Vaginoplasty Research Articles

Pre-pperative low intensity vestibular shockwave therapy (LiSWT) decreases opioid use post-vestibulectomy: A pilot study

ABSTRACT Introduction Surgeons performing complete vestibulectomy with vaginal advancement flap reconstruction for suspected neuroproliferative vestibulodynia (NPV) take into consideration the need for acute pain relief in the early postoperative period as well as risks for persistent post-operative opioid use. Post-operative acute pain has traditionally been managed with narcotics which are effective but are highly addictive and can cause unwanted side effects including nausea/vomiting, impaired mental function, and severe constipation/obstipation. We serendipitously observed that one patient who tried to avoid surgery by undergoing numerous vestibular low intensity shockwave therapy (LiWST) treatments used very few narcotics post vestibulectomy. LiWST is FDA-cleared for pain amelioration. It has been hypothesized that LiSWT downregulates inflammatory cytokines, promotes enhancement of blood flow and angiogenesis through expression of vascular endothelial growth factor and nitric oxide synthesis. Objective We performed a pilot study using pre-operative LiSWT to determine whether or not it might decrease post-operative opioid use (oxycodone/acetaminophen tablets; 5mg/325mg) for acute pain management in patients undergoing complete vestibulectomy with vaginal advancement flap for suspected NPV. Method We studied the post-op opioid use of women who underwent complete vestibulectomy at our facility during the period January 1, 2019 through June 30, 2021. We assessed opioid use based on the patient's recall of the total oxycodone/acetaminophen tablets required in the first 30 days post-vestibulectomy. When possible, patients confirmed the use by counting tablets left in the pill container. Women scheduled to undergo vestibulectomy for suspected NPV were placed in the LiSWT study group if they agreed to undergo vestibular LiSWT treatment daily for the three business days immediately pre-operatively. Using the Urogold 100™MTS, LiSWT involved delivery of 1800 shocks to the vestibule per session, energy flux density 0.05-0.1 mJ/mm2, 3 Hz, membrane pressure 3. We compared the post-op opioid use by women in the LiSWT study group to the use by women who did not undergo pre-op LiSWT. Results Forty-five women (mean age 28 years; range 17 - 57) underwent complete vestibulectomy for suspected NPV during the 30 month period. Twenty women (mean age 27 +/- 9 years) agreed to undergo pre-op LiSWT and post-op opioid use was obtained in all. Twenty-five women (mean age 29 +/- 11 years) did not undergo pre-op LiSWT and opioid use was obtained in 19/25 (76%). Mean post-operative opioid use was 47 +/- 13 (range 25 - 90) tablets in those vestibulectomy patients who did not undergo pre-op vestibular LiSWT; opioid side effects included constipation, nausea, fainting, drowsiness, fatigue, and blurred vision. Mean post-op opioid use was 22 +/- 10 (range 1 - 26) tablets in the 20 vestibulectomy patients who did undergo pre-op vestibular LISWT sessions; opioid side effects were restricted to constipation, sleepiness, and nausea. Conclusion In this pilot study, pre-operative low intensity shockwave therapy decreased post-operative opioid use after complete vestibulectomy with vaginal advancement flap. While encouraging, more research is needed. Disclosure Work supported by industry: no.

Analyzing the learning curve of vaginal pelvic reconstruction surgery with and without mesh by the cumulative summation test (CUSUM)

Women who underwent vaginal pelvic reconstructive surgery with or without mesh consecutively between 2004 and 2018 were retrospectively analyzed to determine the learning curve in vaginal pelvic reconstructive surgery. With cumulative summation (CUSUM) analysis of surgical failure and operation time, we assessed the learning curve of vaginal pelvic reconstructive surgery, including sacrospinous ligament fixation, anterior colporrhaphy, posterior colporrhaphy, and optional vaginal hysterectomy with or without mesh placement. The study is based on two individual surgeons who performed vaginal pelvic reconstructive surgery with or without mesh. Two hundred and sixty-four women with stage III or IV pelvic organ prolapse underwent vaginal pelvic reconstructive surgery by surgeons A or B. The median follow-up time of 44 months ranged from 24 to 120 months. Surgical proficiency was achieved in 32–33 vaginal pelvic reconstructive surgery procedures without mesh and 37–47 procedures in the same surgery with mesh. The total surgical success rates for surgeons A and B were 82.2% and 94.1%, with median follow-up times of 60 and 33 months, respectively. More procedures were needed for the learning curve of vaginal pelvic reconstructive surgery with mesh. Having crossed the proficiency boundary, the surgical success rate and operation time were improved.

