Long-Term Outcomes of the Restoration of Uterovaginal Continuity and Vaginoplasty-Utero-Colo-Neovaginoplasty-in Cervicovaginal Agenesis Using the Sigmoid Colon.

INTRODUCTION AND HYPOTHESIS: Congenital cervicovaginal agenesis in the presence of a functional endometrium is a rare Müllerian anomaly. The management ranges from hysterectomy historically to various reconstructive procedures more recently. We report our experience with utero-colo-vaginoplasty in the management of this anomaly and its long-term follow-up. METHODS: The case records of all the patients with vaginal or cervicovaginal agenesis in our hospital from January 2002 to December 2019 were reviewed retrospectively. The patients were then called for an outpatient visit and examined in detail. The anatomical variations, surgical procedures and outcomes were recorded and analysed. RESULTS: Sixteen patients aged 14 to 26 years were included during the study period. They presented with cyclical painful cryptomenorrhea. Magnetic resonance imaging (MRI) confirmed cervicovaginal or distal vaginal agenesis. All the patients underwent utero-colo-vaginoplasty. Intraoperative rectal injury led to post-operative faecal leak from the perineal wound in one patient in the post-operative period. Restoration of painless menstrual flow was possible in all 16 cases. Long-term complications were seen in 4 patients. These were stenosis of the perineal neovaginal orifice in 2 patients, obstruction at colo-uterine anastomosis in 1 patient and mucosal prolapse at the neovagina in 1 patient. Three of these patients needed secondary surgical procedures. Five were sexually active and reported consummation of penetrative intercourse. None of them had conceived. CONCLUSION: In our experience, utero-colo-vaginoplasty allows for regular painless menstruation and coitus with minimal long-term complications. The sole disadvantage is the failure to conceive.

Laparoscopic Sigmoid Vaginoplasty for the Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome in a Single Center: 20 years' Experience.

INTRODUCTION AND HYPOTHESIS: We investigate the feasibility, safety, and clinical therapeutic effect of laparoscopic sigmoid vaginoplasty in women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. METHODS: We performed a retrospective case review cohort study of 56 patients with MRKHs undergoing laparoscopic sigmoid vaginoplasty in Wuhan Union Hospital between 2000 and 2020, and all patients were followed up. RESULTS: The median operating time was 165 min (120-420 min). The median hospital stay was 10 days (rang 7-15 days). A functional neovagina was created 11-15 cm in length and two fingers in breadth in all patients. No introitus stenosis was observed. No intra- or post-operative complications occurred. Two patients were lost to follow-up after 3 months of outpatient visits. Six patients had no intercourse and were required to wear a vaginal mold occasionally. None of the patients had complained of local irritation or dyspareunia. Patients who had post-surgery sexual intercourse were satisfied with their sexual life and the mean total Female Sexual Function Index (FSFI) score was 25.17 ± 0.63. The cosmetic results were excellent. CONCLUSIONS: The laparoscopic sigmoid vaginoplasty can achieve the goal of making a functional neovagina. The main advantage of this surgical technique is that it is minimally invasive and that there are fewer complications post-operation. It is an acceptable procedure for patients with MRKH syndrome.

The robotic-assisted free jejunal flap for neovaginal canal creation in gender-affirming vaginoplasties.

