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Abosena W, Almetaher HA, El Attar AA, Nofal AH, Elhalaby EA. Outcomes of one-stage feminizing genitoplasty in children with congenital adrenal hyperplasia and severe virilization. Pediatr Surg Int 2024; 40:72. [PMID: 38446278 PMCID: PMC10917856 DOI: 10.1007/s00383-024-05638-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
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.
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Affiliation(s)
- Wael Abosena
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt.
| | | | - Ashraf Ahmed El Attar
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
| | - Ahmed Hassan Nofal
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
| | - Essam Abdelaziz Elhalaby
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
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Ding Y, Wang Y, Lyu Y, Xie H, Huang Y, Wu M, Chen F, Chen Z. Urogenital sinus malformation: From development to management. Intractable Rare Dis Res 2023; 12:78-87. [PMID: 37287654 PMCID: PMC10242390 DOI: 10.5582/irdr.2023.01027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023] Open
Abstract
Urogenital sinus (UGS) malformation, also known as persistent urogenital sinus (PUGS), is a rare congenital malformation of the urogenital system. It arises when the urethra and vaginal opening fail to form properly in the vulva and fuse incorrectly. PUGS can occur as an isolated abnormality or as part of a complex syndrome, and is frequently associated with congenital adrenal hyperplasia (CAH). The management of PUGS is not well-established, and there are no standardized guidelines on when to perform surgery or how to follow up with patients over the long term. In this review, we discuss the embryonic development, clinical evaluation, diagnosis, and management of PUGS. We also review case reports and research findings to explore best practices for surgery and follow-up care, in hopes of increasing awareness of PUGS and improving patient outcomes.
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Affiliation(s)
- Yu Ding
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaping Wang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqing Lyu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Xie
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichen Huang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Wu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongzhong Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Urogenital Development Research Center, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Krege S, Falhammar H, Lax H, Roehle R, Claahsen-van der Grinten H, Kortmann B, Duranteau L, Nordenskjöld A. Long-Term Results of Surgical Treatment and Patient-Reported Outcomes in Congenital Adrenal Hyperplasia-A Multicenter European Registry Study. J Clin Med 2022; 11:jcm11154629. [PMID: 35956243 PMCID: PMC9369813 DOI: 10.3390/jcm11154629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 07/31/2022] [Accepted: 08/03/2022] [Indexed: 11/16/2022] Open
Abstract
Representatives for congenital adrenal hyperplasia (CAH) continue to desire early feminizing surgery in girls with 46,XX-CAH. The aim of this analysis, which included 174 46,XX- individuals with salt-wasting (SW) or simple-virilizing (SV) CAH, a female gender identity, and an age > 16 years participating in a multicenter cross-sectional clinical evaluation study (dsd-LIFE), was to evaluate the long-term results of surgery and patient-reported outcomes (PRO). The gynecological examination (n = 84) revealed some shortcomings concerning surgical feminization. A clitoris was absent in 9.5% of cases, while a clitoral hood was missing in 36.7% of cases. Though all women had large labia, they didn’t look normal in 22.6% of cases. Small labia were absent in 23.8% of cases. There was no introitus vaginae, and the urethra and vagina had no separate opening in 5.1% of cases. A mucosal lining was missing in 15.4% of cases. Furthermore, 86.2% of the women had scars at the region of their external genitalia. A vaginal stenosis was described in 16.5% of cases, and a meatal stenosis was described in 2.6% of cases. Additionally, PRO data showed a very-/high satisfaction rate of 21.3%/40.2% with cosmesis and 23.8%/38.1% with functionality, while 3.3%/10.7% showed a very-/low satisfaction with cosmesis as well as 5.6%/10.3% with functionality. The remaining women—24.6% and 23.8%—were indifferent. Satisfaction concerning sex life was very-/high in 9.6%/27.7%. In 12.0%/16.9% it was very-/low. Furthermore, 33.7% had no opinion. Furthermore, 27.0%/31.6% of the women reported that clitoriplasty, but not clitoridectomy, had a very-/positive influence on their lives, while 1.3%/8.9% felt it to be very-/negative, and 28.4% were indifferent. Vaginoplasty had a very-/positive influence in 25.7%/33.8% and a very-/negative effect in 3.6%/6.8%. 29.7% had no opinion. Additionally, 75.7% of the women preferred feminizing surgery during infancy/childhood, especially concerning clitoreduction. In conclusion, though the majority of the participants (76%) preferred early feminizing surgery and 60% described a positive effect on their lives, about 10% felt it to have been negative. About 15% of the women suffered from insufficient cosmesis and functionality after surgery. Sex life was even described as poor in nearly 30%. Therefore, the decision about early genital surgery in 46,XX-CAH girls should be considered carefully. Parents should get detailed information about possible complications of surgery and should receive support to understand that postponing surgery does not inevitably cause harm for their child. Importantly, genital surgery when performed in children should only be performed in expert centers with a specialized team including surgeons who are trained in feminizing surgery.
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Affiliation(s)
- Susanne Krege
- Department of Urology, Pediatric Urology and Urooncology, Kliniken Essen Mitte, 45136 Essen, Germany
- Correspondence: ; Tel.: +49-201-174-29003; Fax: +49-201-174-29000
| | - Henrik Falhammar
- Department of Endocrinology, Karolinska University Hospital, 171 77 Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76 Stockholm, Sweden
| | - Hildegard Lax
- Institute of Medical Informatics, Biometry and Epidemiology, University of Essen, 45147 Essen, Germany
| | - Robert Roehle
- Institute of Biometry and Clinical Epidemiology, Charite-University Medicine Berlin, 10117 Berlin, Germany
- Institute of Health, Charite-University Medicine Berlin, 10117 Berlin, Germany
| | | | - Barbara Kortmann
- Department of Pediatric Urology, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Lise Duranteau
- Department of Medical Gynaecology and Reference Centre for Rare Diseases of Genital Development, Bicetre Hospital, APHP Paris Saclay University, 94270 Le Kremlin Bicetre, France
| | - Agneta Nordenskjöld
- Department of Women’s and Children’s Health, Center of Molecular Medicine, Karolinska Institutet, 17176 Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
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Barroso U, Massuqueto E, Venturini BA, Rosito TE, Villalta M, Grajales LPC. Corporoplasty: A simplified technique for clitoroplasty. Int Braz J Urol 2022; 48:726-727. [PMID: 35263057 PMCID: PMC9306359 DOI: 10.1590/s1677-5538.ibju.2022.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 01/22/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Clitoroplasty constitutes an important step in feminizing surgery for congenital adrenal hyperplasia (CAH) ( 1 ). In this video we present a technique that aims to preserve clitoral sensitivity and engorgement while minimizing the risk of neurovascular lesion. Materials and methods We present a video of a three-year-old girl with history of CAH classical form, PRADER-III, who underwent clitoroplasty. After an initial endoscopic evaluation of the urogenital sinus, the clitoris was degloved and a rectangular incision was made on the ventral corpora cavernosa 15mm above the corpora bifurcation and 0.5 mm below the coronal sulcus. The cavernous tissue was partially resected. The upper and lower borders of the rectangular gap were closed by a 5-0 PDS running suture similar to the Mikulicz technique. Next, the edge of the glans was deepithelialized to reduce its size. For improved clitoral positioning, the clitoris was sutured to the pubic fat. From that point onward the procedure followed that of a standard vaginoplasty using the en-bloc technique ( 2 - 4 ). Thus far we have performed this technique in 33 patients, with 31 of them being girls with CAH and 2 being women with clitoral hypertrophy. Conclusion Corporoplasty is a simplified technique for clitoroplasty, with the advantage being that is faster and safer than the technique that involves the dissection of the neurovascular bundle. In addition, corporoplasty has the possible benefit of preserving the cavernosal blood flow that permits the engorgement of the clitoris during sexual arousal.