Innovations in the Management of Vaginal Cancer.

Primary vaginal cancer is a rare gynecologic malignancy. Given the rarity of the disease, standardized approaches to management are limited, and a great variety of therapeutic conditions are endorsed. This paper reviews advances in surgical approaches, radiation, chemoradiation, and immunotherapy. Advances in surgical management including the increasing use of laparoscopic and endoscopic approaches, as well as the novel techniques in vaginal reconstruction, are reviewed. Concurrent chemoradiation remains a mainstay of treatment for vaginal cancer and has improved local control of disease and overall survival. Additionally, with metastatic disease or situations where toxicity from CCRT is unacceptable, systemic therapies including immunotherapy approaches are reviewed.

Female Sexual Function Following Radical Cystectomy in Bladder Cancer.

A clear and well-documented gender bias exists in the evaluation of sexual outcomes for women undergoing urologic surgery. Due to the anatomic template of anterior exenteration, women are commonly left with side effects that include sexual dysfunction and the perpetuated effects of surgical menopause. To present evaluation and treatment recommendations for female sexual dysfunction treatment and evaluation, in addition to surgical templates during radical cystectomy (RC). This article reviews current literature regarding sexual function and RC with urinary diversion in female bladder cancer patients. Furthermore, this review will provide a review of techniques for organ and neurovascular preservation, along with novel vaginal reconstruction templates. Our review will further focus on emerging technology, including minimally invasive surgery and organ and nerve preservation, directed at preservation of female sexual function. Clinically, studies have demonstrated that females who have undergone genitalia-sparing and neurovascular preservation during RC regained sexual activity earlier than patients undergoing traditional RC. If organ and nerve preservation is not feasible due to involvement of trigone or bladder neck, vaginal reconstruction can mitigate the sexual dysfunction that results from a loss of the anterior vagina during a standard RC. Female sexual dysfunction is associated with high levels of patient distress and is best comanaged with a multidisciplinary treatment approach, including preoperative counseling, intraoperative nerve, and organ preservation, and postoperative interventions to mitigate sexual side effects. Davis L, Isali I, Prunty M, et al. Female Sexual Function Following Radical Cystectomy in Bladder Cancer. Sex Med Rev 2022;10:231-239.

A Pilot Study of Pre-Operative Vestibular Low Intensity Shockwave Therapy to Decrease Opioid Use Post-Vestibulectomy

ABSTRACT Introduction Surgeons performing complete vestibulectomy with vaginal advancement flap reconstruction for suspected neuroproliferative vestibulodynia (NPV) take into consideration the need for acute pain relief in the early postoperative period as well as risks for persistent post-operative opioid use. Post-operative acute pain has traditionally been managed with narcotics which are effective but are highly addictive and can cause unwanted side effects including nausea/vomiting, impaired mental function, and severe constipation/obstipation. We serendipitously observed that one patient who tried to avoid surgery by undergoing numerous vestibular low intensity shockwave therapy (LiWST) treatments used very few narcotics post vestibulectomy. LiWST is FDA-cleared for pain amelioration. It has been hypothesized that LiSWT downregulates inflammatory cytokines, promotes enhancement of blood flow and angiogenesis through expression of vascular endothelial growth factor and nitric oxide synthesis. Objective We performed a pilot study using pre-operative LiSWT to determine whether or not it might decrease post-operative opioid use (oxycodone/acetaminophen tablets; 5mg/325mg) for acute pain management in patients undergoing complete vestibulectomy with vaginal advancement flap for suspected NPV. Methods We studied the post-op opioid use of women who underwent complete vestibulectomy at our facility during the period January 1, 2019 through June 30, 2021. We assessed opioid use based on the patient's recall of the total oxycodone/acetaminophen tablets required in the first 30 days post-vestibulectomy. When possible, patients confirmed the use by counting tablets left in the pill container. Women scheduled to undergo vestibulectomy for suspected NPV were placed in the LiSWT study group if they agreed to undergo vestibular LiSWT treatment daily for the three business days immediately pre-operatively. Using the Urogold 100™MTS, LiSWT involved delivery of 1800 shocks to the vestibule per session, energy flux density 0.05-0.1 mJ/mm2, 3 Hz, membrane pressure 3. We compared the post-op opioid use by women in the LiSWT study group to the use by women who did not undergo pre-op LiSWT. Results Forty-five women (mean age 28 years; range 17 - 57) underwent complete vestibulectomy for suspected NPV during the 30 month period. Twenty women (mean age 27 +/- 9 years) agreed to undergo pre-op LiSWT and post-op opioid use was obtained in all. Twenty-five women (mean age 29 +/- 11 years) did not undergo pre-op LiSWT and opioid use was obtained in 19/25 (76%). Mean post-operative opioid use was 47 +/- 13 (range 25 - 90) tablets in those vestibulectomy patients who did not undergo pre-op vestibular LiSWT; opioid side effects included constipation, nausea, fainting, drowsiness, fatigue, and blurred vision. Mean post-op opioid use was 22 +/- 10 (range 1 - 26) tablets in the 20 vestibulectomy patients who did undergo pre-op vestibular LISWT sessions; opioid side effects were restricted to constipation, sleepiness, and nausea. Conclusions In this pilot study, pre-operative low intensity shockwave therapy decreased post-operative opioid use after complete vestibulectomy with vaginal advancement flap. While encouraging, more research is needed. Disclosure No

