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Abosena W, Almetaher HA, El Attar AA, Nofal AH, Elhalaby EA. Outcomes of one-stage feminizing genitoplasty in children with congenital adrenal hyperplasia and severe virilization. Pediatr Surg Int 2024; 40:72. [PMID: 38446278 PMCID: PMC10917856 DOI: 10.1007/s00383-024-05638-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2024] [Indexed: 03/07/2024]
Abstract
PURPOSE To present our surgical experience and outcomes in congenital adrenal hyperplasia (CAH) patients with severe virilization using a combined technique of total urogenital mobilization (TUM) and a modified pull-through vaginoplasty to perform a safe and effective one-stage feminizing genital reconstruction for these children. METHODS Fourteen CAH patients with severe virilization, defined by a Prader IV and V rating of the external genitalia, underwent TUM followed by a limited vaginal pull-through procedure from June 2016 to December 2020. Postoperative anatomical and cosmetic outcomes, and urinary continence, were evaluated. RESULTS Out of the 14 cases in this study, 8 were classified as prader IV and 6 as Prader V. The median age at surgery was 11 months (range 6-36 months), and the mean urethral length was 1.4 cm (range 1.2-1.8 cm). The median follow-up period was 4 years. Our cosmetic outcomes were good in 11 (78.5%), satisfactory in 2, and poor in one case. All patients achieved age-appropriate toilet training without urinary incontinence. CONCLUSION Adopting our surgical approach of TUM with modified pull-through vaginoplasty has simplified feminizing surgical reconstruction in CAH cases with severe genital atypia and a very high vaginal confluence with short urethral length, yielding adequate introitus with good anatomical and cosmetic appearance and adequate urinary continence outcomes.
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Affiliation(s)
- Wael Abosena
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt.
| | | | - Ashraf Ahmed El Attar
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
| | - Ahmed Hassan Nofal
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
| | - Essam Abdelaziz Elhalaby
- Pediatric Surgery Department, Faculty of Medicine, Tanta University Hospital, Tanta, 31527, Egypt
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Leszczyńska D, Tuszyńska-Meissner A, Ciebiera M, Włodarczyk M, Zgliczyński W. Giant uterine fibroid and adrenal tumor in a patient who ceased congenital adrenal hyperplasia treatment. Pol Arch Intern Med 2023; 133:16587. [PMID: 37874249 DOI: 10.20452/pamw.16587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Affiliation(s)
- Dorota Leszczyńska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | | | - Michał Ciebiera
- Warsaw Institute of Women’s Health, Warsaw, Poland
- Second Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Marta Włodarczyk
- Department of Biochemistry and Pharmacogenomics, Faculty of Pharmacy, Medical University of Warsaw, Warsaw, Poland
- Centre for Preclinical Research, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland
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Orozco-Poore C, Keuroghlian AS. Neurological Considerations for "Nerve-Sparing" Cosmetic Genital Surgeries Performed on Children with XX Chromosomes Diagnosed with 21-Hydroxylase Congenital Adrenal Hyperplasia and Clitoromegaly. LGBT Health 2023; 10:567-575. [PMID: 37319358 DOI: 10.1089/lgbt.2022.0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Congenital adrenal hyperplasia (CAH) is most often caused by adrenal deficiency of 21-hydroxylase (21-OH). The resulting increase in androgens can cause clitoromegaly in fetuses with XX chromosomes. 21-OH CAH is the most common reason for cosmetic clitoroplasty in childhood. "Nerve-sparing" (NS) clitoral reduction surgeries are described as offering optimal cosmesis, while sparing sensation and nerve function. The methods used to demonstrate NS surgery efficacy, however, such as electromyography and optical coherence tomography, do not evaluate the small-fiber axons that comprise the majority of axons in the clitoris and that transduce sexual pleasure. Although some data show sparing of a portion of the main dorsal nerve trunk of the clitoris, the overall neurobiological consequences of elective clitoral reductions have received little attention. NS surgeries remove dorsal nerve branches that transduce sexual sensation, as well as the corpora cavernosa and cavernous nerve, which provide clitoral autonomic function. While most outcome studies focus on surgeons' perceptions of cosmetic results, studies that assess small-fiber function indicate significant nervous system and sexual impairment. Studies assessing children's clitoral function after surgery with vibrational testing have been ethically condemned. Decades of advocacy against medically unnecessary childhood genital surgeries have highlighted the subsequent physical and psychological harm. Recent studies with CAH patients indicate gender diversity and a lower prevalence of female gender identification than is often cited to justify feminizing surgery. The most effective and ethical NS technique for CAH may be acceptance of gender, sexual, and genital diversity as the infant develops into childhood, adolescence, and adulthood.
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Affiliation(s)
- Casey Orozco-Poore
- Department of Medical Education, Harvard Medical School, Boston, Massachusetts, USA
| | - Alex S Keuroghlian
- Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, USA
- The National LGBTQIA+ Health Education Center at The Fenway Institute, Boston, Massachusetts, USA
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Fiorentino R, La Bella S, Chiavaroli V, Cauzzo C, Di Credico S, Miscia ME, Lauriti G, Lisi G, Chiarelli F, Di Valerio S. Perinatal diagnosis of congenital urogenital sinus abnormality. Congenit Anom (Kyoto) 2023; 63:170-173. [PMID: 37277212 DOI: 10.1111/cga.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/25/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023]
Abstract
Anomalies of the urogenital sinus, which is a transient feature of the early human embryological development, are rare birth defects. Urogenital sinus abnormalities commonly present as pelvic masses, hydrometrocolpos, or ambiguous genitalia and most commonly occur within the context of congenital adrenal hyperplasia. Anomalies of the urogenital sinus requires surgical repair. We experienced a case of a female newborn with congenital urogenital sinus abnormality in which the early diagnosis helped us to prevent complications by decompressing the vagina soon after birth. Antibiotic prophylaxis was sufficient to avoid infections and to decompress the genitourinary system, thus allowing a deferred elective surgery to correct the sinus.
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Affiliation(s)
- Riccardo Fiorentino
- Department of Pediatrics, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Saverio La Bella
- Department of Pediatrics, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Valentina Chiavaroli
- Maternal and Child Health Department, Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - Chiara Cauzzo
- Department of Pediatrics, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Simona Di Credico
- Maternal and Child Health Department, Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
| | - Maria Enrica Miscia
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Pescara, Italy
- Maternal and Child Health Department, Pediatric Surgery Unit, Pescara Public Hospital, Pescara, Italy
| | - Giuseppe Lauriti
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Pescara, Italy
- Maternal and Child Health Department, Pediatric Surgery Unit, Pescara Public Hospital, Pescara, Italy
| | - Gabriele Lisi
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Pescara, Italy
- Maternal and Child Health Department, Pediatric Surgery Unit, Pescara Public Hospital, Pescara, Italy
| | - Francesco Chiarelli
- Department of Pediatrics, Gabriele d'Annunzio University of Chieti and Pescara, Chieti, Italy
| | - Susanna Di Valerio
- Maternal and Child Health Department, Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
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Vitellius G, Donadille B, Decoudier B, Leroux A, Deguelte S, Barraud S, Bertherat J, Delemer B. Unilateral or bilateral adrenalectomy in PPNAD: six cases from a single family followed up over 40 years. Endocrine 2022; 78:201-204. [PMID: 35925470 DOI: 10.1007/s12020-022-03142-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/09/2022] [Indexed: 11/03/2022]
Abstract
The most frequent endocrine Carney complex manifestation is a bilateral primary pigmented nodular adrenocortical disease and bilateral adrenalectomy (BA) is therefore its main treatment. In this study, a 40 years follow-up of six members of the same family with heterozygous PRKAR1A germline mutation, is reported over two generations. The first cases, two sisters with severe hyperandrogenism and Cushing syndrome (CS) diagnosed in 1972 at age 14 and 25, were successfully treated with unilateral adrenalectomy (UA). Their two brothers were then diagnosed, one with a CS-related severe osteoporosis treated with BA and the other with CS treated with UA. The second generation was diagnosed with CS signs at 7 and 21 years of age and were treated with BA and UA respectively. Out of the four patients treated with UA, the only event possibly related to CS was spontaneous episode of pulmonary embolism, 30 years after surgery. Hormonal evaluation revealed either eucortisolism in one patient or partial adrenal deficiency in two and mild hypercortisolism in one patient. For the two patients with BA, one of them accidentally died. The second one, surprisingly, recovered progressively normal cortisol secretion and circadian variation. Steroid substitution was stopped 6 years after her surgery and we demonstrated by iodocholesterol scintigraphy the presence of bilateral adrenal remnants. In conclusion, our results of long term evolution of PPNAD patients show that UA in this subset of patients could be considered to treat CS.
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Affiliation(s)
- G Vitellius
- Service Endocrinologie, Diabète - Nutrition CHU Robert Debré, Reims, France.
| | - B Donadille
- Service Endocrinologie, Diabétologie, et Maladies métaboliques, Saint Antoine, Paris, France
| | - B Decoudier
- Service Endocrinologie, Diabète - Nutrition CHU Robert Debré, Reims, France
| | - A Leroux
- Polyclinique Bezannes, Reims, France
| | - S Deguelte
- Service de Chirurgie Digestive et Endocrinienne, CHU Robert Debré, Reims, France
| | - S Barraud
- Service Endocrinologie, Diabète - Nutrition CHU Robert Debré, Reims, France
- CRESTIC EA 3804, Université de Reims Champagne Ardenne, UFR Sciences Exactes et Naturelles, Moulin de la Housse, BP 1039, 51687, Reims CEDEX 2, France
| | - J Bertherat
- Service d'endocrinologie, Hôpital Cochin, Paris, France
| | - B Delemer
- Service Endocrinologie, Diabète - Nutrition CHU Robert Debré, Reims, France
- CRESTIC EA 3804, Université de Reims Champagne Ardenne, UFR Sciences Exactes et Naturelles, Moulin de la Housse, BP 1039, 51687, Reims CEDEX 2, France
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Aziz NA, Mohd Ali MH, Ramli R. Hysterectomy in a phenotypic male with congenital adrenal hyperplasia (CAH). BMJ Case Rep 2022; 15:e246603. [PMID: 35135794 PMCID: PMC8830105 DOI: 10.1136/bcr-2021-246603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2022] [Indexed: 11/04/2022] Open
Abstract
A young adult patient with 46XX congenital adrenal hyperplasia (CAH) presented with recurrent painful haematuria. CAH was diagnosed at birth following ambiguous genitalia. Hormonal treatment was started, female gender was assigned and feminising genitoplasty was planned, however the patient was lost to follow-up. Gender dysphoria started to occur during childhood which prompted the family to raise the patient as a boy. He eventually identified himself as a male. Examination revealed a male phenotype with severely virilised genitalia. Imaging studies confirmed the presence of uterus with low confluent urogenital sinus. Total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed, and the troublesome symptoms were cured.
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Affiliation(s)
- Nor Azimah Aziz
- Department of Obstetrics & Gynaecology, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | - Masliza Hanuni Mohd Ali
- Department of Internal Medicine (Endocrinology Unit), Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
| | - Roziana Ramli
- Department of Obstetrics & Gynaecology, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia
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Hebenstreit D, Ahmed SF, Krone N, Krall C, Bryce J, Alvi S, Ortolano R, Lima M, Birkebaek N, Bonfig W, Claahsen van der Grinten H, Costa EC, Poyrazoglu S, de Vries L, Flück CE, Guran T, Bugrul F, Güven A, Iotova V, Koehler B, Schröder JT, Konrad D, Gevers E, Krone R, Milenkovic T, Vieites A, Ross R, Tadokoro Cuccaro R, Hughes I, Acerini C, Springer A. Surgical Practice in Girls with Congenital Adrenal Hyperplasia: An International Registry Study. Sex Dev 2021; 15:229-235. [PMID: 34350892 DOI: 10.1159/000517055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 04/29/2021] [Indexed: 11/19/2022] Open
Abstract
In this article international trends in surgical practice in girls with congenital adrenal hyperplasia (CAH) are evaluated. All cases that had been classified in the I-CAH/I-DSD registry as 46,XX CAH and who were born prior to 2017 were identified. Centers were approached to obtain information on surgical decision making. Of the 330 included participants, 208 (63.0%) presented within the first month of life, and 326 (98.8%) cases were assigned female. Genital surgery had been performed in 250 (75.8%). A total of 64.3, 89.2, and 96.8% of cases residing in Europe, South America and Asia, respectively, had at least one surgery. In a logistic regression model for the probability of surgery before the second birthday (early surgery) over time an increase of probability for early vaginal surgery could be identified, but not for clitoral surgery or both surgeries combined. Genitoplasty in girls with CAH remains controversial. This large international study provides a snapshot of current practice and reveals geographical and temporal differences. Fewer surgeries were reported for Europe, and there seems to be a significant trend towards aiming for vaginal surgery within the first 2 years of life.
