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Objective: To reinterpret the surgical anatomy of paracolpium in radical hysterectomy and to explore its implications for the surgery., Setting: The term "paracolpium" first defined by Fothergill in 1907, is essential in radical hysterectomy. However, several challenges remain unresolved. These include: (1) inconsistent terminology in relation to its defined attributes; (2) the lack of consensus on anatomical landmarks; (3) unclear associations with the cardinal and sacral ligaments; and (4) the critical implications and requirements of paracolpium resection in radical hysterectomy practices., Participants: A patient in her 60s diagnosed with stage IB2 cervical cancer was enrolled in a clinical trial and assigned to the laparoscopic surgery group. A step-by-step, narrated video demonstration., Interventions: During the procedure, post-excision of the uterosacral, cardinal, and vesicovaginal ligaments, we identified a ligament-like structure situated between the middle third of the vagina and the pelvic wall. We have termed this structure the "paracolpium ligament." A detailed anatomical description was performed, outlining its crucial attachments: • Medial attachment: middle third of the vagina • Lateral attachment: tendinous arch of the pelvic fascia (TAPF) • Cranial attachment: cardinal-uterosacral ligaments confluence • Caudal attachment: pubococcygeus muscle fascia • Dorsal: paravaginal space • Ventral: pararectal space To ensure a safe dissection, the paracolpium ligament was exposed by removing anterior and posterior fat tissue. The extent of surgical resection was adapted based on the tumor's location. Extensive resection of the paracolpium ligament was essential when the tumor was localized to one side of the vagina to ensure complete removal of the disease; otherwise, preservation of the ligament was considered feasible., Conclusion: In this video, we meticulously name and define the "paracolpium ligament," providing groundbreaking insights into its anatomical and surgical implications in radical hysterectomy. Our findings contribute to a better understanding of surgical anatomy for cervical cancer., (Copyright © 2024 AAGL. Published by Elsevier Inc. All rights reserved.)

The Arabian oryx (Oryx leucoryx) is an antelope that is considered a "vulnerable" species. Lack of knowledge on the structure of its reproductive organs hinders the development of strategies to improve its reproduction. There is only one report on the gross anatomy of the female reproductive organs. With the aim of describing their microanatomy, the ovaries, uterine tubes, uterus, and vagina were collected at necropsy of an adult female oryx. Samples from each organ were analyzed with H&E staining and light microscopy. The squamous to cuboidal germinal epithelium covers the dense tunica albuginea of the ovaries, which encloses the cortex. This merges smoothly with the medulla. The cortex embeds follicles at several stages of development. A rich bed of blood vessels is present in the medulla, especially at the hilum. The uterine tubes are comprised of a serosa, muscularis, and mucosa. The muscularis is constituted of circular smooth muscle covered by a thin layer of longitudinal fibers. The mucosa has longitudinal folds lined by a pseudostratified epithelium with ciliated cells. The uterine horns are constituted of a serosa, muscularis, and mucosa. The muscularis contains an inner circular layer of smooth muscle and an outer longitudinal one. Simple coiled glands are present at the base of the mucosa. From this, highly cellular projections (caruncles) are present, lined by a by a simple columnar epithelium. The cervix contains four dense rings, and its mucosa is lined by longitudinal folds of a simple columnar epithelium, with ciliated cells. Numerous glands are located in the lamina propria and contain simple cuboidal to columnar epithelium. The vaginal wall was made of a serosa, muscularis, and mucosa. The mucosa is made of stratified squamous epithelium non-keratinized. In summary, the histology of the internal reproductive organs of the oryx is like the one of other ruminants., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Rodriguez-Sosa et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Introduction and Hypothesis: Vaginal dimensions have clinical and surgical implications. We sought to quantify the differences between vaginal and labial dimensions in healthy ethnic Chinese and Western women with normal pelvic organ support., Methods: This is a cross-sectional study of a convenience sample of ethnic Chinese nulliparas (n = 33) and Western nulliparas (n = 33) recruited for research purposes. For each subject, magnetic resonance imaging was used to quantify the vaginal and labial dimensions. Specifically, we identified the anterior and posterior vaginal wall, the outline of the cervix in the mid-sagittal and coronal planes, and the distance from the labia majora to the hymenal ring at the urethral meatus., Results: There were significant differences in age and weight between groups. Substantial variation in vaginal and labial dimensions was found within each group. The vaginal and labial dimensions of ethnic Chinese women ranged from 9-21% smaller than those of Western women; In the ethnic Chinese group, increasing weight and BMI correlated with greater labial distance (r = 0.66 and r = 0.63 respectively); as did height and the distance from the vaginal opening to the cervical os (r = 0.5). In the Western group, only weight correlated with the labial distance (r = 0.51)., Conclusions: Significant group differences in vaginal and labial dimensions were found, with the dimensions of Chinese nulliparas being up to 21% smaller than those of Western nulliparas., (© 2024. The International Urogynecological Association.)

Background: Pregnancy and labor can impact women's body contours. After a cesarean section, some women may experience aesthetic issues such as the formation of a panniculus and a bulging mons pubis. This study aimed to investigate the impact of cesarean sections on the dimensions of the mons pubis and their ratios., Methods: The study included 194 multiparous Caucasian women. Participants' ages ranged from 18 to 40 years, and their BMI ranged from 18 to 30. They were divided into two BMI groups. Each group was further subdivided based on the mode of delivery into vaginal delivery (VD) and cesarean section (CS) groups. Manual measurements of the three dimensions of the mons pubis (monal height, monal width, and monal length) were conducted. Measurements were recorded in centimeters in the lithotomy position using iGaging 8-inch digital outside calipers. Monal height is the distance between the anterior surface of the symphysis pubis and the maximum height of the mons pubis (calculated by measuring the distance between the anterior wall of the vagina and the maximum height of the mons pubis minus the distance between the anterior wall of the vagina and the anterior surface of the symphysis pubis). Monal width is the maximum transverse distance between the merging borders of the mons pubis and the fat of the lower abdominal wall. Monal length is the maximum longitudinal distance between the merging upper border of the mons pubis and the fat of the lower abdominal wall and the upper end of the pudendal cleft., Results: No significant statistical difference was observed between the three dimensions of the mons pubis in vaginal delivery and cesarean section populations in the two groups. The changes in the ratios between the two groups' different monal dimensions in the cesarean section population are minimal and do not follow a consistent pattern. There were no significant differences between the dimensions of single and repeated CS populations, with non-trendy changes in the different ratios in the repeated CS group., Conclusion: Even when repeated, cesarean section minimally affects the dimensions and ratios of the mons pubis. However, more studies with standardized fascial and subcutaneous fat closure are needed., (© 2024. The Author(s).)

The perineum is a layered soft tissue structure with mechanical properties that maintain the integrity of the pelvic floor. During childbirth, the perineum undergoes significant deformation that often results in tears of various degrees of severity. To better understand the mechanisms underlying perineal tears, it is crucial to consider the mechanical properties of the different tissues that make up the perineum. Unfortunately, there is a lack of data on the mechanical properties of the perineum in the literature. The objective of this study is to partly fill these gaps. Hence sow perineums were dissected and the five perineal tissues involved in tears were characterized by uniaxial tension tests: Skin, Vagina, External Anal Sphincter, Internal Anal Sphincter and Anal Mucosa. From our knowledge, this study is the first to investigate all these tissues and to design a testing protocol to characterize their material properties. Six material models were used to fit the experimental data and the correlation between experimental and predicted data was evaluated for comparison. As a result, even if the tissues are of different nature, the best correlation was obtained with the Yeoh and Martins material models for all tissues. Moreover, these preliminary results show the difference in stiffness between the tissues which indicates that they might have different roles in the structure. These obtained results will serve as a basis to design an improved experimental protocol for a more robust structural model of the porcine perineum that can be used for the human perineum to predict perineal tears., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

An understanding of ranges in clitoral anatomy is important for clinicians caring for patients including those who have had female genital mutilation, women seeking genital cosmetic surgery, or trans women seeking reconstructive surgery. The aim of this meta-analysis is to investigate the ranges in clitoral measurements within the literature. A meta-analysis was performed on Ovid Medline and Embase databases following the PRISMA protocol. Measurements of clitoral structures from magnetic imaging resonance, ultrasound, cadaveric, and living women were extracted and analyzed. Twenty-one studies met the inclusion criteria. The range in addition to the average length and width of the glans (6.40 mm; 5.14 mm), body (25.46 mm; 9.00 mm), crura (52.41 mm; 8.71 mm), bulb (52.00 mm; 10.33 mm), and prepuce (23.19 mm) was calculated. Furthermore, the range and average distance from the clitoris to the external urethral meatus (22.27 mm), vagina (43.14 mm), and anus (76.30 mm) was documented. All erectile and non-erectile structures of the clitoris present with substantial range. It is imperative to expand the literature on clitoral measurements and disseminate the new results to healthcare professionals and the public to reduce the sense of inadequacy and the chances of iatrogenic damage during surgery., (© 2023 The Authors. Clinical Anatomy published by Wiley Periodicals LLC on behalf of American Association of Clinical Anatomists and British Association of Clinical Anatomists.)