D2 MTE4 Case 11: Adult CAH, how do I optimize treatment?

28 years, female, born of non-consanguineous marriage, assigned female gender had genital ambiguity and seizures on day 10 of life. She presented to us at 9 years with genital ambiguity and hyperpigmentation. Tanner stage A3P4B2, external genitalia: phallic like structure 4.5 cm, posterior labial fusion, single opening, no palpable gonads. Unstimulated 17 OHP 192 ng/ml, testosterone and DHEAS elevated, low basal cortisol, other biochemical parameters normal, CT scan- bilateral adrenal enlargement, so a diagnosis of simple virilizing type of congenital adrenal hyperplasia was made and was started on T. Hydrocortisone and T. Fludrocortisone, after which pigmentation decreased. Gender role and identity as female. Underwent clitoral reduction and vaginal reconstruction. She had spontaneous puberty with pubarche at 7 years, thelarche at 10.5 years and menarche at 12.5 years. Her 17 OHP remained elevated and had early epiphyseal fusion leading to short stature. She had hirsutism at 16 years so she was started on T. Dexamethasone but was again changed to Hydrocortisone as she developed cushingoid features after 2 years. She is married for past 3 years and is eumenorrhic but now presents with primary infertility. Recent investigations revealed 17 OHP 50 ng/ml (Target: 4-12 ng/ml) and T 6.3 nmol/l. Currently on T. Hydrocortisone divided in 5 doses and T. Fludrocortisone 150 mcg. How to further manage fertility and long-term complications.?

Impact of intrarectal diazepam on early postoperative pain following pelvic reconstructive surgery: a double-blind, randomized placebo-controlled trial

