Vaginal Stenosis Research Articles

Vaginal Microbiome as a Biomarker of Vaginal Health and Patient-Reported Outcomes in Women Receiving Pelvic Radiation

<h3>Purpose/Objective(s)</h3> A potential cause of differences in the extent of vaginal changes after radiation is the vaginal microbiome (VM), which is also highly variable and has been associated with vaginal health. Little is known regarding the impact of an altered VM on vaginal health outcomes. The primary objective of the study is to determine the feasibility of implementing a prospective, comprehensive assessment of women's vaginal health using patient reported outcomes (PROs), physical exam findings, and biological correlatives. Secondary objectives are to determine whether women who experience vaginal toxicity have a distinct VM. We hypothesize that clinician-initiated sample collection for biomarker discovery concurrent with vaginal exams will be feasible and that high pre-treatment <i>Lactobacillus</i> to <i>Prevotella</i> ratio will be associated with post-treatment vaginal symptoms. <h3>Materials/Methods</h3> This is a prospective, observational study of women receiving pelvic radiation for Gyn/GI cancers. Pelvic exam data, vaginal swab, and PROs are collected at baseline and then 1, 3, 6, 12, 18, and 24 months after completion of radiation. Feasibility is defined as clinician-collected biomarker collection concurrent with standard of care exams with >90% accrual and compliance. Preliminary baseline to one-month post-radiation changes in sexual function (FSFI), sexual distress (FSDS), and vaginal length were evaluated by paired t-test, and in vaginal stenosis by Wilcoxon rank-sum test. Vaginal swabs are being prepared for combined transcriptomics and metatranscriptomics with human ribosomal depletion and sequencing (2 × 125bp, sequencing platform). Preliminary analysis from our novel methods to simultaneous evaluate changes in microbe relative abundances, microbe expression, vaginal gene expression, vaginal immune cell abundances, and associations with PROs and objective measures of vaginal changes will be available in the spring 2022. <h3>Results</h3> 39/89 participants have been accrued to the ongoing study – 5 anal SCC, 9 rectal AC, 17 cervical (13 SCC, 4 AC), 7 endometrial (6 endometrioid, 1 carcinosarcoma), 1 vaginal SCC. The mean age is 57.6 years. Most participants are white (87.2%), postmenopausal prior to treatment (62%) and married or partnered (54%). All patients were treated with external beam radiation and 17 also received brachytherapy. Baseline mean FSFI and FSDS scores are 14.2 and 8.8, respectively. No change in FSFI, FSDS, or vaginal length were observed in the initial timepoints (n = 39, p=0.69, p=0.97, and 0.62, respectively). We observed a significant change in vaginal diameter (Wilcoxon rank sum, p = 0.04). Human and microbial RNA has been purified for sequencing. Metatranscriptomic VM data is currently being analyzed to assess for changes. <h3>Conclusion</h3> Our novel comprehensive assessment of women's vaginal health and microbiome collection/analysis has been feasible with early results showing a change in vaginal diameter at one month post radiation. Microbiome analysis is pending.

Clinical Outcomes of Patients with FIGO Stage IVB Gynecologic Malignancies Treated with Aggressive Radiotherapy

<h3>Purpose/Objective(s)</h3> Therapeutic options for patients with FIGO stage IVB gynecologic malignancies (GM) are limited. While systemic therapy is the mainstay of treatment, radiotherapy (RT) can play a role. Traditionally, RT has utilized lower doses with a goal of symptom control. However, escalated doses of RT with definitive doses may maximize symptomatic palliation, long term disease control and overall survival (OS). The primary aim of this study is to examine our experience treating FIGO stage IVB GM with escalated doses of RT (external beam radiotherapy, EBRT +/- brachytherapy, BT). <h3>Materials/Methods</h3> Patients with FIGO stage IVB GM treated with RT at a tertiary medical center between 01/2013 and 12/31/21 were retrospectively reviewed. Patients treated with traditional palliative doses (≤30Gy or "quad shot") and those who did not receive RT to the pelvis were excluded. Acute toxicity was defined as occurring ≤30d of RT completion. Demographic and clinical traits were summarized by descriptive statistics. Discrete variables were summarized by frequencies and percentages and continuous variables were summarized by mean, median, and standard deviation. OS and PFS were assessed by Kaplan-Meier method. Bivariate associations were assessed through Spearman's correlation test. Statistics were run using statistical software. <h3>Results</h3> 22 patients met criteria for inclusion, 11 with endometrial, 8 with cervical and 3 with vaginal/vulvar cancer. Median age was 58. Adenocarcinoma was the most common histology (55%). The most common locations of metastatic disease were distant lymph node (23%), bone (23%) and lung (23%). 77% of patients had more than one site of metastatic disease. 13 patients had systemic therapy and 9 had surgery prior to RT. All patients started EBRT, with most common planned fractionation of 45 Gy in 25 fractions. 18 patients (81.8%) completed their prescribed course of EBRT. Only 1 patient discontinued RT due to disease progression. 11 patients completed BT, most commonly (18.2%) with a vaginal cylinder. Only 2 patients (9.1%) experienced a grade 3 (G3) toxicity: 1 dermatitis and 1 fistula. Grade 2 (G2) acute toxicities include: 5% cystitis, 36% proctitis, 5% vaginal stenosis, 14% dermatitis/mucositis, 14% vaginal pain and 23% nausea. G2 late toxicities include: 5% cystitis, 5% proctitis and 5% vaginal pain. At mean follow up of 26.5 months, 40.9% of patients were deceased. 11 patients (50%) experienced disease recurrence/progression, most commonly outside of the RT field (63.6%). Four patients (18.2%) experienced local progression/recurrence. Median time to recurrence/progression was 18.0 months (95% CI 0-49.5). Median OS was 45.0 months (95% CI 15.4-74.6). <h3>Conclusion</h3> Escalated doses of RT for patients with FIGO IVB GM has tolerable acute and late toxicities while providing meaningful locoregional control. This warrants additional investigation into this treatment regimen.

