What is the applicability of tubal ligation with the vaginal natural orifice transluminal endoscopic surgery technique and its value in patient comfort?

OBJECTIVE: The aim of this study was to observe the feasibility of the tubal/adnexal approach using vaginal natural orifice transluminal endoscopic surgery and compare its contribution with surgeon ergonomics and postoperative patient comfort with that of conventional laparoscopy. METHODS: We completed this study retrospectively with 47 patients. Patients were followed at their postoperative first month. We analyzed the usability of the vaginal natural orifice transluminal endoscopic surgery method over conventional laparoscopy by comparing the demographics, surgical data, and postoperative findings collected between the two groups. RESULTS: Patients in the conventional laparoscopy group were older (39.1±3.3 years) than those in the vaginal natural orifice transluminal endoscopic surgery patient group (p=0.005). Pain intensity 24 h after surgery was lower in the vaginal natural orifice transluminal endoscopic surgery group (p=0.003), while sexual function and dyspareunia did not differ between the two groups in the first month. Patients in the vaginal natural orifice transluminal endoscopic surgery group were more relieved about painlessness and the comfort it brought than the conventional laparoscopy group (p=0.027, χ2=12.56). CONCLUSION: Patients subjected to the vaginal natural orifice transluminal endoscopic surgery procedure showed higher levels of satisfaction, less postoperative pain, and greater comfort than those subjected to conventional laparoscopy.

Reviving forgotten techniques: Vaginal salpingectomy in public health system, a retrospective cohort study.

OBJECTIVE: To evaluate the viability of the vaginal route as an alternative to laparoscopy for patients seeking permanent surgical contraception. METHODS: We conducted a retrospective cohort study in 2021, dividing patients into two groups based on their preference: vaginal and laparoscopic salpingectomy. The statistical analysis was conducted using STATA, employing standard statistical methods based on the distribution of variables. RESULTS: The study included 64 patients, with 34 undergoing the vaginal approach and 30 the laparoscopic route. No statistically significant differences were observed in baseline characteristics or complications between the two groups. Both surgical methods were found to be feasible. The vaginal route demonstrated a significantly shorter mean surgical time (P < 0.001). The laparoscopic route exhibited significantly less intraoperative blood loss (P < 0.001) and fewer hospitalization hours (P = 0.008). Postoperative satisfaction and pain levels did not show statistically significant differences. CONCLUSION: Vaginal salpingectomy is a feasible technique with low complication rates, making it a potential option for gynecologists to offer their patients. We propose vaginal route inclusion in the training curriculum for gynecologic surgeons during the residency program, without any subspecialty requirements.

Outcomes of urethral meatal preservation ventral urethroplasty for female urethral stricture: a series of cases.

Objective: To present a series of cases with our initial experience and short-term outcomes of a modified vaginal mucosal flap urethroplasty. Methods: Patients diagnosed with urethral stricture and operated by the same operative technique between January 2012 and January 2018 were followed for at least 6 months. Uroflowmetry and clinical outcomes were evaluated. Results: Nineteen patients were included with an average age of 56.4 years, mean preoperative Qmax of 5.3 ml/s, and PVR of 101.4 mL. After 6 months of the procedure, the mean Qmax improved to 14.7 mL/s (p<0.05), PVR decreased to 47.3 mL (p<0.05), and 84.2% of all patients reported improvement in clinical self-reported symptoms. There was an improvement in symptoms such as voiding effort in 84.2% of patients, weak stream (89.5%), and recurrent urinary tract infection (85.7%). The success rate (absence of symptoms and normal Qmax with no significant PVR) of the procedure was 84.2%. Conclusion: The described technique was considered effective for the treatment of female urethra stricture, with a high clinical success rate and an objective improvement of Qmax and decrease in PVR after 6 months of the procedure.