This article analyses the conceptual histories of words associated with female genital parts to explore how they may affect the lived experience of people with these parts and the quality of gynaecological care they receive. Specifically, we examine the implications of using the word 'vagina' to replace the word 'vulva', or indeed to indicate the entire female genitalia. This article does so through an analysis of existing scholarly work and through text mining methods such as word frequencies, most distinctive word collocates and word-embeddings drawn from literary and women's magazine corpora. We find that words indicating specific female genital parts are very infrequently mentioned in our corpora, which shows that there is a troubling lack of exposure and education in our socio-cultural context when it comes to the female genital anatomy. When they are mentioned, their usage reflects historical and patriarchal associations that have been primarily attached to the word 'vagina'. When it comes to the 'vagina' and 'vulva', the penis is the most prevalent association by far; whereas the most commonly occurring female genital parts are parts to do with reproduction-reinforcing a long-standing and disproportionate emphasis on the female genitalia's reproductive function. Our research also reveals a concerning emphasis on non-evidence-based female hygiene products, thus perpetuating the damaging stereotype of the dirty vagina. These findings may explain many negative patient outcomes such as stigma attached to seeking out timely gynaecological care, lack of informed medical consent and non-evidence-based practices exacerbated by problematic cultural depictions of the female genitalia. They can also explain the neglect of female sexual agency, pleasure and well-being. Understanding historical and contemporary usages of words for the female genitalia has important implications for the quality of patient care today and is a critical component of gender and reproductive justice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction and Hypothesis: Retropubic procedures may disrupt nerves supplying the pelvic viscera; however, knowledge of pelvic neuroanatomy is limited. We sought to characterize somatic and autonomic nerve density within the urethra, periurethral tissue, and anterior vagina., Methods: Axial sections were obtained from pelvic tissue harvested from female cadavers ≤24 h from death at three anatomical levels: the midurethra, proximal urethra, and upper trigone. Periurethral/perivesical tissue was divided into medial and lateral sections, and the anterior vagina into middle, medial, and lateral sections. Double immunofluorescent staining for beta III tubulin (βIIIT), a global axonal marker, and myelin basic protein (MBP), a myelinated nerve marker, was performed. Threshold-based automatic image segmentation distinguished stained areas. Autonomic and somatic density were calculated as percentage of tissue stained with βIIIT alone, and with βIIIT and MBP respectively. Statistical comparisons were made using nonparametric Friedman tests., Results: Six cadavers, aged 22-73, were examined. Overall, autonomic nerve density was highest at the midurethral level in the lateral and middle anterior vagina. Somatic density was highest in the external urethral sphincter (midurethra mean 0.15%, SD ±0.11; proximal urethra 0.19%, SD ±0.19). Comparison of annotated sections revealed significant differences in autonomic density among the lateral, medial, and middle vagina at the midurethra level (0.71%, SD ±0.48 vs 0.60%, SD ±0.48 vs 0.70%, SD ±0.63, p=0.03). Autonomic density was greater than somatic density in all sections., Conclusions: Autonomic and somatic nerves are diffusely distributed throughout the periurethral tissue and anterior vagina, with few significant differences in nerve density among sections analyzed. Minimizing tissue disruption near urethral skeletal muscle critical for urinary continence may prevent adverse postoperative urinary symptoms., (© 2023. The International Urogynecological Association.)

Introduction: Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining., Objectives: The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV., Methods: We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum., Results: We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented., Conclusions: None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge., (© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To explore 3D morphological changes of the bladder, urethra, and vagina following different numbers of vaginal deliveries., Methods: Sampled patients had undergone magnetic resonance imaging for gynecological diseases in Nanfang Hospital. A total of 167 patients who met the study inclusion and exclusion criteria were enrolled and divided into four groups. Mimics and UG software packages were used for reconstructions and measurements, and data were compared with one-way analyses of variance., Results: A total of 167 3D models were constructed, and eight parameters related to the bladder and urethra were measured (5 angles, 2 lengths, and 1 thickness). No statistically significant differences were found between subgroups, although mean plot figures of urethra pubic and α angles showed trends to increase with more deliveries, and the opposite trend was seen for the urethra tilt angle. There were no obvious trends between other parameters and delivery number. There were seven vaginal parameters (6 lengths and 1 shape). Mid-urethral and vaginal gap measurements tended to become wider as delivery number increased, and the opposite was seen for the distal gap. Mid-vaginal 2D cross-sectional shape and the proportion of shallow concave types also tended to significantly increase with more deliveries, especially after the third birth., Conclusion: As the number of deliveries through the vagina increases, the lateral support function of this organ and the urethra become relatively weaker. These fine anatomical changes are related to delivery numbers and become most obvious after the third birth., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

O'Connell et al. proposed that the vestibular bulbs be renamed the "clitoral bulbs" because of their consistent relationship to the clitoris and inconsistent relationship to the vestibule. Normally such proposed esoteric changes in anatomical nomenclature would get little notice by anatomists, yet alone the general public; however, many subsequent articles and books placed this change in the context of centuries of male anatomists and physicians downplaying female sexual anatomy and sexuality. Most prominent is a 2022 book by Rachel Gross, Vagina Obscura: An Anatomical Voyage. Here we review this "Anatomical Voyage" and find author bias in omitting/including erroneous facts in this book. We also present a critique of a 1995 article that appeared in Feminist Studies; Graphical Representations in Anatomy Texts, c1900-1991. This article, which has been repeatedly cited in the clinical literature, asserts that between circa 1950-1980 anatomy textbooks purposely eliminated depicting/labeling the clitoris in illustrations because the authors of the textbooks were reflecting societal norms that de-emphasized the importance of the clitoris. Unfortunately, the methods used by Moore and Clarke are not replicable; and further, their conclusions were not justified because of clear bias in their description and depiction of the anatomy sources they review., (© 2022 American Association of Clinical Anatomists and British Association of Clinical Anatomists.)

What exactly is a vulva? The question remains unresolved. Some sources consider the clitoris, labia, mons pubis, perineum, or vagina to be components of the vulva, while other sources do not. Indeed, disagreement exists among international anatomical and clinical societies with regard to what precise structures form the human vulva. The obfuscation regarding the anatomy of the vulva and, likewise, inconsistencies in vulva-related anatomical terminology have adversely affected communication, research, and healthcare. Therefore, this review was undertaken to provide a comprehensive and critical analysis regarding the past, present, and potential future of vulvar anatomy and vulva-related anatomical terminology. The review reveals that confusion regarding the specific gross anatomical structures that form the vulva has persisted for thousands of years. The review provides novel information regarding the etymology of vulva, contributes important historical context regarding vulva, and gives details regarding related anatomical terminology including clitoris, hymen, labia majora, labia minora, mons pubis, pudendum, pudendum femininum/muliebre, uterus, vagina, et cetera. The review highlights disagreement regarding what specific structures comprise a vulva, identifies sexual bias in anatomical terminology and among noteworthy anatomical resources, and offers novel perspectives regarding anatomical terminology-especially anatomical terminology that relates to the external genitalia. What specific anatomical structures comprise the vulva? This review provides a comprehensive and critical analysis regarding the past, present, and potential future of vulvar anatomy and vulva-related anatomical terminology., (© 2022. The Author(s), under exclusive licence to Japanese Association of Anatomists.)

