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Ibrahim H, Lachkar AA, Bidault V, Delcour C, Paye-Jaouen A, Peycelon M, El-Ghoneimi A. Genito-urinary Reconstruction in Female Children With Congenital Adrenal Hyperplasia: Favorable Surgical Outcomes can be Achieved by Contemporary Techniques and a Dedicated Multidisciplinary Management. J Pediatr Surg 2024:S0022-3468(24)00310-5. [PMID: 38902168 DOI: 10.1016/j.jpedsurg.2024.05.009] [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: 01/02/2024] [Revised: 05/02/2024] [Accepted: 05/06/2024] [Indexed: 06/22/2024]
Abstract
INTRODUCTION Congenital adrenal hyperplasia (CAH) is the most common cause of genital atypia in females. A dedicated multidisciplinary team (MDT) should be included for an optimal management. Here, we aimed to review our surgical experience and to assess long-term urinary, gynecological and endocrine outcomes after primary genitoplasty in this specific cohort. METHODS Patients born with CAH and who underwent feminizing genitoplasty in our institution were retrospectively identified (2001-2021). We analyzed patients' characteristics, intraoperative details, and postoperative urinary, gynecological, and endocrine outcomes. RESULTS Forty patients were included and followed-up for a median (IQR) time of 7 (1-19) years. Thirty-eight (95%) had 21-hydroxylase deficiency. After multidisciplinary decision and written consent from patient and/or family, a single-stage reconstructive surgery was performed at a median age of 10 (3-165) months. Median length of hospital stay was 5 (1-7) days. Procedures were: PUM (N = 35 (87.5%)), TUM (N = 3 (7.5%)), urogenital mobilization was unnecessary in 2 (5%). Reduction clitoroplasty was done in 33 (82.5%) patients. Only 3 (7.5%) experienced significant Clavien-Dindo complications requiring additional surgery during the follow-up period. Recurrent urinary tract infections (UTI) occurred in 6 (15%), one required ureteric reimplantation for symptomatic high-grade vesicoureteric reflux. All patients over 3 years were toilet-trained without incontinence. Severe vaginal stenosis occurred in 1 (2.5%) patient. In patients who achieved puberty, 6/9 had vaginal calibration at a median age of 17.3 (16-21) years without detected stenosis. One (2.5%) had major hypertrophy of the right labia minora requiring labiaplasty. Nine (22.5%) reached puberty. Two (5%) patients developed acne/hirsutism. Short stature was noted in 11 (27.5%) and obesity in 18 (45%). CONCLUSION Based on our contemporary series, genitourinary reconstructive surgery for female patients born with CAH is technically feasible and safe with a low complication rate. A regular follow-up with a MDT to assess long-term complications is necessary, and it is vital to inform patients and families about the different management options with all the risks and benefits of surgery. TYPE OF THE STUDY original research, clinical research. LEVEL OF EVIDENCE Level 3 retrospective study.
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Affiliation(s)
- Hussein Ibrahim
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France; Pediatric Surgery Unit, Assiut University Children Hospital, Assiut, Egypt
| | - Amane-Allah Lachkar
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Valeska Bidault
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Clemence Delcour
- Department of Gynecology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, Robert-Debré University Hospital, APHP, Université Paris Cité, Paris, France; Reference Expert Center for Rare Diseases « Maladies Endocriniennes de la Croissance et du Développement » (CRESCENDO), Paris, France.
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De Win G, De Kort L, Learner H, Noah A, Dautricourt S, Nijman R, Stein R. Long-term risks of childhood surgery. J Pediatr Urol 2024; 20:165-172. [PMID: 37487882 DOI: 10.1016/j.jpurol.2023.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Several patients, who underwent major reconstruction under the care of an experienced pediatric urologist are now, as adults, several years later, appearing with long term problems and complications. This consensus process was undertaken to give an overview of long term consequences (and their management) of urological childhood surgery. MATERIAL AND METHODS Several known urologists with experience in life-long follow up and revisional surgery of patients with congenital conditions were asked to review literature and comment based on their experience about several complications of childhood surgery. RESULTS Renal impairment, metabolic consequences, bladder stones, Vit B 12 deficiency and recurrent infections are often encountered. Also recurrent ureteric strictures and difficulties with catheterizable channel (both obstruction and incontinence) can be challenging to manage. Specific attention is needed regarding female sexuality and pregnancy. Both the development of malignancies in reconstructed bladders as secondary malignancies need to be taken into account during follow up. CONCLUSION Follow up of patients with rare congenital conditions is highly specialized and revisional surgery can be challenging. Therefore, follow up needs to be organized in specialized centers.
