OHVIRA syndrome: clinical implications of a delayed diagnosis

Obstructed Hemi Vagina with Ipsilateral Renal Agenesis (OHVIRA) syndrome is a rarely encountered müllerian duct anomaly. Delayed diagnosis is common due to normal onset of puberty and menstruation. We report a case of a woman in her early 20s with a background history of multiple emergency department visits, ward admissions and surgeries for chronic abdominal pain. She was reviewed at 1 month postlaparotomy for recurrent pelvic abscess and was finally diagnosed to have an OHVIRA syndrome, 11 years after her first clinical presentation. Excision of the vaginal septum completely resolved her symptoms. We are reporting this case to highlight the clinical implications resulting from the delayed diagnosis, to look into factors contributing to the delay and to highlight the importance of having a high index of suspicion to diagnose this unique condition.

Evaluation and Resection of a Longitudinal Vaginal Septum in an Adult

OBJECTIVE

The objective of this video is to demonstrate the diagnosis, evaluation, and techniques for surgical management of a longitudinal vaginal septum, a rare müllerian anomaly.

DESIGN

This is a stepwise demonstration of evaluation and surgical techniques with video narration.

SETTING

The incidence of müllerian defects, which can include any anomaly in the fallopian tube, uterus, cervix, or vagina, has been estimated to be 2% to 4% [1]; 30% to 40% of patients with müllerian defects also have associated renal anomalies [1,2]. In normal development, the müllerian ducts fuse at 10 weeks' gestation and the septum between the 2 ducts is absorbed in a caudal to cephalad direction [3]. The exact incidence of complete longitudinal vaginal septa is unknown as they are very rare [4]. Longitudinal vaginal septa may cause dyspareunia, inability to have penetrative intercourse, labor dystocia, or hygiene issues and be very emotionally distressing for patients [5].

INTERVENTIONS

Preoperative evaluation of an adult with longitudinal vaginal septum that included a careful physical examination and abdominal and pelvic imaging. Intraoperative resection with key strategies: (1) placing a Foley catheter to help avoid urinary tract injuries and (2) intermittent rectal examinations to retract the rectum away from the plane of dissection.

CONCLUSION

Patients who present with longitudinal vaginal septa should undergo evaluation for uterine and renal anomalies. Here, we show that resection of longitudinal vaginal septa in adults is feasible and appropriate for patients who present with inability to have penetrative intercourse. Intraoperatively, care should be taken to avoid injuring the rectum or urinary tract.

Neovagina creation methods in Müllerian anomalies and risk of malignancy: insights from a systematic review

PURPOSE

This systematic review aims to provide a data synthesis about the risk of neovaginal cancer in women with Müllerian anomalies and to investigate the association between the adopted reconstructive technique and the cancer histotype.

METHODS

PubMed, MEDLINE, Embase, Scopus, ClinicalTrials.gov and Web of Science databases were searched from inception to March 1st, 2023. Studies were included if: (1) only women affected by Müllerian malformations were included, (2) the congenital defect and the vaginoplasty technique were clearly reported, (3) the type of malignancy was specified.

RESULTS

Literature search yielded 18 cases of squamous cell carcinoma and two cases of vaginal intraepithelial neoplasia 3 (VAIN 3). Of these, 3 had been operated on according to the Wharton technique, 8 according to the McIndoe technique, 3 with a split-skin graft vaginoplasty, 2 according to the Davydov technique, 2 with a simple cleavage technique, 1 according to the Vecchietti technique and 1 with a bladder flap vaginoplasty. A total of 17 cases of adenocarcinoma and 1 case of high-grade polypoid dysplasia were also described. Of these, 15 had undergone intestinal vaginoplasty, 1 had been operated on according to the McIndoe technique and 1 had undergone non-surgical vaginoplasty. Finally, 1 case of verrucous carcinoma in a woman who had undergone a split-skin graft vaginoplasty, was reported.

CONCLUSION

Although rare, neovaginal carcinoma is a definite risk after vaginal reconstruction, regardless of the adopted technique. Gynaecologic visits including the speculum examination, the HPV DNA and/or the Pap smear tests should be scheduled on an annual basis.

Wharton-Sheares-George vaginoplasty: a safe and efficient technique in patients with Mayer-Rokitansky-Küster-Hauser syndrome

INTRODUCTION AND HYPOTHESIS

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a condition with an underdeveloped or absent vagina and uterus due to embryological growth failure of the Müllerian ducts. Many techniques have been described to construct a neovagina with an acceptable depth that allows penetrative intercourse. This is a step-by-step video tutorial on the Wharton-Sheares-George surgical technique for vaginoplasty in patients with MRKH syndrome.

METHOD

With Wharton-Sheares-George vaginoplasty, the rudimentary Müllerian ducts are incrementally dilated by pushing Hegar dilators in the direction of the pelvic axis, and the resulting median raphe is then intersected using diathermy. As a result, a neovagina is created and an estriol-coated vaginal mold is inserted for 3 days. The patient receives comprehensive discharge instructions, a self-dilation program three times a day, and a monthly follow-up.

RESULTS

A 3-month follow-up showed a high subjective degree of satisfaction with surgery and sexual satisfaction in both patients.

CONCLUSION

Wharton-Sheares-George vaginoplasty is a safe and efficient technique for creating a neovagina for patients with MRKH syndrome.

Insights into enlarged prostatic utricles and Müllerian duct system remnants associated with posterior hypospadias

INTRODUCTION

The prostatic utricle (PU) consists of the caudal remnant of the Müllerian duct and the urogenital sinus. The term "vagina masculina" is used if other Müllerian structures are associated with the PU. This work aims to investigate the incidence, management, and follow up of enlarged PUs and Müllerian remnants in males with posterior hypospadias.

PATIENTS AND METHODS

This study presents a retrospective review of cases presented with posterior hypospadias over a 5-year period. Prior to hypospadias repair, retrograde urethrograms were used to investigate enlarged PU. Subsequently, they were classified according to the Ikoma score and further assessed by karyotyping and cystoscope. Surgical excision was indicated in cases with symptomatic utricles or vagina masculina.

RESULTS

Thirty patients were included in the study in the period between 2015 and 2020 (Table). All cases were asymptomatic initially. Twelve patients were diagnosed with enlarged PU; three of them had vagina masculina. One case with perineal hypospadias had a separate perineal opening for PU. Following hypospadias repair, three of the eight cases treated conservatively turned symptomatic.

DISCUSSION

The incidence of enlarged PU and Müllerian remnants varied among different studies. However, it increased as the severity of hypospadias increased. Preoperative urethrogram was helpful in the diagnosis and classification of PU, but it had its limitations. Cystoscope was more advantageous in diagnosing vagina masculina. Although most cases were asymptomatic, some turned symptomatic after hypospadias repair. Some cases with perineal hypospadias had PU with a separate perineal opening.

CONCLUSION

The incidence of enlarged PUs or Müllerian remnants was 40%. Although cases were asymptomatic before hypospadias surgery, some cases turned into symptomatic after hypospadias repair. In some cases, the PU or Müllerian remnants had a separate perineal opening. They can be classified as a particular form of Ikoma grade III necessitating surgical intervention.

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction

PURPOSE

Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts.

METHODS

Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed.

RESULTS

Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion.

CONCLUSIONS

We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective Study.

Long-term Results of Sexual Function and Body Image After Vaginoplasty With Acellular Dermal Matrix in Women With Mayer-Rokitansky-Küster-Hauser Syndrome

STUDY OBJECTIVE

To describe the long-term anatomic and sexual functional results of vaginoplasty with acellular dermal matrix (ADM) in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) and to evaluate the changes in body image pre- and postoperatively in these patients.