Aim: The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus, the lowest level of the vagina, has not been subject to a recent comprehensive examination and description. Vaginal introital surgery (perineorrhaphy) should be a key part of surgery for a majority of pelvic organ prolapse., Methods: Cadaver studies were performed on the anterior and posterior vestibules and the perineum. Histological studies were performed on the excised perineal specimens of a cohort of 50 women undergoing perineorrhaphy. Included are pre- and postoperative studies which were performed on 50 women to determine the anatomical and histological changes achieved with a simple (anterior) perineorrhaphy., Results: The vaginal introitus is equivalent to the Level III section of the vagina, measured posteriorly from the clitoris to the anterior perineum then down the perineum to the anal verge. The anterior and posterior vestibules, with nonkeratinizing epithelium, extend laterally to the keratinized epithelium of the labia minora (Hart's line). The anterior vestibule has six anatomical layers while the posterior vestibule has three. The perineum has an inverse trapezoid shape. Perineorrhaphy specimens were a mean 2.9 cm wide and 1.6 cm deep. They show squamous epithelium with loose underlying connective tissue. There were no important structures seen histologically, for example, ligaments or muscles. Microscopically, only 6 (12%) were completely normal with 44 (88%) showing minor changes including inflammation and scarring. Considerable anatomical benefits were achieved with such a perineorrhaphy including a 27.6% increase in the perineal length and a 30.8% reduction in the genital hiatus., Conclusion: An understanding of the anatomy and histology of the vaginal introitus can assist with performing a simple and effective perineorrhaphy, the main surgical intervention at the vaginal introitus., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Aim: Vaginal vault (VV) surgery should be a key part of surgery for a majority of pelvic organ prolapse (POP). The surgical anatomy of the VV, the upper most part of the vagina, has not been recently subject to a dedicated examination and description., Methods: Cadaver studies were performed in (i) 10 unembalmed cadaveric pelves (observation); (ii) 2 unembalmed cadaveric pelves (dissection); (iii) 5 formalinized hemipelves (dissection). The structural outline and ligamentous supports of the VV were determined. Further confirmation of observations in post-hysterectomy patients were from a separate study on 300 consecutive POP repairs, 46% of whom had undergone prior hysterectomy., Results: The VV is equivalent to the Level I section of the vagina, measured posteriorly from the top of the posterior vaginal wall (apex or highest part of the vagina) to 2.5 cm below this point. It comprises the anterior fornix (through which cervix protrudes or is removed at hysterectomy), posterior fornix and two lateral fornices. Before hysterectomy, the posterior aspects of the cervix and upper vagina are supported by the uterosacral (USL) and cardinal ligaments (CL), the distal segments of which fuse together to form a cardinal-uterosacral ligament complex (cardinal utero-sacral complex), around 2-3 cm long. Post---hysterectomy, there is some residual USL support to the anterior fornix but the posterior fornix has no ligamentous support and is thus more vulnerable to prolapse., Conclusion: Effective management of VV prolapse will need to be part of most POP repairs. Enhanced understanding of the surgical anatomy of the vaginal vault allows more effective planning of those POP surgeries., (© 2022 The Authors. Neurourology and Urodynamics published by Wiley Periodicals LLC.)

Aim: To study the pathogenetic factors in the development of postcoital cystitis and the efficiency of extravaginal transposition of the urethra., Materials and Methods: Literature data and our point of view on the causes of postcoital cystitis are described. Case histories of 438 patients aged 18 to 61 (mean 24+/-1.3) were analyzed. The efficiency of extravaginal transposition of the urethra for the prevention of recurrence of postcoital cystitis was evaluated., Results: The long-term results of operations in 315 patients were studied. A positive effect was noted in 297 (94.3%), which means the complete recovery or reduction in the frequency of cystitis to 2 or less times a year, while complete recovery occurred in 214 patients. In 18 (5.7%), the surgical procedure was ineffective, which required repeated interventions., Discussion: According to our observations, the external opening of the urethra is located in patients with postcoital cystitis and in healthy women at the same level - before the introitus. During sexual intercourse, everyone experiences vestibulo-vaginal frictional dislocation of the urethra, however, exacerbations of the inflammatory process in the bladder occur only in some females, which is associated with the multifactorial nature of the disease., Conclusion: Postcoital cystitis develops as a result of a complex of factors, the most significant ofwhich are the state of the vaginal microflora, the virulence of uropathogenic bacteria, the anatomical features of the urethra and vagina, its narrowness with a mismatch with the penile size, the intensity and duration of sexual intercourse, severe, complicated childbirth and surgical procedures in this area. Performing extravaginal transposition of the urethra according to Komyakov demonstrated high efficiency in the prevention of recurrence of postcoital cystitis.

Objective: To determine the prevalence of patients who require vaginal cavity remnant excision and obliteration during neourethral stricture repair and to characterize the histological composition of the excised tissue., Methods: A retrospective review was performed of all transgender men who underwent neourethral stricture repair. Preoperative imaging and operative reports were reviewed to determine the presence of a vaginal cavity remnant that was excised and obliterated during neourethral reconstruction. Pathology slides were reviewed by 2 pathologists to determine if there was presence of stratified squamous epithelium consistent with vaginal tissue within the vaginal cavity remnant., Results: A total of 47 consecutive transgender men underwent neourethral stricture repair between January 2014 and December 2020. Of these, 18 patients (38%) with a mean age of 37 years (23-59) underwent excision and obliteration of a vaginal cavity remnant. Seventy eight percent (14/18) had a prior phalloplasty and 22% (4/18) had a prior metoidioplasty. Primary vaginectomy type was not associated with whether or not a patient had a vaginal cavity remnant (P = .12). Histological evaluation demonstrated the presence of vaginal epithelium in all vaginal cavity remnant specimens., Conclusion: A high percentage of transgender men with neourethral strictures present with vaginal cavity remnants despite prior vaginectomy. Pathological evaluation confirms that all vaginal cavity remnant specimens contain vaginal epithelium that was either incompletely excised or regenerated. While the implications of this residual vaginal epithelium require further investigation, total removal of vaginal tissue primarily or during reconstruction is important given the risk of associated symptoms., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Copulatory behavior and genital morphology interact to deliver sperm more effectively during mating, but the nature of this interaction has not been explored in depth in most vertebrates. Alpacas have unusually long copulations lasting 15-20 min, and a unique copulatory behavior, where the penis intromits all the way past the cervix, into the uterine horns. Here we describe the morphology of male and female genitalia and report unique morphological characteristics that may be associated with this unusual insemination mode. Vaginal shape is highly variable, and seemingly not associated with age or parity. The cranial vagina varies between bulbous and cylindrical, while the caudal vagina is typically narrower and always cylindrical. The cervix consists of a series of two to three spirals or rings, and it is often found in a relaxed state that may prevent damage caused by the cartilaginous penis tip as it pushes through the cervix to reach the uterine horns. The uterus and uterine horns have a complex shape with multiple constrictions. The cartilaginous penis tip has a sharp urethral process that may help to push against these constrictions. The diameter of the vaginal lumen is much greater than the diameter of the penis suggesting that there is little direct interaction between them, and that female vaginal shape is not under strong copulatory selection. In effect, the entire female reproductive tract of the female is interacting with the penis during copulation., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Integrative and Comparative Biology.)

Abstract: This study aimed to know the distance of the cervicovaginal junction (CVJ) to the anterior peritoneal reflection (APR) as measured in surgical specimens, and assess the distance between the CVJ and APR to ensure safe anterior colpotomy for vaginal hysterectomy among Korean women.Patients who underwent vaginal hysterectomy were included in the analysis. According to the presence of pelvic organ prolapse or menopausal status, the distance from the CVJ to the APR was assessed preoperatively through transvaginal ultrasonography (TV-US), as well as intraoperatively using surgical specimens. The intraclass correlation coefficient was used to determine the reliability between 2 measurements.In total, 171 patients were included. The median distance from the CVJ to the APR measured on TV-US was 19.8 (3.3-41.3) mm. Meanwhile, the median distance from the CVJ to the APR measured using the surgical specimen was 26.0 (12.0-55.0) mm. The intraclass correlation coefficient for the absolute agreement between 2 measurements was 0.353 (95% confidence interval: 0.002-0.570; P < .001), which is indicative of poor reliability. The median distance from the CVJ to the APR measured using the surgical specimen did not differ significantly between the 2 groups according to pelvic organ prolapse (26.0 [12.0-55.0] vs 27.5 [17.0-55.0] mm, P = .076] and menopausal status (27.0 [15.0-55.0] vs 26.0 [12.0-55.0] mm, P = .237).TV-US does not an accurately measure the dissection plane length from the CVJ to the APR during anterior colpotomy. During vaginal hysterectomy, the median distance from the CVJ to the APR measured using the surgical specimen was 26 (12.0-55.0) mm, which can help decrease surgical complications., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise., Objective: Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to "Terminologia Anatomica," the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding., Study Design: From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review., Results: Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. "Terminologia Anatomica" has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication., Conclusion: This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines., (Copyright © 2021. Published by Elsevier Inc.)

Regional variation in pelvic morphology and childbirth has long occurred alongside traditional labour support and an understanding of possible normal courses of childbirth for each population. The process of migration and globalization has broken down these links, while a European model of 'normal' labour has become widespread. The description of 'normal' childbirth provided within obstetrics and midwifery textbooks, in fact, is modelled on a specific pelvic morphology that is common in European women. There is mounting evidence, however, that this model is not representative of women's diversity, especially for women of non-white ethnicities. The human birth canal is very variable in shape, both within and among human populations, and differences in pelvic shapes have been associated with differences in the mechanism of labour. Normalizing a white-centred model of female anatomy and of childbirth can disadvantage women of non-European ancestry. Because they are less likely to fit within this model, pelvic shape and labour pattern in non-white women are more likely to be considered 'abnormal', potentially leading to increased rates of labour intervention. To ensure that maternal care is inclusive and as safe as possible for all women, obstetric and midwifery training need to incorporate women's diversity. This article is part of the theme issue 'Multidisciplinary perspectives on social support and maternal-child health'.

