Laparoscopic-assisted neo-cervico-vaginal anastomosis and neo-vagina creation in congenital atresia: A retrospective study measuring the outcome and success

Cervico-vaginal agenesis is a developmental disorder classified as a Mullerian duct anomaly.

STUDY OBJECTIVE

We aimed to study the surgical outcomes of vaginoplasty and laparoscopic-assisted cervical-vaginoplasty carried out using our set-up from June 2016 to December 2022. Additionally, we measured the success of our modified laparoscopy-assisted neo-cervical creation.

DESIGN

A retrospective study.

SETTING

The study was conducted in a tertiary care center and included all patients who underwent vaginoplasty and neo-cervico-vaginal creation using the rail-road method.

PATIENTS

A total of 33 patients were followed-up meticulously and their outcomes were noted. The study was retrospective and largely depended on patient compliance during follow-up.

INTERVENTION

Of the 33 patients, 22 underwent vaginoplasty (McIndoe technique) and 11 underwent neo-cervico-vaginoplasty (rail-road method using both open and laparoscopic methods).

MEASUREMENTS AND MAIN RESULTS

The most common presentation was primary amenorrhea (cyclic abdominal pain with primary amenorrhea) and urinary retention. Four patients underwent hysteroscopy-guided hematometra drainage and none underwent hysterectomy. The average vaginal length measured during the follow-up was 5.2 ± 1.90 cm. Significant symptom relief was observed. Longest follow-up duration was 4.7 years with a mean duration of 210 (180) days.

CONCLUSION

Although the procedure is strenuous, postoperative results showed satisfactory outcomes in improving the quality of life of patients. With expertise in the technique, the associated comorbidity is reduced, which provides relief for the patients.

Syndrome of inappropriate secretion of thyroid-stimulating hormone in a subject with galactorrhea and menstrual disorder and undergoing infertility treatment: Case report

RATIONALE

Syndrome of inappropriate secretion of thyroid-stimulating hormone (SITSH) is a rare cause of hyperthyroidism. Thyroid-stimulating hormone (TSH) levels are usually normal or high, and triiodothyronine (FT3) and free thyroxine (FT4) levels are usually high in subjects with SITSH.

PATIENT CONCERN

A 37-year-old woman had experienced galactorrhea and menstrual disorder for a couple of years before. She had undergone infertility treatment in 1 year before, hyperthyroidism was detected and she was referred to our institution.

DIAGNOSIS

She was suspected of having SITSH and was hospitalized at our institution for further examination. The data on admission were as follows: FT3, 4.62 pg/mL; FT4, 1.86 ng/dL; TSH, 2.55 μIU/mL. Although both FT3 and FT4 levels were high, TSH levels were not suppressed, which is compatible with SITSH. In addition, in brain contrast-enhanced magnetic resonance imaging, nodular lesions were observed in the pituitary gland with a diameter of approximately 10 mm. In the thyrotropin-releasing hormone load test, TSH did not increase at all, which was also compatible with TSH-secreting pituitary adenoma. In the octreotide load test, the TSH levels were suppressed. Based on these findings, we diagnosed this subject as SITSH.

INTERVENTIONS

Hardy surgery was performed after the final diagnosis. In TSH staining of the resected pituitary adenoma, many TSH-producing cells were observed. These findings further confirmed the diagnosis of pituitary adenoma producing TSH.

OUTCOMES

Approximately 2 months after the operation, TSH, FT3, and FT4 levels were normalized. Approximately 3 months after the operation, she became pregnant without any difficulty.

LESSONS

We should consider the possibility of SITSH in subjects with galactorrhea, menstrual disorders, or infertility. In addition, we should recognize that it is very important to repeatedly examine thyroid function in subjects with galactorrhea, menstrual disorder, or infertility.

18-Year-old patient with Klinefelter syndrome (47, XXY) and complete androgen insensitivity syndrome (CAIS) - case report

AIMS

The aims of the presented case report are to emphasize the importance of a proper diagnostics and treatment in the case of the coexistence of Klinefelter syndrome (KS, 47 XXY) and complete androgen insensitivity syndrome (CAIS). Since there is no causal treatment it is necessary to provide the patient with a good quality of life, including psychological and sexological support.

MATERIALS AND METHODS

The presented case report is the retrospective analysis of the patient's medical history over the 3 years.

