Gender and cystectomy for bladder cancer: A high-volume tertiary urologic care center experience.

BACKGROUND: Differences have often been reported in the outcomes of bladder cancer (BC) patients according to gender. OBJECTIVE: This study aims to provide data on patients undergoing radical cystectomy (RC) in a high-volume tertiary urologic center and to assess whether gender discrepancies do exist in terms of surgical options and clinical outcomes. MATERIALS AND METHODS: Consecutive BC patients treated between 2016 and 2020 at a single center (Careggi University Hospital, Florence, Italy) were included in the study. The impact of gender on disease stage at diagnosis, overall survival (OS), and type of surgery was analyzed. RESULTS: The study series comprised 447 patients (85 females and 362 males). At a median follow-up of 28.3 months (IQR: 33.5), OS was 52.6% and cancer-specific survival was 67.6%. Significant differences in OS emerged for age, acute myocardial infarction (AMI), Charlson Comorbidity Index (CCI), pT, and pN. OS rates were higher in patients undergoing robot-assisted surgery and in those receiving open orthotopic neobladder (ONB) (p = 0.0001). No statistically significant differences were found between male and female patients regarding surgical offer in any age group, surgical time, early postoperative complications, pathologic stage, and OS. CONCLUSIONS: After adjustment for pathologic tumor stage and treatment modalities, female and male patients showed similar oncologic outcomes. Further studies should be undertaken to evaluate functional results in women subjected to RC.

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.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap.

INTRODUCTION: After extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. METHOD: Patients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. RESULTS: Thirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. CONCLUSION: This long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.

Tissue expander capsule as an induced vascular bed to prefabricate an axial vascularized buccal mucosa-lined flap for tubularized posterior urethral reconstruction: preliminary results in an animal model.

Surgical repair of complex posterior urethral disruptions remains one of the most challenging problems in urology. The efficacy of using a tissue expander capsule as an induced vascular bed to prefabricate axial vascularized buccal mucosa-lined flaps for tubularized posterior urethral reconstruction in a rabbit model was tested. The experiments were performed in three stages. First, silicone tissue expanders were inserted into the groin to induce vascularized capsule pouch formation. Next, buccal mucosa grafts were transplanted into the newly formed capsular tissue supplied by axial vessels for buccal mucosa-lined flap prefabrication. Then, circumferential posterior urethral defects were created and repaired with the buccal mucosa graft (Group 1), the capsule flap (Group 2), and the prefabricated capsule buccal mucosa composite flap (Group 3). After surgery, notable contracture of the tubularized buccal mucosa graft was observed in the neourethra, and none of the rabbits in Group 1 maintained a wide urethral caliber. In Group 2, the retrieved neourethra showed little evidence of epithelial lining during the study period, and the lumen caliber was narrowed at the 3-month evaluation. In Group 3, the buccal mucosa formed the lining in the neourethra and maintained a wide urethral caliber for 3 months. The capsule may serve as an induced vascular bed for buccal mucosa-lined flap prefabrication. The prefabricated buccal mucosa-lined flap may serve as a neourethra flap for posterior urethral replacement.

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.

Epidermoid carcinoma in the neovagina of a patient with Mayer-Rokitansky-Küster-Hauser syndrome. Case report and literature review / Carcinoma epidermoide de neovagina en paciente con síndrome de Mayer-Rokitansky-Küster-Hauser. Reporte de un caso y revisión de la literatura

Objective: To present the case of a squamous carcinoma in the neovagina of a patient with Mayer-Rokitansky-Küster-Hauser syndrome and review of the literature related to treatment and prognosis of vaginal neoplasms or HPV infection in transgender women or with MRKH syndrome. Materials and methods: A 56-year-old woman consulted to the Hospital Universitario of Sevilla (Spain). During the clinical examination, a exophytic tumor at the bottom of the vagina was found and the biopsy reported squamous carcinoma and positive nucleic acid amplification test for human papilloma (HPV) type 16. A literature search of case reports, case series and observational studies published from 2000 to October 2019 in English and Spanish was performed in Medline via PubMed, with the follow- ing terms: "congenital abnormalities"; "Mullerian aplasia"; "neovagina"; "Vaginal neoplasms"; "Squamous carcinoma"; "HPV infection" was performed. Results: 14 studies were finally included; seven corresponded to squamous cell carcinoma, three to adenocarcinoma and four reported HPV infection only. All of the squamous cell carcinomas were at advanced stages due to local or lymphatic compro- mise and received radiotherapy with concomitant chemotherapy or radical surgery. The prognosis was bad in three of the cases. Patients with adenocarcinoma also presented with advanced lesions due to local extensión and received surgical treatment and two cases received concomitant chemotherapy. Only one patient was followed-up for five years or more. HPV infection is common in women who underwent neovagina reconstruction. Conclusions: Patients with neovagina are susceptible to develope squamous carcinomas or adenocarcinomas depending if skin or intestinal tissue grafts are used. According to local compromise at the time of diagnosis, radical or combined treatments are required. Which screening strategies for HPV, squamous cell carcinomas and adenocarcinoma is to be investigated.