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Affiliation(s)
- Gunter De Win
- University Hospital Antwerp, Department of Urology, Edegem, Belgium; ASTARC, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium; Adolescent & Congenital Lifelong Urology, University College London Hospitals, London, UK.
| | | | - Hazel Learner
- Adolescent Gynaecology, University College London Hospitals, London, UK
| | - Anthony Noah
- Adolescent & Congenital Lifelong Urology, University College London Hospitals, London, UK
| | | | - Rien Nijman
- Department of Pediatric Urology, University Medical Center Groningen, the Netherlands
| | - Raimund Stein
- Paediatric and Reconstructive Urology, University Hospital Mannheim, Germany
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Leivas PGC, Schiavon ADA, Resadori AH, Vanin AA, Almeida ADN, Machado PS. Human rights violations in normalizing procedures on intersex children. CAD SAUDE PUBLICA 2023; 39:e00066322. [PMID: 36753094 DOI: 10.1590/0102-311xpt066322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 12/21/2022] [Indexed: 02/08/2023] Open
Abstract
Intersex children in Brazil are still subjected to "normalizing" surgical procedures and subsequent bodily interventions to make their bodies conform to binary views of sex. Resolution n. 1,664/2003 of the Brazilian Federal Council of Medicine legitimizes interventions upon intersex bodies, being the only national normative instrument that address the subject. However, the demands of international intersex political activism have denounced how early childhood interventions for sex designation mutilate children's bodies and violate a number of human rights. This research discusses how early, irreversible, and normalizing procedures performed without the intersex person's consent are human rights violations. Based on the concept of epistemic (in)justice, we first look at the disputes surrounding the evidence that underpin medical practices. We demonstrate how such procedures violate human rights to health, body integrity, autonomy, and sexual and reproductive rights, analyzing which strategies were put into place to prevent them. We propose that intersex people be at the center of decisions regarding their bodies, that non-surgical paths be discussed with patients and their family members, and that early, invasive, mutilating, harmful, cosmetic, and unconsented surgical interventions on intersex children be prohibited. Guiding tools must introduce changes into its regulatory bias to, from an interdisciplinary perspective, include bioethical and human rights bodies, as well as intersex activists.
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Affiliation(s)
- Paulo Gilberto Cogo Leivas
- Ministério Público Federal, Porto Alegre, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil
| | | | | | - Aline Aver Vanin
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brasil.,Programa de Pós-graduação em Letras, Universidade de Santa Cruz do Sul, Santa Cruz do Sul, Brasil
| | | | - Paula Sandrine Machado
- Instituto de Psicologia, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brasil
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Leivas PGC, Schiavon ADA, Resadori AH, Vanin AA, Almeida ADN, Machado PS. Human rights violations in normalizing procedures on intersex children. CAD SAUDE PUBLICA 2023. [DOI: 10.1590/0102-311xen066322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Intersex children in Brazil are still subjected to “normalizing” surgical procedures and subsequent bodily interventions to make their bodies conform to binary views of sex. Resolution n. 1,664/2003 of the Brazilian Federal Council of Medicine legitimizes interventions upon intersex bodies, being the only national normative instrument that address the subject. However, the demands of international intersex political activism have denounced how early childhood interventions for sex designation mutilate children’s bodies and violate a number of human rights. This research discusses how early, irreversible, and normalizing procedures performed without the intersex person’s consent are human rights violations. Based on the concept of epistemic (in)justice, we first look at the disputes surrounding the evidence that underpin medical practices. We demonstrate how such procedures violate human rights to health, body integrity, autonomy, and sexual and reproductive rights, analyzing which strategies were put into place to prevent them. We propose that intersex people be at the center of decisions regarding their bodies, that non-surgical paths be discussed with patients and their family members, and that early, invasive, mutilating, harmful, cosmetic, and unconsented surgical interventions on intersex children be prohibited. Guiding tools must introduce changes into its regulatory bias to, from an interdisciplinary perspective, include bioethical and human rights bodies, as well as intersex activists.