RESULTS

At the age of 15, the patient was directed to genetic testing due to primary amenorrhea. The results of the patient showed an incorrect male karyotype with the SRY gene present (47, XXY). A molecular diagnostics revealed a very rare variant of the androgen receptor (AR) mutation responsible for tissue insensitivity to androgens. The detected mutation has not been described in the available databases so far. Following a diagnosis of the presence of Klinefelter syndrome (KS, 47 XXY) together with complete androgen insensitivity syndrome (CAIS), the patient underwent a bilateral gonadectomy.

CONCLUSIONS

In women with KS and CAIS physiological reproduction and maintenance of normal sex, hormone levels are not possible. A gonadectomy is performed due to the risk of malignant testicular tumors.

Single port laparoscopy combined with vaginal cervicovaginal reconstruction in a patient with congenital atresia of the cervix

OBJECTIVE

To introduce an innovation that combines single port laparoscopic and Wharton-Sheares-George cervicovaginal reconstruction using a small intestinal submucosa (SIS) graft in a patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum (U2aC4V4).

DESIGN

Video article introducing a new surgical technique.

SETTING

University hospital.

PATIENT(S)

A 15-year-old patient with congenital cervical atresia, absence of vagina, and incomplete uterine septum had primary amenorrhea and cyclic lower abdominal pain. The magnetic resonance imaging did not show hematometra and the endometrium was 6 mm when she had lower abdominal pain.

INTERVENTION(S)

A neovagina (depth, 7 cm; width, 2.5 cm) was created using the Wharton-Sheares-George neovaginoplasty. By single laparoscopy, the bladder was separated from the anterior surface of the uterus. With the mold in the neovagina created by the assistant, the apex of neovagina was opened. Then the lower uterine segment was exposed and incised. A T-shaped intrauterine device was connected to an 8-cm-long catheter scissored from a 14-F Foley catheter and was inserted into the uterus to prevent cervical or vaginal stenosis. The upper end of the graft was applied onto the lower uterine segment with delayed absorbable sutures. The lower end was sutured to the high vaginal or vestibular mucosa.

MAIN OUTCOME MEASURE(S)

The feasibility and effect of combination single port laparoscopic with vaginal cervicovaginal reconstruction in the congenital atresia of cervix.

RESULT(S)

The operation was successful. The operating time was 90 minutes. Hospitalization was 3 days. There were no intraoperative and postoperative complications. The patient had resumption of menses at three cycles postoperatively, and she had no dysmenorrhea. No cervical or vaginal stenosis occurred because of the Foley catheter.

CONCLUSION(S)

Single port laparoscopic combined with vaginal cervicovaginal reconstruction provided a minimally invasive, safe, and effective surgical option for the young patient with congenital atresia of cervix. It was successful and without complications or cervical or vaginal stenosis.

The utility of adrenal and ovarian venous sampling in a progesterone-producing adrenal tumor and review of the literature

PURPOSE

A clinical case presenting secondary amenorrhea accompanied by an adrenal adenoma and hyperprogesteronemia is described in this study.

METHODS

Selective catheterization and sampling of adrenal and ovarian veins were performed.

RESULTS

The source of hyperprogesteronemia was located in the right adrenal gland. A progesterone-producing tumor in the right adrenal gland was diagnosed and removed. Twenty-six days after tumor resection, menstruation occurred.

CONCLUSIONS

Progesterone-producing tumors should be considered with the presence of an adrenal mass and hyperprogesteronemia. Combined adrenal and ovarian venous sampling may help to identify the source of progesterone secretion.

Congenital vaginal atresia: A report of 39 cases in a regional Obstetrics and Gynecology Hospital

To investigate the clinical course and management of congenital vaginal atresia. This retro-spective analysis included patients with congenital vaginal atresia treated from March 2004 to August 2014 at the Obstetrics and Gynecology Hospital of Fudan University. Thirty-nine patients were included in this study. Their average age was 16.87±2.2 years when they came to our hospital. Totally, 51% of the patients had isolated congenital vaginal atresia with a normal cervix, whereas the others had either cervical atresia or imperforate hymen. The primary presenting signs and symptoms included primary amenorrhea (71.8%), periodic abdominalgia (41.0%), abdominal pain (36.0%), dyspareunia (10.3%), menstrual disorders (5.1%), and pelvic mass (5.1%). Ultrasound and magnetic resonance imaging (MRI) were effective inspection methods for the screening of urogenital tract-associated anomalies. Vagi-noplasty mainly included simple vagina reconstruction with insertion of a mold (n=22) and split-thickness skin grafting (n=4). In 64% of surgical patients, normal menstrual bleeding was achieved. Four of the patients subsequently became pregnant and delivered at term. Primary amenorrhea, periodic abdominalgia and abdominal pain are the main reasons for the post pubertal patients to visit doctors. Surgical methods can successfully provide these patients an opportunity for subsequent conservative management, can result in normal menstrual bleeding, resolve cyclic pelvic pain, and provide some po-tential for fertility.

