Transumbilical Vaginoplasty Through Fractionated Miniports: A Sutureless Procedure.

BACKGROUND: Vaginal agenesis is a müllerian anomaly characterized by congenital absence of the vagina. In this case series, the authors describe a novel, minimally invasive technique using microport entry for treatment of complete vaginal agenesis. TECHNIQUE: A balloon catheter is passed through a fenestrated perfluoroalkoxy polymer resin-supporting platform, then tied by a silk suture over the caudal end of the inserter. Two 4-mm microports are created intraumbilically; one to insert the scope and the other to introduce the catheter inserter that is advanced under direct vision. The inserter loaded with a catheter is passed across the pelvic floor to position the balloon at the vaginal dimple. The balloon is inflated and tightly positioned against the dimple. The perfluoroalkoxy polymer resin piece is clamped at the umbilicus. Traction is applied to the catheter stem and increased progressively to achieve desired vaginal depth. EXPERIENCE: Twenty-two women aged 17-28 years with vaginal agenesis underwent microport vaginoplasty. Twenty-one women were diagnosed with müllerian agenesis and one patient with androgen insensitivity syndrome. Preoperative vaginal depth ranged between 0.5 and 3 cm. The procedure was well tolerated with no intraoperative or postoperative complications. Patients achieved neovaginal depth between 9 and 11 cm and penetrations scores increased to 80-90%. CONCLUSION: Microport vaginoplasty is a feasible and effective procedure for management of vaginal agenesis.

Dual-Force Vaginoplasty for Treatment of Segmental Vaginal Aplasia.

BACKGROUND: Vaginal aplasia occurs in 1 in 5,000-10,000 female live births. In this report, we evaluated a novel dual-force vaginoplasty technique for treatment of 11 patients with segmental vaginal aplasia. TECHNIQUE: The principle of the approach is to thin the atretic part between two counteracting forces. The instrument was inserted laparoscopically into the proximal hematocolpos. Two balloon catheters, one for drainage and one for traction, were threaded over the inserter. The traction catheter was then threaded over a silicon tube, leaving the balloon in the proximal portion of the vagina and connecting across the vaginal septum to a fenestrated Teflon olive, which was positioned against the distal surface of the vaginal septum. This created a dual "pushing and pulling" force across the septum, which, over 3-4 days, pulls the upper vaginal pouch down while the vaginal dimple is pushed up. The aplastic segment becomes thin and easy to dilate and permits achievement of vaginal patency. The drainage of the hematocolpos is predominantly through the balloon catheter so postoperative wound management is facilitated. EXPERIENCE: Eleven menarchal girls were diagnosed with segmental vaginal aplasia. The dual-force vaginoplasty was performed on each and was tolerated well with no operative complications. They all reported establishment of the menstrual cycle and significant improvement of pain during follow-up. CONCLUSION: Creation of a dual pushing-pulling force on the atretic vaginal segment is a feasible short procedure for management of segmental vaginal aplasia.

Tactile Electrosurgical Ablation: A Technique for the Treatment of Intractable Heavy and Prolonged Menstrual Bleeding.

Objective. To study the efficacy and safety of tactile electrosurgical ablation (TEA) in stopping a persistent attack of abnormal uterine bleeding not responding to medical and hormonal therapy. Methods. This is a case series of 19 cases with intractable abnormal uterine bleeding, who underwent TEA at the Women's Health Center of Assiut University. The outcomes measured were; patient's acceptability, operative time, complications, menstrual outcomes, and reintervention. Results. None of the 19 counseled cases refused the TEA procedure which took 6-10 minutes without intraoperative complications. The procedure was successful in the immediate cessation of bleeding in 18 out of 19 cases. During the 24-month follow-up period, 9 cases developed amenorrhea, 5 had scanty menstrual bleeding, 3 were regularly menstruating, 1 case underwent repeat TEA ablation, and one underwent a hysterectomy. Conclusions. TEA represents a safe, inexpensive, and successful method for management of uterine bleeding emergencies with additional long-term beneficial effects. However, more studies with more cases and longer follow-up periods are warranted.

Laparo endoscopic single site balloon vaginoplasty (LESS-BV).

