Vaginoplasty with Amnion Graft: Management of Mayer-Rokitansky-Kuster-Hauser Syndrome.

Mayer-Rokitansky-Kuster-Hauser syndrome also known as mullerian agenesis is a rare congenital condition in which there is absence of uterus along with upper vagina. Patient usually presents with primary amenorrhea with or without cyclical lower abdominal pain but have normal secondary sexual characters. Modified McIndoe Vaginoplasty with amnion graft is the commonest surgery performed worldwide. A 23 year old girl with normal secondary sexual characters presented with primary amenorrhea with cyclical lower abdominal pain; on examination blind vagina was present. Vaginoplasty with amnion graft was done and vaginal mould was placed. Vaginal dilatation with Hegar's dilator was done weekly until 6 weeks. She is under regular follow-up at present and advised for regular manual dilation at home. McIndoe Vaginoplasty with amnion graft is a simple yet rewarding procedure especially in low resource countries like ours, with good success rate and with minimal postoperative complications. Keywords: Amnion graft; Mayer-Rokitansky-Kuster-Hauser Syndrome; Modified McIndoe Vaginoplasty; Primary amenorrhea; Secondary sexual characters.

Laparoscopic-Assisted Transvaginal Cholecystectomy - the US Military Experience With Long-Term Follow Up.

Objectives: We present our initial clinical experience applying Natural Orifice Transluminal Endoscopic Surgical (NOTES) technique to perform cholecystectomy in ten patients at a military institution. Methods: A posterior colpotomy was created to accommodate a single site working port used to facilitate dissection and gallbladder mobilization under direct visualization via an infraumbilical port. The specimen was retrieved through the vagina and the colpotomy was closed with absorbable suture under direct visualization. Long-term follow up was performed over the phone to assess quality of life with 2 widely used health-related quality of life (HRQoL) surveys including RAND-36 Health Item Survey (Version 1.0),1 and the Female Sexual Function Index (FSFI).2. Results: Ten women underwent a laparoscopic-assisted transvaginal cholecystectomy (TVC) with 7 available for long-term follow-up. The average age was 28.9 years (20-37) and the indications for surgery included symptomatic cholelithiasis (9) and biliary dyskinesia (1). The mean operative time was 129 mins (95-180), and median blood loss was 34 ml (5-400). There were no conversions and the average length of stay was 9.98 hours (2.4-28.8). Pain (analogue scale 1-10) on postoperative day three was minimal (mean 2.3) and was limited to the infraumbilical incision. On average patients returned to work by postoperative day six and resumed normal daily activities at seven days. Immediate postoperative complications included one incident of postoperative urinary retention requiring bladder catheterization. One intra-operative cholangiogram was successfully performed due to elevated preoperative liver enzymes without significant findings. Long-term complications included one asymptomatic incisional hernia repair at the infraumbilical port site. The RAND-36 survey demonstrated an average physical and mental health summary score of 82.2 and 63.7 with an average general health score of 63.6. The average FSFI total score was 21.8. Conclusion: TVC is safe and effective. Implementation may improve operational readiness by returning service members to normal activities more expeditiously than conventional laparoscopy.

A novel magnetic compression technique for establishment of a vesicovaginal fistula model in Beagle dogs.

Vesicovaginal fistula lacks a standard, established animal model, making surgical innovations for this condition challenging. Herein, we aimed to non-surgically establish vesicovaginal fistula using the magnetic compression technique, and the feasibility of this method was explored using eight female Beagle dogs as model animals. In these dogs, cylindrical daughter and parent magnets were implanted into the bladder and vagina, respectively, after anesthesia, and the positions of these magnets were adjusted under X-ray supervision to make them attract each other, thus forming the structure of daughter magnet-bladder wall-vaginal wall-parent magnet. Operation time and collateral damage were recorded. The experimental animals were euthanized 2 weeks postoperatively, and the vesicovaginal fistula gross specimens were obtained. The size of the fistula was measured. Vesicovaginal fistula was observed by naked eye and under a light microscope. Magnet placement was successful in all dogs, and remained in the established position for the reminder of the experiment. The average operation time was 14.38 min ± 1.66 min (range, 12-17 min). The dogs were generally in good condition postoperatively and were voiding normally, with no complications like bleeding and urine retention. The magnets were removed from the vagina after euthanasia. The vesicovaginal fistula was successfully established according to gross observation, and the fistula diameters were 4.50-6.24 mm. Histological observation revealed that the bladder mucosa and vaginal mucosa were in close contact on the internal surface of the fistula. Taken together, magnetic compression technique is a simple and feasible method to establish an animal model of vesicovaginal fistula using Beagle dogs. This model can help clinicians study new surgical techniques and practice innovative approaches for treating vesicovaginal fistula.