Objective: This study aimed to determine if genital hiatus (GH) size is a predictor of worsening pelvic organ prolapse and a preference for a therapeutic intervention in women with pelvic organ prolapse who opt for expectant management over therapeutic intervention at their initial encounter., Methods: This was a retrospective cohort study analyzing the GH size of women who opted for expectant management in the initial treatment of pelvic organ prolapse at one academic institution from 2002 to 2015. Participants were divided into 2 groups: (1) large GH was defined as ≥4 cm and (2) normal GH was defined as <4 cm. The primary outcome was women opting for therapeutic intervention for their prolapse at a later visit, defined as pessary insertion or surgical intervention. Secondary measures evaluated GH as a predictor of worsening anatomy or symptoms., Results: One hundred eleven participants were enrolled. Fifty-two women had a large GH, and 59 women had a normal GH. Median length of follow-up was 24 months (range, 6-110 months). Of the 52 with a large GH, 22 (42%) opted for intervention; of the 59 women with a normal GH, 16 (27%) opted for intervention. There was no statistically significant difference between groups in the number who eventually chose intervention (P = 0.09). There was no difference in secondary outcomes between groups with respect to worsening bother, worsening pelvic organ prolapse quantification stage, or an increase in the prolapse leading edge of ≥2 cm., Conclusions: Women with a large GH, when compared with those with a normal GH, were not more likely to choose intervention over continued observation., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2021 American Urogynecologic Society. All rights reserved.)

While developments in gynecologic health research continue advancing, relatively few groups specifically focus on vaginal tissue research for areas like wound healing, device development, and/or drug toxicity. Currently, there is no standardized animal or tissue model that mimics the full complexity of the human vagina. Certain practical factors such as appropriate size and anatomy, costs, and tissue environment vary across species and moreover fail to emulate all aspects of the human vagina. Thus, investigators are tasked with compromising specific properties of the vaginal environment as it relates to human physiology to suit their particular scientific question. Our review aims to facilitate the appropriate selection of a model aptly addressing a particular study by discussing pertinent vaginal characteristics of conventional animal and tissue models. In this review, we first cover common laboratory animals studied in vaginal research-mouse, rat, rabbit, minipig, and sheep-as well as human, with respect to the estrus cycle and related hormones, basic reproductive anatomy, the composition of vaginal layers, developmental epithelial origin, and microflora. In light of these relevant comparative metrics, we discuss potential selection criteria for choosing an appropriate animal vaginal model. Finally, we allude to the exciting prospects of increasing biomimicry for in vitro applications to provide a framework for investigators to model, interpret, and predict human vaginal health.

Background: Below the anterior peritoneal reflection, the anterior rectal wall and mesorectum are separated from the posterior vaginal wall by a virtual rectovaginal space. In this space, the description of a specific and independent rectovaginal septum as a female counterpart of Denonvilliers fascia has been the subject of debate over the years., Objective: The aim of this study is to perform an accurate anatomical study of the rectovaginal area in a cadaveric simulation model of total mesorectal excision to evaluate the possible structures and the dissection planes contained within the rectovaginal space., Design and Setting: This is a cadaveric study performed at the University of Valencia., Patients: The pelvises of 25 formalin-preserved female cadavers were dissected. All the included specimens were sectioned in a midsagittal plane, at the level of the middle axis of the anal canal., Main Outcome Measures: Careful and detailed dissection was performed to visualize the anatomical structures and potential dissection planes during anterior mesorectal dissection in cadavers. Histological sections were made of the posterior vaginal wall., Results: The rectovaginal space contains loose areolar tissue that allows an easy dissection plane distally. A distinct and independent rectovaginal fascia or septum is not present. The existence of 3 layers fused together in the posterior vaginal wall can be identified more or less precisely because of their different coloration. The histological study confirms this macroscopic arrangement of the posterior vaginal wall in 3 layers: the mucosa, the muscular, and the adventitia. An independent rectovaginal septum can be generated only with a splitting of the adventitia., Limitations: The cadaveric pelvic specimens of the oldest donors might have had age-related degeneration., Conclusions: The present anatomical study has shown only a plane of loose areolar tissue between the rectal and vaginal wall. We can conclude that there is no independent fascia or septum in the rectovaginal space. See Video Abstract at http://links.lww.com/DCR/B456. ANATOMÍA QUIRÚRGICA DEL ESPACIO RECTOVAGINAL: ¿EXISTE UN TABIQUE RECTOVAGINAL INDEPENDIENTE O UNA FASCIA DE DENONVILLIERS EN LAS MUJERES: Debajo del reflejo peritoneal anterior, la pared rectal anterior y el mesorrecto están separados de la pared vaginal posterior por un espacio rectovaginal virtual. En este espacio, la descripción de un tabique rectovaginal independiente específico como contraparte femenina de la fascia de Denonvilliers ha sido objeto de debate a lo largo de los años.Realizar un estudio anatómico preciso del área rectovaginal en un modelo de simulación cadavérica de escisión mesorrectal total, con el fin de evaluar las posibles estructuras y los planos de disección contenidos en el espacio rectovaginal.estudio cadavérico realizado en la Universidad de Valencia.Se disecaron las pelvis de 25 cadáveres femeninos conservados en formalina. Todas las muestras incluidas fueron seccionadas en un plano medio sagital, a la altura del eje medio del canal anal.Se llevó a cabo una disección cuidadosa y detallada para visualizar las estructuras anatómicas y los posibles planos de disección durante la disección mesorrectal anterior en cadáveres. Se realizaron cortes histológicos de la pared vaginal posterior.El espacio rectovaginal contiene tejido areolar laxo que permite un plano de disección fácil distalmente. No hay fascia o tabique rectovaginal distinto e independiente. La existencia de tres capas fusionadas en la pared vaginal posterior puede identificarse con mayor o menor precisión debido a su diferente coloración. El estudio histológico confirma esta disposición macroscópica de la pared vaginal posterior en tres capas: la mucosa, la muscular y la adventicia. Un tabique rectovaginal independiente solo se puede generar con una división de la adventicia.Las muestras pélvicas de cadáveres de los donantes más antiguos pueden haber tenido degeneración relacionada con la edad.El estudio anatómico actual solo ha mostrado un plano de tejido areolar laxo entre la pared rectal y vaginal. Podemos concluir que no hay fascia o tabique independiente en el espacio rectovaginal. Consulte Video Resumen en http://links.lww.com/DCR/B456. (Traducción-Dr. Adrian Ortega).

Objective: To demonstrate techniques for successful donor-to-recipient vaginal anastomosis in uterine transplantation including illustration of a tension-free technique., Design: This video uses live-action footage from surgery, detailed animations, and illustrations to review the step-by-step technique we use for vaginal anastomosis in uterine transplantation. Institutional Review Board approval was obtained for this experimental surgery., Setting: Academic medical center., Patient(s): Patients undergoing uterine transplantation., Intervention(s): Preparation of recipient vagina with illustration of challenges and risk secondary to dense adhesions between bladder and neo-vagina. Use of surgical techniques. Key steps include appropriate preparation of both donor and recipient vaginal tissues and a tension-free closure with horizontal mattress stitches., Main Outcome Measure(s): Intraoperative techniques in the clinical research trial of uterine transplantation., Results: Successful vaginal anastomosis in the uterine transplantation patient., Conclusion(s): This video provides a step-by-step guide to vaginal anastomosis in uterine transplantation patients. Our team has applied techniques from vaginal reconstructive surgery in an attempt to reduce the occurrence of postoperative vaginal strictures, with attention to planned donor and recipient anastomosis site tissue preparation and closure of the anastomosis using a tension-free suturing technique., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: In cross-sectional studies, pelvic organ prolapse is strongly associated with genital hiatus (GH) size. The objective of this study was to estimate prolapse incidence by the size of the GH among parous women followed prospectively., Methods: Data were derived from a longitudinal study of pelvic floor disorders. Participants were followed annually for 2-9 years. Genital hiatus size and prolapse beyond the hymen were assessed with annual pelvic organ prolapse quantification examinations. Kaplan-Meier methods described prolapse-free survival as a function of GH size. Accounting for changes over time in GH size, lognormal models were used to estimate prolapse-free survival by GH size. This analysis was repeated separately for women who gave birth exclusively by cesarean versus those with at least one vaginal birth., Results: Among 1,492 participants, median age at enrollment was 38 years; 153 (10.3%) developed prolapse over 2-9 years. The cumulative probability of prolapse increased substantially as the size of the GH increased. Lognormal models predicted that the estimated median time to develop prolapse would be 33.4 years for women with a persistent GH of 3 cm; in contrast, the estimated median time to develop prolapse would be 5.8 years for a GH of 4.5 cm or greater. Considering separately women who gave birth by cesarean versus those with at least 1 vaginal birth, GH size drastically modified prolapse risk in both birth groups., Conclusions: Prolapse incidence is strongly associated with GH size, regardless of delivery mode. These findings suggest that a wider GH is an important predictor of future prolapse risk., Competing Interests: The author has declared that there are no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

