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López Soto Á, Velasco Martínez M, Ferrández Martínez M, Díaz García A, García Izquierdo O, Marín Sánchez P. Prenatal ambiguous/atypical genitalia: why are we still missing it and how can we improve diagnosis? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:581-585. [PMID: 37773980 DOI: 10.1002/uog.27507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/06/2023] [Accepted: 09/19/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Á López Soto
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - M Velasco Martínez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - M Ferrández Martínez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - A Díaz García
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - O García Izquierdo
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
| | - P Marín Sánchez
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
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López Soto Á, Bueno González M, Urbano Reyes M, Carlos Moya Jiménez L, Beltrán Sánchez A, Garví Morcillo J, Velasco Martínez M, Luis Meseguer González J, Martínez Rivero I, García Izquierdo O. Imaging in fetal genital anomalies. Eur J Obstet Gynecol Reprod Biol 2023; 283:13-24. [PMID: 36750003 DOI: 10.1016/j.ejogrb.2023.01.035] [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: 10/25/2022] [Revised: 01/15/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023]
Abstract
Genital anomalies are a heterogeneous group of congenital pathologies that have become increasingly relevant since the Chicago Consensus of 2005. Their postnatal diagnosis has developed significantly in the last two decades, while prenatal diagnosis seems to be underdeveloped, with few protocols available, fragmented scientific literature, and low diagnostic rates. This review aims to examine the current status of this subspecialty from the perspective of prenatal imaging. Indications for the evaluation of fetal genitalia can be divided into medical and non-medical reasons. Medical reasons include sex-linked disorders, detection of other anomalies, relevant family history, or multiple pregnancy. Non-medical reasons include parental request for sex disclosure. Disclosure of fetal sex may be associated with ethical, legal, and medical issues. The main imaging technology used is 2D ultrasound, although there are other complementary techniques such as 3D, MRI, or Color Doppler. Regarding working methodology, several authors have drawn attention to the lack of standardized protocols and guidelines. Most guidelines tend to limit their recommendations to study indications and ethical issues. Technical proposals, measurements, or working methods have not yet been standardized. Fetal sex determination is usually divided into early and late gestation. Early gestation is based on the sagittal sign. Late gestation is based on direct visualization. There are several measurements to describe male and female genitalia, such as penile length, bilabial diameter, or scrotal diameter. Prenatal diagnosis of genital pathologies presents some particularities such as the wide spectrum of phenotypes, the high frequency of associated deformities, or the time of diagnosis. Some of the most frequent pathologies are ambiguous genitalia, fetal sex discordance, hypospadias, micropenis, clitoromegaly, ovarian cysts, hydro(metro)colpos, and cloacal anomalies. Higher-quality studies and direction from scientific societies through the implementation of clinical guidelines are needed.
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Affiliation(s)
- Álvaro López Soto
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain.
| | | | - Maribel Urbano Reyes
- Prenatal Diagnosis Unit, Department of Obstetrics, HGU Santa Lucía, Cartagena, Spain
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Gozar H, Pascanu I, Ardelean M, Gurzu S, Derzsi Z. Surgical reconstruction of the genitalia in a 3-year-old infant with a 46XX karyotype: case report. Aesthetic Plast Surg 2014; 38:549-53. [PMID: 24793971 DOI: 10.1007/s00266-014-0321-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/04/2014] [Indexed: 02/08/2023]
Abstract
UNLABELLED A 3-year-old patient was hospitalized with ambiguous genitalia (clitoromegaly, labioscrotal fusion, absence of vaginal introitus), classified as stage III/IV according to Prader's virilization scale. Our patient, with a 46XX karyotype, was previously diagnosed with congenital adrenal hyperplasia caused by a deficiency of the adrenal enzyme 21-hydroxylase; corticosteroids and salt replacement therapy have been used. At the present admission, the surgical treatment consisted on clitoroplasty (with the removal of erectile tissue), reconstruction of the labia minor, creation of a neovulva and vaginoplasty. It was a single-step operation to restore the anatomical female structures. She had an uneventful postoperative period and the wound healed well with good cosmetic results. We present the details about the surgical procedure and a short review of data from literature. LEVEL OF EVIDENCE V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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Affiliation(s)
- Horea Gozar
- Department of Pediatric Surgery, University of Medicine and Pharmacy, Tirgu-Mures, Romania
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Ludwikowski BM, González R. The Surgical Correction of Urogenital Sinus in Patients with DSD: 15 Years after Description of Total Urogenital Mobilization in Children. Front Pediatr 2013; 1:41. [PMID: 24400287 PMCID: PMC3864266 DOI: 10.3389/fped.2013.00041] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/08/2013] [Indexed: 11/13/2022] Open
Abstract
Total urogenital sinus mobilization has been applied to the surgical correction of virilized females and has mostly replaced older techniques. Concerns have been raised about the effect of this operation on urinary continence. Here we review the literature on this topic since the description of the technique 15 years ago. Technical aspects and correct nomenclature are discussed. We emphasize that the term "total" refers to an en-bloc dissection and not to the extent of the proximal dissection. No cases of urinary incontinence have been reported following this operation. It is yet too early to evaluate results regarding sexual function but it is likely that the use of a posterior skin flap to augment the introitus will minimize the development of introital stenosis.