[Hematocolpos : an unappreciated diagnosis of hymen imperforation]

The imperforation of the hymen is a relatively rare congenital malformation. It usually manifests itself in adolescence by a hematocolpos. Hematocolpos is the vaginal retention of menstrual blood at puberty. It results clinically in painful amenorrhea and more rarely in a pelvic mass syndrome. The diagnosis is easy, it is primarily clinical. Pelvic ultrasound and nuclear magnetic resonance are the complementary examinations to be performed as a preoperative assessment and to detect any associated genito-urinary malformations.

[Primary amenorrhea by transverse vaginal septum: a case report and review of the literature]

The transverse vaginal septum is one of the rarest anomalies of the reproductive tract classified depending on location. It is manifested by primary amenorrhea, cyclic pain and progressive mass growth at abdominopelvic level, ultrasound and magnetic resonance imaging provides the diagnosis, location and thickness of a transverse vaginal septum, treatment is surgical. We present a case of a teenage patient with primary amenorrhea due to lower transverse vaginal septum with surgical resection and satisfactory follow-up with successful vaginal patency.

Review of intrauterine adhesions

This article has been produced to review the literature on symptomatic and asymptomatic intrauterine adhesions. Electronic resources including Medline, PubMed, CINAHL, The Cochrane Library (including the Cochrane Database of Systematic Reviews), Current Contents, and EMBASE were searched using the Medical Subject Headings (MeSH), including all subheadings, and the keywords "Asherman syndrome," "Hysteroscopic lysis of adhesions," "Hysteroscopic synechiolysis," "Hysteroscopy and adhesion," "Intrauterine adhesions," "Intrauterine septum and synechiae," and "Obstetric outcomes after intrauterine surgery." The vast majority of evidence in the literature consists of uncontrolled case series, with only intrauterine adhesion barriers being assessed in a randomized controlled format. This article reviews epidemiology, pathologic features, classification systems, and treatments. Seven classification systems are described, with no universal acceptance of any one system and no validation of any of them. Hysteroscopy is the mainstay of both diagnosis and treatment, with medical treatments having no role in management. There is a wide range of treatment techniques with no controlled comparative studies, and assessments are descriptive and report fertility and menstrual outcomes, with more severe adhesions having the worst clinical outcomes. One of the most important features of treatment is prevention of recurrence, with the best available evidence demonstrating that newly developed adhesion barriers such as hyaluronic acid show promise for preventing new adhesions.

Hypogonadotropic hypogonadism: a consequence of Chiari-I malformation

Chronic hydrocephalus, most commonly the result of aqueduct stenosis, is associated with both primary and secondary amenorrhea. Only six cases of secondary amenorrhea have been reported to date. We describe a women with cystic fibrosis who presented with secondary amenorrhea as a consequence of Chiari-I malformation and resultant hydrocephalus. The biochemical picture was characterized by hypogonadotropic hypogonadism. Resolution of the amenorrhea was observed to occur following 3rd ventriculostomy.

Imperforate hymen: cause of lower abdominal pain in teenage girls

Imperforate hymen is a relatively rare congenital anomaly. However, it is not an uncommon cause of lower abdominal pain presenting in teenage girls. Without careful history taking and thorough examination, the condition can be missed easily. We report an imperforate hymen presenting as abdominal pain in three teenage girls aged 12, 12 and 13 years, respectively, within a six-month period. The presentation was reviewed and the various types of hymenotomy were discussed.

Laparoscopic excision of uterine adenomyomas

OBJECTIVE

To present a series of six consecutive women with adenomyomas who were successfully managed with a standard treatment strategy to elucidate the feasibility and the effectiveness of laparoscopic treatment of adenomyomas.

DESIGN

Cross-sectional case series.

SETTING(S)

Obstetrics and gynecology department of a tertiary academic hospital and endoscopic unit of a private hospital.

PATIENT(S)

The six cases described in this report were nonpregnant women of reproductive age (mean age, 34.8 years old; range, 29-38 years) who presented in the outpatient gynecological clinic for yearly routine visit (one patient), dysmenorrhea and menorrhagia (three patients), and history of pregnancy loss (two patients).

INTERVENTION(S)

Laparoscopic excision of uterine adenomyomas.