A case control study of vNOTES hysterectomy with the da Vinci surgical system and conventional vNOTES hysterectomy.

The aim of the case control study was to compare surgical outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy with the da Vinci surgical system (dVSS) and conventional vNOTES. A case control study was performed on 25 cases in our hospital. Patients (n = 8) who underwent vNOTES hysterectomy with dVSS were selected to compare with the control group (n = 17) consisted of patients who underwent conventional vNOTES. Patients in the 2 groups underwent different operations respectively, and no case was transferred to transabdominal laparoscopy. In the conventional vNOTES group, 1 patient happened intraoperative hemorrhage of about 1000 mL, and was treated with blood transfusion, and the other one of vNOTES hysterectomy with dVSS had poor incision healing within 1 month after surgery. The other patients had no intraoperative and postoperative complications. The difference of pain scores on the first day (P = .006) and the third day (P = .045) after the 2 surgical methods differed significantly. No statistical differences were observed in operation time, median hospital stay, blood loss, decreased hemoglobin 3 days after surgery, and postoperative white blood cell count. vNOTES hysterectomy with dVSS is safe and feasible, and can achieve the same effect as the conventional vNOTES hysterectomy. And this method may alleviate the pain of patients.

Double longitudinal myotomy in gender-affirming colovaginoplasty: an innovative surgical technique to prevent and treat neovaginal spasms.

BACKGROUND: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients. AIM: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms. METHODS: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed. OUTCOMES: Patient-reported outcomes and neovaginal examination were performed following standardized protocols. RESULTS: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms. CLINICAL IMPLICATIONS: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms. STRENGTHS AND LIMITATIONS: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results. CONCLUSION: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results.

High imperforate transverse vaginal septum with vaginal cicatrisation: a surgical tribulation.

An early adolescent girl was referred to us with cryptomenorrhoea, and pelvic pain consistent with obstructed menstruation. Originally presumed to be a case of imperforate hymen, she was referred to our centre after two failed surgical misadventures at correcting the obstruction. MRI revealed a haematometrocolpos, high transverse complete vaginal septum and an occluded vagina. She underwent a laparoscopic drainage of the collection, septal resection and a vaginoplasty with an absorbable Interceed graft. Postoperative recovery was smooth and she was sent with instructions to use a vaginal mould daily. Successful surgical treatment requires precise preoperative planning with MRI. A vaginal-assisted laparoscopic approach turned out to be advantageous in resecting the septum to a large extent due to the associated cicatrised vagina. The use of Interceed, a novel mould and harnessing system, ensured a favourable postoperative outcome by bolstering patient motivation due to its less challenging technique of use.

Outcomes of one-stage feminizing genitoplasty in children with congenital adrenal hyperplasia and severe virilization.

PURPOSE: To present our surgical experience and outcomes in congenital adrenal hyperplasia (CAH) patients with severe virilization using a combined technique of total urogenital mobilization (TUM) and a modified pull-through vaginoplasty to perform a safe and effective one-stage feminizing genital reconstruction for these children. METHODS: Fourteen CAH patients with severe virilization, defined by a Prader IV and V rating of the external genitalia, underwent TUM followed by a limited vaginal pull-through procedure from June 2016 to December 2020. Postoperative anatomical and cosmetic outcomes, and urinary continence, were evaluated. RESULTS: Out of the 14 cases in this study, 8 were classified as prader IV and 6 as Prader V. The median age at surgery was 11 months (range 6-36 months), and the mean urethral length was 1.4 cm (range 1.2-1.8 cm). The median follow-up period was 4 years. Our cosmetic outcomes were good in 11 (78.5%), satisfactory in 2, and poor in one case. All patients achieved age-appropriate toilet training without urinary incontinence. CONCLUSION: Adopting our surgical approach of TUM with modified pull-through vaginoplasty has simplified feminizing surgical reconstruction in CAH cases with severe genital atypia and a very high vaginal confluence with short urethral length, yielding adequate introitus with good anatomical and cosmetic appearance and adequate urinary continence outcomes.