OBJECTIVE: To evaluate feasibility, advantages, and disadvantages of the laparo-endoscopic single site surgery (LESS) technique for balloon vaginoplasty (BV). STUDY DESIGN: Cohort study. SETTING: Tertiary care facility. RESULTS: LESS-BV was successfully performed in 6 patients with Mullerian aplasia and one with androgen insensitivity syndrome (AIS). Patients presented with failure of intravaginal intercourse and/or dyspareunia. The procedure was performed successfully in conjunction with gonadectomy for the AIS case. The total operative time was 50-75 minutes. No operative complications were reported. Postoperative pain scores ranged from 0 to 2 points at rest and from 20 to 60 points during dressing change, increasing distension, and traction. The depths of the constructed neovaginas measured up to 12.8 cm. Sexual intercourse was initiated on the day of catheter removal. Penetrations and satisfactions scores increased to up 90 points for both partners. CONCLUSIONS: LESS-BV is technically feasible. LESS-BV allows better, stronger midline and long traction pass along the anatomic longitudinal axis of the hypoplastic vagina. Surgical outcomes should be compared prospectively to conventional laparoscopic BV.

A rescue management plan for ruptured balloons during balloon vaginoplasty.

OBJECTIVES: To present the first repeat procedure and a simple way for management of balloon rupture during balloon vaginoplasty (BV) procedures. STUDY DESIGN: Repeat BV (reBV) procedure was done for one case, and a ruptured catheter's end to new catheter's end (ENE) procedure was done for two cases. The anatomic and functional outcomes of reBV and ENE are presented. RESULTS: Balloon rupture and deflation were encountered in a total of 3/45 cases who had undergone BV procedures. Replacement time was 22 min for reBV, and 9 and 10 min for ENE. General anesthesia was needed in the reBV case. Post-operative course and final outcomes were generally good but objectively less favorable in the ENE than in the reBV case (neovaginal depths were 8.5 and 9.4 cm versus 11 cm, respectively). Penetration and satisfaction scores were increased up 85 points for both couples. CONCLUSIONS: Balloon ruptures were reported in 3/45 cases undergoing balloon vaginoplasty. End to new catheter end replacement was a very fast and simple rescue procedure but its preliminary anatomical outcomes were less favorable than the outcomes obtained with the original or repeat procedure.

Hybrid septate uterus, coexistence of bicornuate and septate varieties: a genuine report.

AIM: To highlight the coexistence of a uterine septum in cases diagnosed as bicornuate uterus on the basis of the external shape of the uterine fundus and to present the outcomes of its hysteroscopic management. METHODS: Descriptive clinical report. Cases with two-chambered uterine cavities were recruited with exclusion of cases with pure bicornuate uteri. The differentiation between hybrid and pure septate uterine varieties was based on clinical evaluation, transvaginal ultrasonic evaluation, hysterosalpingography and in addition to bimanual examination under anesthesia. The final diagnosis was confirmed by combined hysteroscopy-laparoscopy examinations. Cases with pure and hybrid septate uteri were managed by hysteroscopic metroplasty and the outcomes were compared. RESULTS: Out of 357 cases of double chambered uteri, 18 cases (5%) were found to be a pure bicornuate variety (PBV), 322 (90.2%) cases were found to have pure septate variety (PSV) and 17 cases (4.8%) were found to have hybrid septate variety (HSV). In HSV, there was external fundal depression dividing only the upper part of the corpus giving an imprecise impression of a bicornuate uterus with a laparoscopic view, but there was a long extension of the dividing interface. Nine cases with HSV were associated with a complete utero-cervico-vaginal septum, and five cases had a complete uterine septum. The diagnosis of asymmetric horns, hemi-obstruction or bicervical uterus was made in three cases with HSV. All cases with a septate uterus were offered hysteroscopic metroplasty, and cases with fundal depression were operated under laparoscopic monitoring. In cases with HSV, the procedure was performed safely and successfully in 16/17 cases (94%). One uterine perforation was encountered, giving a six-fold increase in the perforation risk, and passed uneventfully. Successful reproductive outcomes were reported in 178/189 cases (94.1%) with PSV and in 12/15 (80%) with HSV. CONCLUSIONS: External fundal depressions of variable depths are associating with a septate uterus, indicating coexistence of the two anomalies. These cases are candidates for hysteroscopic metroplasty under appropriate sonographic and/or laparoscopic monitoring.

Failed vaginoplasty: a successful novel blend of minimally invasive approaches.

