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International Journal of Surgery Case... Jun 2024Vaginal agenesis is a rare congenital condition, with an incidence of 1 in 4500 female births.
INTRODUCTION
Vaginal agenesis is a rare congenital condition, with an incidence of 1 in 4500 female births.
CASE REPORT
We present a clinical case of vaginal aplasia with cervical atresia in a 31-year-old woman with primary amenorrhea. We aim to report the diagnostic process and provide a comprehensive outline of different possible treatments.
DISCUSSION
The most common etiology of these agenesis cases is Mayer-Rokitansky-Küster-Hauser syndrome associated with uterine aplasia. However, vaginal aplasia can occur in 9 % of cases where the uterus is present. During embryogenesis, the Müllerian ducts give rise to the fallopian tubes, uterus, and upper two-thirds of the vagina, while the lower portion of the vagina develops from the urogenital sinus. Vaginal aplasia arises from a failure in the development of the terminal portion of the paramesonephric ducts. Abdominal pain, especially periodic pain, is the most common symptom, followed by primary amenorrhea. MRI is considered the gold standard for the diagnosis and precise description of female genital tract anomalies.
CONCLUSION
Total hysterectomy remains a preferred option for cases of complete vaginal atresia to mitigate the risk of cervical or vaginal stenosis, adhesions, and pelvic inflammation resulting from poor menstrual blood drainage.
PubMed: 38954966
DOI: 10.1016/j.ijscr.2024.109957 -
Facts, Views & Vision in ObGyn Jun 2024Vesico-vaginal fistula (VVF) is a rare but debilitating condition, characterised by an abnormal connection between the bladder and vagina. While obstetric-related cases...
BACKGROUND
Vesico-vaginal fistula (VVF) is a rare but debilitating condition, characterised by an abnormal connection between the bladder and vagina. While obstetric-related cases prevail in developing countries, iatrogenic fistulas are more common in industrialised ones, often resulting from pelvic surgeries.
OBJECTIVES
The optimal timing for surgical correction of VVF remains debated, often leaning towards delayed intervention. Here we report a successful early laparoscopic repair of an iatrogenic VVF following hysterectomy.
MATERIALS AND METHODS
The patient, a 54-year-old woman, presented with VVF after a hysterectomy. The laparoscopic repair was performed promptly upon diagnosis.
MAIN OUTCOME MEASURES
To assess the feasibility and effectiveness of an early repair of a gynaecological-related VVF.
RESULTS
First, cystoscopy identified the bladder edge of the VVF. Second, laparoscopy was performed and the vesico-vaginal dissection was carried out. The excision of the previous stitches and of the fibrotic tissue was undertaken to create free flaps for suturing. The bladder was repaired in a double layer, and a single layer was applied to the vagina. Finally, the omentoplasty was done. The patient was discharged on postoperative day 5. No complications occurred.
CONCLUSIONS
This successful case demonstrates the feasibility and safety of early laparoscopic repair for gynaecological surgery-related vesico-vaginal fistulae. While acknowledging the need for further studies to standardise techniques, this report contributes to the evolving understanding of optimal management for this complex condition.
PubMed: 38950535
DOI: 10.52054/FVVO.16.2.014 -
Journal of Family Medicine and Primary... May 2024Vaginal leiomyomas, originating from the anterior vaginal wall, are exceedingly uncommon, with only around 300 reported cases documented in the literature to date. We...
Vaginal leiomyomas, originating from the anterior vaginal wall, are exceedingly uncommon, with only around 300 reported cases documented in the literature to date. We present a rare case of a 50-year-old female who visited the outpatient department with complaints of abnormal uterine bleeding, and heaviness in abdomen with mass protrusion outside introitus since one year. Ultrasonography indicated adenomyosis of the uterus, with a suspected mass protruding through the posterior bladder or anterior vaginal wall. MRI imaging was conducted large polypoidal mass lesion is seen within the vaginal cavity two assymetrical round ends with close proximity to bladder and urethra with pedunculated submucosal uterine fibroid with adenomyotic changes . The provisional diagnosis of? vaginal leiomyoma along with pedunculated submucosal uterine fibroid with Adenomyosis made. Patient planned for Hysterectomy for submucosal leiomyoma with Adenomyosis and excision of vaginal mass via vaginal route. The size of vaginal mass was around size 5 * 6cm size enucleated, redundant vaginal wall excised and same sent for histopathology examination. The cut section of the vaginal mass showed whorled appearance .The Histopathology of vaginal mass showed Vaginal leiomyoma. Postoperative period was uneventful. The patient anatomy was restored and had no complaint of difficulty in urination and symptomatically improved.