Two-Year Preclinical Evaluation of Long-Term Absorbable Poly-4-hydroxybutyrate Scaffold for Surgical Correction of Pelvic Organ Prolapse.

INTRODUCTION AND HYPOTHESIS: Fully absorbable implants may be an alternative to permanent meshes in the correction pf pelvic organ prolapse (POP) as they may reduce adverse events by promoting tissue regeneration and collagen metabolism. This study was aimed at evaluating the long-term host and biomechanical response to a fully absorbable poly-4-hydroxybutyrate (P4HB) scaffold in comparison with polypropylene (PP) mesh. METHODS: Poly-4-hydroxybutyrate scaffold (n = 16) and PP mesh (n = 16) were surgically implanted in the posterior vaginal wall of parous female Dohne Merino sheep. Vaginal explants were evaluated in terms of gross necropsy, host response (immune response, collagen deposition, tissue regeneration), biomechanics, and degradation of P4HB at 12 and 24 months post-implantation. RESULTS: Gross necropsy revealed no infection or fluid collection using P4HB or PP. At 12 months, exposures were observed with both P4HB (3 out of 8) and PP (4 out of 8), whereas at 24 months, exposures were observed only with PP (4 out of 8). The tensile stiffness of the P4HB explants was maintained over time despite complete absorption of P4HB. The collagen amount of the vaginal tissue after P4HB implantation increased over time and was significantly higher than PP at 24 months. P4HB scaffolds exhibited significantly lower myofibroblast differentiation than PP meshes at 24 months. CONCLUSIONS: The P4HB scaffold allowed for gradual load transfer to the vaginal wall and resulted in mechanically self-sufficient tissue. P4HB scaffold had a more favorable host response than PP mesh, with higher collagen content, lower myofibroblastic differentiation, and no exposures at 24 months. P4HB scaffolds have potential as an alternative to permanent implants in treating POP.

Mobility analysis of a posterior sacrospinous fixation using a finite element model of the pelvic system.

INTRODUCTION AND HYPOTHESIS: In order to improve the knowledge POP physiopathology and POP repair, a generic biomechanical model of the female pelvic system has been developed. In the literature, no study has currently evaluated apical prolapse repair by posterior sacrospinous ligament fixation using a generic model nor a patient-specific model that personalize the management of POP and predict surgical outcomes based on the patient's pre-operative Magnetic Resonance Imaging. The aim of our study was to analyze the influence of a right and/or left sacrospinous ligament fixation and the distance between the anchorage area and the ischial spine on the pelvic organ mobility using a generic and a patient-specific Finite Element model (FEM) of the female pelvic system during posterior sacrospinous ligament fixation (SSF). METHODS: Firstly, we used a generic 3D FEM of the female pelvic system previously made by our team that allowed us to simulate the mobility of the pelvic system. To create a patient-specific 3D FEM of the female pelvic system, we used a preoperative dynamic pelvic MRI of a 68 years old woman with a symptomatic stage III apical prolapse and cystocele. With these 2 models, a SSF was simulated. A right and/or left SSF and different distances between the anchorage area and the ischial spine (1 cm, 2 cm and 3 cm.) were compared. Outcomes measures were the pelvic organ displacement using the pubococcygeal line during maximal strain: Ba point for the most posterior and inferior aspect of the bladder base, C point the cervix's or the vaginal apex and Bp point for the anterior aspect of the anorectal junction. RESULTS: Overall, pelvic organ mobility decreased regardless of surgical technique and model. According to the generic model, C point was displaced by 14.1 mm and 11.5 mm, Ba point by 12.7 mm, and 12 mm and Bp point by 10.6 mm and 9.9 mm after left and bilateral posterior SSF, respectively. C point was displaced by 15.4 mm and 11.6 mm and Ba point by 12.5 mm and 13.1mm when the suture on the sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine respectively (bilateral posterior SSF configuration). According to the patient-specific model, the displacement of Ba point could not be analyzed because of a significative and asymmetric organ displacement of the bladder. C point was displaced by 4.74 mm and 2.12 mm, and Bp point by 5.30 mm and 3.24 mm after left and bilateral posterior SSF respectively. C point was displaced by 4.80 mm and 4.85 mm and Bp point by 5.35 mm and 5.38 mm when the suture on the left sacrospinous ligament was performed at 1 cm and 3 cm from the ischial spine, respectively. CONCLUSION: According to the generic model from our study, the apex appeared to be less mobile in bilateral SSF. The anchorage area on the sacrospinous ligament seems to have little effect on the pelvic organ mobilities. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04551859.