Long-Term Results Following Use of Vaginal Electronic Brachytherapy in the Management of Endometrial Cancer

<h3>Purpose/Objective(s)</h3> We evaluated long-term vaginal toxicity and disease outcomes in women treated with vaginal electronic brachytherapy (EBT) following surgical management of endometrial cancer. <h3>Materials/Methods</h3> Women with endometrial cancer treated with adjuvant EBT were included in this study. Women diagnosed with uterine cancer of high-risk histology or advanced stage received EBT following completion of adjuvant chemotherapy. EBT was performed using a miniature low-energy (50-kV peak) X-ray source with a single-channel vaginal cylinder applicator to deliver radiation to the vagina along a specified length of the cylinder. EBT was delivered either as monotherapy or as a sequential boost following completion of pelvic external beam radiation (EBRT). EBT was delivered to 4 cm treatment length prescribed as 7 Gy to 5 mm depth x 3 fractions in the EBT alone group or 6 Gy to vaginal surface x 3 fractions in the EBT boost group. Following completion of EBT, patients were evaluated for all toxicities and recurrences. In this study, we evaluated for treatment related vaginal toxicity (stenosis) which was scored according to the Common Terminology Criteria for Adverse Events version 5.0. Multivariable analysis (MVA) of prognostic factors was performed using Cox Proportional-Hazards Model, and disease-free survival (DFS) and overall survival (OS) were estimated from date of surgery with Kaplan-Meier Method using data management and decision management software. <h3>Results</h3> 70 women were treated from 12/2017-6/2020 with EBT following hysterectomy. Median age of the cohort was 68 years (range, 51-85 years). 37 presented with endometrioid histologies. 32 received adjuvant chemotherapy prior to EBT. 21 presented with stage II or greater disease, and 20 received EBRT prior to EBT boost. EBT was delivered over a median interval of 1.3 weeks (range, 0.3-3.1 weeks). At a median follow-up of 25.0 months (range, 7.2-47.4 months), no patients were found to have ≥ grade 3 vaginal toxicity. The cumulative risk of developing gr 1 and 2 vaginal toxicity at 30 months was 25%. Prescription to 5 mm depth was the only factor associated with development of vaginal toxicity (p<0.05). One vaginal cuff recurrence, one locoregional recurrence, and ten distant recurrences were observed. Advanced tumor stage, high-risk histology, cervical stroma involvement, treatment with chemotherapy, and treatment with EBRT were significantly associated with inferior DFS/OS on MVA. DFS and OS in this group at 12 and 36 months were 94.2%/69.4% and 95.7%/88.3%, respectively. <h3>Conclusion</h3> EBT appears to be a safe, well-tolerated, and a promising alternative treatment option to traditional vaginal brachytherapy using a radioactive source. On MVA, prescription of EBT to 5 mm depth was associated with vaginal stenosis. One local recurrence was observed at 25 months follow-up. Risk of developing vaginal toxicity, DFS, and OS, following treatment with EBT in this heterogeneous population appear to be acceptable and comparable to historical controls (PORTEC 2 PMID 20206777).

Late toxicity within a Phase III clinical trial of IG-IMRT in cervix cancer (PARCER): Reanalysis with time weighted adverse event reporting (MOSES)

Background and purposeThis post-hoc analysis was performed to report the impact of Image guided intensity modulated radiotherapy (IG-IMRT) and three-dimensional conformal radiotherapy (3D-CRT) across organ system and grades of toxicity within PARCER trial (NCT 01279135). Primary endpoint of PARCER focused on grade ≥ 2 late gastrointestinal (GI) toxicity using Common Terminology Criteria for Adverse Events (CTCAE). We now analyze all adverse events using CTCAE and time and severity weighted toxicity reporting method (MOSES). Materials and methodsMOSES was calculated separately for GI, genitourinary (GU)/GI, and any late toxicities (GI, GU, lymphedema, fatigue, vaginal stenosis, fibrosis and constitutional symptoms) by imputing proportionate time weightage to CTCAE. Cumulative MOSES (C-MOSES) for multiple system and multiorgan toxicity was determined. Difference in arms was analyzed as time-to-event and intention-to-treat analysis using CTCAE grade ≥ 1 and C-MOSES ≥ 0.70. ResultsWe observed no difference in the 3-year cumulative incidence of CTCAE grade ≥ 1 GI, GI or GU, or any late toxicity between treatment arms. However, while using C-MOSES, HR of 0.59 (95% CI 0.38–0.92, p = 0.017), 0.68 (95% CI: 0.44–1.05, p = 0.08) and 0.72 (95% CI: 0.52–0.99, p = 0.04) was observed for GI, GI or GU, or any late toxicity within IG-IMRT respectively. ConclusionThis demonstrates superior discrimination of intervention effects using MOSES which demonstrates superiority of IG-IMRT.

