Vaginoplasty using the inner surface or mucosa of the prepuce in children with congenital adrenal hyperplasia

Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision)

Congenital adrenal hyperplasia is a category of disorders characterized by impaired adrenocortical steroidogenesis. The most frequent disorder of congenital adrenal hyperplasia is 21-hydroxylase deficiency, which is caused by pathogenic variants of CAY21A2 and is prevalent between 1 in 18,000 and 20,000 in Japan. The clinical guidelines for 21-hydroxylase deficiency in Japan have been revised twice since a diagnostic handbook in Japan was published in 1989. On behalf of the Japanese Society for Pediatric Endocrinology, the Japanese Society for Mass Screening, the Japanese Society for Urology, and the Japan Endocrine Society, the working committee updated the guidelines for the diagnosis and treatment of 21-hydroxylase deficiency published in 2014, based on recent evidence and knowledge related to this disorder. The recommendations in the updated guidelines can be applied in clinical practice considering the risks and benefits to each patient.

Outcome of feminizing genital reconstruction in female sex assigned disorder of sex development in a low-income country

BACKGROUND

In patients with disorders of sex development (DSD), surgical/medical treatments are undertaken after sex assignment to ensure congruent bodily appearance and function. Genital reconstruction in these patients can be daunting with varied outcome. Understanding these outcomes is imperative, more especially in a developing country where added challenges exist.

OBJECTIVE

This study evaluates the outcome of genital surgery in patients with DSD assigned female sex.

METHODS

A retrospective analysis of 25 cases of female sex assigned DSD managed in two tertiary centers in southeast Nigeria was performed. Data of these cases were collected from the case notes, discharge summaries, and theater records. IBM SPSS Statistics Data Editor, version 21, was used for data entry and analysis.

RESULTS

The patients presented at median age of 12 months (range 2 days-30 years), with 15 (60%) cases reared as female and 10 (40%) reared as male before presentation. The predominant phenotype was phallus with empty fused/unfused labioscrotum and urethra opening in the labioscrotum or perineum in 21 (84%) patients. Evaluation revealed features suggestive of 46XX DSD in 21 (84%) patients, ovotesticular DSD in two (8%), and androgen insensitivity in two (8%). A total of 10 cases required sex reassignment after evaluation. Overall, 24 of the 25 cases had feminizing genital procedures. After a median follow-up period of 2 years (range 2 months-8 years), six (25%) cases developed procedure-related complications, three (12.5%) had social maladjustment, and two (8.3%) patients reported features of gender dysphoria.

DISCUSSION

The procedures of feminizing genitoplasty in this study did not differ from the established procedure. However, as a result of challenges of delayed presentation, inadequate early management, sociocultural factors, and a lack of facilities for full evaluation, some cases may require sex reassignment and more daunting reconstructive procedures. This may give rise to less than optimal outcome. The study was limited by the retrospective nature, small number of cases, and the short duration of follow-up of the cases.

CONCLUSION

Feminizing genital procedures for DSD in our setting may be associated with procedure-related complications and non-surgical complications. Improving surgical technique and addressing the challenges of delayed presentation and fixation on male gender may improve overall outcome.

Vaginoplasty and creating labia minora in children with disorders of sex development

PURPOSE

To report current results of vaginoplasty using the mucosa of the prepuce, and creating labia minora by penile skin in children with disorders of sex development (DSD).

METHODS

In 10 years, we have performed 22 vaginoplasties using the described technique of vaginoplasty, 21 patients with 46, XX DSD and 1 ovotesticular DSD. The assessment of the results of this technique of vaginoplasty was undertaken in several stages: (a) The evaluation of the cosmetic result. (b) The research for a urinary incontinence and urethrovaginal fistulas. (c) The research for a vaginal stenosis by the introduction of a lubricated feeding tube into the vaginal cavity. The labia minora was evaluated by three criteria: its skin should be thin and very supple, it should have a free edge which partially or totally covers the clitoris, urethral meatus, and vaginal orifice; and it is preferable that its color be darker than the rest of the skin.