MAIN OUTCOME MEASURE(S)

Feasibility and effectiveness of laparoscopic management of adenomyomas.

RESULT(S)

The average operating time was 100.5 minutes, and the average estimated blood loss was 163 mL. No event complicated the intraoperative and the postoperative course of these cases, and no case was converted to laparotomy. The mean follow-up was 13.7 months, with complete regression of the symptoms.

CONCLUSION(S)

Excision of adenomyomas presents intraoperative peculiarities involving difficulties in their dissection and manipulation. Laparoscopic management of these lesions appears to be safe and feasible with good follow-up results and limited recurrence rates.

Secondary amenorrhea resulting from traumatic separation of the cervix from the uterine corpus

BACKGROUND

Amenorrhea resulting from crushing trauma of the pelvis is exceptionally rare. The purpose of this case report is to describe the diagnosis of and successful surgical correction of traumatic separation of the cervix from the uterine corpus.

CASE

A nulligravida presented with a complaint of secondary amenorrhea after a motor vehicle accident in which she sustained a crush-type injury to the pelvis. Ultrasonography and laparotomy revealed a complete separation of the uterine corpus from the cervix. The uterine corpus was approximated to the cervix with circumferentially placed sutures to establish a patent outflow tract from the endometrial cavity to the cervical canal.

CONCLUSION

This case demonstrates the successful surgical correction of secondary amenorrhea resulting from traumatic separation of the uterine corpus from the cervix. Normal menstruation resumed 6 weeks after surgery.

[Diagnostic image (332). A young woman with amenorrhoea]

A 16-year-old girl presented with amenorrhoea and a tense abdomen, due to a mature cystic teratoma with the characteristics ofa dermoid cyst.

Amenorrhea due to partial uterine necrosis after uterine artery embolization for control of refractory postpartum hemorrhage

We report a case of a woman in whom selective embolization of both uterine arteries was performed using gelatin sponge for control of refractory postpartum hemorrhage. Ten months after delivery, the women had not resumed noticeable menstruation. Examination and investigation were consistent with partial uterine necrosis and complete obliteration of the cavity.

Hyperprolactinaemia in 271 women: up to three decades of clinical follow-up

OBJECTIVE

To characterize women with hyperprolactinaemia at diagnosis and to assess the effect of treatment after long duration of the disease.

DESIGN

Retrospective chart review.

PATIENTS AND MEASUREMENTS

Two hundred and seventy-one women with hyperprolactinaemia at the Karolinska University Hospital, Stockholm, Sweden between 1974 and 2002 were evaluated retrospectively. Criterion for inclusion was elevated S-PRL (> or = 20 microg/l) found on at least two occasions. Secondary hyperprolactinaemia was excluded. The patients were followed for a median time period of 111 (6-348) months. Two hundred and forty patients were treated with dopamine agonists, 17 underwent surgery, seven received radiotherapy and seven were followed without treatment.

RESULTS

Mean age at diagnosis was 31 (+/- 9.5) years and median PRL level was 72 (25-3500) microg/l. Menstrual disturbances were present in 87% of the women of reproductive age and 47% had galactorrhoea. Microadenomas were found in 63%, macroadenomas in 8% and idiopathic hyperprolactinaemia in 29%. Patients with menstrual disturbances had higher PRL levels than women with normal menstrual function (P < 0.001). We found no differences in PRL levels between patients with or without galactorrhoea (P = 0.578). At the end of clinical follow-up, menstrual cycle was normalized in 94% and galactorrhoea disappeared in 94%. In the medically treated patients, median PRL levels decreased from 70 (25-3100) to 13 (0-89) microg/l, (P < 0.0001). Normalization of PRL level was achieved in 71% of the patients and 80% showed a total or partial degree of tumour shrinkage. In the surgically treated patients, 53% had normal PRL levels without medication at follow-up.

CONCLUSION

Medical treatment was effective in correcting hypogonadism, normalizing PRL levels and reducing tumour size in the majority of the patients after short-term treatment and also in the long run. However, the possibility of transsphenoidal surgery in specific cases must be considered.

Pudendal thigh flap for congenital absence of vagina

OBJECTIVE

To increase the armamentarium of plastic surgeons with description of one of the relatively newer flap for the reconstruction of congenital absence of vagina.

METHODS

All patients of congenital absence of vagina selected for surgery were explained every detail about the procedure. Five out of ten opted for this procedure. In all patients bilateral pudendal thigh flap based on posterior labial artery, a branch of internal pudendal artery, were raised on either side of labia. They were sutured in midline and inserted into the neo-vagina created by dissection in between rectum and urinary bladder.