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Affiliation(s)
| | | | | | - Aline Aver Vanin
- Universidade Federal de Ciências da Saúde de Porto Alegre, Brazil; Universidade de Santa Cruz do Sul, Brazil
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Traitement chirurgical des malformations génitales de l’enfant- contexte juridique. BULLETIN DE L'ACADÉMIE NATIONALE DE MÉDECINE 2022. [DOI: 10.1016/j.banm.2022.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
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Trachta J, Mushtaq I, Petrasova N, Hradsky O, Skaba R. Sexual function in adult females after feminizing genitoplasty for congenital adrenal hyperplasia. J Pediatr Urol 2022; 18:282-286. [PMID: 35260360 DOI: 10.1016/j.jpurol.2022.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 01/06/2022] [Accepted: 02/07/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To investigate sexual function and subjective attitudes towards surgery in adult women after feminizing genitoplasty (FG) for congenital adrenal hyperplasia (CAH). MATERIALS AND METHODS We retrospectively reviewed the medical files of patients who underwent FG from 1996 to 2018. Of those, patients older than 16 years of age were asked to answer non-standardized questions aiming at the awareness of genital surgery and standardized questionnaire evaluating sexual function (GRISS). The anonymized answers were compared to a control group of 50 healthy females. Student's t-test, Pearson's χ2 test, Fisher's exact test and Spearman's rank correlation coefficient were performed. A P-value less than 0.05 was considered significant. RESULTS Out of 106 patients who underwent FG, 64 were included, 55 successfully contacted and 32, aged 17-40 years (median 25.5), answered the questionnaires (58% response rate). In all, 11 patients underwent historical clitorectomy in early childhood by a pediatric gynecologist before 1996 and pull-through vaginoplasty at puberty. A total of 21 patients underwent modern one- or two-staged FG. There were statistically significant differences between the CAH group and controls as to the proportion living in committed partnerships (28% and 84%, respectively; p = 0.0000), having sexual intercourse (41% and 92%, respectively; p = 0.0000) and having their own children (13% and 36%, respectively; p = 0.0369). The median overall GRISS score was 4 (range 1-7) in the CAH group compared to 1 (range 1-9) in the control group, with infrequency and vaginismus representing the least favorable subscales (median 5). In all, 81% of the women operated on for CAH would recommend such an operation to any other individual with CAH and 66% of them suggested the surgery should be performed in early childhood. DISCUSSION By this study we have contributed to the debate over suggestions that FG may cause adverse effects on sexual life of the patients in adulthood, beside already published effects on their mental well-being and LUTS. Despite possible selection bias due to only 58% response rate the comparison with control group shows only a moderate sexual dysfunction and more significant impact on long-term partnership that might be caused by other factors related to CAH beside FG itself. CONCLUSIONS Partnership, offspring, sexual frequency and function were impaired in adult females with CAH after FG. However, the median GRISS score was below the pathological level of 5.
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Affiliation(s)
- Jan Trachta
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, V Uvalu 84, Prague, 15600, Czech Republic.
| | - Imran Mushtaq
- Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Natalia Petrasova
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, Czech Republic.
| | - Ondrej Hradsky
- Department of Pediatrics, Motol University Hospital, Charles University in Prague, Czech Republic.
| | - Richard Skaba
- Pediatric Surgery Department, Motol University Hospital, Charles University in Prague, Czech Republic.