Staged feminizing genitoplasty with total urogenital sinus mobilization

Background: The diagnosis and treatment of individuals with Disorders of Sexual Development is a complex process and requires a multidisciplinary approach. Each individual should be evaluated objectively and the treatment process of each individual has its own unique differences. The aim of this study is to discuss the effectiveness of staged feminizing genitoplasty operations using the total urogenital mobilization technique. Material and methods: Hospital records of patients who underwent vaginoplasty using the TUM technique between 2014 and 2019 by a single surgeon in a pediatric surgery center of a tertiary pediatric hospital were retrospectively reviewed. Results: All ten patients who underwent TUM had 46 XX chromosomes. The TUM procedure for vaginoplasty was performed in all patients by the author. A clitorolabioplasty had been previously performed in six patients with congenital adrenal hyperplasia. The follow-up period of the patients was 1-6 years. No serious complications developed in any of the patients. Neither infection nor tissue necrosis occurred. A second surgical procedure was not required for urinary fistula, vaginal stenosis, urinary incontinence, or early suture dehiscence. Conclusion: This study shows that vaginoplasty can be performed in a single session in infancy for patients with low confluence and a short Urogenital Sinus (UGS). Apart from this, postponing vaginoplasty surgeries to the adolescence period and performing UGS mobilization surgery seem to carry successful results.

THE EXCEPTION OR THE RULE? ANASTOMOTIC VAGINAL STRICTURE AFTER UTERUS TRANSPLANT: CASE SERIES AND SYSTEMATIC REVIEW

To report the incidence and management of vaginal stricture at the donor/recipient anastomosis in all uterus transplants performed in the United States between 2016 and 2021, and to review the literature on vaginal stricture in patients with uterus transplant.

Wharton-Sheares-George vaginoplasty for Müllerian agenesis: A case report

Abstract&#x0D; Background: Müllerian agenesis is a rare embryological disorder that affects 1 in 4500-5000 female livebirths. It may result in anomalies of the uterus, vagina, or both necessitating surgical management.&#x0D; Case presentation: A 23-year-old nulliparous presented to the gynecological ward with amenorrhea, severe lower abdominal pain, and bloating. Physical examination revealed well-developed breasts in Tanner stage v. The vagina was noted as a blind-ending dimple with a patent urethral opening. Pelvic magnetic resonance imaging revealed hematometra in the rudimentary right uterine horn. She was scheduled for diagnostic laparoscopy and Wharton-Sheares-George vaginoplasty. A review four weeks later revealed vaginal stenosis, which was managed laparoscopically, with the excision of the rudimentary uterine horn. Her postoperative recovery was uneventful. Her external genitalia were normal, and the vaginal mucosa was typical, with a depth of 6cm and she is currently using Syracuse vaginal dilators and on long-term follow-up.&#x0D; Conclusion: Wharton-Sheares-George vaginoplasty is a minimally invasive, quick, reliable, and safe procedure for patients with Müllerian agenesis requiring vaginoplasty

Systematic Review of Comparisons Between Plastic and Silicone Dilators: Revealing a Knowledge Gap.

Vaginal stenosis is a distressing side effect of radiation therapy that can impair quality of life. Dilator therapy is an option for patients undergoing pelvic radiotherapy to mitigate vaginal stenosis. Currently, the dilators given to patients by most hospitals are made of plastic, compared to silicone dilators which are available on the market for purchase. We conducted a systematic literature review to find information to guide clinical recommendations to pelvic radiotherapy patients on potential differences regarding the use of plastic vs silicone dilators with regard to efficacy, cost, and patient preferences. A systematic literature review was conducted in Embase, MEDLINE, and PubMed using Emtree terms. To be included in the review, papers needed to: focus on female patients undergoing radiation therapy, assess a vaginal dilator, measure any dilator intervention outcome, and specifically compare plastic vs silicone dilators for any measured outcome (either qualitative or quantitative). The initial search yielded 195 articles. Two area experts, with a third expert for arbitration, read each article and found that none met all review inclusion criteria. No studies were found that compared silicone to plastic dilators with regard to efficacy in treating vaginal stenosis due to radiation therapy, no studies were found that compared cost or cost-effectiveness of the 2 dilator types, and no studies were found comparing patient preferences or experiences (eg, comfort, adherence, ease of use) between the 2 dilator types. The materials used to create dilators have never been rigorously compared in the context of radiotherapy-related vaginal stenosis. Institutions and patients have no data to guide their choice. Significantly more research at the patient and institutional level is needed to explore the potential long-term quality of life and cost benefits of improved adherence with silicone dilator use, and to guide shared decision-making regarding dilator choice.

Treatment Outcomes of Computer Tomography-Guided Brachytherapy in Cervical Cancer in Hong Kong: A Retrospective Review.

