Satisfactory Outcome of Various Novel Modified Laparoscopic Neovaginoplasty Using Autologous Peritoneal Graft.

Management of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser syndrome patients is by creating functional neovagina through surgical or nonsurgical route. Surgical repair using minimally invasive technique is a favorable option in creating neovagina. In this study, the patients underwent neovaginoplasty. Clinical follow-ups were done at 3, 6, and 12 months postoperatively. The primary outcomes were anatomic and functional successes; anatomical success was defined as a ≥6 cm-long neovagina that allows for easy introduction of two fingers, and functional success was defined with Female Sexual Function Index FSFI-6 questionnaire score above 19. Modified neovaginoplasty using autologous peritoneal graft was performed on the patients (n = 6). Follow-up showed mean vaginal lengths of 8.16 cm, mean surgery time of 175 min, mean blood loss of 59.17 ml, and mean duration of hospital stay of 2 days, with an average FSFI-6 score of 25,2. Therefore, we concluded that laparoscopic approach using modified technique of autologous peritoneal graft provides satisfactory result.

Selecting the best surgical approach in various cases of prolapsed pedunculated submucosal fibroids: A case series.

INTRODUCTION: The pedunculated fibroid is classically managed through vaginal myomectomy. However, vaginal myomectomy cannot be safely and easily performed in all cases. We reviewed three cases of prolapsed pedunculated submucosal fibroids, each with a specific surgical difficulty. PRESENTATION OF CASES: The first case had a prolapsed pedunculated uterine fibroid in pregnancy and underwent fibroid extirpation during an emergency cesarean section through the lower uterine segment incision. The second case was a nulliparous woman with recurrent abnormal uterine bleeding due to a giant prolapsed pedunculated uterine fibroid who underwent laparotomy fibroid extirpation through posterior colpotomy, preserving the uterus. The third case had a prolapsed pedunculated uterine fibroid in perimenopause with multiple fibroids and underwent fibroid stalk excision through an isthmic incision to facilitate a safe laparotomy hysterectomy procedure. DISCUSSION: Vaginal removal has become the standard surgical method for prolapsed pedunculated submucous fibroids. However, some possible consequences of vaginal myomectomy include severe stalk bleeding, infection, and uterus inversion induced by excessive traction. Therefore, specific approaches are needed in some circumstances. CONCLUSION: Customised surgical approaches provided safe and efficient access to the prolapsed pedunculated fibroid stalk during myomectomy or hysterectomy.

Case series: Interdigitating "Y" flap for transverse vaginal septum management.

INTRODUCTION: Transverse vaginal septum found in 1/2100 dan 1/72.000 women. The classical management for transvers vaginal septum was septum excision, with risk for vaginal narrowing and vagina shortening after surgery. We reported four cases underwent interdigitating "Y" flap with no vaginal narrowing or shortening after procedure as alternative surgical technique for better result. PRESENTATION OF CASE: The transverse vaginal septums were right behind hymen to 5 cm proximal from hymen (low to mid location). The post-operative evaluation up to eleven months after surgery found no vaginal narrowing or vaginal shortening. A Case with haematosalphing was re-evaluated one month after surgery and found that the haematosalphing has been resolved and no recurrency on 10 months after surgery. Another case with bigger haematosalphing underwent laparotomy salphingostomy concomitantly with "Y" flap procedure and on 11 months evaluation found no recurrent haematosalphing. DISCUSSION: As the septum was relatively thick and composed of 2 embryonic origins, dividing them into distal flaps and proximal flaps was possible. Interdigitating "Y" flap technique offer better preservation in vaginal length and less constricture as the technique spread the tissue tension evenly. Cases with haematosalphings implies that adequate drainage through vagina help evacuate the haematosalphing and prevent recurrency. However longer-term evaluation shall be performed. CONCLUSION: Interdigitating "Y" Flap offers satisfying outcome besides short hospital stay (less intra operative bleeding, no need for postoperative vaginal dilatation, preserved vaginal length and vaginal caliber).

Vulvar-vaginal reconstruction surgery for sexual function in patient with disorders of sex development.

INTRODUCTION AND IMPORTANCE: Amenorrhea can be a transient, intermittent, or permanent condition reflecting the overall health condition of a woman. Primary amenorrhea and ambiguous genitalia appearance warrant more comprehensive diagnosis and treatment, especially in those planning to have a married life. CASE PRESENTATION: A case a 24 years old woman was referred to our hospital with a chief complaint of primary amenorrhea. Previously, she was diagnosed with vaginal agenesis. However, a thorough examination revealed ambiguous genitalia and karyotype result of 46, XY. Following several rounds of discussion with the patient, her family, and her partner, she chose to remain a female and even planned to be married following the treatments. A vaginoplasty followed by clitoral reduction was done with a satisfactory result. CLINICAL DISCUSSION: Disorders of sex development and differentiation is a rare but devastating condition. Various biological, psychological, and social issues are surrounding those affected by it. The burden was further aggravated for those who are late to discover their condition, especially those planning to be married. CONCLUSION: Comprehensive and multidisciplinary approaches are needed to ensure the best outcome for DSD patients.

