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International Urogynecology Journal Nov 2023Bowel vaginoplasty is a surgical method for neovagina construction that, despite its advantages over other techniques, is still burdened by complications such as... (Review)
Review
BACKGROUND
Bowel vaginoplasty is a surgical method for neovagina construction that, despite its advantages over other techniques, is still burdened by complications such as prolapse. The incidence of sigmoid neovagina prolapse (SNP) is difficult to determine, and there are no evidence-based recommendations for treatment. We present a case of SNP and a systematic review of previous cases.
CASE
A 73-year-old woman presented with stage III prolapse of her sigmoid neovagina constructed 51 years prior. Dynamic pelvic MRI revealed that the majority of the prolapse was due to the mucosa's loss of support. Due to the presence of numerous pelvic adhesions, an alternative to the laparoscopic approach was evaluated by a multidisciplinary team which led to the patient being treated using a modification of Altemeier's procedure.
SYSTEMATIC REVIEW
After PROSPERO Registration (CRD42023400677), a systematic search of Medline and Scopus was performed using specific search terms. Study metadata including patient demographics, prolapse measurements, reconstruction techniques, recurrence rates, and timing were extracted. Fourteen studies comprising 17 cases of SNP were included. Vaginal resection of the redundant sigmoid, comprising Altemeier's procedure, was the most definitive surgery, but it was also associated with recurrences in three cases. Laparoscopic sacropexy was the second most definitive surgery with no recurrence reported.
CONCLUSION
Our review shows that the recurrence after correction of sigmoid neovagina prolapses is higher than previously reported. Laparoscopy colposacropexy appeared to be the best approach, but it's not always feasible. In these scenarios, a mucosal resection using the Altemeier's procedure is the most effective surgery.
Topics: Humans; Female; Pregnancy; Aged; Colon, Sigmoid; Prolapse; Vagina; Laparoscopy; Colpotomy; Mullerian Ducts; Congenital Abnormalities; 46, XX Disorders of Sex Development
PubMed: 37490063
DOI: 10.1007/s00192-023-05603-4 -
International Journal of Gynaecology... Mar 2024Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Studies aimed to assess risk factors for pelvic organ prolapse (POP) recurrence following colpocleisis with nonconclusive results.
OBJECTIVE
To investigate risk factors for POP recurrence following colpocleisis.
SEARCH STRATEGY
MEDLINE, PUBMED, Embase, Web of Science, and Cochrane databases were systematically searched.
SELECTION CRITERIA
Experimental and non-experimental studies investigating POP recurrence following colpocleisis.
DATA COLLECTION AND ANALYSIS
We assessed the association between preoperative and postoperative physical examination findings, demographics and medical history, and the risk of recurrence following colpocleisis.
MAIN RESULTS
A total of 954 studies were identified, of which five studies comprising 2978 patients were eligible for analysis. Both preoperative and postoperative genital hiatus length were significantly longer in the recurrence group (mean difference [MD] 0.48, 95% confidence interval [CI] 0.01-0.94, P = 0.04, I = 0% and MD 1.15, 95% CI 0.50-1.81, P = 0.005, I = 0%; respectively). Preoperative total vaginal length (TVL) did not differ between groups (MD 0.05, 95% CI -0.40 to 0.50, P = 0.83, I = 6%), postoperative TVL was found significantly longer in the recurrence group (MD 0.07, 95% CI -0.03 to 1.38, P = 0.04, I = 68%). Both preoperative and postoperative perineal body did not differ between groups. Women with a previous POP surgery were more likely to experience recurrence following colpocleisis (relative risk 2.09, 95% CI 1.18-3.69, P = 0.01, I = 0%). Patient's age and previous hysterectomy did not affect recurrence rates.
CONCLUSION
Wider preoperative and postoperative genital hiatus as well as longer post-operative TVL and previous POP surgery were associated with a higher risk for recurrence following colpocleisis, highlighting the importance of appropriate patient selection and surgical technique in minimizing this risk.