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Affiliation(s)
- Ubirajara Barroso
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil
| | - Eliakim Massuqueto
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil
| | - Bruna A Venturini
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil
| | - Tiago Elias Rosito
- Departamento de Urologia, Hospital de Clínicas de Porto Alegre, RS, Brasil
| | - Marcelo Villalta
- Departamento de Urologia, Universidade Federal da Bahia - UFBA, Salvador, BA, Brasil
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Surgical Outcomes of Clitoroplasty in Children with Congenital Adrenal Hyperplasia and Clitoral Hypertrophy: A 19-Year Experience of a Single Surgeon. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111152. [PMID: 34769670 PMCID: PMC8583494 DOI: 10.3390/ijerph182111152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/14/2021] [Accepted: 10/20/2021] [Indexed: 11/17/2022]
Abstract
This study aimed to describe the experience with clitoroplasty for clitoral hypertrophy in patients with congenital adrenal hyperplasia of a single surgeon. The medical records of female pediatric patients with congenital adrenal hyperplasia who underwent clitoroplasty at a tertiary referral hospital between 2002 and 2020 were retrospectively analyzed. Three different surgical techniques were applied for clitoroplasty: recession without reduction, reduction and recession, and girth reduction and recession. A total of 104 patients underwent clitoroplasty for clitoral hypertrophy. The median patient age at the time of surgery was 10 months (range, 4 months to 10 years). The operation time was longer in reduction clitoroplasty than in recession clitoroplasty without reduction (median, 153 vs. 111 min, p = 0.003). The mean postoperative pain score of the patients did not differ among the different clitoroplasty techniques. During the mean follow-up of 37.7 months, nine (8.6%) patients underwent reperformed clitoroplasty. The rate of reperformed operation was significantly higher in patients who underwent reduction clitoroplasty (17.3%) than in those who underwent recession without reduction (2%) or girth reduction and recession (0%) (p = 0.031). Early clitoroplasty in patients with congenital adrenal hyperplasia yielded good mid-term surgical outcomes in terms of cosmesis and recurrence rate, with minimal perioperative complications.
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Fernandez N, Chavarriaga J, Pérez J. Complete corporeal preservation clitoroplasty: new insights into feminizing genitoplasty. Int Braz J Urol 2021; 47:861-867. [PMID: 33848081 PMCID: PMC8321476 DOI: 10.1590/s1677-5538.ibju.2020.0839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION 46,XX Congenital adrenal hyperplasia (CAH) remains the first cause of genital virilization and current surgical techniques aim to restore female aspect of genitalia while preserving dorsal neurovascular bundle but not at the expense of not preserving erectile tissue. We aim to report our experience with a new surgical technique for clitoroplasty, completely preserving corporeal bodies, neurovascular bundles without dismembering the clitoris, in four patients with over a year follow up. MATERIALS AND METHODS After IRB approval four patients with 46,XX CAH and Prader 5 and 3 external genitalia, underwent feminizing genitoplasty. Complete preservation of erectile tissue was accomplished without a need to dissect dorsal neurovascular bundle. Glans size allowed no need for glanular reduction and there was no need to dismember the corporeal bodies. RESULTS Four patients 12 to 24-months-old underwent complete corporeal preservation clitoroplasty (CCPC), mean age was 18.5 months, mean follow up was 10.25 months. Vaginoplasty was performed in all patients with partial urogenital mobilization (PUM) and Urogenital Sinus flap (UF), only one severely virilized patient required a parasagittal pre-rectal approach to mobilize the vagina. We had no complications until last follow up. CONCLUSION To our knowledge, we are introducing the concept of CCPC without the need of disassembling the corporeal bodies, neurovascular bundle and glans. It stands as a new alternative for feminizing genitoplasty with complete preservation of erectile tissue and no dissection of neurovascular bundle. Although there is still lacking long-term follow-up, it represents a new step in conservative reconfiguration of the external virilized female genitalia.
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Affiliation(s)
- Nicolas Fernandez
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
- Fundacion Santa Fe de BogotaDepartment of UrologyBogotaColombiaDepartment of Urology, Fundacion Santa Fe de Bogota, Bogota, Colombia;
- University of WashingtonSeattle Children's HospitalDivision of UrologySeattleWAUnited StatesDivision of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Julián Chavarriaga
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
| | - Jaime Pérez
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
- Fundacion Santa Fe de BogotaDepartment of UrologyBogotaColombiaDepartment of Urology, Fundacion Santa Fe de Bogota, Bogota, Colombia;
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Stein R, Krege S. Operative Versorgungskonzepte für Menschen mit Varianten der Geschlechtsentwicklung. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0715-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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8
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Krege S, Eckoldt F, Richter-Unruh A, Köhler B, Leuschner I, Mentzel HJ, Moss A, Schweizer K, Stein R, Werner-Rosen K, Wieacker P, Wiesemann C, Wünsch L, Richter-Appelt H. Variations of sex development: The first German interdisciplinary consensus paper. J Pediatr Urol 2019; 15:114-123. [PMID: 30713084 DOI: 10.1016/j.jpurol.2018.10.008] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/10/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION The term variations of sex development subsumes a large number of congenital conditions including chromosomal mosaics and variations of chromosomal, gonadal, and phenotypic sex. A situation of this nature may cause severe distress to both, parents and affected persons. One of the reasons for this is the binary form of gender classification in the society. In the past, because of a fear of possible stigmatization and an inability to cope with complex situations, it has been medical policy and practice for newborns to undergo early, mostly 'feminizing' elective surgery with the aim of achieving an outer genital appearance that is unambiguously male or female. Protests by advocacy groups for the most part as well as the results of outcome studies have shown that the development of affected persons may be very different to what has been expected and often does not result in the intended clear female or male gender identity as had been intended. It, therefore, seemed a matter of urgency to implement this new awareness as well as the ethical and personal human rights perspectives in the recommendations for the medical and psychosocial management of diverse sex development (DSD) in the future. STUDY DESIGN In 2012, an interdisciplinary group of German academics engaged in the field of DSD decided to work on a consensus paper for this topic. It involved the participation of all faculties and non-scientific groups dealing with DSD, in particular advocacy and service-user groups. In a structured consensus, process recommendations were developed based on scientific literature as well as personal experiences of clinicians and affected individuals. RESULTS Finally, 37 recommendations were agreed on. The strength of consensus is reflected in the degree of agreement as expressed in percentages. CONCLUSION The introduction of the consensus paper reflects on the emerging paradigm shift and the necessity for a more open view of gender within society. The paper is intended to aid the performance of appropriate diagnostics in DSD-affected newborns and especially to help parents and affected persons cope with the biological and social consequences of DSD. With regard to medical or surgical therapy, it gives information about the most recent treatment trends.
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Affiliation(s)
- S Krege
- Dept. of Urology, Kliniken Essen-Mitte, Germany.
