Early treatment of vulvar synechiae in childhood - prevention of late complications.

Synechiae of the vulva occurs especially in girls in the so-called resting hormonal period with a minimal serum concentration of estrogens. If the external genitalia of the girl are not treated properly, the mucous membrane of the vaginal entrance is not regularly checked and mechanically removed, then the smegma of the opposite mucous membranes of the vulva can stick together. The place of the adhesion of epithelium in the vaginal introitus can be covered by a new epithelium and can create a firm adhesion, synechiae of the vulva, which is usually asymptomatic and is discovered incidentally during pediatric examination. Clinically significant vulvar synechiae can cause impaired bladder evacuation and recurrent lower urinary tract infections. Dissection of synechiae in the stage of conglutination or thin adhesion is performed manually on an outpatient basis, but extensive and firm adhesions must be divided surgically under general anesthesia. Local application of cream with estriol or betamethasone is also used for the therapy of synechiae of the vulva, but this treatment is more time-consuming compared to rapid manual separation and requires good compliance of the girls and their parents. The prevention of synechiae is based on the education of parents by pediatricians and gynecologists about the need for regular checks of the external genitalia and sufficient hygiene.

Three-year follow-up results of two children born from a transplanted uterus.

AIMS: To evaluate the 3-year follow-up results of two children delivered at our institution in 2019 from mothers with a transplanted uterus. METHODS: Observational data on pregnancy outcomes, neonatal course, and growth trajectory in two children born to mothers after uterus transplantation, including 3-year follow-up and neurodevelopmental status assessed using the Bayley Scales of Infant and Toddler Development, third edition (Bayley-III). RESULTS: Both children were born prematurely via uneventful caesarean sections, to mothers with Mayer-Rokitansky-Küster-Hauser syndrome and a transplanted uterus. An acute caesarean section was performed in one mother because of the onset of regular uterine contractions at 34 weeks and 6 days of pregnancy; in the other mother, an elective caesarean section was performed at 36 weeks and 2 days of gestation. The children were born healthy with no congenital malformations. They had an uneventful postnatal course and showed a normal growth trajectory during 3 years of follow-up. The Bayley-III neurodevelopmental scores of both children were within the normal ranges at ages 2 and 3 years. CONCLUSION: Though pregnancy after uterus transplantation is associated with the risk of premature delivery, no abnormalities were observed in the neonatal course and 3-year follow-up results, including the neurodevelopmental status, of two children born prematurely to mothers with a transplanted uterus. This is the first report on neurodevelopmental outcomes in children born after uterus transplantation. More data on children born after this radical procedure of uterine factor infertility treatment are required to support our promising results.

Adnexal torsion in childhood and adolescence.

The incidence of adnexal torsion in childhood and adolescence is 4.9 per 100,000 girls. Torsion of the adnexa is caused by rotation of the ovary usually with the fallopian tube around the infundibulopelvic ligament. The torsion leads primarily to the interruption of both venous outflow and lymphatic drainage. It causes enlargement of the ovary due its edema with occurrence of hemorrhagic infarctions. Interruption of the arterial inflow leads finally to the necrosis of ovarian tissue. Torsion of the adnexa in childhood occurs usually in enlarged ovary, particularly by a cyst, or when the non-enlarged ovary is excessively mobile due to the extended infundibulopelvic ligament. The characteristic clinical symptoms of adnexal torsion are sudden pain in the lower abdomen with nausea and vomiting. The dia-gnosis of adnexal torsion is based on the typical symptoms, clinical course, and the results of physical and ultrasound examinations. Torsion of the adnexa should be considered in every girl with sudden abdominal pain. To preserve reproductive functions, an early surgery with detorsion of the adnexa should be performed.

Effect of manual lymphatic drainage on upper limb lymphedema after surgery for breast cancer.