PubMed: 38948554
DOI: 10.4103/jfmpc.jfmpc_1229_23 -
Cureus May 2024A cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Proper diagnosis and management of CSP are incredibly important secondary to the risk of uterine...
A cesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy. Proper diagnosis and management of CSP are incredibly important secondary to the risk of uterine rupture and life-threatening hemorrhage. Various medical and surgical management have been described previously. This report looks at two cases of CSP diagnosed at an urban hospital in Atlanta, Georgia. The first woman was 30 years old with a history of five prior CS. She was referred from an abortion clinic for CSP at 6 weeks 2 days gestation. She did not desire future fertility and opted for a hysterectomy. The second woman was 38 years old with a history of three prior CS presenting with vaginal bleeding and abdominal pain and found to have a CSP with a gestation sac measuring 5 weeks 1 day. Given the patient's desires for future fertility, she was treated with a two-dose regimen of systemic intramuscular methotrexate (MTX) at 1 mg/kg with successful resolution of CSP and subsequent intrauterine pregnancy. Due to the high risk of uterine rupture and hemorrhage with CSP, it is important to have a high index of suspicion for diagnosis. Due to the rarity of CSP, and thus difficulty creating quality prospective trials, there is no consensus on the best management yet. Although conservative treatment carries high failure risk, shared decision-making incorporating future fertility desires should be considered when determining management of CSP, and when surgical management is considered a minimally invasive approach should be the standard of care in surgical management.
PubMed: 38947697
DOI: 10.7759/cureus.61311 -
Clinical Case Reports Jul 2024This was the first report of a pseudoaneurysm in a vaginal artery after hysterectomy, unlike other published studies that were of pseudoaneurysms in uterine or vaginal...
KEY CLINICAL MESSAGE
This was the first report of a pseudoaneurysm in a vaginal artery after hysterectomy, unlike other published studies that were of pseudoaneurysms in uterine or vaginal arteries after delivery.
ABSTRACT
A 51-year-old woman presented with massive vaginal bleeding 7 days after a hysterectomy, which caused hemoglobin to drop. The patient was suspicious of having a vaginal artery pseudoaneurysm according to the sonography. Her bleeding was stopped after the ligation of her left internal iliac artery.
PubMed: 38947543
DOI: 10.1002/ccr3.9006 -
International Urogynecology Journal Jun 2024Colpocleisis is a surgical procedure intended to treat pelvic organ prolapse. Compared with other modes of pelvic reconstructive surgery, colpocleisis is associated with... (Review)
Review
INTRODUCTION AND HYPOTHESIS
Colpocleisis is a surgical procedure intended to treat pelvic organ prolapse. Compared with other modes of pelvic reconstructive surgery, colpocleisis is associated with lower morbidity and higher satisfaction, and has a success rate of 91-100% and a reoperation rate of less than 2%. However, there is limited information on how to treat recurrent prolapse after colpocleisis.
METHODS
We performed a review of the existing literature regarding colpocleisis failure and retreatment. A total of 118 articles were reviewed, with 16 articles suitable for inclusion. We also describe a case from our own institution of a "repeat colpocleisis" for recurrent prolapse after previous colpocleisis.
RESULTS
"Repeat colpocleisis" was the most common surgical technique used (18 out of 24 patients, 75.0%). The median follow-up time after the repeat surgery was 12 months, with only 1 patient with recurrence reported owing to recurrent rectocele 2 years after surgery, treated successfully with perineorrhaphy. Other less common techniques included perineorrhaphy, reversal of colpocleisis with native tissue repair, and vaginal hysterectomy with vaginal repair. Our case report describes the surgical management of a patient who had previously undergone LeFort colpocleisis with recurrence of prolapse, subsequently undergoing repeat colpocleisis.
CONCLUSIONS
The colpocleisis failure, though rare, presents a surgical challenge owing to both its rarity and the paucity of information in the literature regarding the optimal mode of management. In this review, the most common technique for surgical management of colpocleisis failure was repeat colpocleisis, with good short-term success rates noted. Additional studies with longer-term follow-up are needed.
PubMed: 38942932
DOI: 10.1007/s00192-024-05852-x -
Journal of Minimally Invasive Gynecology Jun 2024To estimate the risk of bowel obstruction after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify...
STUDY OBJECTIVE
To estimate the risk of bowel obstruction after hysterectomy for benign indications depending on the surgical method (abdominal, vaginal, or laparoscopic) and identify risk factors for adhesive bowel obstruction.
