Neovagina in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Vaginoplasty Using Ileal Flap.

INTRODUCTION: Surgical treatment of patients with malformations of the female genital tract is a complex problem and there are different techniques described in the literature. The goal of all these techniques is the reconstruction of a neovagina that is anatomically similar to a vagina, with adequate length to facilitate sexual functioning and with the lowest risk of possible complications. The aim of this study is to describe the surgical technique for the reconstruction of a neovagina from an ileal segment without a vascular pedicle. MATERIAL AND METHODS: Description of a surgical technique developed in our tertiary university center in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. RESULTS: The vaginoplasty surgery using ileal flap was performed in three steps. In the first part of the intervention a laparoscopic hysterectomy with bilateral salpingectomy was performed. The second step consisted of isolating the ileal segment, ileal anastomosis and preparing the ileal segment. After the isolated segment was prepared, it was repositioned in a vagina mold to configure the neovagina. Finally, the third step included the adaptation of the vaginal mold with the ileal mucosa to the vesicorectal space. CONCLUSION: Ileal vaginoplasty without a vascular pedicle is an option that can be used to reconstruct the vagina, because it provides an excellent tissue for vaginal replacement. This technique can be used in patients with genital malformations of the genital tract with absence or vaginal hypoplasia.

Levator ani muscle avulsion in patients with pelvic floor dysfunction - Does it help in understanding pelvic organ prolapse?

INTRODUCTION: Levator ani muscle (LAM) lesions are an important factor in the development of female pelvic organ prolapse (POP). OBJECTIVE: To determine the prevalence of LAM avulsion by transperineal ultrasound. The second outcome is to evaluate the association between complete avulsion and the type, degree, and number of POP compartments involved. MATERIALS AND METHODS: This was a retrospective cohort study performed in a tertiary hospital that included patients with pelvic floor dysfunction evaluated from January 2016 to March 2020. The presence of LAM avulsion was diagnosed by 3D/4D pelvic floor transperineal ultrasound. We identified women with POP, and they were classified according to the POP-Q system. The association between complete avulsion and the type, degree and number of compartments were calculated using generalized logit models. RESULTS: 848 women were included in the analysis. A complete LAM avulsion was found in 195 patients (23 %). Patients with complete avulsion were 4.7 (CI: 1.98-11.5) times more likely to have POP than patients with partial avulsion. The anterior compartment was the most frequently affected (n = 605, 25.8 %). Women with severe stage POP were 3.13 times (CI: 1.90-5.16) more likely to have bilateral complete LAM avulsion than women with mild prolapse. Patients with three-compartment POP were 2.75 times (CI: 1.53-4.94) more likely to have unilateral complete LAM avulsion than women with POP in one compartment. CONCLUSION: The prevalence of LAM avulsion is high in patients with urogynecological symptoms. Patients with complete LAM avulsion are at greater risk of developing POP and have a more advanced stage of prolapse and involvement of multiple compartments.

A retrospective analysis of the effectiveness of anterior pelvic organ prolapse repair with Prolift versus Elevate vaginal mesh.

OBJECTIVE: To compare the effectiveness of anterior pelvic organ prolapse (POP) repair using Prolift (Ethicon, Somerville, NJ, USA) or Elevate (American Medical Systems, Minnetonka, MN, USA) vaginal mesh at 12 months of follow-up. METHODS: A retrospective study was undertaken using the records for the first 50 Prolift procedures in 2007-2009 and the first 50 Elevate procedures in 2013-2015 performed at a tertiary urogynecology unit in Lisbon, Portugal. Postoperative follow-up occurred at 3, 6, and 12 months. The primary outcome was surgical efficacy using subjective and objective measures (vaginal bulge symptoms and POP quantification system according to the Weber criteria, respectively) at 12 months. RESULTS: Improvement according to the Weber criteria was noted for 10 (25%) of 40 women in the Prolift group and 21 (48%) of 44 in the Elevate group at 12 months (P=0.032). Additionally, the Ba point was higher with Elevate than with Prolift (-2.2 ± 1.1 vs -1.5 ± 1.5; P=0.031). Vaginal bulge symptoms were reported at 12 months by 7 (18%) women in the Prolift group and 3 (7%) in the Elevate group (P=0.021). CONCLUSION: Differences in anatomic results were apparent between the two vaginal mesh groups 12 months after surgery.

King's Health Questionnaire to assess subjective outcomes after surgical treatment for urinary incontinence: can it be useful?

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) are the mainstay of treatment for stress urinary incontinence, but the definition of success varies widely amongst studies. The King's Health Questionnaire (KHQ) was designed to evaluate the impact of urinary incontinence on the quality of life. We hypothesised that the KHQ could be useful for postoperative quantitative assessment of subjective outcomes. MATERIALS AND METHODS: This is a retrospective analysis of 204 patients who underwent incontinence surgery with transobturator MUS between 2004 and 2013. Follow-up was planned at 6, 12 and 24 months and success was evaluated using the cough stress test (objective cure) and the KHQ global score (subjective outcomes). Statistical analysis included receiver operating characteristic (ROC) curves to calculate a cut-off value for the KHQ global score to define subjective cure. The minimal clinically important difference was calculated with a distribution-based method (effect size) to estimate subjective improvement. RESULTS: Objective cure rates were 97 % and 95 % at 6 and 24 months respectively. ROC curves established the cut-off score at ≤ 31 for subjective cure, with sensitivity of 63-100 % and specificity of 82-88 %. Subjective cure rates were 80 % and 85 % at 6 and 24 months respectively. The minimal clinically important difference was set at 10 and an improvement of ≥ 10 points was defined as subjective improvement. Rates varied between 10 and 13 %. CONCLUSIONS: This study showed the value of the KHQ as an evaluation tool after UI surgery and determined clinically relevant threshold scores to define subjective outcomes.