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Affiliation(s)
| | - S Faisal Ahmed
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Nils Krone
- University of Sheffield, Sheffield, United Kingdom
| | - Christoph Krall
- Center for Medical Statistics, Informatics, and Intelligent Systems, Section for Medical Statistics, Medical University of Vienna, Vienna, Austria
| | - Jillian Bryce
- Developmental Endocrinology Research Group, Royal Hospital for Children, University of Glasgow, Glasgow, United Kingdom
| | - Sabah Alvi
- Paediatric Endocrinology, Leeds Children's Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Rita Ortolano
- Department of Medical and Surgical Sciences, Pediatric Unit, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Mario Lima
- Department of Medical and Surgical Sciences, Pediatric Surgery Unit, S.Orsola-Malpighi University Hospital, Bologna, Italy
| | - Niels Birkebaek
- Department of Paediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Walter Bonfig
- Department of Pediatrics TU Munich, Munich, Germany
- Klinikum Wels-Grieskirchen, Wels-Grieskirchen, Austria
| | - Hedi Claahsen van der Grinten
- Department of Paediatric Endocrinology, Radboud University Amalia Childers Hospital Medical Centre, Nijmegen, The Netherlands
| | - Eduardo Correa Costa
- Pediatric Surgery Service, Hospital de Clínicas de Porto Alegre, UFRGS, Porto Alegre, Brazil
| | - Sukran Poyrazoglu
- Istanbul Faculty of Medicine, Department of Paediatrics, Paediatric Endocrinology Unit, Istanbul University, Istanbul, Turkey
| | - Liat de Vries
- The Jesse and Sara Lea Shafer Institute of Endocrinology and Diabetes, Schneider Tel Aviv Children's Medical Center of Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Christa E Flück
- Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics and Department of BioMedical Research, Bern University Hospital Inselspital, University of Bern, Bern, Switzerland
| | - Tulay Guran
- Marmara University, Department of Pediatric Endocrinology and Diabetes, Pendik, Istanbul, Turkey
| | - Fuat Bugrul
- Marmara University, Department of Pediatric Endocrinology and Diabetes, Pendik, Istanbul, Turkey
| | - Ayla Güven
- Saglik Bilimleri University Medical Faculty, Zeynep Kamil Women and Children Hospital, Pediatric Endocrinology Clinic, Istanbul, Turkey
| | - Violeta Iotova
- Department of Paediatrics, Medical University-Varna, UMHAT "Sv. Marina", Varna, Bulgaria
| | - Birgit Koehler
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Jennyver-Tabea Schröder
- Klinik für Pädiatrische Endokrinologie und Diabetologie, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Konrad
- Division of Paediatric Endocrinology and Diabetology, University Children's Hospital, Zurich, Switzerland
| | - Evelien Gevers
- Department of Paediatric Endocrinology, Barts Health NHS Trust, Royal London Hospital, London, United Kingdom
- Centre for Endocrinology, William Harvey Research Institute, Queen Mary University London, London, United Kingdom
| | - Ruth Krone
- Birmingham Women's & Children's Hospital, Department for Endocrinology & Diabetes, Birmingham, United Kingdom
| | - Tatjana Milenkovic
- Department of Endocrinology, Mother and Child Health Care Institute of Serbia "Dr Vukan Čupić", Belgrade, Serbia
| | - Ana Vieites
- Centro de Investigaciones Endocrinológicas, División de Endocrinología, Hospital de Niños Ricardo Gutiérrez, Buenos Aires, Argentina
| | - Richard Ross
- University of Sheffield, Sheffield, United Kingdom
| | | | - Ieuan Hughes
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Carlo Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Alexander Springer
- Department of Paediatric Surgery, Medical University Vienna, Vienna, Austria
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Fernandez N, Chavarriaga J, Pérez J. Complete corporeal preservation clitoroplasty: new insights into feminizing genitoplasty. Int Braz J Urol 2021; 47:861-867. [PMID: 33848081 PMCID: PMC8321476 DOI: 10.1590/s1677-5538.ibju.2020.0839] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/28/2020] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION 46,XX Congenital adrenal hyperplasia (CAH) remains the first cause of genital virilization and current surgical techniques aim to restore female aspect of genitalia while preserving dorsal neurovascular bundle but not at the expense of not preserving erectile tissue. We aim to report our experience with a new surgical technique for clitoroplasty, completely preserving corporeal bodies, neurovascular bundles without dismembering the clitoris, in four patients with over a year follow up. MATERIALS AND METHODS After IRB approval four patients with 46,XX CAH and Prader 5 and 3 external genitalia, underwent feminizing genitoplasty. Complete preservation of erectile tissue was accomplished without a need to dissect dorsal neurovascular bundle. Glans size allowed no need for glanular reduction and there was no need to dismember the corporeal bodies. RESULTS Four patients 12 to 24-months-old underwent complete corporeal preservation clitoroplasty (CCPC), mean age was 18.5 months, mean follow up was 10.25 months. Vaginoplasty was performed in all patients with partial urogenital mobilization (PUM) and Urogenital Sinus flap (UF), only one severely virilized patient required a parasagittal pre-rectal approach to mobilize the vagina. We had no complications until last follow up. CONCLUSION To our knowledge, we are introducing the concept of CCPC without the need of disassembling the corporeal bodies, neurovascular bundle and glans. It stands as a new alternative for feminizing genitoplasty with complete preservation of erectile tissue and no dissection of neurovascular bundle. Although there is still lacking long-term follow-up, it represents a new step in conservative reconfiguration of the external virilized female genitalia.
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Affiliation(s)
- Nicolas Fernandez
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
- Fundacion Santa Fe de BogotaDepartment of UrologyBogotaColombiaDepartment of Urology, Fundacion Santa Fe de Bogota, Bogota, Colombia;
- University of WashingtonSeattle Children's HospitalDivision of UrologySeattleWAUnited StatesDivision of Urology, Seattle Children's Hospital, University of Washington, Seattle, WA, United States
| | - Julián Chavarriaga
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
| | - Jaime Pérez
- Pontificia Universidad JaverianaHospital Universitario San IgnacioDivision of UrologyBogotaColombiaDivision of Urology, Hospital Universitario San Ignacio, Pontificia Universidad Javeriana, Bogota, Colombia;
- Fundacion Santa Fe de BogotaDepartment of UrologyBogotaColombiaDepartment of Urology, Fundacion Santa Fe de Bogota, Bogota, Colombia;
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Zainuddin AA, Grover SR, Soon CH, Ghani NAA, Mahdy ZA, Manaf MRA, Shamsuddin K. A Multicenter Cross-Sectional Study of Malaysian Females With Congenital Adrenal Hyperplasia: Their Body Image and Their Perspectives on Feminizing Surgery. J Pediatr Adolesc Gynecol 2020; 33:477-483. [PMID: 32376362 DOI: 10.1016/j.jpag.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To explore the impact of congenital adrenal hyperplasia (CAH) on body image in Malaysian females with CAH and to understand the perspectives of these young women and their parents toward feminizing genitoplasty (FG). DESIGN Multi-center cross-sectional study. SETTING Two tertiary medical centers in Malaysia. PARTICIPANTS A total of 59 patients with CAH who were raised as females and more than 10 years old, and their parents. METHODS The CAH respondents completed the validated and translated Body Image Disturbance Questionnaires (BIDQ). All CAH respondents and their parents underwent semi-structured interviews to explore their views on FG. MAIN OUTCOME MEASURES Body image disturbance score and perspectives on FG. RESULTS The 59 CAH respondents consisted of 12 children, 29 adolescents, and 18 adults. The majority were of Malay ethnicity (64.4%) with classical CAH (98.3%) and had undergone FG (n = 55, 93.2%). For the BIDQ scores, the median score (interquartile range) for general body image was 1.29 (0.71), range 1.00-3.29, whereas the genital appearance score was 1.07 (0.39), range 1.00-4.29, revealing a greater concern for general body parts over genitalia. With regards to FG, it was perceived as necessary. Infancy and early childhood were perceived as the best timing for first FG by both respondents and parents, most preferring single-stage over 2-stage surgery. CONCLUSIONS General body appearance concerns were greater than for genital appearance, with more impact on the patients' lives. Contrary to much international opinion, feminizing surgery was perceived as necessary and appropriate by CAH respondents and their families, and should be offered in infancy or early childhood. Future qualitative studies are recommended.
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Affiliation(s)
- Ani Amelia Zainuddin
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia.
| | - Sonia Regina Grover
- Department of Pediatric Adolescent Gynecology, Royal Children's Hospital Melbourne, University of Melbourne, Melbourne, Australia
| | - Chong Hong Soon
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Nur Azurah Abdul Ghani
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Zaleha Abdullah Mahdy
- Department of Obstetrics and Gynecology, UKM Medical Center, The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Mohammad Rizal Abdul Manaf
- Department of Community Health, UKM Medical Center The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
| | - Khadijah Shamsuddin
- Department of Community Health, UKM Medical Center The National University of Malaysia (UKM), Kuala Lumpur, Malaysia
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10
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Baskin A, Wisniewski AB, Aston CE, Austin P, Chan YM, Cheng EY, Diamond DA, Fried A, Kolon T, Lakshmanan Y, Williot P, Meyer S, Meyer T, Kropp B, Nokoff N, Palmer B, Paradis A, Poppas D, VanderBrink B, Scott Reyes KJ, Tishelman A, Wolfe-Christensen C, Yerkes E, Mullins LL, Baskin L. Post-operative complications following feminizing genitoplasty in moderate to severe genital atypia: Results from a multicenter, observational prospective cohort study. J Pediatr Urol 2020; 16:568-575. [PMID: 32624410 PMCID: PMC7735165 DOI: 10.1016/j.jpurol.2020.05.166] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 05/17/2020] [Accepted: 05/23/2020] [Indexed: 12/14/2022]
Abstract
Disorders/differences of sex development (DSD) are congenital conditions in which there is atypical chromosomal, gonadal and/or phenotypic sex. While there remains controversy around the traditionally binary concept of sex, most patients with DSD are reared either male or female depending on their genetic sex, gonadal sex, genital phenotype and status of their internal genital tract. This study uses prospective data from 12 institutions across the United States that specialize in DSD care. We focused on patients raised female. Eligible patients had moderate to severe genital atypia (defined as Prader score >2), were ≤2 years of age at entry, and had no prior genitoplasty. The aim of this study is to describe early post operative complications for young patients undergoing modern approaches to feminizing genitoplasty. Of the 91 participants in the cohort, 57 (62%) were reared female. The majority had congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency (n = 52), 1 had ovo-testicular syndrome, 2 had mixed gonadal dysgenesis and 2 had partial androgen insensitivity syndrome (PAIS). Of the 50 participants who received early genitoplasty, 43 (86%) had follow-up at 6-12 months post-surgery. Thirty-two participants (64%) received a clitoroplasty, 31 (62%) partial urogenital mobilization and 4 (8%) total urogenital sinus mobilization. Eighteen percent (9/50) experienced post-surgical complications with 7 (14%) being rated as Clavien-Dindo grade III. Both parents and surgeons reported improved satisfaction with genital appearance of participants following surgery compared to baseline. This information on post-operative complications associated with contemporary approaches to feminizing genitoplasty performed in young children will help guide families when making decisions about whether or not to proceed with surgery for female patients with moderate to severe genital atypia.
