Reconstructive and Reproductive

Surgery in Gynecology, Volume Two:

Gynecological Surgery Malcolm G.
Munro
Visit to download the full and correct content document:
https://textbookfull.com/product/reconstructive-and-reproductive-surgery-in-gynecolog
y-volume-two-gynecological-surgery-malcolm-g-munro/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Reconstructive and Reproductive Surgery in Gynecology,

Volume 1: Fundamentals and Conditions Malcolm G. Munro

https://textbookfull.com/product/reconstructive-and-reproductive-
surgery-in-gynecology-volume-1-fundamentals-and-conditions-
malcolm-g-munro/

Reconstructive and Reproductive Surgery in Gynecology.

Volume 2, Gynecological Surgery Second Edition Gomel

https://textbookfull.com/product/reconstructive-and-reproductive-
surgery-in-gynecology-volume-2-gynecological-surgery-second-
edition-gomel/

Atlas of Reconstructive Breast Surgery Lee L.Q. Pu

https://textbookfull.com/product/atlas-of-reconstructive-breast-
surgery-lee-l-q-pu/

Atlas of Reconstructive Breast Surgery Lee L. Q. Pu

https://textbookfull.com/product/atlas-of-reconstructive-breast-
surgery-lee-l-q-pu-2/
Keighley and Williams Surgery of the Anus Rectum and
Colon Two Volume Set Keighley

https://textbookfull.com/product/keighley-and-williams-surgery-
of-the-anus-rectum-and-colon-two-volume-set-keighley/

Reproductive Surgery The Society of Reproductive

Surgeons Manual 1st Edition Jeffrey M. Goldberg

https://textbookfull.com/product/reproductive-surgery-the-
society-of-reproductive-surgeons-manual-1st-edition-jeffrey-m-
goldberg/

Pediatric Colorectal and Pelvic Reconstructive Surgery

1st Edition Alejandra Vilanova-Sanchez (Editor)

https://textbookfull.com/product/pediatric-colorectal-and-pelvic-
reconstructive-surgery-1st-edition-alejandra-vilanova-sanchez-
editor/

Oral, Head and Neck Oncology and Reconstructive Surgery

1st Edition R Bryan Bell

https://textbookfull.com/product/oral-head-and-neck-oncology-and-
reconstructive-surgery-1st-edition-r-bryan-bell/

Scott-Brown’s Otorhinolaryngology and Head and Neck

Surgery. Volume 3: Head and Neck Surgery, Plastic
Surgery John C Watkinson

https://textbookfull.com/product/scott-browns-
otorhinolaryngology-and-head-and-neck-surgery-volume-3-head-and-
neck-surgery-plastic-surgery-john-c-watkinson/
Reconstructive and Reproductive
Surgery in Gynecology
Second Edition
Volume Two: Gynecological Surgery

Edited by
Malcolm G. Munro
Victor Gomel
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742

© 2019 by Taylor & Francis Group, LLC

CRC Press is an imprint of Taylor & Francis Group, an Informa business

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-138-31420-7 (Pack- Hardback and eBook)

This book contains information obtained from authentic and highly regarded sources. While all reasonable efforts have been made to publish reliable data
and information, neither the author[s] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. The
publishers wish to make clear that any views or opinions expressed in this book by individual editors, authors or contributors are personal to them and do
not necessarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for use by medical, scientific
or health-care professionals and is provided strictly as a supplement to the medical or other professional’s own judgement, their knowledge of the patient’s
medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any
information or advice on dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant national
drug formulary and the drug companies’ and device or material manufacturers’ printed instructions, and their websites, before administering or utilizing
any of the drugs, devices or materials mentioned in this book. This book does not indicate whether a particular treatment is appropriate or suitable for a
particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as to advise and
treat patients appropriately. The authors and publishers have also attempted to trace the copyright holders of all material reproduced in this publication and
apologize to copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged please write
and let us know so we may rectify in any future reprint.

Except as permitted under U.S. Copyright Law, no part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic,
mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or
retrieval system, without written permission from the publishers.

For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact
the Copyright Clearance Center, Inc. (CCC), 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides
licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has
been arranged.

Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without
intent to infringe.

Library of Congress Cataloging‑in‑Publication Data

Names: Munro, Malcolm G., editor. | Gomel, Victor, editor.