[Lower urinary tract injury in transvaginal reconstructive pelvic surgery].

Objective: To explore the characteristics, prevention and treatment strategies of lower urinary tract injury in transvaginal reconstructive pelvic surgery (vRPS). Methods: A retrospective analysis was conducted on 24 patients who suffered lower urinary tract injuries occuring in vRPS from January 2005 to June 2021, among which 4 cases were referred to our hospital from other hospitals. Results: (1) In our hospital, 1 952 patients underwent vRPS for anterior and (or) middle pelvic organ prolapse during that study period, with a 1.0% (20/1 952) incidence of lower urinary tract injuries occurring in 20 cases. (2) Ureteral injuries were observed in 14 cases who underwent transvaginal high uterosacral ligament suspension (1.4%, 14/966). The symptoms were relieved after the removal of sutures. (3) Bladder injuries occurred in 6 cases in our hospital, with 4 cases (0.7%, 4/576) in anterior transvaginal mesh surgery (aTVM), one (0.4%, 1/260) in colpocleisis, and one (0.7%, 1/150) in apical suspension for fornix prolapse. An additional 4 cases of bladder injury were referred to our hospital after aTVM. Among the 8 cases of bladder injury during aTVM, 2 cases were intraoperative incidents. Cystoscopy confirmed that the superficial branch or puncture rod of anterior vaginal mesh had penetrated into the bladder. Re-puncturing and placement of the mesh were successfully performed. No abnormalities were observed during a follow-up period of 4-5 years. Postoperative bladder injuries were identified in 6 cases, characterized by mesh erosion into the bladder and formation of calculi. These injuries were confirmed between 6 months to 2 years after vRPS. The exposed mesh and calculi in the bladder were removed through laparotomy or cystoscopy, followed up for 2-12 years. One case experienced slight re-erosion of mesh to the bladder. Conclusions: Lower urinary tract injuries are difficult to avoid in vRPS, particularly in transvaginal high uterosacral ligament suspension and aTVM. However, the incidence is low. Lower urinary tract injuries during vRPS could be easily detected and managed intraoperatively because of the use of cystoscopy. As long-term postoperative complications, erosion of transvaginal mesh to lower urinary tract postoperatively could be treated correctly, seldom with severe sequelae.

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study.

OBJECTIVE: The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. DESIGN: A diagnostic accuracy study was employed based on a prospective observational design. PARTICIPANTS: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered. SETTING: The study was conducted at endometriosis referral hospitals. METHODS: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. RESULTS: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70-96.92%, 95% CI) for the right side and 87.91% (79.40-93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70-141.90, 95% CI) and 0.09 (0.04-0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12-101.4, 95% CI) and 0.12 (0.07-0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90-98.84%, 95% CI) and 96.22% (94.04-97.74%, 95% CI), respectively. LIMITATIONS: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. CONCLUSIONS: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Transvaginal natural orifice transluminal endoscopic surgery for myomectomy: A more suitable surgical approach for enhanced recovery after surgery.

