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Stojanovic B, Horwood G, Joksic I, Bafna S, Djordjevic ML. Management of vaginoplasty canal complications. Curr Opin Urol 2024; 34:336-343. [PMID: 38898785 DOI: 10.1097/mou.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques. RECENT FINDINGS Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options. SUMMARY Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.
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Affiliation(s)
- Borko Stojanovic
- Belgrade Center for Urogenital Reconstructive Surgery
- Faculty of Medicine, University of Belgrade, Serbia
| | - Geneviève Horwood
- Belgrade Center for Urogenital Reconstructive Surgery
- Department of Obstetrics, gynecology and newborn care, The Ottawa Hospital, Ottawa, Canada
| | - Ivana Joksic
- Hospital for Gynecology and obstetrics, Belgrade, Serbia
| | - Sandeep Bafna
- Belgrade Center for Urogenital Reconstructive Surgery
- Apollo Hospitals Chennai, India
| | - Miroslav L Djordjevic
- Belgrade Center for Urogenital Reconstructive Surgery
- Faculty of Medicine, University of Belgrade, Serbia
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Uccella S, Galli L, Vigato E, D'Alessio C, Di Paola R, Garzon S, Ercoli A. New neovagina-creating technique on the basis of a fasciocutaneous flap for Müllerian agenesis. Fertil Steril 2024; 122:382-384. [PMID: 38554765 DOI: 10.1016/j.fertnstert.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/02/2024]
Abstract
OBJECTIVE To present a new surgical technique on the basis of an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of the external genitalia. DESIGN Video demonstration of the surgical steps. PATIENT(S) An 18-year-old woman with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counseling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve the external genitalia with the chance to have a sensitive vagina guided the choice. INTERVENTION(S) The cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm-long canal bounded anteriorly by the bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying the vascular-from the pudendal artery-and nervous pedicles. A tunnel between the flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching the vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. The inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. During the postoperative period, no special positioning or ambulation restrictions were used. MAIN OUTCOME MEASURE(S) Compliance and sensitivity of the neovagina, esthetic result, and perioperative and long-term complications. RESULT(S) The postoperative course was uneventful, with early mobilization. The length of hospital stay was 16 days to allow proper vaginal dilator use; initial daily followed by intermittent use was planned. At a 2-year follow-up, the neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and esthetic result. CONCLUSION(S) The new surgical technique was feasible and effective, preserving the external genitalia and avoiding graft healing and bowel secretion drawbacks without an intra-abdominal surgical step and related risks. However, more cases-2 cases performed to date with similar results-and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and the connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.
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Affiliation(s)
- Stefano Uccella
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.
| | - Liliana Galli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Enrico Vigato
- Department of Plastic Surgery, AOUI Verona, University of Verona, Verona, Italy
| | - Chiara D'Alessio
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Rossana Di Paola
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Alfredo Ercoli
- Department of Obstetrics and Gynecology, University of Messina, Messina, Italy
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Johannesson L, Humphries LA, Porrett PM, Testa G, Anderson S, Walter JR, Rush M, Ferrando CA, O'Neill K, Richards EG. Classification and treatment of vaginal strictures at the donor-recipient anastomosis after uterus transplant. Fertil Steril 2024:S0015-0282(24)00247-4. [PMID: 38636770 DOI: 10.1016/j.fertnstert.2024.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE To describe the incidence and management of vaginal stricture after uterus transplantation (UTx) in the US, to propose a grading system to classify stricture severity, and to identify risk factors for stricture formation. DESIGN Prospective cohort study. SETTING University Hospital. PATIENTS Recipients undergoing UTx from 2016-2023 at Baylor University Medical Center in Dallas, Cleveland Clinic, the University of Pennsylvania, and the University of Alabama at Birmingham were monitored postoperatively with regular pelvic examinations. Stricture was defined as vaginal narrowing of <3 cm in patients with graft survival of at least 7 days. INTERVENTION Demographic and surgery characteristics. MAIN OUTCOME MEASURES Stricture development and severity (grade 1 for diameter 2-<3 cm, grade 2 for 1-<2 cm, or grade 3 for <1 cm). RESULTS Of the 45 UTx from 2016-2023 (16 deceased donors and 29 