Title: Reconstructive and reproductive surgery in gynecology / edited by Malcolm G. Munro and Victor Gomel.
Description: Second edition. | Boca Raton, FL : CRC Press, [2019] | Includes bibliographical references and index.
Identifiers: LCCN 2018015240| ISBN 9781138035010 (pack- hardback and ebook : alk. paper) | ISBN 9781315269801 (ebook)
Subjects: | MESH: Gynecologic Surgical Procedures | Genital Diseases, Female--surgery | Infertility, Female--prevention & control |
Reconstructive Surgical Procedures
Classification: LCC RG104 | NLM WP 660 | DDC 618.1/059--dc23
LC record available at https://lccn.loc.gov/2018015240

Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
Contents

Contributors v

Volume One: Fundamentals and Conditions

1 Anatomy and surgical dissection of the female pelvis: For the gynecologic surgeon 1
Andrew I. Brill, Robert M. Rogers, Jr., and Victor Gomel
2 Reproductive physiology for the gynecological surgeon 17
Victor Gomel, Malcolm G. Munro, and Peter F. McComb
3 Energy-based surgical devices 27
Andrew I. Brill and Malcolm G. Munro
4 Principles of laparoscopic surgery 47
Sukhbir S. Singh, Olga Bougie, and Malcolm G. Munro
5 Principles of microprocessor-assisted laparoscopic (“robotic”) surgery 73
Erica Dun, Vadim V. Morozov, and Ceana Nezhat
6 Principles of laparotomic and vaginal surgery 85
Victor Gomel and Malcolm G. Munro
7 Principles of hysteroscopic surgery 105
Barry H. Sanders and Malcolm G. Munro
8 Imaging for the gynecologic surgeon 121
Caterina Exacoustos and Margit Dueholm
9 Preservation of fertility in gynecologic surgery: Strategies and techniques 153
Victor Gomel, Mohamed A. Bedaiwy, and Recai Pabuçcu
10 Complications of surgery of the female reproductive tract 159
Nyia Noel, Christina Alicia Salazar, Keith Isaacson, and Malcolm G. Munro
11 Congenital anomalies of the female reproductive tract 181
Joseph S. Sanfilippo and Kathryn D. Peticca
12 Ectopic pregnancy 195
Victor Gomel and Malcolm G. Munro
13 Endometrial polyps 207
Marit Lieng and Jason A. Abbott
14 Adenomyosis: Uterus-sparing treatment 213
Grigoris F. Grimbizis and Themistoklis Mikos
15 Endometriosis: General principles 227
Sukhbir S. Singh, Catherine Allaire, and David L. Olive
16 Uterine leiomyomas 241
Levent Mutlu, Kimberly W. Keefe, and Hugh S. Taylor
17 Pathogenesis of pelvic floor disorders 255
Geoffrey W. Cundiff
18 Pelvic infections and their sequelae 267
Jorma Paavonen
19 Fallopian tube disorders 275
Victor Gomel
20 Postoperative adhesions 283
Victor Gomel and Philippe R. Koninckx
21 Pathogenesis, pathology, and clinical significance of intrauterine adhesions 297
Miriam M.F. Hanstede, Mark Hans Emanuel, and Jason A. Abbott
22 Malignancy 307
Denis Querleu
23 Chronic pelvic pain 323
Fred M. Howard and Malcolm G. Munro
24 Abnormal uterine bleeding 341
Malcolm G. Munro
25 The adnexal mass 361
Denis Querleu

iii
iv Contents

26 Diagnosis, investigation, and nonsurgical management of pelvic organ prolapse and urinary incontinence 371
Yaël Levy-Zauberman and Hervé Fernandez
27 Infertility: Mechanisms and investigation 381
Victor Gomel
28 Recurrent pregnancy loss: A new strategy for evaluation based on genetic testing 399
William H. Kutteh, Carolyn R. Jaslow, Paul R. Brezina, Raymond W. Ke, Amelia P. Bailey, and Mary D. Stephenson

Index 407

Volume Two: Gynecological Surgery

29 Surgery for congenital anomalies: Hysteroscopic, laparoscopic, laparotomic, and vaginal 433
Joseph S. Sanfilippo, Kathryn D. Peticca, and Fabiola Balmir
30 Surgery for vulvar disorders 443
Howard T. Sharp
31 Endometrial sampling and uterine curettage 451
Yaël Levy-Zauberman, Perrine Capmas, and Hervé Fernandez
32 Management of endometrial polyps 457
Jason A. Abbott and Marit Lieng
33 Endometrial ablation 461
Malcolm G. Munro
34 Surgery for intrauterine adhesions 473
Mark Hans Emanuel and Miriam M.F. Hanstede
35 Leiomyomas I: Hysteroscopic and other transvaginal approaches 481
Barry H. Sanders and Malcolm G. Munro
36 Leiomyomas II: Abdominal approaches 493
William H. Parker, Tommaso Falcone, and Malcolm G. Munro, with Alex Kotlyr
37 Leiomyomas III: Image-guided surgery and procedures 507
Scott Chudnoff, Sukrant Mehta, and Eleanor Hawkins
38 Hysterectomy 521
Jon Ivar Einarsson and Mobolaji O. Ajao, with Raymond Reilley
39 Reconstructive surgery of the fallopian tube 533
Victor Gomel
40 Ectopic pregnancy: Surgical management 557
Victor Gomel
41 Ovarian surgery 567
Victor Gomel and Mohamed A. Bedaiwy
42 Endometriosis I: Surgery for endometriosis associated with pain 579
Nicola Berlanda and Paolo P. Vercellini
43 Endometriosis II: Surgical treatment of endometriosis associated with infertility 591
David L. Olive and Mauro Busaca
44 Endometriosis III: Deep infiltrating endometriosis 597
Sukhbir S. Singh and Sugandha Agarwal
45 Procedures specific for chronic pelvic pain 613
Fred M. Howard
46 Surgical treatment of urinary incontinence 619
Yaël Levy-Zauberman, Xavier Deffieux, and Hervé Fernandez
47 Management of pelvic organ prolapse 629
Geoffrey W. Cundiff
48 Surgery during intrauterine pregnancy 645
Michel Canis, Nicolas Bourdel, Céline Houlle, Benoit Rabischong, Revaz Botchorishvili, and Jean L. Pouly
49 Preservation of fertility in malignancy 653
Denis Querleu, Sophie Deutsch-Bringer, and Alejandra Martínez
50 Oocyte and embryo cryopreservation for fertility preservation 665
Ana Cobo and José Remohi

