Novel technique of neovagina creation with uterine serosa in the treatment of vaginal agenesis associated with mullerian agenesis

AbstractObjectiveOur aim was to create a neovagina with the least surgical morbidity and the best functional outcome.Materials and methodsWe hereby describe a new technique (Lee's neovaginoplasty) using a combined laparoscopic and vaginal approach in the creation of a neovagina using the uterine serosa layer from the rudimentary uterus and the peritoneum as a graft to line the vagina. This procedure was performed in three patients who were followed-up for a duration of 4 months to 2 years. Vaginal dilation was maintained with a vaginal mold daily for 3 months and three to four times a week thereafter.ResultsAdequate vaginal length of 6-7 cm and width of 2.5 cm was achieved postoperatively. There were no surgical complications and postoperative recovery was fast. Vaginal examination 1 month later showed healthy vaginal tissue with no necrosis or infection. Long-term follow-up did not show any shortening or stenosis of the vagina. Patients were able to have satisfactory sexual intercourse with no pain.ConclusionThe laparoscopic-vaginal approach of using a uterine serosa and peritoneal graft for creation of a neovagina is a simple and effective approach with minimal surgical morbidity that can create a passageway for satisfactory intercourse

Salpingectomy and prevention of ovarian carcinoma

Advanced cases of epithelial, primary peritoneal, and primary tubal malignancies have relative poor prognosis and collectively remain the most deadly of all gynecologic malignancies. Recently, many studies have demonstrated that the fallopian tubes might be the origin of most high grade ovarian and peritoneal serous carcinoma. In this review, we describe the tubal carcinogenic pathway with the precancerous tubal lesions and the impact of salpingectomy for prevention of ovarian carcinoma

Surgical management of cesarean scar pregnancies – A single tertiary experience

Cesarean scar pregnancies (CSPs) are a rare complication of previous cesarean deliveries. As cesarean section rates continue to increase worldwide, the incidence of CSPs is likely to rise as well. The diagnosis and management of CSPs pose challenging problems to clinicians. Early accurate diagnosis is crucial, as CSP is a life-threatening emergency that can lead to potentially catastrophic consequences such as uterine rupture, hemorrhage, loss of fertility and maternal death. There is no general consensus, however, regarding the best means of management. Various case reports and case series have reported successful outcomes with medical treatment, surgical intervention, interventional radiology, as well as a combination of methods. We present a case series of CSPs managed in our center, a tertiary obstetrics and gynecology hospital. All were treated primarily by conservative and fertility-sparing surgical methods. We have also included a short review of the current literature on this rare but important condition

Laparoscopic management of bladder ectopic pregnancy

Ectopic pregnancy is a potentially life-threatening condition and still the major cause of maternal mortality in the first trimester of pregnancy. It accounts for approximately 10% of maternal deaths. The involvement of the urinary tract is rare, usually occurring after the rupture of an abdominal implanted ectopic embryonic sac. We herein present a case of an ectopic pregnancy implanted in the bladder and successful laparoscopic management. To the best of our knowledge, this is the first description of abdominal pregnancy on the bladder wall in a natural cycle and successful laparoscopic management

Power morcellation—An emerging risk complicating minimally invasive surgery for uterine mesenchymal neoplasms

Study objective: To determine the local incidence and clinical consequences of myoma, after intraperitoneal dissemination via morcellation. Materials and methods: An electronic search for laparoscopic myomectomies in the computer database of the KK Women's and Children's Hospital (Singapore) and sarcomas or myomata with atypical features in the National Cancer Registry (Singapore) was performed for a 10-year study period. The identified patients had their medical records were traced and their data were extracted and studied in detail. Results: The incidence of unexpected diagnosis (i.e., variants, atypia, and malignancy) was 0.23%, and the incidence of unexpected sarcoma was 0.10%. One of four patients who underwent a subsequent laparotomy had peritoneal dissemination. She unfortunately was also the only mortality in this study. Conclusion: Laparoscopic surgery had proven benefits over open surgery, although the dissemination of unexpected malignancy and extrauterine seeding were major concerns. To date, morcellation in the endobag or cutting the specimen using a knife or scissors may be alternative surgical techniques

