Optimizing the Laparoscopic Vecchietti Procedure: Tips and Tricks.

Congenital agenesis of the uterine cervix and vagina in the presence of a functional endometrium is an extremely rare mullerian anomaly Congenital vaginal agenesis occurs with a prevalence of 1/4000-1/5000 live-born females, while the accurate incidence of cervicovaginal agenesis is controversial [1-3]. Cervicovaginal agenesis is usually not diagnosed until menarche. It is manifested by the collection of menstrual blood in the functional endometrium, Fallopian tubes and peritoneal cavity, leading to primary amenorrhea and cyclic abdominal pain

Novel Minimally Invasive Technique of Neovaginoplasty Using an Absorbable Adhesion Barrier

We present two cases of congenital vaginal agenesis with functional uterine corpus, manifesting with periodic lower abdominal pain and hematometra in adolescence. Both patients were successfully treated with the creation of neovagina and neocanal structures to discharge menstrual blood; this may also facilitate the preservation of fertility. Both cases were characterized by degrees of congenital vaginal agenesis, whether short or completely absent, with no communication between the uterine cavity and external genitalia, as confirmed by physical examination and imaging. We surgically reconstructed a neovagina with the modified McIndoe's procedure, using an artificial skin graft, and canalized to the caudal portion of the uterine cavity. Although redilatation of the neocanal was required, no patient suffered severe infection in postoperative course and both now exhibit regular menstruation. Although hysterectomy has classically been the preferred treatment for such cases, recent technical progression enables treatment of such diseases with conservative and minimally invasive surgery, in a safe manner.

Surgical Correction of Vaginal Agenesis via Modified Laparoscopic Vecchietti Procedure

Neovaginoplasty with Left External Pudendal Artery Perforator Flap

The use of free jejunal autograft for the treatment of vaginal agenesis: surgical methods and long-term results

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modified Vecchietti's procedure

Can vaginoplasty in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) be achieved using an acellular porcine small intestinal submucosa (SIS) graft? Vaginoplasty using SIS graft was successfully achieved in women with MRKHS, and the anatomical and functional outcomes of this procedure were comparable to those of laparoscopic peritoneal vaginoplasty. There is a great variety of vaginal reconstruction techniques, which suggests there is no single superior surgical technique. This prospective observational study included 34 patients with congenital vaginal agenesis who underwent vaginoplasty using SIS graft (the SIS group) between December 2011 and July 2013, and 41 patients with the same disease who underwent laparoscopic peritoneal vaginoplasty (the Davydov group) between January 2008 and July 2013. Patient and surgical data, follow-up information, and the female sexual function index (FSFI) scores in the two groups were analysed and compared. Compared with the laparoscopic Davydov procedure, the operating time of vaginoplasty using SIS graft was significantly shorter, and the estimated blood loss was significantly less. Patients in the SIS group had an earlier return of bowel activity, and an earlier return to work. However, the total cost in the SIS group was significantly higher than that in the Davydov group due to the cost of the SIS graft ($3525 per graft). Most patients (28/34 in the SIS group and 37/41 in the laparoscopic Davydov group) returned for their follow-up 9 months post-surgery. The mean length of the neovagina in the SIS group seemed slightly shorter than that in the Davydov group (6.8 ± 0.9 cm versus 7.3 ± 1.3 cm, P = 0.081). Thirteen patients (46%) in the SIS group and 11 (29%) in the Davydov group had a neovagina <7 cm long (P = 0.453), whereas 4 patients (14%) in the SIS group and 3 patients (8%) in the Davydov group had a neovagina <6 cm long (P = 0.201). Sixteen patients in the SIS group and 25 in the Davydov group subsequently had a sexual partner and became sexually active. Four patients in the SIS group and six in the Davydov group reported low total FSFI scores (≤23). There was no statistically significant difference in the total FSFI scores and the scores of all six domains of the FSFI between the two groups. The average time of continuous mould wearing in the SIS group was statistically significantly longer than that in the Davydov group (7.8 ± 3.3 months versus 4.8 ± 1.6 months, P = 0.001). In the patients with a neovaginal length of ≥6 cm, the FSFI score of the women (26.6 ± 2.3 versus 21.5 ± 1.5, P < 0.001) and the satisfactory score of their partner (8.6 ± 1.2 versus 6.6 ± 1.2, P < 0.001) were both statistically significantly higher than patients with a neovaginal length of <6 cm. The main limitation of this study is that it is non-randomized. Further randomized studies are warranted to compare the effects of these two procedures. Despite the need to wear a mould for longer, vaginoplasty using SIS graft provides an attractive, alternative treatment for women with MRKHS. This study was supported by the Chinese National Nature Sciences Foundation (grant number 81471416) and the National Key Clinical Faculty Construction Program of China. No competing interests are declared. N/A.