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Claahsen - van der Grinten HL, Speiser PW, Ahmed SF, Arlt W, Auchus RJ, Falhammar H, Flück CE, Guasti L, Huebner A, Kortmann BBM, Krone N, Merke DP, Miller WL, Nordenström A, Reisch N, Sandberg DE, Stikkelbroeck NMML, Touraine P, Utari A, Wudy SA, White PC. Congenital Adrenal Hyperplasia-Current Insights in Pathophysiology, Diagnostics, and Management. Endocr Rev 2022; 43:91-159. [PMID: 33961029 PMCID: PMC8755999 DOI: 10.1210/endrev/bnab016] [Citation(s) in RCA: 156] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia (CAH) is a group of autosomal recessive disorders affecting cortisol biosynthesis. Reduced activity of an enzyme required for cortisol production leads to chronic overstimulation of the adrenal cortex and accumulation of precursors proximal to the blocked enzymatic step. The most common form of CAH is caused by steroid 21-hydroxylase deficiency due to mutations in CYP21A2. Since the last publication summarizing CAH in Endocrine Reviews in 2000, there have been numerous new developments. These include more detailed understanding of steroidogenic pathways, refinements in neonatal screening, improved diagnostic measurements utilizing chromatography and mass spectrometry coupled with steroid profiling, and improved genotyping methods. Clinical trials of alternative medications and modes of delivery have been recently completed or are under way. Genetic and cell-based treatments are being explored. A large body of data concerning long-term outcomes in patients affected by CAH, including psychosexual well-being, has been enhanced by the establishment of disease registries. This review provides the reader with current insights in CAH with special attention to these new developments.
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Affiliation(s)
| | - Phyllis W Speiser
- Cohen Children’s Medical Center of NY, Feinstein Institute, Northwell Health, Zucker School of Medicine, New Hyde Park, NY 11040, USA
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, School of Medicine Dentistry & Nursing, University of Glasgow, Glasgow, UK
| | - Wiebke Arlt
- Institute of Metabolism and Systems Research (IMSR), College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
- Department of Endocrinology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard J Auchus
- Division of Metabolism, Endocrinology, and Diabetes, Departments of Internal Medicine and Pharmacology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Intitutet, Stockholm, Sweden
- Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Leonardo Guasti
- Centre for Endocrinology, William Harvey Research Institute, Bart’s and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Angela Huebner
- Division of Paediatric Endocrinology and Diabetology, Department of Paediatrics, Universitätsklinikum Dresden, Technische Universität Dresden, Dresden, Germany
| | - Barbara B M Kortmann
- Radboud University Medical Centre, Amalia Childrens Hospital, Department of Pediatric Urology, Nijmegen, The Netherlands
| | - Nils Krone
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Medicine III, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Deborah P Merke
- National Institutes of Health Clinical Center and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
| | - Walter L Miller
- Department of Pediatrics, Center for Reproductive Sciences, and Institute for Human Genetics, University of California, San Francisco, CA 94143, USA
| | - Anna Nordenström
- Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
- Pediatric Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - Nicole Reisch
- Medizinische Klinik IV, Klinikum der Universität München, Munich, Germany
| | - David E Sandberg
- Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI 48109, USA
| | | | - Philippe Touraine