To evaluate the effect of diazepam rectal suppositories on early postoperative pain following hysterectomy and vaginal reconstruction for pelvic organ prolapse. In this institutional review board approved, double-blind, randomized placebo-controlled trial, eligible patients were those scheduled to undergo a total vaginal hysterectomy with reconstructive surgery for prolapse. Consented patients were randomized to receive either a 10mg diazepam rectal suppository or an identical appearing placebo intraoperatively at the completion of surgery. Our primary outcome was vaginal pain 3.5-6 hours postoperatively utilizing the 100mm visual analog scale (VAS). Participants also completed surveys regarding pain at baseline, the morning of postoperative day (POD) one, and two-weeks postoperatively. Secondary outcomes included total morphine equivalents following surgery, patient satisfaction with pain control, and overall satisfaction. Chi-squared test, Fisher’s exact test, and Mann-Whitney test were utilized. Our sample size calculation demonstrated that 55 patients per arm were required to detect a difference in our primary outcome. From February 2020 to August 2021, 130 subjects were randomized. Seven patients withdrew, 113 have been analyzed to date; 57 in the diazepam group, 56 in placebo. The median age was 65 (IQR 27, 80), median BMI was 27.9 (IQR 18.70, 45.90), and 96.5% (n=109) of participants were white. There were no differences in baseline characteristics, prolapse stage, or types of procedures performed between groups. Ninety-nine percent (n=112) of participants had concurrent uterosacral ligament suspension, anterior and posterior repairs. Forty-one percent (n=46) had midurethral slings. Forty-five percent (n=51) had same-day discharge. There were no differences in the amount of intraoperative lidocaine injected (30.84 vs 30.16mL, p=0.679) or amount of rescue narcotics used in the immediate postoperative period (22.5 vs 16 morphine equivalents, p=0.286). There was also no difference in the primary outcome of VAS score for vaginal pain 3.5-6 hours postoperatively (24 vs 21mm, p=0.417). At their 2-week survey, patients in the placebo group reported higher satisfaction with pain control in the hospital (31 vs 41mm, p=0.012) and pain control at home (31 vs 40mm, p=0.043). No differences were noted among patients discharged on POD0 compared to those admitted overnight. In our population, placement of a 10mg Diazepam rectal suppository immediately following pelvic reconstructive surgery did not improve pain or narcotic usage in the early postoperative period. Although the placebo group reported slightly higher satisfaction with pain control two-weeks following surgery, overall pain levels were low. Therefore, we do not feel the addition of diazepam to the post-operative regimen is warranted.

Vaginal reconstruction using a gluteal transposition flap after abdominoperineal excision for anorectal malignancy

The purpose of this study is to present and evaluate a surgical method using gluteal flap for combined perineal and vaginal reconstruction after abdominoperineal excision (APE) with partial vaginectomy for anorectal malignancy. The method is a two-centre study of consecutive patients undergoing APE including partial vaginectomy for anorectal tumours, with immediate combined perineal and vaginal reconstruction using gluteal flaps. Follow-up data were retrieved via retrospective review of medical records, questionnaires and gynaecological examinations. Some 34 patients fulfilled the inclusion criteria. At the time of follow-up, 14 (78%) of the 18 patients alive responded to questionnaires. Seven (50%) of the survey responders agreed to undergo gynaecological examination. Major flap-specific complications (Clavien–Dindo > 2) were observed in 3 (9%) patients. Among survey responders, 11 (79%) had been sexually active preoperatively of which five (45%) resumed sexual activity postoperatively and three (27%) resumed vaginal intercourse. These three patients had all implemented an active vaginal health promotion strategy postoperatively. Perineo-vaginal reconstruction using gluteal flap after extended APE for anorectal malignancy is feasible. Although comparable to other methods of reconstruction, the rate of perineo-vaginal complications is high and post-operative sexual dysfunction is substantial. Postoperative strategies for vaginal health promotion may improve sexual function after vaginal reconstruction.

The Effect of Psychosexual Education on Promoting Sexual Function, Genital Self-Image, and Sexual Distress among Women with Rokitansky Syndrome: A Randomized Controlled Clinical Trial.

To assess the effectiveness of psychosexual education on promoting sexual function and genital self-image and reducing sexual distress through e-learning among women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Randomized controlled trial. Imam Khomeini Hospital "Pelvic Floor Clinic" in Tehran. Thirty-eight 15- to 49-year-old women with MRKH syndrome who had undergone surgical or nonsurgical vaginal reconstruction techniques more than 6 months before the intervention were assigned to 2 parallel intervention and control groups of 19 each. Psychosexual education was delivered through e-learning for the intervention group over an 8-week period, with no limitations of time and space. Sexual function, genital self-image, and sexual distress were evaluated at baseline, and at 4 and 8 weeks after the intervention. The data collection tools included the Persian version of the Female Sexual Function Index, Female Genital Self-Image Scale, and the Revised Female Sexual Distress Scale. The between group mean differences of sexual function, genital self-image, and sexual distress after 4 weeks (-1.2 [95% CI, -2.1 to -0.1], P=.025; -1.9 [95% CI, -2.9 to -0.9], P < .001; 4.2 [95% CI, 2.0-6.4], P < .001, respectively), as well as after 8 weeks (-1.8 [95% CI, -3.1 to -0.5], P=.009; -3.0 [95% CI, -4.5 to -1.5], P < .001; 6.7, 95% CI, 3.9-9.6], P <0.001, respectively) after baseline were significant. Psychosexual education improved sexual function and genital self-image and reduced sexual distress in women with MRKH syndrome. Therefore, using this approach, we can raise individuals' sexual knowledge and skills and correct their sexual beliefs and attitudes.