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Affiliation(s)
- Avi Baskin
- University of California San Francisco Medical Center, United States.
| | | | | | - Paul Austin
- Texas Children's Hospital and Baylor College of Medicine, United States.
| | | | - Earl Y Cheng
- Lurie Children's Hospital of Chicago, United States.
| | | | | | - Thomas Kolon
- Children's Hospital of Philadelphia, United States.
| | | | | | | | - Theresa Meyer
- Lurie Children's Hospital of Chicago, United States.
| | | | | | | | | | - Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, United States.
| | | | | | | | | | | | | | - Laurence Baskin
- University of California San Francisco Medical Center, United States.
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Elsayed S, Badawy H, Khater D, Abdelfattah M, Omar M. Congenital adrenal hyperplasia: Does repair after two years of age have a worse outcome? J Pediatr Urol 2020; 16:424.e1-424.e6. [PMID: 32712187 DOI: 10.1016/j.jpurol.2020.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 05/29/2020] [Accepted: 06/10/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Congenital Adrenal Hyperplasia (CAH) is the commonest cause of disorders of sex development (DSD) in children. The timing of surgery, early versus late, is a subject of current debate. We hypothesize that surgery for congenital adrenal hyperplasia after age two results in a worse outcome than procedures performed earlier in the neonatal period." PATIENTS AND METHODS Retrospectively evaluated children underwent feminizing genitoplasty the period from 2003 to 2015. Sixty-one children included in the study. They were divided into two groups; Group I: those repaired before 2 years of age (early repair), Group II: those repaired after 2 years of age (late repair). We compare both groups as regards the timing, stages of the genitoplasty, genital anatomical assessment, overall cosmetic results and further treatment recommendations. RESULTS Group I: included 35 children with mean age at presentation 1.73 ± 2.27months (3 days-10.0 months) group II: included 26 children with mean age at presentation 18.78 ± 32.25 months (3 days-150.0 months). 88.5% of children were operated in single stage. Overall cosmetic outcome is good in 94.3% in group I versus 19.2% in group II (p < .001), satisfactory in 5.7% in group I versus 53.8% in group II (p < .001), poor in 0% of group I versus 26.9% in group II (p = .002). 94.3% of children in group I needed no further surgeries versus 26.9% of group II (p < .001). DISCUSSION a current unsolved debate is when to perform the feminizing genitoplasty in children with congenital adrenal hyperplasia (CAH), some are pushing to wait till puberty and others are advocating early reconstruction. To take this debate a further forward, we studied retrospectively our operated children and stratified them according to age into below 2 years and after 2 years of age and we found that earlier (before 2 years of age) is better then late (above 2 years of age) repair. CONCLUSIONS Better anatomical findings were significantly observed in patients with early surgical intervention (before the age of 2 years).
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12
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AbouZeid AA, Mohammad SA. Transformation of the female genitalia in congenital adrenal hyperplasia: MRI study. J Pediatr Surg 2020; 55:977-984. [PMID: 32037221 DOI: 10.1016/j.jpedsurg.2020.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/11/2019] [Accepted: 01/16/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE In this report, we aim to define the different degrees of structural abnormality affecting the female genitalia in cases of CAH by using the multiplanar capabilities and high soft tissue resolution of MRI. PATIENTS AND METHODS The study included cases of CAH who were referred to our pediatric surgical facility for genital reconstruction during the period 2016 through 2019. We studied the pelvic MRI anatomy in cases of CAH while referring to clinical and operative findings. To set up a grading scale for the degree of virilization in cases of CAH, we included another two control groups of normal boys and girls representing the two ends of the spectrum. RESULTS The study included 23 cases of CAH who underwent preoperative pelvic MRI examination. All cases had normal chromosomal analysis (46 XX). Their age ranged from 1 to 156 months at time of MRI examination (mean 42.4; median 25). The level of the lower end of the vagina was identified in midsagittal T2WI and confirmed in sequential axial cuts. Based on the level of the lower end of the vagina in relation to the pubic symphysis, we classified cases of CAH into either low or high types. Moreover, we could observe a correlation between the degree of vaginal descent and structural transformation of erectile tissue between both genders. CONCLUSION MRI can have an important role in the evaluation of cases of CAH by displaying the severity of internal anomaly which is crucial for proper preoperative counseling. TYPE OF STUDY Case control study. LEVEL OF EVIDENCE Level III.
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Afsar J, Kachuei A, Hashemipour M, Larki-Harchegani A, Shabib S. A rare enzymatic defect, true isolated 17,20-lyase deficiency leading to endocrine disorders and infertility: case report. Gynecol Endocrinol 2020; 36:297-302. [PMID: 31691616 DOI: 10.1080/09513590.2019.1683819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The cytochrome P450 17A1 catalyzes the formation of 17-hydroxysteroids and 17-ketosteroid. Most defects in CYP17A1 impair both enzymatic activities and cause a combined 17α-hydroxylase/17,20-lyase deficiency, which impairs hormone production (cortisol and sex steroids), sexual development, and puberty. Isolated 17,20-lyase deficiency is usually defined by evidently normal activity of 17α-hydroxylase with a dramatic decline of 17,20-lyase activity or complete inactivity. The changes in enzyme activity lead to a lack in the production of sex steroids with normal levels of glucocorticoid and mineralocorticoid hormones. A 24-years-old married woman, as a product of a consanguineous marriage, presented with infertility and a background marked by primary amenorrhea. Laboratory data showed low normal serum cortisol levels and low levels of 17-hydroxyprogesterone. Also, her adrenal androgens were low but estradiol was normal. The chromosomal investigation uncovered a male karyotype of 46, XY. These clinical and laboratory evidence confirm the determination of an isolated 17,20-lyase deficiency in a genotypic male.
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MESH Headings
- 46, XX Disorders of Sex Development/complications
- 46, XX Disorders of Sex Development/diagnosis
- 46, XX Disorders of Sex Development/genetics
- Adolescent
- Adrenal Hyperplasia, Congenital/complications
- Adrenal Hyperplasia, Congenital/diagnosis
- Adrenal Hyperplasia, Congenital/genetics
- Adrenal Hyperplasia, Congenital/surgery
- Endocrine System Diseases/diagnosis
- Endocrine System Diseases/etiology
- Endocrine System Diseases/surgery
- Female
- Glucocorticoids/therapeutic use
- Humans
- Infertility, Female/diagnosis
- Infertility, Female/etiology
- Infertility, Female/genetics
- Infertility, Female/surgery
- Iran
- Mutation, Missense
- Orchiectomy
- Siblings
- Steroid 17-alpha-Hydroxylase/genetics
- Steroid 17-alpha-Hydroxylase/metabolism
- Young Adult
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Affiliation(s)
- Jamileh Afsar
- Department of Internal Medicine, School of Medicine, Al-Zahra Hospital, Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Kachuei
- Department of Internal Medicine, School of Medicine, Al-Zahra Hospital, Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahin Hashemipour
- Department of Pediatrics, School of Medicine, Imam Hossein Hospital, Isfahan Endocrine and Metabolism Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Amir Larki-Harchegani
- Department of Pharmacology and Toxicology, School of Pharmacy, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Somayeh Shabib
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy, Isfahan University of Medical Sciences, Isfahan, Iran
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Lenzini L, Prisco S, Vanderriele PE, Lerco S, Torresan F, Maiolino G, Seccia TM, Iacobone M, Rossi GP. PTH Modulation by Aldosterone and Angiotensin II is Blunted in Hyperaldosteronism and Rescued by Adrenalectomy. J Clin Endocrinol Metab 2019; 104:3726-3734. [PMID: 30865228 DOI: 10.1210/jc.2019-00143] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/07/2019] [Indexed: 12/13/2022]
Abstract
CONTEXT Accumulating evidence suggests a link between adrenocortical zona glomerulosa and parathyroid gland through mechanisms that remain unexplored. OBJECTIVES To test the hypothesis that in vivo angiotensin II blockade affects PTH secretion in patients with hypertension and that aldosterone and angiotensim II directly stimulate PTH secretion ex vivo. DESIGN AND SETTING We investigated the changes of serum PTH levels induced by oral captopril (50 mg) administration in patients with primary essential hypertension (EH) and with primary aldosteronism (PA) caused by bilateral adrenal hyperplasia (BAH) or aldosterone-producing adenoma (APA), the latter before and after adrenalectomy. We also exposed primary cultures of human parathyroid cells from patients with primary hyperparathyroidism to angiotensin II (10-7 M) and/or aldosterone (10-7 M). RESULTS Captopril lowered PTH levels (in nanograms per liter) both in patients with EH (n = 63; 25.9 ± 8.3 baseline vs 24.4 ± 8.0 postcaptopril, P < 0.0001) and in patients with APA after adrenalectomy (n = 27; 26.3 ± 11.6 vs 24.0 ± 9.7 P = 0.021). However, it was ineffective in patients with full-blown PA caused by APA and BAH. In primary culture of human parathyroid cells, both aldosterone (P < 0.001) and angiotensin II (P = 0.002) markedly increased PTH secretion from baseline, by acting through mineralocorticoid receptor and angiotensin type 1 receptor, as these effects were abolished by canrenone and irbesartan, respectively. CONCLUSION These results collectively suggest an implication of the renin-angiotensin-aldosterone system in PTH regulation in humans, at least in PTH-secreting cells obtained from parathyroid tumors. Moreover, they further support the concept that mild hyperparathyroidism is a feature of human PA that is correctable with adrenalectomy.
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Affiliation(s)
- Livia Lenzini
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
| | - Selene Prisco
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
| | | | - Silvia Lerco
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
| | - Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterolgy, University of Padua, Padova, Italy
| | - Giuseppe Maiolino
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
| | - Teresa Maria Seccia
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterolgy, University of Padua, Padova, Italy
| | - Gian Paolo Rossi
- Hypertension Unit, Department of Medicine-DIMED, University of Medicine of Padova, Padova, Italy
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15
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Łebek-Szatańska A, Nowak KM, Samsel R, Roszkowska-Purska K, Zgliczyński W, Papierska L. Adrenocortical carcinoma associated with giant bilateral myelolipomas in classic congenital adrenal hyperplasia. Pol Arch Intern Med 2019; 129:549-550. [PMID: 30945697 DOI: 10.20452/pamw.14788] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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16
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Abstract
PURPOSE OF REVIEW Genitoplasty in children with disorders of sex development (DSD) is an ethically complex issue. From a surgical perspective, genitoplasty in early childhood is preferred because it is felt to be associated with improved tissue healing, decreased risk of complications, and reduced psychological impact of genital surgery. However, advocacy groups and recent ethics literature have argued for deferring genitoplasty until a child reaches decisional maturity. This article reviews these arguments using an ethical framework and discusses the application and challenges of recent disorders of sex development research. RECENT FINDINGS Recent ethics literature and advocacy groups have argued for deferring genitoplasty until a child reaches decisional maturity. As a counterpoint, urological societies have published arguments supporting the practice of early genitoplasty. Data from DSD research lends some guidance but also has a wide range of outcomes, which makes generalizability difficult. A retrospective, multicenter study of 21 individuals with congenital adrenal hyperplasia who underwent feminizing surgery showed no difference between cases and controls in social functioning, parent-child relationships, or sexual fulfillment. Ninety percent of patients thought genitoplasty should occur within the first year of life. In a study of 52 patients with 46,XY and 46,XX DSDs who underwent masculinizing genitoplasty, 57% thought their physical appearance was 'fair' or 'poor,' and problems with sexual function, urinary incontinence, and short penile length were common. SUMMARY Early genitoplasty in children with DSDs is ethically complex, and discordant results in DSD research makes generalizability difficult. There is unlikely to be a universal solution to the issue of early genitoplasty in children with DSDs; families must be supported while they weigh both parental decision-making and the objective of ensuring an open future for their child.