DESIGN

A retrospective study from March 2015 to September 2021.

SETTING

A tertiary teaching hospital.

PATIENTS

Forty-two patients with MRKH syndrome who underwent vaginoplasty with ADM (the MRKH group) and 30 sexually active, nulliparous, aged-matched women (the control group).

INTERVENTION

The relevant data were retrospectively collected via our electronic medical record system and were analyzed statistically.

MEASUREMENTS AND MAIN RESULTS

Vaginal length was assessed using a 3-cm-diameter mold. The Chinese version of the Female Sexual Function Index questionnaire was used to evaluate sexual function. The Chinese version of the modified body image scale was applied to evaluate body image. The median follow-up time was 57 months (range, 13-91 months). Granulomatous polyps in the neovagina were the most common postoperative complication (7 of 42, 16.7%). Patients with MRKH syndrome can achieve long-term satisfactory outcomes both anatomically and functionally after vaginoplasty with ADM, comparable with those of healthy control women. The vaginal length in the MRKH group was comparable to that in the control group ( 8.04 ± 0.51 cm vs. 8.15 ± 0.46 cm, respectively). The FSFI scores were similar between the MRKH (26.54 ± 3.44) and control (26.80 ± 2.23) groups. The modified body image scale score was significantly decreased after vaginoplasty with ADM.

CONCLUSION

Vaginoplasty with ADM is a minimally invasive and effective procedure for patients with MRKH syndrome.

Mayer-Rokitansky-Küster-Hauser syndrome patients' interest, expectations and demands concerning uterus transplantation

OBJECTIVE

To better understand patients' conditions and expectations before starting a uterus transplantation (UTx) program for women suffering from Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome).

METHOD

A web-based survey was conducted among MRKH patients via the French national association network from March to August 2020. The questionnaire comprised twenty-eight questions about their desire for parenthood, their condition's characteristics and previous reconstructive procedures, opinions and knowledge about UTx.

RESULTS

Among the 148 participants, 88 % reported a desire for parenthood, and 61 % opted for UTx as their first choice to reach this aim. The possibility of bearing a child and having the same genetic heritage were the main motivations. Once informed about the usual course of an UTx protocol, only 13 % of the participants changed their mind and 3 out of 4 of them opted for UT.

CONCLUSION

Uterus transplantation seems to be the first option to reach motherhood in patients suffering from MRKH syndrome. The development of UTx programs could meet the demands of this already well-informed population.

Surgical Correction of Vaginal Agenesis via Modified Laparoscopic Vecchietti Procedure

OBJECTIVE

To describe surgical correction of vaginal agenesis via a modified laparoscopic Vecchietti procedure with the goal of disseminating knowledge and improving surgical technique CASE: An 18-year-old female presented with primary amenorrhea, age-appropriate secondary sex characteristics, a shallow vagina, and 46,XX karyotype. Imaging showed rudimentary uterine horns and normal ovaries, kidneys, and spine. Diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome type I was made. After an unsuccessful attempt at vaginal dilation and extensive counseling, the patient chose to have a laparoscopic Vecchietti procedure. Vecchietti vaginoplasty eliminates the need for grafts and creates a neovagina with accelerated vaginal dilation by stretching the introital mucosa with a spring mechanism.

RESULTS

A modified laparoscopic Vecchietti procedure was performed. Postoperatively, daily suture adjustments were made. When the device was removed after 7 days, the examination revealed a 9-cm vaginal canal, which was maintained with self-dilation.

A case report of laparoscopic surgery for Mayer-Rokitansky-Küster-Hauser syndrome with preservation of functional primordial uterus

BACKGROUND

In the past, the primary treatment for MRKH syndrome (Mayer-Rokitansky-Küster-Hauser syndrome) with a functional primordial uterus was surgical removal of the functional primordial uterus. In rare instances, the endometrium of the functional primordial uterus is well developed, and surgical preservation of the functional primordial uterus provides the possibility of preserving reproductive function for these patients.

CASE PRESENTATION

A 14-year-old female was diagnosed with type I MRKH syndrome with a functional primordial uterus through physical examination and imaging investigations. We freed the functional primordial uterus through laparoscopic surgery and excised a portion of the lower myometrium to create an outlet at a lower uterine segment, which we then intermittently anastomosed to the tip of the artificial vagina. The patient recovered well after the surgery, and a re-examination showed no significant abnormalities.

CONCLUSION

We were successful in preserving the functional primordial uterus using laparoscopic surgery in a patient with MRKH syndrome and connecting it to an artificial vagina through reconstructive surgery to ensure unobstructed menstrual drainage and preserve the reproductive potential of the patient.

Persistent Müllerian Duct Syndrome Diagnosed Incidentally: A Case Report

Persistent Müllerian Duct syndrome is a rare male disorder of sexual development. The phenotypically and genotypically male patient presents with female internal organs (i.e., uterus, cervix, fallopian tubes and upper part of vagina) due to deficiency of anti-mullerian hormone or insensitivity of tissues to Anti Mullerian Hormone. We present a 19 year old male who came with complaint of right iliac fossa pain. He was investigated for acute appendicitis and on imaging, he was diagnosed to have bilateral cryptorchidism with rudimentary uterus. Computed tomography followed by pelvic ultrasonography was done which indicated two testes in abdomen and a soft tissue density structure, identified as a rudimentary uterus located posterior to the urinary bladder. CT scan findings were further confirmed by magnetic resonance imaging pelvis. A trial of stepwise orchidopexy followed by orchidectomy with removal of rudimentary uterus was performed laparoscopically. Additionally, he was counselled for long term sex hormone replacement and reproductive failure in future.

Sigmoid neovagina prolapse treated with Altemeier procedure: case report and systematic review of the literature

BACKGROUND

Bowel vaginoplasty is a surgical method for neovagina construction that, despite its advantages over other techniques, is still burdened by complications such as prolapse. The incidence of sigmoid neovagina prolapse (SNP) is difficult to determine, and there are no evidence-based recommendations for treatment. We present a case of SNP and a systematic review of previous cases.

CASE

A 73-year-old woman presented with stage III prolapse of her sigmoid neovagina constructed 51 years prior. Dynamic pelvic MRI revealed that the majority of the prolapse was due to the mucosa's loss of support. Due to the presence of numerous pelvic adhesions, an alternative to the laparoscopic approach was evaluated by a multidisciplinary team which led to the patient being treated using a modification of Altemeier's procedure.

SYSTEMATIC REVIEW

After PROSPERO Registration (CRD42023400677), a systematic search of Medline and Scopus was performed using specific search terms. Study metadata including patient demographics, prolapse measurements, reconstruction techniques, recurrence rates, and timing were extracted. Fourteen studies comprising 17 cases of SNP were included. Vaginal resection of the redundant sigmoid, comprising Altemeier's procedure, was the most definitive surgery, but it was also associated with recurrences in three cases. Laparoscopic sacropexy was the second most definitive surgery with no recurrence reported.

CONCLUSION

Our review shows that the recurrence after correction of sigmoid neovagina prolapses is higher than previously reported. Laparoscopy colposacropexy appeared to be the best approach, but it's not always feasible. In these scenarios, a mucosal resection using the Altemeier's procedure is the most effective surgery.