RESULTS

This flap was used in five patients with minor postoperative problems and with good anatomical and functional results.

CONCLUSION

Pudendal thigh flap is a useful technique to reconstruct the vagina.

Successful end-to-end cervico-cervical anastomosis in a patient with congenital cervical fragmentation: case report

Cervical agenesis or dysgenesis (fragmentation, fibrous cord and obstruction) is an extremely rare congenital anomaly. Conservative surgical approach to these patients involves uterovaginal anastomosis, cervical canalization, and cervical reconstruction. In failed conservative surgery, total hysterectomy is the treatment of choice. We report what we believe to be the first successful end-to-end cervico-cervical anastomosis of an unusual case of congenital cervical fragmentation. A 15 year old Caucasian female presented complaining of primary amenorrhoea and cyclic, monthly abdominal pain. At laparotomy, a symmetrical transverse disruption of the cervix in a central and distal part was found and an end-to-end cervico-cervical anastomosis of the two cervical fragments was performed with the use of a 16F Foley catheter as a stent into the endocervical canal. One month after surgery the patient had normal menses. We conclude that a thorough investigation of the patient with suspected cervical anomaly is necessary and conservative surgical treatment should be applied as a first-line treatment option. In the presence of functional and intact cervical segments, the reconstruction of the cervical canal with an end-to-end cervico-cervical anastomosis is feasible and effective.

Anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty in women with Rokitansky's syndrome

BACKGROUND

The Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare congenital cause of primary amenorrhea, due to utero-vaginal agenesis. Several surgical techniques have been used to create a neovagina. Neovagina construction with a sigmoid graft appears to be the best option, as it offers adequate length and natural lubrication, allowing early intercourse. However, few data are available on the complications, anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty.

METHODS

From September 1995 to November 2002, seven women with the MRKH syndrome underwent laparoscopic-perineal neovagina construction by sigmoid grafting.

RESULTS

The mean operating time was 312 min (range 220-450 min). The mean fall in haemoglobin was 3.6 g/dl (range 2-4.4 g/dl). Blood transfusion was never necessary. The only perioperative complications were one urinary tract infection and one vulvar haematoma not requiring drainage. The mean hospital stay was 7.7 days (range 6-12 days). The mean length of the neovagina was 11.5 cm (range 7-15 cm), and no shrinkage occurred during follow-up. The neovaginal introitus admitted two fingers in breadth in five of the seven patients. Dilation of the introitus was required in the other two women. None of the four women who had intercourse experienced dyspareunia or discomfort.

CONCLUSION

Our results confirm the feasibility of laparoscopic-perineal neovagina construction by sigmoid colpoplasty, when performed by surgeons with extensive experience in both gynaecological and gastrointestinal laparoscopic surgery. The anatomic and functional results were good.

[Primary amenorrhea caused by impaired cervical development: report of 3 cases]

We report 3 cases of primary amenorrhea accompanied by cyclic abdominal pain. In presented cases primary amenorrhea was caused by the absence of normally developed cervix. We applied surgical treatment--hysterectomy. In 1 case before hysterectomy we tried to reconstruct cervical canal. This effort was unsuccessfull.

A combined surgical and radiologic technique for creating a functional neo-endocervical canal in a case of partial congenital cervical atresia

OBJECTIVE

To recanalize the endocervical canal in a patient with partial congenital cervical atresia.

DESIGN

Case report.

SETTING

University hospital.

PATIENT

A 16-year-old girl referred with a history of primary amenorrhea, polycystic ovaries, and intermittent abdominal pain. Physical examination revealed a normal vagina and external cervical os, but magnetic resonance imaging revealed a solid endocervical tract.

INTERVENTION(S)

At laparotomy the endometrial cavity was accessed transfundally and outlined by injection of water-soluble contrast. A trocar needle was guided transvaginally into the uterus, the tract was dilated, and a 12F stent was placed. Oral contraceptives (OCs) and antibiotics were continued postoperatively.

MAIN OUTCOME MEASURE(S)

Hysterosalpingography and clinical follow-up.

RESULT(S)

The operation and postoperative course were uneventful. Withdrawal bleeding occurred at 8 weeks, after discontinuation of the OCs, at which time the stent was expelled. Later follow-up revealed recurrent narrowing, and the stent was replaced for 14 more weeks. After stent removal, regular menses continued (7 months to date).

