Vaginoscopic Incision of Oblique Vaginal Septum in Adolescents with OHVIRA Syndrome

Successful pneumovaginoscopic surgery for recurrent abscess of OHVIRA syndrome, preventing further recurrence and subsequent pregnancy

INTRODUCTION

OHVIRA syndrome is a rare congenital anomaly of Müllerian duct development characterized by uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. The primary treatment is surgical excision of the obstructed hemivaginal septum and hematometrial drainage. In recent years, minimally invasive approaches such as hysteroscopic or vaginoscopic septum resection have been reported. Furthermore, we originally developed some novel pneumovaginoscopic gynecologic surgeries for years using a device that consists of a cylinder that fits into the vagina and a lid that mounts multiple ports, allowing the vagina to be dilated with carbon dioxide gas, similar to a single-port laparoscope.

MATERIALS AND SURGICAL TECHNIQUE

We report a successful pneumovaginoscopic surgery for a complicated recurrent abscess in a patient with OHVIRA syndrome. Conventional surgery was performed with a single forceps in a liquid, as in cystoscopy or hysteroscopy. However, this new surgery allowed multiple forceps in a gas, as in laparoscopy. So pus and blood were aspirated and washed away without leaking into the abdominal cavity via fallopian tubes. The surgical smoke generated by thermal coagulation also aspirated to clean the field of vision immediately. And thick, complicated abscesses were drained successfully. The patient conceived through IVF with ICSI and delivered safely at full term.

DISCUSSION

Pneumovaginoscopy could benefit complex vaginal surgery cases, such as abscess formation in patients with OHVIRA syndrome.

Hydrometrocolpos: a Contemporary Review of the Last 5 Years

PURPOSE OF REVIEW

The goal of this review is to provide a comprehensive overview of hydrometrocolpos, covering disease etiology, pathophysiology, clinical presentation, and diagnostic and management techniques, and known outcomes.

RECENT FINDINGS

This narrative review presents the literature on hydrometrocolpos in the pediatric population from the past 5 years. We highlight the 69 reported cases of hydrometrocolpos and classify them based on type of obstruction or associated anomaly, discuss new diagnostic algorithms based on imaging, and present novel and underutilized surgical techniques for definitive management. Hydrometrocolpos, a condition characterized by retained fluid causing a distended vagina and uterus in the setting of a distal vaginal outflow obstruction, has a wide range of presentation severity based on the type of obstruction. Whether hydrometrocolpos is due to an isolated condition like imperforate hymen, a complex abnormality like cloacal malformation, or a part of a large congenital syndrome, the mainstay of treatment is decompression of the dilated vagina and surgical correction of the outflow obstruction. Imaging-based diagnostic algorithms and new treatment techniques reported in the literature, as well as longitudinal and patient-reported outcome research, can improve the lives of children affected by this condition.

Renal agenesis: A meta-analysis of its prevalence and clinical characteristics based on 15 641 184 patients

Our objective was to analyse the newest relevant data on worldwide prevalence and associated symptoms of renal agenesis (RA). This meta-analysis builds on previous systematic reviews to include bilateral RA, its symptoms and data on gender, unilateral RA and anomaly location prevalence. Review of available data included records in English and other languages from PubMed, Embase, ScienceDirect, Web of Science, SciELO, BIOSIS, Current Content Connect Korean Journal Database and Russian Citation Index and Google. A total of 15 641 184 patients were analysed in relation to the prevalence of RA. The pooled prevalence of RA was 0.03% (95% CI: 0.03%-0.04%). Based on 500 subjects, a pooled prevalence of 47.96% (95% CI: 31.55%-64.58%) for unilateral and 52.04% (95% CI: 35.42%-68.45%) for bilateral RA has been set. Our study presents the newest generalized findings on bilateral RA. There appears to be universal disease and symptom prevalence with minor differences between world regions, although quality of future observational research should include genomic data. This will provide even further insight into the prognosis of various renal anomalies and their etiologies.

Successful vaginoscopic excision of the vaginal septum in a virgin girl of obstructed hemivagina and ipsilateral renal anomaly: Case report and review of literature

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) is a rare malformation that not only causes severe menstrual cramps shortly after menarche but can also lead to endometriosis and infection in the future. We report a case of OHVIRA successfully managed by vaginoscopic excision of the vaginal septum. A 12-year-old virgin girl presented to our hospital with dysmenorrhea and lower abdominal pain. OHVIRA was diagnosed using magnetic resonance imaging. Vaginoscopic surgery was performed for drainage of hematocolpos and excision of the vaginal septum. Vaginoscopic excision of the vaginal septum was performed using a resectoscope, without a vaginal speculum. The procedure was completed safely without injuring the hymen. This is the first case report of successful excision of the vaginal septum by vaginoscopic surgery for OHVIRA in Japan. Vaginoscopic excision may be one of the effective options for the treatment of vaginal obstruction.