INTRODUCTION: One of the biggest challenges with gender-affirming vaginoplasty was the creation of a long-lasting, durable, patent, and self-lubricating neovaginal canal that allowed for spontaneous, pain-free sexual intercourse. The jejunum was a durable, physiologic, and intestinal option to create the neovaginal canal that minimizes the adverse effects of skin graft, peritoneal, and colonic vaginoplasties. Free jejunal vaginoplasties had been performed in cis females for congenital genitourinary anomalies like Mullerian agenesis or after gynecologic-oncologic surgery but had yet to be reported for gender-affirming vaginoplasties. The purpose of this report was to present a technique for a physiologic, intestinal, gender-affirming vaginoplasty without the disadvantages of colonic vaginoplasties. PATIENTS AND METHODS: This report presented six patients, all natal males who identified as female, undergoing robotic-assisted free jejunal flap gender-affirming vaginoplasty. Mean age was 35.8 years (range: 21-66). Mean body mass index was 33.2 kg/m2 (range: 28.0-41.0). The proximal aspect of the neovaginal canal was created intra-abdominally by elevating peritoneal flaps from the posterior bladder wall to be reflected downward into the external neovaginal canal. The jejunal flap was harvested. The greater saphenous vein was harvested to create an arteriovenous loop between the flap vessels and the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal flap was passed intra-abdominally through the groin incision and then trans-peritoneally into the neovaginal canal. The jejunal segment was inset to the proximal peritoneal flaps and the distal inverted penoscrotal skin of the neovaginal introitus. RESULTS: Mean length of the harvest jejunal segment was 19.2 cm (range: 15-20). Mean time to ambulation, foley removal, and first vaginal dilation were 3.3 (range: 3-4), 4.0 (range: 3-5), and 4.5 days (range: 4-6), respectively. By a mean follow-up duration of 8.0 months (range: 1-14), mean vaginal depth and diameter were 7.0 and 1.3 cm (range: 1.0-1.5), respectively. Two (33.3%) patients experienced postoperative complications, including groin hematoma (n = 1, 16.7%) and reoperation for correction of dehiscence of the jejunal flap to the vaginal introitus (n = 1, 16.7%). CONCLUSION: Gender-affirming surgeons should consider a free vascularized segment of jejunum as an option to line the neovaginal canal in the correct patients.

Vaginal length and sexual function after vertical versus horizontal closure of the vaginal cuff after abdominal hysterectomy: a randomised clinical trial.

This randomised clinical trial aimed to evaluate the vaginal length and female sexual function after vertical and horizontal closure of the vaginal cuff after abdominal hysterectomy. The patients were allocated into two groups, vertical closure and horizontal closure groups. The vaginal length was determined using transperineal ultrasound, once preoperative and again 3 months after the operation. Female sexual function was determined using an Arabic validated female sexual function index questionnaire. Both techniques resulted in a significant shortening of the vaginal length (p-value .001). There was a significant improvement in sexual function in the vertical closure group rather than the horizontal closure one. We concluded that there was no significant difference in the vaginal length after vertical or horizontal closure of the vaginal cuff. However, female sexual function improved significantly in the vertical closure group.Trial registration number: PACTR201909573801168.IMPACT STATEMENTWhat is already known on this subject? Conflicting results exist regarding the effect of different techniques of vaginal length closure on vaginal length and sexual function after hysterectomy.What do the results of this study add? There was no significant difference in the vaginal length after vertical or horizontal closure of the vaginal cuff. However, female sexual function improved significantly in the vertical closure group. This study is considered to be the first one to evaluate the correlation between the vaginal length and the female sexual function.What are the implications of these findings for clinical practice and/or further research? The correlation between vaginal length and female sexual function needs to be evaluated in a multicenter study, recruiting larger number of sexually active women.

Balloon vaginoplasty as a minimally invasive method in the management of vaginal aplasia.

OBJECTIVE: The aim of this article is to describe the management of vaginal aplasia and to introduce minimally invasive surgical procedures for neovagina formation. METHODOLOGY: Literature review obtained from studies and papers dealing with the management of congenital vaginal aplasia. CONCLUSION: Vaginal aplasia is a rare congenital anomaly, often in coincidence with congenital defects of the uropoietic system. Management nowadays favors non-surgical or minimally invasive surgical methods for neovagina formation. Saman et al introduced a new method of neovagina formation, namely balloon vaginoplasty. The advantage of the surgical procedure is traction using a soft Foley balloon, determining both the length and width of the neovagina. The method uses the expansion of the natural vaginal mucosa without the need for dissection of the vesicorectal space. The soft Foley balloon does not cause erosion of the vaginal mucosa.

Significance of urinary liver-type fatty acid-binding protein in patients with normal renal function after undergoing intestinal urinary diversion: a preliminary study.