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Affiliation(s)
- Rebecca M Harris
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts, USA
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17
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Zhao X, Su Z, Liu X, Song J, Gan Y, Wen P, Li S, Wang L, Pan L. Long-term follow-up in a Chinese child with congenital lipoid adrenal hyperplasia due to a StAR gene mutation. BMC Endocr Disord 2018; 18:78. [PMID: 30400872 PMCID: PMC6219181 DOI: 10.1186/s12902-018-0307-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/15/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Congenital lipoid adrenal hyperplasia (CLAH) is an extremely rare and the most severe form of congenital adrenal hyperplasia. Typical features include disorder of sex development, early-onset adrenal crisis and enlarged adrenal glands with fatty accumulation. CASE PRESENTATION We report a case of CLAH caused by mutations in the steroidogenic acute regulatory protein (StAR) gene. The patient had typical early-onset adrenal crisis at 2 months of age. She had normal-appearing female genitalia and a karyotype of 46, XY. The serum cortisol and adrenal steroids levels were always nearly undetectable, but the adrenocorticotropic hormone levels were extremely high. Genetic analysis revealed compound heterozygous mutations at c. 229C > T (p.Q77X) in exon 3 and c. 722C > T (p.Q258X) in exon 7 of the StAR gene. The former mutation was previously detected in only two other Chinese CLAH patients. Both mutations cause truncation of the StAR protein. The case reported here appears to be a classic example of CLAH with very small adrenal glands and is the second reported CLAH case with small adrenal glands thus far. In a 15-year follow-up, the patient's height was approximately average for females before age 4 and fell to - 1 SDS at 10 years of age. Her bone age was similar to her chronological age from age 4 to age 15 years. CONCLUSIONS In conclusion, this is a classic case of CLAH with exceptionally small adrenal glands. Q77X mutation seems to be more common in Chinese CLAH patients. Additionally, this is the first report of the growth pattern associated with CLAH after a 15-year follow-up.
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MESH Headings
- Adolescent
- Adrenal Hyperplasia, Congenital/diagnosis
- Adrenal Hyperplasia, Congenital/genetics
- Adrenal Hyperplasia, Congenital/surgery
- Amino Acid Sequence
- Asian People/genetics
- Child
- Child, Preschool
- Disorder of Sex Development, 46,XY/diagnosis
- Disorder of Sex Development, 46,XY/genetics
- Disorder of Sex Development, 46,XY/surgery
- Female
- Follow-Up Studies
- Humans
- Infant
- Mutation/genetics
- Phosphoproteins/genetics
- Time Factors
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Affiliation(s)
- Xiu Zhao
- Department of Endocrinology, Shenzhen Children’s Hospital, 7019# Yitian Road, Futian District, Shenzhen, 518038 Guangdong Province China
| | - Zhe Su
- Department of Endocrinology, Shenzhen Children’s Hospital, 7019# Yitian Road, Futian District, Shenzhen, 518038 Guangdong Province China
| | - Xia Liu
- Department of Endocrinology, Shenzhen Children’s Hospital, 7019# Yitian Road, Futian District, Shenzhen, 518038 Guangdong Province China
| | - Jianming Song
- Pathology Department, Shenzhen Children’s Hospital, Shenzhen, 518038 China
| | - Yungen Gan
- Radiology Department, Shenzhen Children’s Hospital, Shenzhen, 518038 China
| | - Pengqiang Wen
- Pediatrics Research Institute, Shenzhen Children’s Hospital, Shenzhen, 518038 China
| | - Shoulin Li
- Department of Urology, Shenzhen Children’s Hospital, Shenzhen, 518038 China
| | - Li Wang
- Department of Endocrinology, Shenzhen Children’s Hospital, 7019# Yitian Road, Futian District, Shenzhen, 518038 Guangdong Province China
| | - Lili Pan
- Department of Endocrinology, Shenzhen Children’s Hospital, 7019# Yitian Road, Futian District, Shenzhen, 518038 Guangdong Province China
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18
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Almasri J, Zaiem F, Rodriguez-Gutierrez R, Tamhane SU, Iqbal AM, Prokop LJ, Speiser PW, Baskin LS, Bancos I, Murad MH. Genital Reconstructive Surgery in Females With Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:4089-4096. [PMID: 30272250 DOI: 10.1210/jc.2018-01863] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 08/27/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Females with congenital adrenal hyperplasia (CAH) and atypical genitalia often undergo complex surgeries; however, their outcomes remain largely uncertain. METHODS We searched several databases through 8 March 2016 for studies evaluating genital reconstructive surgery in females with CAH. Reviewers working independently and in duplicate selected and appraised the studies. RESULTS We included 29 observational studies (1178 patients, mean age at surgery, 2.7 ± 4.7 years; mostly classic CAH). After an average follow-up of 10.3 years, most patients who had undergone surgery had a female gender identity (88.7%) and were heterosexual (76.2%). Females who underwent surgery reported a sexual function score of 25.13 using the Female Sexual Function Index (maximum score, 36). Many patients continued to complain of substantial impairment of sensitivity in the clitoris, vaginal penetration difficulties, and low intercourse frequency. Most patients were sexually active, although only 48% reported comfortable intercourse. Most patients (79.4%) and treating health care professionals (71.8%) were satisfied with the surgical outcomes. Vaginal stenosis was common (27%), and other surgical complications, such as fistulas, urinary incontinence, and urinary tract infections, were less common. Data on quality of life were sparse and inconclusive. CONCLUSION The long-term follow-up of females with CAH who had undergone urogenital reconstructive surgery shows variable sexual function. Most patients were sexually active and satisfied with the surgical outcomes; however, some patients still complained of impairment in sexual experience and satisfaction. The certainty in the available evidence is very low.
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Affiliation(s)
- Jehad Almasri
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Feras Zaiem
- Department of Pathology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, Michigan
| | - Rene Rodriguez-Gutierrez
- Division of Endocrinology, Department of Internal Medicine, University Hospital Dr. Jose E. Gonzalez, Autonomous University of Nuevo Leon, Monterrey, Mexico
- Plataforma INVEST Medicina UANL-KER Unit Mayo Clinic, Autonomous University of Nuevo Leon, Monterrey, Mexico
| | | | - Anoop Mohamed Iqbal
- Division of Pediatrics and Adolescent Medicine, Department of Pediatric Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Larry J Prokop
- Mayo Clinic Libraries, Mayo Clinic, Rochester, Minnesota
| | - Phyllis W Speiser
- Division of Pediatric Endocrinology, Cohen Children's Medical Center and Zucker Hofstra Northwell School of Medicine, Lake Success, New York
| | - Laurence S Baskin
- Department of Urology, University of California, San Francisco, California
| | - Irina Bancos
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - M Hassan Murad
- Evidence-Based Practice Research Program, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
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Abstract
INTRODUCTION Feminizing genitoplasties (FG) are controversial, because of possible adverse effects on sex life. Some have suggested limiting surgery to children presenting health problems related to their genital abnormality and patients who may give their informed consent. This paper analyzes research data about late results of FG, to substantiate the choice of whether to operate on children or to limit surgery to adults/adolescents. STUDY DESIGN Review and synthesis of the literature about late results of FG. RESULTS Eleven papers were found, involving different primary diseases and techniques (levels of evidence 3-4). There are no long-term data about corporeal sparing clitoroplasty, ASTRA procedures, and urogenital sinus mobilization. Surgery alters objective genital sensitivity, but most patients attest good subjective post-operative clitoral sensation. Complaints of poor clitoral sensation were related to reoperations, amputation, recession, atrophy, or neurovascular bundle injuries. CAH homozygous (null) genotypes show worse sensitivity and sex life, independent of surgery. Sexual function and avoidance are comparable between post-operated and virgin CAH patients. Problems with global auto-image were related to sexual difficulties. Introitus stenosis is frequent. Patients rarely reported distress concerning FG but vaginal self-dilatation is traumatic. Most patients operated on as young children evaluated timing of their surgery as correct. DISCUSSION Biological, technical, and subjective factors influence females' attitudes towards sexual satisfaction. FG patients tend to be sexually insecure. Some sequelae described in adult women should be uncommon in contemporaneous cohorts, because of new techniques. CONCLUSION Evidence about long-term sequelae of FG are of low quality and methodologically limited by unphysiological sensitivity measurement methods that do not correspond to subjective reports of the patients. Modern techniques have not been evaluated in the long term. The consequences of intentionally raising severely virilized children as females in our contemporaneous society have not been studied: such a decision still represents a social experiment.
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Affiliation(s)
- Lisieux Eyer Jesus
- Department of Pediatric Surgery and Urology, Servidores Do Estado Hospital, Ministry of Health, Rio de Janeiro, Brazil; Department of Pediatric Surgery and Urology, Antonio Pedro University Hospital, Federal Fluminense University, Rio de Janeiro, Brazil.
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20
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Szymanski KM, Whittam B, Kaefer M, Frady H, Cain MP, Rink RC. What about my daughter's future? Parental concerns when considering female genital restoration surgery in girls with congenital adrenal hyperplasia. J Pediatr Urol 2018; 14:417.e1-417.e5. [PMID: 30126743 DOI: 10.1016/j.jpurol.2018.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/12/2018] [Indexed: 11/17/2022]
Abstract
PURPOSE The parental decision-making process regarding female genital restoration surgery (FGRS) for girls with congenital adrenal hyperplasia (CAH) is controversial and poorly understood. The aim of the study aim was to evaluate parental concerns related to their child's future and parental plans about disclosure prior to FGRS. MATERIALS AND METHODS The authors performed an online survey of consecutive parents presenting at a tertiary referral center for consultation regarding FGRS for their daughter with CAH before 3 years of age (2016-2018). Twenty issues initially identified by three families and six clinicians were rated on a 6-point Likert scale of importance ('not at all' to 'extremely'). RESULTS Sixteen consecutive families participated (Prader 3/4/5: 43.8%/43.8%/12.5%). Fourteen girls (87.5%) subsequently underwent FGRS at a median age of 8 months. Most issues (19/20, 95.0%) were ranked 'quite a bit' to 'extremely' important (Table). Top issues were not surgical: Normal physical/mental development, adrenal crisis and side-effects of medications. Surgery-related and self-image concerns followed in importance. Least prioritized issues were multiple genital exams ('quite a bit' important) and the child not being involved in the decision to proceed with FGRS ('somewhat' important). On average, no issues were considered 'not at all' or 'a little' important. Disclosure of FGRS to their daughter was the 15th prioritized issues. Almost all families (93.8%, 1 unsure) planned to disclose the surgery to their daughter, although many were unsure when and how to do it (33.3% and 37.5%, respectively). COMMENT Initial efforts to understand the complex process of parental decision-making regarding FGRS in the context of CAH, a complex, multifactorial disease, are presented. Parents of infant girls with CAH simultaneously weigh multiple life-threatening concerns with a decision about FGRS. While issues of genital ambiguity and surgery are important, they are not overriding concerns for parents of girls with CAH. Parents report significant uncertainty about appropriate timing and approach to disclosing FGRS to their daughters. Unfortunately, best practice guidelines for this process are lacking. The findings are not based on actual history of disclosure but on parents' anticipated behavior. Further data are need from parents, children, and women with CAH about successful disclosure. Being a single-center series, these data may not correspond to the wider CAH community. CONCLUSIONS Parental decision-making regarding FGRS is multifactorial. Even when considering FGRS, parents' largest concerns remain focused on the life-threatening and developmental effects of CAH and side-effects of its medical treatment. The disclosure process deserves further attention.
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Affiliation(s)
- K M Szymanski
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA.
| | - B Whittam
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - M Kaefer
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - H Frady
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - M P Cain
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
| | - R C Rink
- Division of Pediatric Urology, Riley Hospital for Children at IU Health, IN, USA
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21
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Shiryaev ND, Kagantsov IM, Sizonov VV, Dubrov VI. [Disorders of sexual differentiation in children: a critical look at open questions (part II)]. Urologiia 2018:121-125. [PMID: 30035431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Surgical management of children with disorders of sexual differentiation (DSD) is one of the most difficult problems in pediatric urology. In the second part of the article we continue to discuss the controversies concerning the surgical management of patients with the classical form of congenital adrenal hyperplasia and 46, XX karyotype - feminizing genitoplasty and its different types.