OBJECTIVE: To evaluate outcomes of a novel blend of techniques for treating vaginal contractures secondary to previous conventional constructive surgeries. STUDY DESIGN: Balloon vaginoplasty and scar tissue hydrolysis/hydro-disintegrations (BV/STH) were performed for three cases with vaginal scars after previously failed vaginoplasties. The outcomes measured were operative complications, vaginal depths as measured by a calibrated vaginometer, and functional outcomes as measured by changes in the penetration and satisfaction (P/S) scores on a 0-100 point visual analog scale. RESULTS: BV/STH was performed successfully for 3 women with previously failed vaginoplasties. They included a case with a previous partial thickness skin grafting, one with previous labial flaps and one with previous amnion membrane graft. Preoperative P/S scores ranged from 20 to 30 points. Initially BV was done in addition to multiple snips of the scar tissue with a 2mm scalpel. No operative complications were reported but we failed to achieve progressive increase in vaginal depth after day 4. Scar tissue was injected with a mixture of lidocaine and normal saline. Progressive increase in depth was dramatically improved after scar hydro-disintegration. The depths of the resultant neovaginas were 10, 11 and 11.6 cm. Postoperative P/S scores increased up to 90. CONCLUSIONS: BV/STH was successfully performed as a revision surgery for blind vaginas with fibrosis. This report highlights a wider range of possible applications of balloon vaginoplasty.

Inverted balloon vaginoplasty: an obstructed upper vaginal pouch was pulled downward to form a neovagina.

Inverted balloon vaginoplasty technique was performed for a case with segmental vaginal aplasia and upper hematocolpos within 50 min operative time without any complications. The neovagina was naturally covered, 11 cm in depth and communicated with dimple at hymen's site. Regular painless menstruations were reported.

An adolescent affliction: nephrectomy and persistent severe pains due to misdiagnosed non-communicating "retroperitoneal" uterine horn.

STUDY OBJECTIVE: To report the existence and management of retroperitoneal functioning uterine horn in a case with unicornuate uterus and to emphasis the significance of its misdiagnosis. STUDY DESIGN: Case report. SETTING: Assiut University, Woman's Health Hospital. PARTICIPANTS: An adolescent female with progressive pains related to menstruation. INTERVENTIONS: Extraperitoneal resection of the obstructed uterine horn. MAIN OUTCOME MEASURE: Operative time, complications and postoperative pains. RESULTS: A patient aged 11 years presented with severe lower abdominal pains, history of correction of ectopia vesicae in infancy, and recent history of nephrectomy for ipsilateral obstructed pelvic kidney. MRI and transrectal ultrasonography showed a pelvic mass with thick wall. Laparoscopy showed unicornuate uterus with only the left horn was being visualized. Hysteroscopy showed normal vagina and cervical canal communicating with normal left hemi-cavity. Extraperitoneal approach via extending the incision of previous nephrectomy was done under laparoscopic monitoring. Excision of the horn was done totally extraperitoneal without puncturing its covering parietal peritoneum within 65 min. No operative or postoperative complications were reported. Menstrual pains showed dramatic improvement after the procedure. CONCLUSIONS: The present report is the first to describe the existence of a retroperitoneal functioning uterine horn with description of a successful extraperitoneal approach for its excision. Nephrectomy in the present case might be attributed to misdiagnosis of this problem.

Outpatient balloon vaginoplasty for treatment of vaginal aplasia: retropubic balloon vaginoplasty was performed as an office procedure under local anesthesia.

We evaluated the feasibility and operative and postoperative outcomes of office balloon vaginoplasty. Office balloon vaginoplasty was performed successfully for a case with vaginal aplasia. She was currently married and presenting with minimal penetration and dyspareunia. We successfully performed the procedure through retro-pubic space under local anesthesia within 25 min total operative time and it was well tolerated by the patient. No operative complications were reported. The resulting neovagina was cosmetically attractive and 10 cm in depth. Sexual intercourse was started on the day of catheter removal. Penetration and satisfaction scores increased up to 90 points for both partners.

Successful canalization of a noncommunicating uterine horn by horn-vaginal anastomosis: preliminary findings of a novel approach for an unclassified anomaly.

PURPOSE: The aim of this study was to present the preliminary results of a new technique for horn-vaginal anastomosis. METHODS: Horn-vaginal anastomosis without any dissection at the lower pole of the horn or vaginal apex at the site of anastomosis. This was followed by dilation and silicone stent retention for 4 months. RESULTS: The patient was a 14-year-old presenting with primary amenorrhea and severe recurrent cyclic lower abdominal pain. The total operative time was 115 minutes. No operative complications were reported. The patient developed stenosis of the tract after 2 successive menstrual periods (MP). The third period was retained. Transvaginal dilatation of the communication tract was successfully accomplished, and a silicon stent was left in place for 5 successive MP. The patient is now menstruating in a regular pattern for 15 successive MP, and an office hysteroscopic examination showed a patent tract with a normal hemicavity leading to a normal tubal ostia. CONCLUSIONS: Communication between a well-developed noncommunicating uterine horn and vagina was accomplished with successful establishment of the menstrual outflow tract. Regular menstrual pattern was successfully reestablished for 15 consecutive menstrual periods.

