Use of Laparoscopy in Intersex Patients

The history of surgery in disorders of sexual development

Disorders of sexual development (DSD) have been documented throughout human history with fascination. Healers of all cultures have struggled to explain, and later correct with surgery, the physical manifestations of DSD. DSD was portrayed in the mythology, legends, and art of the ancient Greeks, Romans, Sumerians, Babylonians, and Egyptians. Techniques of feminizing genitoplasties date to the time of Celsus in the time of Christ. Acceptable operative therapy for feminine phenotypes of DSD came in the 19th and 20th centuries. Masculinizing procedures, inherently more complex than feminizing genitoplasties, initially were variations of procedures for severe forms of hypospadias. Today most total penile reconstruction procedures use reconstructive and microvascular techniques invented in 20th century.

Impact of laparoscopy for diagnosis and treatment in patients with disorders of sex development

OBJECTIVE

To review laparoscopy in patients with disorders of sex development (DSD) in order to clarify its usefulness in diagnosis, devising subsequent therapeutic strategies and managing patients with various conditions.

PATIENTS AND METHODS

Between April 1992 and December 2012, 29 laparoscopic surgeries were performed in 25 DSD patients. Among them, ten were diagnostic laparoscopy including gonadal biopsy, and 19 were therapeutic laparoscopy. Surgical procedures and complications were evaluated.

RESULTS

For diagnostic laparoscopy, laparoscopic gonadal biopsy was performed in three patients. Inspection, with or without open gonadal biopsy, was performed on four out of seven patients with 46XY DSD or mixed gonadal dysgenesis (MGD). Additional surgery was planned and performed based on diagnostic laparoscopic findings in six out of seven patients. In the three patients with ovotesticular DSD, the gonadal pathology was diagnosed as: testis/ovary in one, testis/ovotestis in one and ovary/ovotestis in one--this was from the laparoscopic inspection and/or gonadal biopsy. However, the final diagnoses were bilateral ovotestis in two patients and ovary/ovotestis in one patient. For therapeutic laparoscopy, surgical procedures were: gonadectomy in 17 patients (bilateral in 13, unilateral in three, partial in two); hysterectomy in two patients; orchiopexy in one; and sigmoid vaginoplasty in one patient (included multiple procedures). There were no severe perioperative complications. In the four patients with a history of diagnostic laparoscopy, no severe intra-abdominal adhesions that would disturb therapeutic laparoscopic surgery were observed.

CONCLUSION

While diagnostic laparoscopy was helpful in devising a therapeutic surgical strategy in most of the patients with DSD who were suspected as having complex gonadal status or Müllerian duct derivatives, attention must be paid to precisely diagnosing the gonadal status in ovotesticular DSD. On the other hand, therapeutic laparoscopic surgeries were valuable procedures in treating DSD patients, even with a history of previous diagnostic laparoscopy.

The use of laparoscopy in intersex patients

The management of intersex patients is a challenge. Although in the majority of patients the diagnosis may be made on the basis of cytogenetic and biochemical tests, there is a selective group of patients with difficulties in the establishment of final diagnosis and gender assignment. Since laparoscopy has been used in the management of impalpable gonads in the normal male population, it may be an alternative method for the diagnosis and surgical management of intersex patients. Thus we have evaluated our experience with laparoscopy in intersex population. Over the last 10 years (1995-2005) more than 80 intersex patients underwent surgical correction at our department. Out of those, 14 patients with a median age of 3 years (range 2-18 years) underwent laparoscopic surgery. Laparoscopic gonadectomy with subsequent estrogen replacement was performed following gonadal biopsy in five patients with androgen insensitivity syndrome (AIS). In three patients with mixed gonadal dysgenesis (MGD) gonadal biopsy was performed. In two of those the initial diagnosis was changed to true hermaphroditism, and they underwent removal of ovotestis from one side and orchidopexy of the normal testis on the other. In one patient with MGD, timed gonadectomy following laparoscopic biopsy was performed due to malignant potential of the streak gonads. In two patients with persistent müllerian duct syndrome (PMDS), laparoscopic orchidopexy was performed following gonadal biopsy. Three patients with total gonadal dysgenesis (TGD) underwent laparoscopic gonadectomy and one with true hermaphroditism underwent laparoscopic biopsy followed by bilateral inguinal orchiectomy with preservation of the ovarian tissue. Our data show that the laparoscopic gonadal biopsy remains the only way to obtain morphologic gonadal structure and to establish a final diagnosis in doubtful cases. Magnification and easy access to the pelvic cavity allow removal of gonads or ductal structures with the advantages of minimally invasive procedure.