living donors), 3 were excluded from the analysis because of graft loss within 7 days. Of the 42 remaining recipients, 39 (92.9%) had Mayer-Rokitansky-Küster-Hauser syndrome and 3 (7.1%) had a prior hysterectomy. Twenty-eight (66.7%) UTx recipients developed postoperative vaginal strictures with a median time to stricture of 33 days (interquartile range 19-53 days). Most strictures were of moderate severity, with 4 (14.3%) strictures categorized as grade 1, 19 (67.9%) as grade 2, and 5 (17.9%) as grade 3. History of Mayer-Rokitansky-Küster-Hauser syndrome and preoperative recipient vaginal length were significant risk factors for stricture, after adjustment for donor and recipient age and body mass index, anastomosis technique, total ischemia time, center, and year. Patients with longer preoperative vaginal length had a lower risk of stricture (hazard ratio 0.45, 0.29-0.70). The severity grading of the stricture was associated with the effectiveness of a nonoperative treatment approach (grade 1 vs. grade 3). No patients with grade 3 strictures improved with self-dilation alone; all required surgical repair and/or dilation under anesthesia. Conversely, for grade 1 or 2 strictures, self-dilation alone was successful in 47.8% (11/23), and no grade 1 strictures required surgical repair. CONCLUSIONS Vaginal stricture is a common postoperative complication after UTx, affecting >65% of recipients. Short preoperative vaginal length and history of müllerian agenesis in the recipient are significant risk factors. Vaginal self-dilation was effective for some mild to moderate strictures, although dilation under anesthesia or surgical repair was required in most cases. CLINICAL TRIAL REGISTRATION NUMBERS Dallas UtErus Transplant Study (DUETS) at Baylor University Medical Center (NCT02656550), Uterine transplantation for the treatment of uterine factor infertility at the Cleveland Clinic (NCT02573415), The University of Pennsylvania Uterus Transplant for Uterine Factor Infertility Trial (UNTIL) (NCT03307356).
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Affiliation(s)
- Liza Johannesson
- Department of Obstetrics and Gynecology, Baylor University Medical Center, Dallas, Texas; Department of Surgery, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas.
| | - Leigh A Humphries
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paige M Porrett
- Department of Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Giuliano Testa
- Department of Surgery, Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas
| | | | - Jessica R Walter
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Margaret Rush
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cecile A Ferrando
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
| | - Kathleen O'Neill
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elliott G Richards
- Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, Ohio
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Li L, Adeyemi-Fowode O, Bercaw-Pratt JL, Hakim J, Dietrich JE. Surgical Management of OHVIRA and Outcomes. J Pediatr Adolesc Gynecol 2024; 37:198-204. [PMID: 38070700 DOI: 10.1016/j.jpag.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 11/12/2023] [Accepted: 11/20/2023] [Indexed: 12/30/2023]
Abstract
STUDY OBJECTIVE Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) includes uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomaly. Surgical management of this condition relies on accurate diagnosis to excise the obstructed longitudinal vaginal septum (OLVS). Vital considerations involve identifying the side affected, ipsilateral renal anomaly (IRA), thickness of the septum (TS), septal axis (SA), and distance of the septum to perineum (DSP). The study aimed to evaluate the preoperative characteristics, imaging findings, and surgical outcomes of OHVIRA. METHODS Institutional review board approval was obtained for this retrospective chart review. ICD-10 codes identified OHVIRA cases between 2012 and 2019 at a single children's hospital. Patient demographic characteristics, magnetic resonance imaging findings, surgical management, outcomes, and complications were reviewed. Descriptive statistics were utilized. RESULTS Twenty-six patients met inclusion criteria. Most were diagnosed at puberty (92%). Abdominal pain (50%) was the most common presenting complaint. The mean age of diagnosis was 13.2 years overall and 11.2 years for those with regular cycles vs 13.4 years for those with irregular cycles. Preoperative imaging showed predominant right-sided OLVS (50%), IRA (77%), and oblique SA (65%). All patients underwent vaginoscopy, septum resection, and vaginoplasty, except 1 who was managed with an abdominal drain as a neonate. Four required postoperative vaginal stent or Foley, with DSP greater than 5 cm in all cases. One intraabdominal abscess complication occurred. No instances of hematocolpos re-accumulation or reoperation were observed during the 3-year follow-up period. CONCLUSION This study demonstrates that detailed preoperative planning and a systematic surgical approach lead to favorable outcomes in OHVIRA irrespective of the OLVS laterality, TS, SA, or DSP.