| | - F Eckoldt
- Dept. of Pediatric Surgery, University of Jena, Germany
| | - A Richter-Unruh
- Dept. of Pediatric Endocrinology, University of Münster, Germany
| | - B Köhler
- Dept. of Pediatric Endocrinology and Diabetology, Charite - University of Berlin, Germany
| | - I Leuschner
- Dept. of Pathology, University of Kiel, Germany
| | - H-J Mentzel
- Section of Pediatric Radiology, University of Jena, Germany
| | - A Moss
- Division of Pediatric Endocrinology and Diabetes, Dept. of Pediatrics and Adolescent Medicine, University of Ulm, Germany
| | - K Schweizer
- Institute for Sex Research and Forensic Psychiatry, University Medical Center, Hamburg-Eppendorf, Germany
| | - R Stein
- Department of Pediatric, Adolescent and reconstructive Urology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | | | - P Wieacker
- Institute of Human Genetics, University of Münster, Germany
| | - C Wiesemann
- Institute of Medical Ethics and History of Medicine, University of Göttingen, Germany
| | - L Wünsch
- Dept. of Pediatric Surgery, University of Lübeck, Germany
| | - H Richter-Appelt
- Institute for Sex Research and Forensic Psychiatry, University Medical Center, Hamburg-Eppendorf, Germany
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Fares AE, Marei MM, Abdullateef KS, Kaddah S, El Tagy G. Laparoscopically Assisted Vaginal Pull-Through in 7 Cases of Congenital Adrenal Hyperplasia with High Urogenital Sinus Confluence: Early Results. J Laparoendosc Adv Surg Tech A 2019; 29:256-260. [DOI: 10.1089/lap.2018.0194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmed E. Fares
- Department of Pediatric Surgery, Fayoum University Hospital, Faculty of Medicine, El Fayoum University, El Fayoum, Egypt
| | - Mahmoud M. Marei
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Khaled S. Abdullateef
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Sherif Kaddah
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Gamal El Tagy
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
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Speiser PW, Arlt W, Auchus RJ, Baskin LS, Conway GS, Merke DP, Meyer-Bahlburg HFL, Miller WL, Murad MH, Oberfield SE, White PC. Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab 2018; 103:4043-4088. [PMID: 30272171 PMCID: PMC6456929 DOI: 10.1210/jc.2018-01865] [Citation(s) in RCA: 554] [Impact Index Per Article: 92.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 01/29/2023]
Abstract
Objective To update the congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency clinical practice guideline published by the Endocrine Society in 2010. Conclusions The writing committee presents updated best practice guidelines for the clinical management of congenital adrenal hyperplasia based on published evidence and expert opinion with added considerations for patient safety, quality of life, cost, and utilization.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children’s Medical Center of New York, New York, New York
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Wiebke Arlt
- University of Birmingham, Birmingham, United Kingdom
| | | | | | | | - Deborah P Merke
- National Institutes of Health Clinical Center, Bethesda, Maryland
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Heino F L Meyer-Bahlburg
- New York State Psychiatric Institute, Vagelos College of Physicians & Surgeons of Columbia University, New York, New York
| | - Walter L Miller
- University of California San Francisco, San Francisco, California
| | - M Hassan Murad
- Mayo Clinic’s Evidence-Based Practice Center, Rochester, Minnesota
| | - Sharon E Oberfield
- NewYork–Presbyterian, Columbia University Medical Center, New York, New York
| | - Perrin C White
- University of Texas Southwestern Medical Center, Dallas, Texas
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11
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Kim S, Rosoklija I, Johnson EK. Surgical, Patient, and Parental Considerations in the Management of Children with Differences of Sex Development. CURRENT PEDIATRICS REPORTS 2018. [DOI: 10.1007/s40124-018-0177-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
Female patients with congenital adrenal hyperplasia (CAH) have varying degrees of atypical genitalia secondary to prenatal and postnatal androgen exposure. Surgical treatment is focused on restoring normal genitalia anatomy by bringing the vagina to the normal position on the perineum, separating the distal vagina from the urethra, forming a normal introitus and preserving sexual function of the clitoris by accepting moderate degrees of hypertrophy as normal and strategically reducing clitoral size only in the most severely virilized patients. There remains a need for continued monitoring of patients as they go through puberty with the possibility of additional surgery for vaginal stenosis. Anatomically based surgery and refinement in surgical techniques with acceptance of moderate degrees of clitoral hypertrophy as normal should improve long-term outcomes.
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Affiliation(s)
- Laurence S Baskin
- UCSF Benioff Children's Hospital, 1825 Fourth St, 5th Floor, San Francisco, CA 94143.
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13
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Marei MM, Fares AE, Musa N, Abdelsattar AH, Sharaf A, Hassan MM, Elkotby M, Eltagy G, Hafez M, Elbarbary MM. Timing and Outcome Concerns regarding Feminizing Genitoplasty from the Perspective of Egyptian Families of Girls with Virilized External Genitalia. Horm Res Paediatr 2016; 85:49-57. [PMID: 26645541 DOI: 10.1159/000442200] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 11/03/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital adrenal hyperplasia in females leads to virilization of external genitalia and persistent urogenital sinus. There are controversies regarding the timing and outcomes of surgery. Deferring surgeries beyond childhood is difficult to implement in conservative societies, and may result in stigmatization and distress to individuals with disorders of sexual differentiation and their families. METHODS Thirty girls with virilization due to congenital adrenal hyperplasia were admitted for single-stage feminizing genitoplasty, between 2011 and 2014. We prospectively studied the concerns and input of the families represented by the mothers. After comprehensive counselling, the mothers completed a questionnaire to clarify their priorities and concerns related to surgery. RESULTS Surgeries were performed at a mean age of 22 months. Most cases ranged between Prader's degrees III and IV. Egyptian families believe that early surgical reconstruction is in the best interest of their girls. They are marginally more concerned about functional outcomes and future child bearing than external appearance and cosmetic outcomes. CONCLUSIONS Social difficulties noticeably add challenges to the management plan within conservative societies. Early genital reconstructive surgery, when reasonably indicated, needs to remain a viable option. Comprehensive psychosocial support within a multidisciplinary approach is needed to defer feminizing genitoplasty in selected cases to adolescence.
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Affiliation(s)
- Mahmoud M Marei
- Department of Pediatric Surgery, Endocrinology and Metabolism Pediatric Unit (DEMPU), Cairo University, Cairo, Egypt
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Higuchi T, Holmdahl G, Kaefer M, Koyle M, Wood H, Woodhouse C, Wood D. International Consultation on Urological Diseases: Congenital Anomalies of the Genitalia in Adolescence. Urology 2016; 94:288-310. [DOI: 10.1016/j.urology.2016.03.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
OBJECTIVE In 2001, this team published an observational study of the clinical outcomes of a cohort of adolescent girls born with ambiguous genitalia. The poor outcomes observed represented a major scientific challenge to the standard practice of childhood feminising genital surgery. That publication was one of several contributing to a call for change in surgical practice, which culminated in the publication of the Chicago Consensus Document in 2006. The aim of this current study was to repeat the same evaluation of clinical outcomes on a recent cohort of adolescent girls and compare the two cohorts to identify differences in adolescent outcomes which may indicate a change in paediatric surgical practice. METHODS This was an observational study of a current cohort of adolescent girls treated in childhood for ambiguous genitalia and referred to a specialist adolescent disorders of sex development (DSD) service for assessment. Data were collected on surgical history, genital examination findings and treatment recommendations for 30 consecutive adolescents over a 5-year period. Findings were compared with those of a similar cohort of adolescent girls published over a decade previously. RESULTS Clitoral surgery remained common (93% vs 100%, current cohort vs historical cohort). However, concomitant vaginoplasty was performed less frequently (80 vs 100% current vs historical). Vaginoplasty revision surgery was also less commonly required (65 vs 81%), although 24% of the recent cohort still required major revision surgery prior to intercourse. There was some improvement to the cosmetic outcomes as deemed by the surgical team using the same criteria as the previous report. CONCLUSIONS This study provides some slight evidence of recent practice change. There was a small reduction in the number of vaginoplasties performed in childhood and an improvement in vaginoplasty outcomes and cosmesis. However, there was no identifiable change in management of clitoromegaly and the numbers of clitoral reduction operations remained high. This is surprising given the clear evidence of a detrimental impact of surgery on clitoral sensation and sexual function.