Index 671
Contributors

Jason A. Abbott MD PhD Mauro Busaca MD

Professor, Gynaecological Surgery Professor, Department of Gynecology and Obstetrics
University of New South Wales University of Milan
Royal Hospital for Women Milan, Italy
Sydney, Australia
Michel Canis MD
Sugandha Agarwal MBBS MS Professor, Department of Gynecologic Surgery
Senior Research Officer, Department of Obstetrics and University of Clermont-Auvergne
Gynecology CHU Estaing
Vardhman Mahavir Medical College Clermont-Ferrand, France
Safdarjung Hospital
New Delhi, India Perrine Capmas MD PhD
Department of Gynecology and Obstetrics
Mobolaji O. Ajao MD MPH Service de Gynécologie-Obstétrique
Instructor, Department of Obstetrics, Gynecology and University of Paris-Sud
Reproductive Biology Hôpital Bicêtre
Division of Minimally Invasive Gynecologic Surgery Paris, France
Harvard Medical School
Brigham and Women’s Hospital Scott Chudnoff MD MSc
Boston, Massachusetts Clinical Professor, Department of Obstetrics and Gynecology
Columbia University Irving College of Physicians and Surgeons
Fabiola Balmir MD Stamford Health
Fellow, Department of Obstetrics and Gynecology Stamford, Connecticut
Division of Reproductive Endocrinology and Infertility
University of Pittsburgh Ana Cobo PhD
Pittsburgh, Pennsylvania Director of Cryopreservation Unit
IVI, Valencia
Mohamed A. Bedaiwy MD PhD Valencia, Spain
Professor and head, Department of Obstetrics and
Gynecology Geoffrey W. Cundiff MD
Division of Reproductive Endocrinology and Infertility Professor and Head, Department of Obstetrics and
University of British Columbia Gynecology
Vancouver, Canada University of British Columbia
Vancouver, Canada
Nicola Berlanda MD
Adjunct Professor, Department of Gynecology and Obstetrics Xavier Deffieux MD PhD
Gynecologic Surgery Unit Department of Gynecology and Obstetrics
University of Milan Service de Gynécologie-Obstétrique
Milan, Italy University of Paris-Sud
Antoine Béclère Hospital
Revaz Botchorishvili MD Paris, France
Department of Gynecologic Surgery
University of Clermont-Auvergne Sophie Deutsch-Bringer MD
CHU Estaing Department of Obstetrics and Gynecology
Clermont-Ferrand, France University Hospital
Montpellier, France
Nicolas Bourdel MD PhD
Department of Gynecologic Surgery
University of Clermont-Auvergne
CHU Estaing
Clermont-Ferrand, France

v
vi Contributors

Jon Ivar Einarsson MD MPH PhD Yaël Levy-Zauberman MD

Professor, Department of Obstetrics, Gynecology and Department of Gynecology and Obstetrics
Reproductive Biology University of Paris-Sud
Harvard Medical School Hôpital Bicêtre
Division of Minimally Invasive Gynecologic Surgery Paris, France
Brigham and Women’s Hospital
Boston, Massachusetts Marit Lieng MD PhD
Associate Professor, Department of Obstetrics and Gynecology
Mark Hans Emanuel MD PhD University of Oslo
Visiting Professor, Department of Gynaecology Oslo University Hospital
University of Utrecht Oslo, Norway
Senior Consultant
University Medical Center Alejandra Martínez MD
Utrecht, The Netherlands Department of Surgery
Institut Claudius Regaud
Tommaso Falcone MD Institut Universitaire du Cancer de Toulouse
Professor, Department of Surgery Toulouse, France
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University Sukrant Mehta MD
Medical Director Assistant Clinical Professor, Department of Obstetrics and
Cleveland Clinic London Gynecology
London, England David Geffen School of Medicine at UCLA
University of California, Los Angeles
Hervé Fernandez MD PhD Los Angeles, California
Professor and Head, Department of Gynecology and Obstetrics
University of Paris-Sud Malcolm G. Munro MD
Hôpital Bicêtre Clinical Professor, Department of Obstetrics and Gynecology
Paris, France David Geffen School of Medicine at UCLA
University of California, Los Angeles
Victor Gomel MD Kaiser Permanente Los Angeles Medical Center
Professor Emeritus, Former Head, Department of Obstetrics Los Angeles, California
and Gynecology
Faculty of Medicine David L. Olive MD
University of British Columbia Wisconsin Fertility Institute
Vancouver, Canada Middleton, Wisconsin