Complications of pediatric urological laparoscopy: mistakes and risks

PURPOSE

We evaluate the results and complications of laparoscopic urological procedures in children.

MATERIALS AND METHODS

In a 3-year period 4,350 laparoscopic procedures were performed at 8 Italian centers of pediatric surgery. We analyzed only the data of urological procedures for a total of 701 laparoscopic operations on patients 1 month to 14 years old. The indications for surgery were cryptorchidism in 414 cases, varicoceles in 159, ambiguous genitalia in 37, total nephrectomy in 34, partial nephrectomy in 4, adrenalectomy in 3 and other diagnostic procedures in 50. We adopted a retroperitoneoscopic approach in 72 cases (10.3%) and a laparoscopic approach in 629 (89.7%). Patient records were analyzed to search for any complication that may have occurred during the laparoscopic procedure and assess how they were managed.

RESULTS

We recorded 19 complications (2.7%) in our series, of which 6 required conversion to open surgery and 13 did not. There was no mortality. At a maximum followup of 4 years all children were alive and had no problems related to the laparoscopic complications.

CONCLUSIONS

Our study shows that pediatric laparoscopic urological surgery has an acceptable rate of complications with no mortality. We believe that routine use of open laparoscopy in pediatric patients is a key factor to help avoid complications. Most complications can be avoided with surgeon and team experience, together with proper compliance with the indications for surgery.

Laparoscopic gonadectomy and excision of müllerian remnant in an adult intersex patient

Laparoscopy can assist in the diagnosis and treatment of intersex patients. We report a rare case in which laparoscopic gonadectomy and hysterosalpingectomy were performed in a phenotypically-male intersex patient first diagnosed in adulthood.

Laparoscopic management of intersexual states

Laparoscopy has gained acceptance as the ideal method of surgical treatment of the internal [figure: see text] genital organs in patients with intersex disorders. The intersexual states for which laparoscopy is needed are female and male pseudohermaphroditism, true hermaphroditism, and Turner's syndrome. In these patients, the indications for laparoscopy are the removal of normal gonads and ductal structures that are contrary to the assigned gender and the removal of dysgenetic gonads that are nonfunctional and that present potential for malignancy. In addition to being a minimally invasive surgery, one of the main advantages of this method is the lack of scars, a fact much appreciated by patients and their parents. Generally, gonadectomy is a straightforward operation because the gonads present with an accessible pedicle. Laparoscopic orchidopexy has been standardized and can be performed in patients in whom the testis must be relocated to the scrotum. The removal of ductal structures is also easily performed in most cases, whereas hysterectomy with resection of the vagina may present some difficulties owing to the location of these structures. In patients with a long vaginal component of the urogenital sinus, the distal segment must be removed by a retrograde perineal access, usually performed simultaneously with genitoplasty. Endocrinologists must be aware of the application of this method of treatment in intersex patients, and urologists proficient in laparoscopic techniques must extend their field of work in this area.