Experiencia de la histeropexia vaginal, usando prótesis de polipropileno / Experience of vaginal hysteropexy, using polypropylene prosthesis

Introducción: El prolapso de órganos pélvicos (POP) o distopia genital, es el descenso o desplazamiento de los órganos del suelo pélvico a través del canal vaginal o fuera de este. Objetivo: Evaluar los resultados de la histeropexia vaginal en la corrección quirúrgica del prolapso genital apical grado III o IV, usando prótesis de polipropileno; además describir la tasa de éxito, recurrencias y complicaciones. Método: Estudio de cohorte, en 42 mujeres sometidas a histeropexia vaginal (histero-cistopexia ortotópica) mediante prótesis de polipropileno (Splentis®), entre 2016 y 2021. Se realizaron tres evaluaciones postoperatorias (tres, seis y 12 meses). Se hizo muestreo no probabilístico. Se utilizó estadística descriptiva. Resultados: La edad media fue de 56,19 ± 9,27 años. El tiempo quirúrgico de 58,95 ± 13,74 minutos, el sangrado quirúrgico de 119,85 ± 68,73 ml. La tasa de éxito a los 12 meses fue del 90,47%. La recurrencia del prolapso apical fue del 4,76% a los seis meses y del 9,52% a los 12 meses; el de compartimento anterior a los seis meses arrojó un 7,14%, frente al 11,9% a los 12 meses. El 14,28% de las pacientes presentaron complicaciones menores. La incidencia de incontinencia urinaria de esfuerzo a los 12 meses fue del 16,66%. Conclusiones: la histeropexia vaginal es un procedimiento efectivo y seguro, con bajas tasas de recurrencias o complicaciones. Es importante que se sigan haciendo estudios con mejores diseños estadísticos.

Introduction: Pelvic organ prolapse (POP), or genital dystopia, is the descent or displacement of pelvic floor organs through the vaginal canal or outside of it. Objective: To evaluate the results of vaginal hysteropexy in the surgical correction of grade III or IV apical genital prolapse, using polypropylene prosthesis; also describe the success rate, recurrences and complications. Method: Cohort study in 42 women undergoing vaginal hysteropexy (orthotopic hystero-cystopexy) using a polypropylene prosthesis (Splentis®); between 2016 and 2021. Three postoperative evaluations were carried out (three, six and twelve months). Non-probabilistic sampling was done. Descriptive statistics were used. Results: The mean age was 56.19 ± 9.27 years. Surgical time of 58.95 ± 13.74 minutes, surgical bleeding of 119.85 ± 68.73 ml. The success rate after twelve months was 90.47%. Apical prolapse recurrence was 4.76% at six months and 9.52% at twelve months; that of the previous compartment, after six months it showed 7.14%, compared to 11.9% after twelve months; 14.28% of the patients presented minor complications. The incidence of stress urinary incontinence, at twelve months, was 16.66%. Conclusions: Vaginal hysteropexy is an effective and safe procedure, with low rates of recurrence or complications. It is important that studies continue to be carried out with better statistical designs.

Treatment of women with vaginal laxity: systematic review with meta-analysis.