Miriam M.F. Hanstede MD William H. Parker MD

Consultant, Department of Obstetrics and Gynecology Clinical Professor, Department of Obstetrics, Gynecology and
Spaarne Gasthuis Hoofddorp/Haarlem Reproductive Sciences
Amsterdam, The Netherlands University of California, San Diego School of Medicine
La Jolla, California
Eleanor Hawkins MD
The Women’s Health Center Kathryn D. Peticca MD
Fountain Valley, California Graduate Medical Resident, Department of Obstetrics,
Gynecology and Reproductive Sciences
Céline Houlle MD University of Pittsburgh
Department of Gynecologic Surgery Pittsburgh, Pennsylvania
University of Clermont-Auvergne
CHU Estaing Jean L. Pouly MD
Clermont-Ferrand, France Department of Gynecologic Surgery
University of Clermont-Auvergne
Fred M. Howard MS MD CHU Estaing
Former Professor Emeritus, Department of Obstetrics and Clermont-Ferrand, France
Gynecology
University of Rochester School of Medicine and Dentistry
Rochester, New York
 Contributors vii

Denis Querleu MD Joseph S. Sanfilippo MD MBA

Honorary Professor of Oncology Professor, Department of Obstetrics, Gynecology and
University of Toulouse Reproductive Sciences
Toulouse, France Division of Reproductive Endocrinology and Infertility
Institut Bergonié Cancer Center University of Pittsburgh
Bordeaux, France Pittsburgh, Pennsylvania

Benoit Rabischong MD Howard T. Sharp MD

Department of Gynecologic Surgery Professor, Department of Obstetrics and Gynecology
University of Clermont-Auvergne University of Utah
CHU Estaing University of Utah Health Sciences Center
Clermont-Ferrand, France Salt Lake City, Utah

José Remohí MD Sukhbir S. Singh MD

Professor of Obstetrics and Gynaecology Associate Professor, Department of Obstetrics and
School of Medicine Gynecology
University of Valencia University of Ottawa
IVI Fertility The Ottawa Hospital Research Institute
Valencia, Spain Ottawa, Canada

Barry H. Sanders MD Paolo Vercellini MD

Clinical Professor, Department of Obstetrics and Gynecology Professor of Gynecology and Obstetrics
Faculty of Medicine University of Milan
University of British Columbia Department of Clinical Sciences and Community Health
Vancouver, Canada Fondazione IRCCS Ca’Granda Ospedale Maggiore Policlinico
Milan, Italy
http://taylorandfrancis.com
Surgery for congenital anomalies
Hysteroscopic, laparoscopic, laparotomic,
29
and vaginal
JOSEPH S. SANFILIPPO, KATHRYN D. PETICCA, and FABIOLA BALMIR

Key points
•• Surgical management of Müllerian anomalies has been revolutionized by imaging, and the development of hysteroscopic
and laparoscopic surgical techniques that have rendered laparotomic management infrequent, and office hysteroscopic
management of selected anomalies a reality.
•• The CONUTA system of classification provides increased granularity allowing for more accurate descriptions of Müllerian
anomalies affecting the uterine corpus, particularly when they affect the cervix and the vagina.
•• For women with Mayer–Rokitansky–Kuster–Hauser syndrome (CONUTA U5-C4-V4) the success rate of the patient self-­
administered “Frank technique” is about 85%–90%.
•• For those with vaginal agenesis for whom the Frank technique isn’t feasible or successful, there exist other procedures, such
as the Vecchietti and Davydov procedures that can be performed under laparoscopic guidance without the need for skin
grafting.
•• Isolated cervical agenesis (CONUTA U0-C4-V0 or V4) has been treated with procedures linking the corpus to the existing or
artificially created vagina, but study sample sizes are small, and there is inadequate reporting of pregnancy outcomes to
allow for meaningful counseling of patients.
•• The unicornuate uterus and variants, CONUTA U4-C3 (rAFS Class IIb), are often associated with abnormalities of the urinary
tract, such as unilateral renal agenesis, and can be treated with laparoscopically directed removal of the underdeveloped or
obstructed uterine horn.
•• Uterus didelphus, which is CONUTA U3b-C2 (rAFS Class III) and rAFS Class VI (there is no corresponding CONUTA designation)
generally require no surgical or medical intervention to deal with symptoms or to improve pregnancy outcomes.
•• The bicornuate uterus, CONUTA U3a-C0 (rAFS IV a/b), can be treated expectantly, or with Strassman metroplasty with hyster-
otomy and unification of the two endometrial cavities.
•• The septate uterus, CONUTA U2-C0/1 (rAFS Va/b), can generally be treated with hysteroscopically directed transection of the
septum.