TITULO: CARCINOMA EPIDERMOIDE DE NEOVAGINA EN PACIENTE CON SÍNDROME DE MAYER- ROKITANSKY-KÜSTER-HAUSER. REPORTE DE UN CASO Y REVISIÓN DE LA LITERATURA. Objetivo: Presentar el caso de una paciente con síndrome de Mayer-Rokitansky-Küster-Hauser, con diagnóstico de carcinoma escamoso en neovagina, y realizar una revisión de la literatura del tratamiento y pronóstico de las neoplasias o la infección por VPH de tejidos neovaginales en mujeres transgénero o con síndrome MRKH. Materiales y métodos: Mujer de 56 años de edad que consulta en un hospital universitario regional de la ciudad de Sevilla (España). Tras la exploración clínica se aprecia una tumoración exofítica en fondo de vagina, con resultado de biopsia de carcinoma escamoso y cultivo positivo para virus del papilloma humano (VPH) tipo 16. Se realizó una búsqueda bibliográfica en la base de datos Medline vía PubMed, con los términos: "congenital abnormalities"; "mullerian aplasia"; "neovagina"; "vaginal neoplasms"; "squamous carcinoma"; "HPV infection", de reportes y series de caso, y estudios observacionales publicados desde el año 2000 hasta octubre de 2019 en inglés y español. Resultados: Se incluyeron 14 estudios; de estos, siete correspondieron a carcinoma escamocelular, tres a adenocarcinoma y cuatro informan infección solo por VPH. Todos los carcinomas escamocelulares presentaban estadios avanzados por compromiso local o linfático y recibieron radioterapia con quimioterapia concomitante o cirugía radical. El pronóstico fue malo en tres de los casos. Las pacientes con adenocarcinoma también presentaron lesiones avanzadas con compromiso local, el tratamiento fue quirúrgico, con quimioterapia concomitante en dos de los casos. Solo una paciente tuvo seguimiento mayor a cinco años. La infección por VPH es frecuente en mujeres sometidas a construcción de neovagina. Conclusiones: Las pacientes con neovagina son susceptibles de desarrollar carcinomas escamosos si se utilizaron injertos cutáneos, o adenocarcinomas en aquellas en las que se reconstruyó la vagina a partir de injertos tisulares intestinales. Dado que al momento del diagnóstico presentan compromiso local, a menudo requieren tratamientos radicales o combinados. Se debe investigar cuáles son las mejores estrategias de tamizaje de VPH, cáncer escamoso y adenocarcinoma en este tipo de pacientes.

Barbed Suture versus Conventional Suture for Vaginal Cuff Closure in Total Laparoscopic Hysterectomy: Randomized Controlled Clinical Trial.