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Tugtepe H, Thomas DT, Turan S, Cizmecioglu F, Hatun S, Bereket A, Dagli ET. Does common channel length affect surgical choice in female congenital adrenal hyperplasia patients? J Pediatr Urol 2014; 10:948-54. [PMID: 24703836 DOI: 10.1016/j.jpurol.2014.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 02/19/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Partial/total urogenital sinus mobilization (UGSM) is one of the recommended techniques for treatment of female congenital adrenal hyperplasia (CAH). In this study we compared the length of common channel (CC) and type of operation performed in CAH patients. PATIENTS AND METHODS We retrospectively analyzed data of patients receiving surgery for female CAH. Patients were separated into three groups: group 1 had partial UGSM, group 2 had total UGSM, and group 3 had total UGSM plus the vaginal anterior wall was made from CC. Age at surgery, length of CC, surgical time, follow-up time, and complications were compared. RESULTS There were a total of 29 patients. For groups 1, 2, and 3, the average age at surgery was 47.2 months, 14.4 months, and 21.3 months, respectively, and the average CC length was 1.25 cm, 3.1 cm, 4.3 cm, respectively. The average time of surgery was 165 min, 193.1 min, 282.5 min, respectively. The average follow-up time was 34.7 months, 36.3 months, 28.3 months, respectively. There were two complications (UGS flap necrosis and opening of sutures) in the third group. CONCLUSION We advise the use of partial UGSM for CC of 0.5-2 cm, total UGSM for CC of 2.5-3.5 cm, and total USM with use of CC as the anterior vaginal wall in CC ≥ 4 cm in length. Good cosmetic and functional results are obtained with this approach.
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Affiliation(s)
- Halil Tugtepe
- Marmara University, School of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Istanbul, Turkey.
| | - David Terence Thomas
- Marmara University, School of Medicine, Department of Pediatric Surgery, Istanbul, Turkey
| | - Serap Turan
- Marmara University, School of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Istanbul, Turkey
| | - Filiz Cizmecioglu
- Kocaeli University, School of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Kocaeli, Turkey
| | - Sukru Hatun
- Kocaeli University, School of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Kocaeli, Turkey
| | - Abdullah Bereket
- Marmara University, School of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, Istanbul, Turkey
| | - E Tolga Dagli
- Marmara University, School of Medicine, Department of Pediatric Surgery, Division of Pediatric Urology, Istanbul, Turkey
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Balaya V, Aubin A, Rogez JM, Douard R, Delmas V. [The dorsal nerve of the clitoris: surgical applications]. Morphologie 2014; 98:8-17. [PMID: 24462285 DOI: 10.1016/j.morpho.2013.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 12/09/2013] [Accepted: 12/24/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To describe the course of the dorsal nerve of the clitoris (DNC) to better define its anatomy in the human adult and to help surgeons to avoid iatrogenic injury during surgical procedures. METHOD An extensive review of the current literature was done on Medline via PubMed by using the following keywords: "anatomie du clitoris", "anatomy of clitoris", "nerf dorsal du clitoris", "dorsal nerve of clitoris", "réparation clitoridienne", "transposition clitoridienne", "surgery of the clitoris", "clitoridoplasty". This review analyzed dissection, magnetic resonance imaging, 3-dimensional sectional anatomy reconstruction and immuno-histochemical studies. RESULTS The DNC comes from the pudendal nerve. He travels from under the inferior pubis ramus to the posterosuperior edge of the clitoral crus. The DNC reappears under the pubic symphysis and enters the deep component of the suspensory ligament. He runs on the dorsal face of the clitoral body at 11 and 1 o'clock. Distally, he gives many nervous ramifications, runs along the tunica and enters the glans. CONCLUSION The NDC might be surgically injured (i) under the pubic symphysis, at the union of the two crus of clitoris and (ii) on the dorsal surface of the clitoral body. The pathway of the DNC on the dorsal face of the clitoris permits to approach the ventral face of the clitoris without risk of iatrogenic injuries. The distance between the pubic symphysis and the DNC implies that the incision should be done just under the pubic symphysis. Distally, the dissection of the DNC next the glands appears as dangerous and impossible, considering that the DNC is too close to the glandular tissues.
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Affiliation(s)
- V Balaya
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service d'obstétrique et de chirurgie gynécologique, hôpital de la Pitié-Salpétrière, 47, boulevard de l'Hôpital, 75013 Paris, France
| | - A Aubin
- Laboratoire d'anatomie, faculté de médecine, université de Nantes, 1, rue Gaston-Veil, 44035 Nantes cedex, France
| | - J-M Rogez
- Laboratoire d'anatomie, faculté de médecine, université de Nantes, 1, rue Gaston-Veil, 44035 Nantes cedex, France
| | - R Douard
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service de chirurgie générale et digestive, hôpital Avicenne, 125, rue de Stalingrad, 93000 Bobigny, France; UFR SMBH, université Paris-Nord, 74, rue Marcel-Cachin, 93017 Bobigny, France.
| | - V Delmas
- URDIA EA 4465, université Paris Descartes, 45, rue des Saints-Pères, 75006 Paris, France; Service d'urologie, hôpital Bichat-Claude-Bernard, 46, rue Henri-Huchard, 75018 Paris, France
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Zainuddin AA, Grover SR, Shamsuddin K, Mahdy ZA. Research on quality of life in female patients with congenital adrenal hyperplasia and issues in developing nations. J Pediatr Adolesc Gynecol 2013; 26:296-304. [PMID: 23507003 DOI: 10.1016/j.jpag.2012.08.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2011] [Revised: 07/30/2012] [Accepted: 08/07/2012] [Indexed: 11/16/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is the commonest cause of ambiguous genitalia for female newborns and is one of the conditions under the umbrella term of "Disorders of Sex Development" (DSD). Management of these patients require multidisciplinary collaboration and is challenging because there are many aspects of care, such as the most appropriate timing and extent of feminizing surgery required and attention to psychosexual, psychological, and reproductive issues, which still require attention and reconsideration, even in developed nations. In developing nations, however, additional challenges prevail: poverty, lack of education, lack of easily accessible and affordable medical care, traditional beliefs on intersex, religious, and cultural issues, as well as poor community support. There is a paucity of long-term outcome studies on DSD and CAH to inform on best management to achieve optimal outcome. In a survey conducted on 16 patients with CAH and their parents in a Malaysian tertiary center, 31.3% of patients stated poor knowledge of their condition, and 37.5% did not realize that their medications were required for life. This review on the research done on quality of life (QOL) of female patients with CAH aims: to discuss factors affecting QOL of female patients with CAH, especially in the developing population; to summarize the extant literature on the quality of life outcomes of female patients with CAH; and to offer recommendations to improve QOL outcomes in clinical practice and research.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
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Urinary incontinence - an unusual indication for early vaginoplasty in late presenting congenital adrenal hyperplasia. J Pediatr Adolesc Gynecol 2013; 26:e103-4. [PMID: 23602038 DOI: 10.1016/j.jpag.2013.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 12/08/2012] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
BACKGROUND Congenital adrenal hyperplasia (CAH) is an autosomal recessive condition leading to deficient cortisol with an incidence of 1/16,000. Patients with CAH typically present early with ambiguous genitalia or as an emergency with adrenal crisis. CASE We report an atypical late presentation of a 4-year-old girl with pubertal-like symptoms and urinary incontinence, due to a persistent urogenital sinus (UGS). An early vaginoplasty was successfully performed allowing the patient to achieve continence. CONCLUSION Literature describing the symptoms of CAH with UGS is scarce. The case is unusual in demonstrating pubertal-like symptoms and urinary incontinence due to the late presentation of a persistent UGS, highlighting the need for an open mind in assessment of children with urinary incontinence. Timing of surgery is controversial, and cases need to be considered on an individual basis.
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Fuchs J, Warmann SW, Seitz G, Schäfer J, Schröder M, Obermayr F. Laparoscopically assisted vaginal pull-through for high urogenital sinus: a new surgical technique. Urology 2012; 79:1180-3. [PMID: 22446347 DOI: 10.1016/j.urology.2012.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 12/07/2011] [Accepted: 01/06/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate feasibility and outcome of a laparoscopically assisted vaginal pull through procedure for suprasphincteric high urogenital sinus malformation with hydrometrocolpos and normal external genitalia. METHODS A tension-free anastomosis of the vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through via an externally introduced expandable trocar, thereby avoiding perineal or perirectal dissection. RESULTS The approach resulted in good cosmetic and unimpaired functional outcome. Voiding cystourethrography showed normal lower urinary tract anatomy. No disturbances of bladder function could be detected 2 years after surgery. CONCLUSION Laparoscopic assisted vaginal pull-through is a new approach for high UGS that significantly improved exposure of the uretro-vaginal junction, allowed extensive mobilization of the vagina and showed excellent cosmetic and functional result.