BACKGROUND: Despite several treatments that have been used for women reporting vaginal laxity (VL), to our knowledge no systematic review is available on the topic so far. AIM: In this study, we sought to summarize the best available evidence about the efficacy and safety of interventions for treating VL, whether conservative or surgical. METHODS: A comprehensive search strategy was performed in Medline, Embase, Scopus, Web of Science, and Cochrane Library for reports of clinical trials published from database inception to September 2022. Studies selected for inclusion were in the English language and were performed to investigate any type of treatment for VL, with or without a comparator, whether nonrandomized studies or randomized controlled trials (RCTs). Case reports and studies without a clear definition of VL were excluded. OUTCOMES: The outcomes were interventions (laser, radiofrequency, surgery, and topical treatment), adverse effects, sexual function, pelvic floor muscle (PFM) strength, and improvement of VL by the VL questionnaire (VLQ). RESULTS: From 816 records, 38 studies remained in the final analysis. Laser and radiofrequency (RF) were the energy-based treatment devices most frequently studied. Pooled data from eight observational studies have shown improved sexual function assessed by a Female Sexual Function Index score mean difference (MD) of 6.51 (95% CI, 5.61-7.42; i2 = 85%, P < .01) before and after intervention, whether by RF (MD, 6.00; 95% CI, 4.26-7.73; i2 = 80%; P < .001) or laser (MD, 6.83; 95% CI, 5.01-8.65; i2 = 92%; P < .01). However, this finding was not shown when only 3 RCTs were included, even when separated by type of intervention (RF or laser). When RF treatment was compared to sham controls, VLQ scores did not improve (MD, 1.01; 95% CI, -0.38 to 2.40; i2 = 94%; P < .001). Patient PFM strength improved after interventions were performed (MD, 4.22; 95% CI, 1.02-7.42; i2 = 77%; P < .001). The ROBINS-I (Risk Of Bias In Nonrandomized Studies of Interventions) tool classified all non-RCTs at serious risk of bias, except for 1 study, and the risk of bias-1 analysis found a low and unclear risk of bias for all RCTs. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) certainty of the evidence was moderate for sexual function and the VLQ questionnaire and low for PFM strength. CLINICAL IMPLICATIONS: Sexual function in women with VL who underwent RF and laser treatment improved in observational studies but not in RCTs. Improvement in PFM strength was observed in women with VL after the intervention. STRENGTHS AND LIMITATIONS: Crucial issues were raised for the understanding of VL, such as lack of standardization of the definition and for the development of future prospective studies. A limitation of the study was that the heterogeneity of the interventions and different follow-up periods did not make it possible to pool all available data. CONCLUSIONS: Vaginal tightening did not improve sensation in women with VL after intervention, whereas RF and laser improved sexual function in women with VL according to data from observational studies, but not from RCTs. PFM strength was improved after intervention in women with VL.

Combined clinical and radiological remission of rectovaginal fistulas using fractional CO2 vaginal laser: a case series and medium-term follow-up.

INTRODUCTION: Despite the advances in surgical and clinical approaches, there is no consensus regarding the best line of treatment from rectovaginal fistula (RVF). Faced with a challenging scenario in the approach of RVF, the fractional CO2 laser receives attention as a possible form of treatment. OBJECTIVES: A single-center, prospective, open-label study evaluating the effectiveness and safety of laser therapy for RVF treatment. SUBJECTS AND METHODS: The total of 15 patients was recruited at the Juiz de Fora University Hospital between August 2018 and July 2022. Inclusion criteria were presence of clinically suspects RVF of any etiology confirmed by pelvic magnetic resonance image (MRI) and gynecological examination. Five fractional CO2 laser sessions with monthly interval followed by complete evaluation through clinical examination and pelvic MRI were performed for all patients after the completion of treatment. Analysis of sexual function before and after the treatment was performed using Female Sexual Quotient (FSQ). RESULTS: The evaluation through physical examination showed no persistent inflammatory signs in the vagina for all patients. Additionally, 10 of out 15 (67.7%) patients achieved clinical remission of RVF symptoms, while 33.3% patients reported significant improvement. Of note, five patients who did not have previous sexual activity returned to regular sexual activity while seven patients who have baseline sexual activity had improvement in their sexual function as assessed by the FSQ. Three out of four ostomized patients had their ostomy reversed and remained without complains. All six patients with RVF secondary to Crohn's disease reported a marked improvement in symptoms and sexual function. In seven (47%) patients radiological remission was confirmed by pelvic MRI. CONCLUSION: CO2 fractional laser can be considered a promising and safe therapeutic alternative for the management of RVF.