International Experiences with Vaginal Lengthening Treatment Among Individuals with Müllerian Agenesis: A Mixed-Methods Study

STUDY OBJECTIVE

To understand variations and experiences of vaginal lengthening internationally in individuals with congenital underdevelopment of the uterus, cervix, and upper vagina or Müllerian agenesis METHODS: In this study, we used a cross-sectional mixed-methods design incorporating quantitative and qualitative questionnaires. Adults with Müllerian agenesis completed questionnaires with quantitative and open-ended qualitative questions about their vaginal lengthening experiences. Data were analyzed using descriptive statistics and inductive thematic analysis.

RESULTS

Of 616 respondents meeting inclusion criteria (representing 40 countries), 46% (n = 284) reported no vaginal lengthening intervention. Vaginal lengthening was commonly reported by participants from North America and Europe (59%) and less commonly by participants from Africa, Asia, and South America (16%). Of those who had undergone vaginal lengthening, 72% reported dilator use, 34% coital dilation, and 39% surgery. Four major themes were identified in response to the open-ended vaginal lengthening experience question: (1) difficult physical symptoms, (2) practical and psychosocial challenges, (3) intimate relationships and sexual satisfaction, and (4) impact of experiences with healthcare providers.

CONCLUSION

This study highlights vaginal lengthening practices internationally and shared themes related to significant challenges and positive experiences. The findings show room for improvement in the counseling and care surrounding vaginal lengthening. Future research should investigate factors that influence decision-making about vaginal lengthening and work toward international consensus on best care practices in Müllerian agenesis.

Rokitansky Syndrome or Cervicovaginal Atresia?

STUDY OBJECTIVE

To investigate the possibility of conservative management of rudimentary uterine horns associated with vaginal agenesis.

DESIGN

Observational study on cohort of consecutive cases treated with the same criteria from 2008 to 2021.

SETTING

Two academic institutions and teaching hospitals in Milan, Italy.

PATIENTS

Eight patients with vaginal agenesis associated with rudimentary cavitated uterine horns treated by the same team and postoperatively followed.

INTERVENTIONS

All the subjects underwent the same standardized surgical procedure: laparoscopy, intraoperative ultrasound, and horn-vestibular direct anastomosis. Postoperatively vaginoscopy was performed every 6 months.

MEASUREMENTS AND MAIN RESULTS

The postoperative course was generally uneventful and the mean hospital stay was 4.3 ± 2.5 (SD) days. All the patients began to menstruate a few months after the operation. Menstrual flows were light but regular. All patients had a neovaginal length > 4 cm at 1 year postoperatively, reaching approximately 6 cm at 2 years. During the follow-up period, 5 patients were sexually active without dyspareunia. In all cases, surgery restored the continuity of the neovagina and uterine horn through the creation of a "vaginal-horn fistula tract."

CONCLUSION

In patients with vaginal agenesis associated with the presence of a uterine cavitary horn, it is possible to recover not only sexual activity but also menstrual function. The horn-vestibular anastomosis may be considered a valid, safe, and effective therapeutic option but requires accurate preoperative and intraoperative evaluation of rudimentary uterine structures.

Evaluation of Sexual Function Outcomes in Patients with Rokitansky Syndrome: A Systematic Review and Meta-analysis

OBJECTIVE

In patients with Rokitansky syndrome, vaginal agenesis can be treated using various surgical techniques, and various factors can affect each surgery outcome in the long term. This meta-analysis aimed to evaluate sexual function outcomes in patients with Rokitansky syndrome after various surgery techniques.

DATA SOURCES

Searches were conducted in Google Scholar, PubMed, Cochrane database, ScienceDirect, Web of Science, and ClinicalTrials.gov. Systematic searches were conducted on studies published until November 2022 (CRD42022370735).

METHODS OF STUDY SELECTION

During the first stage of database scanning and reference check, 1820 results were identified, and an evaluation of the total 10 studies was finally conducted. The inclusion criteria involved selecting randomized controlled trials that focused on assessing sexual function after surgical treatment in patients of all ages with Rokitansky syndrome.

TABULATION, INTEGRATION, AND RESULTS

EndNote version 20 software was used to organize and identify duplicate articles through screening. The Joanna Briggs Institute's critical appraisal tool was used to evaluate each study's quality for bias potential. The results showed that the total scores of female sexual functions in patients with Rokitansky syndrome after vaginoplasty were significantly lower than in healthy women (standardized mean difference, -0.233; p <.05; range, -0.376 to -0.090). The 6-domain analysis of the Female Sexual Function Index questionnaire revealed that lubrication (p <.05) and satisfaction (p <.05) were significantly lower in patients undergoing vaginoplasty.

CONCLUSION

All surgical techniques to create a neovagina for patients with Rokitansky syndrome have successfully affected the sexual function outcomes. Considering all other factors affecting sexual function outcomes in the long term, more quantitative and qualitative studies are needed to assess sexual satisfaction in patients treated with surgical techniques.

[Robotic-assisted resection of a symptomatic Müllerian duct cyst]

Cysts in the lesser pelvis are a rare disease and most often an incidental finding from routine diagnostic investigation. Published information is controversial. These cysts are distinguished by localisation, content of the cyst and accompanying anatomical anomalies. In this case, we report a 33 years old man who presented to our clinic due to a large retrovesical cyst. Because of lower abdominal pain and problems with defecation, the cyst was diagnosed by ultrasound. Further radiological diagnostic testing confirmed the presence of a retrovesical cyst of unknown malignancy, which was retrospectively evaluated as a Müllerian duct cyst. Due to symptoms and potential malignancy of the cyst, the decision was made to perform surgery. With the help of the operation robot, this benign cyst was safely and completely removed. In a follow-up, the patient presented free of symptoms and sonographically there was no sign of recurrence. Therefore robotic-assisted resection is a safe procedure to treat large symptomatic Müllerian duct cysts.

Management of partial Müllerian agenesis: staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification

INTRODUCTION

The objectives of this video are to provide a brief overview of Müllerian agenesis, discuss a case of partial vaginal agenesis with a functional uterus, and present the steps of a staged McIndoe procedure for the creation of a neovagina and utero-neovaginal unification.

METHODS

We give an overview of Mayer-Rokitansky-Küster-Hauser syndrome, and review its incidence, clinical presentation, diagnostic evaluation, and treatment options. We present the case of a 23-year-old woman with partial vaginal agenesis, and her clinical course through conservative management with hormonal suppression and dilator therapy leading up to urogynecological surgical treatment. We describe a staged surgical approach that highlights the value of cystoscopy and laparoscopy to better delineate our patient's anatomical variations. Additionally, a mini-laparotomy and placement of an intrauterine Malecot catheter allowed for the drainage of prominent hematometra, relief of menstrual outflow obstruction, and epithelialization of a tract between the uterus and the planned neovaginal space. Ultimately, a neovagina was created using a staged McIndoe technique, leading to utero-neovaginal unification and unobstructed menses.

CONCLUSION

In conclusion, our approach should be considered a feasible option for anatomical restoration via the creation of a neovagina in patients with Müllerian anomalies, even in the presence of a functional uterus.

Neovaginoplasty With Nile Tilapia Skin: Cytological and Microbiota Evaluation

OBJECTIVES

To study the clinical, cytological, and vaginal microbiota findings in patients with Mayer-Rokitansky-Küster-Hauser syndrome who underwent neovaginoplasty using Nile tilapia fish skin.