BACKGROUND: Liver-type fatty acid-binding protein (L-FABP) in urine is one of the early diagnostic biomarkers for acute and chronic kidney injuries. Although this protein is also identified in the intestine, there is no verified reference value for patients with intestinal urinary diversion (UD). The aim of the present study was to measure L-FABP values in such patients and compare them with the results for patients without UD. METHODS: Spot urine specimens were collected from 41 patients with UD and 50 subjects without UD with estimated glomerular filtration rates of over 60 ml/min/1.73 m2, and the L-FABP values were measured. The normal upper cutoff value in healthy subjects without UD is considered to be 7.24 µg/g Cr. First, the median values of the two groups were compared. Next, the subjects with negative proteinuria and without comorbidities associated with renal function were further selected and the median values of the groups were compared. RESULTS: The mean age was significantly higher in the UD group. The types of UD were ileal conduit (38 patients) and ileal neobladder (three patients). The median L-FABP value in the UD group was significantly higher than that in the non-diversion group (89.1 µg/g Cr vs. 2.0 µg/g Cr, p < 0.0001). After adjustment for their backgrounds, the median value remained higher in the UD group. CONCLUSIONS: L-FABP values in subjects with UD are higher than in those without UD. By this result, to develop a reference value in patients with intestinal UD population, further studies are required.

Surgical Video Tutorial: Treatment of Congenital Vaginal Agenesis: Laparoscopic Modified Davydov in 8 Steps.

OBJECTIVE: To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches. DESIGN: Production of a step-by-step surgical video tutorial with narrative video footage. SETTING: Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as "covering" tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2]. INTERVENTIONS: We treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners. CONCLUSION: The Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.

Neovagina Creation: A Novel Improved Laparoscopic Vecchietti Procedure in Patients with Mayer-Rokitansky-Küster-Hauster Syndrome.

STUDY OBJECTIVE: To report a new improved laparoscopic Vecchietti vaginoplasty in patients with congenital vaginal agenesis and to investigate its efficacy and safety. DESIGN: A retrospective descriptive and case-control study. SETTING: Single academic institution. PATIENTS: Women who were diagnosed with Mayer-Rokitansky-Küster-Hauster (MRKH) syndrome and underwent our new improved laparoscopic Vecchietti procedure from July 2010 to June 2019 were selected as the study group. The eligible participants had congenital vaginal agenesis with normal 46,XX karyotype and ovarian function. Age-matched, nulliparous, sexually active women were selected as the control group. INTERVENTIONS: Women with MRKH syndrome in the study group underwent the novel improved laparoscopic Vecchietti procedure. All participants in both groups were required to complete Female Sexual Function Index and Female Genital Self-Image Scale questionnaires. MEASUREMENTS AND MAIN RESULTS: The effects of our procedure, including the anatomic and functional efficacy of the neovagina, were the primary outcomes. The secondary outcomes consisted of the perioperative complications, surgical morbidities, and long-term postoperative discomfort. A total of 79 patients with MRKH syndrome underwent our new improved Vecchietti vaginoplasty, of whom 44 (55.7%) were diagnosed as Type I MRKH syndrome, whereas 35 (44.3%) were Type II MRKH syndrome. At a 30-month follow-up after surgery, an anatomic neovagina measuring 10.44 cm in length and 1.30 cm in width was achieved. All 79 patients obtained anatomic success with 92.41% of functional efficacy. Compared with 81 age-matched, nulliparous women in the control group, there was no statistical difference regardless of individual measure or total Female Sexual Function Index scores (p >.05). The Female Genital Self-Image Scale assessment showed a significantly lower score in patients undergoing the vaginoplasty (20.14 ± 3.05 vs 22.95 ± 2.12; p <.001). There were no severe perioperative complications except 1 mild bladder injury and 1 transient fever. CONCLUSION: Our novel improved laparoscopic Vecchietti vaginoplasty is a relatively safe and effective method for surgical treatment of congenital vaginal agenesis. It may be an alternative to neovagina creation for reaching satisfying anatomic and functional efficacy and improving patients' sexual function.

Robotic intracorporeal orthotopic neobladder in the supine Trendelenburg position: a stepwise approach.

Robotic radical cystectomy with urinary diversion has become increasingly utilized for the surgical management of bladder cancer. Orthotopic neobladder reconstruction is still performed worldwide primarily via an extracorporeal approach because of the difficulty associated with robotic intracorporeal reconstruction. The objective of this article is to demonstrate a stepwise approach for robotic intracorporeal neobladder in a standardized manner that adheres to the principles of open surgery.