OBJECTIVE: Evaluation of the effect of manual lymphatic drainage on lymphedema of the upper limb after previous axillary lymphadenectomy/sentinel node bio-psy during the maintenance phase of lymphedema after the breast cancer surgery. MATERIAL AND METHODS: A total of 30 patients after surgical treatment of unilateral breast cancer underwent 10 manual lymphatic drainages within 8 consecutive weeks. All patients underwent upper limb circumference measurements before and after the study and completed two specialized EORTC questionnaires (QLQ-C30 and QLQ-BR23). RESULTS: The average time between surgery and admission into this study was 32.5 months. In the beginning of the study, lymphedema was present for an average of 19.8 months. At the end of a series of manual lymphatic drainages, the average volume decrease of the limb with lymphedema was 3% (1.5-5.6%). In contrary, the average loss of volume on the healthy (control) upper limb was only 0.4%. The average reduction of lymphedema volume after therapy achieved 57% (37-88%). After a series of manual lymphatic drainages, the results of the EORTC QLQ-C30 questionnaire showed a statistically significant improvement in physical and role functions, fatigue, nausea and vomiting, pain, dyspnea and constipation, while the results of the EORTC QLQ-BR23 questionnaire showed a statistically significant improvement in the arm and breast symptoms. There was no statistically significant deterioration in any of the monitored parameters. CONCLUSION: The results of the study showed a positive effect of manual lymphatic drainage on the maintenance phase of lymphedema in patients after breast cancer surgery. The questionnaires showed a significant improvement in hand and arm symptoms as well as an improvement of the other functions and symptoms affecting quality of life. Further studies should be performed on groups of patients with the maintenance phase of upper limb lymphedema to confirm or disprove our results.

Early initiation of embryo transfers after uterus transplantation to shorten the administration of immunosuppressive therapy.

Uterus transplantation seems to be a promising method for the causal treatment of absolute uterine factor infertility in women with an absent or non-functional uterus. Since uterus transplantation is still experimental in nature, there are no strict guidelines regarding each step of this comprehensive treatment method. Prior to uterus transplantation, ovarian stimulation and in vitro fertilization are performed on the potential uterus recipient, and the obtained embryos are cryopreserved and stored for the transfers after transplantation when only non-fetotoxic maintenance immunosuppressants are administered. In the first human uterus transplantation study, the start of embryo transfers was set at 12 months after transplantation. Due to the growing experience, especially with early rejections after transplantation and the course of pregnancy, several ongoing studies have experimentally shortened the uterus transplant-to-embryo transfer interval to 6 months. Shortening the total time of immunosuppression administration after uterus transplantation is the main reason for early initiation of embryo transfers after transplantation. However, the safety of an interval of less than one year between uterine transplantation and the first post-transplant embryo transfer should be further studied.

Distal vaginal agenesis and differential diagnosis of other causes of hematocolpos.

Distal vaginal agenesis is an obstructive congenital malformation of the female reproductive tract. The distal part of the vagina is replaced by fibrous tissue and the outflow of the menstrual blood and secretion of the cervical glands is disabled. This congenital anomaly most often manifests during expected menarche by primary amenorrhea and cyclic lower abdominal pain caused by cryptomenorrhea with gradually increasing hematocolpos and hematometra. The dia-gnosis is based on gynecological examination and the suspected anomaly is confirmed by ultrasound examination and magnetic resonance imaging. Therapy of distal vaginal agenesis is exclusively surgical. A pull-through vaginoplasty is the method of choice for distal vaginal agenesis not exceeding 3cm. With a greater extent of agenesis and the risk of postoperative vaginal stenosis, replacement of the missing part of the vagina with other tissues or modified balloon vaginoplasty can be used. The aim of the treatment is to enable the evacuation of the menstrual blood, ensure quality sexual intercourse and the possibility of reproduction.

Sexuality and quality of life after nerve-sparing radical hysterectomy for cervical cancer: A prospective study.