Simple SummaryThis retrospective study reviews 135 patients with locally advanced cervical cancer treated with chemo-radiotherapy with image-guided adaptive brachytherapy with CT guidance. The study has a long follow-up period of 53.6 months. The outcome was excellent with a five-year local control, pelvic control, distant metastasis-free survival and overall survival rates being 90.7%, 84.2%, 80.0% and 87.2%, respectively. Adenocarcinoma was significantly associated with worse local control, pelvic control, distant metastasis-free survival and overall survival rates.(1) Background: To report the long-term clinical outcomes of computer-tomography (CT)-guided brachytherapy (BT) for locally advanced cervical cancer. (2) Methods: A total of 135 patients with FIGO stage IB-IVA cervical cancer treated with definitive radiotherapy +/− chemotherapy with an IGABT boost at Queen Mary Hospital, Hong Kong, between November 2013 and December 2019 were included. Treatment included pelvic radiotherapy 40 Gy/20 Fr/4 weeks +/− chemotherapy then CT-guided BT (7 Gy × 4 Fr) and a sequential parametrial boost. The primary outcome was local control. Secondary outcomes were pelvic control, distant metastasis-free survival, overall survival (OS) and late toxicities. (3) Results: The median follow-up was 53.6 months (3.0–99.6 months). The five-year local control, pelvic control, distant metastasis-free survival and OS rates were 90.7%, 84.3%, 80.0% and 87.2%, respectively. The incidence of G3/4 long-term toxicities was 6.7%, including proctitis (2.2%), radiation cystitis (1.5%), bowel perforation (0.7%), ureteric stricture (0.7%) and vaginal stenosis and fistula (0.7%). Patients with adenocarcinomas had worse local control (HR 5.82, 95% CI 1.84–18.34, p = 0.003), pelvic control (HR 4.41, 95% CI 1.83–10.60, p = 0.001), distant metastasis-free survival (HR 2.83, 95% CI 1.17–6.84, p = 0.021) and OS (HR 4.38, 95% CI: 1.52–12.67, p = 0.003) rates. Distant metastasis-free survival was associated with HR-CTV volume ≥ 30 cm3 (HR 3.44, 95% CI 1.18–9.42, p = 0.025) and the presence of pelvic lymph node (HR 3.44, 95% CI 1.18–9.42, p = 0.025). OS was better in patients with concurrent chemotherapy (HR 4.33, 95% CI: 1.40–13.33, p = 0.011). (4) Conclusions: CT-guided BT for cervical cancer achieved excellent long-term local control and OS. Adenocarcinoma was associated with worse clinical outcomes. (4) Conclusion: CT-guided BT for cervical cancer achieved excellent long-term local control and OS. Adenocarcinoma was associated with worse clinical outcomes.

Long-Term Results of Surgical Treatment and Patient-Reported Outcomes in Congenital Adrenal Hyperplasia-A Multicenter European Registry Study.

Representatives for congenital adrenal hyperplasia (CAH) continue to desire early feminizing surgery in girls with 46,XX-CAH. The aim of this analysis, which included 174 46,XX- individuals with salt-wasting (SW) or simple-virilizing (SV) CAH, a female gender identity, and an age > 16 years participating in a multicenter cross-sectional clinical evaluation study (dsd-LIFE), was to evaluate the long-term results of surgery and patient-reported outcomes (PRO). The gynecological examination (n = 84) revealed some shortcomings concerning surgical feminization. A clitoris was absent in 9.5% of cases, while a clitoral hood was missing in 36.7% of cases. Though all women had large labia, they didn’t look normal in 22.6% of cases. Small labia were absent in 23.8% of cases. There was no introitus vaginae, and the urethra and vagina had no separate opening in 5.1% of cases. A mucosal lining was missing in 15.4% of cases. Furthermore, 86.2% of the women had scars at the region of their external genitalia. A vaginal stenosis was described in 16.5% of cases, and a meatal stenosis was described in 2.6% of cases. Additionally, PRO data showed a very-/high satisfaction rate of 21.3%/40.2% with cosmesis and 23.8%/38.1% with functionality, while 3.3%/10.7% showed a very-/low satisfaction with cosmesis as well as 5.6%/10.3% with functionality. The remaining women—24.6% and 23.8%—were indifferent. Satisfaction concerning sex life was very-/high in 9.6%/27.7%. In 12.0%/16.9% it was very-/low. Furthermore, 33.7% had no opinion. Furthermore, 27.0%/31.6% of the women reported that clitoriplasty, but not clitoridectomy, had a very-/positive influence on their lives, while 1.3%/8.9% felt it to be very-/negative, and 28.4% were indifferent. Vaginoplasty had a very-/positive influence in 25.7%/33.8% and a very-/negative effect in 3.6%/6.8%. 29.7% had no opinion. Additionally, 75.7% of the women preferred feminizing surgery during infancy/childhood, especially concerning clitoreduction. In conclusion, though the majority of the participants (76%) preferred early feminizing surgery and 60% described a positive effect on their lives, about 10% felt it to have been negative. About 15% of the women suffered from insufficient cosmesis and functionality after surgery. Sex life was even described as poor in nearly 30%. Therefore, the decision about early genital surgery in 46,XX-CAH girls should be considered carefully. Parents should get detailed information about possible complications of surgery and should receive support to understand that postponing surgery does not inevitably cause harm for their child. Importantly, genital surgery when performed in children should only be performed in expert centers with a specialized team including surgeons who are trained in feminizing surgery.