CONCLUSION

In select cases of congenital cervical atresia, recanalization may be safely performed with the use of the combined surgical-radiologic technique described, with good short-term outcome.

[Laparoscopic fenestration of the ovaries]

The authors have performed an ovary fenestration in 220 women with primary or secondary amenorrhea. This was made with the help of instrumentation for laparoscopy and a monopolar electrodiathermic coagulator with differently shaped endings. The power supply was provided from Martin Elektrotom 2000. A spontaneous recovers of the menstruation was achieved in 36.84% of the cases as a result of the endoscopic intervention. A follows up pregnancy was achieved in 12.4% of the women. Considering the obtained results, the authors recommend the use of a laparoscopic ovary fenestration when a women with ovarian cysts is treated.

Reconstruction of urethrovaginal fistula and vaginal atresia in an adolescent girl after an abdominoperineal-vaginal pull-through procedure

OBJECTIVE

To report a rare case of urethrovaginal communication and vaginal atresia.

DESIGN

To reconstruct the communication and the vaginal route.

SETTING

Division of Pediatric and Adolescent Gynecology and Corrective Gynecological Surgery, University of Athens, and "Alexandra" Hospital.

PATIENT(S)

A 16-year-old girl with cyclic hematuria, periodic pelvic pain, and primary amenorrhea.

INTERVENTION(S)

Diagnostic studies, followed by an abdominoperineal-vaginal pull-through procedure.

MAIN OUTCOME MEASURE(S)

Reconstruction of the urethrovaginal fistula and vaginal route.

RESULT(S)

Normal menstruation through the vaginal route.

CONCLUSION(S)

A careful examination of every infant's external genitalia should be performed immediately after delivery. A urethrovaginal fistula should be corrected in time to facilitate menstrual flow and improve future reproductive potential.

Magnetic resonance imaging of the uterus after endometrial resection

OBJECTIVE

Despite the increasing popularity of endometrial resection for the treatment of menstrual problems, the long term sequelae of this procedure are poorly recognised. As diagnostic hysteroscopy following endometrial resection is frequently unrewarding and transvaginal ultrasound is incapable of detecting subtle changes in endometrial morphology, magnetic resonance imaging was employed to evaluate the uterus.

DESIGN

Retrospective study of unselected post-operative women.

METHODS

Fifty-nine women, of whom 22 were amenorrhoeic, were studied a mean number of 34 months after endometrial resection, using a 1.5 Tesla magnetic resonance imaging system with a pelvic phased array coil for signal reception. T2-weighted FSE images were acquired through the long and short uterine axis and volumetric assessment of each uterine layer performed using an ISG Allegro workstation.

MAIN OUTCOME MEASURES

The location and volume of residual endometrium, the volume of junctional zone and myometrial tissue, and the presence of additional intrauterine and pelvic pathology were recorded.

RESULTS

Residual endometrium was demonstrated in all except three amenorrhoeic women, with a similar mean volume present in menstruating and amenorrhoeic groups. Additional findings included adenomyosis, haematometra, fallopian tube dilatation and free intraperitoneal fluid.

CONCLUSIONS

The majority of amenorrhoeic and all menstruating women have residual endometrium after endometrial resection. The lack of communication of islands of residual endometrium with the uterine cavity results in haematometra formation, fallopian tube dilatation and possibly free intraperitoneal fluid.

Primary amenorrhea: evaluation with MR imaging

PURPOSE

To determine the accuracy of magnetic resonance (MR) imaging in the evaluation of patients with a history of primary amenorrhea.

MATERIALS AND METHODS

Twenty-nine patients with primary amenorrhea underwent T2-weighted MR imaging in the axial and sagittal planes. Contrast material-enhanced and unenhanced T1-weighted MR imaging was performed in selected cases. MR imaging findings were correlated with surgical findings in 23 patients and with clinical findings in six patients.

RESULTS

Surgical correlation was available in 14 of 17 patients with female anatomic anomalies (Mayer-Rokitansky-Küster-Hauser syndrome [n = 9], transverse vaginal septum [n = 3], imperforate hymen [n = 1], cervical agenesis [n = 1]), which confirmed MR imaging findings. In nine of 12 patients with congenital disorders of sexual differentiation (testicular feminization [n = 5], true hermaphrodite [n = 2], gonadal dysgenesis [n = 2]) who underwent surgical correlation, 13 of 16 (81%) gonads were correctly localized with MR imaging. Overall, there was excellent correlation between the classification of patients with MR imaging versus classification with the combination of surgical and laboratory findings (K = 0.88).

