One-stage surgical case management of a two-year-old Arabian horse affected by male-pseudo hermaphroditism.

A two-year-old Arabian horse presented for abnormal external genitalia and dangerous stallion-like behavior was diagnosed with disorder of sexual development (DSD), also known as intersex/hermaphroditism. Standing 1-stage surgical procedure performed under sedation, and local anesthesia to concurrently eliminate stallion-like behavior, risk of neoplastic transformation of intraabdominal gonads, and to replace ambiguous external genital with a functional, and cosmetically more acceptable anatomy. Step-1) Laparoscopic abdominal exploration and gonadectomy; Step-2) Rudimentary penis resection and perineal urethrostomy. The horse tolerated surgery well (combined surgery time 185 min) with no complications. At macroscopic examination of the gonads, they resembled hypoplastic testis-like tissues. Microscopic examination confirmed presence of seminiferous tubules, Leydig and Sertoli/granulosa cells. Cytogenetic evaluation revealed a 64,XX karyotype, SRY-negative. The stallion-like behavior subsided within days post-operatively. Long-term follow-up revealed the genitoplasty site healed without urine scalding or urethral stricture. The owner satisfaction was excellent and the horse could be used post-surgery as an athlete.

Medical and Surgical Management of Conditions of the Penis and Prepuce.

The inability of a bull to reproduce due to its inability to impregnant fertile cows is called impotentia generandi. This infertility may be due to the inability to achieve erection, the inability to complete coitus, or the inability to produce an adequate volume of morphologically normal spermatozoa. Therapies targeting the urogenital tract of the bull can restore reproductive capabilities. Veterinarians can provide consultation regarding both management and selection criteria that will, in some cases, lower the overall risk of loss associated with the development of some conditions of the penis and prepuce.

The effect of preoperative scopolamine patch use on postoperative urinary retention in urogynecologic surgeries.

INTRODUCTION AND HYPOTHESIS: This study aims to determine whether the use of preoperative transdermal scopolamine is associated with an increased risk of postoperative urinary retention in urogynecologic surgeries. METHODS: This is a retrospective chart review study of women who underwent surgery between January 1, 2018, and December 31, 2020. Patients who received a scopolamine patch versus those who did not were compared using demographic and perioperative variables utilizing Pearson's chi-squared test and t-test of Wilcoxon rank-sum. A logistic regression was performed to evaluate the effect of scopolamine on the patients' postoperative voiding trial results, controlling for confounders. P-value < 0.05 was considered statistically significant. RESULTS: A total of 449 women underwent a vaginal or laparoscopic hysterectomy, midurethral sling placement, uterosacral or sacrospinous ligament suspension, sacrocolpopexy, anterior/posterior colporrhaphy, or other urogynecologic surgeries with 109 (24.2%) having received transdermal scopolamine. A significantly higher number of women with preoperative scopolamine [n = 50 (45.9%)] failed their voiding trial compared to those without scopolamine [n = 100 (29.4%), p = 0.0016]. The adjusted model yielded an odds ratio of 1.75 (95% CI: 1.08-2.85) of a failed voiding trial in the scopolamine group. When comparing the odds of failing voiding trial by surgery type, those with a midurethral sling placed during surgery had an adjusted odds ratio of 3.12 (95% CI: 2.01-4.87), as compared to those without a midurethral sling. CONCLUSIONS: Use of a transdermal scopolamine patch for nausea and vomiting prophylaxis is associated with increased risk of postoperative urinary retention across all urogynecologic surgeries.

Perioperative antibiotic prescribing in surgery departments of two private sector hospitals in Madhya Pradesh, India.