OBJECTIVE: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is widely recognized for its potential benefits, including reducing post-surgical pain and leaving no discernible scarring. However, the anatomical specificity of the vNOTES approach may elevate the risk of nearby organ damage, such as the rectum and bladder. Thus, this study aims to demonstrate the safety and relative merits of vNOTES over transumbilical laparoendoscopic single-site surgery (LESS). METHODS: The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 110 patients who underwent myomectomy in vNOTES or LESS from January 2021 to December 2022. This study prospectively collected and compared perioperative and follow-up data of the two groups. RESULTS: In the vNOTES group, patients had shorter postoperative anal exhaust time, lower pain medications use rate, shorter hospital stay but higher intraoperative conversion rate, and higher postoperative fever rate. vNOTES decreased the anal exhaust time by approximately 8.7 h (95 %CI: -16.182, -1.262, p = 0.007). Moreover, vNOTES reduces pain medication use risk by 73.1 % (OR: 0.269, 95 %CI: 0.172, 0.318, p = 0.016). CONCLUSION: Relative to LESS, vNOTES can make patients mitigate postoperative discomfort, accelerate the recovery of gastrointestinal function, curtail hospitalization duration, and enable a more rapid return to daily activities in myomectomy. However, vNOTES has a higher risk of surgical conversion and adjacent organ injury. Therefore, larger scale prospective studies are needed to prove its security and promote the widespread application of vNOTES in myomectomy.

The Effect of Obesity on Vaginoplasty Outcomes.

BACKGROUND: Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS: A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS: A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS: Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review.

OBJECTIVE: To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES: We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION: Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS: The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION: Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42022327490.

Effects of Obesity on Urogynecologic Prolapse Surgery Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature on outcomes of pelvic organ prolapse (POP) surgery in patients from various body mass index (BMI) categories to determine the association between obesity and surgical outcomes. DATA SOURCES: PubMed, EMBASE, and Cochrane databases were searched from inception to April 12, 2022; ClinicalTrials.gov was searched in September 2022 (PROSPERO 2022 CRD42022326255). Randomized and nonrandomized studies of urogynecologic POP surgery outcomes were accepted in which categories of BMI or obesity were compared. METHODS OF STUDY SELECTION: In total, 9,037 abstracts were screened; 759 abstracts were identified for full-text screening, and 31 articles were accepted for inclusion and data were extracted. TABULATION, INTEGRATION, AND RESULTS: Studies were extracted for participant information, intervention, comparator, and outcomes, including subjective outcomes, objective outcomes, and complications. Outcomes were compared among obesity categories (eg, BMI 30-34.9, 35-40, higher than 40), and meta-analysis was performed among different surgical approaches. Individual studies reported varying results as to whether obesity affects surgical outcomes. By meta-analysis, obesity (BMI 30 or higher) is associated with an increased odds of objective prolapse recurrence after vaginal prolapse repair (odds ratio [OR] 1.38, 95% CI, 1.14-1.67) and after prolapse repair from any surgical approach (OR 1.31, 95% CI, 1.12-1.53) and with complications such as mesh exposure after both vaginal and laparoscopic POP repair (OR 2.10, 95% CI, 1.01-4.39). CONCLUSION: Obesity is associated with increased likelihood of prolapse recurrence and mesh complications after POP repair. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022326255.

Comparison of different suture techniques for laparoscopic vaginal cuff closure.

Laparoscopic hysterectomy is a commonly performed procedure. However, one high-risk complication is vaginal cuff dehiscence. Currently, there is no standardization regarding thread material or suturing technique for vaginal cuff closure. Therefore, this study aimed to compare extracorporeal and intracorporeal suturing techniques for vaginal cuff closure using a pelvic trainer model. Eighteen experts in laparoscopic surgery performed vaginal cuff closures with interrupted sutures using intracorporeal knotting, extracorporeal knotting and continuous, unidirectional barbed sutures. While using an artificial tissue suturing pad in a pelvic trainer, experts performed vaginal cuff closure using each technique according to block randomization. Task completion time, tension resistance, and the number of errors were recorded. After completing the exercises, participants answered a questionnaire concerning the suturing techniques and their performance. Experts completed suturing more quickly (p < 0.001, p < 0.001, respectively) and with improved tension resistance (p < 0.001, p < 0.001) when using barbed suturing compared to intracorporeal and extracorporeal knotting. Furthermore, the intracorporeal knotting technique was performed faster (p = 0.04) and achieved greater tension resistance (p = 0.023) compared to extracorporeal knotting. The number of laparoscopic surgeries performed per year was positively correlated with vaginal cuff closure duration (p = 0.007). Barbed suturing was a time-saving technique with improved tension resistance for vaginal cuff closure.