INTRODUCTION are variable and need to be considered on a case-by-case

As described in Chapter 11, approximately 10% of females
are born with a congenital anomaly of the reproductive
tract, and while many do not benefit from interventions,
a number will experience improved clinical outcomes
with an appropriate surgical procedure.1,2 From a histori-
cal perspective, the surgical management of anomalies
involving the reproductive tract has, in many instances,
changed dramatically because of advances in surgical
technique and technology. As detailed in Chapter 11, the
advent of minimally invasive surgical technological inno-
vation has provided clinicians with a plethora of options
for management.
Hysteroscopy is not only a means for assessment of the
uterine cavity; it is also the method of access for reconstruc-
tive surgical intervention. Resectoscopes, radiofrequency
needles (RFNs), and electromechanical morcellators
complement more traditional operative instruments that
include scissors and biopsy forceps placed through the
operative channel. Indications for concurrent laparoscopy
basis with knowledge that intraoperative sonographic
monitoring is often at least as efficacious and, in most
instances, readily available to the reproductive surgeon.
VAGINAL AND CERVICAL
Transverse vaginal septum (CONUTA V3)
The incidence of transverse vaginal septum is 1:80,000,
with variable location and extent, occupying some por-
tion of the lower, middle, and/or upper segments of the
vagina.3 The septa are more commonly perforate (61%),
with resultant menses, but are frequently imperforate
(39%), the latter being associated with amenorrhea and
hematocolpos.4
As described in Chapter 11, evaluation of these
patients requires a combination of physical examina-
tion, transperineal or transvaginal sonography, and,
frequently, MRI. Examination of both the vagina and
rectum allows for assessment of the caudal aspect of the

433
434 Surgery for congenital anomalies

septum and for the presence of hematocolpos, should it

exist, cephalad to the obstruction. However, MRI allows
a more complete evaluation of the vaginal canal, includ-
ing characterization of the position, length, and thick-
ness of the septum, as these findings are important in
designing the surgical approach. The septum may be
present at a number of levels in the vagina; viz. low
(14%), mid (40%), and high (46%). 5
Surgical correction of the transverse vaginal septum is (a) (b)
the management of choice. Ideally, we recommend per-
forming resection surgery at the time of puberty to allow
for improved healing of the vaginal epithelium in the pres-
ence of physiological levels of systemic estrogen. Following
menarche, complete transverse septa are typically associ-
ated with distension of the upper vagina in the form of
a hematocolpos, a circumstance that facilitates the surgi-
cal resection. The overall strategy for thin septa is resec-
tion with vaginal epithelial reapproximation. Another
approach when there exists a thickened transverse septum (c) (d)
or partial atresia of the vault is the modified Z-plasty tech-
nique described by Grünberger. Here, eight vaginal epi-
thelial flaps are created and add vaginal vault length of up
to 1 cm (Figure 29.1). This procedure also minimizes the
risk of vaginal stenosis by postoperatively employing the
use of a rigid plastic vaginal mold with concurrent use of
estrogen cream.6 Another consideration for patients with
complete obstruction is the potential sequelae of retro-
grade menstruation that include endometriosis and asso-
ciated adhesion formation secondary to inflammation. In
such instances, simultaneous laparoscopy should be con- (e) (f )
sidered to manage the resulting adhesive disease. Relief of
the outflow tract obstruction frequently results in com-
Figure 29.1 Grünberger Z-plasty technique for trans-
plete reversal of even extensive endometriosis.7
verse vaginal septum (From Wierrani F, et al., Fertil Steril.
The imperforate septum is generally approached vagi-
2003;79(3):608-12. With permission.)
nally. The procedure should be preceded by catheteriza-
tion of the bladder with a Foley catheter. The surgeon must
remain cognizant of both the bladder and the rectum dur- for example, 2-0 or 3-0 polyglactin 910 positioned with a
ing the resection. For thick transverse septa, the process is tapered (non-cutting) needle such as a SH, V20, CT-1, or
started by placing a large bore spinal needle through the GS-21 design (depending on the manufacturer), the former
septum to confirm and orient the presence and location especially if there is space limitation within the vagina.
of the hematocolpos with the aspiration of old, thickened With thicker vaginal septa, if there is a significant gap,
blood. Resection of the septum is then undertaken, a pro- the vaginal epithelium can be addressed with the Z-plasty
cess that can include use of a monopolar radiofrequency technique, which is performed to add length to the vagina
(RF) electrical needle or blade electrode used to incise and minimize the risk of vaginal stenosis. Where Z-plasty
through the center of the septum along the needle tract. is not feasible, a split-thickness skin graft may be required
This incision should be created with extreme care, avoid- with postoperative placement of a vaginal stent. The role
ing posterior or anterior deviation toward the rectum or for a postoperative acrylic vaginal stent when a skin graft
urethra. With such electrodes, a setting of 25–35 watts is not used is controversial; there is no available quality
“cutting” current is generally effective for septum dissec- evidence to provide guidance. Consequently, the use of a
tion. In cases of thin septa, resection should be done as stent should be determined by the surgeon on a case-by-
widely as possible to reduce postoperative vaginal steno- case basis if there is concern for contraction of the newly
sis. Upon completion of the resection, it is important to created space. Postoperatively, the maintenance of vaginal
perform a careful rectal examination to detect otherwise depth is important. If the patient is not sexually active, a
occult injury. vaginal stent should be considered. The vaginal stent can
It is important to establish continuity of the vaginal be placed either routinely each evening at bedtime or, at
epithelium across the area of resection. Consequently, least, several times per week.
once the septum is resected, the proximal and distal ends The abdominal perineal approach is rarely used. This
should be approximated with interrupted sutures with, technique can be considered if the transverse vaginal