Müllerian duct anomalies: successful endoscopic management of a hybrid bicornuate/septate variety.

STUDY OBJECTIVE: To highlight the coexistence of uterine septum in cases diagnosed as bicornuate uterus on basis of the external shape of uterine fundus. STUDY DESIGN: Case report with description of the technique. SETTING: Women's Health Assiut University Hospital. PARTICIPANTS: An adolescent female with progressive pains dating since menarche. INTERVENTIONS: Hysteroscopic resection under laparoscopic monitoring through an intact hymen. MAIN OUTCOME MEASURE: Operative time, complications, postoperative abdominal pain, appearance of the uterine cavity RESULTS: A patient with a septate uterus with a fundal depression and hemiuterine obstruction underwent hysteroscopic resection under laparoscopic monitoring. Laparoscopy was beneficial in diagnosis and treatment of associated pathology and monitoring the hysteroscopic procedure. Hysteroscopic metroplasty was performed and resulted in unification of the lower two thirds of the uterus. Dysmenorrhea was dramatically improved after the procedure. Subsequent office hysteroscopy confirmed restoration of a unified lower uterine corpus anatomy mimic to the original bicornuate state. CONCLUSIONS: External fundal depression which characterizes bicornuate uterus was associated with a septate uterus with hemi uterine obstruction. This report demonstrates the coexistence of the two anomalies. Endoscopic management of this patient was safe and successful.

Enhancement balloon vaginoplasty for treatment of blind vagina due to androgen insensitivity syndrome.

OBJECTIVE: To evaluate the safety and feasibility of enhancement balloon vaginoplasty (EBV) in cases with blind vagina due to androgen insensitivity syndrome. DESIGN: Case series with description of the technique. SETTING: Women's Health Center, Assiut University, and Sohage Teaching Hospital, Sohage University. PATIENT(S): Three X,Y females (two cases presenting with apareunia and the third presenting with severe dyspareunia). INTERVENTION(S): Laparoscopy-assisted EBV. MAIN OUTCOME MEASURE(S): Operative time, complications, depth and width of neovagina, and functional status. RESULT(S): Our cases were currently married phenotypical females and had 46,X,Y karyotypes. They had well developed secondary sexual characters, but they presented with failure of intravaginal intercourse. EBV was performed successfully for three X,Y females. The total operative time was 38-45 minutes. No operative complications were reported, and there were no reported postoperative complications as a result of moving the direction of traction. The resultant neovagina's depths were 10, 11, and 12 cm, respectively. Sexual intercourse was set off on the day of discharge. Penetration and satisfaction scores increased up to 90 points for both partners. CONCLUSION(S): It was feasible and safe to move centrally the direction of traction and to move the point of catheter exit up with apparently better outcomes than conventional balloon vaginoplasty for treatment of blind vagina due to androgen insensitivity syndrome.

Anterior abdominal wall cervicopexy for treatment of stage III and stage IV uterine prolapse.

OBJECTIVE: To study the operative and postoperative outcomes of anterior abdominal wall cervicopexy (AWC) for treatment of stage III and stage IV uterine prolapse. METHODS: AWC was performed by anchoring the supravaginal cervix to the anterior abdominal wall. This was done following obliteration of the pouch of Douglas via laparotomy. RESULTS: Among 37 patients, AWC was performed in 21 women with stage III and 16 women with stage IV uterine prolapse. Overcorrection was observed in 3 women. Postoperatively, 2 women experienced febrile morbidity and 5 had urinary retention. Thirteen women complained of urinary frequency, but all reported improvement at 3-month follow up. Among 24 women who became pregnant, 14 delivered vaginally, 5 delivered by cesarean, and 5 had an ongoing pregnancy. Four recurrences occurred: 2 stage II and 2 stage III prolapses. Three of these women had delivered by cesarean, while the fourth recurrence occurred after the patient's third vaginal birth. CONCLUSIONS: AWC is a simple and effective procedure to treat stage III and stage IV uterine prolapse. However, some surgical modifications and more studies are required to ascertain its validity.

Tactile cold scissor metroplasty as a novel backup method for hysteroscopic metroplasty.