STUDY OBJECTIVE: To determine the surgical time, suture time, presence of postoperative dyspareunia, and complications that occur after closing the vaginal cuff with a barbed suture compared with conventional suture. DESIGN: A randomized, controlled clinical trial (Canadian Task Force classification I). SETTING: Private gynecologic clinic in Medellin, Colombia. PATIENTS: One hundred fifty women who underwent total laparoscopic hysterectomy for benign pathology. INTERVENTIONS: The patients underwent total laparoscopic hysterectomy with intracorporeal closure of the vaginal cuff and were randomized to 2 groups, 1 using a barbed suture (V-Loc 90; Medtronic/Covidien, New Haven, CT) and 1 using polyglactin 910 (coated Vicryl suture; Ethicon/Johnson & Johnson, New Brunswick, NJ). MEASUREMENTS AND MAIN RESULTS: The total operative time, closing time of the vaginal vault, presence of complications in the cuff, and incidence of postoperative dyspareunia were recorded. The patients were evaluated at a postoperative office visit 2 weeks after the procedure and by telephone interview at 24 weeks. Seventy-five patients were included in the barbed suture group and 75 patients in the polyglactin 910 group. The average time to complete the suture of the vaginal cuff was 12.01 minutes (± 5.37 standard deviation) for the barbed suture group versus 13.49 minutes (± 6.48) in the polyglactin 910 group (95% confidence interval, -.44 to 3.4; p = .130). Blood loss was 31.56 ± 22.93 mL in the barbed suture group versus 30.82 ± 21.75 mL in the polyglactin 910 group (95% confidence interval, -7.95 to 6.47; p = .840). The frequency of postoperative events such as hematoma, cellulitis, cuff dehiscence, fever, emergency consultation, and hospitalization was not statistically significant between groups. No statistically significant difference was found regarding deep dyspareunia at 24 postoperative weeks. CONCLUSION: No differences were found in surgical time or frequency of adverse events when comparing patients after vaginal cuff closure with barbed suture versus polyglactin 910.

Repair of colonic neovaginal stenosis using a biological graft in a male-to-female transgender patient.

INTRODUCTION AND HYPOTHESIS: One in 2900 genotypical men report gender dysphoria, and many undergo gender confirmation surgery to match their physical phenotype to their identity. A variety of surgical techniques are used in male-to-female transgender patients, one of which is bowel vaginoplasty, and postoperative stenosis of the colonic neovagina is common. Extracellular matrix grafts have been used in vaginal reconstruction. with porcine urinary bladder matrix (UBM) acting as a scaffold for smooth-muscle tissue and matrix regeneration. The aim of this surgical video is to describe the use of a UBM biological graft in repair of introital stenosis due to recurrent granulation tissue in the colonic neovagina of a male-to-female transgender patient. METHODS: A 32-year-old male-to-female transgender patient with a history of rectosigmoid neovagina formation for genital gender confirmation surgery 12 months prior presented with genital granulation tissue and stenosis of her neovaginal introitus. Despite two surgical revisions, the patient developed recurrence of granulation tissue and obliteration of the neovaginal introitus, preventing sexual function of the neovagina. RESULTS: Reconstruction of the neovaginal introitus was performed using UBM. The patient noted improvement in comfort, hygiene, and quality of life following the procedure. This video describes our surgical technique and perioperative clinical findings. CONCLUSIONS: We report the novel use of UBM biological graft in the revision of a neovaginal introitus after former rectosigmoid vaginoplasty in a male-to-female transgender patient.

Vaginoplasty and creating labia minora in children with disorders of sex development.

PURPOSE: To report current results of vaginoplasty using the mucosa of the prepuce, and creating labia minora by penile skin in children with disorders of sex development (DSD). METHODS: In 10 years, we have performed 22 vaginoplasties using the described technique of vaginoplasty, 21 patients with 46, XX DSD and 1 ovotesticular DSD. The assessment of the results of this technique of vaginoplasty was undertaken in several stages: (a) The evaluation of the cosmetic result. (b) The research for a urinary incontinence and urethrovaginal fistulas. (c) The research for a vaginal stenosis by the introduction of a lubricated feeding tube into the vaginal cavity. The labia minora was evaluated by three criteria: its skin should be thin and very supple, it should have a free edge which partially or totally covers the clitoris, urethral meatus, and vaginal orifice; and it is preferable that its color be darker than the rest of the skin. RESULTS: The cosmetic outcome was considered by parents and the surgeon as very satisfactory in 11 patients (50% of cases), satisfactory in 4 patients (18.2%), and unsatisfactory in 7 patients (31.8%). The postoperative complications were five cases of proximal stenosis (22.7%), one distal stenosis (stenosis of introitus) and two necrosis of the preputial flap. No urethrovaginal fistula and urinary incontinence were reported. CONCLUSIONS: In infant and young child, when it is difficult to make use of complete urogenital mobilization, the mucosa of the prepuce can be an alternative to create a neovagina, its histological constitution is identical to a vaginal wall, and it does not prevent to have a good labia minora.

