Pregnancy and Placenta Increta in a Noncommunicating Uterine Horn.

BACKGROUND: We present a rare case of pregnancy and invasive placentation in a unruptured, noncommunicating rudimentary uterine horn at 20 weeks' gestation. CASE: The patient was followed with ultrasound throughout early pregnancy and initial imaging for dating purposes showed a pregnancy within a communicating right horn of the uterus. At the 18-week anatomy ultrasound, the pregnancy was discovered to be within the noncommunicating, rudimentary left horn of the uterus. This was confirmed using pelvic magnetic resonance imaging. The patient opted for surgical management and subsequently underwent laparotomy and removal of the noncommunicating uterine horn and pregnancy. Placental tissue was adherent to the level of the serosa during surgery and pathologic diagnosis was significant for a placenta increta. SUMMARY AND CONCLUSION: The patient recovered well from surgery and subsequently went on to have a successful term pregnancy delivered via cesarean section for breech in the right horn 15 months later.

Who Should be Following the Trans-Female Patient Pre and Post Vaginoplasty? An Argument for the Pediatric Gynaecologist.

Increasing numbers of transgender patients are opting for gender-affirming care. Since pediatric and adolescent gynaecology (PAG) providers perform the majority of vaginoplasty procedures for developmental anomalies of the female reproductive tract (such as vaginal agenesis), this commentary supports the position that PAG providers should be involved in the pre- and postoperative care of trans women.

Resident Perspectives on Competency-By-Design Curriculum.

OBJECTIVE: The Royal College of Physicians and Surgeons of Canada is implementing a competency-by-design (CBD) curriculum for residency training across Canada. Although praise and criticism have been published regarding competency-based residency training, little has been published from the resident perspective. The University of Calgary obstetrics and gynaecology residents were surveyed to gather information on their viewpoints and allow their expectations and concerns to be incorporated into the design and implementation process for the curriculum. METHODS: An anonymous survey was administered to residents from the University of Calgary obstetrics and gynaecology program. The survey contained a mixture of Likert-scale responses, multiple-choice questions, and free-text response questions. Summary statistics were used to analyze the Likert-scale and multiple-choice responses, and thematic analysis was performed on free-text responses (Canadian Task Force Classification Level III). RESULTS: The survey respondents identified several anticipated benefits and challenges regarding the CBD curriculum. Overall, resident respondents seemed optimistic about the curriculum redesign; however, many residents identified concerns, including potential impacts on work relationships, challenges with operating room and call scheduling given the less rigid structure of CBD, and the amount of time and effort that evaluation will require. CONCLUSION: Residents offer a valuable perspective on CBD curriculum redesign and implementation. Gathering their input and including it in the curriculum redesign and implementation process will only strengthen the new curriculum and resident buy-in.

Difficulties in Transition of Care from Pediatric to Adult Gynecology Providers: Should We Maintain Care into Adulthood?

There is evidence that transfer of care for older adolescent patients to adult care is associated with a deterioration in health, especially in those with chronic conditions. Because several specific conditions in pediatric and adolescent gynecology continue into adulthood, it is important that patients have a seamless healthcare transition. In this commentary, it is argued that instead of arranging transfer, long-term retention of patients by the same physician or physician team may be the more caring, patient-centered approach.

Audit of referrals for concern regarding labial appearance at the Royal Children's Hospital: 2000-2012.

AIM: To audit the clinical features and outcomes for all patients referred to our centre with concerns regarding labial appearance. METHODS: Young females referred to a paediatric/adolescent gynaecology tertiary centre between 2000 and 2012 with concerns regarding their labial appearance were retrospectively identified. Adolescents presenting with anomalies were excluded. Retrospective chart review was undertaken to identify reasons for referral, patient characteristics, outcome of referral and concurrent health problems. RESULTS: In total, 46 females presenting with concerns about labial appearance were identified. Five were excluded. Median age of the study population was 14.5 years (range 5-21 years). Only four (9.8%) underwent surgery after a minimum of five consultations each, with mental health review in three of four cases prior to surgery. None of the 41 patients had documented abnormal labia; however, 6 patients had asymmetry, and 3 had a labial width of >5 cm. Of mothers, 24% (n = 10) raised the initial concern regarding labial appearance to a physician, of whom, 50% of patients had a comorbid condition. In total, 70.7% initially reported interference with daily activities, and 87.8% were reassured following discussion. CONCLUSIONS: With appropriate education and counselling, the majority of girls with concerns regarding labial appearance can be managed without surgery. Overall, our data support current international policy that female cosmetic genital surgery not be performed in mature minors unless there are specific indications. More research about characteristics of patients referred with labial concerns, definition of labial size and long-term satisfaction of conservative versus surgical methods is necessary to determine the best approach.

Literature Review of Periclitoral Cysts in the Prepubertal Population.