- Department of Endocrinology and Reproductive Medicine, Center for Rare Endocrine Diseases of Growth and Development, Center for Rare Gynecological Diseases, Hôpital Pitié Salpêtrière, Sorbonne University Medicine, Paris, France
| | - Agustini Utari
- Division of Pediatric Endocrinology, Department of Pediatrics, Faculty of Medicine, Diponegoro University, Semarang, Indonesia
| | - Stefan A Wudy
- Steroid Research & Mass Spectrometry Unit, Laboratory of Translational Hormone Analytics, Division of Paediatric Endocrinology & Diabetology, Justus Liebig University, Giessen, Germany
| | - Perrin C White
- Division of Pediatric Endocrinology, UT Southwestern Medical Center, Dallas TX 75390, USA
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Ishii T, Kashimada K, Amano N, Takasawa K, Nakamura-Utsunomiya A, Yatsuga S, Mukai T, Ida S, Isobe M, Fukushi M, Satoh H, Yoshino K, Otsuki M, Katabami T, Tajima T. Clinical guidelines for the diagnosis and treatment of 21-hydroxylase deficiency (2021 revision). Clin Pediatr Endocrinol 2022; 31:116-143. [PMID: 35928387 PMCID: PMC9297175 DOI: 10.1297/cpe.2022-0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Tomohiro Ishii
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Kenichi Kashimada
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Naoko Amano
- Department of Pediatrics, Keio University School of Medicine, Tokyo, Japan
| | - Kei Takasawa
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | | | - Shuichi Yatsuga
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
| | - Tokuo Mukai
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | - Shinobu Ida
- Differences of Sex Development (DSD) and Adrenal Disorders Committee, Japanese Society for Pediatric Endocrinology
| | | | | | | | | | | | | | - Toshihiro Tajima
- Committee on Mass Screening, Japanese Society for Pediatric Endocrinology
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Scarpa MG, Iaquinto M, Codrich D, Schleef J. Bilateral sactosalphinx and congenital adrenal hyperplasia: case report on two rare conditions in two virgin girls. Ital J Pediatr 2021; 47:141. [PMID: 34187553 PMCID: PMC8244243 DOI: 10.1186/s13052-021-01089-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 05/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sactosalpinx means a collection of fluid (serum, blood or pus) in the fallopian tube. CAH (Congenital Adrenal Hyperplasia) is a typical 46XX DSD (Disorder of Sex Development) due to a steroidogenic enzymatic defect. Both conditions are rare and can lead to reduced fertility rate. CASE PRESENTATION We describe two post-menarche virgin girls with CAH who were hospitalized for acute abdomen due to laparoscopically confirmed sactosalpinx. Case 1 recovered after conservative management, case 2 after a second-look and bilateral salpingectomy. The first case consisted of right sactosalpinx and previous peritonitis reported; the second one of bilateral symptomatic pyosalpinx and previous vaginal stenosis. Recurrent abdominal pain persisted at follow-up in Case 1: post-operative MRI (Magnetic Resonance Imaging) showed bilateral hydrosapinx that disappeared at a following ultrasound scan control. Follow-up was uneventful 36 months after surgery in Case 2, except for the surgical revision of the vaginal introitus. CONCLUSIONS CAH-sactosalpinx association is a very rare but not negligible event. We suggest a conservative approach for sactosalpinx if tubal and/or ovary torsion can be excluded. Pyosalpinx is more challenging to treat, but during pediatric age we suggest starting with a conservative approach, especially in patients with CAH who have a potential low fertility rate. Careful gynecological follow-up after menarche is recommended to rule out any further causes of infertility.
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Affiliation(s)
- Maria-Grazia Scarpa
- Pediatric Surgery Department - Institute for Maternal and Child Health, IRCCS Burlo Garofolo, via dell'Istria, 65/1, Trieste, Italy.