BACKGROUND: Single-dose perioperative antibiotic prophylaxis (PAP) is recommended for clean, non-infectious surgeries to prevent surgical site infections. However, the common practice of unindicated use and prolonged use of antibiotics contributes to the development and spread of antibiotic resistance (ABR). The present study explores the perioperative use of antibiotics among inpatients with surgical indications at surgery departments of a teaching (TH) and a non-teaching (NTH) tertiary care hospital in Madhya Pradesh, India. METHODS: Data was collected manually for all inpatients for 3 years (April 2008-August 2011). Patients with non-infectious surgical indications were selected for detailed analysis at the diagnosis group level. RESULTS: Out of 12,434 enrolled inpatients (TH 6171 and NTH 6263), the majority (> 85%) received antibiotics. None of the inpatients received the recommended single-dose PAP. The average duration of antibiotic treatment was significantly longer at the TH compared to the NTH (9.5 vs 4.4 days, p < 0.001). Based on the study aim, 5984 patients were classified in four diagnosis groups: upper or lower urinary tract surgery indications (UUTSI and LUTSI), and routine or emergency abdominal surgery indications (RASI and EASI). In both hospitals, quinolones were the most prescribed antibiotics for UUTSI (TH 70%, NTH 37%) and LUTSI (TH 70%, NTH 61%) antibiotic. In the TH, aminoglycosides (TH 32%) were commonly prescribed for RASI and imidazole derivatives (75%) for EASI. In the NTH, cephalosporins (39%) and imidazole derivatives (56%) were the most prescribed in RASI and EASI, respectively. CONCLUSIONS AND RECOMMENDATIONS: High prescribing of antibiotics in all four selected diagnoses groups was observed at both hospitals. In spite of the recommended single-dose PAP, antibiotics were mainly prescribed for longer durations. The unrecommended use of antibiotics is a risk factor for the development of AMR. Improving the quality of antibiotic prescribing by a stewardship program focusing on the development and implementation of local prescribing guidelines is needed.

Standing male equine urogenital surgery.

The advantages of performing standing male urogenital surgeries are numerous when compared with performing the same surgery in the anesthetized animal. Some traditional standing male urogenital surgeries, such as castrations, may be faster and cheaper to perform. Laparoscopic standing male urogenital surgeries may allow for improved visualization of the surgical field, decreased hemorrhage, and decreased morbidity and convalescence. Limitations of standing procedures may include increased danger to the surgeon because of fractious behavior of the patient, and increased expense and training associated with instrumentation for specialized procedures such as laparoscopy.

Effect of Intravenous Hydrocortisone on Preventing Postoperative Sore Throat Followed by Laryngeal Mask Airway Use in patients Undergoing Urogenital Surgeries.

INTRODUCTION: Postoperative sore throat is a common complication which can lead to discomfort after operation and delay in patients' returning to normal daily activities. The present study was carried out to evaluate the influence of intravenous hydrocortisone on preventing postoperative sore throat followed by laryngeal mask airway use. METHODS: Sixty patients who were scheduled to undergo urogenital surgery were divided into two groups. Five minutes before anesthesia induction, 100 mg of intravenous hydrocortisone or placebo with the same volume were given to the patients randomly. At the end of the operation and after LMAs were removed, patients were asked about having sore throat at hours 2, 4 and 24 after operation. RESULTS: There were three and six cases of sore throat after operation in hydrocortisone and in placebo groups respectively which showed no significant statistical difference (P=0.472). No cases of moderate or severe pain were reported in any of the patients in both groups and no statistically significant difference was observed regarding pain severity in recovery, hours 2, 4 or 24 after operation. CONCLUSION: Based on the statistical data obtained from this research, administrating intravenous hydrocortisone five minutes before anesthesia induction has no effect on postoperative sore throat severity and degree in urogenital surgeries.

Reconstrução tardia da região abdominal inferior e vulvar como tratamento complementar para sequelas pós-correção de extrofia vesical / Delayed reconstruction of the vulvar and lower abdominal regions as a complementary treatment for postsurgical sequelae of bladder exstrophy correction

Patients with malformations of the exstrophy-epispadias complex, including bladder exstrophy, may present for correction of deformities and sequelae in abdominal area, after primary treatment of urogenital malformations, performed early in life and in multiple stages. The secondary correction with aesthetic and functional goals is usually performed after growth and definition of hairy and fat distribution as well as after completion of urological treatment. Psychological aspects should also be considered. We report three female patients, with a history of bladder exstrophy correction in the neonatal period, presenting multiple deformities in the abdominal and vulvar areas, treated at our institution...

Os portadores de malformações do complexo extrofia-epispádia, incluindo a extrofia vesical, podem se apresentar para correções de deformidadese sequelas abdominais após o tratamento primário das malformações urogenitais, realizado nos primeiros anos de vida e em múltiplos estágios. A correção secundária, com objetivos estéticos e funcionais, é normalmente realizada após o crescimento e definição da distribuição pilosae adiposa, bem como após a finalização do tratamento urológico. Os aspectos psicológicos também devem ser considerados. Relatamos uma série de três casos de pacientes do sexo feminino, com antecedente decorreção de extrofia vesical no período neonatal, apresentando múltiplas deformidades na região abdominal e vulvar, submetidas à reconstrução em nosso serviço...