Sexual Pain Symptoms in Premenopausal Women with Vulvar Lichen Sclerosus

ABSTRACT Introduction Lichen sclerosus (LS) is a chronic, inflammatory skin condition that primarily affects the anogenital epithelium in women. Vulvar LS has historically been regarded as a condition of premenarchal girls and postmenopausal women, overlooking women of reproductive age. Although vulvar LS characteristically presents with pruritis, specialists in LS have clinically observed that premenopausal women often present with dyspareunia related to introital tearing and vulvar skin changes. Objective This study aims to characterize the clinical presentation of vulvar LS among premenopausal women related to sexual pain. Methods A cross-sectional web-based study was conducted in premenopausal women with biopsy-confirmed vulvar LS between the ages of 18-50 years. Participants completed a 28-question survey evaluating characteristics of symptoms, as well as timing and accuracy of diagnosis. Numerical data were expressed as mean +/- standard deviation. Bivariate Pearson correlation was used to determine the relationship between age of symptom onset and time interval to diagnosis. Results Of the 956 responses received, 503 met inclusion criteria of biopsy confirmed LS and premenopausal status. Self-reported ethnicity of the study population was 87% White, 4% Latina or Hispanic, 2% Asian, and 1% Black. The mean age of the population was 37 years, ranging from 19-50 years. There was a 4-year delay in diagnosis, with an average age of symptom onset of 27 years and average age of diagnosis of 32 years. There was an inverse correlation between the age at which symptoms began and the time interval to diagnosis with a Pearson correlation coefficient of -0.487 (t(455)=14.184, p&amp;lt;.0001). Most prevalent symptoms were dyspareunia (68%), tearing with intercourse or vaginal insertion (63%), and decreased clitoral sensation (35%). Symptoms reported as most affecting the individual were dyspareunia (44%), tearing with intercourse or vaginal insertion (39%) and pruritis (25%), followed by decreased clitoral sensation (13%). Symptoms that most frequently prompted patients to seek medical attention were dyspareunia (35%), pruritus (31%), and tearing with intercourse or vaginal insertion (26%). Only 4% of respondents reported that decreased clitoral sensation prompted medical attention. Most prevalent skin changes included hypopigmentation (81%), vulvar fissures (72%), labial resorption (60%), clitoral phimosis (39%), and vaginal stenosis (37%), with vulvar fissures affecting the individual the most (48%) and prompting medical attention (39%). Sixty-six percent of respondents initially received an alternative diagnosis, most commonly vulvovaginal yeast infection (49%). Conclusions Vulvar LS affects premenopausal women and often causes skin changes related to sexual function. This condition is often misdiagnosed as vulvovaginal candidiasis, leading to a delay in diagnosis of 4 years, which is consistent with existing literature. LS symptoms in premenopausal women related to sexual function and pain include dyspareunia, tearing with intercourse or vaginal insertion, and decreased clitoral sensation. These symptoms may be more concerning to premenopausal women, who are more likely to be sexually active, than the classic symptoms of vulvar pruritis found predominantly in postmenopausal women. Vulvar LS should be considered and evaluated in women of all ages presenting with vulvar symptoms and sexual pain. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Consultant for Good Clean Love and Mahana Therapeutics; Part-time employee of Dare Bioscience, has received research funding from Dare Science, SST, Endoceutics, The Cellular Medicine Association, and Ipsen for other projects, and is a consultant for Ipsen, SST, and AMAG

Vaginal 11-point and volumetric dose related to late vaginal complications in patients with cervical cancer treated with external beam radiotherapy and image-guided adaptive brachytherapy

ObjectiveTo investigate the vaginal 11-point and volumetric dose-toxicity relationships in definitive cervical cancer radiotherapy. MethodsA retrospective cohort study of patients with cervical cancer with a complete response of at least 12 months was performed. Additional per vaginal examinations and patient-scoring questionnaires on the date of patient enrolment were assessed for vaginal strictures. Retrospective dosimetric analysis of vaginal 11-point and volumetric doses was performed with descriptive and probit analyses to investigate dose-toxicity relationships. ResultsNinety-seven patients were included in the study, with a 20-month median follow-up. The incidence rate of grade 3 vaginal strictures was 22.7%. A comparison between patients with grade 1–3 vaginal strictures revealed significant differences in age, stage, initial tumour size, and vaginal involvement. PIBS + 2, PIBS, PIBS-2, D + 5, and D2cc were all significantly different among grade 1–3 vaginal strictures and showed significant probit coefficients. The lateral dose points were significantly higher in grade 2 strictures, but negative probit coefficients failed to establish causal inferences. Post-estimation analyses yielded effective doses (ED) for 15% and 20% probability of grade 3 vaginal strictures (ED15 and ED20) for PIBS + 2 at 57.4 and 111 Gy3, respectively. PIBS-2 yielded an ED20 of 7 Gy3. D + 5 yielded positive ED10, ED15, and ED20 values of 52.2, 66.6, and 78 Gy3, respectively. ConclusionsThis study showed a significant relationship between age, tumour size, and lower-third vaginal involvement with the incidence of vaginal toxicity. The goal of a cumulative radiotherapy dose of ≤ 55 Gy3 to PIBS + 2, ≤5 Gy3 to PIBS-2, and ≤ 65 Gy3 to D + 5 points may reduce the risk of grade 3 vaginal stenosis to less than 15–20%.

Stevens Johnson Syndrome: Past, Present, and Future Directions Gynecologic Manifestations and Management in SJS/TEN.