Objective: This study aimed to assess anatomy relative to sacral sutures 20 to 24 months after robotic sacrocolpopexy., Methods: This was an institutional review board-approved prospective anatomy study of women undergoing robotic sacrocolpopexy. After placement of suture into the anterior longitudinal ligament, a small vascular clip was secured on the base of the suture. Subjects were imaged at 6 weeks and between 20 and 24 months after surgery. Measurements were calculated by the primary investigator and radiologist coinvestigator., Results: Of the 11 subjects enrolled in the initial 6-week postoperative study, 5 (45%) completed the long-term follow-up. Regarding the vascular anatomy, no significant changes were documented. Similarly, the major urologic structure, the right ureter, was stable at 16 mm from the clip. A significant change was noted, however, in the distance from the apex of the vagina to the sacral suture. At 6 weeks postoperatively, the mean (SD) distance from the vaginal apex to the clip was 69.3 (14) mm; this increased to 85.2 (11.3) mm at the long-term follow-up (P = 0.004)., Conclusions: Reassuringly, the position of the clip remained stable, which is reflected in the constancy of the measurements to the vascular landmarks. Nevertheless, alteration in the distance to the vaginal apex suggests elongation of the mesh or vaginal tissue with time. Although the increase in length was greater than 1.5 cm, it may bear clinical relevance in certain patients. This information may help guide surgeons regarding appropriate mesh tensioning during this critical step of the procedure., Competing Interests: The authors have declared that there are no conflicts of interest., (Copyright © 2019 American Urogynecologic Society. All rights reserved.)

Female urinary incontinence mainly relates to damage of female urethra supporting structures, while its anatomy and function specially in which the connective tissue part are still unclear and controversial. We study it based on 4 thin-sectional, high-resolution, transverse sectional anatomical images [Chinese Visible Human (CVH) images] and 10 high-resolution MRI images from volunteers. The female urethral supporting structures and its adjacent structures were segmented and three-dimensional (3D) reconstructed with Amira software. The urethral supporting structures include muscular and connective tissue supporting structures. Muscular supporting structures are composed of levator ani muslce and striated urethral sphincter, the connective tissue supporting structures are composed of anterior vaginal wall, pubovesical muscle, pubovesical ligament, lateral vesical ligament, and tendinous arch of pelvic fascia (TAPF). The anterior vaginal wall includes tight and loose connections between urethral, bladder, and vagina. The lateral vesical ligament connects the proximal part of the urethra to the TAPF. The pubovesical muscle is crescent shaped and continues with the detrusor of the bladder superior and directly connects the TAPF laterally. The TAPF is an obvious fibrous structure that originates at the middle-posterior surface of the pubis, travels onto the parietal pelvic fascia, and inserts posteriorly onto the ischial spine. The anterior vaginal wall, the pubovesical muscle, the lateral vesical ligament, and the TAPF create the "hammock" structure and supplement DeLancey's theory. Its support to the proximal urethra and neck of bladder is crucial to maintain stability and urinary continence during increased abdominal pressure.

Introduction: The aim of this work was to analyze the transvaginal approach in minimally invasive surgery in terms of anatomical, histopathological and functional characteristics, to show the safety of this surgical approach., Methods: Anatomical study was first conducted by dissection on fresh cadavers of adult women in order to measure the distance between the vaginal incision and the ureters, rectum and hypogastric nerves. In parallel, an anatomopathological study detailed and compared the macroscopic and histological characteristics of the anterior and posterior surfaces of vaginal samples obtained from cadavers and patients in the context of a hysterectomy for benign pathology. Finally, patients who underwent a transvaginal approach nephrectomy or transplantation were retrospectively enrolled for a clinical examination and an evaluation of their sexuality., Results: The anatomical study conducted on seventeen cadavers showed that the posterior vaginal fornix was remote from the major structures of the pelvis such as rectum, ureters, hypogastric plexus, which allowed a safe incision. Mechanical tests further demonstrated that the posterior vaginal fornix was more extensible than the anterior and histological features showed no major vascular or nervous structures. Ten patients were included in the retrospective clinical study. Long-term follow up showed no negative impact on the texture of the vagina or satisfaction from sexual intercourse., Conclusions: Anatomical, histological and functional data supported that transvaginal approach by posterior vagina fornix incision is a minimally invasive surgery that can be performed safely and effectively by a skilled surgeon in cases with a specific surgical indication for this approach., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: The objective of this study was to measure the anatomical distance from the cervicovaginal junction to the uterovesical peritoneal reflection (CJ-PR)., Methods: A total of 120 hysterectomy patients were selected as study subjects. The uterus was removed, and the CJ-PR distance was immediately measured. For total vaginal hysterectomy, measurement was performed intraoperatively. The cervical length was also measured postoperatively., Results: The median (interquartile) CJ-PR distance for all subjects was 3.3 (2.9-3.7) cm. Comparison of premenopausal and postmenopausal women without prolapse revealed median CJ-PR distances of 3.3 (3.0-3.6) cm and 3.0 (2.6-3.4) cm, respectively. The CJ-PR distance was longer in women with prolapse (4.6 [3.7-5.6] cm) than in those without prolapse (3.2 [2.8-3.6] cm). The median cervical lengths were 3.1 (2.7-3.6) cm for postmenopausal patients without prolapse and 4.4 (3.6-5.8) cm for postmenopausal patients with prolapse., Conclusions: Knowledge of the CJ-PR distance may help gynecologists predict how far the uterovesical PR is from the anterior vaginal incision., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2020 American Urogynecologic Society. All rights reserved.)

The aim was to compare short-term results of transvaginal hybrid-NOTES (NSR) with traditional laparoscopic technique in sigmoid resection (LSR) in cases of diverticulitis. Natural Orifice Transluminal Endoscopic Surgery has been evolved as a minimally invasive procedure to reduce the operative trauma due to the absence of specimen extraction through the abdominal wall causing less postoperative pain, and shorter hospital stay. Despite the increasing use and published case series of NSR for diverticulitis as a laparoscopic procedure with transvaginal stapling and specimen extraction, there are no studies comparing this procedure with LSR. Twenty NSR patients operated at the Cologne-Merheim Medical Center have been documented and compared with 20 female LSR patients matched for body mass index, American Society of Anesthesiologists-classification (ASA), Hansen/Stock classification, and age. To ensure comparability regarding peri- and postoperative care, only procedures performed by the same surgeon were included. Procedural time, intra- and postoperative complications, conversion rate, postoperative pain, the duration of an epidural catheter, analgesic consumption, and postoperative length of hospital stay were analyzed. There were no significant differences in the sum of pain levels (p = 0.930), length of procedure (p = 0.079), intra- and postoperative complications, as well as duration of an epidural catheter. On the contrary, there were significant positive effects for NSR on morphine requirement at day seven and eight (p = 0.019 and p = 0.035 respectively) as well as the postoperative length of hospital stay (p = 0.031). This retrospective study reveals significant positive effects for NSR compared to LSR regarding length of hospital stay as well as morphine consumption after removal of the epidural catheter, whereas there were no significant differences in complication rate and procedural time. In summary, NSR is an adequate alternative to traditional laparoscopic sigmoid resection considering the surgeons experience and the patient's personal preferences.

Although knowledge about the reproduction of snakes of the genus Bothrops has increased recently, many questions remain regarding sperm storage by these neotropical pitvipers. The relationship between two known sperm storage sites-the nonglandular uterus and the infundibulum-has yet to be detailed for Bothrops. In addition, the formation of uterine muscular twisting (UMT) and its function in sperm storage in the nonglandular uterus have been questioned. This article presents data on both sperm storage sites (posterior infundibulum and nonglandular uterus) in the Amazonian lancehead, Bothrops atrox, aiming to address the role of UMT in bothropoid reproduction considering female reproductive stages, timing of sperm storage, and morphology and histochemistry of sperm receptacles. The oviduct of B. atrox is composed of the infundibulum (anterior and posterior), the glandular uterus, the nonglandular uterus and the pouch. Sperm storage occurs in the posterior infundibulum and nonglandular uterus in vitellogenic females. In the posterior infundibulum sperm is stored in receptacles, while in the nonglandular uterus it is stored in crypts in the UMT of vitellogenic females. Both sperm storage sites possess granules testing positive for neutral mucopolysaccharides in the presence of spermatozoa, possibly favoring the conditions for spermatozoa surveillance during sperm storage in the reproductive tract., (© 2019 American Association for Anatomy.)