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Affiliation(s)
- Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
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21
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Abstract
The birth of a new baby is one of the most dramatic events in a family, and the first question is usually "is it a boy or a girl?" The newborn infant with ambiguous external genitalia often comes as a surprise for the doctors as well as the parents and is sometimes described as an endocrine emergency situation presenting a problem of sex assignment. The nomenclature such as 'intersex', 'hermaphrodite', and 'pseudohermaphrodite' is out of date as well as confusing, and many urologists are concerned that these confusing terms could be perceived to be pejorative by some affected families. In response to concerns regarding outdated and controversial terms, the Chicago Consensus held in 2005 recommended new terminology based on the umbrella term disorders of sex differentiation (DSDs). The term DSD has a comprehensive definition including any problem noted at birth in which the genitalia are atypical in relation to the chromosomes or gonads. The karyotype is used as a prefix defining the classification of DSD. DSDs are rare and complex. The optimal management of patients with DSD must be individualized and multidisciplinary, considering all aspects, including psychological care and full disclosure of alternatives relating to surgery type and timing. Although further studies are necessary to confirm guidelines and recommendations fitting for the individual patients with DSD, this article is an attempt to provide a balanced perspective for new taxonomy, clinical evaluation, and medical, surgical, and psychological management of DSD.
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Affiliation(s)
- Kun Suk Kim
- Department of Urology, University of Ulsan College of Medicine, Seoul, Korea
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22
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Laterza RM, De Gennaro M, Tubaro A, Koelbl H. Female pelvic congenital malformations. Part I: embryology, anatomy and surgical treatment. Eur J Obstet Gynecol Reprod Biol 2011; 159:26-34. [DOI: 10.1016/j.ejogrb.2011.06.042] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 04/30/2011] [Accepted: 06/09/2011] [Indexed: 11/15/2022]
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Affiliation(s)
- Rajiv Saini
- Department of Periodontology and Oral Implantology, Rural Dental College-Loni, Tehsil - Rahata, Ahmednagar, Maharashtra, India. E-mail:
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Sexual function and attitudes toward surgery after feminizing genitoplasty. J Urol 2011; 185:1900-4. [PMID: 21439585 DOI: 10.1016/j.juro.2010.12.099] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Indexed: 01/23/2023]
Abstract
PURPOSE Sexual function and attitudes toward surgery were evaluated in females who had undergone feminizing genitoplasty in childhood. MATERIALS AND METHODS Sexual function and attitudes toward surgery were assessed by a questionnaire in 24 females who had undergone genitoplasty in childhood. Of 16 females who were prenatally exposed to androgens 15 had congenital adrenal hyperplasia and 8 had androgen insensitivity. A total of 18 patients who had reached adulthood were compared with 900 age matched normal controls by using the Female Sexual Function Index questionnaire. RESULTS Of the 24 patients 19 had undergone clitoral reduction and 21 had undergone reconstruction of the vaginal introitus. Sigmoid bowel had been used in vaginal reconstruction in 5 patients. There were 17 patients who believed that the genital operation was performed at a proper age, 3 who thought it was done too late while none thought it was performed at too young an age. Two patients regretted the operation, 1 of whom had undergone clitoral resection without nerve preservation and the other had a sigmoid vagina. The control group had more often and earlier (median age 17 vs 19 years) experiences with sexual intercourse. Overall sexual function was similar in the sexually active controls and patients. Decreased sexual desire and problems in achieving orgasm were common but severe pain experiences during penetrative sex were rare in both groups. CONCLUSIONS Sexual intercoital relationships started later in females who underwent genital reconstruction in childhood. Early surgery is preferred by the patients and satisfactory sex life is possible in adulthood.
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Park S, Ha SH, Kim KS. Long-term follow-up after feminizing genital reconstruction in patients with ambiguous genitalia and high vaginal confluence. J Korean Med Sci 2011; 26:399-403. [PMID: 21394309 PMCID: PMC3051088 DOI: 10.3346/jkms.2011.26.3.399] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/10/2011] [Indexed: 11/20/2022] Open
Abstract
We evaluated the long-term results of feminizing genital reconstruction in patients with genital ambiguity with high vaginal confluence. The medical records of 10 consecutive patients with ambiguous genitalia and high vaginal confluence who underwent feminizing genital reconstruction from 1996 to 2007 were reviewed. Seven patients had congenital adrenal hyperplasia, one had mixed gonadal dysgenesis, one had partial androgen insensitivity, and one had 5-alpha reductase deficiency syndrome. Median age at operation was 21 months (range, 2-47 months). Median follow up was 7.7 yr. Of the six patients who underwent feminizing genital reconstruction with the Gonzalez method, three had good results. Of the other three patients, one had a urethrovaginal fistula and underwent fistula repair 9 yr after, one had distal vaginal stenosis and underwent revision vaginoplasty 9 yr after, and one had a urethrovaginal fistula and urethral stricture. The patient with urogenital mobilization had persistent urogenital sinus. Feminizing genitoplasty using the Gonzalez method showed good long-term results in patients with ambiguous genitalia and Congenital adrenal hyperplasia. The procedure is less invasive than other approaches and results in excellent cosmetic outcomes; and complications can be corrected by relatively simple procedures.
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Affiliation(s)
- Sungchan Park
- Department of Urology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Seong Heon Ha
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kun Suk Kim
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Madzou S, Ouédraogo C, Gillard P, Lefebvre-Lacoeuille C, Catala L, Sentilhes L, Descamps P. Chirurgie plastique reconstructrice du clitoris après mutilations sexuelles. ANN CHIR PLAST ESTH 2011; 56:59-64. [DOI: 10.1016/j.anplas.2009.08.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2009] [Accepted: 08/16/2009] [Indexed: 11/30/2022]
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Affiliation(s)
- Richard C Rink
- Department of Pediatric Urology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA.
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Speiser PW, Azziz R, Baskin LS, Ghizzoni L, Hensle TW, Merke DP, Meyer-Bahlburg HFL, Miller WL, Montori VM, Oberfield SE, Ritzen M, White PC. Congenital adrenal hyperplasia due to steroid 21-hydroxylase deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2010; 95:4133-60. [PMID: 20823466 PMCID: PMC2936060 DOI: 10.1210/jc.2009-2631] [Citation(s) in RCA: 646] [Impact Index Per Article: 46.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE We developed clinical practice guidelines for congenital adrenal hyperplasia (CAH). PARTICIPANTS The Task Force included a chair, selected by The Endocrine Society Clinical Guidelines Subcommittee (CGS), ten additional clinicians experienced in treating CAH, a methodologist, and a medical writer. Additional experts were also consulted. The authors received no corporate funding or remuneration. CONSENSUS PROCESS Consensus was guided by systematic reviews of evidence and discussions. The guidelines were reviewed and approved sequentially by The Endocrine Society's CGS and Clinical Affairs Core Committee, members responding to a web posting, and The Endocrine Society Council. At each stage, the Task Force incorporated changes in response to written comments. CONCLUSIONS We recommend universal newborn screening for severe steroid 21-hydroxylase deficiency followed by confirmatory tests. We recommend that prenatal treatment of CAH continue to be regarded as experimental. The diagnosis rests on clinical and hormonal data; genotyping is reserved for equivocal cases and genetic counseling. Glucocorticoid dosage should be minimized to avoid iatrogenic Cushing's syndrome. Mineralocorticoids and, in infants, supplemental sodium are recommended in classic CAH patients. We recommend against the routine use of experimental therapies to promote growth and delay puberty; we suggest patients avoid adrenalectomy. Surgical guidelines emphasize early single-stage genital repair for severely virilized girls, performed by experienced surgeons. Clinicians should consider patients' quality of life, consulting mental health professionals as appropriate. At the transition to adulthood, we recommend monitoring for potential complications of CAH. Finally, we recommend judicious use of medication during pregnancy and in symptomatic patients with nonclassic CAH.