Topics: Pregnancy; Humans; Female; Colpotomy; Vagina; Pelvic Organ Prolapse; Hysterectomy; Risk Factors; Treatment Outcome; Gynecologic Surgical Procedures; Recurrence
PubMed: 37488940
DOI: 10.1002/ijgo.14999 -
Archives of Gynecology and Obstetrics Mar 2024This systematic review aims to provide a data synthesis about the risk of neovaginal cancer in women with Müllerian anomalies and to investigate the association between... (Review)
Review
PURPOSE
This systematic review aims to provide a data synthesis about the risk of neovaginal cancer in women with Müllerian anomalies and to investigate the association between the adopted reconstructive technique and the cancer histotype.
METHODS
PubMed, MEDLINE, Embase, Scopus, ClinicalTrials.gov and Web of Science databases were searched from inception to March 1st, 2023. Studies were included if: (1) only women affected by Müllerian malformations were included, (2) the congenital defect and the vaginoplasty technique were clearly reported, (3) the type of malignancy was specified.
RESULTS
Literature search yielded 18 cases of squamous cell carcinoma and two cases of vaginal intraepithelial neoplasia 3 (VAIN 3). Of these, 3 had been operated on according to the Wharton technique, 8 according to the McIndoe technique, 3 with a split-skin graft vaginoplasty, 2 according to the Davydov technique, 2 with a simple cleavage technique, 1 according to the Vecchietti technique and 1 with a bladder flap vaginoplasty. A total of 17 cases of adenocarcinoma and 1 case of high-grade polypoid dysplasia were also described. Of these, 15 had undergone intestinal vaginoplasty, 1 had been operated on according to the McIndoe technique and 1 had undergone non-surgical vaginoplasty. Finally, 1 case of verrucous carcinoma in a woman who had undergone a split-skin graft vaginoplasty, was reported.
CONCLUSION
Although rare, neovaginal carcinoma is a definite risk after vaginal reconstruction, regardless of the adopted technique. Gynaecologic visits including the speculum examination, the HPV DNA and/or the Pap smear tests should be scheduled on an annual basis.
Topics: Humans; Female; Vagina; Plastic Surgery Procedures; Vaginal Neoplasms; Carcinoma, Squamous Cell; Adenocarcinoma; Mullerian Ducts; 46, XX Disorders of Sex Development; Congenital Abnormalities; Gynecologic Surgical Procedures; Treatment Outcome
PubMed: 37466686
DOI: 10.1007/s00404-023-07086-6 -
Journal of Clinical Medicine Jun 2023The most important causative agent of neoplasms in the anogenital area is the human papillomavirus (HPV). Due to the anatomical proximity of the genital and anus area... (Review)
Review
BACKGROUND
The most important causative agent of neoplasms in the anogenital area is the human papillomavirus (HPV). Due to the anatomical proximity of the genital and anus area and the ease with which HPV infection is transmitted, it seems that patients after the treatment of HPV-related gynecological diseases may have an increased risk of developing a second HPV-related neoplasm anal cancer. The aim of this study was to determine the risk of anal intraepithelial neoplasia (AIN) and anal cancer (AC) among patients after the treatment of HPV-related gynecological diseases.
METHODS
We conducted a comprehensive review of the available literature from multiple databases. The study was performed following and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 guidelines. Moreover, we assessed the quality of each study using QUADAS-2.
RESULTS
Twenty-five studies were included in the final analysis. Patients after the treatment of HPV-related gynecological diseases have a significantly higher risk of AC (mean standardized incidence ratio (SIR) = 5.387, mean incidence risk (IR) = 0.096%, mean IR per 100,000 person-years = 10.37) and AIN (mean IR = 23.683%) compared to the population risk.
CONCLUSIONS
patients with HPV-related gynecological diseases should constitute a group for which an appropriate primary and secondary screening for AC should be introduced.