OBJECTIVE: Nerve-sparing radical hysterectomy (NSRH) decreases the negative postoperative consequences of radical surgery for cervical cancer, such as bladder evacuation disorders, colorectal motility disorders, and sexual dysfunction. The aim of this study was to prospectively assess the sexuality and quality of life in a group of women who underwent NSRH with lymphadenectomy for cervical cancer. MATERIALS AND METHODS: A total of 65 patients with early-stage cervical cancer underwent NSRH between 2014 and 2016. Patient examinations and questionnaire surveys (Female Sexual Function Index questionnaire and European Organization for Research and Treatment of Cancer questionnaires QLQ-C30 and QLQ-CX24) were conducted, before and one year after the surgery. RESULTS: After the exclusion of 19 sexually inactive women and 10 women who received adjuvant anticancer treatment, 36 sexually active patients treated solely with nerve-sparing surgery were eligible for evaluation. The mean age was 47 years. The average preoperative vaginal length was 9.4 cm, whereas the postoperative length was shortened to 7.1 cm. This study showed no negative impact of NSRH on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, sexual enjoyment, and sexual worry. The worsening of sexual functioning was recorded during the one-year follow-up. The QLQ-C30 questionnaire confirmed postoperative improvement in global health status and role, emotional, and social functioning. CONCLUSION: Our study showed using standardized questionnaires that NSRH has no negative impact on sexual desire, arousal, satisfaction, orgasm, pain, sexual activity, frequency of sexual intercourse, sexual enjoyment, and sexual worry, while only the worsening of sexual functioning was recorded. Moreover, NSRH did not cause postoperative deterioration in the quality of life parameters.

Hymenal atresia - a rare congenital anomaly with the risk of late diagnosis.

OBJECTIVE: Comprehensive analysis of causes, clinical signs, dia-gnostic process, differential dia-gnosis and therapy of hymenal atresia. METHODS: Literature search using the Web of Science, Google Scholar and PubMed databases with keywords and analysis of articles published in high impact and reviewed journals. RESULTS: Hymenal atresia is a congenital malformation of a womans genitals, which is manifested by complete obstruction of the vaginal introitus by a closed hymen. It should be dia-gnosed in the neonatal period, but clinically it usually manifests itself only during puberty as a result of menstrual blood retention (cryptomenorrhea) with the cyclic abdominal pain at monthly intervals. The therapy is based on optimally timed surgical creation of communication in the hymen (hymenotomy, hymenectomy) enabling free evacuation of menstrual contents. The aim of this simple treatment method is immediate subjective relief from pain and a permanent solution to this congenital anomaly. CONCLUSION: Knowledge of all types of congenital malformations of the female genitalia is a basic condition for an early and effective dia-gnostic process in adolescent girls with abdominal pain. The girl who has not yet menstruated and has cyclic lower abdominal pain and a tumor behind the pubic symphysis should be examined by a specialist in pediatric and adolescent gynecology who will confirm hymenal atresia according to a bluish and closed hymen, and suggest prompt and effective therapy.

Uterine artery pseudoaneurysm in pregnant women with previous pelvic endometriosis.

Uterine artery pseudoaneurysm (UAP) is a rare complication during pregnancy that can cause serious consequences in both the pregnant woman and the fetus. Herein, we have described the cases of two pregnant women with UAP. Both patients had a history of laparoscopy for management of endometrioid ovarian cysts. Neither patient was operated in the retroperitoneum or around the uterine vessels. UAP was diagnosed by Doppler ultrasonography and confirmed by magnetic resonance imaging. Due to exacerbation of hypogastric pain, the first patient was treated shortly after admission to the hospital at the 23rd week of gestation by endovascular intervention with occlusion of the UAP using microcoils. The patient's complaints resolved immediately, and a healthy baby was delivered via planned Cesarean section at the 38th gestational week. In the second case with twin pregnancy, angiography was performed at the 27th gestational week; however, the feeding vessel of the UAP could not be identified. The patient was followed up at weekly intervals, and due to increasing left hypogastric pain, cesarean section was performed at the 33rd gestational week. During surgery, the left internal iliac artery was ligated and the entire pseudoaneurysm was successfully removed. Both women gave birth to healthy neonates; however, the therapeutic approaches were distinct in both cases. As the previous laparoscopic surgeries in both patients were performed only in the adnexal area, and not around the uterine arteries in the parametria, the endometrial decidual reaction could have caused the UAPs in the described cases.

Histopathological examination of the ectocervical biopsy in non-transplanted uteri: A study contributing to the provisional scoring system of subclinical graft rejection after uterus transplantation.

