Rectovaginal fistula as a complication of rectal injury during vaginal reconstructive surgery: A case report.

INTRODUCTION AND IMPORTANCE: Rectovaginal fistula is a complication that may occur due to rectal injury during vaginal reconstructive surgery. To prevent these complications, the recognition of the injury is an important factor so that primary repair can be done. The primary repair can reduce the risk of complications such as fistula formation, and also reduce the physical and psychological impact on the patient. CASE PRESENTATION: A 33-year-old woman, came with a chief complaint of fecal leakage from the vagina and abdominal pain three months before admission with a history of vaginal reconstructive surgery due to vaginal agenesis. Eleven years after the reconstruction, the patient was diagnosed with recurrent obstruction caused by vaginal synechia. During the surgery of synechia release, rectum injury occurred. Even though primary closure repair was done at that time, several months later there was a complication of rectovaginal fistule formation in the form of fecal leakage from the vagina. The corrective surgery is performed in collaboration with a surgical gastroenterologist. CLINICAL DISCUSSION: Iatrogenic rectal injury may occur during gynecological surgery. A fistula that occurs after the reconstruction of vaginal agenesis is a high-type rectovaginal fistula, making the repairs more complex. Collaboration surgery between surgical gastroenterologist and gynecologist may be an option in such cases. CONCLUSION: Rectovaginal fistula is a rare but serious complication of vaginal reconstructive surgery. Early recognition, immediate management, and postoperative follow-up are essential in cases of rectal injury during vaginal reconstructive surgery.

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.

Longitudinal vaginal septum with normal uterus and cervix - A case report.

INTRODUCTION AND IMPORTANCE: Longitudinal vaginal septum is usually associated with uterine anomalies, such as septate uterus and didelphys uterus. Normal uterus and cervix found in longitudinal vaginal septum is a rare case but can affect sexual activities and reproductive outcomes. CASE PRESENTATION: We present a case of a 42-year-old woman with a history of primary infertility for 7 years was referred by the endocrinology division due to the presence of a longitudinal vaginal septum and difficulty in performing intrauterine insemination. Transvaginal ultrasound revealed a normal-shaped and sized uterus. The cervix appeared normal as well and was located 6.27 cm from the vaginal introitus. CLINICAL DISCUSSION: Incomplete vaginal septum in normal uterus and cervix is very rare, mostly it's associated with partial or complete duplication of the Mullerian ducts. Surgical correction of this condition is necessary for reproductive constraints and patient complaints. CONCLUSION: This case is very rare and is associated with the pathophysiology of the vaginal septum It is important to establish a diagnosis for this malformation as surgical intervention generally provide satisfactory outcomes.

Introducing Modified Technique of Combined Vaginal and Laparoscopic Approach for Creation of Neovagina.

INTRODUCTION AND IMPORTANCE: There are many methods described in the literature for creating a functional neovagina. However, the best method has yet to be determined. In our urogynecology training center, neovaginoplasty was usually performed by vaginal approach using modified McIndoe technique with amnion graft and >7 days hospitalization was required. However, we tried to combine both vaginal and laparoscopic modified technique of neovaginoplasty to improve the functional and surgical outcome as well as shortened hospital stay. CASE PRESENTATION: A 27-year-old woman came to our center with a chief complaint of primary amenorrhea and she was diagnosed with vaginal agenesis as part of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. She underwent neovaginaplasty using a combined vaginal and laparoscopic approach with autologous peritoneal graft. Patient was discharged the next day. The follow up result (6-24 months) was excellent with total vaginal length was 8 cm and FSFI score 34.5. CLINICAL DISCUSSION: The use of peritoneal graft using a laparoscopic approach for vaginal reconstruction was chosen in this case after proper counseling with the type of vaginal mucosal lining as the primary consideration. We combined our routine vaginal approach technique with laparoscopic approach to provide an autologous peritoneal graft and considered modifying the technique by extending the peritoneal dissection laterally to facilitate mobilization of the peritoneum to cover the whole surface of neovagina. CONCLUSION: Combined vaginal and laparoscopic modified technique of neovagina creation may present as treatment option for MRKH patients with excellent anatomical and functional result, minimal surgical complication and shorter hospital stay.