CONCLUSION

MR imaging is useful in the work-up of patients who present with primary amenorrhea both for accurate diagnosis of pathologic conditions and for surgical planning.

Successful treatment of severe uterine synechiae with transcervical resectoscopy combined with laminaria tent

Seven patients with secondary amenorrhoea were diagnosed as having severe uterine synechiae by hysterosalpingography (HSG) and hysteroscopy, which revealed short, narrow and/or scarred uterine cavities as cone or column shapes. Laminaria tents were used to distend the uterine cavity prior to transcervical resectoscopy to completely dissect the dense adhesions. A more traditional postoperative management included an intrauterine device, oestrogen and antibiotics. Transcervical resectoscopy combined with laminaria appears to be a safe and effective means of restoring the uterine cavity. All seven patients not only achieved normal menstruation but also normal uterine cavity as confirmed by subsequent HSG and hysteroscopy. In addition, three patients thereafter became pregnant, two of whom have had successful term deliveries.

Surgical management of complete obliteration of the endometrial cavity

OBJECTIVE

To describe a technique for surgical management of complete obliteration of the endometrial cavity.

DESIGN

A report of a series of three patients.

SETTING

A university-based hospital.

PATIENT(S)

Three patients with complete obliteration of the endometrial cavity.

INTERVENTION(S)

Transfundal scar removal using stents in the fallopian tubes to serve as landmarks.

MAIN OUTCOME MEASURE(S)

Regular withdrawal bleeding.

RESULT(S)

Regular menses in all three patients.

CONCLUSION(S)

The technique described here show promise for establishing uterine cavity integrity in cases of complete endometrial obliteration where there are no landmarks in the uterine cavity.

[The role of hysteroscopy in the diagnosis and treatment of uterine adhesions. Apropos of 15 cases]

In this study, the authors raise the question of the morbidity related to Asherman's syndrome and demonstrate that hysterectomy is the best method for diagnosis and treatment. In a group of 15 patients, secondary sterility and secondary amenorrhea were the main reasons for consultation, 11 patients underwent surgical hysteroscopy and the other fourteen received conventional treatment. The main etiological factors identified were curettage and cesarian section. A normal cavity was successfully reconstructed in 12 cases (80%) after between one and three treatments. Normal menstruation was restored in all patients. In the obstetric field, there were 7 pregnancies, resulting in 6 deliveries and one miscarriage. Hysteroscopy therefore constitutes a real step forward in the diagnosis and treatment of Asherman's syndrome; it may be possible to extend its advantage to all forms of endouterine neoformations.

[Spontaneous conception after laparoscopic coagulation of the ovarian surfaces in a patient with primary normogonadotropic hyperandrogenemic amenorrhea]

A patient with primary amenorrhoea was kept under hormonal replacement therapy and oral contraceptives since the age of sixteen. At the age of 30 she first consulted the endocrinologist because of infertility after one year of "post-pill-amenorrhoea". This first hormone check detected a severe hypertestosteronaemia (1.3 ng/ml). During four stimulation cycles using gonadotropins she showed a polyfollicular reaction and finally developed a hyperstimulation WHO II. During the following cycle she underwent hystero- and laparoscopy; laparoscopic electrocoagulation of the ovarian surface (LEOS) was carried out during this treatment. She subsequently conceived spontaneously twice.

Treatment of abnormal uterine bleeding with the gynecologic resectoscope

The gynecologic resectoscope, recently approved by the Food and Drug Administration for the treatment of abnormal uterine bleeding, was evaluated for its success in the treatment of women with this complaint. Through June 1990, 216 patients were treated with this modality. Ninety were treated with transcervical myomectomy alone since they still desired fertility preservation or wished to avoid hysterectomy. Of the patients treated, 189 (87.5%) had follow-up evaluation for at least three months and some as long as three years. Of the ninety patients treated with resection of a submucous myoma, greater than 90% had a marked improvement in their symptoms, with decreased menstrual bleeding. Of the 96 patients treated with endometrial ablation, 50% were amenorrheic, 26% had hypomenorrhea, 17% had eumenorrhea, and 7% were unimproved. There was only one case of fluid overload, and no patients required a blood transfusion. Complications included two cases of endometritis and one perforation at the time of retrieval of myoma fragments. Four patients required placement of a 30-mL Foley catheter for control of postoperative bleeding. Gynecologic resectoscopy is a safe and effective alternative to major surgery in the management of abnormal uterine bleeding for which conservative measures have not been effective.