INTRODUCTION: Uterus transplantation is a causal treatment for absolute uterine factor infertility. Assessing rejection signs using a histopathological examination of the ectocervical biopsy from the transplanted uterus is common practice in all human uterus transplants worldwide to date. A provisional scoring system was used for the histopathological assessment of subclinical rejection signs in uterus recipients. Here we hypothesized that histopathological and immunohistochemical findings in the normal uteri would differ from the borderline category of subclinical rejection in uterine transplants. MATERIAL AND METHODS: This prospective observational study included ectocervical biopsies of 54 women who underwent hysterectomy for benign reasons. All biopsy samples were assessed histopathologically and immunohistochemically. RESULTS: Most of the ectocervical biopsies showed clustering lymphocytic infiltrates affecting the stromal-epithelial interface with the epithelial influx of lymphocytes, primarily CD45RO-positive activated T-cells with CD8 T-lymphocyte predominance. CD4-positive T-lymphocytes and B-cells were rarely detected in the ectocervix. These morphological findings and immunoprofiles of lymphocytic populations overlapped with the so-called borderline changes defined in the provisional scoring system for rejection in the transplanted uteri. The immunoprofiles of ectocervical and endocervical lymphocytic populations differed, with strikingly prominent B-cell participation in the endocervix vs the rare detection of B-cells in the ectocervix. CONCLUSIONS: The histopathological and immunohistochemical findings in the uteri of premenopausal women were similar to the borderline category of the currently used provisional scoring system of subclinical uterine rejection utilized in all uterine transplant studies. However, future similar studies are required to validate our findings.

Methods for neovagina creation in women with Mayer-Rokitansky-Küster-Hauser syndrome for subsequent uterus transplantation.

Mayer-Rokitansky-Küster-Hauser syndrome is a rare female congenital anomaly that presents with an inability to have coital sexual intercourse and absolute uterine factor infertility. Both surgical and nonsurgical approaches have been described for the treatment of vaginal agenesis to allow satisfactory coitus. Transplantation of the uterus has the challenge of achieving pregnancy and delivery of her own genetic and biological children in a woman without a natural uterus. Women of reproductive age with a congenital form of absolute uterine factor infertility are considered appropriate recipients of a uterus in the experimental phase of uterus transplantation trials. A neovagina in the normal anatomic position covered by natural non-keratinized mucosa is one of the main assumptions for surgical and reproductive success in transplant recipients. More than 70 uterine transplants have been performed to date, and more than 25 childbirths have been achieved by several research centers in the recipients of a uterus with uterine agenesis. In women with Mayer-Rokitansky-Küster-Hauser syndrome, skin-graft neovagina, Vecchietti's vaginoplasty, and self-dilation using Frank's and Ingram's methods are appropriate techniques to create a neovagina if transplantation of the uterus is intended in the future.

Sexuality in women with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: Evaluation of the quality of sexual life of women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) after neovagina creation using dilation and surgical techniques. METHODS: Literature search of articles published in the years 2000­2021 using the databases Web of Science, Google Scholar and PubMed by key words: Mayer-Rokitansky-Küster-Hauser syndrome, neovagina, female sexuality and Female Sexual Function Index. We used a standardized international Female Sexual Function Index and other quantitative and qualitative parameters of sexual satisfaction to assess sexual function and overall satisfaction in women with neovagina. RESULTS: It is possible to develop functional neovagina in women with MRKHS by either conservative or surgical techniques. The choice of the method used depends on the experience and skill of the surgeon, on the technical possibilities and equipment of the department, and on the anatomical predispositions and preferences of the patient. Satisfaction with sexual life also depends on the psychosexual maturity and sexual demands of both partners as well as on regular vaginal rehabilitation and quality of long-term psychological support. The functional results of dilation and surgical methods are comparable according to objective criteria. They only differ in individual aspects which correspond to the overall personality traits as well as to the character and quality of cohabitation. CONCLUSION: Women with MRKHS are primarily handicapped by coital insufficiency and inability to reproduce naturally. Creating a neovagina technically allows them to realize satisfactory coitus, but in most cases, they are still frustrated by the primary problem of "physical indisposition" and complicated path to motherhood.