RESULTS

The cosmetic outcome was considered by parents and the surgeon as very satisfactory in 11 patients (50% of cases), satisfactory in 4 patients (18.2%), and unsatisfactory in 7 patients (31.8%). The postoperative complications were five cases of proximal stenosis (22.7%), one distal stenosis (stenosis of introitus) and two necrosis of the preputial flap. No urethrovaginal fistula and urinary incontinence were reported.

CONCLUSIONS

In infant and young child, when it is difficult to make use of complete urogenital mobilization, the mucosa of the prepuce can be an alternative to create a neovagina, its histological constitution is identical to a vaginal wall, and it does not prevent to have a good labia minora.

Clitoroplasty: A variant of the technique by Acimi

Objectives

To evaluate the mid-term results of clitoroplasty through the reduction of the length and diameter of the corpus cavernosum, as well as the volume of the glans.

Patients and methods

From October 2003 to July 2015, we performed 29 clitoroplasties using the described procedure. The median (range) age of the patients was 18 (3–47) months. After surgery we evaluated the volume of the clitoris, the appearance of glans, and its sensitivity to light touch, pressure, and pain.

Results

The length of the apparent part of the glans remained large (>10 mm) in four patients (14%), was an average size (between 5 and 10 mm) in 11 (39%), and small (<5 mm) in 13 (46%). The length of the corpus cavernosum was <20 mm and its diameter <5 mm in all cases. The sensitivity of the reduced clitoris to touch, pressure and pain seemed normal in all patients. In addition, we never found the circumflex arteries and nerves of the penis (on histological examination of excised pieces of corpus cavernosum) in all children operated on during the first 3 years of life. The circumflex arteries of the penis begin to develop, only after the fourth year. This anatomical finding is an argument for performing clitoroplasty at an early age to avoid any risk of intraoperative and postoperative bleeding.

Conclusions

The sensitivity of the clitoral glans appeared to be normal in all cases, with a good cosmetic appearance of the external genitalia in most patients.

Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know

Surgical management of classical congenital adrenal hyperplasia (CAH) in 46, XX females has evolved significantly. Virilization of the genitalia of 46, XX females with CAH begins prenatally as a result of excess fetal androgen production. Improved understanding of anatomy and surgical outcomes has driven changes in surgical techniques as well as the timing of surgery. For endocrinologists treating these patients, it is important to understand the outcome of genitoplasty, identify patients who need further treatment and direct these patients to experienced surgeons. We performed a literature search on PubMed of publications addressing CAH and genital reconstruction published in the English language from 1990 to the present. In accordance with our institutional review board, we performed a retrospective analysis of clitoroplasty and/or vaginoplasty procedures performed by a single surgeon at our institution from 1996 to 2015. We found that genital reconstruction in 46, XX CAH patients is associated with few immediate post-operative, infectious, and urinary complications. Vaginal stenosis is a common complication of vaginal reconstruction and requires evaluation by an experienced surgeon. Clitoral pain or decreased sensation can be associated with clitoral recession and clitorectomy. Outcomes in sexual satisfaction and gender identity can also be impacted by surgical technique and success. Long term follow up and patient reported feedback are crucial to our understanding and management of this special group of patients. Improved awareness and understanding of the complications of genital surgery will allow endocrinologists to know what to ask patients and be ready to provide them with a resource with the understanding and experience to help them improve their quality of life.

Surgical reconstruction of the genitalia in a 3-year-old infant with a 46XX karyotype: case report

A 3-year-old patient was hospitalized with ambiguous genitalia (clitoromegaly, labioscrotal fusion, absence of vaginal introitus), classified as stage III/IV according to Prader's virilization scale. Our patient, with a 46XX karyotype, was previously diagnosed with congenital adrenal hyperplasia caused by a deficiency of the adrenal enzyme 21-hydroxylase; corticosteroids and salt replacement therapy have been used. At the present admission, the surgical treatment consisted on clitoroplasty (with the removal of erectile tissue), reconstruction of the labia minor, creation of a neovulva and vaginoplasty. It was a single-step operation to restore the anatomical female structures. She had an uneventful postoperative period and the wound healed well with good cosmetic results. We present the details about the surgical procedure and a short review of data from literature.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.