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Affiliation(s)
- N D Shiryaev
- Northern State Medical University of Minzdrav of Russia, Arkhangelsk, Russia
- Republican Childrens Clinical Hospital, Syktyvkar, Russia
- Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
- RostSMU of Minzdrav of Russia, Rostov-on-Don, Russia
- Childrens Hospital #2, Minsk, Republic of Belarus
| | - I M Kagantsov
- Northern State Medical University of Minzdrav of Russia, Arkhangelsk, Russia
- Republican Childrens Clinical Hospital, Syktyvkar, Russia
- Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
- RostSMU of Minzdrav of Russia, Rostov-on-Don, Russia
- Childrens Hospital #2, Minsk, Republic of Belarus
| | - V V Sizonov
- Northern State Medical University of Minzdrav of Russia, Arkhangelsk, Russia
- Republican Childrens Clinical Hospital, Syktyvkar, Russia
- Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
- RostSMU of Minzdrav of Russia, Rostov-on-Don, Russia
- Childrens Hospital #2, Minsk, Republic of Belarus
| | - V I Dubrov
- Northern State Medical University of Minzdrav of Russia, Arkhangelsk, Russia
- Republican Childrens Clinical Hospital, Syktyvkar, Russia
- Pitirim Sorokin Syktyvkar State University, Syktyvkar, Russia
- RostSMU of Minzdrav of Russia, Rostov-on-Don, Russia
- Childrens Hospital #2, Minsk, Republic of Belarus
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22
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MacKay D, Nordenström A, Falhammar H. Bilateral Adrenalectomy in Congenital Adrenal Hyperplasia: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2018; 103:1767-1778. [PMID: 29554355 DOI: 10.1210/jc.2018-00217] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/09/2018] [Indexed: 02/04/2023]
Abstract
CONTEXT Management of congenital adrenal hyperplasia (CAH) involves suppression of the hypothalamic-pituitary-adrenal axis using supraphysiological doses of exogenous glucocorticoids. This can pose a challenge, with Cushing syndrome a frequent complication of adequate suppression. Bilateral adrenalectomy, with subsequent replacement of glucocorticoids and mineralocorticoids at physiological doses, has been proposed as an alternative therapeutic strategy. OBJECTIVE To review the outcomes after bilateral adrenalectomy for CAH. DATA SOURCES A systematic search of PubMed/MEDLINE and Web of Science, identifying relevant reports published up to 10 January 2018. STUDY SELECTION Case reports or case series were included if they reported individual patient data from patients with CAH who had undergone bilateral adrenalectomy. DATA EXTRACTION Information regarding the following was extracted: first author, country, sex, age at adrenalectomy, year of adrenalectomy, diagnosis, molecular abnormality, pre- and postoperative biochemistry, pre- and postoperative medications, pre- and postoperative body mass index, indication for adrenalectomy, surgical technique, gross and microscopic adrenal characteristics, follow-up duration, and short- and long-term postoperative outcomes. DATA SYNTHESIS We identified 48 cases of bilateral adrenalectomy for CAH, with patients aged from 4 months to 56 years at surgery. The most common indication for surgery was the inability to control hyperandrogenism/virilization and/or Cushing syndrome (n = 30; 62%). Most patients (n = 34; 71%) reported symptomatic improvement postoperatively, with some cases of short-term (n = 5; 10%) and long-term (n = 13; 27%) adverse outcomes. CONCLUSIONS Bilateral adrenalectomy for CAH appears to be a reasonable therapeutic option for carefully selected patients who have had unsatisfactory outcomes with conventional medical management.
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Affiliation(s)
- Diana MacKay
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Anna Nordenström
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Endocrinology, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Endocrinology, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Menzies School of Health Research, Darwin, Northern Territory, Australia
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23
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Bernabé KJ, Nokoff NJ, Galan D, Felsen D, Aston CE, Austin P, Baskin L, Chan YM, Cheng EY, Diamond DA, Ellens R, Fried A, Greenfield S, Kolon T, Kropp B, Lakshmanan Y, Meyer S, Meyer T, Delozier AM, Mullins LL, Palmer B, Paradis A, Reddy P, Reyes KJS, Schulte M, Swartz JM, Yerkes E, Wolfe-Christensen C, Wisniewski AB, Poppas DP. Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia. J Pediatr Urol 2018; 14:157.e1-157.e8. [PMID: 29398588 PMCID: PMC5970022 DOI: 10.1016/j.jpurol.2017.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/23/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches. OBJECTIVE The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia. STUDY DESIGN This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings. RESULTS Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied. DISCUSSION In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population. CONCLUSION In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.
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Affiliation(s)
- K J Bernabé
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - N J Nokoff
- Children's Hospital Colorado, Aurora, CO, USA
| | - D Galan
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - D Felsen
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA
| | - C E Aston
- University of Oklahoma Health Sciences Center, Department of Pediatrics, Oklahoma City, OK, USA
| | - P Austin
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - L Baskin
- University of California San Francisco, San Francisco, CA, USA
| | - Y-M Chan
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - D A Diamond
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - R Ellens
- Children's Hospital of Michigan, Detroit, MI, USA
| | - A Fried
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - S Greenfield
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Kolon
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - B Kropp
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - Y Lakshmanan
- Children's Hospital of Michigan, Detroit, MI, USA
| | - S Meyer
- Women and Children's Hospital of Buffalo, Buffalo, NY, USA
| | - T Meyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - A M Delozier
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - L L Mullins
- Oklahoma State University, College of Arts and Sciences, Stillwater, OK, USA
| | - B Palmer
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - A Paradis
- St. Louis Children's Hospital, St. Louis, Missouri, USA
| | - P Reddy
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K J Scott Reyes
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - M Schulte
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J M Swartz
- Children's Hospital Boston, Department of Urology, Boston, MA, USA
| | - E Yerkes
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - C Wolfe-Christensen
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA; Children's Hospital of Michigan, Detroit, MI, USA
| | - A B Wisniewski
- Genitourinary Institute, Cook Children's Hospital, Fort Worth, TX, USA
| | - D P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, USA.
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24
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Poppas D. Response to Letter to the Editor re 'Urinary Continence Outcomes Following Vaginoplasty in Patients with Congenital Adrenal Hyperplasia'. J Pediatr Urol 2017; 13:536. [PMID: 28434639 DOI: 10.1016/j.jpurol.2017.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 03/16/2017] [Indexed: 11/20/2022]
Affiliation(s)
- Dix Poppas
- New York Presbyterian Hospital/Weill Cornell Medicine, 525 East 68th St, Box 94, Room F931, New York, NY, 10065, United States.
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25
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Ozisik H, Yurekli BS, Simsir IY, Altun I, Soyaltin U, Guler E, Onay H, Sarsik B, Saygili F. Testicular Adrenal Rest Tumor (TART) in congenital adrenal hyperplasia. Eur J Med Genet 2017; 60:489-493. [PMID: 28676275 DOI: 10.1016/j.ejmg.2017.06.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 11/19/2022]
Abstract
Congenital adrenal hyperplasia is one of the most common autosomal recessive genetic disorders. Testicular adrenal tumors are significant complications of congenital adrenal hyperplasia. We would like to present two patients of testicular adrenal rest tumors. Patient 1 24 year-old male, he was diagnosed with congenital adrenal hyperplasia at the age of 8 due to precocious puberty. He received hydro-cortisone treatment until the age of 18. Testicular mass had been detected and right radical orchiectomy had been applied 6 months ago and reported as testicular adrenal rest tumor. In scrotal ultrasound, a mixed type mass lesion (6 × 4x3 cm) covering a large part of left testis was observed. The imaging findings were consistent with adrenal rest tumor. The patient took adrenocorticotropic hormone supressive therapy with dexamethasone 0.75 mg once a day. Patient 2, 38 year-old male, he had been followed-up as adrenal insufficiency for 35 years. He underwent right orchiectomy operation due to the testicular mass in 2010 and the pathological examination revealed Leydig cell tumor. In scrotal ultrasound, small multifocal lesions were detected on the left testis and resection was done. It was reported as testicular adrenal rest tumor. He is being followed-up with glucocorticoid treatment according to androgen and adrenocorticotropic hormone levels. Early diagnosis of testicular adrenal rest tumor is significant in preventing irreversible testicular damage and infertility. In the differential diagnosis, we should keep in mind that testicular adrenal rest tumor can mimic other testicular tumors such as primary germ cell tumors.
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Affiliation(s)
- Hatice Ozisik
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey.
| | - Banu Sarer Yurekli
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilgin Yildirim Simsir
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ilker Altun
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Utku Soyaltin
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
| | - Ezgi Guler
- Ege University, Faculty of Medicine, Department of Radiology, Turkey
| | - Huseyin Onay
- Ege University, Faculty of Medicine, Department of Medical Genetics, Turkey
| | - Banu Sarsik
- Ege University, Faculty of Medicine, Department of Pathology, Turkey
| | - Fusun Saygili
- Ege University, Faculty of Medicine, Department of Endocrinology and Metabolism Diseases, Turkey
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26
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Wang LC, Poppas DP. Surgical outcomes and complications of reconstructive surgery in the female congenital adrenal hyperplasia patient: What every endocrinologist should know. J Steroid Biochem Mol Biol 2017; 165:137-144. [PMID: 26995108 DOI: 10.1016/j.jsbmb.2016.03.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/11/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
Abstract
Surgical management of classical congenital adrenal hyperplasia (CAH) in 46, XX females has evolved significantly. Virilization of the genitalia of 46, XX females with CAH begins prenatally as a result of excess fetal androgen production. Improved understanding of anatomy and surgical outcomes has driven changes in surgical techniques as well as the timing of surgery. For endocrinologists treating these patients, it is important to understand the outcome of genitoplasty, identify patients who need further treatment and direct these patients to experienced surgeons. We performed a literature search on PubMed of publications addressing CAH and genital reconstruction published in the English language from 1990 to the present. In accordance with our institutional review board, we performed a retrospective analysis of clitoroplasty and/or vaginoplasty procedures performed by a single surgeon at our institution from 1996 to 2015. We found that genital reconstruction in 46, XX CAH patients is associated with few immediate post-operative, infectious, and urinary complications. Vaginal stenosis is a common complication of vaginal reconstruction and requires evaluation by an experienced surgeon. Clitoral pain or decreased sensation can be associated with clitoral recession and clitorectomy. Outcomes in sexual satisfaction and gender identity can also be impacted by surgical technique and success. Long term follow up and patient reported feedback are crucial to our understanding and management of this special group of patients. Improved awareness and understanding of the complications of genital surgery will allow endocrinologists to know what to ask patients and be ready to provide them with a resource with the understanding and experience to help them improve their quality of life.
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Affiliation(s)
- Lily C Wang
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States.
| | - Dix P Poppas
- The Comprehensive Center for Congenital Adrenal Hyperplasia, The Komansky Center for Children's Health, Department of Urology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY, United States
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27
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Vouillarmet J, Fernandes-Rosa F, Graeppi-Dulac J, Lantelme P, Decaussin-Petrucci M, Thivolet C, Peix JL, Boulkroun S, Clauser E, Zennaro MC. Aldosterone-Producing Adenoma With a Somatic KCNJ5 Mutation Revealing APC-Dependent Familial Adenomatous Polyposis. J Clin Endocrinol Metab 2016; 101:3874-3878. [PMID: 27648962 DOI: 10.1210/jc.2016-1874] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Recurrent somatic mutations in KCNJ5, CACNA1D, ATP1A1, and ATP2B3 have been identified in aldosterone-producing adenomas (APAs). The question as to whether they are responsible for both nodulation and aldosterone production is not solved. CASE DESCRIPTION We describe the case of a young patient who was diagnosed with severe arterial hypertension due to primary aldosteronism at age 26 years, followed by hemorrhagic stroke 4 years later. Abdominal computed tomography showed bilateral macronodular adrenal hyperplasia. Identification of lateralized aldosterone secretion led to right adrenalectomy, followed by normalization of biochemical and hormonal parameters and amelioration of blood pressure. The resected adrenal showed three nodules, one of them expressing aldosterone synthase and harboring a somatic KNCJ5 mutation. A Weiss revisited index of 3 of the APA prompted us to perform a second 18F-2-fluoro-2-deoxy-D-glucose-positron emission tomography after surgery, which revealed abnormal rectal activity despite the absence of clinical symptoms. Gastrointestinal exploration showed multiple polyps with severe dysplasia, and the diagnosis of familial adenomatous polyposis was established in the presence of a germline heterozygous APC gene mutation. Sequencing of somatic DNA from the APA and a second adrenal nodule revealed biallelic APC inactivation due to loss of heterozygosity in both nodules. CONCLUSIONS This case report underlines the need for establishing the frequency of germline APC variants in patients with primary aldosteronism and bilateral macronodular adrenal hyperplasia because their presence may predispose to APA development and severe hypertension well before the first familial adenomatous polyposis symptoms appear. From a mechanistic point of view, it supports a two-hit model for APA development, whereby the first hit drives increased cell proliferation whereas the second hit specifies the pattern of hormonal secretion.