Diagnostic capabilities of transperineal ultrasound (TPUS) to evaluate anal sphincter defect post obstetric anal sphincter injury (OASIS)? A systematic review.

INTRODUCTION: Endoanal ultrasound (3D-EAUS) is the gold standard imaging investigation for evaluating the anal sphincter; unfortunately, it is not universally available in most obstetric units. This study aims to appraise the ability of transperineal ultrasound (TPUS) compared with 3D-EAUS as the gold standard to identify anal sphincter defects after primary repair of OASIS. METHODS: A systematic search of major databases to identify diagnostic accuracy of 3D-TPUS in evaluating anal sphincter defects. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were designed for this systematic review. The risk of bias and applicability concerns were assessed using the QUADAS-2 tool. Our eligibility criteria are patients with a history of primary repair of anal sphincter injuries (OASIS). They were followed up after the primary repair to detect the anal sphincter defect using 3D-TPUS vs. 3D-EAUS as a gold standard. RESULTS: Two eligible observational studies were included and assessed for risk of bias using the QUADAS-2 tool and showed a low risk of bias and a low risk of concerns. 3D-TPUS had various sensitivity to detect external anal sphincter defects in two studies; meanwhile, the specificity was around 67-70%. For detecting the internal anal sphincter defects, 3D-TPUS had low sensitivity but high specificity (93-94%). CONCLUSION: 3D-TPUS had various sensitivity to detect external anal sphincter defects and low sensitivity to detect internal anal sphincter defects. On the other hand, 3D-TPUS had low specificity for detecting external anal sphincter defects and high specificity for detecting internal anal sphincter defects.

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.

Management of recurrent adhesion after vaginal recanalization surgery by using interdigitating Y-flap technique: Case series.

INTRODUCTION: Adhesion is one of complication after vaginal recanalization surgery that occurs due to the free tissue attached during the wound healing process and should be treated carefully. Otherwise, it will become obstruction to the vagina and lead to hematocolpos. The chosen techniques should prevent recurrent adhesion, synechia or stenosis. In this case series, we performed interdigitating Y-flap technique for managing recurrent synechiae post recanalization vaginal surgeries to prevent future stenosis. PRESENTATION OF CASE: The first case was a 16 years old teenager, complained not menstruating and abdominal pain. Patient already had recanalization vagina surgery for correcting distal vaginal agenesis two years ago. After that, patient already had menstruation. There were hematometra, hematocolpos and vaginal adhesion from examination. The second case was a 12 years old teenager, complained having slight blood menstruation after septum excision surgery. From the examination, there was stenosis vagina at 3 cm proximal from hymenal ring. Both patients were treated by interdigitating Y-flap surgery for correcting the synechiae. After follow up treatment, there was no complaint from patients. DISCUSSION: Both patients were having synechia post vaginal recanalization surgery. To prevent recurrent synechiae, we decided to do interdigitating Y-Flap technique for correcting synechiae. With this technique, the scar tissue may not develop contractured scar and narrowing vagina. CONCLUSION: Interdigitating Y-Flap technique may become an option for managing complex recurrent adhesion, synechia or stenosis. This technique is simple, easier and reduces the risk of stenosis in the future with better scar formations.

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.

Level of agreement and acceptance of the 20-Minute versus 60-Minute sanitary pad test as a method for measuring the severity of stress urinary incontinence: randomised crossover trial.