Evaluation and management of vaginoplasty complications.

PURPOSE OF REVIEW: Indications for vaginoplasty include congenital conditions such as adrenal hyperplasia, cloacal malformations, and Müllerian agenesis, acquired conditions including stenosis from radiation or surgical resection for malignancy, and gender affirmation. All vaginoplasty techniques carry significant risk of both immediate and long-term complications. RECENT FINDINGS: The purpose of this study is to provide a review of the evaluation and management of the neovagina, addressing management of human papilloma virus infections and complications including stenosis, fistula, prolapse, and neovaginal colitis. SUMMARY: Gynecologists who care for patients who have had a vaginoplasty need to understand the importance of long-term follow up and care, including evaluation and management of complications.

Evaluation of amnion in creation of neovagina in women with Mayer-Rokitansky-Kuster-Hauser syndrome.

OBJECTIVE: To assess the outcome of amnion vaginoplasty in cases of vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome managed at the authors' institution. DESIGN: Retrospective study. SETTING: Tertiary care hospital. PATIENT(S): Fifty women with MRKH who underwent neovaginoplasty. INTERVENTION(S): Modified McIndoe's vaginoplasty was done in all the patients, using human amnion graft. MAIN OUTCOME MEASURE(S): Functional status assessed by Female Sexual Function Index, anatomic status (length and width of neovagina), and epithelialization of vagina. RESULT(S): Mean (±SD) vaginal length after surgery was 8.2 ± 1 cm. Mean vaginal length at 6-month follow-up in sexually active patients was significantly longer as compared with the patients who were not sexually active after surgery (8.4 ± 1.04 cm vs. 6.6 ± 2.4 cm). Mean Female Sexual Function Index score was 30.8 ± 2.1. Vaginal biopsy showed complete epithelialization of vaginal mucosa. CONCLUSION(S): In a developing nation like India, McIndoe's method with amnion graft seems to be a promising option owing to its low cost, easy availability, and safety, ease of the procedure not requiring any special instrument, physiologic outcome with respect to epithelialization of the vagina without hair growth, and satisfying functional outcome.

Robotic Intracorporeal Orthotopic Neobladder: Urodynamic Outcomes, Urinary Function, and Health-related Quality of Life.

BACKGROUND: Intracorporeal orthotopic neobladder (iONB) creation following robotic radical cystectomy is an emerging procedure and robust functional data are required. OBJECTIVE: To evaluate urodynamic features of iONB and bladder cancer-specific and general health-related quality-of-life (HRQOL) outcomes. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively assessed 28 men who underwent iONB creation (January 2012 to October 2013) and compared results to a previously characterized cohort of 79 of open ONB procedures. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: iONB pressure-volume properties were characterized using multichannel urodynamics (UDS). The Bladder Cancer Index (BCI) questionnaire, modified with mucus- and pad-related questions, and the Short Form Health Survey (SF-36) were used to evaluate urinary function and HRQOL. ONB cohorts were compared for functional outcomes and BCI score. Multivariable linear regression was used to assess predictors of BCI score. RESULTS AND LIMITATIONS: The median follow-up was 9.4 mo for the iONB and 62.1 mo for the open ONB group (p<0.0001); ≥2-yr follow-up had been completed for one (4%) patient in the iONB group compared to 75 (95%) patients in the open ONB group (p<0.0001). In UDS tests, the iONB group had minimal postvoid residual volume, normal compliance, and a mean capacity of 514 cm(3) (range 339-1001). BCI mean scores for urinary function (p=0.58) and urinary bother (p=0.31) were comparable between the groups. The surgical approach was not associated with the BCI score on multivariable analysis. Rates of 24-h pad use were comparable between iONB and open ONB groups (pad-free 17% vs. 19%; ≤2 pads 84% vs. 79%), as reflected by total pad usage (p=0.1); pad size and daytime wetness were worse in the iONB group. The clean intermittent catheterization rate was 10.7% in the iONB and 6.3% in the open ONB group. Limitations include the retrospective comparison, small number of patients and short follow-up for the iONB group. CONCLUSIONS: iONB had adequate UDS characteristics and comparable bladder cancer-specific HRQOL scores to open ONB. However, pad size and daytime wetness were worse for iONB, albeit over significantly shorter follow-up. PATIENT SUMMARY: We demonstrate that the volumetric and pressure characteristics are acceptable for a neobladder created using an entirely robot-assisted laparoscopic technique after bladder removal for cancer. Urinary function and quality-of-life outcomes related to the robotic technique were compared to those for neobladders created via an open surgical technique. We found that urinary function and bother indices were comparable; however, the robotic group required larger incontinence pads that were wetter during the daytime. This may be explained by the significantly shorter duration of recovery after surgery in the robotic group.

Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy.

ERCP in surgically altered anatomy requires the endoscopist to fully understand the procedural goals and the reconstructed anatomy before proceeding. Altered anatomy presents a variety of challenges unique to enteroscopy, and others related to accessing the biliary or pancreatic duct from unusual orientations. Both side-viewing and forward-viewing endoscopes, as well as single and double balloon techniques, are available for ERCP in these settings. Endoscope selection largely depends on the anatomy and length of reconstructed intestinal limbs. Endoscopist experience with performing ERCP in surgically altered anatomy is the most important factor for determining outcomes and success rates.

Changes in filtering bleb morphology after bleb-related infection.

PURPOSE: To verify, by use of data collected by the Japan Glaucoma Society Survey of Bleb-related Infection (JGSSBI), that bleb morphology changes within 12 months of the development of bleb-related infection. METHODS: JGSSBI data from 57 eyes of 57 patients with primary open-angle glaucoma and normal tension glaucoma who developed a bleb-related infection were analyzed. Morphological features of the blebs were graded by use of a predetermined grading system. Multiple logistic regression analysis was conducted to identify factors relating to bleb morphology which were associated with poor outcome. RESULTS: Bleb sizes, including both circumferential and tangential lengths, were significantly smaller for stage IIIa/IIIb infections than for stage I/II bleb infections (P = 0.009 and P = 0.026 for the circumferential and tangential lengths, respectively; Fisher's direct probability test). The bleb wall also became significantly thicker during stage IIIa/IIIb infections (P = 0.003). After infection, intraocular pressure (IOP) increased significantly for all cases but was no different in the three subgroups (i.e. stage I, stage II, and stage IIIa/IIIb bleb infections). Multiple logistic regression analysis revealed that a stage III infection was significantly associated with a poor outcome for the bleb. CONCLUSIONS: This study revealed that the filtering bleb became smaller, both tangentially and circumferentially, and thicker, after stage III infections than after stage I or II infections.

Serial changes in the bleb wall after glaucoma drainage implant surgery: characteristics during the hypertensive phase.

PURPOSE: To investigate serial changes in the bleb wall using anterior segment optical coherence tomography (AS-OCT) in patients who had undergone Ahmed glaucoma valve (AGV) implantation. METHODS: A total of 52 patients who had undergone AGV implantation were enrolled. Reflectivity and mean thickness of the bleb wall were examined using AS-OCT at 1 day, 1 week, 1 month, 3 months and 6 months postoperatively. Intra-ocular pressure (IOP) and the number of glaucoma medications were evaluated. The hypertensive phase was defined as IOP >21 mmHg during the first 3 months after surgery. Patients were divided into two groups: hypertensive and non-hypertensive groups. RESULTS: Following AGV implantation, IOP decreased at each time-point during postoperative follow-up (p value < 0.001, all) with a peak in the first month. Mean bleb wall thickness showed a U-shaped curve postoperatively, being thinnest 1 month after the operation. Reflectivity showed an inverted U-shaped curve postoperatively, being brightest 1 month after the operation. A hypertensive phase was observed in 44 patients (84.6%). The bleb wall was significantly more reflective (130.67 ± 27.00 versus 106.57 ± 10.35; p = 0.044) in the hypertensive group than in non-hypertensive group 1 month postoperatively. CONCLUSIONS: Hypertensive phase peaked at 1 month after aqueous shunt surgery. At that time, the bleb wall had the highest reflectivity. The unique IOP pattern after tube surgery is related to fibrosis of the bleb wall qualitatively. Specific modulation of wound healing may be the target for attempts to decrease the development of hypertensive phase.

Long-term outcome and quality of life after supercharged jejunal interposition for oesophageal replacement.