septum is difficult to appreciate and there is no hemato-
colpos to allow for bulging of the septum. We recommend
that during laparoscopy, a 5 mm colpotomy incision is
created, followed by the placement of a suction irrigator
tip through the incision allowing the compartment of the
vagina to be distended. Concurrently, at the perineum, an
incision is created vaginally over the bulge. Moreover, we
find that the suction irrigator tip can also be used to apply
pressure to the septum and locate the area of the septum
for incision.
It would stand to reason that outcomes, in part, are
predicated upon whether the septum is imperforate, i.e.,
associated with amenorrhea, or perforate and has an open
area for egress of menstrual fluid. The imperforate septum
can lead to a hematocolpos that, over time, can apply pres-
sure on the septum, thereby causing thinning. The imper-
forate septum can also facilitate surgical interventions by
allowing for bulging of the septum that facilitates dissec-
tion away from surrounding structures. The location and
the thickness of the septum are also important prognostic
variables. A high vaginal septum is technically more diffi-
cult to surgically correct. In general, complication rates are
low.4 The main long-term complication is vaginal stenosis,
which may generally be managed by vaginal dilation. As
previously mentioned, the risk of this adverse event can be
minimized with postoperative use of a vaginal stent placed
by the patient until she becomes sexually active.8
Longitudinal vaginal septum (CONUTA V1 and V2)
Since a longitudinal vaginal septum, CONUTA V1 or V2
from the ESHRE system, is often associated with other
Müllerian anomalies, most commonly the didelphic and
septate uteri (ASRM Class 3 and 5, respectively), this find-
ing must prompt further workup for other abnormalities
(see Chapter 11). This type of septum, when not associated
with outflow tract obstruction, typically doesn’t present
until the patient attempts tampon insertion or becomes
sexually active. The patient may bleed despite tampon
insertion, and experience dyspareunia secondary to vagi-
nal compromise. The septum can be complete, which is
more often associated with uterus didelphys (AFS Class 3;
CONUTA U3), or can be fenestrated.
Management is surgical transection, usually performed
after menarche. Prior to surgery, it is important for the
surgeon to perform a careful pelvic examination to evalu-
ate the length of the septum and to confirm the presence
and number of cervices. There are several techniques
from which to select, with perhaps the most common and
traditional being serial resection and suture ligation of
segments using Haney- or Kelley-type clamps and a scal-
pel, scissors, or monopolar needle or blade electrode for
transection.
Alternatively, and if possible, the entire length of the
septum can be clamped with appropriate Peon or Kelly
clamps and then transected with a monopolar blade or
needle electrode; then the clamps can be sequentially
removed and the incisions closed with a continuous, lock-
ing 2-0 polygalactin 210 suture.9
Müllerian anomalies affecting the uterus 435
Additionally, Perez-Millcua et al. introduced the
LigaSure™ (Medtronic/Covidien Minneapolis, MN) for
vaginal septum transection starting at the most caudal
portion of the septum and extending cephalad until the
cervix or cervices are reached. As an RF bipolar vessel-­
sealing ­system the Ligasure has an advantageous small jaw
that can be used to maneuver tight vaginal spaces. The ther-
mal energy spread is 1–4 mm and is, therefore, less likely
to cause adjacent bladder or rectal injury. While it is prob-
ably unnecessary, the edges of the resected area can then be
oversewn with interrupted polyglactin 910 (or equivalent),
and a vaginal mold can be considered for use immediately
postoperatively to minimize stricture and scarring of the
vagina (Video 29.1).10
There have also been reports of hysteroscopic techniques
such as RF resectoscopy being used for transection of a
vaginal septum in virginal girls and women who prefer to
maintain an intact hymen. In this case, the vagina is dis-
tended with fluid media, and RF electrical energy through
a cutting loop or needle-cutting electrode is then applied
to the magnified fibrous layer of the septum. Ultrasound
guidance is used simultaneously.
With each method, periodic rectal examination should be
undertaken to ensure that the zone of dissection is kept away
from the bowel. The resections (or transections) are ideally
brought to the level of the cervix or cervices; care must be
taken not to traumatize the cervix (or cervices) at the upper
limits of resection.8 In general, reapproximation of denuded
vaginal epithelium is often necessary in the area of resec-
tion or transection. Absorbable sutures, e.g., 3-0 polyglactin
910, can be used to reapproximate the vaginal epithelium.
Although post-operative stenosis or adhesion formation is a
rare sequella of longitudinal septum resection, reassessment
in two to four weeks is appropriate to evaluate the vagina and
break down anteroposterior adhesions that may have formed.
MÜLLERIAN ANOMALIES AFFECTING THE UTERUS
rAFS Class I-hypoplasia/agenesis (CONUTA U5)
Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome
(CONUTA U5b-C4-V4)
Psychologically, it is important that procedures designed
to create a vagina be initiated at an appropriate age, con-
sidering several factors, including the patient’s sexual
orientation, her motivation for the surgery, and the avail-
ability of professional and family support. Consequently,
psychosocial counseling before treatment intervention is
appropriate.11
Non-operative techniques can be very successful and,
consequently, should be considered the first line approach.9
The original technique (Frank technique) employs the
patient’s use of graduated Lucite (vaginal) dilators of
progressively increasing diameter to create a functional
vagina (Figure 29.2).12 The process begins at the vaginal