Vaginoscopic Incision of Vaginal Septum With Preservation of the Hymen in a Child With Obstructed Hemi-Vagina Ipsilateral Renal Agenesis (OHVIRA) Syndrome

Obstructed hemi-vagina ipsilateral renal agenesis (OHVIRA) syndrome, also known as Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian duct anomalies that usually presents after menarche. Although there is increasing awareness about OHVIRA syndrome, high suspicion is needed for the diagnosis. Awareness of the syndrome is crucial for the management and to prevent serious complications. Surgical techniques and age at the surgery are still debatable but, minimally invasive vaginoscopic resection of the vaginal septum should be considered when feasible as it not only allows division of septum with preservation of hymen, but it provides excellent visualization, is less traumatic, and has promising postoperative outcomes. Hymenal integrity is of great concern in specific populations with cultural values. In this report, we present the case of a 24-month-old girl diagnosed with OHVIRA syndrome during a routine follow-up for renal agenesis and was managed with vaginoscopic incision of the vaginal septum using a pediatric cystoscope while maintaining the hymenal integrity.

Correlation Analysis of Serum Pepsinogen, Interleukin, and TNF-α with Hp Infection in Patients with Gastric Cancer: A Randomized Parallel Controlled Clinical Study

Background

Gastric cancer pathological biopsy and visual examination have been the gold standard for gastric cancer diagnosis, but their operation is costly, demanding, and risky, so it is especially important to find an effective examination method in clinical practice.

Aims

To investigate the correlation between serum pepsinogen I (PGI), pepsinogen II (PGII), pepsinogen I and II ratio (PGR), IL-6, and TNF-α and Helicobacter pylori (Hp) infection in patients with gastric cancer.

Materials and Methods

Fifty patients with Hp-infected gastric cancer admitted to the Department of Gastroenterology of our hospital from January 2019 to December 2021 were selected for the study as the observation group, and another 50 patients without Hp-infected gastric cancer were selected as the comparison group to compare the correlation analysis of PGI, PGII, PGR, IL-6, and TNF-α with Hp infection between the two groups after admission and treatment.

Results

After measurement, PGI and PGII in the observation group were significantly lower than those in the comparison group, and TNF-α, IL-18, and IL-6 in the observation group were significantly higher than those in the comparison group, and the comparative differences were all statistically significant (P < 0.05). The results of multivariate logistic regression model analysis of independent risk factors for gastric cancer showed that IL-18, hs-CRP, and tumor necrosis factor- (TNF-) α were risk factors for Hp infection in gastric cancer.

Conclusion

The expression of IL-18, hs-CRP, and TNF-α factors in Hp-infected gastric cancer patients is correlated. IL-6, IL-18, and TNF-α are involved in the entire process from the onset to the development of Hp-positive gastric mucosal inflammation in patients, which is of great value in the diagnosis of gastric cancer and helps to assess the degree of progression and prognosis of gastric cancer.

Effect of Vaginoscopy versus Conventional Hysteroscopy on Pain, Complications, and Patient Satisfaction in Patients with Endometrial Polyps

Background

Hysteroscopy is considered the gold standard for diagnosing intrauterine pathology. Traditional hysteroscopy requires the placement of a vaginal speculum and cervical forceps, which are large in diameter, causing discomfort and pain to the patient and even causing vagal reflexes.

Aims

To investigate the impact and clinical value of vaginoscopy versus conventional hysteroscopy on pain, complications, and patient satisfaction in patients with endometrial polyps and to analyse the advantages of clinical application of vaginoscopy examination.

Materials and Methods

One hundred and twenty-five patients with endometrial polyps treated in our hospital from May 2021 to December 2021 were selected for this study and divided into 52 cases in the hysteroscopy group and 73 cases in the vaginoscopy group according to the random remainder grouping method. Conventional hysteroscopy was used, and in the vaginoscopy group, vaginoscopy was performed. The impact of pain, complications, patient satisfaction, and clinical value of the two groups was observed and compared.