Radical Cystectomy after Previous Radiation or Pelvic Surgery: Is It Associated with Increased Morbidity?

BACKGROUND: Radical cystectomy is a complicated surgery with significant risks. Complications of Clavien-Dindo grade 3-4 range from 25% to 40% while risk of mortality is 2%. Pelvic surgery or radiotherapy prior to radical cystectomy increases the challenges of this surgery. OBJECTIVES: To assess whether radical cystectomy performed in patients with prior history of pelvic surgery or radiation was associated with increased frequency of Clavien-Dindo grade 3 or higher complications compared to patients without prior pelvic intervention. METHODS: We retrospectively evaluated all patients who underwent radical cystectomy at our center over a 7-year period. All patients with pelvic radiation or surgery prior to radical cystectomy comprised group 1, while group 2 included the remaining patients. RESULTS: In our study, 65 patients required radical cystectomy at our institution during the study period. Group 1 was comprised of 17 patients and group 2 included 48 patients. Four patients from group 2 received orthotopic neobladder, while an ileal conduit procedure was performed in the remaining patients. Estimated blood loss and the amount of blood transfusions given was the only variable found to be statistically different between the two groups. One patient from group 1 had four pelvic interventions prior to surgery, and her cystectomy was aborted. CONCLUSIONS: Radical cystectomy may be safely performed in patients with a history of pelvic radiotherapy or surgery, with complication rates similar to those of non-irradiated or operated pelvises.

Percutaneous paraspinal access to the azygos vein to create a neo-vena cava.

We present the case of a child with congenital heart disease repaired in infancy with diffuse central venous occlusions resulting in central venous insufficiency, superior vena cava (SVC) syndrome, and intracranial bleeds. He presented to the catheterization laboratory for multiple transcatheter interventions to recanalize central venous channels which were unsuccessful by conventional methods. Therefore, extravascular venous channels were created to decompress his upper body by creation of a neo-SVC and his lower body with a neo-azygos vein to the neo-SVC. The latter procedure required direct percutaneous access from a paraspinal approach in order to obtain continuity with the azygos vein. At latest follow-up the patient is clinically well and asymptomatic.

Ileal conduit or orthotopic neobladder: selection and contemporary patterns of use.

PURPOSE OF REVIEW: The orthotopic neobladder and ileal conduit are the two most commonly utilized urinary diversions among patients undergoing radical cystectomy. Although orthotopic diversion offers several advantages, only 20% of patients nationally receive this diversion, with decreasing utilization over time. The purpose of this article is to review advantages of each diversion type and considerations in patient selection, review trends in diversion utilization and perioperative and functional outcomes, and examine recent studies evaluating methods of optimizing diversion selection and patient satisfaction and outcomes. RECENT FINDINGS: Decreasing utilization of orthotopic diversion has coincided with the increasing utilization of minimally invasive surgical techniques. A multicentre robotic series demonstrated a higher incidence of high-grade complications with intracorporeal diversion, reflecting the learning-curve associated with this technique. Patient satisfaction with urinary diversion is associated with informed decision-making and goal alignment. Ongoing quality of life studies is aiming to identify predictors of patient satisfaction with the selected urinary diversion and may help guide patient counselling. SUMMARY: Given the potential advantages of orthotopic diversion, its decreasing use is a concerning trend. Elucidating patient goals and informed decision-making are critical to patient satisfaction. A patient-centred approach should be used when selecting the type of urinary diversion for a given patient.

Successful Endovascular Repair of a Ruptured Common Iliac Artery Aneurysm Associated with an Ileal Pouch Neobladder Fistula.

A spontaneous fistula between a ruptured common iliac artery aneurysm and the ileal pouch neobladder is quite rare. We present the case of a 74-year-old man presenting with intense abdominal pain and massive hematuria. Computed tomography angiography revealed a ruptured common iliac artery aneurysm-ileal pouch neobladder fistula. His hemodynamics was unstable; emergent endovascular aortic repair was performed successfully. Infection and dysfunction of the neobladder were avoided owing to appropriate management.

A Retrospective Review of Vaginal Cuff Dehiscence: Comparing Absorbable and Nonabsorbable Sutures.