DESIGN
A national registry-based cohort.
SETTING
Danish hospitals during the period 1984-2013.
PATIENTS
Danish women who underwent hysterectomy for benign indications (N=125,568).
INTERVENTIONS
Abdominal hysterectomies were compared with vaginal hysterectomies, laparoscopic hysterectomies, and minimally invasive (vaginal and laparoscopic) hysterectomies.
MEASUREMENTS AND MAIN RESULTS
The incidence of bowel obstruction according to the surgical method was compared using Cox proportional hazard regression. The covariates included were the time period, age, concomitant operations, prior abdominal surgery or disease, and socioeconomic factors. In a sub-analysis (n=35,712 women) of the period 2004-2013, detailed information from the Danish Hysterectomy Database enabled the inclusion of patient-related, surgery-related, and complication-related covariates. The overall crude incidence of bowel obstruction was 17.4/1000 hysterectomies (2196 incident cases). The 10-year cumulative incidence of bowel obstruction differed between the surgical routes (abdominal, 1.7%; laparoscopic, 1.4%; and vaginal, 0.9%). In multiple adjusted analyses, the risk of bowel obstruction was higher after abdominal hysterectomy than after vaginal (HR 1.64 [95% CI 1.39-1.93]) and minimally invasive (vaginal or laparoscopic) hysterectomy (HR 1.54 [1.33-1.79]). Additional pre-existing risk factors for bowel obstruction at the time of hysterectomy were increased age, low education, low income, smoking, high ASA comorbidity score, history of infertility, abdominal infection, and prior abdominal surgery (apart from cesarean section),penetrating lesions in abdominal organs, or operative adhesiolysis. Perioperative risk factors at the time of hysterectomy included concomitant removal of the ovaries, adhesiolysis, blood transfusion, readmission, and overall presence of perioperative complications.
CONCLUSION
Abdominal hysterectomy is associated with a 54% higher risk of bowel obstruction than minimally invasive (laparoscopic or vaginal) hysterectomy.
PubMed: 38942232
DOI: 10.1016/j.jmig.2024.06.010 -
JAMA Oncology Jun 2024Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between Black individuals and White...
IMPORTANCE
Poor performance of the transvaginal ultrasonography triage strategy has been suggested as a contributor to racial disparity between Black individuals and White individuals in endometrial cancer (EC) stage at diagnosis in population-level simulation analyses.
OBJECTIVES
To examine the false-negative probability using ultrasonography-measured endometrial thickness (ET) thresholds as triage for EC diagnosis among Black individuals and assess whether known risk factors of EC modify ET triage performance.
DESIGN, SETTING, AND PARTICIPANTS
This retrospective diagnostic study of merged abstracted electronic health record data and secondary administrative data (January 1, 2014, to December 31, 2020) from the Guidelines for Transvaginal Ultrasound in the Detection of Early Endometrial Cancer sample assessed Black individuals who underwent hysterectomy in a 10-hospital academic-affiliated health care system and affiliated outpatient practices. Data analysis was performed from January 31, 2023, to November 30, 2023.
EXPOSURE
Pelvic ultrasonography within 24 months before hysterectomy.
MAIN OUTCOME AND MEASURES
Ultrasonography performed before hysterectomy as well as demographic and clinical data on symptom presentation, endometrial characterization, and final EC diagnosis were abstracted. Endometrial thickness thresholds were examined for accuracy in ruling out EC diagnosis by using sensitivity, specificity, and negative predictive value. False-negative probability was defined as 1 - sensitivity. Accuracy measures were stratified by risk factors for EC and by factors hypothesized to influence ET measurement quality.
RESULTS
A total of 1494 individuals with a uterus (median [IQR] age, 46.1 [41.1-54.0] years) comprised the sample, and 210 had EC. Fibroids (1167 [78.1%]), vaginal bleeding (1067 [71.4%]), and pelvic pain (857 [57.4%]) were the most common presenting diagnoses within 30 days of ultrasonography. Applying the less than 5-mm ET threshold, there was an 11.4% probability that someone with EC would be classified as not having EC (n = 24). At the 4-mm (cumulative) threshold, the probability was 9.5%, and at 3 mm, it was 3.8%. False-negative probability at the 5-mm threshold was similar among EC risk factor groups: postmenopausal bleeding (12.4%; 95% CI, 7.8%-18.5%), body mass index greater than 40 (9.3%; 95% CI, 3.1%-20.3%); and age 50 years or older (12.8%; 95% CI, 8.4%-18.5%). False-negative probability was also similar among those with fibroids on ultrasonography (11.8%; 95% CI, 6.9%-18.4%) but higher in the setting of reported partial ET visibility (26.1%; 95% CI, 10.2%-48.4%) and pelvic pain (14.5%; 95% CI, 7.7%-23.9%).
