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Ding Y, Wang Y, Lyu Y, Xie H, Huang Y, Wu M, Chen F, Chen Z. Urogenital sinus malformation: From development to management. Intractable Rare Dis Res 2023; 12:78-87. [PMID: 37287654 PMCID: PMC10242390 DOI: 10.5582/irdr.2023.01027] [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: 03/29/2023] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 06/09/2023] Open
Abstract
Urogenital sinus (UGS) malformation, also known as persistent urogenital sinus (PUGS), is a rare congenital malformation of the urogenital system. It arises when the urethra and vaginal opening fail to form properly in the vulva and fuse incorrectly. PUGS can occur as an isolated abnormality or as part of a complex syndrome, and is frequently associated with congenital adrenal hyperplasia (CAH). The management of PUGS is not well-established, and there are no standardized guidelines on when to perform surgery or how to follow up with patients over the long term. In this review, we discuss the embryonic development, clinical evaluation, diagnosis, and management of PUGS. We also review case reports and research findings to explore best practices for surgery and follow-up care, in hopes of increasing awareness of PUGS and improving patient outcomes.
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Affiliation(s)
- Yu Ding
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yaping Wang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiqing Lyu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hua Xie
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yichen Huang
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Min Wu
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Fang Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhongzhong Chen
- Department of Urology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Clinical Research Center For Hypospadias Pediatric College, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Urogenital Development Research Center, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Bailez MM, Costanzo M, Guercio G. Role of minimally invasive surgery (MIS) in different sexual development (DSD). Semin Pediatr Surg 2021; 30:151078. [PMID: 34412885 DOI: 10.1016/j.sempedsurg.2021.151078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Differences/disorders of sex development (DSD) are a heterogeneous group of congenital conditions in which the development of chromosomal, gonadal, or anatomical sex is atypical. Patients usually present during the newborn period but occasionally some cases remain unrecognized until later in infancy or even adolescence. Genital appearance, psychosocial support, sociocultural background, gender identity development, and genetic and biochemical analysis in addition to ethical and legal implications need to be considered when deciding on the appropriate treatment strategy. Surgeons are important members of the multidisciplinary expert teams involved in the initial approach and long-term follow-up. Surgical care of DSD patients is one of the main challenges. Recommendations regarding the opportunity and timing of surgical procedures are still under discussion. Surgical procedures are aimed to reduce urologic problems, prevent the risk of gonadal germ-cell cancer, and facilitate sexual function and reproduction. Providing its excellent visualization, access to pelvic structures and less postoperative adhesion MIS has been an important tool in the diagnosis and treatment of DSD. The role of MIS will be summarized in: 1) Gonadal biopsy / gonadectomy 2) Treatment of urogenital sinus/vaginoplasty 3) Vaginal Replacement 4) Resection / treatment of Mullerian structures.
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Affiliation(s)
- Maria Marcela Bailez
- Department of Pediatric Surgery, Hospital de Pediatría "Prof. Dr. J.P. Garrahan", Buenos Aires, Argentina.
| | - Mariana Costanzo
- Department of Endocrinology, Hospital de Pediatría "Prof. Dr. J.P. Garrahan", Buenos Aires, Argentina
| | - Gabriela Guercio
- Department of Endocrinology, Hospital de Pediatría "Prof. Dr. J.P. Garrahan", Buenos Aires, Argentina
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Ulusoy O, Sabuncu S, Karakuş OZ, Ateş O, Hakgüder G, Olguner M, Akgür FM. Urinary continence after high urogenital sinus repair conducted with posterior prone approach: electromyography-uroflowmetric assessment. Int Urol Nephrol 2021; 53:1813-1818. [PMID: 34037908 DOI: 10.1007/s11255-021-02895-7] [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: 03/16/2021] [Accepted: 05/22/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE We aimed to present the results of urinary continence assessment objectively with electromyography (EMG)-uroflowmetry after high urogenital sinus (HUGS) repair with posterior prone approach without division of rectum. METHODS The records of patients who underwent HUGS repair via posterior prone approach between January 2005 and July 2018 were reviewed retrospectively. Incontinence, dysuria, hesitation, and straining during urination were evaluated during the clinical follow-up. Dysfunctional voiding scoring system was used as a questionnaire. Patients were re-evaluated with EMG-uroflowmetry in terms of voiding volume and pattern, voiding time, maximum flow rate, average flow rate, maximum flow time, and post-voiding residual volume. RESULTS Seven patients with HUGS were treated with a posterior prone approach. The median age of the patients was 18 months (8-21 months). The median UGS length was 4.4 cm (3.6-5.5 cm), urethral length was 1.1 cm (1.0-1.5 cm), and vaginal length was 4.9 cm (4.1-5.1 cm). No urination or defecation problems were described by the patients or their parents. When the results of the dysfunctional voiding scoring systems questionnaire were analyzed, results scored 7 (range 5-8). EMG-uroflowmetric test graphics of the patients showed normal flow curves without plateau, intermittency or irregularity. Pelvic EMG assessment was normal in all patients. CONCLUSION EMG-uroflowmetry has shown objectively that urinary continence and normal voiding pattern are preserved after HUGS repair with posterior prone approach without division of rectum.