Robot-assisted donor hysterectomy in uterus transplantation - a modality to increase reproducibility.

Uterus transplantation is a non-lifesaving vascularized composite allotransplantation procedure requiring immunosuppression until removal of the graft. The focus of uterus transplantation is changing regarding refining individual treatment procedures included in this complex treatment of absolute uterine factor infertility, such as robot-assisted donor hysterectomy. The inferior hypogastric nerve plexus should be preserved during robotic dissection of the ureter and uterine vessels to prevent postoperative complications such as urine and fecal evacuation disturbances and sexual disorders. As most uterus transplantations have been performed in living donor concepts, robot-assisted donor hysterectomy should contribute to increased availability of uterus transplantation, particularly because it uses the precise blood-less technique of surgical dissection in the deep pelvis and has cosmetic benefits among living donors.

Current ethical aspects of absolute uterine factor infertility treatment using uterus transplantation.

OBJECTIVE: An analysis of ethical studies related to uterus transplantation in the treatment of absolute uterine factor infertility. METHODS: Literary research using the Web of Science, Google Scholar and Pubmed databases with the following keywords: absolute uterine factor infertility, ethics, deceased donor, living donor, and uterus transplantation. An analysis of articles published in impact and reviewed journals between 2000-2021. RESULTS: Uterus transplantation is a promising treatment method for women with absolute uterine factor infertility. In the experimental studies, an ultimate goal of this complex treatment was repeatedly achieved: childbirth through a caesarean section. An important milestone towards the application of uterus transplantation in human was the Montreal criteria of its ethical feasibility, published in 2012-2013. In 2012, the first uterus transplant study from a living donor started in Sweden and, in 2016, further studies were initiated worldwide. The first childbirth from the transplanted uterus in 2014 increased the interest of ethicists in various aspects of this experimental treatment, and this trend continues. Current ethical analyzes are focused particularly on the comparison of advantages and disadvantages related to the utilization of living and deceased donors of uterus; comparing ethical aspects of gestational surrogacy and uterus transplantation; uterus transplantation as an extremely radical form of assisted reproduction; its impact on adoptions; uterus transplantation in trans-gender women; the importance of establishing an international registry for uterus transplants; and other important ethical issues associated with this complex form of assisted reproduction. CONCLUSION: Uterus transplantation is still in an experimental stage. The ethical analysis of the individual steps of this comprehensive method in the treatment of female infertility should be carried out continuously, in connection with the gradually presented outcomes of ongoing scientific research studies.

Lessons learned from the Czech uterus transplant trial related to surgical technique that may affect reproductive success.

Uterus transplantation is an experimental method in the treatment of infertility in women with congenital or acquired absence of uterus. The majority of uterus transplants worldwide have been performed in women with Mayer-Rokitansky-Küster-Hauser syndrome, with neovagina and absent uterus. We report two aspects affecting reproductive success related to the surgical technique of transplantation. The first is the stenosis of vaginal-neovaginal anastomosis between the graft's vaginal rim and the recipient's neovagina. The second is a firm fixation of the uterus close to the pubic symphysis. Both these aspects contribute to the technical difficulty of embryo transfer to the transplanted uterus.

Assisted Reproductive Techniques and Pregnancy Results in Women with Mayer-Rokitansky-Küster-Hauser Syndrome Undergoing Uterus Transplantation: the Czech Experience.