Results

The time taken for the examination varied between the different hysteroscopic methods, with the hysteroscopy group taking the longest time compared to the vaginoscopy group (P < 0.01). The VAS scores immediately after the examination and 30 minutes after the examination were both significantly higher in the hysteroscopy group than in the vaginoscopy group (P < 0.01). The difference in NPY, PGE2, and 5-HT after the pain-causing mediator intervention was significantly better in the vaginoscopy group than in the hysteroscopy group. The difference in the incidence of complications such as abortion syndrome, cervical laceration, uterine perforation, and haemorrhage after treatment was significantly lower in the vaginoscopy group than in the hysteroscopy group. In the vaginoscopy group, the satisfaction rate was 91% significantly higher than that of the hysteroscopy group (P < 0.05).

Conclusion

The vaginoscopy technique shortens the examination and treatment time, reduces patient pain, improves patient compliance, reduces the use of preintervention drugs and anaesthetics, and reduces complications.

Endoscopic Treatment of a Severe Vaginal Stenosis Following Battery Insertion in an 11-Year-Old Girl

Acquired vaginal strictures are rare entities in children. As a result, they are generally difficult to manage and tend to recur despite appropriate initial therapy. This case study reports the staged management of vaginal stenosis following the insertion of a button battery. In this case, an 11-year-old girl experienced at 4 years old a battery insertion in the vaginal canal by her neighbor's son, who was 6-year-old at the time. Two weeks from insertion, the parents noted the foreign body discharge spontaneously. The girl had not complained of any symptoms at the time and had been asymptomatic for many years. In November 2020, she came to the emergency department reporting cramping abdominal pain accompanied by mucopurulent discharge. An abdominal ultrasound showed the presence of hematometrocolpos, and a vaginal stenosis dilation under general anesthesia was performed the following day. After 3 weeks, the stenosis was still present, preventing the passage of Hegar number 4. The girl was subjected to a vaginoscopic stenosis resection utilizing a monopolar hook passed through an operative channel. A Bakri catheter filled with 120 mL of water was left in place. After 10 days, the girl was discharged home with the Bakri inserted. Two weeks after discharge, she was reevaluated in the outpatient setting, where the Bakri was removed with no signs of residual stenosis. Acquired vaginal stenosis could be demanding to treat, particularly with the sole conservative approach. A first-line option can be the Hegar dilation. The endoscopic approach can be a second-line, minimally invasive treatment, but long-term outcomes are difficult to predict.

Vaginoscopic Incision of Oblique Vaginal Septum in an Adolescent Girl with OHVIRA Syndrome: Simple Management of Complicated Anomaly

OHVIRA syndrome comprises uterine didelphys, obstructed hemivagina, and ipsilateral renal agenesis. It usually presents with pain abdomen and pelvic or vaginal mass with normal menses. Early diagnosis is important to prevent complications in later life. The case of a 12-year-old girl who presented with pain abdomen and progressive dysmenorrhea for the last 6 months (since menarche) is discussed. She was managed successfully with vaginoscopic septal incision with simultaneous preservation of hymenal integrity.

OHVIRA syndrome pre-operatively diagnosed using vaginoscopy and hysteroscopy: A case report

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare Mullerian duct anomaly. Cases with pelvic inflammatory disease or endometriosis have been reported, which may influence fertility or the quality of life of patients; therefore, an accurate and early diagnosis is essential. The present study reports the case of patient (25-year-old female, gravida 0 para 0) with OHVIRA syndrome. Magnetic resonance imaging and a computed tomography scan revealed uterus didelphys and right renal agenesis. An opening was found on the vaginal septum during the menstrual period. Upon diagnostic vaginoscopy and hysteroscopy through the opening, the right vaginal cavity was enclosed, and the right uterine cervix and cavity were normal. The patient was diagnosed with OHVIRA syndrome. Her vaginal septum was surgically removed under direct visualization and the pathological findings of the resected septum revealed a benign squamous epithelium. The post-operative course was uneventful and restenosis of the vagina was not observed. On the whole, the present study demonstrates that the technique, diagnostic vaginoscopy and hysteroscopy, is minimally invasive and is sufficient for the diagnosis of incomplete vaginal obstruction-type OHVIRA syndrome.