Vaginal Reconstruction with a Double-Sided Biomembrane--Preclinical Experimental Study on Large Animals

Vaginal Reconstruction with a Double-Sided Biomembrane--Preclinical Experimental Study on Large Animals

Neovaginoplasty with pudendal thigh flap for repair of vaginal agenesis: A case report and review of literature

Surgical management of vaginal agenesis constitutes a significant technical challenge. The goal of vaginal reconstruction is to create a neovagina that is both functionally and aesthetically satisfactory using a simple and reliable technique applicable to most. Bilateral pudendal thigh flaps were used to reconstruct neovagina for a 13-y girl with congenital vaginal agenesis. She presented with cyclical abdominal pain and hematometra, had normal secondary sexual characteristics and grossly normal external genitalia with a dimpling at the site of the vaginal orifice without lower vaginal tract.

Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study

IntroductionBeyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. MethodThis retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients’ data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. ResultsOne hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. ConclusionbTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.

Results of treatment of fifty children with persistent cloaca in one center

BACKGROUND: The preserved cloaca is a particular type of anorectal anomaly. The combination of urological, genital, and rectal abnormalities makes radical reconstruction difficult. MATERIALS AND METHODS: This study examined operations performed in 50 patients with persistent cloaca treated from 2010 to 2021. Two groups are presented: the first with 35 children and a short canal (3 cm), and the second with 15 children and a long canal (3 cm). We examined the prognosis for bowel control, the type of operation, the need for vaginal reconstruction, complications after surgery, and the days of hospital stay. RESULTS: Anomalies of the Mllerian ducts in the second group (94%) were higher than in the first (36%) (p 0.001). The sacral index and myelodysplasia did not differ in both groups. The sacral index in the first group was 0.62 0.14, and in the second group, it was 0.58 0.14 (p = 0.520). Myelodysplasia in the first group was 33%, and in the second group, it was 38% (p = 0.744). Total urogenital mobilization (51%) was used in the first group, and abdominal reconstruction (54%) was used in the second group. Vaginal reconstruction was required in 28% of patients in the first group and 60% in the second group. Complications were 3.5 times more likely in the first group (60% versus 17% in the second) (p = 0.003). The length of hospital stay in patients in the second group was longer than that of patients in the first group. CONCLUSION: Our study data demonstrate that the reconstruction of a persistent cloaca requires individual planning of the operation, considering the length of the canal and the state of all structures forming the cloaca.

A calcified pelvic mass in a girl with cloacal anomalies

A 15-year-old girl, who had been experiencing right lower abdominal pain for 24 h, visited our emergency department. She had a history of cloacal anomalies, including duplication of the vagina and uterus, for which she underwent rectal and vaginal reconstruction at the age of 1 year. Coexisting anomalies included left kidney agenesis, neurogenic bladder with right grade I vesicoureteral reflux, and tetralogy of Fallot after corrective repair. She has been receiving clean intermittent catheterization for neurogenic bladder since the age of 2 years.

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)

The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity. Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function. Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity. For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.

Refinement of recto-sigmoid colon vaginoplasty using a three-dimensional laparoscopic technique.

To investigate the feasibility, safety, and outcomes of three-dimensional (3D) laparoscopic vaginoplasty with a rectosigmoid colon flap for vaginal reconstruction.Following appropriate preoperative patient counseling, 17 consecutive patients underwent vaginoplasty using a 3D laparoscopic system. Perioperative and postoperative outcomes were retrospectively evaluated.Between September 2016 and February 2020, 17 patients underwent 3D laparoscopic vaginoplasty with a rectosigmoid colon flap. Of them, 15 (88%) were transgender female patients, and 2 (12%) were cisgender female patients with congenital deformities. Among the 15 transgender patients, 12 (80%) underwent de novo surgeries and 3 (20%) underwent re-do surgeries. The mean age at the time of operation was 33.0 years, and the mean total operation time was 529 ± 128 minutes. The initial intraoperative mean vaginal depth was 15.2 ± 1.3 cm, and the 30-day readmission rate was 5.9% (1/17 cases). The mean follow-up duration was 24.8 months.Perioperative and postoperative outcomes suggest that 3D laparoscopic rectosigmoid colon vaginoplasty is a potentially acceptable, effective, and safe method for vaginal reconstruction.