dimple with the patient instructed about the proper orien-
tation and angle of dilator placement to minimize the risk
of trauma to the urethra. Success rates are in the realm of
85%–90% regarding satisfactory coitus.9,13
436 Surgery for congenital anomalies
Figure 29.2 Vaginal obturators or dilators. These devices,
of progressively increasing length and diameter, may be used
by patients with vaginal agenesis to progressively create a
functional vagina, starting with the smallest and progressing
as appropriate to the largest size. They also can be of use for
women with “vaginismus” to desensitize the muscles of the
perineum and pelvic floor, and postoperatively following sur-
gical vaginal reconstruction. This brand, from Vaginismus.com,
comprises six dilators and a universal handle. The smallest,
attached to the handle, is 0.6 inches (15 mm) wide and 3.48
inches (88 mm) long. The largest (far right) is 1.5 inches (38 mm)
in diameter and 5.96 inches (151 mm) long.
The Ingram passive dilation technique uses a bicycle
seat to secure the dilator in place while providing increas-
ing pressure to create a functional vagina.14 The goal of
these techniques is the creation of a vagina more than 7 cm
in length and the achievement of successful coitus. The
available evidence suggests that this approach is associ­
ated with a success rate of 90%.9,13,15,16
One of the original surgical approaches to vaginal
agenesis was the Wharton–Sheares–George technique, in
which the surgeon identifies and then dilates the vestigial
Müllerian ducts in the space between the two labia, just
dorsal and lateral to the urethral meatus. Hegar or simi-
lar dilators are used, aligned with the axis of the urethra
and then firmly pressed to form two parallel tunnels with
a resulting intervening central septum. This surgically cre-
ated septum is subsequently transected (as for a longitu-
dinal vaginal septum) to form a blind pouch.17 With the
George modification, only a vaginal mold is inserted into
the cavity and left for a week, when it is exchanged for a
larger obturator. This device is then used by the patient day
and night for three months after which time epithelializa-
tion has occurred to the point that intercourse is possible.18
A procedure designed to create a blind pouch between
the bladder/urethra and rectum that is then lined with
a split thickness skin graft was originally described by
Abbe in 1898,19 and then later revised by Macindoe and
colleagues.20,21 The Abbe–Macindoe procedure can be
performed in a fashion like that of the Wharton proce-
dure or by incising the perineum between urethra and
rectum with subsequent development of the usually avas-
cular rectovaginal space with a combination of blunt and
sharp dissection (Figure 29.3). Then the vaginal stent or
mold is covered with an inverted split-thickness graft
typically taken from the skin of the buttocks or thigh.
Unfortunately, the graft site can be a source of morbid-
ity and provides a less than ideal cosmetic result. A num-
ber of options to the split thickness grafts have evolved
including the use of amnion,22 artificial dermis,23 and in
vitro cell culture; each of these tissue types was designed
to develop into vaginal squamous epithelium. Long-term
outcome studies are not available regarding the effectiv-
ity these options. With use of any of these techniques,
a vaginal mold is continuously left in place for at least a
week, but then, to preserve the vaginal length and cali-
ber, is used in daily by the patient, until she is engaged in
regular sexual intercourse.
There exist several other methods for creating a vagina
that combine a laparoscopic and vaginal approach. The
laparoscopic Vecchietti procedure is a modification of the
original laparotomic approach24 and uses a segmented
acrylic mold placed in the vaginal dimple with sutures
brought out through the abdominal wall in a way that
allows for continuous traction.25
There are several variations in technique (Figure 29.4)
(Video 29.2). For one, after emptying the bladder and
establishing a pneumoperitoneum, the laparoscope is
placed transumbilically and two ancillary cannulas are
positioned in the left and right lower quadrant.26 The peri-
toneum between the bladder and the uterine remnant is
incised for about 5 mm with an appropriate instrument,
most commonly laparoscopic scissors. One of the lapa-
roscopic ports is replaced with a specially designed liga-
ture carrier that is passed just subperitoneally and then
caudally between the rectum and bladder, guided by a
finger placed in the rectum. Cystoscopy and anoscopy/­
sigmoidoscopy are performed to ensure that the needle
has not captured the lumen of either viscus. The needle
is then used to penetrate the skin of the “pesudohymen”
or vaginal dimple between the anus and urethra. Threads
attached to the acrylic “olive” are threaded through the
fenestration in the ligature carrier that is withdrawn,
thereby pulling the threads into the peritoneal cavity and
then subperitoneally and out through the abdominal wall
where they are affixed to a traction device. Alternatively,
the ligature carrier can be used via the vaginal dimple,
placed under firm stretch in a cephalic direction in a fash-
ion that allows, with laparoscopic assistance, puncture
into the peritoneal cavity. The threads are then drawn
through the subperitoneal space and subsequently exter-
nalized with the ligature carrier.25 The suture threads are
tightened 1–1.5 cm/d for seven to ten days. Subsequently, a
vaginal dilator is used to complement coitus, all of which
is focused on maintenance of adequate vaginal length and
satisfactory intercourse. Success regarding coitus has been
excellent and reported at over 90%.26–28
The Davydov procedure, originally performed laparo-
tomically and described from Russia in 1969, creates the
neovagina by lining the dissected vesicorectal space with
peritoneum advanced from the adjacent peritoneal cav-
ity.29 The laparoscopic Davydov procedure (Figure 29.5)