Objectives: To examine the gross and histologic anatomy of the proximal, mid, and distal posterior vaginal compartment and discuss implications for surgical repair., Study Design: In this cadaver study, pelvic organs were resected en bloc, immersed in formalin solution, and transected in the mid sagittal plane. Measured distances included: posterior vaginal wall length, cervicovaginal junction or vaginal cuff to posterior peritoneal reflection, peritoneal reflection to proximal edge (apex) of perineal body, and perineal body apex to hymenal remnant (height). The posterior vaginal wall was divided into 3 segments along the midsagittal plane and submitted in whole tissue blocks for staining. Histologic analysis included that of 2 young nulliparous women whose tissue was harvested within 12 hours of death., Results: Eleven cadavers were examined. Median (interquartile range [IQR]) posterior vaginal length was 7.6 (2.2) cm. The peritoneum attached to the posterior vaginal wall a median (IQR) of 1.3 cm (0.5 cm) distal to the cervicovaginal junction (n = 8). The rectovaginal space, spanning from the peritoneal reflection to perineal body apex, had a median (IQR) length of 4.7 cm (2.1 cm). Microscopic examination of the mid segment revealed a layer of loose fibroadipose tissue between the vaginal/rectal walls, with no distinct dense fibroconnective tissue layer. The median (IQR) perineal body height was 2.3 cm (1.2 cm). No discrete fibrous capsule was seen surrounding the external anal sphincter muscle., Conclusions: These findings support evidence showing absence of a rectovaginal fascia. The anal sphincter lacks a fibrous capsule, which is important during closure of third-/fourth-degree obstetric lacerations., Competing Interests: The authors have declared they have no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

The conventional anatomical study of specimens requires cutting processes which destruct the limited specimens. A non-destructive method, namely an ultrasonography, can be used to assess the anatomical organ information of those specimens. The aim of this research is to analyse the macroanatomy of the female reproductive organ in the Sunda porcupine (Hystrix javanica), using ultrasonographical imaging. In this study, four formaldehyde-fixed reproductive organ specimens of the Sunda porcupine were used. A 10-12 MHz linear ultrasound transducer was utilized to provide an imaging format of both longitudinal and transversal views. Photographic images were then used as comparison with a sonographic image. The results show that the ultrasound image of the Sunda porcupine reproductive organ soft tissue was hypoechoic, the lumen and antrum follicles were anechoic, while atretic follicles and the mons pubis were hyperechoic. Generally, the size of the organ was not significantly different between photographical and ultrasonographical imaging (p > .05). In conclusion, ultrasound images can be utilized for anatomical studies of the Sunda porcupine reproductive organs without destructing the specimen., (© 2020 Wiley-VCH GmbH.)

Data regarding urethral supporting structures are insufficient for understanding the mechanism of stress urinary incontinence. Whether smooth muscle fibers contribute to urethral support and pelvic floor support structures is unclear. This study aimed to clarify the histological structures and spatial distributions of smooth muscle tissues surrounding the urethra and vagina. Using cadaveric specimens, macroscopic anatomical and histological evaluations were conducted. Six female cadavers were used for macroscopic observations. Ten female cadavers were used for histological observations. Three pelvises were cut in a plane vertical to the urethra, and the other pelvises were cut in a plane parallel to the urethra and vagina to observe tissues surrounding the urethra and vagina. The major tissue component around the proper muscle layer of the urethra was smooth muscle tissue, which mediated among the urethra, pubis, and levator ani. Smooth muscle tissues laterally extended the smooth muscle fibers, both superiorly and inferiorly toward the levator ani, with a few fibers inserted in the levator ani. Smooth muscle was found between the urethral walls and pubic bones. Smooth muscle may contribute to the mechanism of pelvic floor support.

Introduction: Androgens have been shown to exert beneficial effects on vaginal physiology, at least partially independent of their aromatization to estrogens. Androgen deficiency in the vagina and in the other genitourinary tissues contributes to the development of vulvovaginal atrophy and genitourinary syndrome of menopause, resulting in impaired arousal and lubrication and dyspareunia., Objectives: To summarize the role of testosterone in modulating vaginal structure and function., Methods: A qualitative review of the relevant literature on the topic was performed using the PubMed database. We present a summary of preclinical and clinical evidence supporting the involvement of testosterone (T) in vaginal physiopathology and discuss it in terms of the role of the vagina in female sexual response., Results: Androgens are important in the differentiation of the vagina and in maintaining trophic and functional actions in postnatal life, as suggested by the detection of the androgen receptor and of the key enzymes involved in androgen synthesis. T is essential for the integrity of vaginal tissue structure (including non-vascular smooth muscle thickness and contractility and collagen fiber compactness) and for the complex neurovascular processes that regulate arousal and lubrication (vascular smooth muscle relaxation via the NO/cGMP/PDE5 pathway, nerve fiber density and neurotransmission). T has also been reported to modulate nociception, inflammation, and mucin secretion within the vagina. Available and potential androgen-based treatments for vulvovaginal atrophy/genitourinary syndrome of menopause and for other conditions leading to female genital arousal disorder and dyspareunia are presented., Conclusions: The vagina is both an androgen-target and synthesis organ. Preclinical and clinical data consistently suggest that T plays an important role in maintaining vaginal health and genital sexual function. Maseroli E, Vignozzi L. Testosterone and Vaginal Function. Sex Med 2020;8:379-392., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Evaluation of the female pelvic floor muscles is commonly carried out with digital examination and assigning a modified Oxford scale score or vaginal manometry. Racial differences can influence the size of the levator hiatus (LH) with "black" or African nulliparous women having a significantly larger LH compared to Caucasian women. The aim of this study was to assess the impact of LH size on manometry readings of simulated pelvic floor muscle contractions (PFMCs) using a small and large model LH., Methods: Small and large LH models were created using published data for size. Inflation of a pressure cuff placed circumferentially in the LH model represented a simulated PFMC. The models were examined in a supine position by three examiners and a perineometer twice each at varying simulated PFMC strength., Results: Positive correlation was found between increasing simulated PFMC strength with a higher Oxford score following digital examination and manometry readings for both the small (r s  = .87, r s  = .98) and large (r s  = .95, r s  = .87) models. There was good to excellent inter and intraobserver correlation for digital assessment of both models. The manometry measurements showed a much larger incremental rise from baseline in the small model compared with the large model (P < .05)., Conclusion: This study demonstrates that perineometer readings are affected by natural variations in LH size and PFMC strength. Therefore improvement to pelvic floor strength cannot be interpreted and measurements cannot be compared with others unless the LH size is known or digital examination is carried out., (© 2020 Wiley Periodicals LLC.)

The purpose of this study is to investigate the feasibility and performance of a stationary, non-focused dual-sectored tubular transurethral ultrasound applicator for thermal exposure of tissue regions adjacent to the urethra for treatment of stress urinary incontinence (SUI) through acoustic and biothermal simulations on 3D anatomical models. Parametric studies in a generalized tissue model over dual-sectored ultrasound applicator configurations (acoustic surface intensities, lateral active acoustic output sector angles, and durations) were performed. Selected configurations and delivery strategies were applied on 3D pelvic anatomical models. Temperature and thermal dose distributions on the target region and surrounding tissues were calculated. Endovaginal cooling was explored as a strategy to mitigate vaginal heating. The 75-90° dual-sectored transurethral tubular transducer (3.5 mm outer diameter (OD), 14 mm length, 6.5 MHz, 8.8-10.2 W/cm 2 ) and 2-3-min sonication duration were selected from the parametric study for acoustic and biothermal simulations on anatomical models. The transurethral applicator with two opposing 75-90° active lateral tubular sectors can create two heated volumes for a total of up to 1.8 cm 3 over 60 EM 43 °C , with at least 10 mm radial penetration depth, 1.2 mm urethral sparing, and no lethal damage to the vagina and adjacent bone (< 60 EM 43 °C ). Endovaginal cooling can be applied to further reduce the vaginal wall exposure (< 15 EM 43 °C ). Simulations on 3D anatomical models indicate that dual-sectored transurethral ultrasound applicators can selectively heat pelvic floor tissue lateral to the mid-urethra in short treatment durations, without damaging adjacent vaginal and bone tissues, as a potential alternative treatment option for stress urinary incontinence. Graphical abstract Schema for in silico investigation of transurethral ultrasound thermal therapy applicator for minimally invasive treatment of SUI.