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Affiliation(s)
| | - Ricardo González
- Auf der Bult Kinder und Jugendkrankenhaus , Hannover , Germany ; Charité Universitätsmedizin Berlin, Virchow Klinikum , Berlin , Germany
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Mansour S, Hamed S, Adel L, Kamal R, Ahmed D. Does MRI add to ultrasound in the assessment of disorders of sex development? Eur J Radiol 2012; 81:2403-10. [DOI: 10.1016/j.ejrad.2011.12.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2011] [Revised: 07/06/2011] [Accepted: 12/14/2011] [Indexed: 11/16/2022]
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Fuchs J, Warmann SW, Seitz G, Schäfer J, Schröder M, Obermayr F. Laparoscopically assisted vaginal pull-through for high urogenital sinus: a new surgical technique. Urology 2012; 79:1180-3. [PMID: 22446347 DOI: 10.1016/j.urology.2012.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 12/07/2011] [Accepted: 01/06/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate feasibility and outcome of a laparoscopically assisted vaginal pull through procedure for suprasphincteric high urogenital sinus malformation with hydrometrocolpos and normal external genitalia. METHODS A tension-free anastomosis of the vagina to the perineum was realized after laparoscopic mobilization of the vagina, separation from the bladder neck at the confluence and pull-through via an externally introduced expandable trocar, thereby avoiding perineal or perirectal dissection. RESULTS The approach resulted in good cosmetic and unimpaired functional outcome. Voiding cystourethrography showed normal lower urinary tract anatomy. No disturbances of bladder function could be detected 2 years after surgery. CONCLUSION Laparoscopic assisted vaginal pull-through is a new approach for high UGS that significantly improved exposure of the uretro-vaginal junction, allowed extensive mobilization of the vagina and showed excellent cosmetic and functional result.
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Affiliation(s)
- Jörg Fuchs
- Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital, Tuebingen, Germany
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Park S, Ha SH, Kim KS. Long-term follow-up after feminizing genital reconstruction in patients with ambiguous genitalia and high vaginal confluence. J Korean Med Sci 2011; 26:399-403. [PMID: 21394309 PMCID: PMC3051088 DOI: 10.3346/jkms.2011.26.3.399] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 01/10/2011] [Indexed: 11/20/2022] Open
Abstract
We evaluated the long-term results of feminizing genital reconstruction in patients with genital ambiguity with high vaginal confluence. The medical records of 10 consecutive patients with ambiguous genitalia and high vaginal confluence who underwent feminizing genital reconstruction from 1996 to 2007 were reviewed. Seven patients had congenital adrenal hyperplasia, one had mixed gonadal dysgenesis, one had partial androgen insensitivity, and one had 5-alpha reductase deficiency syndrome. Median age at operation was 21 months (range, 2-47 months). Median follow up was 7.7 yr. Of the six patients who underwent feminizing genital reconstruction with the Gonzalez method, three had good results. Of the other three patients, one had a urethrovaginal fistula and underwent fistula repair 9 yr after, one had distal vaginal stenosis and underwent revision vaginoplasty 9 yr after, and one had a urethrovaginal fistula and urethral stricture. The patient with urogenital mobilization had persistent urogenital sinus. Feminizing genitoplasty using the Gonzalez method showed good long-term results in patients with ambiguous genitalia and Congenital adrenal hyperplasia. The procedure is less invasive than other approaches and results in excellent cosmetic outcomes; and complications can be corrected by relatively simple procedures.
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Affiliation(s)
- Sungchan Park
- Department of Urology, University of Ulsan College of Medicine, Ulsan University Hospital, Ulsan, Korea
| | - Seong Heon Ha
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kun Suk Kim
- Department of Urology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Abstract
PURPOSE OF REVIEW The current management of patients with intersex, now designated as disorders of sex development, is presented in the context of updated etiological and outcome data, refined surgical procedures and the need for a multidisciplinary approach. RECENT FINDINGS The recently published consensus statement, the primary publication cited herein, includes known genetic causes of disorders of sex development, and provides a perspective for clinical evaluation, and medical, surgical and psychological management. The importance of fetal hormone exposure, genital development, gonadal differentiation and potential of fertility, full disclosure and parental involvement in decisions is crucial. All need a sex assignment; recommendations should be based upon what is judged to be the most likely adult gender identity, diagnosis, genital appearance and surgical options, fertility, cultural pressures, family dynamics and social circumstance, with deference given to psychosocial factors when the outcome is unpredictable. Surgery is discouraged for mild genital variations, but surgery during infancy is recommended for those with major genital ambiguity. SUMMARY Even with greater understanding of the genetic causes of disorders of sex development, the complex management of these patients must be individualized, considering all aspects, informing as age-appropriate the parents and patient. Further etiology and outcome studies are needed.
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Affiliation(s)
- Zeina M Nabhan
- Section of Pediatric Endocrinology/Diabetology, Department of Pediatrics, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana 46202, USA.
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Current World Literature. Curr Opin Obstet Gynecol 2007; 19:496-501. [PMID: 17885468 DOI: 10.1097/gco.0b013e3282f0ffad] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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