Stevens Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) are severe mucocutaneous hypersensitivity disorders characterized by sudden onset epidermal necrosis. Acute manifestations of SJS/TEN often include vulvovaginal erosions, ulcerations, vaginal discharge, bleeding, vaginal pain, dysuria, and urinary retention. If not treated, this can lead to complications such as vulvovaginal adhesions, vaginal stenosis or dryness, pain, dyspareunia, bleeding, and adenosis. Even with adequate treatment, there are lasting impacts including difficulty with vaginal exams and psychological distress. Early recognition and treatment of vulvovaginal involvement are crucial to preventing severe sequelae. Despite the potentially devastating consequences of genitourinary involvement of SJS/TEN, involvement of the mucocutaneous surfaces of the vulva and vagina is inconsistently documented, and protocols for treatment and follow-up are not well-established. The treatment of vulvovaginal involvement relies largely on expert opinion, and there is little data on the efficacy of suggested management. The goal of this review was to identify whether establishing a clinical pathway increased treatment of vulvovaginal SJS/TEN and to optimize our standardized protocol to prevent genitourinary sequelae.MethodsWe conducted a retrospective chart review of female patients with SJS/TEN at Harborview Medical Center, University of Washington from 2008 to 2021. Demographic and clinical data including gynecologic consultation, exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record. We compared data before and after implementation of a clinical care pathway in 2017.ResultsWe reviewed a total of 88 charts of women with possible SJS/TEN between 2008 and 2021. Of these 88 charts, 77 were found to have clear biopsy proven diagnosis of SJS/TEN. A total of 42 patients were found to have vulvovaginal involvement (55%) and gynecology was consulted in 43% of cases. 50% of patients (n = 21) with vulvovaginal involvement were recommended treatment with vaginal dilators and steroid ointment and 34% of patients with genital involvement received no treatment.Between 2008 and May of 2017 (pre-protocol), we found 55 patients with SJS/TEN. 55% of patients (n = 29) had vulvovaginal involvement (n = 26 vulvar, n = 21 vaginal). Gynecology was only consulted in 26% (n = 14) of patients. Of the 21 females with vaginal involvement, only 38% (n = 8) had dilators/vaginal molds with steroid ointment recommended. Of the 26 females with vulvar involvement, 31% (n = 8) had no vulvar treatment recommendations with the remaining 69% having some documentation that ranged from gauze placement only (19%) to topical lidocaine, barrier cream, antibiotic or antifungal cream/ ointment, lubricant, or topical steroid ointment (50%). Menstrual suppression was recommended in 38% (n = 9) of menstruating females. An antifungal medication was only prescribed in 4% of patients.Following implementation of the clinical pathway for the treatment of SJS/TEN in 2017, 22 females with SJS/TEN were identified. 72% (n = 16) had documented vulvovaginal involvement (n = 16 vulvar, n = 9 vaginal). Gynecology consultations took place in 86% (n = 19) of patients. We identified several improvements after implementation of the protocol. Gynecology consults overall increased from 26% pre-, to 86% post-protocol. For patients with vulvovaginal involvement, consultations were completed in 93% compared to 50% prior to protocol. Of note, the finding of vulvovaginal lesions increased from 53 to 72%. Dilator use with topical steroid ointment was consistently recommended, as was antifungal use and menstrual suppression.ConclusionHaving a protocol in place for treatment of female patients with SJS/TEN increased the consistency of Gynecologic consultation and the documentation and treatment of vulvovaginal SJS/TEN. We identified the need to improve clinical follow-up after discharge from the hospital, which could be arranged as multidisciplinary visits and would be a good option to assess long-term outcomes (pain, sexual activity, etc.). With regards to future directions, we are in the process of assessing long-term data on quality of life and sexual functioning. The impact of treatment in the acute setting on the development of chronic sequelae needs to be established, as does the management of long-term sequelae like vaginal dryness, pain, dyspareunia. The role of local estrogen and vaginal laser still needs to be explored. Pelvic floor physical therapy might play a significant role in rehabilitation and has yet to be studied.

Implementation of Image-Guided Brachytherapy for Pediatric Vaginal Cancers: Feasibility and Early Clinical Results.

Simple SummaryBrachytherapy is one of the cornerstones of the treatment of pediatric vaginal tumors in combination with surgery and chemotherapy from a conservative perspective. In this retrospective series, we present our experience with 3D pulsed dose rate brachytherapy for the treatment of children with vaginal tumors. Our results show that this treatment has good compliance and provides an excellent local control rate. The toxicity rate is also favorable, with gynecological toxicities being the most frequent. Given the rarity of these diseases, their management should be entrusted to expert centers.Background: Brachytherapy (BT) has a major role in pediatric cancers of the lower genital tract, as part of a multimodal organ conservative strategy. Scarce data are available on the location of image-guided BT. Methods: Medical records of all consecutive girls treated in our center between 2005 and 2020 for a vaginal tumor with exclusive image-guided PDR-BT were retrospectively examined, with a focus on treatment parameters, patient compliance, and clinical outcome, including analysis of local control, survival and late toxicity rates. Results: Twenty-six patients were identified, with a median age of 25 months. Histological types were rhabdomyosarcoma, malignant germ cell tumor (MGCT) and clear cell adenocarcinoma in 18 (69%), 7 (27%) and 1 (4%) patients, respectively. Ten (33%) patients had prior surgery and 25 (96%) received chemotherapy prior to BT. The median prescribed dose was 60 Gy through pulses of 0.42 Gy. Global compliance was satisfactory, but three (12%) patients required replanning because of applicator displacement. After a median follow-up of 47.5 months, one patient with MGCT referred for salvage treatment of a local recurrence had a local and metastatic relapse. The local control rate probability was 96% at the last follow-up. Late toxicity rates ≥ grade 2 and ≥ grade 3 were reported in 23% and 11%, respectively, with gynecological toxicities being the most frequent side effect. Two patients required dilatation for vaginal stenosis. Conclusions: PDR-BT allowed similar local control compared to the historical low-dose rate technique. An indirect comparison suggests fewer treatment-related toxicities by integrating image guidance and optimization capabilities, but longer follow-up is necessary. Due to the rarity of the disease and the technical aspects of BT in these very young patients, referral to specialized high-volume centers is recommended.

The association of vagina equivalent dose in 2Gy fraction (EQD2) to late vagina toxicity in patients of cervical cancer treated with WPRT plus IGABT

To evaluate the associations of vaginal dose parameters and incidence of vaginal stenosis in patients with cervical cancer treated with image-guided brachytherapy (IGBT). Fifty-four patients with cervical cancer treated with IGBT were included. The vagina contouring was done on previously treated CT images and the vaginal dose points were marked. The cumulative dose in EQD2 from EBRT and IGBT was calculated for both aspects and the vaginal toxicity was evaluated. At median follow-up time of 18.5 months, grade 2 or higher vaginal stenosis was observed in 24% of patients. On univariate analysis, parameters that were associated with ≥ grade 2 vaginal stenosis were age, mean dose of lateral 5 mm vagina, dose at PIBS-2 cm, mid vaginal D0 .03cc, mid vagina D1cc, lower vagina D0.03cc, lower vagina D0.1cc, lower vagina D1cc and lower vagina D2cc. On multivariate analysis, the significant parameters were age > 68.5 years old (P = 0.038), mean dose of lateral 5-mm (P = 0.034), and dose at PIBS-2 cm (P = 0.042). Age > 68.5 years old, mean dose of lateral 5 mm vagina and dose at PIBS-2 cm were associated with grade 2 or higher vaginal stenosis.