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Affiliation(s)
- Julien Vouillarmet
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Fabio Fernandes-Rosa
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Julia Graeppi-Dulac
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Pierre Lantelme
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Myriam Decaussin-Petrucci
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Charles Thivolet
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Jean-Louis Peix
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Sheerazed Boulkroun
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Eric Clauser
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
| | - Maria-Christina Zennaro
- Hospices Civils de Lyon (J.V., J.G.-D., C.T.), Centre Hospitalier Lyon-Sud, Service d'Endocrinologie, Diabète et Obésité, 69310 Pierre Bénite, France; Inserm, UMRS_970 (F.F.-R., S.B., E.C., M.-C.Z.), Paris Cardiovascular Research Center, 75015 Paris, France; Université Paris Descartes (F.F.-R., S.B., E.C., M.-C.Z.), Sorbonne Paris Cité, 75006 Paris, France; Assistance Publique-Hôpitaux de Paris (F.F.-R., M.-C.Z.), Hôpital Européen Georges Pompidou, Service de Génétique, 75015 Paris, France; Hospices Civils de Lyon (P.L.), Hôpital de la Croix-Rousse, Service de Cardiologie, European Society of Hypertension Excellence Center, 69317 Lyon, France; Université de Lyon (P.L.), CREATIS; CNRS UMR5220; Inserm U1044; INSA-Lyon; Université Claude Bernard Lyon 1, 69100 Lyon, France; Hospices Civils de Lyon (M.D.-P.), Centre Hospitalier Lyon-Sud, Service d'anatomo-pathologie, université Claude Bernard Lyon I, 69310 Pierre Bénite, France; Université Claude Bernard Lyon I (P.L., M.D.-P., C.T.), 69100 Lyon, France; Inserm U1060 (C.T.), Faculté de médecine Lyon sud, 69921 Oullins, France; Hospices Civils de Lyon (J.-L.P.), Centre Hospitalier Lyon-Sud, Service de chirurgie digestive et endocrinienne, 69495 Pierre Bénite, France; Assistance Publique-Hôpitaux de Paris (E.C.), Hôpital Cochin, Service de Biologie Hormonale, 75014 Paris, France
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Adolf C, Asbach E, Dietz AS, Lang K, Hahner S, Quinkler M, Rump LC, Bidlingmaier M, Treitl M, Ladurner R, Beuschlein F, Reincke M. Worsening of lipid metabolism after successful treatment of primary aldosteronism. Endocrine 2016; 54:198-205. [PMID: 27179655 DOI: 10.1007/s12020-016-0983-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/03/2016] [Indexed: 01/12/2023]
Abstract
Primary aldosteronism (PA) describes the most frequent cause of secondary arterial hypertension. Recently, deterioration of lipid metabolism after adrenalectomy (ADX) for aldosterone-producing adenoma (APA) has been described. We analysed longitudinal changes in lipid profiles in a large prospective cohort of PA patients. Data of 215 consecutive PA patients with APA (n = 144) or bilateral idiopathic adrenal hyperplasia (IHA, n = 71) were extracted from the database of the German Conn's Registry. Patients were investigated before and 1 year after successful treatment by ADX or by mineralocorticoid receptor antagonists (MRA). Glomerular filtration rate (GFR), fasting plasma glucose and components of lipid metabolism including triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were determined at 8.00 after a 12-h fasting period. One year after initiation of treatment mean serum potassium levels and blood pressure normalized in the patients. HDL-C and TG developed inversely with decreasing HDL-C levels in patients with APA (p = .046) and IHA (p = .004) and increasing TG levels (APA p = .000; IHA p = .020). BMI remained unchanged and fasting plasma glucose improved in patients with APA (p = .004). Furthermore, there was a significant decrease of GFR in both subgroups at follow-up (p = .000). Changes in HDL-C and TG correlated with decrease in GFR in multivariate analysis (p = .024). Treatment of PA is associated with a deterioration of lipid parameters despite stable BMI and improved fasting plasma glucose and blood pressure. This effect can be explained by renal dysfunction following ADX or MRA therapy.
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Affiliation(s)
- Christian Adolf
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany
| | - Evelyn Asbach
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany
| | - Anna Stephanie Dietz
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany
| | - Katharina Lang
- Medizinische Klinik I, Julius-Maximilians-Universität, Würzburg, Germany
| | - Stefanie Hahner
- Medizinische Klinik I, Julius-Maximilians-Universität, Würzburg, Germany
| | | | | | - Martin Bidlingmaier
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany
| | - Marcus Treitl
- Institut für Klinische Radiologie, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Roland Ladurner
- Klinik für Viszeral- und Endokrine Chirurgie, Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Ludwig-Maximilians-Universität, Ziemssenstr. 1, 80336, Munich, Germany.
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Debillon E, Velayoudom-Cephise FL, Salenave S, Caron P, Chaffanjon P, Wagner T, Massoutier M, Lambert B, Benoit M, Young J, Tabarin A, Chabre O. Unilateral Adrenalectomy as a First-Line Treatment of Cushing's Syndrome in Patients With Primary Bilateral Macronodular Adrenal Hyperplasia. J Clin Endocrinol Metab 2015; 100:4417-24. [PMID: 26451908 DOI: 10.1210/jc.2015-2662] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Bilateral adrenalectomy is the reference treatment for Cushing's syndrome (CS) related to primary bilateral macronodular adrenal hyperplasia (PBMAH). It is, however, responsible for definitive adrenal insufficiency. OBJECTIVE The objective of the study was to evaluate the clinical interest of unilateral adrenalectomy (UA) of the larger gland for the treatment of CS related to PBMAH. DESIGN, SETTING, PATIENTS, AND INTERVENTION This was a retrospective study in four tertiary French centers including all 15 patients with PBMAH and CS who underwent UA of the larger gland between 2001 and 2015. MAIN OUTCOME MEASURES Urinary free cortisol, plasma cortisol, ACTH, body mass index, blood pressure, plasma glucose, and lipids were registered pre- and postoperatively and on follow-up. Median follow-up was 60 months (interquartile range 39-105), including 8 of 15 patients followed up for at least 5 years. RESULTS A normal or low urinary free cortisol was obtained in 15 of 15 patients (100%) postoperatively. Six patients (40%) became adrenal insufficient, of whom three of six recovered a quantitatively normal cortisol secretion on follow-up. Decrease of both body mass index and blood pressure were observed at 1 year, and decrease of blood pressure was persistent 5 years postoperatively. Diabetes was cured in four of six patients. Two patients experienced a recurrence of hypercortisolism, and one was treated with mitotane, whereas the other underwent a second adrenal surgery 9 years after initial UA. CONCLUSION UA induced remission of hypercortisolism in all patients, with sustained significant clinical improvement. The rates of both definitive adrenal insufficiency and 5-year recurrence were low. UA appears an interesting alternative to bilateral adrenalectomy as a first-line treatment in PBMAH responsible for overt CS.
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Affiliation(s)
- Emmanuelle Debillon
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Fritz-Line Velayoudom-Cephise
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Sylvie Salenave
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Philippe Caron
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Philippe Chaffanjon
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Tristan Wagner
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Maximilien Massoutier
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Benoit Lambert
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Marine Benoit
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Jacques Young
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Antoine Tabarin
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
| | - Olivier Chabre
- Service d'Endocrinologie-Diabétologie-Nutrition (E.D., M.B., O.C.), Service de Chirugie Endocrine et Thoracique (P.Ch.), and Centre d'Investigation (M.M.), Clinique, Centre Hospitalier Universitaire de Grenoble, F-38043 Grenoble, France; Service d'Endocrinologie (F.V.-C., A.T.) and Service de Chirurgie Digestive et Endocrinienne (T.W.), Centre Hospitalier Universitaire de Bordeaux, F-33600 Pessac, France; Service d'Endocrinologie et des Maladies de la Reproduction and Centre de Référence des Maladies Endocriniennes Rares de la Croissance (S.S., J.Y.), Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, and Service de Chirurgie Digestive et Endocrinienne (B.L.), Hôpital Bicêtre F-94275 Le Kremlin-Bicêtre, France; and Service d'Endocrinologie et Maladies Métaboliques (P.Ca.), Centre Hospitalier Universitaire Larrey, F-31059 Toulouse, France
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Affiliation(s)
- Arlene B. Baratz
- Androgen Insensitivity Syndrome—Disorders of Sex Development Support Group, P.O. Box 2148, Duncan, OK 73534 USA
| | - Ellen K. Feder
- Department of Philosophy and Religion, American University, 4400 Massachusetts Ave. NW, Washington, DC 20016 USA
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Pina C, Khattab A, Katzman P, Bruckner L, Andolina J, New M, Yau M. Ovarian carcinoma in a 14-year-old with classical salt-wasting congenital adrenal hyperplasia and bilateral adrenalectomy. J Pediatr Endocrinol Metab 2015; 28:663-7. [PMID: 25427061 DOI: 10.1515/jpem-2014-0299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/26/2014] [Indexed: 11/15/2022]
Abstract
A 14-year-old female with classical congenital adrenal hyperplasia because of 21-hydroxylase deficiency underwent bilateral adrenalectomy at 6 years of age as a result of poor hormonal control. Because the patient was adrenalectomized, extra adrenal androgen production was suspected. Imaging studies including pelvic ultrasound and pelvic magnetic resonance imaging (MRI) were obtained to evaluate for adrenal rest tumors of the ovaries. Abdominal MRI was obtained to evaluate for residual adrenal tissue. A cystic lesion arising from her right ovary suspicious for ovarian neoplasm was noted on pelvic MRI. Right salpingo-oophorectomy was performed and histopathological examination revealed ovarian serous adenocarcinoma, low-grade, and well-differentiated. Tumor marker CA-125 was elevated and additional ovarian cancer staging workup confirmed stage IIIC due to one lymph node positive for carcinoma. The patient then developed a large left ovarian cyst, which led to a complete total abdominal hysterectomy and removal of the left ovary and fallopian tube. Pathology confirmed ovarian serous adenocarcinoma with microscopic focus of carcinoma in the left ovary. After numerous complications, the patient responded well to chemotherapy, CA-125 levels fell and no evidence of carcinoma was observed on subsequent imaging. To our knowledge, this is the first reported case of an ovarian serous adenocarcinoma in a patient with CAH. Although rare, we propose that the ovaries were the origin of androgen production and not residual adrenal tissue. The relationship between CAH and ovarian carcinomas has yet to be established, but further evaluation is needed given the poor survival rate of high-grade serous ovarian carcinoma.