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Affiliation(s)
- Lucy Li
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas.
| | - Oluyemisi Adeyemi-Fowode
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Jennifer L Bercaw-Pratt
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Julie Hakim
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas; Division of Pediatrics, Baylor College of Medicine, Houston, Texas
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Papastefan ST, Collins SA, Mueller MG, Geynisman-Tan J, Reynolds M, Cheng EY, Yerkes EB, Grabowski JE. Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction. J Pediatr Surg 2024; 59:124-128. [PMID: 37802758 DOI: 10.1016/j.jpedsurg.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/28/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts. METHODS Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed. RESULTS Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion. CONCLUSIONS We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated. LEVEL OF EVIDENCE IV. TYPE OF STUDY Retrospective Study.
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Affiliation(s)
- Steven T Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Sarah A Collins
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Margaret G Mueller
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Julia Geynisman-Tan
- Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Earl Y Cheng
- Division of Urology, Department of Urology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elizabeth B Yerkes
- Division of Urology, Department of Urology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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HadaviBavili P, İlçioğlu K, Hamlacı Başkaya Y. Evaluation of Sexual Function Outcomes in Patients with Rokitansky Syndrome: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2023; 30:705-715. [PMID: 37271411 DOI: 10.1016/j.jmig.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/06/2023]
Abstract
OBJECTIVE In patients with Rokitansky syndrome, vaginal agenesis can be treated using various surgical techniques, and various factors can affect each surgery outcome in the long term. This meta-analysis aimed to evaluate sexual function outcomes in patients with Rokitansky syndrome after various surgery techniques. DATA SOURCES Searches were conducted in Google Scholar, PubMed, Cochrane database, ScienceDirect, Web of Science, and ClinicalTrials.gov. Systematic searches were conducted on studies published until November 2022 (CRD42022370735). METHODS OF STUDY SELECTION During the first stage of database scanning and reference check, 1820 results were identified, and an evaluation of the total 10 studies was finally conducted. The inclusion criteria involved selecting randomized controlled trials that focused on assessing sexual function after surgical treatment in patients of all ages with Rokitansky syndrome. TABULATION, INTEGRATION, AND RESULTS EndNote version 20 software was used to organize and identify duplicate articles through screening. The Joanna Briggs Institute's critical appraisal tool was used to evaluate each study's quality for bias potential. The results showed that the total scores of female sexual functions in patients with Rokitansky syndrome after vaginoplasty were significantly lower than in healthy women (standardized mean difference, -0.233; p <.05; range, -0.376 to -0.090). The 6-domain analysis of the Female Sexual Function Index questionnaire revealed that lubrication (p <.05) and satisfaction (p <.05) were significantly lower in patients undergoing vaginoplasty. CONCLUSION All surgical techniques to create a neovagina for patients with Rokitansky syndrome have successfully affected the sexual function outcomes. Considering all other factors affecting sexual function outcomes in the long term, more quantitative and qualitative studies are needed to assess sexual satisfaction in patients treated with surgical techniques.