PubMed: 37445251
DOI: 10.3390/jcm12134216 -
The Cochrane Database of Systematic... Jul 2023Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at... (Review)
Review
BACKGROUND
Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women.
OBJECTIVES
To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations.
SEARCH METHODS
We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE.
MAIN RESULTS
We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus). No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone.
AUTHORS' CONCLUSIONS
There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design. There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.
Topics: Female; Humans; Middle Aged; Estrogens; Pelvis; Pessaries; Postmenopause; Urinary Bladder
PubMed: 37431855
DOI: 10.1002/14651858.CD014592.pub2 -
Obstetrics and Gynecology Aug 2023To assess the prevalence of high-risk human papillomavirus (hrHPV) and human papillomavirus (HPV)-associated abnormalities in the neovaginas of postvaginoplasty...
OBJECTIVE
To assess the prevalence of high-risk human papillomavirus (hrHPV) and human papillomavirus (HPV)-associated abnormalities in the neovaginas of postvaginoplasty transfeminine patients to inform potential HPV-screening guidelines for this patient population.
DATA SOURCES
MEDLINE, ClinicalTrials.gov , the Cochrane Library, Scopus, and Google Scholar were searched through September 30, 2022.
METHODS OF STUDY SELECTION
The population included transfeminine individuals who had undergone vaginoplasty with an outcome of subsequent positive HPV diagnosis or HPV-related lesions. Randomized clinical trials, cohort studies, cross-sectional studies, and case reports available in English were included in the analysis. Identified articles were doubly screened, and accepted articles were doubly extracted.
TABULATION, INTEGRATION, AND RESULTS
Of 59 abstracts identified, 30 were screened for eligibility, of which 15 met the criteria for review. Included studies were assessed for vaginoplasty procedure type, time elapsed between vaginoplasty and HPV testing, HPV type, location and manner of sample collection, method of HPV diagnosis, and classification and location of HPV-associated neovaginal lesions. Studies were assigned a grade of evidence of very low, low, moderate, or high based on study design, precision, directness, and risk of bias. Prevalence of neovaginal hrHPV ranged from 8.3% to 20% in identified studies, and per-study prevalence of HPV-related neovaginal abnormalities ranged from 0% to 8.3% in patients.
CONCLUSION
The current body of research demonstrates that, after vaginoplasty, transfeminine individuals may develop neovaginal HPV infection with associated cytologic abnormalities or grossly apparent lesions. In some included studies, neovaginal HPV-associated lesions were highly advanced before they were identified. A small number of studies assessed neovaginal HPV prevalence in transfeminine individuals, with hrHPV prevalence ranging from 8.3% to 20%. However, broader conclusions about neovaginal HPV prevalence are limited by a lack of high-grade evidence in the existing literature. More rigorous prevalence research is needed to inform preventative care guidelines for transfeminine individuals at risk of developing HPV-related neovaginal complications.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO, CRD42022379977.
Topics: Female; Humans; Human Papillomavirus Viruses; Papillomavirus Infections; Prevalence; Cross-Sectional Studies; Vagina; Papillomaviridae; Uterine Cervical Neoplasms
PubMed: 37411025
DOI: 10.1097/AOG.0000000000005264 -
International Urogynecology Journal Nov 2023Recurrent urinary tract infections (rUTIs) are a burden to patients and the health care economy. Vaginal probiotics and supplements have gained significant attention in...
INTRODUCTION AND HYPOTHESIS
Recurrent urinary tract infections (rUTIs) are a burden to patients and the health care economy. Vaginal probiotics and supplements have gained significant attention in mainstream media and lay press as a non-antibiotic alternative. We performed a systematic review to determine whether vaginal probiotics are an effective means of prophylaxis for rUTI.
METHODS
A PubMed/MEDLINE article search was performed from inception to August 2022 for prospective, in vivo use of vaginal suppositories for the prevention of rUTIs. Search terms included: vaginal probiotic suppository (34 results), vaginal probiotic randomized (184 results), vaginal probiotic prevention (441 results), vaginal probiotic UTI (21 results), and vaginal probiotic urinary tract infection (91 results). A total of 771 article titles and abstracts were screened.