STUDY OBJECTIVE: To compare the rate of spontaneous and complete vaginal cuff dehiscence (VCD) using absorbable versus nonabsorbable sutures for vaginal cuff closure. DESIGN: Retrospective comparative cohort design. SETTING: Freestanding ambulatory surgery center in suburban Maryland. PATIENTS: Women age >18 years old who underwent hysterectomy for benign conditions between October 2013 and April 2018. INTERVENTION: Laparoscopic retroperitoneal hysterectomy was performed by 2 gynecologic surgical specialists. Transvaginal cuff closure was performed using either absorbable Vicryl (polyglactin 910) sutures (n = 881) or nonabsorbable Ethibond (polyester) sutures (n = 574). The nonabsorbable sutures were surgically removed after 90 days. MEASUREMENTS AND MAIN RESULTS: No statistically significant differences in age, race, weight, body mass index, parity, uterine weight, or number of comorbidities were noted between the nonabsorbable and absorbable suture groups. Spontaneous vaginal cuff dehiscence (VCD) occurred in 3 patients (0.52%) in the nonabsorbable group and in 12 patients (1.4%) in the absorbable group (p = .183). Eleven of the 12 cases of VCD in the absorbable group were precipitated by intercourse and occurred within 90 days of surgery. CONCLUSION: Our data suggest that use of a nonabsorbable suture may be an effective approach to prevent spontaneous VCD, but the benefits should be weighed against the inherent risk associated with a second procedure to remove sutures.

Tilapia Skin for Neovaginoplasty after Sex Reassignment Surgery.

STUDY OBJECTIVE: To describe a new technique of neovaginoplasty after a female sex reassignment surgery using a tilapia skin as a graft. DESIGN: Stepwise demonstration of a new technique with narrated video of a single case report. The patient provided oral and written informed consent. Moreover, this video report is part of a multicenter, Investigational Review Board-approved study. SETTING: Women's university hospital in Campinas, Brazil. INTERVENTIONS: Neovaginoplasty technique using tilapia skin with the following key strategies: (1) corpus cavernosum removal, (2) vagina tunnel creation, (3) mold coating with tilapia skin, (4) mold fixation, and (5) postoperative care. The patient remained with the mold coated with tilapia skin for 5 days; after this time, the mold was removed, and the tissue graft was adhered and incorporated in the new vaginal canal. After 2 months, the tissue resembled a vaginal mucosa, and the vaginal length was 8 cm. The patient has not had intercourse yet. CONCLUSION: We introduce an alternative for low-morbidity neovaginoplasty based on the experience of plastic surgery in burned grafts. The procedure described offers an alternative option to develop an anatomic neovagina with tissue similar to mucosa tissue by a simple, low-morbidity minimally invasive procedure.

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

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

Sexual Function following Laparoscopic versus Transvaginal Closure of the Vaginal Vault after Laparoscopic Hysterectomy: Secondary Analysis of a Randomized Trial by the Italian Society of Gynecological Endoscopy Using a Validated Questionnaire.

STUDY OBJECTIVE: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. DESIGN: Secondary analysis of a prospective randomized controlled trial. SETTING: Three academic research centers. PATIENTS: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. INTERVENTIONS: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. MEASUREMENTS AND MAIN RESULTS: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively). CONCLUSION: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.).

[Robot-assisted radical cystectomy with neobladder formation].