METHODS

This is a cross-sectional study with 7 cisgender women with Mayer-Rokitansky-Küster-Hauser syndrome who had previously undergone neovagina reconstruction using Nile tilapia fish skin at a university hospital. Local institutional review board approval and written permission from the patient were obtained. Between August 2019 and November 2021, within 12 to 24 months after surgery, vaginal specimens were obtained for conventional oncotic and hormonal cytology, and for Gram staining. The Nugent scores were calculated. Colposcopy was also performed.

RESULTS

Squamous cells without atypia were found in all patients. Five patients had intermediate vaginal microbiota (Nugent score of 4), which was determined by the presence of few lactobacilli on Gram staining. In hormonal cytology, 4 patients presented with findings compatible with menacme. No colposcopic change was observed. When postsurgical dilation was performed correctly, a mean vaginal length of 8.3 cm was maintained after 1 year of follow-up.

CONCLUSIONS

Squamous cells without atypia were present in neovaginas with Nile tilapia fish skin. Most vaginal contents revealed intermediate microbiota and hormonal results compatible with menacme. Studies with a greater number of patients are necessary for a more comprehensive understanding of the microbiome in neovaginas with this new technique, thereby providing support for the treatment and prevention of associated pathologies.

Update on Mayer-Rokitansky-Küster-Hauser syndrome

This review presents an update of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome on its etiologic, clinical, diagnostic, psychological, therapeutic, and reproductive aspects. The etiology of MRKH syndrome remains unclear due to its intrinsic heterogeneity. Nongenetic and genetic causes that may interact during the embryonic development have been proposed with no definitive etiopathogenesis identified. The proportion of concomitant extragenital malformations varies in different studies, and the discrepancies may be explained by ethnic differences. In addition to physical examination and pelvic ultrasound, the performance of pelvic magnetic resonance imaging is crucial in detecting the presence of rudimentary uterine endometrium. MRKH syndrome has long-lasting psychological effects on patients, resulting in low esteem, poor coping strategies, depression, and anxiety symptoms. Providing psychological counseling and peer support to diagnosed patients is recommended. Proper and timely psychological intervention could significantly improve a patient's outcome. Various nonsurgical and surgical methods have been suggested for treatment of MRKH syndrome. Due to the high success rate and minimal risk of complications, vaginal dilation has been proven to be the first-line therapy. Vaginoplasty is the second-line option for patients experiencing dilation failure. Uterine transplantation and gestational surrogacy are options for women with MRKH syndrome to achieve biological motherhood.

Robert's uterus (asymmetric septate uterus): a rare congenital Müllerian duct anomaly

Müllerian anomalies such as Robert's uterus, which was first described by the French gynaecologist Dr Helene Robert in 1969, are rare clinical entities and have been reported in <3% of the female population. Robert's uterus is a rare phenomenon with a relative dearth of reported cases. Affected individuals may present with pelvic pain and dysmenorrhoea that intensifies near menses or acutely, with severe abdominal pain to the emergency department. They are also associated with adverse pregnancy outcomes, abnormal fetal presentation, preterm labour, recurrent pregnancy loss and infertility. Although ultrasound has a role in its initial assessment, MRI is the best modality to further delineate its anatomy. It is typically managed via laparotomy and total horn resection, endometrectomy of the blind cavity or abdominal metroplasty. The authors present the case of a 40-year-old woman at 19+3 weeks gestation with acute onset of left-sided abdominal pain. A transvaginal ultrasound and MRI of the pelvis confirmed a Robert's uterus with a viable pregnancy in the upper left horn. She developed a ruptured horn with significant haemoperitoneum. An emergency laparotomy was performed and a non-viable fetus was evident. Only a few cases of pregnancy in the blind hemicavity have been reported so far. This case also highlights the importance of considering this diagnosis in young females presenting with dysmenorrhoea and normal menstrual flow. It is imperative to render a prompt diagnosis, as minimally invasive procedures may be more effective if detected before the formation of adnexal endometriomas.

Uterine Transplantation: Recipient Patient Populations

Uterine transplantation is an emerging treatment for patients with uterine factor infertility (UFI). In order to determine patient candidacy for transplant, it is imperative to understand how to identify, counsel and treat uterine transplant recipients. In this article, we focus on patient populations with UFI, whether congenital or acquired, including Mayer-Rokitansky-Kuster-Hauser, complete androgen insensitivity syndrome, hysterectomy, and other causes of nonabsolute UFI. Complete preoperative screening of recipients should be required to assess the candidacy of each individual prior to undergoing this extensive treatment option.

Balloon vaginoplasty as a minimally invasive method in the management of vaginal aplasia

OBJECTIVE

The aim of this article is to describe the management of vaginal aplasia and to introduce minimally invasive surgical procedures for neovagina formation.

METHODOLOGY

Literature review obtained from studies and papers dealing with the management of congenital vaginal aplasia.

CONCLUSION

Vaginal aplasia is a rare congenital anomaly, often in coincidence with congenital defects of the uropoietic system. Management nowadays favors non-surgical or minimally invasive surgical methods for neovagina formation. Saman et al introduced a new method of neovagina formation, namely balloon vaginoplasty. The advantage of the surgical procedure is traction using a soft Foley balloon, determining both the length and width of the neovagina. The method uses the expansion of the natural vaginal mucosa without the need for dissection of the vesicorectal space. The soft Foley balloon does not cause erosion of the vaginal mucosa.

New Advances in Transplants and Bioengineering Aid in Replacing the Womb

When Kayla Edwards turned 13, she began to wonder if she was different. It started as a seed of suspicion when her friends began their menstrual cycles, and hers never arrived. Her grandmother was late, she learned, but for Edwards, it still seemed odd. She had hit puberty's other benchmarks-the hormones, the breasts-just no cycle.

Three degrees of separation: complete uterine and cervical septa

OBJECTIVE

To review the diagnosis and management of 3 variations of incomplete müllerian duct fusion and reabsorption.

DESIGN

Narrated video delineating the surgical management of 3 müllerian anomalies; this video was deemed exempt from review by the institutional review board of the Mayo Clinic.

SETTING

Tertiary care academic medical center.

PATIENT(S)

This video focuses on 3 müllerian anomalies: complete septate uterus with a single septate cervix (septate uterus unicollis); complete septate uterus with duplicated cervix (septate uterus bicollis); and complete duplication of the uterus and cervix (uterine didelphys).

INTERVENTION(S)

Magnetic resonance imaging (MRI), cervical septoplasty, operative hysteroscopy, and uterine septoplasty.

MAIN OUTCOME MEASURE(S)

Several variations of uterine malformations exist. In our practice, we differentiate complete septate uteri as either unicollis or bicollis via MRI and vaginal examination. The bicollis presentation can be identified on MRI by the "lambda sign," which is seen as the 2 cervices that diverge as they enter the vagina. This is in comparison with the unicollis presentation when the single septate cervix can be traced with parallel lines as it enters the vagina. The circle method is described in this video to help distinguish between a single and duplicated cervix on examination.

RESULT(S)

The cervical and uterine septa were resected completely in the patient with a complete septate uterus unicollis. In contrast, the uterine septum was resected completely and the 2 cervical canals were not incised in the case of the complete septate uterus bicollis. Although uterine and cervical septa resection is controversial, our practice is to avoid the incision of the 2 cervical canals in cases that are more clearly consistent with a bicollis classification.

CONCLUSION(S)

Müllerian anomalies represent a continuum of disorders caused by different degrees of disruption in embryogenesis. MRI with vaginal gel and vaginal examination are tools to help classify the anomaly and guide surgical management.