We aimed to measure the level of agreement and acceptance ratio of the 20-minute versus 60-minute sanitary pad test in female patients with stress urinary incontinence (SUI). This is one-sample cross-experimental design. SUI patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital in Jakarta, Indonesia were consecutively enrolled as participants. We first administered the 20-minute test, followed by the 60-minute test, or vice versa, within 1 week. The participants did not know the type of test performed or asked during the interview. Random Number Generator software by stattrek.com was used to determine which test was performed first for each participant. Participants were interviewed using a questionnaire at the end of each test. The 20-minute sanitary pad test exhibited a good level of agreement with the 60-minute sanitary pad test (kappa R = 0.84). Forty-two respondents (84.0%) reported that they were "satisfied" with the 20-minute sanitary pad test and eight respondents (16.0%) reported that they were "very satisfied". There was a good agreement between the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI. The 20-minute sanitary pad test achieved a relatively higher level of participant satisfaction.Impact statementWhat is already known on this subject? Patients at the Urogynecology Outpatient Clinic at Cipto Mangunkusumo Hospital have a positive acceptance in the 20-minute and 60-minute sanitary pad test for assessing the severity of SUI.What do the results of this study add? From this result, the authors considered that this method can help in assessing the severity of SUI, especially in Indonesia.What are the implications of these findings for clinical practice and/or further research? As these findings, the authors think that they might be useful as a standard of assessed the severity of SUI. This method does not harmful and easy to apply for every patient with SUI.

Genital self-image as predictor of sexual dysfunction in women with pelvic organ prolapse in Indonesia.

BACKGROUND: The incidence of sexual dysfunction increases in women with pelvic organ prolapse. In addition to physical factors, other important components that influence each other in sexual dysfunction are psychological aspects and genital self-image. Sociocultural factors also affect individual sexuality and sexual behavior. Until now, there are no data and the relationship between genital self-image and sexual dysfunction in pelvic organ prolapse is not known in Indonesia. OBJECTIVE: This study aims to analyze the correlation of genital self-image with sexual dysfunction in women with pelvic organ prolapse. METHODS: In this cross-sectional study, 113 consecutive women with pelvic organ prolapse were selected in urogynecology referral centers in Jakarta. Demographic data, physical examination, and guided interviews were filled in to complete the Female Sexual Function Index and Female Genital Self-Image Scale-7 questionnaires. Preliminary research has been carried out in the form of language translation and cultural validation of the Indonesian version of the Female Genital Self-Image Scale-7 questionnaires. RESULTS: There is a significant correlation between genital self-image and sexual dysfunction, where the lower Female Genital Self-Image Scale-7 score significantly predicts the lower Female Sexual Function Index score (p < 0.000; odds ratio: 14.17). CONCLUSION: Genital self-image is the main variable that affects sexual function in women with pelvic organ prolapse. It is necessary to evaluate and treat genital self-image because sexual function is an integrated component of quality of life.

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.

Transverse vaginal septum managed by simple flap surgery technique: A case report.

BACKGROUND: Transverse Vaginal Septum (TVS) is a rare congenital abnormality, classified as the Mullerian duct anomaly development.1,2 TVS incidence range from 1:2.000 to 1:72.000. Management of TVS may only requirement local excision with a simple end to end anastomosis of the vagina, and use of skin grafts, but this technique has been reported has common complications of secondary tissue contracture, which often lead to stenosis of the vagina.3 In this case we managed TVS with simple flap technique to avoid such postoperative complications and maintain caliber of vagina. CASE: A 11 years old girl complained cyclical abdominal pain since a year ago without history of menstrual blood. Patient already had vaginal surgery for removing menstrual blood, but after vaginal surgery the menstrual blood cannot be removed, then referred to our hospital. Ultrasound examination revealed hematometra and hemocolpos. The septum location was 3,38 cm proximal distance from vaginal introitus with the thickness of 8.1 mm. We performed simple excision of the septum with formerly performed distal vaginal septum mucosa preparation creating lateral flaps, then approximating the flaps to the edge of the proximal vaginal mucosa with interrupted suture continued with hymenorraphy. The patient has no complaint 6 months after surgery with vaginal length 8 cm, and had regular menstrual cycle. CONCLUSION: A simple flap surgery technique can be done in transverse vaginal septum, with no complication such as tissue contracture, vaginal stenosis, or insightly scarring. This is a simple technique and can be done with hymenorraphy to restore normal anatomy of hymen.

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.