BACKGROUND: The consequences of major conduit necrosis following oesophagectomy are devastating. Jejunal interposition with vascular supercharging is an alternative reconstructive method if colon is unavailable. Aims of this study were to review the long-term outcome and quality of life of patients undergoing this surgery in our tertiary unit. METHODS: Patients undergoing oesophageal reconstruction with supercharged jejunum were identified and retrospective review of hospital notes performed. Each patient was then interviewed for follow up data and quality of life assessment using the EORTC QLQ-C30 questionnaire. RESULTS: Six patients (5 men) (median age 59 years (range 34-72) underwent supercharged pedicled jejunal (SPJ) interposition from May 2005-August 2010. Indications for surgery were loss of both gastric and colonic conduits following surgery for oesophageal cancer (n = 4), loss of gastric conduit and previous colectomy (n = 1) and lastly, gastric and colonic infarction in a strangulated paraoesophageal hernia (n = 1). Median time to reconstruction was 12 months [6-15 range]. There were no in-hospital deaths. Median postoperative stay was 46 days [13-118]. Three patients required surgical re-intervention for leak, sepsis and reflux, respectively. Median follow up was 6.5 years [range 7-102 months]. One patient died seven months following surgery due to respiratory complications. On follow up, 5 patients have an enteral diet without supplemental nutrition, maintaining weight and good quality of life scores. CONCLUSIONS: Supercharged jejunal interposition is a suitable alternative conduit for delayed oesophageal replacement in patients with otherwise limited reconstructive options. Good functional outcomes can be achieved despite formidable technical challenges in this group.

Autologous in vitro cultured vaginal tissue for vaginoplasty in women with Mayer-Rokitansky-Küster-Hauser syndrome: anatomic and functional results.

STUDY OBJECTIVE: To present the procedure and the results of a technique in which in vitro autologous cell cultures were used for the canal lining in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) subjected to vaginoplasty with a modified Abbè-McIndoe technique. MRKHS is a rare anomaly characterized by vaginal agenesis with variable müllerian duct abnormalities. The Abbè-McIndoe procedure is 1 of the most frequent surgical treatments adopted in these women. In the last decades, several modifications have been introduced by different authors, mostly changing the lining material, but no consensus has been reached on what material should be used for the neovagina canal wall lining. DESIGN: A pilot study (Canadian Task Force classification II-1). SETTING: Policlinico Umberto I, "Sapienza" University of Rome. PATIENTS: A consecutive series of 23 women with MRKHS underwent neovaginoplasty with autologous vaginal tissue as the graft material between 2006 and 2013. INTERVENTIONS: Each patient with MRKHS was subjected to a full-thickness mucosal biopsy from the vaginal vestibule. After enzymatic dissociation, cells were inoculated onto collagen IV-coated plates and cultured for 2 to 3 weeks. The patients were subjected to vaginoplasty with a modified Abbè-McIndoe technique with autologous in vitro cultured vaginal tissue. Patients underwent clinical follow-up visits at 1, 3, 6, and 12 months after surgery and every year thereafter. Anatomic, functional, and sexual results were assessed. MEASUREMENTS AND MAIN RESULTS: In all cases, the vagina appeared normal in length and depth. A vaginal cytology and a vaginal biopsy obtained at the 3-month follow-up visit revealed physiological vaginal tissue. All 23 patients completed the Female Sexual Function Index questionnaire at 12 months after surgery. The results showed a total score of 27.2. These results indicate a satisfactory quality of sexual life. CONCLUSION: The modified Abbè-McIndoe technique with autologous vaginal tissue appears to be safe and feasible. This technique allows normal and satisfying sexual intercourse. Larger series with longer follow-ups will be necessary to confirm if this technique represents the ideal procedure for vaginal agenesis.

[Efficacy of the use of remnant stomach in esophagoplasty].

In the period from 2001 till 2010 there were 117 extirpations of the oesophagus with single-stage plasty of the stomach in 94 patients and plasty of the large intestine--in 23 cases. Gastric resections were performed earlier in 50 (42.7%) patients, though gastrectomy took place in 39 (78%) patients. The accumulated experience allowed making an assessment of immediate and long-term results of esophagoplasty to patients, who had earlier the gastric resection. The incompetence of oesophagogastric anastomosis was noted in 2 times more frequent and the formation of stenosis of given anastomosis in 3 times more often. I order to improve the results of esophagoplasty, the method of serousmyotomy was applied in the cases of remnant stomach.