Characterizing genitourinary exam disruptions in women presenting to a sexual health after cancer program.

e24048 Background: While treatment-related sexual health sequelae are documented using validated patient-reported outcome measures, the anatomic changes associated with cancer treatment are not well described, which may lead to an underestimation of the severity of these symptoms. To fill this knowledge gap and improve the management of these anatomic disruptions, we sought to objectively report the genitourinary findings of women presenting to a sexual health after cancer program over one year. Methods: At their first visit, patients undergo a thorough history and physical with a focus on the genitourinary exam. Patient demographics, primary symptoms, and treatment history were retrospectively collected and correlated to vaginal assessment scale (VAS) scores of female cancer patients presenting to the MUSIC (Menopause, Urogenital, Sexual Health and Intimacy Clinic) Program at an NCI-designated cancer center. Results: Between 2020-2021, 104 female cis-gender women with a median age of 46 (range 19-75) at diagnosis were seen. 56% identified as Hispanic/Latinx. Mean age was 47 (19-75), and most were treated for breast (80%) or gynecologic (10%) cancer. Primary complaints included vaginal dryness (53%), painful sex (45%), low desire (36%), hot flashes (22%), problems with orgasm (5%), urinary symptoms (10%), chronic pelvic pain (4%), or a need for complex contraceptive counseling (1%). Of those where a VAS was performed (n = 89), patients were found to have mild or moderate/severe loss of rugae (78%), loss of elasticity (84%), loss of vascularity (86%), and/or dryness (88%). Alarmingly, almost half were found to have some element of vaginal stenosis on exam, either vaginal scarring/adhesions (6%), foreshortened vagina (13%), or a narrowed introitus (47%) (Table). Conclusions: In an initial consult of women seeking care for sexual health after cancer treatment, the most common concerns were vaginal dryness, painful sex, and low desire. Despite only approximately half reporting either dryness or painful sex, most were found to have genitourinary disruptions in anatomy at presentation, including vaginal stenosis. The presence of vaginal stenosis in sexual health survivors who did not undergo pelvic radiation deserves future study as these findings often present as a complete inability to have penetrative intercourse.[Table: see text]

“Labia Majora Fasciocutaneous Flap Reconstruction in Complex Urogynecological Fistulas With Vaginal Deficit - A Versatile Approach”

ObjectiveTo appraise the pivotal points of different modifications of labia majora fasciocutaneous flap in combating the challenges of complex urogynecological fistula repair in the form of 7 cases. MethodsSeven patients with complex urogynecological fistulas with vaginal deficit were treated over last 3 years. The challenges associated with them were non-capacious rigid vagina, irradiated and inflamed surrounding tissues, inelasticity, long-standing fistula with radiation-induced vesicovaginal fistula(VVF), an iatrogenic urethrovaginal fistula with anterior vaginal wall loss with vaginal stenosis, and a case of vesicolabial fistula with a history of forceps delivery and transvaginal VVF repair. Transvaginal repair with labia majora fasciocutaneous flap along with fat pad with relevant technical modifications was contemplated in all. ResultsAll radiation-induced VVF patients demonstrated no leak in the postoperative period barring one who became dry after transvaginal colpocleisis later. The patient with urethrovaginal fistula and vaginal stenosis was continent, had capacious vagina, and without any leak with regular menstrual periods. The female with vesicolabial fistula remained dry at the end of 6-month follow-up. ConclusionTransvaginal repair using the labia majora fasciocutaneous flap and the demonstrated technical modifications can be a feasible option in repairing complex urogynaecological fistulas associated with vaginal wall deficit.