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Affiliation(s)
- Parisa HadaviBavili
- Faculty of Health Sciences, Department of Midwifery (HadaviBavili and Dr. Hamlacı Başkaya), Sakarya University, Sakarya, Türkiye; Sakarya University, Institute of Health Science, Department of Midwifery, Sakarya, Türkiye.
| | - Kevser İlçioğlu
- Faculty of Health Sciences, Department of Nursing/ Obstetrics and Gynaecology Nursing (Dr. İlçioğlu), Sakarya University, Sakarya, Türkiye
| | - Yasemin Hamlacı Başkaya
- Faculty of Health Sciences, Department of Midwifery (HadaviBavili and Dr. Hamlacı Başkaya), Sakarya University, Sakarya, Türkiye
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Dietrich JE. NASPAG Pediatric and Adolescent Gynecology Surgery Compensation Survey. J Pediatr Adolesc Gynecol 2023; 36:167-172. [PMID: 36162720 DOI: 10.1016/j.jpag.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/30/2022] [Accepted: 09/19/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Over the last decade, the field of pediatric and adolescent gynecology (PAG) has rapidly expanded on the basis of a need for this specialized training to care for children and adolescents with gynecologic concerns. There are 18 PAG fellowship programs within the United States and Canada. Since 2017, which marked the beginning of the American Board of Obstetrics and Gynecology (ABOG) Focused Practice Examination in PAG and PAG Maintenance of Certification program, there has been a growing recognition of this specialty, given the unique population served. However, there is a paucity of information related to compensation in PAG. As the field has grown and more PAG fellow graduates are sought by children's hospitals throughout the United States and Canada, there is an urgent need to ensure that salary is equitable for these specialty PAG providers given the unique skills acquired during fellowship training, beyond that of obstetrics and gynecology (OBGYN) residency. This initial survey aimed to focus on compensation for PAG surgeons in the United States. OBJECTIVES To survey NASPAG PAG surgeons in the United States about current benefits, practice metrics, and compensation METHODS: A 15-question anonymous survey was sent to PAG surgeons in the United States in February 2022, with 3 reminders sent by email to engage voluntary participation. The survey aimed to understand practice characteristics, current compensation, and relative value unit (RVU) benchmarks. Descriptive statistics were utilized. Compensation means and quartiles were calculated in U.S. dollars for the following categories: assistant professor, associate professor, and full professor. The compensation mean was also calculated for private/hybrid and instructor categories. RESULTS Among 255 eligible members, 88 completed the survey, for a participation rate of 34.5%. Sixty-three point six percent reported having completed a PAG fellowship, whereas one-third reported specializing in this area with no fellowship available at the time. Three-fourths reported having achieved ABOG Focused Practice PAG certification. Most providers were academic (75%) and working full time (82.9%). Among academicians, most were assistant professors (48%) and on the non-tenure track (50.6%). RVU benchmarks varied, with 40.2% reporting OBGYN generalist targets and only 18.3% reporting PAG-specific targets, despite most physicians practicing only PAG (62.5%) and less than 30% practicing PAG plus some adult OBGYN. Salary support varied, with 57% employed by a hospital. Incentives were common, with most receiving a bonus at the end of the year (52.9%). As expected, full professors reported higher mean compensation ($345k) as compared with less senior colleagues ($248k and $302k for assistant and associate professors, respectively). Private practice/hybrid practitioners reported compensation ($251k) similar to that of assistant professors ($248k). Only 2 instructor-level physicians completed the survey. The mean number for this level is skewed and is not a reliable predictor for this academic level. Quartiles could not be calculated for this category. CONCLUSION This is the first survey addressing compensation in the field of PAG in the United States. There is an ongoing need to collect this information to prepare PAG fellow graduates for the job market. Additional surveys, including an understanding of the compensation landscape in Canada, are needed in the future to address specific questions related to compensation for those who have less than 50% clinical time.