OBJECTIVE: To study the operative, anatomic, and functional outcome of tactile cold scissor metroplasty (TCSM) as a backup method for hysteroscopic metroplasty. DESIGN: Case series with description of the technique. SETTING: Assiut University Women's Health Center. PATIENT(S): Three cases with failed hysteroscopic metroplasty out of 127 cases with uterine septa scheduled for hysteroscopic resection. INTERVENTION(S): The TCSM procedure was performed in three cases under direct laparoscopic monitoring. MAIN OUTCOME MEASURE(S): Operative time, complications, hysteroscopic appearance of the cavity, reproductive outcome, and reintervention rates. RESULTS: The TCSM procedure was performed successfully in the three cases with a short total operative time (10-12 minutes). Subsequent office hysteroscopic appearance was satisfactory. Patients were then followed up for a period of time ranging from 3 to 28 months. One case had a successful pregnancy outcome, one has an ongoing pregnancy, and the last one did not get pregnant so far. CONCLUSION(S): Tactile cold scissor metroplasty is a useful, safe, and effective backup procedure for hysteroscopic metroplasty.

Endoscopically monitored canalization for treatment of congenital cervical atresia: the least invasive approach.

OBJECTIVE: To study feasibility, safety, and anatomic and functional outcomes of endoscopically monitored canalization for treatment of congenital cervical atresia. DESIGN: Case series with description of the technique. SETTING: Assiut University Women's Health Center. PATIENT(S): Five with congenital cervical atresia, two of them with associated vaginal aplasia. INTERVENTION(S): The three cases with isolated cervical atresia underwent laparoscopic canalization under vaginoscopic monitoring (LC-VM). The two cases with associated vaginal aplasia underwent laparoscopic canalization under tactile monitoring (LC-TM). Cystoscopy was done for all cases to ensure bladder and urethral integrity. MAIN OUTCOME MEASURE(S): Operative time, complication rate, menstrual pattern, and reintervention rate. RESULT(S): The LC-VM procedure was performed successfully in three cases within 20-25 minutes. The two cases with associated vaginal aplasia underwent LC-TM; one them was successful and the other was complicated with bladder puncture. Follow-up ranged from 3 to 36 months, and all had regular menstruation. CONCLUSION(S): Laparoscopic canalization under vaginoscopic monitoring is a simple, effective, and minimally invasive way of management of isolated cervical atresia. However it seems not to be the ideal technique and needs further refinements for treatment of cervical atresia associated with vaginal aplasia.

Retropubic balloon vaginoplasty for management of Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: To study operative, postoperative, anatomic, and functional outcomes of retropubic balloon vaginoplasty (RBV) for the management of vaginal aplasia. DESIGN: Case series with description of the technique. SETTING: Assiut University Woman Heath Center. PATIENT(S): Three women with vaginal aplasia due to müllerian agenesis. All had pelvic adhesions due to previous surgeries. INTERVENTION(S): A Foley catheter was inserted in the retropubic space from the suprapubic area to the vaginal dimple. Cystoscopy was done to ensure bladder and urethral integrity. Patients were treated postoperatively by controlled traction and distension for a week. MAIN OUTCOME MEASURE(S): Depth and width of neovagina, penetration, and satisfaction scores. RESULT(S): The mean operative time was 9 to 11 minutes. No operative complications were recorded. Pain scores ranged from 0 to 20 points at rest and from 20 to 50 points during dressing. Vaginal depth as well as penetration and satisfaction scores showed statistically significant increases. CONCLUSION(S): Retropubic balloon vaginoplasty is a simple, safe, and effective alternative approach for creation of a neovagina, especially when laparoscopy is unfeasible or unsafe.

Modified balloon vaginoplasty: the fastest way to create a natural: minor changes in technique eliminate the need for customized instruments.

We studied the feasibility of performing balloon vaginoplasty (BV) with conventional laparoscopic instruments through 2 modified techniques aiming at providing BV for open use. Three of 6 cases with vaginal aplasia were offered modified laparoscopically assisted balloon vaginoplasty (LAB-V) and the other 3 cases underwent modified retropubic balloon vaginoplasty (RBV). We measured operative time, complications, anatomical outcomes, functional outcomes, and re-intervention rates. Modified RBV and LAB-V were performed successfully in the 6 cases within 9-12 and 29-38 min, respectively. The neovagina depths were 8-10 and 9-12 cm, respectively. Anterior rectal wall needle puncture was encountered in 1 case of LAB-V group and posterior urethral wall puncture in an abnormally dilated urethra in 1 case of the RBV group; both cases passed uneventfully. Intercourse was initiated after removal of all catheters. The neovagina was a cosmetically appealing mimic to nature and stained with iodine up to its apex. It was feasible to perform balloon vaginoplasty operations without specialized instrument sets with comparable outcomes.