Purpose: To determine whether the preoperative Ba and D point could help to guide the choice of surgical procedure for POP. Materials and Methods: This prospective cohort study included 250 subjects with anterior/apical defect from January 2012 to June 2015. All subjects underwent a complete preoperative evaluation and completed 12 months of follow-up. Based on the connection of preoperative Ba and D point of Pelvic Organ Prolapse Quantification (POP-Q), patients were assigned two groups: 137 patients who underwent anterior vaginal repair with mesh (AVM) and 113 patients who underwent AVM combined with sacrospinous ligament fixation (SSLF). The primary outcomes were anatomical cure and recurrence rate of both procedures. Secondary outcomes were prolapse symptom, quality of life and sexual function based upon validated questionnaires. The complications were also recorded in both groups. Results: Both groups were homogeneous preoperatively. The anatomical success rates for the anterior, apical and posterior vaginal compartments were 99.2%, 97.0% and 97.7% in the AVM group, respectively. For patients who underwent AVM-SSLF, the anatomical success rates for the anterior, apical and posterior compartments were 96.1%, 98.1% and 98.1%, respectively. The recurrence for both techniques was low. Both procedures presented a significant improvement with regard to postoperative quality of life (QOL), prolapse symptoms, and sexual function after 1-year follow-up. Conclusion: The preoperative Ba and D point correlated with surgical choice for the treatment of anterior/apical prolapse, which further decided the surgical outcomes for prolapse support.

Uterine adenocarcinoma occurs in more than 60% of female rabbits aged 4 years and over. To cure or prevent this uterine disorder, ovariohysterectomy should be performed. Although knowledge of the arterial supply to the ovary, uterus, and vagina is required, few studies have described the arterial anatomy. Therefore, we dissected ovarian, uterine, and vaginal arteries in 15 New Zealand White and 15 Japanese White rabbits to clarify the anatomy. The ovarian artery arose from the abdominal aorta, and in 50% of cases, the left artery emerged more cranially than the right artery. The ovarian artery provided the ovarian, uterine, and tubal branches with three branching types. The most frequent type (67% of the halves on the right and 63% of the halves on the left) exhibited three branches that independently arose from the ovarian artery. The uterine artery usually originated from the umbilical artery, with its ramification pattern divided into two types, having one or two uterine arteries, respectively. The most frequent type (all halves on the right and 83% of the halves on the left) had one uterine artery that originated from the umbilical artery. We observed three types of vaginal artery origins, with the branching type where the vaginal artery arose from the internal iliac artery being the most frequent (97% of the halves on the right and 90% of the halves on the left). The detailed arterial supply pattern of the rabbit female genital organs determined in the present study will be helpful when performing rabbit gynecological surgeries. Anat Rec, 303:1478-1488, 2020. © 2019 American Association for Anatomy., (© 2019 American Association for Anatomy.)

Asymmetric genitalia and lateralized mating behaviors occur in several taxa, yet whether asymmetric morphology in one sex correlates or coevolves with lateralized mating behavior in the other sex remains largely unexplored. While lateralized mating behaviors are taxonomically widespread, among mammals they are only known in the harbor porpoise (Phocoena phocoena). Males attempt copulation by approaching a female exclusively on her left side. To understand if this unusual lateralized behavior may have coevolved with genital morphology, we quantified the shape of female and male harbor porpoise reproductive tracts using 2D geometric morphometrics and 3D models of the vaginal lumen and inflated distal penis. We found that the vaginas varied individually in shape and that the vaginas demonstrated both significant directional and fluctuating asymmetry. This asymmetry resulted from complex 3D spirals and vaginal folds with deep recesses, which may curtail the depth or direction of penile penetration and/or semen movement. The asymmetric shapes of the vaginal lumen and penis tip were both left-canted with similar angular bends that mirrored one another and correspond with the left lateral mating approach. We suggest that the reproductive anatomy of both sexes and their lateral mating behavior coevolved.

Introduction: The women pelvic floor is a complex system, which seems to endure several modifications during pregnancy and childbirth. Our primary purpose was to build an extensive 3 dimensional (3D) numerical anatomical model of the women pelvic floor., Methods: First, the role and the location of each organ, muscle, or ligament, were identified through an extensive literature review. Then, different entities were selected because of their visibility and importance in the pelvic floor. Each entity was identified using anatomical knowledge, and outlined on 2 dimensional (2D) MRI images, that were carried out on 4 pregnant women, using sequences T1, T2 and proton density weighted, through AVIZO program. The overlay of these 2D outlines produced a 3D geometrical reconstruction, which was then reworked with the program CATIA to obtain a usable geometric model., Results: We identified and integrated 15 anatomical structures to the geometrical model, including organs, ligament and muscles from the pelvis and perineum. This geometrical model allowed us to obtain a visual interactive representation with 3D images. These different steps resulted in the creation of a complete numerical model of the female pelvic floor, which might be used in Finite Element simulation., Conclusion: A new complete and accurate 3D numerical anatomical model of the women pelvic floor was elaborated. It presents simultaneously analytical prospects, through the observation of the strains and deformations that are imposed on the different structures, and educational prospects, through the detailed visual representation of several situations., (Copyright © 2019 Elsevier Masson SAS. All rights reserved.)

The presence/absence and number of vaginae is a major characteristic for the systematics of the Monogenea. Three gastrocotylid genera share similar morphology and anatomy but are distinguished by this character: Pseudaxine Parona & Perugia, 1890 has no vagina, Allogastrocotyle Nasir & Fuentes Zambrano, 1983 has two vaginae, and Pseudaxinoides Lebedev, 1968 has multiple vaginae. In the course of a study of Pseudaxine trachuri Parona & Perugia 1890, we found specimens with structures resembling "multiple vaginae"; we compared them with specimens without vaginae in terms of both morphology and molecular characterisitics (COI barcode), and found that they belonged to the same species. We also investigated the male copulatory organ (MCO) of this species, the accuracy of the original description of which is known to be a matter of debate. We found that the genital atrium is armed with 12 hooks arranged as a single circle and a central hollow stylet which is probably involved in traumatic insemination. We redescribed Pseudaxine trachuri based on newly collected specimens from off the coast of Algeria and Museum specimens from off France. Specimens from the type-host, Trachurus trachurus, were found to be similar, for both molecular sequences and morphology, to those found on Boops boops. We can therefore confirm, for the first time with molecular evidence, that B. boops is a host of this parasite. We consider that Pseudaxinoides was erected on the basis of an erroneous interpretation of structures which are not vaginae and, consequently, propose the transfer of most of its species to Pseudaxine, as P. australis (Lebedev, 1968) n. comb., P. bychowskyi (Lebedev, 1977) n. comb., P. caballeroi (Lebedev, 1977) n. comb., P. cariacoensis (Nasir & Fuentes-Zambrano, 1983) n. comb., and P. vietnamensis (Lebedev, Parukhin & Roitman, 1970) n. comb. We also propose Allogastrocotyle dillonhargisorum nom. nov. for Pseudaxine bivaginalis Dillon & Hargis, 1965 to avoid a secondary homonymy., (© C. Bouguerche et al., published by EDP Sciences, 2020.)

The discovery of the G-spot and verification of its anatomy and histology paved the way to better understanding. Until 2012, the G-spot was defined as a physiological sexual response phenomenon with no identifiable anatomical correlate. The weakness of this definition is that a physiological response cannot exist without an anatomical basis, so the question motivating the present study was formulated: Are current scientific-clinical data sufficient to resolve the controversy about the anatomical existence of a G-spot? It is important to stipulate that no systematic review of the G-spot has hitherto been published. Manual and electronic searches revealed postmortem and in vivo studies describing the G-spot and findings reported within PRISMA-IPD guidelines. The objective of the present review was to provide evidence-based information related to the G-spot. Articles were quality-assessed using validated instruments. Publications on the G-spot from 1950 to May 2019 were reviewed. Of the 279 full-text articles examined, 30 met the eligibility criteria. The findings indicate that there are reliable scientific-clinical data to support the existence of an anatomical G-spot structure. Transient anterior-distal vaginal wall engorgement is caused by blood entrapment within the G-spot structure. Histological examination effectively ruled out the G-spot as the organ cannot be responsible for female ejaculation since no glandular tissue was identifiable. Finally, the results of this study could assist in developing new therapeutic, surgical interventions to treat secondary G-spot dysfunction. Additionally, this review indicates ample opportunities for further scientific-clinical investigations and has thereby moved the field forward. Clin. Anat. 32:1094-1101, 2019. © 2019 Wiley Periodicals, Inc., (© 2019 Wiley Periodicals, Inc.)