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Oßwald A, Plomer E, Dimopoulou C, Milian M, Blaser R, Ritzel K, Mickisch A, Knerr F, Stanojevic M, Hallfeldt K, Schopohl J, Kuhn KA, Stalla G, Beuschlein F, Reincke M. Favorable long-term outcomes of bilateral adrenalectomy in Cushing's disease. Eur J Endocrinol 2014; 171:209-15. [PMID: 24975318 DOI: 10.1530/eje-14-0214] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Bilateral adrenalectomy (BADX) is an important treatment option for patients with Cushing's syndrome (CS). Our aim is to analyze the long-term outcomes, surgical, biochemical, and clinical as well as morbidity and mortality, of patients who underwent BADX. DESIGN A total of 50 patients who underwent BADX since 1990 in two German centers were identified. Of them, 34 patients had Cushing's disease (CD), nine ectopic CS (ECS), and seven ACTH-independent bilateral adrenal hyperplasia (BAH). METHODS Standardized follow-up examination was performed in 36 patients with a minimum follow-up time of 6 months after BADX and a median follow-up time of 11 years. RESULTS Surgical morbidity and mortality were 6 and 4% respectively. All patients were found to be in remission after BADX. Almost all Cushing's-specific comorbidities except for psychiatric diseases improved significantly. Health-related quality of life remained impaired in 45.0% of female and 16.7% of male patients compared with a healthy population. The median number of adrenal crises per 100 patient-years was four. Nelson tumor occurred in 24% of CD patients after a median time span of 51 months. Long-term mortality after 10 years was high in ECS (44%) compared with CD (3%) and BAH (14%). CONCLUSIONS BADX is an effective and relatively safe treatment option especially in patients with CD. The majority of patients experience considerable improvement of Cushing's symptoms.
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Affiliation(s)
- Andrea Oßwald
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Eva Plomer
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Christina Dimopoulou
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, GermanyMedizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Monika Milian
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Rainer Blaser
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Katrin Ritzel
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Anne Mickisch
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Ferengis Knerr
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Milan Stanojevic
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Klaus Hallfeldt
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Jochen Schopohl
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Klaus A Kuhn
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Günter Stalla
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IVLudwig-Maximilians-Universität München, Klinikum der Universität München, Ziemssenstraße 1, D-80336 Munich, GermanyDepartment of EndocrinologyMax Planck Institute of Psychiatry, München, GermanyDepartment of NeurosurgeryUniversity Hospital Tuebingen, Tübingen, GermanyIMSEKlinikum rechts der Isar der TU München, München, Germany andChirurgische Klinik und Poliklinik - InnenstadtKlinikum der Ludwig-Maximilians-Universität München, München, Germany
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Abstract
This chapter refers only to female patients with congenital adrenal hyperplasia (CAH). CAH represents the largest subgroup of individuals with 46,XX disorders of sex development. The stimulation of the androgen production leads to a prenatal virilization among these girls. The phenotype is influenced by the severity of the enzyme defect, leading to a virilization of the external genitalia in varying degrees. On the other hand, the affected girls are clearly anatomically female with regularly developed female internal genitalia. Female puberty and potential female fertility are therefore to be expected. The operation to feminize the genitalia includes the separation of the sinus urogenitalis, the creation of a functionally wide enough vagina, the remodeling of the labioscrotal folds to create larger labia, and, if necessary, a reduction clitoroplasty. Considering the lack of scientific evidence, it is not possible to make definitive statements regarding the timing of surgery for girls with CAH. There are no studies that prove whether one- or two-stage surgery provides more or clearer advantages.
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Affiliation(s)
- Felicitas Eckoldt-Wolke
- Clinic for Pediatric Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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35
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Martínez-Criado Y, Gómez AL, Fernández-Hurtado MA, Barrero R, García-Merino F. [Role of pediatric urologist in the treatment of congenital adrenal hyperplasia: a study of satisfaction and psychosocial aspects]. Cir Pediatr 2013; 26:75-80. [PMID: 24228357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE Study the role of the pediatric urologist in the treatment of CAH and the satisfaction of families and patients to identify the psychosocial aspects that we can improve. MATERIAL AND METHODS Retrospective study in girls with CAH treated in our center. We reviewed the medical records, analyzing the variables: place of birth, age at diagnosis, surgery, complications and follow up. Analysis of satisfaction and psychosocial aspects by telephone survey. RESULTS Between 1975-2011, 25 girls with CAH have been treated in our center. Cystoscopy and vaginoscopy was performed before clitoroplasty in 68% (16 girls), adding vulvovaginoplasty in 40% and vaginal descent in the 20%. The mean age was 8.78 +/- 2.30 months. Vaginal stenosis was the main complication (36%), performing introitus plasty in two girls, vaginal expansion in other 2 and dilation of the rest. 15 surveys were made, all expressed satisfaction with treatment, and only 6.67% reported shortages information. With the aesthetic results of the genitoplasty 20% showed dissatisfaction. The family concern was constant at 60%, and sporadic in the rest. 13.3% required psychological support. Currently 80% have normal psychosocial life. CONCLUSION The HSC requires a multidisciplinary approach right from birth to allow adequate psychosocial development. The pediatric urologist has an important weight in the multidisciplinary treatment. Realizing early feminizing genitoplasty decreases family impact and increases satisfaction. The prolonged follow-up will allow the detection and treatment of complications.
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Affiliation(s)
- Y Martínez-Criado
- Servicio de Urología Pediátrica, Hospital Virgen del Rocío, Sevilla.
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Abstract
OBJECTIVE To investigate the prevalence of lower urinary tract symptoms (LUTS) in a Finnish cohort of patients who had undergone feminizing genitoplasty in childhood. PATIENTS AND METHODS Information on LUTS was assessed using the Danish Prostatic Symptom Score questionnaire: 24 out of 45 females (53%) returned the questionnaire; 16 patients with prenatal androgen exposure (congenital adrenal hyperplasia = CAH group) and eight with androgen insensitivity (AIS group). RESULTS Urge urinary incontinence was reported by 13% of the patients in both the CAH and AIS groups and by 15% of the controls. Stress urinary incontinence was reported by 31% of the patients in the CAH group, 13% of the patients in the AIS group and 22% of the controls. Distressing voiding symptoms were reported by 19% of the patients in the CAH group, 13% of the patients in the AIS group and 28% of the controls, and of these straining and incomplete emptying were the most prevalent. CONCLUSIONS LUTS are as common in female DSD patients with feminizing genitoplasty as they are in controls. Some degree of distressing incontinence occurred in 13%-25% of the young female patients and the controls.
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Affiliation(s)
- Riitta Fagerholm
- Department of Paediatric Surgery, Children's Hospital, University of Helsinki, Stenbäckinkatu 11, 00290 Helsinki, Finland
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Stanescu DE, Langdon DR. 50 years ago in the Journal of Pediatrics: female adrenogenital syndrome: early surgical repair. J Pediatr 2013; 162:61. [PMID: 23260311 DOI: 10.1016/j.jpeds.2012.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Diana E Stanescu
- Division of Endocrinology and Diabetes, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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Crocker MK, Barak S, Millo CM, Beall SA, Niyyati M, Chang R, Avila NA, Van Ryzin C, Segars J, Quezado M, Merke DP. Use of PET/CT with cosyntropin stimulation to identify and localize adrenal rest tissue following adrenalectomy in a woman with congenital adrenal hyperplasia. J Clin Endocrinol Metab 2012; 97:E2084-9. [PMID: 22904181 PMCID: PMC3485588 DOI: 10.1210/jc.2012-2298] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Adrenalectomy is an experimental treatment option for select patients with congenital adrenal hyperplasia who have failed medical therapy. After adrenalectomy, adrenal rest tissue can remain in extraadrenal locations, cause recurrent hyperandrogenism, and be difficult to localize. OBJECTIVE The aim of the study was to investigate the usefulness of positron emission tomography/computerized tomography (PET/CT) in identifying adrenal rest tissue. SUBJECT A female with salt-wasting 21-hydroxylase deficiency who had bilateral adrenalectomy at age 17 yr presented with hyperandrogenism at age 32 yr. Pelvic magnetic resonance imaging and ultrasound imaging were nondiagnostic for the source of androgen production. METHODS AND RESULTS A baseline F-18 labeled fluoro-2-deoxy-d-glucose (18F-FDG) PET/CT scan showed no active uptake; however, a second scan preceded by a 250-μg cosyntropin injection identified three areas of active uptake near both ovaries. Subsequent ovarian venous sampling showed elevations in 17-hydroxyprogesterone, androstenedione, and 21-deoxycortisol in both ovarian veins compared to a peripheral vein at baseline and more so after cosyntropin administration. At laparoscopy, three well-circumscribed nodules (2.4 × 0.9 × 1.3 cm, 1.2 × 1.5 × 1.5 cm, and 2 × 1.5 × 1 cm) lying lateral to the fallopian tubes adjacent to the broad ligaments were removed. The paraovarian nodules and previously removed adrenal glands had similar histology and immunohistochemistry. Postoperatively, androgen concentrations were undetectable, with no response to cosyntropin stimulation. CONCLUSIONS Patients with CAH after an adrenalectomy may experience recurrent hyperandrogenism due to adrenal rest tissue. 18F-FDG PET/CT with cosyntropin stimulation accurately identified adrenal rest tissue not visualized with conventional imaging, allowing for successful surgical resection.
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Affiliation(s)
- Melissa K Crocker
- National Institutes of Health (NIH), The Eunice Kennedy Shriver National Institute of Child Health andHuman Development (M.K.C., J.S., D.P.M.), Bethesda, Maryland 20892, USA.
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Affiliation(s)
- S C McGeoch
- Department of Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK.
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Agrawal S, Vadher P. Disorder of sex development: a case of missed opportunity. Indian Pediatr 2010; 47:896. [PMID: 21048251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Nordenström A, Frisén L, Falhammar H, Filipsson H, Holmdahl G, Janson PO, Thorén M, Hagenfeldt K, Nordenskjöld A. Sexual function and surgical outcome in women with congenital adrenal hyperplasia due to CYP21A2 deficiency: clinical perspective and the patients' perception. J Clin Endocrinol Metab 2010; 95:3633-40. [PMID: 20466782 DOI: 10.1210/jc.2009-2639] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Females with congenital adrenal hyperplasia (CAH) due to a CYP21A2 deficiency are exposed to androgens during fetal development, resulting in virilization of the external genitalia. Little is known about how these women feel that the disease has affected their lives regarding surgery and psychosexual adaptation. OBJECTIVE Our objective was to investigate the correlation between the surgical results, the self-perceived severity of the disease, and satisfaction with sexual life and relate the results to the CYP21A2 genotype. DESIGN AND PARTICIPANTS Sixty-two Swedish women with CAH and age-matched controls completed a 120-item questionnaire, and a composite score for sexual function was constructed. The surgical outcome, including genital appearance and clitoral sensitivity, was evaluated by clinical examination. The patients were divided into four CYP21A2 genotype groups. RESULTS The sexual function score, but not for genital appearance, was higher in the patients satisfied with their sexual life. This was also true of the patients who were satisfied with the surgical result. There were discrepancies between the patients' perception of the impact of the condition on their sexual life and what health professionals would assume from clinical examination. The patients in the null genotype group scored lower on sexual function and satisfaction with their sexual life and had more surgical complications, also compared with the slightly less severe I2-splice genotype group. CONCLUSION Our data show that the null genotype group was considerably more affected by the condition than the other groups and should be regarded as a subgroup, both psychologically and from a surgical perspective. Genotyping adds clinically valuable information.
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Affiliation(s)
- Anna Nordenström
- Department of Pediatrics, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
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Vidal I, Gorduza DB, Haraux E, Gay CL, Chatelain P, Nicolino M, Mure PY, Mouriquand P. Surgical options in disorders of sex development (dsd) with ambiguous genitalia. Best Pract Res Clin Endocrinol Metab 2010; 24:311-24. [PMID: 20541154 DOI: 10.1016/j.beem.2009.10.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Disorders of sexual development (DSD) include three main groups of patients: (1) The virilised 46,XX DSD essentially represented by congenital adrenal hyperplasia (CAH) ; (2) The undervirilised 46,XY DSD essentially represented by hypospadias; and (3) the chromosomic jigsaws essentially represented by mixed gonadal dysgenesis. It is in this last group that gender assignment remains a difficult decision involving various indicators, which can be split into four categories: (1) the inside sex (i.e., genes, hormones and target tissues); (2) the outside sex (i.e., anatomy of genitalia including size of the genital tubercle, mullerian cavity and potential adult height of the patient); (3) the functional sex (i.e., potential sexuality and fertility); and (4) and the social sex (i.e., the cultural medium in which the child is brought up). The challenge is to outline the future individual identity of the child in the postnatal period using these indicators. Current evolutions of surgical techniques of 'feminisation' and 'masculinisation' are described as well as their outcomes.