Pregnancies after reconstructive surgery for congenital cervicovaginal atresia.

Eighteen women aged 12 to 20 years with congenital cervicovaginal atresia were treated with a new technique of surgical canalization. All are now having regular menses. Two pregnancies have been achieved, with delivery of viable neonates. Surgical correction of this anomaly during adolescence may aid in restoration of menstrual and reproductive function.

Experience with gynaecological laparoscopies in Wad Medani Hospital, Sudan.

OBJECTIVE: To assess the value and safety of laparoscopy in gynaecological practice in a tertiary care centre in Sudan to determine the magnitude of tubal disease as an aetiological factor in female infertility. DESIGN: A prospective case series study. SETTING: Department of Obstetrics and Gynaecology in a tertiary care Teaching Hospital in Sudan. SUBJECTS: Seven hundred and three women selected for laparoscopy for various reasons. MAIN OUTCOME MEASURES: Indications for laparoscopy findings and complications. RESULTS: Infertility was the main indication (94.32%). Tubal disease was diagnosed in 46.6% of all infertile women studied. The overall complication rate was 22.76 per 1000; two major complications and no death. CONCLUSION: Laparoscopy is a valuable and safe procedure and and is useful in solving patients' problems, especially infertility. Tubal disease is a major aetiological factor in female infertility.

PIP: This prospective case series study determined the main indications and complications of laparoscopy, evaluated the role of laparoscopy in infertility management at Medani Hospital in Sudan, and examined the magnitude of tubal diseases as an etiological factor in infertility. A total of 703 women selected for laparoscopy for different reasons were enrolled in the study. Infertility, both primary and secondary, was the main indication for laparoscopy, accounting for 94.32% of cases. Of all infertile women studied, 46.6% were diagnosed as having tubal disease. The overall complication rate was 22.76/1000, with two major complications and no death. The rest were minor complications, which required only 24-hour monitoring with no further management. In conclusion, the study results suggest that laparoscopy is a valuable and safe procedure in the management of various gynecological problems, especially infertility.

Reproductive characteristics and the age at inception of the perimenopause in a British National Cohort.

Data from a British national cohort of women born in 1946 were used to investigate the hypothesis that the rate of depletion of oocyte numbers is associated with the age at which a woman reaches the inception of the perimenopause. Menopausal status was obtained using an annual questionnaire, sent to the cohort since the age of 47 years, and risk factor information from contacts with the survey throughout earlier life. Parous women entered the perimenopause later than nulliparous women. Those with the most children had the latest perimenopause, where the estimated hazard ratio for women having four or more children compared with those having none was 0.56 (95% confidence interval 0.39-0.81). Women who had a unilateral oophorectomy reached perimenopause earlier then those who had not (hazard ratio = 1.96, 95% confidence interval 1.15-3.35). There was some evidence that early age at menarche and short menstrual cycles were associated with an earlier perimenopause. No relation was observed with oral contraceptive pill use. Results provided some support for the hypothesis under consideration, while estimates of the median age at inception of the perimenopause due to these factors ranged from 46 to 50 years, which is an important variation with respect to later health.

An update on the management of uterine fibroids.

PIP: In Jamaica, uterine fibroids are the most common reason for major surgery in hospital gynecology wards. No treatment is needed in asymptomatic women with small fibroids (less than 12-week size). When fibroids are symptomatic, however, they need to be treated. Medical therapy alone (e.g., gonadotropin-releasing hormone agonists) has produced disappointing results. Myomectomy by laparotomy is the method of choice in most women. Adhesion formation can be reduced by careful operative technique, limited number of incisions, and use of an Interceed barrier to prevent contact between damaged tissue. However, a recurrence rate of 27% has been reported after 10 years, necessitating reoperation. Hysterectomy is recommended in women who have completed childbearing. Depo-Provera has been used to reduce the menorrhagia associated with uterine fibroids, but its effect is temporary and there is no impact on the size and growth of the fibroids.^ieng

Prolapse of Filshie clips following vaginal hysterectomy.