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Affiliation(s)
- Phyllis W Speiser
- Cohen Children's Medical Center of New York and Hofstra University School of Medicine, New Hyde Park, New York 11040, USA
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Vanderbrink BA, Rink RC, Cain MP, Kaefer M, Meldrum KK, Misseri R, Karmazyn B. Does preoperative genitography in congenital adrenal hyperplasia cases affect surgical approach to feminizing genitoplasty? J Urol 2010; 184:1793-8. [PMID: 20728173 DOI: 10.1016/j.juro.2010.05.082] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE Genitography has traditionally been an imperative part of radiographic evaluation in females born with congenital adrenal hyperplasia before surgical reconstruction. We evaluated the role of preoperative genitogram in surgical reconstruction planning and how it correlates with intraoperative findings. MATERIALS AND METHODS We retrospectively reviewed the records of 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty at our institution between 2003 and 2009. Preoperative genitogram findings were recorded and correlated with operative findings. RESULTS A total of 42 preoperative genitograms were available for review in 40 patients with congenital adrenal hyperplasia who underwent feminizing genitoplasty. Genitography revealed complete anatomy of the urogenital sinus in 30 cases (72%) while bladder filling alone was present in 9 (21%) and vaginal filling was noted in 2 (5%). The urogenital sinus could not be catheterized in 1 patient (2%). Vesicoureteral reflux was identified in 6 patients (15%) with a mean grade of 2. Vaginoplasty was done with a flap technique in 37 patients (more than 90%) while the remaining 3 underwent pull-through vaginoplasty. In no case did genitogram reveal anatomy that was not visible via endoscopy or at reconstruction. The vaginoplasty technique was based on endoscopic and intraoperative findings, and not on genitogram. CONCLUSIONS Genitography during preoperative evaluation in females with congenital adrenal hyperplasia undergoing feminizing genitoplasty did not reveal urogenital sinus anatomy completely in 25% of the patients in our series. Preoperative genitogram did not influence the surgical approach. Its value as preoperative imaging in patients with congenital adrenal hyperplasia may be limited.
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Affiliation(s)
- Brian A Vanderbrink
- Department of Urology, James Whitcomb Riley Hospital for Children, Indianapolis, Indiana 46202, USA.
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30
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Vidal I, Gorduza DB, Haraux E, Gay CL, Chatelain P, Nicolino M, Mure PY, Mouriquand P. Surgical options in disorders of sex development (dsd) with ambiguous genitalia. Best Pract Res Clin Endocrinol Metab 2010; 24:311-24. [PMID: 20541154 DOI: 10.1016/j.beem.2009.10.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Disorders of sexual development (DSD) include three main groups of patients: (1) The virilised 46,XX DSD essentially represented by congenital adrenal hyperplasia (CAH) ; (2) The undervirilised 46,XY DSD essentially represented by hypospadias; and (3) the chromosomic jigsaws essentially represented by mixed gonadal dysgenesis. It is in this last group that gender assignment remains a difficult decision involving various indicators, which can be split into four categories: (1) the inside sex (i.e., genes, hormones and target tissues); (2) the outside sex (i.e., anatomy of genitalia including size of the genital tubercle, mullerian cavity and potential adult height of the patient); (3) the functional sex (i.e., potential sexuality and fertility); and (4) and the social sex (i.e., the cultural medium in which the child is brought up). The challenge is to outline the future individual identity of the child in the postnatal period using these indicators. Current evolutions of surgical techniques of 'feminisation' and 'masculinisation' are described as well as their outcomes.
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Affiliation(s)
- Isabelle Vidal
- Department of Paediatric Urology and Surgery, Hôpital Mère-Enfants, and Claude-Bernard University, 69677 Bron, France
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Frost-Arner L, Aberg M, Jacobsson S. Clitoral sensitivity after surgical correction in women with adrenogenital syndrome: a long term follow‐up. ACTA ACUST UNITED AC 2009; 37:356-9. [PMID: 15328775 DOI: 10.1080/02844310310007863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Surgical reduction of hypertrophy of the clitoris in early childhood, as well as vaginal reconstruction or vaginoplasty during the early teens, is required in girls with adrenogenital syndrome. In eight women (age >17 years) with adrenogenital syndrome, the sensitivity of the surgically reduced clitoris was evaluated by examination of vibration and light touch sensitivity, more than one year after vaginoplasty. When they were compared with a group of women who had not been operated on, the sensitivity to vibration and light touch were similar if the clitoris had been reduced as a one-stage procedure. In one woman who had had a second reduction, sensitivity was impaired. All women reported that the vaginal reconstruction was successful as far as sexual activity was concerned. Six of the eight had stable relationships with boyfriends or husbands. No pregnancies or children were reported.
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Affiliation(s)
- Lieselotte Frost-Arner
- Department of Plastic and Reconstructive Surgery, Malmö University Hospital, Malmö, Sweden.
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Kalfa N, Liu B, Cao M, Vilella M, Hsieh M, Baskin LS. 3-dimensional neuroanatomy of the human fetal pelvis: anatomical support for partial urogenital mobilization in the treatment of urogenital sinus. J Urol 2008; 180:1709-14; discussion 1714-5. [PMID: 18708223 DOI: 10.1016/j.juro.2008.03.089] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2007] [Indexed: 10/21/2022]
Abstract
PURPOSE Retrospective reviews suggest that the functional outcomes of surgery of the urogenital sinus have often been unsatisfactory and to our knowledge the long-term results of newer surgical techniques have yet to be evaluated. A precise understanding of pelvic fetal neuroanatomy is germane for optimizing surgical correction of the urogenital sinus. MATERIALS AND METHODS The pelves of 10 human female fetuses were serially sectioned. Masson's trichrome staining and immunochemistry for the neuronal marker S100 (Dako Corp., Carpinteria, California) along with anatomical computer reconstruction allowed 3-dimensional analysis of the nerves in relation to the pelvic structures as an animated motion picture. RESULTS Two types of neuronal structures were identified. 1) A dense perivisceral foil of branching nerves closely surrounded the pelvic organs. The localization of most nerves was on the external faces of the viscera with a limited fraction in the rectovaginal and urethrovaginal septa. This innervation was from the anterior cephalad periurethral area to the posterior caudal perirectal area. 2) A significant amount of nerves surrounded the cephalad urethra on its anterior and posterior faces. CONCLUSIONS Based on these anatomical data during surgical repair of a urogenital sinus we would advocate minimal mobilization of the lateral faces of the vagina, avoiding dissection of the proximal urethra above the pubic bone and electing a vaginal flap in severe cases.
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Affiliation(s)
- Nicolas Kalfa
- Center for Study and Treatment of Hypospadias, Department of Urology, University of California-San Francisco Children's Medical Center, University of California-San Francisco, San Francisco, California 94143, USA
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Abstract
PURPOSE OF REVIEW The current management of patients with intersex, now designated as disorders of sex development, is presented in the context of updated etiological and outcome data, refined surgical procedures and the need for a multidisciplinary approach. RECENT FINDINGS The recently published consensus statement, the primary publication cited herein, includes known genetic causes of disorders of sex development, and provides a perspective for clinical evaluation, and medical, surgical and psychological management. The importance of fetal hormone exposure, genital development, gonadal differentiation and potential of fertility, full disclosure and parental involvement in decisions is crucial. All need a sex assignment; recommendations should be based upon what is judged to be the most likely adult gender identity, diagnosis, genital appearance and surgical options, fertility, cultural pressures, family dynamics and social circumstance, with deference given to psychosocial factors when the outcome is unpredictable. Surgery is discouraged for mild genital variations, but surgery during infancy is recommended for those with major genital ambiguity. SUMMARY Even with greater understanding of the genetic causes of disorders of sex development, the complex management of these patients must be individualized, considering all aspects, informing as age-appropriate the parents and patient. Further etiology and outcome studies are needed.