STUDY OBJECTIVE: This study aimed to evaluate the reproductive potential of patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who were candidates for uterus transplantation (UTx) before inclusion in the experimental trial, and to summarize the existing experience with posttransplantation embryo transfers in functionally successful cases. DESIGN AND SETTING: A prospective study at a tertiary medical center. PARTICIPANTS: Ten pre-UTx women with MRKHS and 7 successful UTx cases. INTERVENTIONS AND MAIN OUTCOME MEASURES: Ovarian stimulations, frozen embryo collection, embryo transfers, and incidence of pregnancy in MRKHS women in the pre- and posttransplantation periods. RESULTS: The average number of ovarian stimulations to collect the required frozen embryos was 1.9 (1-3). On average, the number of aspirated oocytes was 16.4 (7-38), 12.6 (5-26) oocytes were fertilized, and 7.0 (1-18) embryos were cryopreserved per cycle. To date, the average number of embryo transfers per recipient was 4.9 (3-8), and the embryo transfer/pregnancy rate was 8.8% (3 of 34). Three pregnancies have been achieved to date, including a missed abortion in the 8th week, a birth in the 35th week, and an ongoing pregnancy in the 30th week. CONCLUSIONS: Despite the small number of UTx cases, our data indicated that women with MRKHS showed a good response to ovarian stimulation and blastocyst formation. Although the procedures for fertilization, cryopreservation, and transfer of the embryos were standardized, the success rate per embryo transfer achieved in the study group has been low to date.

Urinary tract morbidity after nerve-sparing radical hysterectomy in women with cervical cancer.

INTRODUCTION AND HYPOTHESIS: Nerve-sparing radical hysterectomy (NSRH) has been developed as a method of cervical cancer treatment to reduce surgical morbidity compared with radical abdominal hysterectomy. The aim of this study was to analyze the short- and long-term effects of NSRH on urinary tract function. METHODS: A study group of 117 patients underwent NSRH type C1 with pelvic lymphadenectomy for cervical cancer stages IB1-IB2 without adjuvant radiotherapy at our department. A total of 106 patients aged 21-74 years (mean age 44.8) were available for follow-up at 1 year after surgery. A transurethral catheter was left in place for 48 h after surgery, and the postvoid residual (PVR) volume was measured after its removal. One week before surgery and 12 months after NSRH, lower urinary tract function was evaluated by an urodynamic examination. RESULTS: Five days after surgery, the PVR volume was greater than 100 ml in 5 patients (4.7%) and a suprapubic catheter was inserted into these women for bladder training over the following days. Within 14 days after surgery, urination without PVR was achieved in all women who underwent surgery. Postoperatively, a slight increase in the average maximum bladder cystometric capacity was recorded from 420 to 445 ml (p value 0.009) without prolonging the voiding time. Other urodynamic parameters were not significantly different before and 12 months after NSRH. CONCLUSIONS: In this series, NSRH preserved voiding function and bladder sensation at 1 year and did not appear to compromise oncological outcome.

Uterine transplantation in an era of successful childbirths from living and deceased donor uteri: Current challenges.

BACKGROUND AND AIMS: Uterine transplantation (UTx) is an experimental sterility treatment method in women with absolute uterine factor infertility. This article describes the current trends and risks in UTx and provides an overview of our experience with this method, to date. METHODS: Based on our experience with the Czech UTx trial and the published results of other trials, we describe the possibilities and risks of this perspective method in the treatment of absolute uterine factor infertility (AUFI). RESULTS: Twelve healthy babies were born in 2014-2018 after more than 40 uterine transplantations. There is no general consensus whether it is more suitable to transplant uteri from living or deceased donors, and nulliparous or parous women (with proven obstetrical functionality). Most centers prefer to collect at least ten frozen embryos from in vitro fertilization (IVF) cycles before transplantation. The serious complication of a surgically successful uterine transplantation is posttransplant partial stenosis of the uterine-vaginal anastomosis that may be a technical problem for embryo transfer, outflow of menstrual blood, and sexual satisfaction due to the narrowed and shortened vagina. This paper concludes that, currently, procurement of the uterus and the transplant procedure are surgically feasible and that none of the transplanted uteri have been lost due to rejection but only because of graft thrombosis or infection. CONCLUSION: Uterine transplantation, after optimization of surgical methods, selection of suitable donors, standardization of immunosuppressive therapy, adjustment of assisted reproductive technologies and obstetrical proceedings might be an effective therapeutic method for women with AUFI who wish to have their own biological child.

Clinical pregnancy after deceased donor uterus transplantation: Lessons learned and future perspectives.