The aim of this study was to compare the technical feasibility and long-term anatomical and functional outcomes of a novel laparoscopic vaginoplasty using single peritoneal flap (SPF) and Davydov's laparoscopic technique in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. From September 2004 to September 2013, a comparative study was conducted of 98 patients with MRKH syndrome who underwent either laparoscopic vaginoplasty using SPF (SPF group, 62 cases) or Davydov's laparoscopic technique (Davydov group, 36 cases) in a university-based tertiary care hospital. Intraoperative and postoperative parameters and anatomical examination findings of the two groups were compared. Functional results were assessed using the Female Sexual Function Index (FSFI). All surgical procedures were performed successfully, with no intraoperative complications in either group. Patients in the SPF group had a significantly shorter operative time and less intraoperative blood loss than patients in the Davydov group. The postoperative course was identical for all patients in the two groups. The mean length and width of the neovagina in the two groups at hospital discharge, the 6-month follow-up, and the 12-month follow-up did not differ significantly. There were no significant differences between the groups with regard to the postoperative FSFI scores at 12months after surgery. Although the long-term anatomical and functional outcomes of the two laparoscopic peritoneal vaginoplasty techniques are similar, laparoscopic vaginoplasty using SPF, which has many advantages and is easily performed by the gynecologist, is a more feasible and effective approach to creating a neovagina in patients with MRKH syndrome.

Vaginal reconstruction after tumor resection or in congenital vaginal agenesis remains a challenging area in surgery, with many techniques previously described underlining the continued search for an ideal method. In this preliminary report, a series of patients are presented who underwent vaginal reconstruction using a deep inferior epigastric artery perforator (DIEP) flap. Between May of 2004 and February of 2005, five patients underwent vaginal reconstruction using the pedicled DIEP flap. Four patients had congenital vaginal agenesis and one had a complete vaginal resection because of a tumor. The flaps ranged in size from 9 x 10 cm to 11 x 12 cm. All flaps survived, although one patient developed a posterior space hematoma that required draining. Of the five patients, two were sexually active and enjoyed satisfactory penetrative intercourse after reconstruction. This series demonstrates that a new vagina can be created from the pedicled DIEP flap and that the reconstruction is reliable, with low donor-site morbidity. The major disadvantage of this technique is the conspicuous abdominal scar.