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Affiliation(s)
- Oktay Ulusoy
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey.
| | - Serra Sabuncu
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
| | - Osman Zeki Karakuş
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
| | - Oğuz Ateş
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
- Division of Pediatric Urology, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
| | - Gülce Hakgüder
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
- Division of Pediatric Urology, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
| | - Mustafa Olguner
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
- Division of Pediatric Urology, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
| | - Feza Miraç Akgür
- Department of Pediatric Surgery, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
- Division of Pediatric Urology, Faculty of Medicine, Dokuz Eylul University, 35340, Balcova, Izmir, Turkey
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Shiryaev ND, Kagantsov IM, Sizonov VV. [Disorders of sex differentiation: state of the problem 15 years after the Chicago consensus]. PROBLEMY ENDOKRINOLOGII 2020; 66:70-80. [PMID: 33351341 DOI: 10.14341/probl12514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/01/2020] [Accepted: 07/09/2020] [Indexed: 06/12/2023]
Abstract
It is well known that the nomenclature and classification were changed in 2005 at the international consensus conference on intersex disorders, held in Chicago, where, among others, the following recommendations were proposed: (1) all children should be assigned a gender identity, and this should be done as quickly as possible, taking into account the time required for the examination. (2) all infants with congenital adrenal hyperplasia and 46,XX karyotype, including those with pronounced masculinization, must be raised as women. (3) Surgical treatment should be performed early and in cases of feminizing genitoplasty, clitoral reduction should be performed simultaneously with reconstruction of the urogenital sinus (separation of the vagina and urethra). An analysis of contemporary literature shows that all these theories, proposed 15 years ago at the Chicago meeting, failed to stand the test of time. New nomenclature and classification are constantly being revised. Currently, many groups of patients want to abolish the term «sexual maturity disorders.» Recommendations regarding gender reassignment and appropriate early surgical treatment have been completely ignored in some countries. All this was largely facilitated by the confrontational activities of a number of support groups.
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Affiliation(s)
| | - Ilya M Kagantsov
- Pitirim Sorokin Syktyvkar State University; Republican Children's Clinical Hospital
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Fares AE, Marei MM, Abdullateef KS, Kaddah S, El Tagy G. Laparoscopically Assisted Vaginal Pull-Through in 7 Cases of Congenital Adrenal Hyperplasia with High Urogenital Sinus Confluence: Early Results. J Laparoendosc Adv Surg Tech A 2019; 29:256-260. [DOI: 10.1089/lap.2018.0194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmed E. Fares
- Department of Pediatric Surgery, Fayoum University Hospital, Faculty of Medicine, El Fayoum University, El Fayoum, Egypt
| | - Mahmoud M. Marei
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Khaled S. Abdullateef
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Sherif Kaddah
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
| | - Gamal El Tagy
- Department of Pediatric Surgery, Cairo University Specialized Pediatric Hospital, Faculty of Medicine (Kasr Alainy), Cairo, Egypt
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Total urogenital sinus mobilization for ambiguous genitalia. J Pediatr Surg 2018; 53:808-812. [PMID: 28917585 DOI: 10.1016/j.jpedsurg.2017.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/11/2017] [Accepted: 08/11/2017] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Genital ambiguity is a very common phenomenon in disorders of sex development (DSD). According to the Chicago Consensus 2006, feminizing genitoplasty, when indicated, should be performed in the most virilized cases (Prader III to V). Advances in the knowledge of genital anatomy in DSD have enabled the development and improvement of various surgical techniques. Mobilization of the urogenital sinus (MUS), first described by Peña, has become incorporated by most surgeons. However, the proximity of the urethral sphincter prompts concern over urinary incontinence, especially for full mobilization of the urogenital sinus. OBJECTIVE To retrospectively evaluate the short-term surgical results of feminizing genitoplasty with total mobilization of the urogenital sinus in patients with DSD. METHODS Review of medical records of all patients undergoing feminizing genitoplasty with mobilization of the urogenital sinus. We evaluated the rates of complications from surgery and of urinary incontinence, as well as cosmetic results, according to the opinion of the surgeon and the family. RESULTS A total of 8 patients were included in the study. The mean age at surgery was 51months. Congenital adrenal hyperplasia (CAH) was diagnosed in six patients, and gonadal dysgenesis in the other two. The vagina was separated from the urethra, with suitable distance in all cases. No patient had urinary incontinence after surgery. The mean follow-up of patients was. 20months (3-56months). In all cases, surgeons recorded being satisfied with the aesthetic result of post-surgical genitalia. The family was recorded as satisfied with the aesthetic result of the genitalia after surgery. In every case, there was no need for a second surgical procedure. CONCLUSION The total mobilization of the urogenital sinus is a feasible and safe technique. The technique permits good cosmetic results, and urinary incontinence is absent. TYPE OF STUDY Therapeutic study. LEVEL OF EVIDENCE Level III.