RESULTS
A total of 8 articles fit the inclusion criteria and were reviewed and summarized. Four were randomized controlled trials, with 3 of the studies having a placebo arm. Three were prospective cohort studies, and 1 was a single arm, open label trial. Five of the 7 articles that specifically evaluated for rUTI reduction with vaginal suppositories did find a decreased incidence with probiotic use; however, only 2 had statistically significant results. Both of these were studies of Lactobacillus crispatus and were not randomized. Three studies demonstrated the efficacy and safety of Lactobacillus as a vaginal suppository.
CONCLUSION
Current data support the use of vaginal suppositories containing Lactobacillus as a safe, non-antibiotic measure, but actual reduction of rUTI in susceptible women remains inconclusive. The appropriate dosing and duration of therapy remain unknown.
Topics: Humans; Female; Suppositories; Prospective Studies; Lactobacillus; Vagina; Urinary Tract Infections
PubMed: 37392226
DOI: 10.1007/s00192-023-05568-4 -
Menopause (New York, N.Y.) Aug 2023Ospemifene is a novel selective estrogen receptor modulator developed for the treatment of moderate to severe postmenopausal vulvovaginal atrophy (VVA). (Meta-Analysis)
Meta-Analysis
Efficacy, tolerability, and endometrial safety of ospemifene compared with current therapies for the treatment of vulvovaginal atrophy: a systematic literature review and network meta-analysis.
IMPORTANCE
Ospemifene is a novel selective estrogen receptor modulator developed for the treatment of moderate to severe postmenopausal vulvovaginal atrophy (VVA).
OBJECTIVE
The aim of the study is to perform a systematic literature review (SLR) and network meta-analysis (NMA) to assess the efficacy and safety of ospemifene compared with other therapies used in the treatment of VVA in North America and Europe.
EVIDENCE REVIEW
Electronic database searches were conducted in November 2021 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized or nonrandomized controlled trials targeting postmenopausal women with moderate to severe dyspareunia and/or vaginal dryness and involving ospemifene or at least one VVA local treatment were considered. Efficacy data included changes from baseline in superficial and parabasal cells, vaginal pH, and the most bothersome symptom of vaginal dryness or dyspareunia, as required for regulatory approval. Endometrial outcomes were endometrial thickness and histologic classifications, including endometrial polyp, hyperplasia, and cancer. For efficacy and safety outcomes, a Bayesian NMA was performed. Endometrial outcomes were compared in descriptive analyses.
FINDINGS
A total of 44 controlled trials met the eligibility criteria ( N = 12,637 participants). Network meta-analysis results showed that ospemifene was not statistically different from other active therapies in most efficacy and safety results. For all treatments, including ospemifene, the posttreatment endometrial thickness values (up to 52 wk of treatment) were under the recognized clinical threshold value of 4 mm for significant risk of endometrial pathology. Specifically, for women treated with ospemifene, endometrial thickness ranged between 2.1 and 2.3 mm at baseline and 2.5 and 3.2 mm after treatment. No cases of endometrial carcinoma or hyperplasia were observed in ospemifene trials, nor polyps with atypical hyperplasia or cancer after up to 52 weeks of treatment.
CONCLUSIONS AND RELEVANCE
Ospemifene is an efficacious, well-tolerated, and safe therapeutic option for postmenopausal women with moderate to severe symptoms of VVA. Efficacy and safety outcomes with ospemifene are similar to other VVA therapies in North America and Europe.