CONCLUSION AND RELEVANCE
These findings suggest that the transvaginal ultrasonography triage strategy is not reliable among Black adults at risk for EC. In the presence of postmenopausal bleeding, tissue sampling is strongly recommended.
PubMed: 38935372
DOI: 10.1001/jamaoncol.2024.1891 -
Current Opinion in Obstetrics &... Aug 2024Hysterectomy is the most common gynecologic surgical procedure performed on women in the United States. While there are data supporting that hysterectomy for benign... (Review)
Review
PURPOSE OF REVIEW
Hysterectomy is the most common gynecologic surgical procedure performed on women in the United States. While there are data supporting that hysterectomy for benign indication often does not reduce sexual function and may in fact improve sexual function as fibroids and endometriosis are resected, it remains unclear if there are factors within the perioperative period that affect sexual function in the years following surgery. To date, there is no consensus on what factors can optimize patients' sexual function after hysterectomy.
RECENT FINDINGS
We present the current literature that assesses factors which may contribute to sexual function after hysterectomy. Preoperative demographic factors, including increasing age, pelvic pain, and preoperative sexual dysfunction, play a large role in postoperative sexual function. Perioperatively, there is a growing amount of data suggesting that premenopausal salpingo-oophorectomy at the time of hysterectomy may increase the risk of sexual dysfunction after hysterectomy, and no conclusive evidence that subtotal hysterectomy improves sexual function. The route of hysterectomy and technique of cuff closure can impact sexual function after hysterectomy due to the risk of shortening the vaginal length.
SUMMARY
There is a lack of high-quality evidence that can provide a consensus on factors to optimize sexual function after hysterectomy. A growing area of research in the excision of endometriosis procedures is the consideration of nerve-sparing surgery. Considering the many variables that exist when counseling a patient on benign hysterectomy and its effects on sexual function, it is critical to understand the current research that exists with regards to these factors.
Topics: Humans; Female; Hysterectomy; Sexual Dysfunction, Physiological; Risk Factors; Endometriosis; Postoperative Complications; Pelvic Pain; Salpingo-oophorectomy
PubMed: 38934105
DOI: 10.1097/GCO.0000000000000959 -
AJOG Global Reports May 2024In vitro fertilization is the most used assisted reproductive technology in the United States that is increasing in efficiency and in demand. Certain states have...
BACKGROUND
In vitro fertilization is the most used assisted reproductive technology in the United States that is increasing in efficiency and in demand. Certain states have mandated coverage that enable individuals with low income to undergo in vitro fertilization treatment.
OBJECTIVE
This study aimed to evaluate if socioeconomic status has an impact on the perinatal outcomes in in vitro fertilization pregnancies. We hypothesized that with greater coverage there may be an alleviation of the financial burden of in vitro fertilization that can facilitate the application of evidence-based practices.
STUDY DESIGN
This was a retrospective, population-based, observational study that was conducted in accordance with the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample database over the 6-year period from 2008 to 2014 during which period 10,000 in vitro fertilization deliveries were examined. Maternal outcomes of interest included preterm prelabor rupture of membranes, preterm birth (ie, before 37 weeks of gestation), placental abruption, cesarean delivery, operative vaginal delivery, spontaneous vaginal delivery, maternal infection, chorioamnionitis, hysterectomy, and postpartum hemorrhage. Neonatal outcomes included small for gestational age neonates, defined as birthweight <10th percentile, intrauterine fetal death, and congenital anomalies.
RESULTS
Our study found that the socioeconomic status did not have a statistically relevant effect on the perinatal outcomes among women who underwent in vitro fertilization to conceive after adjusting for the potential confounding effects of maternal demographic, preexisting clinical characteristics, and comorbidities.
CONCLUSION
The literature suggests that in states with mandated in vitro fertilization coverage, there are better perinatal outcomes because, in part, of the increased use of best in vitro fertilization practices, such as single-embryo transfers. Moreover, the quality of medical care in states with coverage is in the highest quartile in the country. Therefore, our findings of equivalent perinatal outcomes in in vitro fertilization care irrespective of socioeconomic status possibly suggests that a lack of access to quality medical care may be a factor in the health disparities usually seen among individuals with lower socioeconomic status.
PubMed: 38919707
DOI: 10.1016/j.xagr.2024.100329