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Affiliation(s)
- Isabelle Vidal
- Department of Paediatric Urology and Surgery, Hôpital Mère-Enfants, and Claude-Bernard University, 69677 Bron, France
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Telles-Silveira M, Tonetto-Fernandes VF, Schiller P, Kater CE. [Congenital adrenal hyperplasia: a qualitative study on sex definition and redesignation dilation surgery and psychological support (part II)]. Arq Bras Endocrinol Metabol 2009; 53:1125-1136. [PMID: 20126870 DOI: 10.1590/s0004-27302009000900009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2009] [Accepted: 08/05/2009] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To identify relevant questions related to sex definition and re-designation and reconstructive surgery in patients with congenital adrenal hyperplasia (CAH), and to understand the role of the psychologist in providing care for these patients. METHODS We selected 21 subjects: 7 pediatric endocrinologists from 5 Brazilian Public Health System institutions, 9 parents and 6 patients with CAH, according to a qualitative research model. In this paper, 3 of the studied categories are analyzed: 'sex definition and re-designation', 'reconstructive surgery/vaginal dilation', and 'psychology'. RESULTS Parents' main anguish relates to the situation of an unnamed sex at birth, whereas sex re-designation was distressful to physicians. A sense of loneliness when dealing with the disease and treatment was a common anguish among patients; dilation procedures were the major complaint. In general, physicians recommend that genital reconstructive surgery be performed early on to avoid future trauma. CONCLUSIONS In such a complex scenario, it is remarkable that not all the reference service staff have a psychologist on duty. Difficulties to deal with questions involving sexuality were evident and dilation procedures are an additional source of trauma for these patients.
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Miguélez Lago C. [Editorial comment on: Feminizing genitoplasty in adrenal congenital hyperplasia: one or two surgical steps?]. ARCH ESP UROL 2009; 62:731-732. [PMID: 20564815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Moriya K, Higashiyama H, Tanaka H, Mitsui T, Nakamura M, Nonomura K. Long-term outcome of vaginoplasty with the bilateral labioscrotal flap. J Urol 2009; 182:1876-81. [PMID: 19692073 DOI: 10.1016/j.juro.2009.02.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Indexed: 11/19/2022]
Abstract
PURPOSE We report the long-term outcome of vaginoplasty with the bilateral labioscrotal flap with special emphasis on vaginal stenosis. MATERIALS AND METHODS Of 23 children with ambiguous genitalia and low vaginal entry who underwent vaginoplasty between January 1985 and July 2003 with the bilateral labioscrotal flap 13 followed more than 5 years after surgery who were 10 years old or older at the most recent evaluation were included in this long-term outcome study. Vaginal caliber was estimated according to a previously described assessment system adopted for vaginoplasty results. RESULTS The underlying disease was congenital adrenal hyperplasia in 11 cases, mixed gonadal dysgenesis in 1 and ovotesticular sexual development disorder in 1. Mean age at vaginoplasty and at the most recent evaluation was 3.8 (range 2.0 to 12.9) and 14.6 years (range 10.9 to 21.5), respectively. Vaginal caliber at the most recent evaluation was adequate in 6 patients (46%), stenotic in 5 (39%) and strictured in 2 (15%). Three of the 7 patients diagnosed with stricture or stenosis were diagnosed at age less than 12 years. One of these patients diagnosed with stricture was treated with dilation and the other 2 patients were observed. These patients had no trouble with menstruation. Four patients diagnosed with stricture or stenosis at age 14 years or older were treated surgically with dilation in 1 and perineal flap vaginoplasty in 3. They showed adequate vaginal caliber at 3 to 31 months of followup. In 7 patients evaluated at the beginning of puberty and several years later vaginal caliber had enlarged in 5 but remained unchanged in 2. CONCLUSIONS To our knowledge this is the first report of the long-term outcome of vaginoplasty with the bilateral labioscrotal flap. Although vaginal stenosis/stricture was observed at puberty in about half of the patients, severe stricture was uncommon. Serial evaluation for vaginal stenosis/stricture at the beginning of puberty for menstruation and several years later for vaginal intercourse is recommended in patients treated with vaginal reconstruction.
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Affiliation(s)
- Kimihiko Moriya
- Department of Urology, Hokkaido University Graduate School of Medicine, Kita-Ku, Sapporo, Japan.
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Liu GH, Li HZ, Mao QZ, Ji ZG, Xia M, Xie Y, Hu MM, Liu YW. [Diagnosis and treatment of primary pigmented nodular adrenocortical disease report of 4 cases]. Zhonghua Yi Xue Za Zhi 2009; 89:2138-2139. [PMID: 20058620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To study the diagnosis and treatment of primary pigmented nodular adrenocortical disease (PPNAD). METHODS The clinical data including symptom, endocrinal examination, surgical operation and prognosis of 4 cases of PPNAD hospitalized from 2000 to 2007 were analyzed respectively, relative literature were reviewed. RESULTS 1 case received total adrenalectomy needed adrenocortical hormone postoperatively, 3 cases responded favorably to subtotal adrenalectomy and did not need adrenocortical hormone, however, 1 case was diagnosed of thyroid carcinoma 2 years after subtotal adrenalectomy. CONCLUSIONS PPNAD is a rare subtype of ACTH-independent Cushing's syndrome, the diagnosis is depend on symptom, endocrinal examination and pathology. Total adrenalectomy is suitable to the patients with obvious symptom; subtotal adrenalectomy to the patients with mild symptom, the lesion of other endocrinal organ must be followed up postoperatively.
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Affiliation(s)
- Guang-Hua Liu
- Department of Urology, Peking Union Medical Collage Hospital, Chinese Academy of Medical Science, Beijing 100730, China
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Abstract
Classical congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency leads to glucocorticoid and mineralocorticoid deficiency. Management should be viewed as a process of care which requires input from an interdisciplinary team. Glucocorticoid therapy should take the form of hydrocortisone in a starting dose of 15 mg/m(2)/day (divided into three doses), and the dose should be titrated to blood or urine profiles of cortisol and 17-hydroxyprogesterone. Mineralocorticoid replacement (9 alpha-fludrocortisone) requires higher doses in infancy and childhood than in adolescence. The starting dose should be 150 microg/m(2)/day, and the dose thereafter titrated to plasma renin activity and blood pressure. Despite adequate glucocorticoid substitution and concordance with medical therapy, control can be difficult during puberty due to alterations in the clearance of hydrocortisone, and dosing schedules may need to be adjusted to account for this. Follow-up should address the many facets of CAH, which should be assessed at an annual review, and a suggested protocol is presented.
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Affiliation(s)
- Peter C Hindmarsh
- Developmental Endocrinology Research Group, Institute of Child Health, University College London, London, UK.
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John M, Menon SK, Shah NS, Menon PS. Congenital adrenal hyperplasia 11beta-hydroxylase deficiency: two cases managed with bilateral adrenalectomy. Singapore Med J 2009; 50:e68-e70. [PMID: 19296015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This series describes two patients with congenital adrenal hyperplasia due to 11beta-hydroxylase deficiency. The first patient, a ten-year-old with XX genotype, reared as a male, presented with resistant hypokalaemia and hypertension. The second patient, a 23-year-old with XY genotype, presented with bilateral adrenal masses and resistant hypertension. Both the patients were offered bilateral adrenalectomy. These two patients are described with a discussion on the role of bilateral adrenalectomy in the management of difficult cases of congenital adrenal hyperplasia. The association of myelolipoma and testicular rests with this condition is also discussed.
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Affiliation(s)
- M John
- Department of Endocrinology, Seth Gordhandas Sunderdas Medical College & King Edward Memorial Hospital, Parel, Mumbai 400012, India.
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Oswiecimska JM, Paradysz A, Zyczkowski M, Ziora KT, Pikiewicz-Koch A, Stojewska M, Dyduch A. Effects of feminizing surgery for ambiguous genitalia - a novel scale for evaluation of cosmetic and anatomical results. Neuro Endocrinol Lett 2009; 30:262-267. [PMID: 19675521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/25/2009] [Indexed: 05/28/2023]
Abstract
INTRODUCTION Ambiguous genitalia always present diagnostic and therapeutic problem. Long-term results of feminizing operations are unsatisfactory in some cases and reports from follow-up after feminizing genitoplasty are rare in the literature. Systematic studies are needed to evaluate ultimate function of all girls undergoing feminizing surgery. In our opinion, the lack of worldwide-accepted scale for the assessment of long-term effects of feminizing genitoplasty, enabling the possibility of comparing outcomes between institutions and countries, may contribute to this deficit of reliable data. AIM The aim of the study was the evaluation of the outcomes of surgical management of masculinization using a novel scale developed by the authors. MATERIAL AND METHODS We examined 43 patients aged 3-24 years (mean age 15,4 years) operated due to ambiguous genitalia. Most of the patients were females with congenital adrenal hyperplasia (CAH) diagnosed in 38 of subjects (88.4%).The patients were operated at the age from 10 months - 15 years (mean age 4,5 years). Five patients had to be reoperated. The effects of surgical management in ambiguous genitalia were assessed using our own scale. We evaluated five anatomical and cosmetic parameters (general appearance, size of pudendal labia, symmetry of pudendal labia symmetry, size and position of clitoris, size of introitus and position of urethra opening), each of them was scored 0-2 points. RESULTS In 36 of examined patients the result of the surgery was considered good, in 4 patients - satisfactory and in 3 - poor. The most common complication of feminizing genitoplasty in our patients was stenosed vagina (in 10 patients, 23.8%). Location of urinary coil in anterior wall of vagina was found in 6 patients (13.9%) and in 1 patient it was invisible (2.3%). Post-operational clitoral enlargement was found in 3 cases (6.9%). CONCLUSION Taking into consideration controversial data about the results of feminizing genitoplasty, a standarized, well-defined and commonly accepted scale enabling comparison between methods and institutions is necessary. In our opinion scoring scale makes the evaluation more precise and the results are more comparable.
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Affiliation(s)
- Joanna M Oswiecimska
- Department of Paediatrics in Zabrze, Silesian University of Medicine in Katowice, Poland.
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Nordenskjöld A, Holmdahl G, Frisén L, Falhammar H, Filipsson H, Thorén M, Janson PO, Hagenfeldt K. Type of mutation and surgical procedure affect long-term quality of life for women with congenital adrenal hyperplasia. J Clin Endocrinol Metab 2008; 93:380-6. [PMID: 18029470 DOI: 10.1210/jc.2007-0556] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT In congenital adrenal hyperplasia (CAH) caused by different mutations, feminizing surgery is mostly performed in childhood, and many patients are lost to follow-up. OBJECTIVE/PATIENTS A follow-up study on 62 CAH women aged 18-63 yr and 62 age-matched controls to correlate findings of both operative method and mutation was performed. DESIGN Semistructured interviews were performed in cases and controls, as well as a gynecological examination in the cases. The results were correlated with disease-causing mutations and earlier surgical procedures if performed. SETTING The study was conducted at university hospital referral clinics. MAIN OUTCOME MEASURES Gynecological examination in all cases correlated to previous surgery (n = 49), type of mutation, and questionnaire responses. RESULTS Half of the CAH women claimed that the disease affected their sex life. The women were less satisfied with their genitals, whether operated or not. Clitoris size and functions were affected by the surgical method. Five women had a clinically evident vaginal stenosis on examination. However, almost half of patients experienced a narrow vagina. The overall psychosexual aspects of life were affected in these patients with later sexual debut, fewer pregnancies and children, and an increased incidence of homosexuality. These quality of life factors were correlated to the severity of the mutations. CONCLUSIONS The overall quality of life in adult women with CAH is affected both by the type of mutation and operative procedure. Indications for clitoroplasty should be restrictive. Medical, surgical, and psychological treatment should be centralized.
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Affiliation(s)
- Agneta Nordenskjöld
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.
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