Rol de la laparoscopia en el manejo del síndrome OHVIRA: reporte de un caso y su relación con la endometriosis / Role of laparoscopy in the management of OHVIRA syndrome: a case report and its relation to endometriosis

El síndrome de hemivagina obstruida y anomalía renal ipsilateral (OHVIRA) es producido por una alteración en el desarrollo de los conductos de Müller y Wolff en la vida fetal. El síndrome es poco frecuente, se reporta una prevalencia de 1/2.000 a 1/28.000 casos. La endometriosis se presenta en un 19% de los casos complicando esta patología. El tratamiento del síndrome OHVIRA consiste en resecar el tabique vaginal drenando el hematocolpos. Hasta el momento no existe un consenso en recomendar la realización de una laparoscopia diagnóstica. El objetivo de este estudio es reportar la eventual importancia de la laparoscopia diagnóstica/terapéutica como parte del manejo del síndrome OHVIRA.

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is caused by a defect in the development of Müllerian and Wolffian ducts at fetal life. The syndrome is uncommon, with a reported prevalence of 1/2,000 to 1/28,000 cases. Endometriosis is present in 19% of cases complicating this pathology. Treatment of OHVIRA syndrome consists in resecting the vaginal septum and draining the hematocolpos. Until now there isnt an agreement on recommending diagnostic laparoscopy as part of the treatment. The aim of this study is to report the importance of diagnostic/therapeutic laparoscopy in the management of OHVIRA syndrome.

Microablative fractional radiofrequency for sexual dysfunction and vaginal Trophism: A randomized clinical trial.

OBJECTIVES: To evaluate Microablative Fractional Radiofrequency (MAFRF) as a possible option in treating vaginal atrophy. METHODS: This was a randomized, controlled clinical trial with postmenopausal women diagnosed with vaginal atrophy. The treatment consisted of three sessions of MAFRF, compared to vaginal estrogen administration and an untreated control group. Assessments occurred at baseline and 90 days. The primary endpoints were sexual function, evaluated by the Female Sexual Function Index (FSFI), and vaginal health, assessed by the Vaginal Health Index (VHI). Secondary outcomes included vaginal microbiota composition (Nugent score) and epithelial cell maturation (Maturation Value ‒ MV). RESULTS: One hundred and twenty women (40 in each group) were included. Concerning the FSFI, both groups, MAFRF (median 4.8 [3.6‒6.0]) and vaginal estrogen (mean 4.7 ± 1.1), experienced improved sexual desire when compared to the control group (median 3.6 [2.4‒4.8]). Regarding the total score of VHI, the authors observed an improvement in the mean of the MAFRF (23.7 ± 2.0) and vaginal estrogen groups (23.5 ± 1.9) when compared to the control (14.8 ± 2.9). The Nugent score was reduced in the MAFRF and estrogen groups (p < 0.01) compared to the control group. Lastly, the MV was modified after treatment with MAFRF (p < 0.01) and vaginal estrogen (p < 0.001). No differences existed between the MAFRF and vaginal estrogen groups in the studied variables. No adverse effects were reported following the MAFRF protocol. CONCLUSIONS: Radiofrequency was comparable in efficacy to estrogen administration for treating vulvovaginal atrophy. It deserves consideration as a viable option in managing this condition.

Applicability of vaginal energy-based devices in urogynecology: evidence and controversy.

OBJECTIVE: This study aimed to analyze the evidence and controversies about the use of vaginal energy-based devices (laser and radiofrequency) for treatment of genitourinary syndrome of menopause, recurrent urinary tract infection, urinary incontinence, and genital prolapse through a literature review. METHODS: A search of literature databases (PubMed, Medline) was performed for publications in December 2022. Keywords included genitourinary syndrome of menopause, vaginal laxity, vaginal/vulvovaginal atrophy, urinary tract infection, urgency incontinence, frequency, urgency, stress urinary incontinence, genital prolapses AND energy-based devices, AND vaginal laser, AND vaginal radiofrequency, AND CO2 laser, AND Er:YAG laser. Publications in English from the last 7 years were reviewed and selected by the authors. RESULTS: The literature regarding vaginal energy-based devices in the treatment of urogynecological conditions is primarily limited to prospective case series with small numbers and short-term follow-up. Most of these studies showed favorable results, improvement of symptoms with low risk, or no mention of serious adverse events. Consensus statement documents from major medical societies suggest caution in recommending these therapies in clinical practice until more relevant data from well-designed studies become available. CONCLUSION: The potential of the vaginal laser and radiofrequency as a therapeutic arsenal for the evaluated urogynecological conditions is great, but qualified research must be done to prove their efficacy and long-term safety, define application protocols, and recommend the use of these technologies in clinical practice.

