use of vaginal dilators ≥ 9 months requires further analysis in studies evaluating late vaginal toxicity.

Exploring Brachytherapy Discharge Educational Needs of Gynecological Cancer Patients.

Brachytherapy (BT) plays a fundamental role in the treatment of gynecological cancers. Patient education for vaginal self-management and dilator use post-BT involves an interdisciplinary team of healthcare professionals (HCPs) and there is a paucity of post-BT education guidelines. Our objective was to determine the educational needs of gynecological cancer patients surrounding vaginal self-management post-BT and to determine enablers and barriers to the provision of education by HCPs. This cross-sectional study recruited gynecological oncology patients receiving external beam radiotherapy and BT for curative intent. Patients completed a questionnaire to assess their vaginal self-management educational needs, preferred education modality, and desired timing of post-BT education. HCPs were invited to complete a questionnaire to identify enablers and barriers to providing BT education. Twenty patients and 53 HCPs participated. All patients rated each topic as very important/important with information about preventing vaginal stenosis as the most important overall (89%). When asked about topics they addressed during BT education, most HCPs reported that "explaining what vaginal stenosis is and the negative effects of stenosis" was always discussed with patients (N = 37/49, 77%). Barriers to providing post-BT education, including the patients' language and culture, as well as enablers, such as the use of written resources and tools for patients, were identified. Despite a high level of engagement, current education surrounding vaginal self-management post-BT may be inadequate.

PO44 Presentation Time: 4:45 PM: HDR Intracavitary Brachytherapy in the Management of Recurrent VaIN3: A Case Report and Review of the Literature

<h3>Purpose</h3> Vaginal intraepithelial neoplasia, or VaIN, is a pre-cancerous condition in the cell of the vagina. It has an estimated occurrence of 0.2-0.3 cases per 100,000 women in the U.S. It is classified into three groups based on histologic characteristics: low-grade (VaIN 1), intermediate-grade (VaIN 2), and high-grade (Vain 3). High-grade lesions includes vaginal carcinoma-in-situ and are known as a pre-malignant lesion most likely to progress to vaginal cancer. Risk factors include HPV, cigarette smoking and immunodeficiency. VaIN 1 are usually treated with close observation; VaIN 2 and 3 usually require prompt treatments including excision (wide local excision, partial or total vaginectomy), ablation (CO2 laser, ultrasonic surgical aspiration), topical therapy (imiquimod, fluorouracil), and radiation therapy. Yet no standard treatment exists. Given that it is a rare pre-malignant condition, there have been limited reports on the use of intracavitary brachytherapy. Proper dose prescription remains challenging, especially for patients with history of hysterectomy. <h3>Materials and methods</h3> We report a case of a 70 year-old female with history of hysterectomy 15 years ago for endometriosis and recurrent diffuse VaIN3 that was refractory to multiple lines of local therapy who received HDR cylinder brachytherapy. The report includes clinical and diagnostic studies, dosimetric considerations in treatment planning for improved target coverage, and a review of the limited existing literature of HDR brachytherapy for VaIN3. <h3>Results</h3> HDR, MDR and LDR had all been utilized to treat VaIN with comparable tumor control and toxicity. Reported acute side effects include vaginitis, urethritis, and proctitis; whereas late side effects include vaginal atrophy/fibrosis/telangiectasia/stenosis. What made this case especially challenging is her past surgical history of hysterectomy. The vaginal vault is difficult to assess after hysterectomy with potential abnormal cells sequestered above the suture line, and is thus prone to underdosing. Therefore some institutions prefer to use ovoids rather than cylinder to adequately cover the upper vagina; whereas others argue that cylinder is better for treating extensive lesions by providing a uniform coverage of the entire vagina despite higher toxicity. Upper vagina is also noted to tolerate a higher radiation dose compared to lower vagina. Doses are often prescribed to different depths based on location in the vagina, or on doses to the OARs. Our patient was treated with a dose of 30Gy in 5 fractions given twice weekly, prescribed to 3mm depth for the proximal 3cm vagina and to surface for the remaining 5cm vagina. She had complete clinical response and was encouraged to continue vaginal dilator use to prevent vaginal stenosis and regular follow-ups with pelvic exams. <h3>Conclusions</h3> HDR brachytherapy is a feasible and effective alternative approach to treat patients who are non-surgical candidates, have recurrent disease or disease refractory to previous treatments, or have extensive multifocal VaIN. Our case would be a valuable addition to the existing limited literature regarding the treatment efficacy and proper dose prescription for this rare condition.