MP28-17 CHARACTERIZING THE CHALLENGES TRANSFEMININE INDIVIDUALS FACE IN SEEKING UROLOGICAL CARE

You have accessJournal of UrologyCME1 May 2022MP28-17 CHARACTERIZING THE CHALLENGES TRANSFEMININE INDIVIDUALS FACE IN SEEKING UROLOGICAL CARE Andrew Denisenko, Andrew Salib, Jessica Bulafka, Sabina Spigner, Vishal Swaminathan, Peyton Stauffer, Cassra B. Clark, Andrew Shumaker, Rosemary Frasso, and Paul H. Chung Andrew DenisenkoAndrew Denisenko More articles by this author , Andrew SalibAndrew Salib More articles by this author , Jessica BulafkaJessica Bulafka More articles by this author , Sabina SpignerSabina Spigner More articles by this author , Vishal SwaminathanVishal Swaminathan More articles by this author , Peyton StaufferPeyton Stauffer More articles by this author , Cassra B. ClarkCassra B. Clark More articles by this author , Andrew ShumakerAndrew Shumaker More articles by this author , Rosemary FrassoRosemary Frasso More articles by this author , and Paul H. ChungPaul H. Chung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002571.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Medical providers will encounter transgender individuals in their practice, and it is important that they understand the unique needs and backgrounds of this population. We sought to characterize the challenges transfeminine individuals face in seeking urological care through a developed questionnaire. METHODS: IRB approval was obtained to develop (with feedback from the transgender community) and administer a 58-item questionnaire assessing urinary and sexual health. Participants were recruited from the local community and the Philadelphia Trans Wellness Conference and provided a $20 gift card for their time. We assessed demographic factors, therapies, surgeries, complications, and urologic care experiences of these participants and compared vaginoplasty and non-vaginoplasty patients. RESULTS: 53 transfeminine individuals (11 vaginoplasty, 10 orchiectomy, 32 no procedure) with mean age of 40 (range 21-80) completed the questionnaire. Of the 12 respondents who met age-based criteria for prostate cancer screening, 8 underwent screening, 4 did not undergo screening, and 2 were not offered screening. 30 (56%) patients were not offered sperm preservation counseling. Vaginoplasty complications were reported by 6 respondents (54%) with 3 reports of wound separation, numbness, or inadequate vaginal depth, and single occurrences of abnormal scarring, vaginal stenosis, meatal stenosis, rectovaginal fistula, and chronic pain (n=11). We noted that those who had undergone vaginoplasty were significantly more likely to see a provider for urinary complaints (p=0.042), with 3 (27%) of these patients electing to see a urologist. Of the 14 patients from the entire cohort who were not willing to see a urologist, 29% cited discomfort with discussing urinary or sexual issues, while 7% cited fear of being misgendered. Across both groups, 30 individuals (57%) reported that they experienced a lack of knowledge about transgender health needs from members of a urology practice. CONCLUSIONS: Our findings illustrate the challenges transgender individuals face in obtaining care. We noted that participants who had vaginoplasty were more likely to see a urologist, which may reflect greater familiarity with the medical system. Many patients are reluctant to seek care due to discomfort or fear, and a majority experienced lack of knowledge about their health needs. This highlights a critical need for provider education on transgender issues in order to provide a safe and inclusive environment to better care for these patients. Source of Funding: World Professional Association for Transgender Health © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e467 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Denisenko More articles by this author Andrew Salib More articles by this author Jessica Bulafka More articles by this author Sabina Spigner More articles by this author Vishal Swaminathan More articles by this author Peyton Stauffer More articles by this author Cassra B. Clark More articles by this author Andrew Shumaker More articles by this author Rosemary Frasso More articles by this author Paul H. Chung More articles by this author Expand All Advertisement PDF DownloadLoading ...

Vaginal reconstruction: Progress by perforator flaps

ABSTRACT Introduction Gracilis and rectus abdominis myocutaneous flaps have been used for reconstruction of a wide range of vaginal defects, but recently, minimally invasive reconstruction with various perforator flaps has become popular. Vaginal reconstruction for the past 41 years is reported. Patients Summary 15 cases of vaginal defects were surgically treated. The case was that the age at surgery was 23 to 87 years, with an average of 55 years. The original disease is vesico-vaginal fistula 6 cases, Paget cancer 4 cases, labial1 cancer 1 case, pudendal radiation ulcer associated with lymphedema 1 case, Rokitansky syndrome 1 case, GID (Male to female)1 case, vaginal stenosis 1 case. Flaps for reconstruction are: gracilis musculocutaneous flap 5, superficial circumflex artery perforators (SCIP) flap 4, pudendal artery perforator flap 3, medial femoral perforator Flap 2, scrotal flap 1, gracilis perforator flap 1, free latissimus dorsi musculocutaneous flap 1. Reconstruction using multiple flaps was performed for extremely widespread defects. Results and Conclusion Postoperative follow-up was 2weeks to 20 years with an average of 2.5 years. As complications, recurrence of bladder-vaginal fistula occurred in 2 of 6 cases (33%), and partial necrosis of the flap was observed in 1 of 16 cases (6%). For vaginal reconstruction, the surrounding myocutaneous flap or perforator flap can be selected depending on the depth and extent of the defect. Donors can be closed by using combined flaps, especially for a wide range of defects. Irradiated bladder-vaginal fistulas may require a bilateral approach from the bladder and vagina. In the future, reconstructive surgery that considers sexual function will be required for GID as well. Disclosure Work supported by industry: no. A consultant, employee (part time or full time) or shareholder is among the authors (Luxanos).

DILATATION OF IATROGENIC VAGINAL STENOSIS WITH AN ABSORBABLE OXIDIZED REGENERATED CELLULOSE

OBJECTIVE: Iatrogenic vaginal stenosis adversely affects the sexual life of couples. The definitive treatment of this condition is possible by redilatation of vagina. This study aims to investigate the outcomes of vaginal dilatation procedure performed using an absorbable oxidized regenerated cellulose.MATERIAL AND METHODS: 29 patients who could not have intercourse due to Iatrogenic vaginal stenosis underwent vagina enlargement surgery using an absorbable oxidized regenerated cellulose in the period of April 2014 to August 2020. The results were analysed with the help of the standard ‘Patient Global Impression of Improvement Scale (PGI-I) which evaluates patient satisfaction in particular.RESULTS: The mean follow-up period was 16 monts (14 - 24 months). No major perioperative complication was detected except from perianal hemotoma treated with antibiotics and drainage in a case. At 6th month follow up visit, 27 patients reported pain free sexual intercourse. Two patients needed re-dilatation 4 and 6 months later respectively.Based on the scores of patients as “much better ‘’and ‘’very much better” on the PGI-I scale, satisfaction rate was 93% at 6th month follow up visit.CONCLUSIONS: Vaginal dilatation surgery with absorbable oxidized regenerated cellulose seems to be a safe and effective procedure with positive anatomical and functional results. However, many comparative studies a