PIP: The medical literature includes more than 100 cases of prolapse of the fallopian tube, most of which were associated with vaginal hysterectomy. This article reports the first case of prolapse of Filshie clips after vaginal hysterectomy in a woman who had previously undergone laparoscopic sterilization. The 45-year-old patient reported irregular vaginal bleeding without pain in the 3 months following hysterectomy. The procedure had been complicated by a large vaginal vault hematoma. Clinical examination revealed 2 Filshie clips and part of the left fallopian tube at the vaginal vault, but no evidence of granulation tissue or fistulae. The clips were excised vaginally and the vault was closed. The patient's recovery was uneventful. Vaginal removal of Filshie clips is recommended at hysterectomy to prevent reperitonealization over the clips and their subsequent prolapse.^ieng

Commentary: promising results but wider recruitment needed.

PIP: Concerns about high rates of hysterectomy have increased interest in alternative surgical and medical treatments for menorrhagia. Hysteroscopic procedures that ablate and resect the endometrium without hysterectomy have been widely adopted but have increased, rather than decreased, the surgical workload in the UK. In addition, most patients prefer surgery to the available medical treatments. A study of the use of levonorgestrel-releasing IUD for treatment of menorrhagia found that more than 80% of women awaiting hysterectomy found this an attractive and effective alternative. However, future research will have to determine the attractiveness of this treatment to patients waiting for a minimally invasive surgical treatment. Alternative trial designs, such as the use of partially randomized patient preference trials, may be needed because it is not possible to create a blind control group in randomized trials of the use of the medicated IUD. The study findings, however, clearly support the use of the levonorgestrel IUD for treatment of menorrhagia. Further research will be required to evaluate long-term clinical effectiveness, cost effectiveness, and patient satisfaction.^ieng

Reliability of reported age at menopause.

Age at menopause is an important epidemiologic characteristic whose reliability of reporting in the US population is not known. The authors examined four hypotheses about the reliability of reported age at menopause in the United States: 1) women with hysterectomy-induced menopause more reliably report their age at menopause than women who have undergone natural menopause; 2) reliability declines with time since menopause; 3) reliability declines with age; and 4) women with higher educational levels report their age at menopause more reliably than women with less education. The authors used linear regression models among 2,545 women in the First National Health and Nutrition Examination Survey and Followup Study (1971-1984) and compared responses at first and follow-up interviews. Among women who had undergone a natural menopause, 44% reported their age at menopause within one year from the first to second interviews; among women who had undergone a hysterectomy-induced menopause, 59% reported their age at menopause within one year from first to follow-up interviews. Only hysterectomy status and years from menopause to follow-up interview were significantly associated with the absolute difference between age at menopause reported at first and follow-up interviews. The authors conclude that caution in studies involving age at menopause may enhance our understanding of this critical event in the lives of women.

Obstetric and gynaecological patients in an intensive care unit: a 1 year review.

Management of the critically ill patient forms a significant proportion of obstetric and gynaecological (O & G) practice. There have however, been very few reports on the management of such patients in intensive care units (ICU). We review all O & G patients admitted to the surgical ICU at King Edward VIII Hospital, Durban, South Africa, and make recommendations regarding management of such patients. The medical records of all O & G patients admitted to the surgical ICU between the period January-December 1992 were analysed. Of all admissions to the ICU 13.6% (n = 122) were O & G patients. Eclampsia was the most common diagnosis accounting for 66% of all obstetric admissions. Of all eclamptics in the study period 24% were admitted to the ICU. The overall maternal mortality was 21%. O & G patients form a major workload of surgical ICUs and the majority of these patients are women with eclampsia. Management of such patients requires an understanding of the physiological changes of normal and abnormal pregnancies. Therefore, all large obstetrical units in developing countries should establish their own ICU in order that patient care, health personnel training and continuing health care education may be improved.

PIP: Management of critically ill patient forms a significant proportion of obstetric and gynecological (O&G) practice. There have, however, been very few reports on the management of such patients in intensive care units (ICUs). The authors review all O&G patients admitted to the surgical ICU at King Edward VIII Hospital, Durban, South Africa, and make recommendations regarding management of such patients. The medical records of all O&G patients admitted to the surgical ICU during January-December 1992 were analyzed. Of all admissions to the ICU, 13.6% (n = 122) were O&G patients. Eclampsia was the most common diagnosis, accounting for 66% of all obstetric admissions. Of all eclamptics during the study period, 24% were admitted to the ICU. The overall maternal mortality was 21%. O&G patients form a major workload of surgical ICUs, and the majority of these patients are women with eclampsia. Management of such patients requires an understanding of the physiological changes of normal and abnormal pregnancies. Therefore, all large obstetrical units in developing countries should establish their own ICUs so that patient care, health personnel training, and continuing health care education may be improved.