Müllerian Duct Anomalies: Role in Fertility and Pregnancy

Müllerian duct anomalies (MDAs) have important implications for the reproductive health of female patients. In patients with both infertility and recurrent pregnancy loss, the incidence of MDAs is as high as 25%. Congenital uterine anomalies are often only part of a complex set of congenital anomalies involving the cervix, vagina, and urinary tract. Multiple classification systems for MDAs exist, each with different criteria that vary most for the diagnosis of septate uterus. Recognizing the features that guide clinical management is essential for interpretation. Identification of an MDA should prompt evaluation for associated urinary tract anomalies. In patients with infertility who seek to use assisted reproductive technologies such as intrauterine insemination, recognition of MDAs may have an affect on reproductive success, particularly in patients who have an incomplete and clinically occult septum that divides the cervix. Two-dimensional US is the first-line modality for evaluating the uterus and adnexa. Three-dimensional (3D) US or MRI may help to visualize the external uterine fundal contour and internal indentation of the endometrial cavity, which are two morphologic characteristics that are keys to the diagnosis of congenital uterine anomalies. Hysterosalpingo contrast-enhanced US may be performed in conjunction with 3D US to evaluate uterine morphologic characteristics, the endometrial cavity, and tubal patency in a single examination. MRI helps to characterize rudimentary uteri in patients with müllerian hypoplasia and allows assessment for ectopic ureters, abnormally positioned ovaries, or associated deep infiltrative endometriosis. Online supplemental material is available for this article. ©RSNA, 2021.

Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA): Early diagnosis, treatment and outcomes

OBJECTIVE

To describe and summarize the early diagnosis, treatment and outcomes of obstructed hemivagina and ipsilateral renal anomaly (OHVIRA).

METHODS

Data from patients with OHVIRA treated at the study centre over the last decade were analysed retrospectively, including demographic characteristics, symptoms, diagnosis, treatment and outcomes. Relevant published literature was also reviewed in this study.

RESULTS

In total, 11 cases were diagnosed with OHVIRA over the study period, ranging in age from 3 to 14 years (median 11 years). Four cases were asymptomatic, four had abdominal pain and three had urinary symptoms. All 11 cases underwent vaginoplasty. Ureteral bladder re-implantation (n = 1), dysplastic nephrectomy (n = 1), separation of labia minora adhesions (n = 1), perineoplasty (n = 1) and urethroplasty (n = 1) were performed. Cases were followed up for 2 months to 8 years (median 5 years) with good follow-up outcomes.

CONCLUSIONS

Based on the cases in this study and the relevant literature, ultrasound appears to be an effective method for the diagnosis of OHVIRA. Experienced ultrasonographers are able to achieve a high corrected diagnosis rate. The differential diagnosis of OHVIRA should be considered by paediatric surgeons, urologists, emergency physicians and gynaecologists when they identify patients with didelphys uterus or renal agenesis. Early surgery can reduce the risk of potential genital tract infection and gynaecological complications.

Adolescent gynaecology: anaesthetic and peri-operative care implications

Adolescents represent a quarter of the world's population, yet their specific healthcare needs have often not been acknowledged. Whilst many operations in this population will be performed in specialist tertiary centres and children's hospitals, it is likely that care will be sought in a variety of healthcare settings, and so it is important to have an understanding of the particular approach to this age group. Paediatric and adolescent gynaecology emerged as a speciality in 2000 with the inauguration of the British Society for Paediatric and Adolescent Gynaecology, a specialist society of the Royal College of Obstetricians and Gynaecologists. This is a multidisciplinary group, comprising paediatricians, paediatric surgeons, psychologists and nurses, although the majority of the members are gynaecologists. In this review, we will describe the peri-operative implications of adolescent gynaecological surgery and the considerations that need to be applied to this specific age group, such as consent, the operative setting and key personnel. We will also discuss specialist situations which are likely to fall to an adolescent gynaecology setting, such as management of those with Mullerian abnormalities, which often present with pelvic pain in adolescence. We discuss those with a history of ritual female genital cutting (female genital mutilation), trans men and those with significant learning difficulties. In all circumstances, teamwork, reflection and pragmatism are key.

Herlyn-Werner-Wunderlich syndrome: Report of a delayed diagnosed case with video presentation of the operative technique of vaginal septum resection

Herlyn-Werner-Wunderlich (HWW) syndrome is a rare congenital anomaly of Mullerian duct development characterized by uterus didelphys with blind hemivagina and ipsilateral renal agenesis. We present a case of a 29-year-old nulliparous woman, who was referred to our hospital complaining of chronic pelvic pain, dyspareunia, and a palpable mass in her vagina. At the age of 12, she underwent surgery because of a didelphys uterus diagnosis. Subsequently, she was operated on twice for endometriomas. At our institution, clinical and imaging findings revealed an obstructed hemivagina setting the diagnosis of HWW syndrome. Some of the various syndrome types may go unnoticed for months or even years after the onset of menstruation. Early diagnosis, followed by proper surgical treatment, is the key to avoid potentially severe complications.