MP04-11 LAPAROSCOPY ASSISTED PERITONEAL PULL-THROUGH VAGINOPLASTY IN TRANSGENDER WOMEN, AN OLD TECHNIQUE IN MODERN TIME

You have accessJournal of UrologyTrauma/Reconstruction/Diversion: External Genitalia Reconstruction and Urotrauma (including transgender surgery) I (MP04)1 Sep 2021MP04-11 LAPAROSCOPY ASSISTED PERITONEAL PULL-THROUGH VAGINOPLASTY IN TRANSGENDER WOMEN, AN OLD TECHNIQUE IN MODERN TIME Marta Bizic, Borko Stojanovic, Marko Bencic, Slavko Matic, and Miroslav Djordjevic Marta BizicMarta Bizic More articles by this author , Borko StojanovicBorko Stojanovic More articles by this author , Marko BencicMarko Bencic More articles by this author , Slavko MaticSlavko Matic More articles by this author , and Miroslav DjordjevicMiroslav Djordjevic More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001971.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The gold standard in genital gender affirming surgeries (GGAS) is penile inversion vaginoplasty. In cases in whom penile skin is lacking. Either because of medication with puberty blockers or radical circumcision, or inadequate penile skin length, different options for neovaginal reconstruction must be offered to the patients. We asses laparoscopy assisted peritoneal pull-through vaginoplasty in combination with penile skin flaps for transgender women. METHODS: During two years period (March 2018-June 2020), we performed 47 primary laparoscopy assisted peritoneal pull-through vaginoplasties in transgender women. The surgery consisted of complete penectomy to the pubic bones in all patients, bilateral orchiectomy in 42 patients (5 patients had bilateral orchiectomy, prior the GGAS), clitoroplasty, urethroplasty, vulvoplasty and vaginoplasty using peritoneal flaps in combination with inverted penile skin flap. In two patients in whom lichen sclerosis was suspected removal of the affected skin was performed before creation of the neovagina. Two peritoneal flaps were dissected from the posterior aspect of the bladder and anterior aspect of the rectum in about 5cm in width and about 7cm in length and anastomosed with interrupted sutures with asymmetrically fashioned penile skin flap in order to prevent neovaginal stenosis. Vaginal packing is placed for the period of 5 days postoperatively, together with two drains. Urinary catheter is placed for urine derivation for 2 weeks. Compressive dressing is applied. RESULTS: Follow-up ranged from 6 to 23 months (mean 13 months). All patients were instructed to perform regular dilation of their neovagina for the first 12 months postoperatively by a pelvic floor physiotherapist. Even though peritoneum was found to produce some lubrication, patients were advised to use the lubricant during the sexual intercourse. Complications occurred in 5 of our patients: 3 had prolonged hematoma of the labia majora, one had neovaginal introitus dehiscence and one had superficial necrosis of the left labia majora. None of the complications required additional surgeries. The depth of the neovagina at the control check-up in 6 months after surgery was 14.7±0.5cm, while width was about 3.4±0.4cm. Majority of patients (≈96%) were satisfied with the new genitals, sensitivity, lubrication and possibility of engaging in sexual intercourse according to self-reports. One patient required reduction of the size of her clitoris because of hypersensitivity and the other one requested laser treatment of the incisional scars. CONCLUSIONS: Albeit known for quite a long time in vaginal reconstruction for cis-women languishing over vaginal agenesis and different states of vaginal absence, peritoneal pull-through vaginoplasty offers promising outcomes in transgender women GGAS that will give self-lubricating neovagina, with insignificant scarring and complications and high degree of patient's satisfaction. Source of Funding: / © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e71-e71 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Marta Bizic More articles by this author Borko Stojanovic More articles by this author Marko Bencic More articles by this author Slavko Matic More articles by this author Miroslav Djordjevic More articles by this author Expand All Advertisement Loading ...