The levonorgestrel-releasing intrauterine device: a wider role than contraception.

The Levonorgestrel-releasing intrauterine device (LNG IUD) provides excellent contraception; it may reduce the rate of pelvic inflammatory disease (PID) and ectopic pregnancy compared to other 'modern' copper releasing IUDs; it can safely be used in the puerperium for breast-feeding mothers, and it significantly reduces menstrual blood loss and pain. While it was developed primarily as a contraceptive, its potential role in managing heavy and painful menstruation and the symptoms of the climacteric may eventually be just as important. Amongst developed countries New Zealand and Australia have some of the highest hysterectomy rates. By the age of 50 years 1 in 4 women in New Zealand and 1 in 5 women in Australia will have had a hysterectomy (A,B). In New Zealand 90% of these are performed for heavy menstrual bleeding and fibroids (A). The LNG IUD has been shown to be effective treatment for both these conditions and its introduction to New Zealand and Australia would offer women an additional choice beyond surgery.

Japan discloses 16,520 "eugenic" sterilizations.

PIP: In Japan, the government has reported that the Eugenic Protection Law led to sterilization of 16,520 people from 1949 to 1994. The Eugenic Protection Law was replaced in 1996 with a Maternal Protection Law. Both laws provide legal loopholes that allow women to have abortions despite the 1907 Criminal Abortion Law. The disclosure was sparked when Sweden announced that approximately 60,000 of its people were sterilized between 1935 and 1976 for eugenic reasons. It was then disclosed that Denmark had sterilized approximately 11,000 people from 1929 to 1967, Finland sterilized 11,000 people and performed 4000 involuntary abortions from 1945 to 1970, and Norway had 2000 sterilizations. A consortium of 17 Japanese groups and individuals representing women and the disabled requested that the Japanese Minister of Health and Welfare issue an apology and provide compensation to victims of coercive sterilization. The group is calling for research into coercive sterilizations to be conducted in ways that respect the privacy of the victims. The government response has been that no apologies or compensation would be forthcoming because the sterilizations were legal under existing law and (it claims) were not coercive.^ieng

Reduced risk of ovarian cancer in women with a tubal ligation or hysterectomy. The World Health Organization Collaborative Study of Neoplasia and Steroid Contraceptives.

Possible relationships between tubal ligation and hysterectomy and epithelial ovarian cancer were assessed in data that were collected for a multinational hospital-based case-control study conducted between 1979 and 1988. Histologically confirmed incident cases (n = 393) were compared with controls (n = 2563) matched on age, hospital, and year of interview. A nonsignificant reduction in risk was observed for tubal ligation [odds ratio (OR), 0.72; 95% confidence interval (CI), 0.48-1.08] and hysterectomy (OR, 0.58; 95% CI, 0.26-1.27). There was no trend in risk with time since tubal ligation. The possible protective effect of tubal ligation was greatest in women of parity less than four. The apparent protective effect of tubal ligation was seen only for clear cell (OR, 0.32; 95% CI, 0.006-2.50) and endometrioid (OR, 0.20; 95% CI, 0.046-1.46) tumors, suggesting a hormonal mechanism for the observed associations.

Conclusions of a round-table that took place during a seminar on the prevention of TB and HIV transmission in health care settings, Douala, Cameroon, January 1995.

PIP: Gynecologists and obstetricians in Africa are at high risk of being exposed to tuberculosis (TB) and HIV during child delivery. To protect themselves against infection, they must wear cuffs which cover gown sleeves and refuse to work with fingerstalls which do not cover the hand. There must be one pair of gloves per woman giving birth and the wearing of glasses and a mask is advised. To reduce the risk of disease transmission from mother to fetus, the uterus should not be punctured in case HIV is present in the amniotic fluid. The lower birth canal should be disinfected using betadinel before delivery. Care must be taken in using electrodes for monitoring, clearing the mouth and nasal passages. Forceps should be used only when clearly indicated and absolutely needed. Furthermore, the highly contaminated placenta should be handled carefully, while traditional midwives must be properly trained and followed up. Retain the BCG vaccination of all children before they leave the maternity hospital or as soon as possible and condom use should be promoted against TB and HIV transmission.^ieng