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Sircili MHP, Bachega TSS, Madureira G, Gomes L, Mendonca BB, Dénes FT. Surgical Treatment after Failed Primary Correction of Urogenital Sinus in Female Patients with Virilizing Congenital Adrenal Hyperplasia: Are Good Results Possible? Front Pediatr 2016; 4:118. [PMID: 27833904 PMCID: PMC5081340 DOI: 10.3389/fped.2016.00118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 10/12/2016] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Genital reconstruction in female patients with virilizing congenital adrenal hyperplasia (CAH) is very challenging. Our aim was to evaluate the techniques employed to treat complications after failure of primary urogenital sinus (UGS) surgery, as well as the result of these reoperations. PATIENTS AND METHODS Twenty girls with virilizing CAH who were previously submitted to genitoplasty in our service and elsewhere had recurrent UGS stenosis and vaginal introitus stenosis that required surgical treatment. The main symptoms were recurrent urinary tract infection (UTI) in nine, dyspareunia in six, and hematocolpos in three (two associated with sepsis). The anatomical findings were the persistence of UGS with stenosis in 17 patients and vaginal introitus stenosis in 3. The mean age at procedure was 15.2 years, averaging 13.1 years after the first surgery. The surgical techniques employed were isolated perineal flap in 17 patients and perineal flap with partial mobilization of UGS in 3. The mean follow-up after the procedure was 4.8 years (varying from 1 to 17 years). RESULTS Vaginal dilations were performed after surgery in 15 patients. Good functional and anatomical results were obtained in 15 patients, with vaginal introitus amenable to dilators of 3.0 cm in diameter. Five patients with high vaginal insertion had recurrent vaginal stenosis and required a surgical revision. No patients presented menstrual obstruction or UTI after surgery. Eight of the 15 adult patients are sexually active. CONCLUSION The reoperation to treat failed primary UGS treatment using Y-V flap and partial mobilization techniques associated with vaginal dilations, promoted good anatomical, and functional results with low morbidity in 75% of the patients.
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Affiliation(s)
- Maria Helena Palma Sircili
- Division of Urology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil; Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Guiomar Madureira
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Larissa Gomes
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Berenice Bilharinho Mendonca
- Division of Endocrinology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Francisco Tibor Dénes
- Division of Urology, Hospital das Clínicas, School of Medicine, University of São Paulo , São Paulo , Brazil
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Abstract
Great controversies and misunderstandings have developed around the relatively recently coined term disorders of sex development (DSD). In this article, we question the wisdom of including XX individuals with congenital adrenal hyperplasia (CAH) in the DSD category and develop arguments against it based on the published literature on the subject. It is clear that females with CAH assigned the female gender before 24 months of age and properly managed retain the female gender identity regardless of the Prader grade. Females with CAH and low Prader grades have the potential for a normal sexual and reproductive life. Those with greater degrees of prenatal androgen exposure (Prader grades IV and V) raised as females also identify themselves as females but experience more male-like behavior in childhood, have a greater rate of homosexuality, and have greater difficulty with vaginal penetration and maintaining pregnancies. Improvement in surgical techniques, better endocrinological, psychological, and surgical follow-up may lessen these problems in the future. Given the fact that the term DSD includes many conditions with problematic gender identity and conflicts with the gender assigned at birth, it may be appropriate to exclude females with CAH from the DSD classification.
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Affiliation(s)
- Ricardo González
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
| | - Barbara M Ludwikowski
- Pediatric Surgery and Urology, Auf der Bult Kinder- und Jugendkrankenhaus , Hannover , Germany
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