Background: Assessment of pelvic configuration is an important factor in the prediction of a successful vaginal birth. However, manual evaluation of the pelvis is practically a vanishing art, and imaging techniques are not available as a real-time bed-side tool. Unlike the obstetrical conjugate diameter (OC) and inter spinous diameter (ISD), the pubic arch angle (PAA) can be easily measured by transperineal ultrasound. Objectives: Three-dimensional computed tomography bone reconstructions were used to measure the three main birth canal diameters, evaluate the correlation between them, and establish the normal reference range for the inlet, mid-, and pelvic outlet. Study design: Measurements of the PAA, obstetric conjugate (OC), and ISD were performed offline using three-dimensional post processing reconstruction in bone algorithm application of the pelvis on examinations performed for suspected renal colic in nonpregnant reproductive age woman. The mean of two measurements was used for statistical analysis which included reproducibility of measurements, regression curve estimation between PAA, OC, and ISD, and calculation of the respective reference range centiles for each PAA degree. Results: Two hundred ninety-eight women comprised the study group. The mean ± SD of the PAA, ISD, and OC were 104.9° (±7.4), 103.8 mm (±7.3), and 129.9 mm (±8.3), respectively. The intra- and interobserver agreement defined by the intraclass correlation coefficient (ICC) was excellent for all parameters (range 0.905-0.993). A significant positive correlation was found between PAA and ISD and between PAA and OCD (Pearson's correlation = 0.373 ( p  < .001), and 0.163 ( p  = .022), respectively). The best regression formula was found with quadratic regression for inter spinous diameter (ISD): 34.122778 + (0.962182*PAA - 0.002830*PAA 2 ), and linear regression for obstetric conjugate (OC): 110.638397 + 0.183156*PAA. Modeled mean, SD, and reference centiles of the ISD and OCD were calculated using the above regression models as function of the PAA. Conclusions: We report significant correlation between the three pelvic landmarks with greatest impact on the prediction of a successful vaginal delivery: the PAA which is easily measured sonographically and the ISD and OC which are not measurable by ultrasound. This correlation may serve as a basis for future studies to assess its utility and prognostic value for a safe vaginal delivery.

The number of days (DN) when hens lay fertile eggs as well as the number of fertile eggs (FN) were produced after a single artificial insemination (AI), including the two duration of fertility (DF) traits. Indeed, they are the key production performance that associates with the production cost of hatching egg when its determination the interval between successive artificial inseminations. However, the relevant genes response for regulating the DF has not been uncovered yet. Therefore, we performed a weighted gene co-expression network analysis (WGCNA) to investigate the insight into co-expression gene modules on DF process in hens. The total mRNA was extracted from the utero-vaginal junction (UVJ, with the sperm storage function in hen's oviduct which is the biological basis for DF) of 20 hens with several levels of DF traits, and performed transcriptome sequences of mRNA. As a result, three co-expression gene modules were identified to be highly correlated with DF traits. Moreover, the expression changes of top 5 hub genes in each module with DF traits were further confirmed in other 20 hens by RT-PCR. These findings highlighted the co-expression modules and their affiliated genes as playing important roles in the regulation of DF traits.

Introduction and Hypothesis: Recurrent post-coital urinary infection (rUTI)-usually cystitis-is a common entity among otherwise healthy young women. However, little is known about the possible influence of genital anatomical variations. Only a shorter urethral meatus-anus distance has been described as a risk factor. The aim of this study was to evaluate our hypothesis that a shorter urethra-vagina distance is involved in the etiology of post-coital urinary infection., Methods: In this prospective case-control study, 61 young women aged between 18 and 40 years with an acute post-coital UTI and a history of intercourse-related rUTI were consecutively recruited between January 2013 and February 2018. Fifty-six age-matched, sexually active women with no history of UTI served as controls. Perineal measurements included the distances between the clitoris-urethra (C-U), urethra-vagina (U-V), urethra-anus (U-A) and perineum. Demographic and sexual behavior characteristics and the morphology of the urethral meatus were also noted. Univariate analysis compared variables between groups. ROC analysis was used to define the efficiency of perineal measurements in predicting outcome. Odds ratios and 95% confidence intervals for UTI-predisposing variables were estimated using logistic regression analysis., Results: The U-V and U-A distance was shorter in patients compared with controls [median (interquatile range): 16 mm (14-18) vs. 21 mm (19-23) and 51 mm (47-53) vs. 59 mm (55-62), respectively, p < 0.001]. The U-V performed better in ROC analysis than the U-A distance (AUC 0.952 vs. 0.875, p = 0.023). The only statistically significant parameters in multivariate analysis influencing UTI were BMI (OR: 0.702; 0.510-0.967, p = 0.030) and U-V (OR: 0.297; 0.161-0.549, p < 0.001)., Conclusions: Our results indicate an association between shorter urethra-vagina distance and post-coital rUTIs.

Introduction and Hypothesis: Posthysterectomy vaginal length has been previously associated with postoperative sexual dysfunction, but evidence for this in the literature is controversial. The purpose of this meta-analysis was to investigate whether vertical or horizontal closure of the vaginal cuff has a direct effect on posthysterectomy vaginal length and on postoperative sexual dysfunction., Methods: The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched Medline, Scopus, Clinicaltrials.gov , EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar databases., Results: Overall, five randomized trials were included in this meta-analysis with 223 patients. The results suggest that horizontal closure of the vaginal cuff results in a shorter vaginal length compared with vertical closure [mean difference (MD) -0.77 cm, 95% confidence interval (CI) -1.12 to -0.43]. Mean vaginal length significantly decreased when the horizontal method was used (MD -0.61 cm, 95% CI -0.97 to -0.24). The subgroup analysis revealed that vertical closure was associated with longer vaginal length only in cases treated with vaginal hysterectomy. Trial sequential analysis revealed that our meta-analysis had adequate power to support these results. Postoperative sexual function was evaluated in only one study; no differences were observed., Conclusions: Findings of our meta-analysis suggest that horizontal closure of the vaginal vault results in shorter vaginal length in vaginal hysterectomies; thus, we suggest that this technique be avoided. Data concerning quality of life of patients and specifically sexual dysfunction remain extremely limited and should be studied in future trials.

The female genital tract originates from the Müllerian ducts during embryological development. Fusion of the ducts occurs in different segments depending on the animal species, resulting in a variational number of the respective organ. Current literature on genital tract morphology of laboratory rodents is controversial. Therefore, the present study aimed at determining an anatomically correct definition of the uterus in laboratory guinea pigs, mice and rats. In all three rodent species, we found two separate cervical canals that communicate with an individual uterus via discrete ostia uteri interna. The correct anatomical definition should therefore be uterus duplex bicollis, vagina simplex., (© 2019 Blackwell Verlag GmbH.)

Objectives: To compare vaginal axis and posterior cul-de-sac measurements in women who have undergone hysterectomy and women with an intact uterus., Methods: This was a retrospective cohort study comparing magnetic resonance imaging findings in women who had undergone hysterectomy with women with an intact uterus. The primary outcome was change in the upper, middle, and lower vaginal axes relative to the pelvic inclination correction system line. Secondary outcomes included angles between the upper-middle and middle-lower vagina, depth of the posterior cul-de-sac, and total vaginal length., Results: In the hysterectomy group, the middle vaginal axis was significantly more anterior as compared with the intact uterus group (61.3 degrees ± 12.7 vs 49.4 degrees ± 23.6, P = 0.01). The upper-middle and the middle-lower vaginal angles were significantly more obtuse in the hysterectomy group than the intact uterus group (112.3 degrees ± 28.7 vs 69.3 degrees ± 56.6, P = 0.01 and 145.4 degrees ± 13.2 vs 130.9 degrees ± 29.7, P = 0.02, respectively). The mean depth of the posterior cul-de-sac and the total vaginal length were significantly shorter in the hysterectomy group than the intact uterus group (5.5 mm ± 7.6 vs 21.8 mm ± 11.9, P < 0.0001 and 78.7 mm ± 3.9 vs 100 mm ± 15.9, P < 0.001, respectively)., Conclusions: The vaginal anatomy of women who have undergone hysterectomy differs significantly from that of women with an intact uterus.

Purpose: Penile inversion vaginoplasty is the most common procedure for genital reconstruction in transwomen. While penile inversion vaginoplasty usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. We describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen., Materials and Methods: Between 2017 and 2018 we identified 41 transwomen who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6 cm wide by 8 cm long peritoneal flaps were raised from the anterior aspect of the rectum and the sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina., Results: Average ± SD age of the 41 patients was 34 ± 14 years. Average procedure duration was 262 ± 35 minutes and average length of stay was 5 days. Average followup was 114 ± 79 days. At the most recent followup vaginal depth and width were measured to be 14.2 ± 0.7 and 3.6 ± 0.2 cm, respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin., Conclusions: Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well vascularized apex with acceptable anticipated complications.