Primary Amenorrhea and Virilization in a True Hermaphrodite with a Rare Dicentric Y Chromosome

A 24-year-old woman was evaluated for primary amenorrhea and virilization. Karyotyping revealed a rare dicentric Y chromosome with complex mosaicism. Subsequent total abdominal hysterectomy/bilateral salpingo-oophorectomy demonstrated true hermaphroditism manifested by a right ovotestis, a left streak gonad, and Mullerian structures on the right despite the presence of testicular tissue. With the exception of short stature, Turner stigmata were not present despite the predominance of a 45,X cell line. The literature is reviewed.

Transsphenoidal microsurgery for prolactin-secreting pituitary adenomas

The authors present the results of transsphenoidal microsurgery in 100 women with the amenorrhea-galactorrhea syndrome caused by pituitary adenomas associated with hyperprolactinemia (prolactinomas). As the surgical results were closely related to the preoperative levels of serum prolactin, the patients were divided into two groups: patients with preoperative prolactin less than 200 ng/ml (Group 1), and those with preoperative prolactin greater than 200 ng/ml (Group 2). The results in Group 1 (72 patients) were significantly better. In this group, 56 (78%) patients regained normal menstrual cycles, and 55 (76%) had return of elevated prolactin to normal following surgery. In Group 2 (28 patients), however, only 11 (39%) resumed normal menstrual periods postoperatively, and 13 (*46%) had return of elevated prolactin levels to normal. There was good correlation between tumor size and the preoperative level of prolactin. Of the 72 women in Group 1, 58 (81%) had tumors less than 1 cm (microadenomas), whereas of the 28 women in Group 2, only four (14%) had tumors of that size. All patients with visual field deficits preoperatively improved or had a normal visual examination postoperatively; none was made worse by surgery. Four patients (three in Group 2) have required additional surgery and/or irradiation. In the last six patients of the series, contrast-enhanced coronal computerized tomography slices made with the updated General Electric scanner detected five microadenomas. Considering that a relatively high percentage of sellar polytomograms are negative in patients with proven microadenomas (that is, only 40 of 72 patients in Group 1 has abnormal polytomography), it is likely that sellar polytomography will significantly decrease in importance in the diagnostic work-up of these patients. The authors provide a rationale for transsphenoidal microsurgery in these patients as opposed to other forms of management, such as bromocriptine therapy and irradiation.

Galactorrhea-amenorrhea syndrome: follow-up of forty-five patients after pituitary tumor removal

Forty-five patients with galactorrhea-amenorrhea were followed during a period of 1 to 8 years (mean 3.1) after transsphenoidal prolactinoma removal. The ratios of patients who appear to be cured to the total numbers treated were 20 patients of 27 with grade I tumors; six of 10 with grade II; two of five with grade III; and none with grade IV tumors. Six patients with normal prolactin levels one week postoperatively had relapse later, as did three with normal prolactin levels 2 months postoperatively. A normal prolactin level 6 months postoperatively predicted ultimate cure. The 19 pregnancies that occurred in 15 patients, four with high prolactin levels, were uneventful. Prolactin rose normally with pregnancy and returned to prepregnancy level in all but one patient. Prolactin responses to stimulation tests were blunted for 6 months after successful tumor removal. By 1 year, responses to thyrotropin releasing hormone and metoclopramide tests were returning to normal, although responses to chlorpromazine and hypoglycemia remained blunted. The postoperative inhibition of normal lactotropes for 6 months is suggested. Ultimate cure cannot be determined before 6 months and conception should be deferred until then.

[Female hyperprolactinaemia. 19 cases (author's transl)]

The authors were able to confirm the ineffectiveness of vitamin B6. The correction of hyperprolactinaemia by bromocriptine restored ovarian function immediately, or after the failure of surgical treatment. It would still be premature to determine the exact place of surgery in this type of pathology.

The use of laparoscopy in gynaecology

Diagnostic laparoscopy is of most value in the evaluation of infertility and for completing the gynaecological investigation of obscure cases of chronic pelvic pain. Its use to exclude ectopic pregnancy, salpingitis and pelvic cancer is more controversial. The management of some cases of primary amenorrhoea is aided by laparoscopic gonadal biopsy. The excessive demand for female sterilization will ensure that the laparoscope continues to be used for this purpose and is leading to a compromise. The surgical techniques which have been proved to be most effective are being replaced by methods favoured for their potential reversibility and rapid patient turn-over. If all our laparoscopes were abandoned, gynaecological surgery would perhaps not suffer a major setback, but, for the present, those who neglect laparoscopy are losing an important dimension of modern practice.