Reparación quirúrgica por vía vaginal de fístulas vesicovaginales: una experiencia exitosa / Vaginal surgical repair of vesico-vaginal fistulas: a successful experience

OBJETIVO: Se presenta una serie de casos de reparación por vía vaginal de fístula vesicovaginal (FVV) de nuestro centro. MATERIAL Y MÉTODOS: Estudio observacional descriptivo. Se evaluaron todas las pacientes con reparación quirúrgica de FVV en el Centro de Innovación de Piso Pélvico del Hospital Sótero del Río entre 2016 y 2022. RESULTADOS: Se reportaron 16 casos, de los cuales el 81,3% fueron secundarios a cirugía ginecológica. En todos se realizó la reparación por vía vaginal, con cierre por planos. En el 94% (15/16) se logró una reparación exitosa en un primer intento. El tiempo de seguimiento poscirugía fue de 10 meses (rango: 3-29). No hubo casos de recidiva en el seguimiento. Una paciente presentó fístula de novo, la cual se reparó de manera exitosa en un segundo intento por vía vaginal. Se reportaron satisfechas con la cirugía 15 pacientes, con mejoría significativa de su calidad de vida. Una paciente reportó sentirse igual (6,3%), pero sus síntomas se debían a síndrome de vejiga hiperactiva que la paciente no lograba diferenciar de los síntomas previos a la cirugía. CONCLUSIÓN: Las FVV en los países desarrollados son secundarias a cirugía ginecológica benigna. La cirugía por vía vaginal en nuestra serie demostró una alta tasa de éxito, con mejora significativa en la calidad de vida de las pacientes.

OBJETIVE: We present a case series of vesico-vaginal fistulas (VVF) vaginal repair in our center. MATERIAL AND METHODS: Descriptive observational study. All patients with surgical repair of VVF at the Centro de Innovación en Piso Pélvico of Hospital Sótero del Río were evaluated between September 2016 and September 2022. RESULTS: 16 cases were reported. 81.3% were secondary to gynecological surgery. In all cases, a vaginal repair was performed, with a layered closure. 94% (15/16) had no contrast extravasation at the time of examination, confirming fistula closure. The follow-up time was 10 months (range: 3-29). There were no cases of recurrence during follow-up. 1 patient presented de novo fistula which was successfully repaired in a second attempt vaginally. 15/16 patients reported being satisfied with the surgery, with significant improvement in quality of life. 1 patient reported feeling the same (6.3%), but her symptoms were due to overactive bladder syndrome that the patient could not differentiate from the symptoms prior to surgery. CONCLUSION: VFV in developed countries are mainly secondary to benign gynecological surgery. Vaginal surgery in our series achieved a significant improvement in the quality of life of patients.

Neovaginoplasty With Nile Tilapia Skin: Cytological and Microbiota Evaluation.