The Use of Interdigitating Y-Flap Technique for Imperforate Hymen.

Imperforate hymen is a rare condition affecting 1 of 2,000 women worldwide. Its treatment is surgical hymenectomy to relieve obstruction and reduce the risk of secondary endometriosis. Current surgical techniques for imperforate hymen pose risks of postoperative complications such as stenosis and ascending infection; thus, a new technique is needed. A case of a 12-year-old girl with a progressively bulging mass was presented. Physical examination revealed hematocolpos due to imperforate hymen. Surgery, using interdigitating Y-flap technique, was performed on the patient. The surgical outcome was satisfactory, and no postoperative complication was found during a follow-up visit.

Secondary pyosalpinx after reconstructive surgery of vaginal agenesis patient with bilateral hematosalpinx: A case report.

INTRODUCTION AND IMPORTANCE: Congenital or hypoplasia vaginal agenesis is a very rare condition caused by the failure of developmental Mullerian ducts. The prevalence is 0.001%-0.025% populations. This condition often misdiagnosed because the symptom does not appear. Acute symptoms such as abdominal pain may occur due to the obstruction of retrograde menstrual flow. In this case, we presented a case complex management of vaginal atresia with pyosalpinx, hematometra and bilateral hematosalpinx. PRESENTATION OF CASE: A 12 years old teenager, non-sexually active, complained cyclic abdominal pain that worsening in seven months before admission. Patient never had menstrual blood flow during her life. Patient was diagnosed with hematometra, hematocolpos, bilateral hematosalpinx and distal vaginal agenesis. Amnion graft neovagina was performed. Five days after surgery, patient started to have fever. On the seventh days after surgery, amnion graft was removed. The next two days patient still had fever. Because of continuous fever, patient was test of COVID 19. The result was positive. On the eleventh days after the first surgery, patient complained abdominal pain VAS 3-4. Patient was diagnosed with pyosalpinx by ultrasound examination. Laparotomy was done performing adhesiolysis, bilateral salpingectomy, and omentectomy. DISCUSSION: In our case vaginal reconstruction surgery from vaginal approach has been done without management of the bilateral hematosalpinx because the consideration of small caliber of bilateral hematosalpinx. But then complications were developed when vaginal canal was opened, bilateral hematosalpinx were transformed into bilateral pyosalpinx and continue to developed into bilateral tubal abscess. We assume during this process, the bacteria from vagina could fastly infecting the blood and transformed it into pus and grew until tubal abscess. CONCLUSION: The surgical intervention in vaginal agenesis must be considered as a treatment and not only focus on the reconstruction. Laparoscopy or laparotomy may offered as options for combination treatment with vaginal approach reconstructive surgery for vaginal agenesis with obstruction complications such as hematometra and hematosalpinx to prevent the worst condition like ascending infection or misdiagnosed other severe conditions.

Cervical elongation caused by big cervical fibroid resembling malignant cervical prolapse? Management via vaginal surgery.

INTRODUCTION: Cervical elongation could lead to cervical elongation thus worsen the descent of uterine prolapse. In certain cases, this hypertrophic and hyperplastic mass could have fragile surface with some bleeding and necrotic, resembling cervical cancer. As case of cervical elongation due to cervical fibroid is quite rare, such cases are valuable to be reported. We present two cases of cervical fibroid with cervical elongation resembling cervical malignancy. PRESENTATION OF CASE: First case was A 59-year-old lady with intractable vaginal mass since one day before admission. Bleeding from the mass was positive. We found a bulky vaginal mass exceeding hymenal ring, 14 × 7 × 6 cm sized, with some necrotic and discharge, foul smelling, and some bleeding area. Ultrasound evaluation revealed a cervical fibroid with differential diagnosis cervical malignancy. The second case was Mrs 53-year-old with vaginal mass since last year. For the last 7 months the mass has been bigger and could not be inserted into vagina, with some bleeding. We found globular vaginal mass 12 × 9 × 6 cm exceeding hymenal ring, with some necrotic and reddish surface, foul smelling, discharge, and some blood. Ultrasound evaluation revealed cervical mass on anterior lip with elongated cervices. Both cases have been menopaused. As the clinical presentation resembling malignancy, we did biopsy. The biopsy results were no evidence of malignancy, then we did Manchester fothergill, and colporaphy as needed. DISCUSSION: Length between internal to external cervical ostium ≥ 5 cm correlated to cervical elongation. Growing cervical mass could drag the cervix, predisposing to cervical elongation and prolapse. Cervical fibroids protruded through vagina was usually pedunculated. But in our cases, the fibroids were not pedunculated but manifested as a bulky mass on the cervical tissue with some bleeding and necrotics, mimicking cervical malignancy. The most important initial management besides ultrasound evaluation was mass biopsy. CONCLUSION: In such cervical fibroids with cervical elongation resembling cervical malignancy, biopsy is compulsory to determine the diagnosis and to lead the management.