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Affiliation(s)
- Zeina M Nabhan
- Section of Pediatric Endocrinology/Diabetology, Department of Pediatrics, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Pippi Salle JL, Braga LP, Macedo N, Rosito N, Bagli D. Corporeal sparing dismembered clitoroplasty: an alternative technique for feminizing genitoplasty. J Urol 2007; 178:1796-800; discussion 1801. [PMID: 17707426 DOI: 10.1016/j.juro.2007.03.167] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2006] [Indexed: 11/23/2022]
Abstract
PURPOSE Management for clitoral enlargement remains controversial. New understanding of clitoral function stimulated a search for more conservative surgical approaches, such as recession or partial resection. However, these techniques risk decreasing clitoral sensation or causing painful erections. Moreover, irreversibility continues to be the principal problem that fuels patient, surgeon and societal anxiety in the management of this challenging developmental issue. We describe a new technique, corporeal sparing dismembered clitoroplasty, that dismembers the corporeal bodies and preserves all clitoral structures. MATERIALS AND METHODS After obtaining full informed consent and institutional review board approval 8 consecutive patients with clitoral enlargement underwent corporeal sparing dismembered clitoroplasty. Five girls had congenital adrenal hyperplasia (Prader IV and V in 4 and 1, respectively), 1 had ovotesticular disorder of sexual differentiation and 2 had partial androgen insensitivity syndrome. One pubertal girl was tested with warm, cold and pain clitoral stimulation before and after surgery. For the clitoroplasty technique the glans and its neurovascular bundles are dissected from the corpora. The isolated corpus is then completely divided starting at the bifurcation. Each separated hemicorpus is rotated inferior and lateral, to be placed inside the labial scrotal folds. The glans is reduced by superficial excision of its epithelium and fixed to the pubic attachments. Labia minora are constructed with preputial Byars flaps. Labioplasty and vaginoplasty are then routinely performed. RESULTS Eight patients 6 months to 13 years old underwent this procedure. Followup was 6 to 12 months. All patients recovered well from surgery without early complications. The initial cosmetic result was good in all girls. The hemicorpora were easily palpated inside their labia majora pouches, which retained the desired cosmetic appearance following feminizing genitoplasty. All glans clitoris were preserved. The teenaged patient does not report painful erections. She has maintained clitoral sensation and is satisfied with the cosmetic result. CONCLUSIONS Conservative reconfiguration of the female genitalia without removing genital structures is feasible in girls with clitoral enlargement. The cosmetic appearance of the genitalia is acceptable, at least to the surgeon and parents, in that the enlarged clitoris is hidden. The physiological consequences of the current operation and any surgery in the future to reverse it are unknown. With these aspects in mind we believe that corporeal sparing dismembered clitoroplasty should be incorporated into the armamentarium of surgeons involved in the treatment of clitoral enlargement and presented as an option for feminizing genitoplasty.
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Affiliation(s)
- João L Pippi Salle
- Division of Urology, Hospital for Sick Children, Toronto, Ontario, Canada
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Abstract
There are two very interesting paediatric urology papers; in the first, authors from London describe the long-term functional outcomes of female genital reconstruction in childhood, and in the second, authors from Italy present a morphological and manometric study of VUR.
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Affiliation(s)
- Naomi S Crouch
- Department of Obstetrics and Gynaecology, University College Hospital, London, UK
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Burgu B, Duffy PG, Cuckow P, Ransley P, Wilcox DT. Long-term outcome of vaginal reconstruction: comparing techniques and timing. J Pediatr Urol 2007; 3:316-20. [PMID: 18947763 DOI: 10.1016/j.jpurol.2006.09.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2006] [Accepted: 09/28/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In a retrospective review, to analyse the long-term outcomes of vaginal reconstruction, comparing techniques and timing. PATIENTS AND METHODS We identified 63 patients who underwent a total of 71 vaginoplasties in 1985-2000. The techniques used were posterior skin flap (42), intestinal replacement (21) and pull through (8). The majority of operations were performed before puberty (63%) and as primary procedures (79%). Presenting diagnoses were congenital adrenal hyperplasia (23), cloacal exstrophy (8), true persistent cloaca (12), androgen insensitivity (8), urogenital sinus anomaly (6), mixed gonadal dysgenesis (3), true hermaphroditism (2) and sacrococcygeal teratoma (1). RESULTS The mean age at operation was 83.9 (2-235) and mean follow up was 116.8 (48-232) months. Strictures and discharge were the most common problems. Nine patients underwent revision surgery and a fistula repair was required in two patients. Mucosal prolapse was observed in one ileo- and one colovaginoplasty patient, and diversion colitis occurred after colovaginoplasty in one patient. More complications occurred in operations performed prior to than following puberty. CONCLUSION If vaginoplasty is the only indicated operation, delaying until puberty may minimize complications. When other genital surgery is indicated or in the presence of symptoms pre-pubertal vaginoplasty should be performed, since the second procedure usually involves simple dilatations and is associated with good results.
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Affiliation(s)
- Berk Burgu
- Great Ormond Street Children's Hospital NHS Trust and Guys Hospital, London, UK.
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Rivkees SA. It is (sort of) a boy and (sort of) a girl. You have (sort of) a say and you (sort of) don't? The uneasiness of genital restoration surgery. J Pediatr Endocrinol Metab 2006; 19:1285-9. [PMID: 17220055 DOI: 10.1515/jpem.2006.19.11.1285] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Samuelson ML, Baker LA. Autologous buccal mucosa vulvovaginoplasty for high urogenital sinus. J Pediatr Urol 2006; 2:486-8. [PMID: 18947663 DOI: 10.1016/j.jpurol.2005.09.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2005] [Accepted: 09/05/2005] [Indexed: 10/25/2022]
Abstract
Feminizing genitoplasty for mid to high urogenital sinus confluence is challenging surgery, especially in the postpubertal patient. We report a surgical alternative for a complex postpubertal case with scarce perineal tissue. An autologous buccal mucosa vulvovaginoplasty was performed in a postpubertal patient with adrenogenital syndrome, permitting vaginal lengthening, creation of labia minora and minimal urethral dissection. This surgical approach avoided female hypospadias, as seen with the total urogenital sinus mobilization repair, and the risks of extensive urethral dissection, seen with the vaginal pull-through procedure, but yet solved the dilemma of mucosal coverage for the vulva and anterior vaginal wall. Buccal mucosa is a natural replacement for the female vulvar and vaginal glabrous skin, and is an excellent adjunct or alternative in challenging reconstructions.
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Affiliation(s)
- Mindy L Samuelson
- Department of Urology, University of Texas Southwestern Medical Center at Dallas, Southwestern Medical School, 5323 Harry Hines Boulevard, Dallas, TX 75390-9110, USA
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Lee PA, Houk CP, Ahmed SF, Hughes IA. Consensus statement on management of intersex disorders. International Consensus Conference on Intersex. Pediatrics 2006; 118:e488-500. [PMID: 16882788 DOI: 10.1542/peds.2006-0738] [Citation(s) in RCA: 669] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Peter A Lee
- Department of Pediatrics, MC-085, Penn State College of Medicine, Milton S. Hershey Medical Center, Box 850, 500 University Dr, Hershey, Pennsylvania 17033-0850, USA.
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40
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Abstract
Management of intersex disorders
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Affiliation(s)
- I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Box 116, Level 8, Hills Road, Cambridge CB2 2QQ, UK.