"Three-Dimensional Printed Mold for Neovaginal Cavity Maintenance in Vaginal Agenesis: A Case Report"

Vaginal agenesis is one of the most common congenital anomalies of the female genital tract, occurring in 1 out of 5,000 to 10,000 live born females [1]. It may present either as an isolated developmental defect or within a complex of other anomalies and is commonly associated with Mayer Rokitansky Küster Hauser syndrome. Several surgical methods for vaginal reconstruction have been introduced in the literature

Predicting the return of bladder function following vaginal native tissue repair using data from a suprapubic catheter regimen.

To evaluate time to return of normal voiding function following native tissue vaginal reconstruction and evaluate risk factors for postoperative urinary retention (POUR). A retrospective cohort analysis of women undergoing vaginal reconstruction and suprapubic catheter with standardized regimen for voiding trials. Postvoid residual <150 ml at 4 h post catheter clamping was used as surrogate marker for return of bladder function. Univariate and multivariate regression analyses were used to identify risk factors for return of bladder function >4 days after surgery. Between 2013 and 2018, 148 women underwent surgery, 124 were analyzed. Mean age was 67 years (±11.1), 62.9% (n = 78) had greater than or equal to stage 3 prolapse. Mean time to return of bladder function: 4.1 days (±3.1). Significant risk factors for >4 days to return of bladder function on univariate analysis included (mean ± SD): surgery length (150.4 min ±44.6) (odds ratio [OR], 1.24; confidence interval [CI], 1.12, 1.38); anesthesia length (228.1 min ±53.5) (OR, 1.12; CI: 1.04, 1.23); length of stay (2.2 days ±2.7) (OR, 2.43; CI: 1.11, 5.35); hysterectomy (OR, 3.10; CI: 1.39, 6.90); estimated blood loss (124.4 ml ±64.8) (OR, 1.39; CI: 1.04, 1.87). Postmenopausal status was protective (OR, 0.17; CI: 0.03, 0.92.). On multivariate analysis, significant findings were diabetes mellitus (OR, 0.18; CI: 0.04, 0.93) and surgery length (OR, 1.21; CI: 1.06, 1.38). Hysterectomy, surgical length and estimated blood loss were significantly associated with delayed return of bladder function after native tissue vaginal reconstruction. This data can help clinicians tailor postoperative voiding trials after failed initial attempt.

Utilization and perioperative outcome of minimally invasive pelvic exenteration in gynecologic malignancies: a national study in the United States

<h3>Objectives:</h3> To examine characteristics and short-term perioperative outcomes related to minimally invasive pelvic exenteration for gynecologic malignancy. <h3>Methods:</h3> This comparative effectiveness study is a retrospective population-based analysis of the National Inpatient Sample from 10/2009-9/2015. Women with cervical, uterine, vaginal, and vulvar malignancies who underwent pelvic exenteration were evaluated based on the use of laparoscopic or robotic-assisted surgery. Patient demographics and intraoperative/postoperative complications related to a minimally invasive surgical approach were assessed. <h3>Results:</h3> Among 1,159 women who underwent pelvic exenteration, 39 (3.4%) had the procedure performed via a minimally invasive approach. The majority of minimally invasive cases were robotic-assisted (<i>n</i>=25, 64.1%). Women in the minimally invasive group were more likely to be White and have cervical cancer, but less likely to be obese and receive vaginal reconstruction or colostomy when compared to those in the open surgery group (all, <i>P</i><0.05). Overall perioperative complication rates were similar between the minimally invasive and open surgery groups (74.4% versus 78.9%, <i>P</i>=0.549), but the minimally invasive group had a decreased risk of high-risk complications compared to the open surgery group (adjusted-odds ratio 0.24, 95% confidence interval 0.09-0.65). Specifically, a minimally invasive approach was associated with decreased incidence of hemorrhage and sepsis compared to an open approach (all, <i>P</i><0.05). The minimally invasive group had a shorter length of stay (median, 9 versus 15 days) and lower total charge (median, $118,711 versus $213,640) compared to the open surgery group (both, P<0.001). <h3>Conclusions:</h3> Laparotomy remains the main surgical approach for pelvic exenteration for gynecologic malignancy in the United States. Minimally invasive pelvic exenteration need to be carefully evaluated before widely adopting this approach.