The Peritoneal Neovagina after Davydov's Laparoscopic Procedure in Mayer-Rokitansky-Küster-Hauser Syndrome: Morphology and Ultrastructure Investigation of the New Epithelium

STUDY OBJECTIVE

To investigate the clinical appearance and morphologic and ultrastructural aspects of the mucosa of the peritoneal neovagina after laparoscopic Davydov neovaginoplasty in patients with Mayer-Rokitansky-Küster-Hauser syndrome.

DESIGN

The study group was a prospective, observational, experimental cohort of cases treated in the same institution between 2015 and 2019. Patients were followed up at 3, 6, and 12 months after surgery and then every 12 months.

SETTING

Single-center academic institution and teaching hospital in Milan, Italy.

PATIENTS

Fifty-one consecutive subjects with clinical and imaging diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome surgically treated by the same team and postoperatively followed.

INTERVENTIONS

All the subjects underwent the same standardized surgical procedure and thereafter were followed up at 3, 6, and 12 months after surgery and then every 12 months; a minimum follow-up of 12 months was achieved in all cases. Vaginoscopy and Schiller test were performed at each follow-up visit, and a biopsy specimen of the neovagina was obtained in a limited number of patients (6 out of 51) for light microscopy (LM) and scanning electron microscopy (SEM) analysis of the tissue.

MEASUREMENTS AND MAIN RESULTS

In vaginoscopy, the neovaginal mucosa appeared homogeneous, smooth, and pink all along the neovaginal tract; the Schiller test detected iodine positivity at different degrees of extension upward from the hymenal ring, starting at 3 months postoperatively with almost complete positivity between 6 to 12 months in all cases. LM demonstrated adequate thickness and differentiation of the new mucosa along with the presence of glycogen storage; SEM revealed an ultrastructural surface appearance very close to normality. The main difference compared with a normal vagina was the reduced presence of vaginal mucosal folds.

CONCLUSION

Under different techniques (vaginoscopy, Schiller test, LM, and SEM), a minimum of 6 months after surgery, the peritoneal neovagina epithelium showed aspects comparable to the natal mucosa of the vagina.

Report of the first live birth after uterus transplantation in People's Republic of China

OBJECTIVE

To present the first live birth after uterine transplantation (UTx) in the People's Republic of China.

DESIGN

Case study.

SETTING

University hospital.

PATIENT(S)

A 22-year-old woman with Mayer-Rokitansky-Kuster-Hauser syndrome and previous surgery for vaginal reconstruction and UTx.

INTERVENTION(S)

Endometrial preparation, frozen embryo transfer, pregnancy follow-up, and cesarean section.

MAIN OUTCOME MEASURE(S)

Results of in vitro fertilization, frozen embryo transfer, ultrasound measurements during pregnancy, rejection diagnosis and treatment, delivery, live birth, and histology of uterus.

RESULTS(S)

Frozen embryo (cleavage stage) transfer started 1.5 years after UTx. The first embryo transfer (n = 2) resulted in a biochemical pregnancy. The second, third, and fourth embryo transfer (n = 2, 2, 3) did not result in pregnancy. The fifth embryo transfer (n = 3) resulted in pregnancy with two gestational sacs, but with spontaneous disappearance of one in early pregnancy. During early pregnancy three episodes of vaginal bleedings occurred (gestational weeks 6 + 2, 13 + 1, and 16 + 3), with a spontaneously resorbing subchorionic hematoma diagnosed at the last bleeding episode. Bleeding episodes were treated with corticosteroids and tacrolimus. During pregnancy, blood flow velocity waveforms and fetal growth parameters were normal. A subacute cesarean section was performed at gestational week 33 + 6 due to uterine contraction pattern suggesting imminent labor. A healthy boy (2,000 g) with Apgar scores of 10, 10, 10 was delivered. The uterus was kept for a possible second pregnancy.

CONCLUSION(S)

The first live birth after UTx in the People's Republic of China is reported and this occurred after a robotic-assisted laparoscopic uterus retrieval from the mother.

Lower urinary tract symptoms in patients with Mayer-Rokitansky-Kuster-Hauser syndrome after neo-vagina creation by Davydov's procedure

INTRODUCTION

Lower urinary tract symptoms (LUTS) in subjects with Mayer-Rokitansky-Küster-Hauser syndrome treated by Davydov's laparoscopic neo-vaginoplasty were measured.

METHODS

Davydov's laparoscopic neo-vaginoplasty was undertaken at the Department of Obstetrics/gynecology, San Raffaele Hospital, Milan, Italy, from November 2015 to July 2017, by two highly qualified surgeons. All women completed the ICIQ-UI Short Form questionnaire before and after treatment. LUTS were scored at recruitment, hospitalization, and 1, 3, 6 and 12 months after surgery.

RESULTS

Twenty-one women (mean age 21 years ± 5.9) were operated on with no major complications. Mean surgery duration was 79 min (± 55 min). Before the operation, one patient (1/21; 4.8%) reported occasional urinary loss that persisted after surgery and throughout 12 months of follow-up. After the operation, one patient (1/21; 4.8%) had urinary retention, requiring self-catheterization for 2 weeks. One month after surgery, stress incontinence was recorded in one case (1/19; 5.2%) and urge incontinence in two cases (2/19; 10.5%). At 3-month follow-up, these three patients were free of symptoms.

CONCLUSION

The rate of LUTS is lower than that reported by others using alternative surgical procedures. To the best of our knowledge, this is the first report validating LUTS after Davydov's neo-vaginoplasty.

Mayer-Rokitansky-Küster-Hauser syndrome as an interdisciplinary problem

The Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, also known as Müllerian agenesis or aplasia, is a congenital disease manifested by the aplasia of the uterus and the upper 2/3 of the vagina; its incidence is 1 in 4,000-5,000 female live births. We can distinguish 2 types of the MRKH syndrome: type I, which is characterized by an isolated absence of 2/3 of the vagina and uterus; and type II or MURCS (Müllerian duct aplasia, unilateral renal agenesis and cervicothoracic somite anomalies), which is also associated with other symptoms. The treatment of the MRKH syndrome patients aims at creating a neovagina and enabling sexual intercourse. Non-surgical techniques are the first-choice methods, and more than 90% of patients notice an anatomical and functional improvement if they are well-prepared emotionally. If non-surgical treatment does not bring about the expected results, a surgical procedure remains an option. The surgical method is mainly determined by the surgeon's experience. There are a few types of operations, though none of them seems superior to others. The next challenge is to provide these patients with a chance to become parents. Nowadays, a uterine transplant, a surrogate or adoption are the available solutions. An interdisciplinary approach is required, and the treatment should consist of medical and psychological support. This review presents the current knowledge about the MRKH syndrome with regard to the current methods of non-surgical and surgical treatment as well as a summary of the associated psychological problems.

Cystoscopy and mucosectomy: Essentials in the management of persistent müllerian duct syndrome with transverse testicular ectopia

OBJECTIVES

The concurrence of Persistent Müllerian Duct Syndrome and transverse testicular ectopia is rare. The risk of damage to the vas deferens and the deferential blood supply hinders some surgeons from complete excision of potentially malignant Müllerian duct remnants.

METHODS

We present a unique surgical technique of Persistent Müllerian Duct Syndrome in a patient with right inguinal hernia accompanying transverse testicular ectopia.