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Abstract
The birth of an intersex child prompts a long-term management strategy that involves a myriad of professionals working with the family. There has been progress in diagnosis, surgical techniques, understanding psychosocial issues and in recognizing and accepting the place of patient advocacy. The Lawson Wilkins Paediatric Endocrine Society (LWPES) and the European Society for Paediatric Endocrinology (ESPE) considered it timely to review the management of intersex disorders from a broad perspective, to review data on longer term outcome and to formulate proposals for future studies. The methodology comprised establishing a number of working groups whose membership was drawn from 50 international experts in the field. The groups prepared prior written responses to a defined set of questions resulting from an evidence based review of the literature. At a subsequent gathering of participants, a framework for a consensus document was agreed. This paper constitutes its final form.
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Affiliation(s)
- I A Hughes
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 2QQ, UK.
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Sircili MHP, de Mendonca BB, Denes FT, Madureira G, Bachega TASS, e Silva FADQ. Anatomical and functional outcomes of feminizing genitoplasty for ambiguous genitalia in patients with virilizing congenital adrenal hyperplasia. Clinics (Sao Paulo) 2006; 61:209-14. [PMID: 16832553 DOI: 10.1590/s1807-59322006000300005] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
UNLABELLED The ideal surgical technique and appropriate age for performing feminizing genitoplasty are debatable, and few long-term outcome studies have been reported. PURPOSE To report a retrospective study on anatomical and functional outcomes of feminizing genitoplasty in patients with virilizing congenital adrenal hyperplasia. METHODS We selected 34 patients (mean age = 3.4 +/- 2.5 yr) with genital ambiguity classified according to Prader stage. Follow-up ranged from 2 to 16 years. Clitoral length ranged from 1.9 to 5.0 cm; 28 patients had a single perineal orifice, and 6 had a double orifice. The surgical technique included clitorovaginoplasty in a single procedure and was carried out before 2 years of age in 18 patients. Clitoroplasty was performed with glans preservation in all patients. Blood supply was exclusively maintained by the frenular pedicle in 97% of the cases, whereas clitoral dorsal nerves and vessels were preserved in the remaining 3%. The opening of the urogenital sinus was performed using either the Y-V perineal flap procedure (25 patients) or the cut-back incision procedure (8 patients). RESULTS Good morphological and functional results were achieved in 68% of the patients; 21% of the patients had surgical complications, such as incision bleeding (2 cases), glans necrosis (1 girl with Prader V), and vaginal introitus stenosis (4 cases). Three of the latter underwent dilation with acrylic molds in the post-pubertal period with good functional results. CONCLUSIONS We conclude that single-stage feminizing genitoplasty consisting of vulvoplasty, clitoroplasty, and Y-V perineal flap produced good cosmetic and functional results in virilized girls with congenital adrenal hyperplasia, with few complications. In addition, this surgical approach prevented the need for neovaginaplasty even in patients with high vaginal insertion.
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Abstract
OBJECTIVE To describe variations in genital dimensions of normal women. DESIGN Observational cross-sectional study. SETTING Elizabeth Garrett Anderson Hospital, University College Hospital NHS Trust, London, UK. POPULATION Fifty premenopausal women having gynaecological procedures not involving the external genitalia under general anaesthetic. METHODS A cross sectional study using digital photography and measurements of the external genitalia. MAIN OUTCOME MEASURES Clitoral size, labial length and width, colour and rugosity, vaginal length, distance from clitoris to urethral orifice, distance from posterior fourchette to anterior anal margin. RESULTS A wide range of values were noted for each measurement. There was no statistically significant association with age, parity, ethnicity, hormonal use or history of sexual activity. CONCLUSION Women vary widely in genital dimensions. This information should be made available to women when considering surgical procedures on the genitals, decisions for which must be carefully considered between surgeon and woman.
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Affiliation(s)
- Jillian Lloyd
- Department of Gynaecology, Elizabeth Garrett Anderson Hospital, University College London Hospitals, Huntley Street, London WC1E 6AU, UK
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Abstract
Urologic surgery offers a broad spectrum of reconstructive procedures in males and females. A distinction should be made between constructive surgery as in cases of malformations or transsexualism and reconstructive procedures mainly after extensive tumor resections. Besides the description of different techniques in (re)construction of the external genitalia in females, the following article also addresses considerations concerning the indication for this kind of surgery and discusses some general aspects in plastic and reconstructive surgery.
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Affiliation(s)
- S Krege
- Urologische Klinik, Universität, Essen.
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Affiliation(s)
- Margaret H MacGillivray
- Department of Pediatrics, Division of Pediatric Endocrinology, University at Buffalo School of Medicine and Biological Sciences, Buffalo, New York, USA
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46
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Abstract
PURPOSE The neuroanatomy of the female lower urogenital tract remains controversial. We defined the topographical anatomy and differential immunohistochemical characteristics of the dorsal nerve of the clitoris, the cavernous nerve and the nerves innervating the female urethral sphincter complex. MATERIALS AND METHODS A total of 16 normal female human pelvic specimens at 14 to 34 weeks of gestation were studied by immunohistochemical techniques. Serial sections were stained with antibodies raised against the neuronal markers S-100 and neuronal nitric oxide synthase (nNOS), vesicular acetylcholine transporter, calcitonin gene-related peptide and substance P. The serial sections were computer reconstructed into 3-dimensional images. RESULTS Under the pubic arch at the hilum of the clitoral bodies the branches of the cavernous nerves joined the clitoral dorsal nerve to transform its immunoreactivity to nNOS positive. The cavernous nerves originated from the vaginal nervous plexus occupying the 2 and 10 o'clock positions on the anterolateral vagina and they traveled at the 5 and 7 o'clock positions along the urethra. The urethral sphincter complex was innervated by nNOS immunoreactive and nonimmunoreactive nerve fibers arising from the vaginal nervous plexus and pudendal nerve, respectively. CONCLUSIONS The dorsal nerve of the clitoris receives nNOS positive branches from the cavernous nerve as a possible redundant mechanism for clitoral erectile function. The urethral sphincter complex has dual innervation, which pierces into the urethral sphincter complex at different locations. The study of the neuroanatomy of the female lower urogenital tract is germane to the strategic design of female reconstructive surgery.
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Affiliation(s)
- Selcuk Yucel
- Department of Urology and Pediatrics, University of California-San Francisco Children's Medical Center, University of California-San Francisco, San Francisco, California 94143, USA
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Affiliation(s)
- C R J Woodhouse
- The Institute of Urology and Nephrology, University College London, and The Hospital for Children, Great Ormond Street, London, UK.
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48
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Affiliation(s)
- S M Creighton
- Elizabeth Garrett Anderson and Obstetric Hospital University College London Hospitals, London, UK.
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49
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Abstract
Surgery for patients with genital ambiguity must be based on an accurate diagnosis, thorough understanding of the genital anatomy and realistic expectations for the patient, family and treating multi-specialty team. The goal is to create a functional and cosmetic outcome consonant with the gender assignment with the least amount of morbidity to the patient and family. An understanding of the normal genital neuroanatomy is essential for a successful surgical approach and outcome. Based on fetal human specimens, we have refined the three-dimensional relationship of the dorsal nerve of the clitoris, the female cavernosal nerve and the vaginal plexus. The surgical approach to patients with severe clitoral virilization should preserve erectile function and the neural innervation of the clitoris. When indicated, surgery should be performed in infancy to minimize psychological trauma and surgical complications from scarring. Herein, we review the neuroanatomy of the female genitalia and the implications for the rare patient who needs surgical reconstruction.
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Affiliation(s)
- Laurence S Baskin
- Pediatric Urology, UCSF Children's Medical Center, University of California, Children's Hospital, San Francisco, CA 94143, USA.
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50
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Affiliation(s)
- S M Creighton
- Middlesex Clinic, Elizabeth Garrett Anderson and Obstetric Hospital, University College London Hospitals, London, UK.
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