Topics: Female; Humans; Dyspareunia; Vagina; Hyperplasia; Bayes Theorem; Network Meta-Analysis; Vulva; Atrophy; Tamoxifen; Selective Estrogen Receptor Modulators; Vaginal Diseases; Endometrial Neoplasms
PubMed: 37369079
DOI: 10.1097/GME.0000000000002211 -
International Journal of Gynaecology... Jan 2024Outpatient hysteroscopy is a safe, feasible, and optimum procedure for the diagnosis and management of intrauterine pathologies. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Outpatient hysteroscopy is a safe, feasible, and optimum procedure for the diagnosis and management of intrauterine pathologies.
OBJECTIVE
To determine the best approach of outpatient hysteroscopy (vaginoscopic vs traditional) in terms of pain, duration of procedure, feasibility, safety, and acceptability.
SEARCH STRATEGY
PubMed, Embase, Google Scholar, and Scopus were searched from January 2000 to October 2021. No filters or restrictions were applied.
SELECTION CRITERIA
Randomized controlled trials comparing vaginoscopic hysteroscopy with traditional hysteroscopy in an outpatient setting.
DATA COLLECTION AND ANALYSIS
Two authors independently performed a comprehensive literature search and collected and extracted data. The summary effect estimate was determined using both fixed effects and random-effects models.
RESULTS
Seven studies with 2723 patients (vaginoscopic [n = 1378] and traditional hysteroscopy [n = 1345]) were included. Vaginoscopic hysteroscopy was associated with a significant reduction in intraprocedural pain (standardized mean difference, -0.05 [95% confidence interval (CI), -0.33 to -0.23], I = 0%), procedural time (standardized mean difference, -0.45 [95% CI, -0.76 to -0.14], I = 82%), and fewer side effects (relative risk, 0.37 [95% CI, 0.15-0.91], I = 0%). The procedure failure rate was similar in both approaches (relative risk, 0.97 [95% CI, 0.71-1.32], I = 43%). Complications were mostly documented with traditional hysteroscopy.
CONCLUSION
Vaginoscopic hysteroscopy reduces the pain and duration compared with traditional hysteroscopy.
Topics: Pregnancy; Female; Humans; Hysteroscopy; Pain; Vagina; Outpatients
PubMed: 37306153
DOI: 10.1002/ijgo.14902 -
BJOG : An International Journal of... Nov 2023Over one-quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated...
Over one-quarter of women in the UK have a caesarean birth (CB). More than one in 20 of these births occurs near the end of labour, when the cervix is fully dilated (second stage). In these circumstances, and when labour has been prolonged, the baby's head can become lodged deep in the maternal pelvis making it challenging to deliver the baby. During the caesarean birth, difficulty in delivery of the baby's head may result - this emergency is known as impacted fetal head (IFH). These are technically challenging births that pose significant risks to both the woman and baby. Complications for the woman include tears in the womb, serious bleeding and longer hospital stay. Babies are at increased risk of injury including damage to the head and face, lack of oxygen to the brain, nerve damage, and in rare cases, the baby may die from these complications. Maternity staff are increasingly encountering IFH at CB, and reports of associated injuries have risen dramatically in recent years. The latest UK studies suggest that IFH may complicate as many as one in 10 unplanned CBs (1.5% of all births) and that two in 100 babies affected by IFH die or are seriously injured. Moreover, there has been a sharp increase in reports of babies having brain injuries when their birth was complicated by IFH. When an IFH occurs, the maternity team can use different approaches to help deliver the baby's head at CB. These include: an assistant (another obstetrician or midwife) pushing the head up from the vagina; delivering the baby feet first; using a specially designed inflatable balloon device to elevate the baby's head and/or giving the mother a medicine to relax the womb. However, there is currently no consensus for how best to manage these births. This has resulted in a lack of confidence among maternity staff, variable practice and potentially avoidable harm in some circumstances. This paper reviews the current evidence regarding the prediction, prevention and management of IFH at CB, integrating findings from a systematic review commissioned from the National Guideline Alliance.
Topics: Infant; Female; Pregnancy; Humans; Cesarean Section; Labor, Obstetric; Fetus; Uterus; Cervix Uteri
PubMed: 37303275
DOI: 10.1111/1471-0528.17534