| | - Marianna Iaquinto
- Pediatric Surgery Department - Institute for Maternal and Child Health, IRCCS Burlo Garofolo, via dell'Istria, 65/1, Trieste, Italy
| | - Daniela Codrich
- Pediatric Surgery Department - Institute for Maternal and Child Health, IRCCS Burlo Garofolo, via dell'Istria, 65/1, Trieste, Italy
| | - Jürgen Schleef
- Pediatric Surgery Department - Institute for Maternal and Child Health, IRCCS Burlo Garofolo, via dell'Istria, 65/1, Trieste, Italy
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Bidault V, Botto N, Paye-Jaouen A, Leger J, Josset-Raffet É, Martinerie L, Peycelon M, El-Ghoneimi A. New method for early evaluation of clitoris innervation using clitoro-perineal reflex after feminizing genitoplasty in early childhood: a pilot-study. Sci Rep 2021; 11:7087. [PMID: 33782453 PMCID: PMC8007626 DOI: 10.1038/s41598-021-86434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 03/08/2021] [Indexed: 11/20/2022] Open
Abstract
A major complication of feminizing genitoplasty in children is the loss of clitoral sensation with serious impact at adult life. We suggest a new method to evaluate the surgical results during childhood based on the bulbocavernosus or clitoro-perineal reflex (CPR). The afferent pathway of CPR implies the intact sensory receptors on the clitoral glans. Girls with congenital adrenal hyperplasia who were followed-up medically without surgery or who underwent feminizing genitoplasty with or without clitoroplasty were included (2002-2018). All clitoroplasties were standardized reduction clitoroplasty with preservation of neurovascular bundles associated with vaginoplasty and vestibuloplasty. Standardized examinations were prospectively performed including the CPR starting at one year postoperatively. The reflex was triggered by gentle touch of the glans by a cotton swab. Contraction of the perineal muscles was considered positive. Thirty-two children were operated at a median age of 8.6 months (5.8-12.1). Median follow-up (FU) was 3.9 years (1.3-6.4). Twenty-four patients had clitoroplasties: 17 were tested for CPR at one-year FU, and all had a positive test. Eight girls had genitoplasty without clitoral surgery, two of them were tested and were positive. Ten patients were managed without surgery, two of them were tested for the CPR and were positive. The reflex was always triggered easily and repeated at least twice during the FU. The clitoro-perineal reflex is a simple, non-invasive and reproducible test in early childhood and may serve as an early evaluation tool of clitoral innervation after feminizing genitoplasty. These results need to be confirmed at long term and completed at adult life.
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Affiliation(s)
- Valeska Bidault
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Nathalie Botto
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Annabel Paye-Jaouen
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Juliane Leger
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Éliane Josset-Raffet
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Laetitia Martinerie
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
- Department of Pediatric Endocrinology, University Children Hospital Robert-Debré, APHP, University of Paris, Paris, France
| | - Matthieu Peycelon
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France
| | - Alaa El-Ghoneimi
- Department of Pediatric Surgery and Urology, University Children Hospital Robert-Debré, APHP, University of Paris, 48, Bd Sérurier, 75935, Paris Cedex 19, France.
- Centre de Référence Maladies Endocriniennes de La Croissance Et du Développement (CRMERC), Paris, France.
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11
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Shiryaev ND, Kagantsov IM, Sizonov VV. [Disorders of sex differentiation: state of the problem 15 years after the Chicago consensus]. PROBLEMY ENDOKRINOLOGII 2020; 66:70-80. [PMID: 33351341 DOI: 10.14341/probl12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 06/12/2023]
Abstract
It is well known that the nomenclature and classification were changed in 2005 at the international consensus conference on intersex disorders, held in Chicago, where, among others, the following recommendations were proposed: (1) all children should be assigned a gender identity, and this should be done as quickly as possible, taking into account the time required for the examination. (2) all infants with congenital adrenal hyperplasia and 46,XX karyotype, including those with pronounced masculinization, must be raised as women. (3) Surgical treatment should be performed early and in cases of feminizing genitoplasty, clitoral reduction should be performed simultaneously with reconstruction of the urogenital sinus (separation of the vagina and urethra). An analysis of contemporary literature shows that all these theories, proposed 15 years ago at the Chicago meeting, failed to stand the test of time. New nomenclature and classification are constantly being revised. Currently, many groups of patients want to abolish the term «sexual maturity disorders.» Recommendations regarding gender reassignment and appropriate early surgical treatment have been completely ignored in some countries. All this was largely facilitated by the confrontational activities of a number of support groups.