INTRODUCTION: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder formation is a complex surgical procedure. AIM: To describe the main stages of RARC and to analyze its short-term results. MATERIALS AND METHODS: RARC with ileocystoplasty was performed in 16 patients, most of whom were men (n=14). In 15 patients, the indication for surgery was bladder cancer (BCa), while one patient has radiation-induced sigmoid fistula with a formation of small, contracted bladder. During radical cystectomy (RC), the lower ureters were dissected, followed by posterior dissection of the bladder with mobilization from both sides to the pelvic fascia, clipping and transection of the vesical pedicles, and suturing of the dorsal venous complex with urethral dissection. After pelvic lymph node dissection, 40 cm of the ileum was resected, after that two distal segments of 15 cm were U-shaped, and a 1.5 cm incision was made in the lower part of the bowel, followed by a formation of the urethral anastomosis. Then bowel segments were detubularized, and continuous suture on the posterior and anterior walls of the neobladder was done. Ureters were implanted in the proximal tubular part of the resected colon according to the Nesbit technique. RESULTS: The mean operation time was 380 minutes. The blood loss ranged from 80 to 200 ml; however, blood transfusion was not performed. Complications during 30-days after RARC were observed in 7 (43.7%) patients, including 4 (25%) of class I-II according to Clavien - Dindo, and 3 (18.7%) of class III-IV. In patients with leakage at the uretero- intestinal anastomosis (n=2) and urethro-neobladder anastomosis (n=1), percutaneous drainage was performed, which allowed to resolve these complications. There were no cases of bowel obstruction. One patient with gastrointestinal bleeding required blood transfusion. The 90-day late complications occurred in 6 (37.5%) patients, including 2 cases of upper urinary tract infection. One patient died of acute myocardial infarction. CONCLUSION: RARC is a contemporary minimally invasive method for muscle-invasive BCa. Stepwise approach to RARC with intracorporeal neobladder formation may reduce the operation time and the rate of complications.

Pouch Versus No Pouch Following Total Gastrectomy: Meta-analysis of Randomized and Non-randomized Studies.

OBJECTIVE: The aim of the study was to assess the impact of pouch reconstruction on perioperative outcomes, postprandial symptoms, nutritional and anthropometric parameters, and overall quality of life after total gastrectomy for gastric malignancy. SUMMARY BACKGROUND DATA: The short-term perioperative risks and longer term functional value of creating a small-bowel reservoir after total gastrectomy are contended. METHODS: A search for randomized and non-randomized studies comparing reconstruction with or without a pouch was conducted. Treatment effects were computed using pairwise random-effects meta-analysis and meta-regression, and the systematic review was conducted in accordance with PRISMA and MOOSE guidelines. RESULTS: A total of 17 randomized trials and 8 observational studies involving 1621 participants were included. Pouch creation is associated with an increased operation time [259.3 vs 235.8 min; weighted mean difference (WMD) 23.5, 95% confidence interval (CI) 9.8-37.2], but not hospitalization duration. There was no difference in overall postsurgical complications, including anastomotic leak and abdominal abscess. Pouch formation markedly reduces the risk of dumping syndrome at 3 to 6 months [8.1% vs 32.4%; risk ratios (RR) 0.36, 95% CI, 0.21-0.60] and 12 to 24 months (2.8% vs 23.6%; RR 0.27, 95% CI, 0.16-0.46). The functional advantages of pouch reconstruction persist at 1 to 2 years, with aggregated data indicating considerably lower risks of esophagitis and heartburn (63% relative reduction), dumping syndrome (73% relative reduction), and food intake disturbance (50% relative reduction). At 12 to 24 months, albumin levels (40.5 vs 37.9 g/L; WMD 2.59, 95% CI, 1.35-3.84) and body mass index (22.2 vs 20.9 kg/m; WMD 1.28, 95% CI, 0.61-1.94) are significantly higher among participants with a pouch. CONCLUSIONS: Pouch creation improves long-term functional and nutritional outcomes after total gastrectomy, without greater perioperative morbidity.

Neovagina creation methods and their potential impact on subsequent uterus transplantation: a review.

Congenital uterovaginal aplasia commonly occurs in Mayer-Rokitansky-Küster-Hauser syndrome. Various methods of neovagina creation exist, including nonsurgical self-dilation, surgical dilation, and surgical procedures involving skin or intestinal transplants. Subsequent uterus transplantation is necessary to enable pregnancy. We review the main characteristics, advantages, and disadvantages of established neovagina creation methods and discuss their suitability regarding subsequent uterus transplantation. Suitability criteria include sufficient vaginal length, absence of previous major intra-abdominal surgery, a natural vaginal axis, and a natural vaginal epithelium. In conclusion, Vecchietti-based laparoscopically assisted neovagina creation provides ideal functional conditions for uterus transplantation. Nonsurgical self-dilation and Wharton-Sheares-George vaginoplasty may also be suitable. TWEETABLE ABSTRACT: This review discusses the main advantages and disadvantages of neovagina creation methods with regard to subsequent uterus transplantation.