AIM: To describe our first clinical pregnancy following a uterus transplant from a brain-dead donor and to discuss current issues with deceased donor uterus transplantation as they relate to obstetrical success. METHODS: In August 2016, a 26-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome was the fourth person worldwide to receive a uterine transplant from a deceased donor and was the second in our trial. in vitro fertilization treatments using the long gonadotropin-releasing hormone agonist protocol preceded the transplantation procedure. Frozen embryo transfers were performed in months 12, 13, 16, 19 and 23 after transplant. RESULTS: Recovery of the uterus of a 24-year-old brain-dead nulliparous donor and the transplant procedure itself was uncomplicated. No abnormalities were revealed on Pap smears, which were performed every 6 months during the post-transplant period, and cervical biopsies showed no epithelial dysplasia. The fifth frozen embryo transfer resulted in a clinical pregnancy. Three weeks after embryo transfer, an intrauterine gestational sac containing an embryo with a heartbeat was detected. One week later, signs of a missed abortion were revealed by ultrasound. Two weeks later, spontaneous bleeding occurred, and an ultrasound examination performed a week later confirmed an empty uterine cavity. CONCLUSION: In light of present research, both deceased donor uterine procurement and transplantation surgeries are technically feasible; however, more experience is needed to determine the pregnancy success rate associated with this method. Thus, additional trials of deceased donor uterine transplantation should be performed in the future to continue research related to this promising concept for the treatment of absolute uterine factor infertility.

Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes.

BACKGROUND: Surgery is the optimal treatment for a severe form of clitoral phimosis (CP) that is initiated by lichen sclerosus (LS) and causes female sexual dysfunction. AIM: We aimed to determine the etiology of clitoral phimosis, its influence on sexual function, and outcomes after surgical treatment. METHODS: In this prospective cohort study, we observed the occurrence of clitoral phimosis and related changes in a group of 3,650 sexually active heterosexual women with a mean age of 34.8 ± 14.9 years (20-45 years) from September 2014 to September 2016. Ultimately, we compared the changes in sexual function and distress and satisfaction with postoperative genital appearance in 9 patients with severe clitoral phimosis at 12 months after surgical treatment. MAIN OUTCOME MEASURES: Sexual function was evaluated using the Female Sexual Distress Scale-Revised and the Female Sexual Function Index, and the patient's genital self-image was evaluated using the Female Genital Self-Image Scale; gynecologic examinations were performed on all patients. RESULTS: Various forms of CP were found in 46 of 3,650 patients (1.3%). Severe forms of CP were found in 9 cases, but it was complicated by stenosis of vaginal introitus in only 2 cases. These 9 patients underwent circumcision, and 2 of them underwent perineoplasty. Female sexual dysfunction occurred mainly in those with LS and severe forms of phimosis. Sexual function, as indicated by the total Female Sexual Function Index score, was significantly improved at 12 months after surgery (17.9 ± 0.9 vs 26.6 ± 0.5; P < .001). The Female Genital Self-Image Scale score assessing genital perception was significantly higher after surgery than before in women who underwent clitoral circumcision (20 ± 3.0 vs 12.3 ± 3.3; P < .001). The Female Sexual Distress Scale-Revised score was significantly lower after surgery than before (21.3 ± 6.2 vs 33.8 ± 6.9; P < .001). Sexual function in 2 women with CP and stenosis of vaginal introitus improved after surgery, but the sexual distress level did not decrease significantly. CLINICAL IMPLICATIONS: The results of this study will help clinicians to centralize treatment methods and advise patients on the management of clitoral phimosis. STRENGTHS & LIMITATIONS: This is a study evaluating postoperative results of sexual function, distress, and satisfaction with genitalia in women with severe CP, using validated questionnaires. However, the small number of patients and the absence of an appropriate control group are limitations. CONCLUSION: Surgical treatment of clitoral phimosis can improve sexual function, but because LS-a common underlying cause-is chronic in nature, patients may experience recurrence. Chmel R, M Novácková, Fait T, et al. Clitoral Phimosis: Effects on Female Sexual Function and Surgical Treatment Outcomes. J Sex Med 2019;16:257-266.