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Affiliation(s)
| | - Ilya M Kagantsov
- Pitirim Sorokin Syktyvkar State University; Republican Children's Clinical Hospital
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12
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Kudela G, Gawlik A, Koszutski T. Early Feminizing Genitoplasty in Girls with Congenital Adrenal Hyperplasia (CAH)-Analysis of Unified Surgical Management. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17113852. [PMID: 32485822 PMCID: PMC7312042 DOI: 10.3390/ijerph17113852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/20/2020] [Accepted: 05/27/2020] [Indexed: 12/23/2022]
Abstract
AIM To analyze a single-centre experience in feminizing genitoplasty in virilized girls with congenital adrenal hyperplasia (CAH). METHODS Review of medical records of all 46, XX CAH patients undergoing single stage feminizing genitoplasty between 2003 and 2018 was performed. RESULTS A total of 31 girls aged from 4 months to 10 years were included in the study. The majority (n = 26/31, 84%) were operated before 2 years of age (median 8 months). External virilization was rated as Prader 3 (n = 7/31), Prader 4 (n = 21/31) and Prader 5 (n = 3/31). The urethrovaginal confluence location was low in 19 and high in 12 girls with a percentage distribution similar in Prader 4 and 5 (p > 0.05) but significantly different in Prader 3 (p = 0.017). The follow-up ranged from 12 months to 15 years. All parents assessed the cosmetic result as satisfactory. Perioperative complications occurred in two patients and included rectal injury (n = 1/31) and prolonged bleeding (n = 1/31). Three patients developed late complications including labial atheromas (n = 2/31) and vaginal stricture requiring surgical dilatation (n = 1/31). Low confluence did not decrease the risk of complications. CONCLUSIONS Early feminizing genitoplasty in girls with congenital adrenal hyperplasia, irrespective of virilization severity, gives satisfactory cosmetic results and is characterized by low and acceptable surgical risk. Nevertheless, the most important determinant of the effectiveness of such management would be future patients' satisfaction.
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Affiliation(s)
- Grzegorz Kudela
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
- Correspondence: ; Tel.: +48-501 460 285
| | - Aneta Gawlik
- Department of Pediatrics and Pediatric Endocrinology, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Tomasz Koszutski
- Department of Pediatric Surgery and Urology, Medical University of Silesia, 40-752 Katowice, Poland;
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13
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Wisniewski AB, Batista RL, Costa EMF, Finlayson C, Sircili MHP, Dénes FT, Domenice S, Mendonca BB. Management of 46,XY Differences/Disorders of Sex Development (DSD) Throughout Life. Endocr Rev 2019; 40:1547-1572. [PMID: 31365064 DOI: 10.1210/er.2019-00049] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/23/2019] [Indexed: 12/11/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions that result in discordance between an individual's sex chromosomes, gonads, and/or anatomic sex. Advances in the clinical care of patients and families affected by 46,XY DSD have been achieved since publication of the original Consensus meeting in 2006. The aims of this paper are to review what is known about morbidity and mortality, diagnostic tools and timing, sex of rearing, endocrine and surgical treatment, fertility and sexual function, and quality of life in people with 46,XY DSD. The role for interdisciplinary health care teams, importance of establishing a molecular diagnosis, and need for research collaborations using patient registries to better understand long-term outcomes of specific medical and surgical interventions are acknowledged and accepted. Topics that require further study include prevalence and incidence, understanding morbidity and mortality as these relate to specific etiologies underlying 46,XY DSD, appropriate and optimal options for genitoplasty, long-term quality of life, sexual function, involvement with intimate partners, and optimizing fertility potential.