OBJECTIVES: To study the clinical, cytological, and vaginal microbiota findings in patients with Mayer-Rokitansky-Küster-Hauser syndrome who underwent neovaginoplasty using Nile tilapia fish skin. METHODS: This is a cross-sectional study with 7 cisgender women with Mayer-Rokitansky-Küster-Hauser syndrome who had previously undergone neovagina reconstruction using Nile tilapia fish skin at a university hospital. Local institutional review board approval and written permission from the patient were obtained. Between August 2019 and November 2021, within 12 to 24 months after surgery, vaginal specimens were obtained for conventional oncotic and hormonal cytology, and for Gram staining. The Nugent scores were calculated. Colposcopy was also performed. RESULTS: Squamous cells without atypia were found in all patients. Five patients had intermediate vaginal microbiota (Nugent score of 4), which was determined by the presence of few lactobacilli on Gram staining. In hormonal cytology, 4 patients presented with findings compatible with menacme. No colposcopic change was observed. When postsurgical dilation was performed correctly, a mean vaginal length of 8.3 cm was maintained after 1 year of follow-up. CONCLUSIONS: Squamous cells without atypia were present in neovaginas with Nile tilapia fish skin. Most vaginal contents revealed intermediate microbiota and hormonal results compatible with menacme. Studies with a greater number of patients are necessary for a more comprehensive understanding of the microbiome in neovaginas with this new technique, thereby providing support for the treatment and prevention of associated pathologies.

Buccal mucosa graft vaginoplasty: A viable option demonstrated step-by-step.

INTRODUCTION: Persistent cloaca, defined as confluence of the rectum, the vagina and the urethra into a single common channel, has an estimated incidence of 1/50,000 live births. We describe the buccal mucosa graft vaginoplasty for a 11 year old female with cloaca, who underwent at the age of 11 months a Peña repair. We performed the vaginoplasty after the onset of uterine pain due to the beginning of menstruation. MATERIAL AND METHODS: We accessed the lower lip for superficial dissection to harvest the graft. The donor site has been kept with as much submucosal fat as possible to avoid damage to the buccinatoria muscles. A second graft was further obtained from the cheek. Both grafts were submitted to multiple small sections to produce a mesh graft and increase its size. A arciform incision anterior to the anal canal and posterior to the urethra was performed followed by consecutive dissection with eletrocautery to gain profundity. The mesh-graft was placed over the neovaginal cavity and sutured with 4.0 PDS monofilament suture used to suture and then quilt the graft in place. The vaginal capacity was confirmed by ease of a two-digit insertion. Haemostasis was confirmed before the insertion of a soft vaginal mold. The patient remained with an indwelling urinary catheter. The mold was equivalent to 24Fr and had 13 cm of profundity and Foley tube were removed after 14 days postoperatively. RESULTS: Patient had an excellent postoperative course and had been instructed to perform vaginal dilatation every 3 h during the day. Current follow up is 10 months. DISCUSSION: Buccal mucosal grafting has advantages over the use of keratinized skin flaps and intestinal flaps. Buccal mucosa is ideal for female genital reconstruction, given its color, texture, lack of hair and mild mucous production. In our particular case, we connected the neovagina after two months of adequate healing to the native 1/3 through laparoscopic approach. CONCLUSIONS: BMG vaginoplasty is a viable alternative to treat females with cloaca at adolescence.

Robotic excision of vaginal pouch in ovotesticular disorder of sexual development.

PURPOSE: Ovotesticular disorder of sexual development (DSD) is the rarest of DSDs with an incidence of 1:20000 (1). Management of vaginal pouches in such cases is warranted for symptomatic presentations and laparoscopy is considered the gold standard treatment (2). We report a rare case of robotic excision of a large symptomatic vaginal pouch in a 19-year-old boy with ovotesticular DSD. MATERIAL AND METHODS: A 19-year-old boy with ovotesticular DSD post hypospadias repair in early childhood presented with complaints of recurrent UTIs, ballooning of urethra during micturition and post-void dribbling. Ultrasound, voiding cystourethrogram (VCUG) and magnetic resonance imaging (MRI) were suggestive of a vaginal pouch. The patient underwent endo-evaluation followed by robot-assisted excision of the vaginal pouch. Endo-evaluation showed two orifices in the posterior urethra. The posterior orifice was leading into a blind-ending rudimentary uterus and the true urethra was lying anteriorly. The DaVinci Xi Robotic Surgical System was used and the entire pouch was dissected free of the surrounding tissues using monopolar scissors. The pouch was transected just a few millimetres from its junction with the urethra. The urethra was then closed with V-loc 4-0 suture. The patient was discharged on postoperative day 2 and the catheter was removed on day 21. RESULTS: Follow-up VCUG at 6 weeks did not show any residual pouch. There was no complaint of post-void dribbling or UTI at 30 months of follow-up. CONCLUSION: Robot-assisted laparoscopy should be considered as an alternative to laparoscopy for the primary treatment of a large symptomatic vaginal pouch.