RESULTS

During exploration, both testes were detected in the right inguinal canal. When the hernia sac was opened, a primitive uterus and fallopian tubes without fimbria were identified confirming Persistent Müllerian Duct Syndrome. A 4 Fr catheter was placed into the os of the Müllerian duct remnants via the verumontanumorifice, and then a urethral catheter was placed. The full-thickness excision of proximal Müllerian duct remnant swere performed. The distal part of Müllerian duct remnants was layed open and only mucosa was excised for preserving vas deferens. Resection was completed just above its junction with the urethra with the aid of 4Fr catheter marked at centimeter intervals and the cuffwas oversewn. High ligation for right inguinal hernia and bilateral orchidopexy were performed.

CONCLUSIONS

Removal of Müllerian duct remnantsis advised in order to reduce the jeopardy of malignancy, urinary tract infections, stones and hematuria. On the other hand, excision down to urethra which can compromise the integrity and vascularity of the vas deferens is diffucult, even in experienced surgical hands. Complete excision of these structures by mucosectomy of the distal part of remnant which lay closed to vas deferens is a safe and effective method. Cystoscopy assistance and placement of a catheter into MDRs were essential for the complete excision of this mucosa. To the best of our knowledge, cystoscopy assisted mucosectomy in Persistent Müllerian Duct Syndrome has not been reported previously.

A Phenotypic Female Adolescent with Primary Amenorrhea and Dysmorphic Features

We report on a case of a 14-year-old phenotypic female with a microdeletion at 13q31.1-q31.3, dysmorphic facial and limb features, and neurologic symptoms. She presented to her pediatrician with concerns for delayed puberty, and laboratory analysis revealed hypergonadotropic hypogonadism. She was found to have an XY karyotype and streak gonads. Further genetic studies did not reveal another cause for her gonadal dysgenesis and, to our knowledge, an association with her known 13q-microdeletion has not yet been reported. Given the risk of malignancy with XY gonadal dysgenesis, the patient had surgery to remove the gonads and had no postoperative complications after a 6-month follow-up visit. We also discuss the role of the pediatrician in cases of delayed puberty, from initial diagnosis to definitive management. [Pediatr Ann. 2019;48(12):e495-e500.].

Epidermoid carcinoma in the neovagina of a patient with Mayer-Rokitansky-Küster-Hauser syndrome. Case report and literature review

Objective

To present the case of a squamous carcinoma in the neovagina of a patient with Mayer-Rokitansky-Küster-Hauser syndrome and review of the literature related to treatment and prognosis of vaginal neoplasms or HPV infection in transgender women or with MRKH syndrome.

Materials and methods

A 56-year-old woman consulted to the Hospital Universitario of Sevilla (Spain). During the clinical examination, a exophytic tumor at the bottom of the vagina was found and the biopsy reported squamous carcinoma and positive nucleic acid amplification test for human papilloma (HPV) type 16. A literature search of case reports, case series and observational studies published from 2000 to October 2019 in English and Spanish was performed in Medline via PubMed, with the follow- ing terms: "congenital abnormalities"; "Mullerian aplasia"; "neovagina"; "Vaginal neoplasms"; "Squamous carcinoma"; "HPV infection" was performed.

Results

14 studies were finally included; seven corresponded to squamous cell carcinoma, three to adenocarcinoma and four reported HPV infection only. All of the squamous cell carcinomas were at advanced stages due to local or lymphatic compro- mise and received radiotherapy with concomitant chemotherapy or radical surgery. The prognosis was bad in three of the cases. Patients with adenocarcinoma also presented with advanced lesions due to local extensión and received surgical treatment and two cases received concomitant chemotherapy. Only one patient was followed-up for five years or more. HPV infection is common in women who underwent neovagina reconstruction.

Conclusions

Patients with neovagina are susceptible to develope squamous carcinomas or adenocarcinomas depending if skin or intestinal tissue grafts are used. According to local compromise at the time of diagnosis, radical or combined treatments are required. Which screening strategies for HPV, squamous cell carcinomas and adenocarcinoma is to be investigated.

Novel Minimally Invasive Technique of Neovaginoplasty Using an Absorbable Adhesion Barrier

Our objective was to provide a minimally invasive neovaginoplasty technique to construct a nearly physiologic vagina to facilitate sexual functioning and appropriate vaginal length in patients with congenital vaginal agenesis. This retrospective study at a tertiary care hospital comprised 52 patients with congenital vaginal agenesis because of Mayer-Rokitansky-Küster-Hauser syndrome or androgen insensitivity syndrome presented for vaginal reconstruction. Modified McIndoe vaginoplasty was done in all patients between 2010 and 2018 using a vaginal mold created with glove, nonadherent petroleum gauze, and Interceed absorbable adhesion barrier (Ethicon, Johnson & Johnson, Somerville, NJ) that was placed in the neovagina space created between the bladder and rectum for 7 days. Operative details, complications, length and width of the neovagina, and functional outcome were evaluated. The mean operation time was 35 minutes. The mean length of the constructed neovagina was 8.4 cm × 3.4 cm at 6 weeks follow-up. Epithelialization was completed by 4 to 6 months. All patients reported satisfactory sexual activity with no pain and good mucosal sensitivity. This modified neovaginoplasty technique is easy to perform, involves painless postoperative dilatations as the cornerstone of treatment, and results in adequate secretion, allowing lubrication and acceptable physiologic results.

The Interest of Women with Mayer-Rokitansky-Küster-Hauser Syndrome and Laparoscopic Vecchietti Neovagina in Uterus Transplantation

STUDY OBJECTIVE

The goal of this study was to assess a group of women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with surgically created neovaginas in the interest of uterus transplantation (UTx) and to recruit the first group of applicants for a UTx trial.

DESIGN AND SETTING

This was an original prospective study using semistructured interviews.

PARTICIPANTS

A study group of 50 women with MRKH syndrome with Vecchietti neovaginas was recruited via letter of invitation.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Interest of MRKH women in obtaining experimental UTx for the treatment of absolute uterine factor infertility.

RESULTS

A total of 50 women responded via e-mail and 31 (62% [31 of 50] of the study group) expressed serious interest in UTx after complete information about its risks and benefits was provided during the first semistructured interview. They subsequently agreed to participate in additional interviews and further examinations. Because of various reasons, only 9 women were prepared to enter our UTx trial (18% [9 of 50] of the study group). Three recipients/donors were accepted into the living donor arm and 6 into the deceased brain donor arm of the trial.

CONCLUSION

Nearly two-thirds of our MRKH syndrome study group women with surgically created neovaginas were interested in UTx and motivated to undergo this method of absolute uterine factor infertility treatment. Therefore, this group of women might be approached to participate in ongoing and future UTx trials. Future studies of women with MRKH syndrome might confirm or disprove the results of our survey.

Vaginal reconstruction with the modified rectosigmoid colon: surgical technique, long-term results and sexual outcomes

Although vaginal reconstructions with intestinal segments require particularly complex surgical procedures, this technique has become popular with respect to fairly good functional and esthetic outcomes. This study describes cases of vaginal reconstruction performed using a modified rectosigmoid colon held in an ischemic state in order to reduce secretion and denervated in order to prevent defecation problems. Vaginal reconstructions with rectosigmoid colon were performed on 43 patients. In this retrospective study, 34 patients had Müllerian agenesis, while nine had undergone male to female sex reassignment surgery in which adequate vaginal depth had not been achieved. A rectosigmoid colon with its vascular pedicle was used and left in an ischemic state. All nerve structures within the pedicle were excised intraoperatively. Follow-up period was between 12 and 60 months. Partial necrosis occurred in one patient which was reconstructed with local flap. Hematoma developed beneath the skin incision in two cases, but resolved with conservative treatment. A good esthetic outcome was achieved in all cases. Sexual function was assessed using the Female Sexual Function Index (FSFI) in 15 patients. Fourteen out of 15 patients scored above 26.5 on this scale and were determined as having no sexual dysfunction (FSFI score ≥26.5). In conclusion, vaginal reconstruction with denervated rectosigmoid held in an ischemic state appears to be a reasonable option among several available reconstruction techniques.