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Affiliation(s)
- Amy B Wisniewski
- Psychology Department, Oklahoma State University, Stillwater, Oklahoma
| | - Rafael L Batista
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Elaine M F Costa
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Courtney Finlayson
- Division of Endocrinology, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maria Helena Palma Sircili
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Department of Surgery, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Sorahia Domenice
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
| | - Berenice B Mendonca
- Division of Endocrinology, Department of Internal Medicine, University of São Paulo Medical School, University of São Paulo, São Paulo, Brazil
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14
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Zukunftsprägende Entwicklungen in der Kinderurologie. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-0753-x] [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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15
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Liao LM, Hegarty P, Creighton S, Lundberg T, Roen K. Clitoral surgery on minors: an interview study with clinical experts of differences of sex development. BMJ Open 2019; 9:e025821. [PMID: 31171549 PMCID: PMC6561419 DOI: 10.1136/bmjopen-2018-025821] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES Clitoral surgery on minors diagnosed with differences of sex development is increasingly positioned as a violation of human rights. This qualitative study identified how health professionals (HPs) navigate the contentious issues as they offer care to affected families. DESIGN Qualitative analysis of audio-recorded semistructured interviews with HPs. All of the interviews were transcribed verbatim for theoretical thematic analysis. SETTING Twelve specialist multidisciplinary care centres for children, adolescents and adults diagnosed with a genetic condition associated with differences of sex development. PARTICIPANTS Thirty-two medical, surgical, psychological and nursing professionals and clinical scientists in 12 specialist centres in Britain and Sweden formed the interview sample. RESULTS All interviewees were aware of the controversial nature of clitoral surgery and perceived themselves and their teams as non-interventionist compared with other teams. Data analyses highlighted four strategies that the interviewees used to navigate their complex tasks: (1) engaging with new thinking, (2) holding on to historical assumptions, (3) reducing the burden of dilemmas and (4) being flexible. In response to recent reports and debates that challenge clitoral surgery on minors, HPs had revised some of their opinions. However, they struggled to reconcile their new knowledge with the incumbent norms in favour of intervention as they counsel care users with variable reactions and expectations. The flexible approach taken may reflect compromise, but the interviewees were often trapped by the contradictory values and assumptions. CONCLUSIONS If the pathology-based vocabularies and narratives about genital diversity could be modified, and normative assumptions are questioned more often, clinicians may be more adept at integrating their new knowledge into a more coherent model of care to address the psychosocial concerns that genital surgery purports to overcome.
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Affiliation(s)
- Lih-Mei Liao
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter Hegarty
- School of Psychology, University of Surrey, Guildford, UK
| | - Sarah Creighton
- Women’s Health Division, University College London Hospitals NHS Foundation Trust, London, UK
| | - Tove Lundberg
- Department of Psychology, Lund University, Lund, Sweden
| | - Katrina Roen
- School of Social Sciences, University of Waikato, Hamilton, New Zealand
- Department of Psychology, University of Oslo, Oslo, Norway
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16
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Hemesath TP, de Paula LCP, Carvalho CG, Leite JCL, Guaragna-Filho G, Costa EC. Controversies on Timing of Sex Assignment and Surgery in Individuals With Disorders of Sex Development: A Perspective. Front Pediatr 2019; 6:419. [PMID: 30687685 PMCID: PMC6335325 DOI: 10.3389/fped.2018.00419] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022] Open
Abstract
Appropriate management of disorders of sex development (DSD) has been a matter of discussion since the first guidelines were published in the 1950s. In the last decade, with the advent of the 2006 consensus, the classical methods, especially regarding timing of surgery and sex of rearing, are being questioned. In our culture, parents of DSD newborns usually want their children to undergo genital surgery as soon as possible after sexual assignment, as surgery helps them to confirm the assigned sex. Developmental psychology theories back this hypothesis. They state that anatomic differences between sexes initiate the very important process of identification with the parent of the same sex. Sex-related endocrinological issues also demand early care. For example, using dihydrotestosterone cream to increase penile length or growth hormone treatment to improve final height require intervention at young ages to obtain better results. Although the timing of surgery remains controversial, recent evidence suggests that male reconstruction should be performed between 6 and 18 months of age. Feminizing surgery is still somewhat controversial. Most guidelines agree that severe virilization requires surgical intervention, while no consensus exists regarding mild cases. Our perspective is that precocious binary sex assignment and early surgery is a better management method. There is no strong evidence for delays and the consequences can be catastrophic in adulthood.
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Affiliation(s)
- Tatiana Prade Hemesath
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Psycology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Leila Cristina Pedroso de Paula
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Endocrinology Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
| | - Clarissa Gutierrez Carvalho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Julio Cesar Loguercio Leite
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Medical Genetics Service, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Guilherme Guaragna-Filho
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatrics Department, School of Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Eduardo Corrêa Costa
- PADS DSD Program, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, Brazil
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