Laparoscopic surgery in urology

Not more than 10 years ago, laparoscopy was introduced to the armamentarium of urology. The start was slow, with pelvic lymphadenectomy, nephrectomy and varicocelectomy being about the only indications. However, very soon great enthusiasm developed, and almost every urological operation was performed by means of laparoscopy. For several reasons this exaggerated enthusiasm had to be followed by disappointment. First of all, laparoscopy turned out not to be as easy as many would have liked it to be. Due to a low frequency of operations, many surgeons were never able to overcome their learning curve, and the early literature reflects this problem. Unlike general surgery where cholecystectomy developed into a pacemaker operation, which forced everybody to go ahead with laparoscopy, urology was long searching for good and frequent indications for this new technique. Within the last few years, the pendulum has swung back to the other side. Adrenalectomy was one of the first indications where laparoscopy proved superior to open surgery in every aspect. Several other good indications have followed, some of which, namely cryptorchidism, nephrectomy and pyeloplasty, will be presented in detail to give an example. But the breakthrough that recently occurred is due to the success of laparoscopy in the field of oncologic surgery. Laparoscopic radical nephrectomy has shown its surgical efficiency as well as its oncologic efficacy. However, the main interest is now focused on radical prostatectomy, since this is the most frequently performed operation in urology by now. Recently this operation could be developed to a standardized technique, but only time will tell its true impact. Several indications will change in the future, but laparoscopy is here to stay.

Minimally invasive surgery in pediatric endocrinology

The use of minimally invasive surgery (MIS) in children and adolescents is steadily increasing. The aim of the present review was to summarize the status of MIS in pediatric endocrinology. We found that laparoscopic procedures have been proven useful for the diagnosis or treatment of endometriosis and its associated manifestations, undescended testicles, ambiguous genitalia, adnexal torsion and ovarian cyst. Considering the safety and efficacy of these applications, the more rapid recovery of the patients, and the considerably less pain induced, we believe MIS will gradually take precedence over standard procedures in many areas of endocrinology in the young population.

The use of laparoscopy in the management of adnexal pathologies in children

BACKGROUND

The authors' experience of using laparoscopy in the management of 23 girls (mean age: 8.9 years; range: 3 months-15 years) with various adnexal pathologies over a 3-year period is reviewed.

METHODS

Of the 23 patients, seven were evaluated for congenital gonadal pathologies, 15 presented with abdominal pain and one patient had an antenatally diagnosed adnexal mass. Detailed laparoscopic examination of the pelvic cavity and laparoscopic gonadectomy were successfully performed in all seven patients with congenital gonadal pathologies: mosaic Turner's syndrome (n = 2), gonadal dysgenesis (n = 3) and testicular feminization syndrome (n = 2). Of 15 patients presenting with abdominal pain, 11 had an adnexal mass, two had acute appendicitis and two had pelvic inflammatory disease.

RESULTS

Laparoscopic excision of the adnexal masses were successfully performed in 10 of 11 patients. Conversion to open surgery was required in one patient with a huge teratoma. Laparoscopic appendicectomy was successfully performed in both patients with acute appendicitis while diagnostic laparoscopy was the only procedure required in the two patients with pelvic inflammatory disease. Laparoscopy in the infant with an antenatally diagnosed adnexal mass confirmed this to be an omental cyst, which was successfully excised. All patients recovered without complications and good cosmetic result was universally achieved.

CONCLUSION

Laparoscopy is safe and effective in both diagnosis and treatment of adnexal pathologies in children.

Laparoscopic surgery in children

The surgeon should be aware of the extensive applications of endoscopic surgery in the pediatric patient. The ability to provide surgical care in association with either outpatient or short-stay hospitalizations appear to be cost-effective and appropriate state-of-the-art medical care. Because the array of surgical instruments continues to evolve, new and innovative endoscopic procedures will continue to become increasingly available.

A Truly “Complex” Case of Urethral Stricture

Diagnosis of pseudohermaphroditism (gonads and secondary characteristics of the opposite sex) after puberty is rare. We observed a mis-diagnosed case of pseudohermaphroditism caused by the persistence of Mullerian ducts (vagina, uterus and Fallopian tubes) in a 72-year-old patient, who had previously undergone several operations for urethral stenosis and bilateral criptorchidism.