Endometriosis: A review of the diagnosis and pain management

Endometriosis is characterized by the presence of endometrial tissues outside the uterus. It affects females in their reproductive years, and may be an estrogen-dependent condition. The estimated prevalence of endometriosis in the general population is as high as 10%, and is increased in females with subfertility. The diagnosis of endometriosis is usually suspected clinically and confirmed by transvaginal ultrasound or magnetic resonance imaging of the pelvis. The gold standard of diagnosis is surgical visual inspection of the pelvic organs by an experienced surgeon during laparoscopy. A positive histology will confirm the diagnosis; however, a negative histology does not exclude it. Serum cancer antigen-125 levels may be increased in women with endometriosis, however, it is a poor diagnostic tool in comparison to laparoscopy. The management of endometriosis is dependent on whether the primary problem is pain or subfertility. The primary objectives of an intervention include removing endometriotic implants, removing nodules or cysts, restoring normal anatomy, reducing disease progression, and providing symptomatic relief. Treatment must be individualized and take into consideration the impact of the condition on quality of life. This may require a multidisciplinary approach that involves a pain clinic and counseling services

Single incision laparoscopic surgery in gynecology: Evolution, current trends, and future perspectives

Minimally invasive surgery has become the standard of care for different procedures in various subspecialties. Single-incision laparoscopic surgery (SILS) is a rapidly developing field that may mark the new frontier in laparoscopy. The ongoing and continuous efforts to decrease morbidity and improve cosmesis from laparoscopic surgery has led to minimization in number and size of ports required for these procedures. SILS is laparoscopic surgery performed through a single, small skin incision 15-20 mm in size, usually hidden in the umbilicus. SILS is not a new endeavor, but recent advances in conventional laparoscopic techniques and instrumentation has made SILS more feasible and safer for patients. Within a short span of time there has been an increase in the number of studies and clinical reports depicting the use of SILS in gynecology. As this novel field moves forward, a review of its evolution and current status is requisite. The objective of this article is to review the contemporary literature on SILS in gynecology and the recent advances in techniques and instrumentation used in SILS. The ongoing refinement of surgical techniques and instrumentation has resulted in increasing use of SILS across many subspecialties. Recently published studies have proven the feasibility, safety, and reproducibility of SILS in various gynecologic procedures

Pregnancy Outcomes in HIV-Positive Women in Singapore

Singapore had her first HIV patient tested sero-positive in 1985. Ever since then, the number of new patients being diagnosed has been on the uprising trend. Based on the current evidences in the literature, we look at how our local practice should be positioned. The objective is to study the general profile of all HIV-positive women in Singapore and to compare the difference in vertical transmission rate between women with very low viral count i.e. < 50 copies/ml who underwent caesarean section and normal vaginal deliveries. Also with proper intrapartum and postpartum advice and care, we look at the outcome of unbooked pregnancies. A ten-year retrospective review of HIV-positive women who delivered in KK Women's & Children's Hospital (Singapore) was conducted. All case notes were reviewed and data was collected and analysed using Microsoft Excel. A total of 75 deliveries by 67 women were identified. Four neonates were tested HIV-positive, amounting to a vertical transmission rate of 5.3%. Of the 12 women who were found to have viral counts of less than 50 copies/ml before their deliveries, four underwent normal vaginal deliveries while eight underwent caesarean sections. All babies were tested HIV-negative. Among the five unbooked pregnancies and two pregnancies that were booked at term, one neonate was found to be positive (14.3%). There is no difference in perinatal transmission in women with very low viral count irrespective of the mode of delivery. For those women with unbooked pregnancies, proper intrapartum care, neonatal anti-retroviral therapy together with avoidance of breastfeeding reduces vertical transmission rate and improves neonatal outcome