Higher symptom score, larger residual rectocele, and lower rectal compliance predict failure of improvement after surgical treatment of rectocele

Background: Rectocele is a frequent finding in women and is usually asymptomatic. However, it is sometimes associated with symptoms of obstructed defecation syndrome (ODS). While most patients with ODS due to rectocele respond well to conservative treatment, some may require surgical treatment. The aim of the study was to determine the predictors of failure of symptom improvement after rectocele repair. Methods: The study included adult women with rectocele who underwent surgical treatment by transperineal repair (TPR) or transvaginal repair (TVR). The preoperative and postoperative assessment was done using the Wexner constipation score, anorectal manometry, and defecography. Results: A total of 93 female patients with a mean age of 43.7 years were included. Among them, 65.6% of patients underwent TPR and 34.4% underwent TVR; 22 (23.7%) patients reported failure of significant improvement in ODS symptoms after surgery. The independent predictors of failure of improvement were higher preoperative Wexner score (odds ratio, OR: 1.4, 95% confidence interval, CI: 1.09-1.84, p = 0.009), larger residual rectocele after repair (OR: 2.95, 95% CI: 1.43-6.08, p = 0.003), and lower postoperative maximum tolerable volume (OR: 0.949, 95% CI: 0.907-0.992, p = 0.02). The predictive cutoff point for the preoperative Wexner score was 15. Conclusions: Patients with a preoperative Wexner score higher than 15 and larger residual rectocele after surgery may experience little improvement in symptoms after rectocele repair. Although TPR was associated with a poorer relief of symptoms than did TVR; it was not an independent predictor of failure. (AU)

Robotic management of congenital urethra-vaginal fistula with transverse vaginal septum

ABSTRACT Introduction: The transverse vaginal septum (TVS) with congenital urethra-vaginal fistula (CUVF) is a rare anomaly of the mullerian duct (1, 2). Incomplete channelling of the vaginal plate, or an abnormality in the fusion of the vaginal component of mullerian duct with the urogenital sinus results in TVS (1, 3, 4). High CUVF occurs due to the persistent communication between the urogenital sinus and utero-vaginal primordium at the tubercle sinus, whereas low CUVF is due to excessive apoptosis of the vaginal plate during channelling (5). The principles of management of CUVF with TVS include: 1) TVS resection, 2) Create a neovagina. We present a case of CUVF with TVS managed by robotic assistance. Material and methods: A 24-year-old female, married for 3 years, presented with cyclical hematuria since menarche, dyspareunia and primary infertility. Examination revealed blind ending vagina 4cm from the introitus. Magnetic resonance imaging revealed a fistulous communication between urethra and vagina, and TVS. Cystourethroscopy confirmed a proximal urethra-vaginal fistula. Urethroscopy guided puncture of the TVS was performed, tract dilated and a catheter was placed across it. Robotic assisted transvaginal approach was planned. Air docking of robot was performed. Traction on the catheter was given to identify the incised edges of the septum. Vaginal flaps were raised laterally, fistulous tract was excised. Proximal vagina mucosa was identified and vaginoplasty was performed. Result: Patient's postoperative recovery was uneventful. Urethral catheter was removed after 5 days. She had normal voiding and menstruation. Vaginoscopy performed at 1st month follow-up, revealed an adequate vaginal lumen. Vaginal moulds were advised for 6 weeks during the night, following which she resumed her sexual activity. She conceived 6 months post-surgery, and delivered a child by caesarean section. Conclusion: We successfully managed this case by resection of septum, neovagina creation and thereby achieving normal menstruation and conception. The advantages of robotic approach were magnification, precision and manoeuvrability in a limited space, avoiding a vaginal release incision.