Obstructive Müllerian Anomalies in Menstruating Adolescent Girls: A Report of 22 Cases

STUDY OBJECTIVE

To assess the clinical course of obstructive Müllerian anomalies found in girls after menarche.

DESIGN

A retrospective case series of adolescents who, between 2009 and 2016, were treated for vaginal or uterine obstructive malformations diagnosed after menarche.

SETTING

Division of Gynecology, Poznań University of Medical Sciences, Poznań, Poland.

PARTICIPANTS AND INTERVENTIONS

Twenty-two patients who, at the age range between 11.4 and 18.2 (median, 13.1) years, between 2 and 74 (median 7.5) months after menarche, underwent surgical repair of obstructive genital anomaly.

MAIN OUTCOME MEASURES

Müllerian defect type, presentation, radiologic findings, pre- and postoperative course.

RESULTS

Eighteen patients (18 of 22; 81.8%) were diagnosed with obstructed hemivagina ipsilateral renal anomaly syndrome. One patient (1 of 22; 4.5%) was diagnosed with uterus didelphys and unilateral cervical atresia. Three patients (3 of 22; 13.6%) had unicornuate uterus with a cavitated, noncommunicating rudimentary horn. The right side was affected in 13 patients (13 of 22; 59.1%), and the left side in 9 patients (9 of 22; 40.9%; P > .05). All but 1 patient had renal agenesis on the side of obstruction. Before repair of the obstructive genital anomaly, 4 patients underwent unnecessary surgeries for misdiagnosed ovarian cysts. Serious complications (pelvic inflammatory disease, vesicovaginal fistula) occurred in 2 patients with microperforated pyocolpos. Pelvic endometriosis was found in 4 of our patients.

CONCLUSION

Our case series suggests that obstructed hemivagina ipsilateral renal anomaly syndrome is the most common obstructive Müllerian anomaly diagnosed in adolescents after menarche. The differential diagnosis for unilateral kidney agenesis accompanied by dysmenorrhea in adolescent girls should include obstructive genital tract anomaly. Accurate diagnosis of an obstructive genital anomaly early after menarche might help prevent unnecessary surgeries and infection-related complications. Meanwhile, prompt surgical correction of an obstructive genital tract anomaly results in relief of symptoms and might reduce the risk of endometriosis.

Transverse Vaginal Septum: Report of Two Patients with MRI Findings

The transverse vaginal septum is a rare form of Mullerian duct anomaly, and is a disorder of vertical fusion of Mullerian system with the sinovaginal bulb. Magnetic resonance imaging (MRI)is very useful in the detection, classification and management planning of this rare anomaly. We present two cases of transverse vaginal septum in two patients of different age groups and with different clinical presentations. The findings on MRI, related to presence of vaginal septum and the management work-up, are also discussed.

Decidualization is Impaired in Endometrial Stromal Cells from Uterine Rudiments in Mayer-Rokitansky-Küster-Hauser Syndrome

BACKGROUND/AIMS

Uterine rudiments from patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) contain all tissues typically found in the uterus. Endometrium from the rudiments predominantly exhibits basalis-like features, and endometrial proliferative capacity in patients' epithelium and stroma is significantly lower.

METHODS

This single-center, prospective study conducted at a major German university hospital compared in-vitro decidualization in cultured ESCs from MRKHS patients and hysterectomy controls. Primary ESC cultures were established from both sources. Hormone-induced prolactin and IGFBP-1 secretion served as a measure of their ability to undergo decidualization in response to hormonal stimulation. Expression levels of 8 key marker genes of decidualization were also determined.

RESULTS

At day 9, mean secretion of prolactin and IGFBP-1 was significantly reduced by 89.0% and 99.5%, respectively, in MRKHS ESCs vs. hysterectomy controls, both indicating impaired decidualization of MRKHS ESCs. Key decidual markers confirmed impaired decidualization in MRKHS patients.

CONCLUSION

Our results indicate that the ESCs from MRKHS patients lack hormone responsiveness as a potential sign of dysfunctional hormone receptor function, which may also play a role in the onset of MRKHS. Further studies are needed to corroborate our findings, directly address receptor function, and elucidate the role of other potential determinants of uterine development and adult function.

[Two Surgical Cases of Müllerian Cyst Arising From the Posterior Mediastinum]

We experienced 2 cases of Müllerian cyst. Case 1 was a 48-year-old woman with a paravertebral cystic tumor. The tumor grew from 23 to 31 mm in diameter for the 3 years. She underwent video-assisted thoracic surgery(VATS) for the excision of the tumor. Case 2 was a 40-year-old woman with a paravertebral cystic tumor, who underwent VATS. The Histological finding showed that the tumors of both cases were the cysts lined by non-stratified cuboidal to columnar epithelium and epithelial cells were positive in the nucleus with estrogen receptor immunohistochemically. The resected cysts were finally diagnosed as Müllerian cyst. Twenty four published cases of Müllerian cyst were reported before, including symptomatic and growing cases. There were some reports of malignant transformation in cases of pelvic origin.

Quadro-Cornuate Uterus

Congenital malformations of the female genital tract are a group of miscellaneous deviations from normal anatomy with diverse spectrum. Mullerian anomalies are thought to be present in 0.5% of female population. Three quarter of women remain asymptomatic, the remaining quarter presents with a variety of symptoms including primary amenorrhea, cyclical pain, severe dysmenorrhea, pelvic mass, ectopic pregnancy, infertility and recurrent miscarriages. The American Fertility Society (AFS) classification has been the most widely used classification for categorizing these abnormalities. Recently, European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) proposed another classification system of female genital anomalies which provides a comprehensive description and categorization of almost all of the currently known anomalies. This case report describes a 23-year, married, parous woman with severe dysmenorrhea. Workup revealed a right adnexal mass which preoperatively was consistent with noncommunicating horn(s) of uterus. Peroperatively a new entity, a uterus with four cornua, was seen.

Laparoscopic Davydov Procedure for the Creation of a Neovagina in Patients with Mayer-Rokitansky-Kuster-Hauser Syndrome: Analysis of 7 Cases

OBJECTIVE

Several surgical techniques have been described for creating a neovagina in patients with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome, however as yet there is no standardized treatment. The aim of this report is to assess anatomic and functional outcomes after the laparoscopic Davydov procedure for the creation of a neovagina in patients with MRKH syndrome.

METHODS

Seven patients with MRKH syndrome underwent the laparoscopic Davydov technique from January 2005 to August 2010. The anatomic and functional results were evaluated after 3, 6, 12, 24, 36, 48, and 60 months.

RESULTS

The surgical procedure was performed with no major complications except in one case in which an intraoperative bladder injury occurred and was successfully corrected. The mean duration of surgery was 162.9 minutes (range, 120-230 min). Mean lengths/widths (cm) of the neovagina were 6.4/2.6, 6.5/2.5, 6.5/2.8, 6.4/2.8, 7.1/2.8, and 7.2/2.8 at 3, 6,12, 24, 36, 48, and 60 postoperative months, respectively.

CONCLUSION

The laparoscopic Davydov procedure seems to be a safe and effective surgical treatment for patients with MRKH syndrome if postoperative intermittent self dilation was done.