Dear Editors, We read with attention the study entitled “Long-term follow-up comparison of two different bi-layer dermal substitutes in tissue regeneration: Clinical outcomes and histological findings,” and we want to emphasise that our clinical experience with the two devices Integra and Nevelia is different. Dermal substitutes are becoming more essential in the treatment of acute and chronic wounds. A dermal substitute improves functional and cosmetic results in the long term and outcome. They allow the formation of a new dermis with chemical and elasticity characteristics like normal skin. According to Yannas et al,1, 2 a dermal substitute with regenerative activity must have an appropriate pore size, which is critical to the optimal in-growth of patients' fibroblasts and endothelial cells. Yannas et al define this pore size as between 20 and 125 μm. Another important characteristic of a regenerative dermal substitute is the controlled half-time degradation time of 14 ± 7days. Finally, another important feature of a dermal substitute (DS) to create dermis is surface chemistry. For Yannas et al, in DS the ligand densities of myofibroblasts (MFB) should 200 μM α1β1 or α2β1 ligands. This important feature allows these cells to anchor in a better way to the scaffold, and therefore the MFB can create a better dermis pattern.3 Only Integra integra dermal regeneration template (IDRT) has these important features that allow a better interaction between cells and scaffold. Concerning of the scaffold composition, we also want to emphasise that the glycosaminoglycan (GAG) and chondroitin 6 sulfate are important constituents for a regenerative scaffold. Chondroitin 6 sulfate increases the half-life of the scaffold and allows a better interaction between cells and scaffold.4 The degradation rate of scaffolds for wound repair is usually controlled by glutaraldehyde-induced cross-links. This chemical cross-link can lead to an immunogenic response to the scaffold. In the manufacturing process of Integra IDRT, the collagen is cross-linked with GAG and allows for the use of a less quantity of the solvent compared with the scaffolds that are composed only with collagen. Yannas et al show that chondroitin 6 sulfate increases the modulus of resistance and elasticity of the scaffold GAGs Cross-linking and maintaining allows to keep the degradation duration half-time faster compared with the one of scaffold without GAG, that needs more glutaraldehyde, leading to higher foreign response. In this study, the authors make a comparison between Integra and Nevelia in traumatic wounds. The authors observed a difference at 3 years of follow-up measured with MSS, which is a subjective assessment scar scale. First, we want to emphasise that the sample size is limited. Moreover, Integra Dermal Regeneration Template is the only dermal substitute that has a long and significant clinical history in several indications. Several randomised control trials (RCT) show that Integra showed better functional and aesthetic outcomes at long follow-up not only with subjective scar scales but also instrumentally. Lagus et al,5 in a randomised controlled trial, showed that patients reported favourable aesthetic outcomes as measured by the Vancouver Scar Scale. In another randomised clinical trial in paediatric patients, Branski et al6 evaluated the long-term cosmetic and functional results (18-24 months). Also in this study, Integra showed significant improvement in the Hamilton Burn Scar scale. Integra has also other studies that showed its efficacy in terms of functional and cosmetic outcome in burned hands. Among them, Danin7 employed a Cutometer to evaluate the quality of the scars obtained after using Integra Dermal Regeneration Template. When data and elasticity (cutometrical data) were compared for Integra Dermal Regeneration Template-treated burns and normal skin, there were no statistically significant differences between the Integra and normal skin. Another study by Dantzer8 assessed the safety and performance of Integra Dermal Regeneration Template when used to treat deep hand burns and reconstruct scars; there was 100% Integra Dermal Regeneration Template graft take improvement of Vancouver Scar Scale and favourable cosmetic and functional outcomes. After our searches (PubMed, Medline) we noticed that Nevelia has a limited number of studies (only four observational retrospective studies) to show its systematic efficacy in terms of aesthetics and functional outcomes, and in terms of artificial dermis take a percentage that is an important feature of a dermal implant. Integra IDRT has shown in RCT a high take rate even in traumatic wounds.9 Another limitation of this study is that wounds with, exposed tendons or bones, are excluded. One important function of a dermal substitute is the ability to cover avascularised tissue, such as tendons and bones. When we have soft tissue defects overlying exposed tendon, it is important to avoid adhesions, restoration of functionality, and getting good aesthetic outcomes. Shores et al showed that Integra IDRT in the reconstruction of soft tissue with exposed tendons of paratenon in upper and lower extremity allows immediate tendon coverage with good cosmesis and tendon function and a high split-thickness skin graft take rate of 92.5%.10 Yeong et al11 found the same results in the treatment of bone-exposed wounds in burn patients with Integra. In conclusion, Integra has shown the ability to cover poor avascularised structures that allow high split-thickness skin graft take rates. From our experience, a dermal substitute should promote neodermis suitable to be grafted, even in a wound with poor vascularization. Due to the exclusion criteria of this study, we cannot evaluate the efficacy of Nevelia on these wounds. Nicoletti et al in an observational study to treat scalp defects, describe better cosmetic outcomes using Integra comparing with Hyalomatrix and Nevelia.12 An RCT on Integra in chronic wounds17 also showed higher complete healing of wounds. Integra has also several studies on the traum wounds a higher take rate, and the scars outcomes measured with Vancouver scale gave better scores13-15 (Vakerio, Seavey, Weigert). Regarding the histological findings, we also have some concerns. In this study, they claim that Integra collagen was still present after 3 weeks, while Nevelia was completely resorbed. Stern et al16 in their histologic study on 131 patients found the same discovery and identified six phases of repair with Integra. The presence of a scaffold after 3 weeks is a clear sign that the structure of the scaffold is strong. We think that the presence of the scaffold after 3 weeks is an important feature because Integra continues to act as a scaffold during the process of wound healing. Moreover, the presence of Integra collagen means that the chemical cross-link associated with GAGs is a better choice for a regenerative scaffold. In this study, the authors talk about the findings of Agrawal et al. We want to emphasise that according to Agrawal et a's findings, Integra showed a mixed M1/M2 macrophage in histologic samples of Sprague Dawley rats and that this response is associated with a more constructive tissue remodelling response. This is confirmed by the functional and aesthetic outcomes of several studies of Integra that show Integra creates a dermis similar to normal skin. Due to the low clinical and preclinical literature of Nevelia, there is no evidence of macrophage polarisation and tissue remodelling of this device. In our clinical experience with Nevelia, we have had some difficulty to remove the reinforced polyester silicon sheet, because of its tendency to encapsulation. For the clinical outcomes in some cases with Nevelia, there was a rapid degradation of the scaffold. This rapid degradation led to the formation of granulation tissue and led to a contracted scar. In conclusion, considering that most significant literature and clinical use of Integra in several indications (burns, traumatic, chronic wounds, reconstructive surgery) and the aesthetic and functional outcomes, we continue to consider Integra the only dermal substitute able to create dermis with aesthetic and functional outcomes similar to normal skin and the only dermal substitute for regenerative medicine.

