Vaginal surgery for congenital anomalies.

Congenital anomalies of the vagina may be isolated to the vagina or be part of a more complex Mullerian tract anomaly with possible fertility concerns. Patient age, complete assessment of the anomaly before surgery, and the psychologic implications for the patient are important components of the initial evaluation and treatment planning. Imaging, including magnetic resonance imaging, should be used to assess the extent of the anomaly and possibly other organ systems involved. Surgeries for imperforate hymen, longitudinal septum, and low thin transverse septum are relatively straightforward. More complicated surgeries should be performed by a specialized surgical team.

Premenarchal ovarian torsion and elevated CA-125.

BACKGROUND: Ovarian tumors are the most common gynecologic malignancy occurring in childhood, with germ cell tumors being most frequent. This contrasts with adults where epithelial tumors account for most ovarian neoplasms. Tumor markers are an integral part of the work-up and may guide management. CASE: A 6-year-old girl with a persistent adnexal mass was found to have a highly elevated CA-125. Other tumor markers were normal. Laparoscopy revealed an enlarged, adherent ovary. A minilaparotomy revealed an ovary filled with necrotic material. This necrotic material was excised and the ovary was spared. The pathology was consistent with necrosis. Follow-up ultrasonography and CA-125 were normal. SUMMARY AND CONCLUSIONS: This case demonstrates for the first time the association of an elevated CA-125 and ovarian torsion in a pediatric patient. This benign finding allowed attempting a conservative ovary-sparing approach during the surgery even in the presence of a highly elevated CA-125. However, in general, for children CA-125 is of limited utility, as it will not affect the indication for surgical exploration of persistent masses and elevations in CA-125 may discourage ovarian conservation.

Anti-Müllerian hormone and inhibin B variability during normal menstrual cycles.

OBJECTIVE: To describe anti-Müllerian hormone (AMH) variation across normal menstrual cycles. DESIGN: Cohort study. SETTING: Academic environment. PATIENT(S): Twenty regularly menstruating women. INTERVENTION(S): Serum AMH and inhibin B assayed daily during one normal menstrual cycle. MAIN OUTCOME MEASURE(S): Intracycle variability of AMH and inhibin B. RESULT(S): Data were classified into quartiles of AMH area-under-the-curve (AUCs). Mean AMH AUC was 15.7 ng/mL for quartile 1 versus 43.5, 80.9 and 144.9 ng/mL for quartiles 2, 3, and 4. Mean AMH levels (ng/mL) were 0.67, 1.71, 3.02, and 5.33, respectively. There was no variation in quartile 1 AMH rate of change from stochastic modeling, but in quartiles 2 to 4, there were increased rates of change in days 2 to 7. Women in quartile 1 had the lowest mean inhibin B (24.2 pg/mL vs. 44.3, 43.2, and 42.2 pg/mL), and had shorter menstrual cycles (24.6 days) than women in quartiles 3 and 4 (28.2 and 28.4 days). CONCLUSION(S): There were two menstrual cycle patterns of AMH. The "aging ovary" pattern included low AMH levels with little variation, lower inhibin B, and shorter cycle lengths. The "younger ovary" pattern included higher AMH levels with significant variation days 2 to 7, suggesting that for women with AMH>1 ng/mL, the interpretation of AMH levels is contingent upon the day of the menstrual cycle on which the specimen is obtained.

Delayed iliac artery thrombosis after blunt trauma during operative laparoscopy.

Major vascular injury during laparoscopic surgery is an uncommon but serious complication. A small number of earlier case reports describe delayed diagnosis of vascular lacerations. Herein we report a unique case of a robot-assisted laparoscopic resection of an obstructed uterine horn, complicated by delayed postoperative presentation of a common iliac artery thrombus without extravascular hemorrhage. The injury was likely caused by blunt trauma to the exterior of the vessel with damage to the vascular intima and subsequent dissection. Meticulous surgical technique, accurate diagnosis, and subsequent treatment are essential to decrease morbidity from such major vascular injuries at the time of laparoscopy.