STUDY OBJECTIVE: Clitoral cysts in the pediatric population are rare conditions that require careful evaluation. In this review of the literature we discuss the evaluation of clitoral abnormalities in the pediatric population, the development of clitoral cysts, and how to differentiate benign from malignant tumors. In addition, a summary of relevant cases of clitoral tumors in the literature are discussed. DESIGN: Literature review. DATA SOURCE: A MedLine and advanced PubMed search was conducted of all English language articles published using the search terms "clitoris" and "cyst" until February 2015. Reference tracing was completed for all articles for completeness. MAIN OUTCOME: Literature review of clitoral cysts in the prepubertal population. RESULTS: In total, we found 15 cases of benign, spontaneously forming clitoral cysts reported. Eleven of those cases document symptom onset before puberty. Reports of other benign clitoral lesions in the pediatric population include 1 angiokeratoma, 1 hemangiopericytoma, 1 granular cell tumor, 6 hemangiomas, and approximately 30 neurofibromas. Clitoral malignancies in the pediatric population are even more rare with only 3 cases of clitoral schwannomas, 2 rhabdomyosarcomas, 1 lymphoma, and 1 endodermal sinus tumor documented in the literature. CONCLUSION: Clitoral cysts must be considered as a possible cause of clitoral enlargement in the prepubertal population. Clitoral tumors are distinguished clinically from hormonal abnormalities and intersex disorders by their hormonal profile, and the presence of an underlying mass. Ultrasound and magnetic resonance imaging might be useful imaging modalities to further characterize the clitoral enlargement. When confirmed as the most likely diagnosis, surgical resection is the mainstay of treatment for clitoral cysts.

Literature Review of Benign Müllerian Papilloma Contrasted With Vaginal Rhabdomyosarcoma.

STUDY OBJECTIVES: Benign müllerian papillomas of the genital tract are rare and, hence, can be mistaken for vaginal rhabdomyosarcoma on initial clinical review. This review of the literature will consolidate the previous cases of müllerian papilloma reported and looks for clues to differentiate the 2 entities. DESIGN AND SETTING: We provide a case report and literature review, with patients from a pediatric adolescent gynecology clinic in a tertiary center. METHODS: We conducted a search of English-language publications from 1951 (the first case report) until January 2014 by using the search words "Müllerian papilloma" and "prepubertal bleeding." References from previous published reports were also obtained for completeness. MAIN OUTCOME: Literature review of benign müllerian papilloma. RESULTS: Since 1951, 56 cases of müllerian papilloma were reported, including 4 cases at our institution. Comorbid conditions were found in 31.5% of cases (with 3 cases associated with mesenchymal tumors). The average length of time from onset of symptoms (primarily vaginal bleeding) to diagnosis was 6.7 months (range, 1 day to 3 years), with only 1 case diagnosed incidentally. Median age of presentation was 5 years (range, 1 day to 52 years). Most cases were localized and resected with ease. Histology reveals complex papillary lesions without cytologic atypia. CONCLUSION: Benign müllerian papilloma is distinguished from the more significant diagnosis of vaginal rhabdomyosarcoma by initial length of vaginal bleeding at presentation, lack of vaginal wall extension, ease of resection, and histopathology. This is compared with vaginal rhabdomyosarcoma which commonly exhibits both localized and distant spread.

Systematic review of sexual function and satisfaction following the management of vaginal agenesis.

Historically, sexual satisfaction following the management of vaginal agenesis was assessed subjectively. Standardized sexual function questionnaires are being used more frequently as instruments to accurately and more objectively assess the subjective nature of sexual outcomes as part of a more holistic approach to the care of women with vaginal agenesis. Articles concerning the management of vaginal agenesis were systematically reviewed, with specific focus on those that discussed functional outcomes, sexual satisfaction and psychosomatic outcomes, and in particular attempted to measure these outcomes. A total of 6,691 articles on vaginal agenesis were identified, with 106 of these reporting sexual satisfaction and psychosomatic outcomes. Only 1 randomized control trial (RCT) was identified, the remaining articles being made up of case series or case reports. Only 17 articles used standardized objective assessment of sexual satisfaction. While the bowel technique had the longest vaginal length at 12.87 cm, it had the most number of complaints of dyspareunia (4.8%), stenosis (10.5%) and the lowest average subjective sexual satisfaction. The Davydov method used standardized sexual function assessments most frequently. This technique had a higher average score than both the bowel vaginoplasty technique in the only RCT and the Vecchietti method in a prospective assessment. Overall, the management of vaginal agenesis requires a multidisciplinary approach to fully support these patients from initial diagnosis, through management decision-making and long-term follow-up, through transition to adulthood.

Dilation and surgical management in vaginal agenesis: a systematic review.

INTRODUCTION: The management of vaginal agenesis is currently determined by geographical location and surgeon preference. The optimal treatment is unknown and the majority of articles on technique and outcome focus on personal case series with little standardisation of reporting and follow-up. METHODS: Six thousand six hundred and ninety-one articles concerning the management of vaginal agenesis were systematically reviewed, with 162 fitting the inclusion criteria. RESULTS: Only one randomised control trial was included with the remaining articles made up of case series or case reports. The bowel vaginoplasty method was most commonly reported historically with 945 patients and 45 articles included. The Vecchietti procedure had the shortest operative time, but the highest number of urological injuries (2.1 %). The split thickness procedure had the highest infection rate (4.2 %) and re-operation rate (7.84 %). CONCLUSION: Overall, the conservative method using dilation had the fewest complications, with an average vaginal length of 6.65 cm (± 1.39 cm). However, with an operative procedure full consent is imperative, as is an understanding of the need for postoperative dilation with the majority of techniques.