Background: Supracondylar humeral fracture (SHF) is the most common type of fracture in children. Moreover, lateral and posterior surgical approaches are the most frequently chosen approaches for open reduction surgery in displaced SHF when closed reduction fails. However, previous literature showed mixed findings regarding functional and cosmetic outcomes. Currently, no systematic review and meta-analysishas comparedthese two procedures. Methods: Our protocol was registered at PROSPERO(registration number CRD42021213763). We conducted a comprehensive electronic database search in MEDLINE, EMBASE, and CENTRAL. Two independent reviewers screened the title and abstract, followed by full-text reading and study selection based on eligibility criteria. The quality of the selected studies was analyzed with the ROBINS-I tool. Meta-analysis was carried out to compare the range of motion (functional outcome) and cosmetic outcome according to Flynn's criteria. This systematic review was conducted based on PRISMA and Cochrane handbook guidelines. Results: Our initial search yielded 163 studies, from which we included five comparative studies comprising 231 children in the qualitative and quantitative analysis. The lateral approach was more likely to result in excellent (OR 1.69, 95% CI [0.97-2.93]) and good (OR 1.12, 95% CI [0.61-2.04]) functional outcomes and less likely to result in fair (OR 0.84,95% CI [0.34-2.13]) and poor (OR 0.42, 95% CI [0.1-1.73]) functional outcomes compared to the posterior approach. In terms of cosmetic results, both approaches showed mixed findings. The lateral approach was more likely to result in excellent (OR 1.11, 95% CI [0.61-2.02]) and fair (OR 1.18, 95% CI [0.49-2.80]) but less likely to result in good (OR 0.79, 95% CI [0.40-1.55]) cosmetic outcomes. However, none of these analyseswerestatistically significant (p> 0.05). Conclusion: Lateral and posterior surgical approaches resulted in satisfactory functional and cosmetic outcomes. The two approaches are comparable for treating SHF in children when evaluated with Flynn's criteria.

Preoperative, intraoperative, and postoperative anesthetic considerations in gynecologic cancer surgery are discussed. Preoperatively, the anesthetist must document the patient's disease state, physical condition, responses to prior chemotherapeutic regimens and toxic side effects, particularly from Adriamycin and bleomycin. Laboratory studies should include electrolytes, hepatic, renal, and hematologic indices. The anesthetist should also recognize that patients may be under great emotional stress, which may require prescribing anti-anxiety medications for several days prior to surgery. Planning the anesthetic includes consultation with the surgeon relative to procedure planned, positioning requirements, anticipated blood loss, monitoring and postoperative care requirements. Intraoperative considerations again involve close communication with the surgeon. The use and benefits of a combined regional/general anesthetic technique are discussed. Postoperative considerations are directed toward hemodynamic stability and control of postoperative pain. Techniques of epidural narcotic and local anesthetic administration, as well as patient-controlled analgesia (PCA) are discussed.

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity. To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation. A review of relevant literature through May 2017 was performed via PubMed. To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty. A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications. A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, etal. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

Hysteroscopic Resection of an Endocervical Cesarean Scar Fibroid