Cloacal Dysgenesis Sequence in a Preterm Neonate.

BACKGROUND Cloaca malformations result from a disproportion of apoptosis, cell growth, and maturation. The range of cloacal malformations is extensive and diverse, with a lack of a straightforward classification system. Cloacal dysgenesis sequence (CDS), also known as urorectal septum malformation sequence, is a rare cloaca variant described as the absence of a perineal orifice. Prenatal magnetic resonance imaging and antenatal ultrasounds may reveal a cloacal malformation; however, many patients are not diagnosed with cloacal malformation until birth. CASE REPORT We present a case of a female neonate delivered by a 23-year-old G2P1T1A0L0 mother who had received comprehensive prenatal care. During pregnancy, bilateral multicystic dysplastic kidneys were identified prenatally, leading to the in utero placement of a vesicoamniotic shunt. The physical exam revealed a distended abdomen with reduced abdominal musculature and laxity, ascites, a vesicoamniotic shunt in place, absent urethra, ambiguous genitalia with no vaginal opening, no perineal opening, and clubfoot. Abdominal radiograph showed findings consistent with significant abdominal ascites. An exploratory laparotomy was performed that included diverting colostomy, mucous fistula creation, tube vaginostomy, removal of the vesicoamniotic shunt, and suprapubic tube placement. The patient recovered well from this operation with no complications. CONCLUSIONS CDS is an uncommon condition in pediatric patients, and although sonographic findings can reveal urinary tract abnormalities, prenatal imaging might not always identify CDS. Our case underscores the uniqueness of the case and the significance of early detection and immediate medical and surgical intervention.

Requests for vulvoplasty as gender-affirming surgery: a cross-sectional study in Denmark.

BACKGROUND: Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark. AIM: In this study we sought to quantify the need for offering vulvoplasty in Denmark. MATERIALS AND METHODS: An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022. OUTCOMES: Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it. RESULTS: A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future. CLINICAL IMPLICATIONS: Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered. STRENGTHS AND LIMITATIONS: Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated. CONCLUSION: The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

Importance of vaginal packing after laparoscopic sacrocolpopexy - retrospective study.

OBJECTIVE:  To compare the subjective and objective results of laparoscopic sacrocolpopexy (LSC) with and without the introduction of a vaginal packing one year after surgery. Methodology: This is a retrospective cohort study of 125 women after laparoscopic sacrocolpopexy operated on in 2013-2016 with complete annual follow-up. Patients with a total hysterectomy were excluded from the study. Basic patient characteristics, preoperative POP-Q and surgery data were collected. The subjective outcome of the surgery was assessed using the PGI-I (patient global impression of improvement). The anatomic outcome of the surgery was evaluated using the composite definition of surgical failure based on POP-Q (Ba ≥ -1, C ≥ -3, Bp ≥ -1). Patients were divided into two groups according to whether or not they had vaginal packing after surgery. Statistical analysis was performed using c2, Wilcoxon and Fischer test according to the distribution of normality. Results: A total of 125 women were enrolled in the study; 48 (38.4%) after LSC, 58 (46.4%) with concomitant supracervical hysterectomy and 19 (15.2%) after sacrohysterocolpopexy. Vaginal packing was introduced for 24-48 hours after surgery in 86 (68.8%) women. The groups did not differ in age, body mass index, smoking or preoperative pelvic organ prolapse quantification system. We did not observe statistically significant differences in PGI-I first year after surgery. The difference in anatomic surgical failure did not reach statistical significance, although more failures were observed in the group without packing (12.8 vs. 3.5%; P = 0.09). The mean C-point value one year after surgery was lower in the non-tamponade group (-7 vs. -7.5; P < 0.009). No mesh extrusion or serious complications were recorded in the monitored group. Conclusion: Vaginal packing after LSC probably does not affect patient satisfaction after surgery, however, it may be associated with better anatomical outcome one year after the surgery. The results of the study must be confirmed by a more detailed prospective evaluation.