Laparoscopic Vaginal-Assisted Hysterectomy With Complete Vaginectomy for Female-To-Male Genital Reassignment Surgery.

STUDY OBJECTIVE: Total hysterectomy with bilateral salpingo-oophorectomy and vaginectomy for genital reassignment surgery is a complex procedure that is usually performed with a combined vaginal and abdominal approach. The aim of this study was to describe the feasibility of laparoscopic vaginectomy in sex reassignment surgery. METHODS: We reviewed the relevant medical history, intra/postoperative complications, and surgical results of all patients diagnosed with gender dysphoria and submitted to totally laparoscopic gender confirmation surgery in our department between January 2007 and March 2015. In total, 23 patients underwent total hysterectomy with bilateral salpingo-oophorectomy and vaginectomy in a single intervention. The vaginal mucosa was conserved to be used for the penile neourethra during the subsequent phalloplasty. MEASUREMENTS AND MAIN RESULTS: The surgeries had an average operating time of 155 ± 42 minutes. No intraoperative complications were registered. In all patients, the vagina was totally removed, and, in most cases (n = 20), we were able to remove laparoscopically more than 50% of the vagina. Three patients had postoperative complications. One patient presented with hemoperitoneum on the second postoperative day; another presented with prolonged urinary retention, and a third patient developed a perineal hematoma 1 month after surgery. Patients were discharged less than 72 hours after surgery, except the patient who developed a postoperative hemoperitoneum. For all patients, we obtained an adequate specimen of vaginal mucosa to reconstruct the penile neourethra for the subsequent phalloplasty. CONCLUSION: This study suggests the feasibility of laparoscopic vaginectomy in genital reassignment surgery. The procedure can be executed as a continuation of the hysterectomy with the potential advantage of the laparoscopy providing better exposure of the anatomic structures with low blood losses (less than 500 mL) and few complications. Furthermore, using this approach, adequate-sized vaginal mucosa flaps were obtained for the urethral reconstruction.

Incontinence surgery in obese women: comparative analysis of short- and long-term outcomes with a transobturator sling.

INTRODUCTION AND HYPOTHESIS: Midurethral slings (MUS) are still discussed in complex incontinence situations, such as obesity, lacking sustained efficacy validation in this particular sub-population. We hypothesized that the outcomes of a transobturator MUS, such as TVT-O, do not differ according to body mass index (BMI) over a 4-year period. METHODS: We conducted a retrospective analysis of 281 women who underwent TVT-O at our institution, between 2004 and 2012. Patients were stratified into obese (BMI ≥ 30 kg/m(2)) or non-obese (BMI < 30 kg/m(2)). We compared preoperative and postoperative parameters, including objective cure (negative stress test), complications, and quality of life scores. Data were collected at 0, 6, 12, 24, and 48 months. We used Fisher's exact test for categorical variables and Student's t test or the Mann-Whitney U test for continuous variables. RESULTS: Baseline characteristics of the obese (n = 122) and non-obese groups (n = 159) were similar. We found no significant differences between groups in terms of objective cure rates at all follow-up evaluations, with 95.8 % and 95 % at 48 months in the non-obese and obese groups respectively. There were no significant differences in the cumulative complication rates of both groups. Quality of life assessment also showed no significant differences between groups at all follow-up visits. At 48 months our follow-up rate was 59 % (n = 96) and 60.4 % (n = 72) in the non-obese and obese group respectively (p = 0.9). CONCLUSIONS: The TVT-O procedure is effective and safe in the long term for stress incontinence treatment, regardless of BMI.

Route of delivery following successful external cephalic version.

OBJECTIVE: To evaluate the delivery route and the indications for cesarean delivery after successful external cephalic version (ECV). METHODS: A retrospective matched case-control study was conducted at a hospital in Lisbon, Portugal, between 2002 and 2012. Each woman who underwent successful ECV (n = 44) was compared with the previous and next women who presented for labor management and who had the same parity and a singleton vertex pregnancy at term (n = 88). The outcome measures were route of delivery, indications for cesarean delivery, and incidence of nonreassuring fetal status. RESULTS: Attempts at ECV were successful in 62 (46%) of 134 women, and 44 women whose fetuses remained in a cephalic presentation until delivery were included in the study. The rates of intrapartum cesarean delivery and operative vaginal delivery did not differ significantly between cases and controls (intrapartum cesarean delivery, 9 [20%] vs 16 [18%], P = 0.75; operative vaginal delivery, 14 [32%] vs 19 [22%], P = 0.20). The indications for cesarean delivery after successful ECV did not differ; in both groups, cesarean delivery was mainly performed for labor arrest disorders (cases, 6 [67%] vs controls, 13 [81%]; P = 0.63). CONCLUSION: Successful ECV was not associated with increased rates of intrapartum cesarean delivery or operative vaginal delivery.

Acute fetal asphyxia after gastric rupture in a pregnant patient with a gastric band.

We report a 37-year-old primigravida with a gastric band who developed the clinical picture of abdominal pain, vomiting and regurgitation coexistent with a cardiotocogram with severe variable decelerations with absent variability at 33 weeks' gestation. After partial improvement with gastric band enlargement, new aggravation of symptoms and recurrence of a pathological cardiotocogram led to an emergency cesarean section. Intraoperatively, hemoperitoneum from gastric rupture was verified and partial gastrectomy was performed. After bariatric surgery, pregnant women are at increased risk of gastrointestinal complications, which may need prompt and multidisciplinary diagnosis and management in order to avoid maternal-fetal morbidity and mortality.