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Affiliation(s)
- Jennifer E Dietrich
- NASPAG Executive Board; Department of Obstetrics and Gynecology and Department of Pediatrics, Division Director Pediatric and Adolescent Gynecology, Baylor College of Medicine, Chief of Pediatric and Adolescent Gynecology, Texas Children's Hospital, Houston, Texas.
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Dietrich JE. Diagnosis and Management of Mullerian Anomalies Across Differing Resource Settings: Worldwide Adaptations. J Pediatr Adolesc Gynecol 2022; 35:536-540. [PMID: 35489471 DOI: 10.1016/j.jpag.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 04/06/2022] [Accepted: 04/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Mullerian anomalies affect 7% of reproductive age women. It is important to have a basic understanding of these conditions, given they can affect women at any stage of life and have potential impacts on fertility and pregnancy. This article seeks to review these anomalies as well as specific diagnostic pitfalls and strategies to approach these conditions in both high- and low-resource environments. METHODS This review was undertaken with a PubMed focused search, using terms related to the diagnosis and management of Mullerian anomalies in many worldwide settings. Consideration was made to assess the medical resources available in low- and middle-income countries (LMICs), which could impact diagnostic and management decisions, compared with high-income countries (HICs). Concurrent medical conditions and both gynecologic and obstetric outcomes were also searched. Practice recommendations from international societies were also reviewed and compared. Finally, 4 conditions were evaluated more closely to assess management differences based on geographic locations and whether the countries were LMICs or HICs; specifically, those evaluated were lower vaginal atresia, uterovaginal agenesis, bicornuate uterus, and septate uterus. DISCUSSION Mullerian anomalies encompass a wide variety of conditions, ranging from subtle anatomic changes without concurrent anomalies to complex conditions, associated with anomalies of the kidney or spine, which could impact the ability to manage certain conditions based on medical resources available geographically. A systematic approach and provider expertise is important for appropriate diagnosis and management, independent of geographic location. Counseling is critical for medical and surgical decision-making and might be limited or guided by the resources available in certain settings or even by existing laws. CONCLUSIONS Limited outcomes are available among patients with Mullerian anomalies in LMICs; however, the management varies based on the basic tools available to address acute needs, as well as long-term fertility and obstetric concerns. More research is needed in this population, which could help drive the importance of early diagnosis and management not only in HICs but also in LMICs, where individualization strategies are key.
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Affiliation(s)
- Jennifer E Dietrich
- Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Department of Pediatrics, Baylor College of Medicine, 6651 Main St, Ste 1050, Houston, TX 77030, United States.
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The current and future state of surgery in reproductive endocrinology. Curr Opin Obstet Gynecol 2022; 34:164-171. [PMID: 35895956 DOI: 10.1097/gco.0000000000000797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The last decade has witnessed a radical change in the field of reproductive surgery. The increasing success of in-vitro fertilization (IVF) has caused a huge shift in emphasis with many downstream consequences. This review outlines the changes and provides insight into the future of reproductive surgery. RECENT FINDINGS With compelling evidence that IVF overcomes the detrimental effects of endometriosis on infertility and with two new oral medications available for management of endometriosis, momentum is shifting towards nonsurgical management of endometriosis. There is increasing recognition that except for submucous myomas, other myomas are unlikely to affect fertility and miscarriage. This, in addition to many emerging alternative modalities for management of myomas (oral GnRH antagonists, radiofrequency ablation), is likely to further decrease classic myomectomies but provide alternative, less invasive options. Caesarean scar defects have been recognized as having significant reproductive consequences and surgical management has become the standard of care. Fallopian tubes are now implicated in development of ovarian cancer, and as a result, salpingectomies are being performed in lieu of tubal ligations. Tubal anastomosis will soon become a historical surgery. Division of uterine septum remains controversial, and a clear answer will remain elusive. Uterine transplant is the single most significant advance in reproductive surgery in the past century. SUMMARY Reproductive surgery is evolving with the times. Although some surgical techniques will become historical, others will become mainstream.
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