Hysteroscopic treatment of Müllerian duct anomalies

Müllerian duct anomalies are a broad and complex spectrum of abnormalities that are often associated with infertility, obstetric complications as well as gynecological disorders among women of reproductive age. Operative hysteroscopy is the gold standard in the treatment of most of those anomalies amenable to surgical correction. The evidence to date shows an ongoing increase in the release of recommendations in favour of operative hysteroscopic treatment, in concert with the progressive refinement of hysteroscopic technologies and techniques. The aim of this paper was to describe and critically evaluate the role of the currently available hysteroscopic techniques for treating Müllerian duct anomalies, taking into account their indications, feasibility and efficacy as well as their impact on the reproductive outcome. Special attention will be paid to the most recently developed minimally invasive treatments for uterine and vaginal anomalies.

Laparoscopic Modified Vecchietti Technique for Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Report of Two Cases

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital disorder characterized by uterine aplasia and aplasia of the upper part of the vagina. It presents with primary amenorrhea in a 46, XX individual. In this paper, we report the cases of two patients with MRKH syndrome treated with the laparoscopic modified Vecchietti technique using the optimized new instruments. A neovagina was successfully created in these two patients. This minimally invasive technique offers improvements in terms of operative time, complications, and functionality.

The Utility of Core Needle Biopsy and Fine-Needle Aspiration in the Workup of Tumors of Suspected Müllerian Origin

OBJECTIVES

Core needle biopsy (CNB) and fine-needle aspiration (FNA) for tumors of suspected Müllerian origin may prevent unnecessary laparotomies and allow patients the benefit of neoadjuvant chemotherapy. An assessment of the utility and limitations of CNB/FNA, with incorporation of current immunohistochemistry, is needed.

STUDY DESIGN

Two hundred nineteen female patients with CNB/FNA of the omentum, pelvis, abdomen, adnexa, ovary, uterus, and fallopian tube were identified. From these, 30 consecutive CNB/FNA with corresponding surgical resection were reviewed to assess diagnostic agreement and identify potential diagnostic pitfalls.

RESULTS

The most frequent diagnosis overall was adenocarcinoma (96/219; 43.8%), most commonly adenocarcinoma of gynecologic origin (65/219; 30%). Nondiagnostic or unsatisfactory material was present in a minority of cases (10/219; 5%). In the 30 CNB/FNA cases examined for diagnostic agreement with surgical resection, 24 (80%) had exact or essential agreement with the final diagnosis. Of the 23 cases that were positive and/or suspicious on cytology, 18 (78%) had neoadjuvant chemotherapy or radiation treatment prior to surgical resection.

CONCLUSIONS

The majority of CNB/FNA for tumors of suspected Müllerian origin are diagnostic, correlate with the surgical resection, and contribute to management. A standard diagnostic algorithm is suggested.

Sexual and Psychosocial Functioning in Women with MRKHS after Neovaginoplasty According to Wharton-Sheares-George: A Case Control Study

Background

Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) has a major impact on a woman’s psychological and sexual well-being. In most of the studies that addressed treatment techniques, postoperative sexual function was reported to be satisfactory; however, comparatively few studies have additionally provided an accurate analysis of psychosocial functions in MRKHS patients following different kinds of neovaginal treatment. This study is to evaluate sexual and psychosocial functioning after creation of a neovagina according to Wharton-Sheares-George in women with MRKHS.

Methods

We performed a case-control-study using multiple measures to assess sexual and psychosocial functioning. Ten MRKHS patients and 20 controls of a University hospital and tertiary center for pediatric and adolescent gynecology were assessed. The follow-up assessment comprised 6 standardized questionnaires (Female Sexuality Function Index, FSFI; Patient Health Questionnaire, PHQ; Brief Symptom Inventory, BSI; World Health Organization Quality of Life Assessment, WHOQoL-BREF; Parental Bonding Instrument, PBI; and a German questionnaire on body image). The main outcome measures were sexual function, psychological status, quality of life, body image, and parental bonding styles.

Findings

Sexual function, psychological status (including depressive and somatic symptoms), quality of life, and own-body experience were at least as good in operated MRKHS patients as in controls. In some measures (FSFI, PHQ-15, psychological domain of the WHOQoL-BREF, and BSI Positive Symptom Total), patients scored significantly better than controls. The results of the PBI indicated a close and sustainable mother-daughter-relationship in MRKHS patients.

Conclusions

We found no evidence for an impairment of sexual or psychosocial functioning in patients after neovaginoplasty according to Wharton-Sheares-George. MRKHS may not necessarily compromise sexual and psychological well-being, provided that the syndrome is properly managed by a multidisciplinary team of health professionals.

[Comparison study between Vecchietti's and Davydov's laparoscopic vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome]

OBJECTIVE

To compare Vecchietti's and Davydov's laparoscopic techniques for vaginoplasty in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome.

METHODS

From January 2010 to December 2013, 13 patients underwent the Vecchietti's laparoscopic procedure (Vecchietti group), and 15 patients underwent the Davydov's laparoscopic procedure (Davydov group). Intraoperative parameters and postoperative results were compared.

RESULTS

Both of the two groups were successfully treated. The neovagina in both groups were wide with good elasticity, softness and smoothness. The operation time [(39±7) versus (73±11) minutes], the intraoperative blood loss [(21±6) versus (63±10) ml], the anal exsufflation time after surgery [(19±5) versus (28±6) hours] and the recovery period of body temperature after surgery [(35±10) versus (46±10) hours] of the Vecchietti group were less than those of the Davydov group (all P<0.05). But the neovagina length [(8.8±0.5) versus (9.6±0.5) cm] was shorter and the Female Sexual Function Index scale score [26.8±2.0 versus 28.5±1.7] was lower in the Vecchietti group than those in the Davydov group (all P<0.05). The postoperation hospital duration didn't reached statistical difference between the two groups [(7.5±0.9) versus (7.1±0.7) days, P>0.05]. No intraoperative complication occurred. After surgery, 2 patients were found vaginal polyps and 8 patients were suffered from pain in the Davydov group, while all patients were suffered from pain in the Vecchietti group.

CONCLUSIONS

Both Vecchietti's and Davydov's laparoscopic techniques are simple, safe and effective surgical methods for vaginal reconstruction. In contrast, the Vecchietti's procedure is more time efficient and minimally invasive, while the Davydov's procedure can get less pain, longer vagina and higher sexual satisfaction.

Oestrogen receptor alpha expression in neovaginal tissue of women following modified Abbé-McIndoe technique and in premenopausal women

The aim of the study was to compare the expression of oestrogen receptor alpha (ERα) in neovaginal tissue of patients with vaginal agenesis following neovaginoplasty using regenerated, oxidised cellulose in premenopausal women. A prospective, observational case-control study was performed on eight patients with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty and 10 control premenopausal women following benign gynaecologic surgery. 6F11 monoclonal antibody was used to determine ERα expression in the vaginal mucosa. Quantitative and qualitative evaluations were performed, respectively, in vaginal epithelium and stroma. The thickness of the vaginal epithelium was determined as the vertical distance between the basal layer cells and the apical surface of the superficial layer. The percentage of ERα-expressing cells was higher in the control group, except in the superficial zone of the epithelium. In the stromal tissue, ERα was detected in only one patient from the neovagina group compared with nine women in the control group. The neovagina group had a statistically thinner epithelium. Our study suggests that women with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty using regenerated oxidised, cellulose experience relatively local hypo-oestrogenism in the first year after surgery, with repercussion in vaginal trophism.