Vaginal collagen I and III changes after carbon dioxide laser application in postmenopausal women with the genitourinary syndrome: a pilot study.

OBJECTIVE: The aim of the study was to evaluate the clinical response and collagen remodeling in the vaginal wall after three sessions of carbon dioxide (CO2) laser application. METHODS: Fourteen postmenopausal women with vulvovaginal atrophy, aged 45-65 years and sexually active, were evaluated with clinical questionnaires, gynecological examinations and histological techniques before and after 20 weeks of treatment (ClinicalTrials.gov NCT03939078). Treatment consisted of 3-monthly sessions of the CO2 laser. Clinical questionnaires included the Vaginal Health Index, the Female Sexual Function Index and the International Consultation on Incontinence Questionnaires Short Form. Biopsies were taken from the lateral vaginal wall at week 0 (left wall) and week 20 (right wall). Tissue samples were stained with hematoxylin and eosin, Periodic Acid-Schiff, Picrosirius Red Stain and Orcein dyes. Immunohistochemical study was used to quantify collagens I and III in the samples. RESULTS: The mean age was 54.4 ± 4.5 years, and the average time of amenorrhea was 7.6 ± 5.1 years. The Female Sexual Function Index and the Vaginal Health Index Score values increased while the International Consultation on Incontinence Questionnaire Short Form score decreased after the programmed treatment. There was no significant change in vaginal pH. Histological studies showed increases in the total and superficial epithelial cell layers, and type III collagen fibers (from 10.86 ± 7.66 to 16.87 ± 3.96, p < 0.05), and immunohistochemical studies confirmed the significant increase in collagen III. CONCLUSION: Histological findings revealed epithelial atrophy reversal and collagen remodeling of the vaginal wall. Immunohistochemical analysis showed an increase in collagen type III fibers.

Vaginal stenosis in women with cervical or endometrial cancer after pelvic radiotherapy: a cross-sectional study of vaginal measurements, risk for sexual dysfunction and quality of life.

INTRODUCTION AND HYPOTHESIS: Radiotherapy (RT) for cervical (CC) and endometrial cancer (EC) is known to lead to vaginal stenosis (VS), but the comparison between vaginal anatomical measurements and the risk of sexual dysfunction presents a wide variety of results among the literature. Thus, we sought to assess the prevalence of VS, vaginal measurements, sexual dysfunction and QOL in women with CC and EC submitted to pelvic RT with or without previous surgery. METHODS: Cross-sectional study that included 61 women with CC and 69 with EC. VS was classified by the Common Terminology Criteria for Adverse Effects version 5.0 (CTCAE v5.0), sexual function by the validated Female Sexual Function Index (FSFI) and QOL by the validated World Health Organization questionnaire (WHOQOL-BREF). Acrylic cylinders were used for vaginal measurements. Uni-/multivariate analyses to address factors associated with VC in both groups were performed. RESULTS: The prevalence of VS was 79% and 67% within patients with CC and EC, respectively. Vagina length was decreased in both groups without statistical difference (7.2 ± 1.7 vs. 6.6 ± 1.8;p = 0.072). Vaginal diameter was significantly higher (p = 0.047) in women with EC (25.4 ± 6.3) than in those with CC (23.1 ± 5.7). Sexual dysfunction was highly prevalent for both CC and EC (88% vs. 91%; p = 0.598). There was no difference in all WHOQOL-BREF domains between women with CC and EC. CONCLUSIONS: VS is highly prevalent in CC and EC patients, with vaginal length decreased in both groups but with a higher vaginal diameter in those with EC. Nevertheless, sexual dysfunction is highly prevalent in both groups.