Absence
of vagina
(a) (b)
(c) (d)
STSG
(g)
(f )
(h) (i)
Figure 29.3 (a–k) Macindoe procedure. (Modified from www.atlasofpelvicsurgery.com. With permission.)
is simply a minimally invasive adaptation of the same
procedure (Video 29.3). 30 With the bladder catheterized,
the procedure is started laparoscopically by separat-
ing the urinary bladder from the rectum after form-
ing a 4–5 cm transverse peritoneal incision between
the two rudimentary uterine remnants, generally with
laparoscopic scissors. With a finger in the rectum, the
incision can be extended for about 1 cm between the
bladder and rectum. From the perineum, the vesicorec-
tal space is identified after making an “H”-shaped inci-
sion, and developed in a fashion similar to that used for
the Wharton–Sheares–George technique with a large
27–28 Hegar dilator or with a combination of sharp and
blunt dissection until the peritoneal edges are seen. The
incised peritoneum is mobilized and drawn down cau-
dally through this space and sutured to the edge of the
“H” incision with interrupted 3-0 delayed absorbable
monofilament sutures. After identifying the location
of the ureters, a purse string or two “hemipursestring”
sutures of a 2-0 delayed absorbable monofilament are
positioned to include the lateral aspect of the meso-
rectum, the anterior rectal serosa, the peritoneum of
Müllerian anomalies affecting the uterus 437
(e)
(j) (k)
the bladder dome, the round ligaments, the uteroovar-
ian ligament, and lateral peritoneal leaf. This step can
be accomplished either before or after the anastomosis
of the peritoneum and the vestibule. 31 A vaginal stent
(mold) is left in place for ten days followed by fitting with
a permanent mold to complement maintenance of vagi-
nal depth with intercourse.
The potential complications associated with these pro­
cedures include injury to bowel, bladder, and urethra as
well as surgical bleeding. In addition, reduced vaginal
length is likely to occur if there is lack of compliance with
use of molds and/or coitus. Stricture and contracture
secondary to scarring can occur as well as formation of
granulation tissue and, if a split skin graft is used, hair
growth in the vagina. Vesicovaginal, urethrovaginal, or
rectovaginal fistula formation is also possible if there is
injury to these adjacent structures. Vaginal vault prolapse
is a potential problem after any intervention. However,
overall, the incidence of such complications is low and in
general less than 10%.13,15,16
Other methods of vaginoplasty are less popular and
include use of bowel, sigmoid, jejunum, and ileum to line
438 Surgery for congenital anomalies

the newly created vagina; however, foul-smelling mucus

discharge and requirement for laparotomy make these
approaches less desirable.32
Success rates are at least 74% when vaginoplasty tech-
niques are viewed as a whole.16 Functional success based
on the validated Female Sexual Function Index reflects
a range of 0 (poor) to 36 (extremely satisfied); this index
provides scores of 25.2+/–3.7 for vaginal dilation and 27.9
+/–3.0 with vaginoplasty, compared to the general popula-
tion of 30.2 +/–6.1.13,14,16,33
Instances of isolated agenesis of the lower vaginal tract
may result from errors in the development of the sino-
vaginal bulbs and the vaginal plate. This can present as
primary amenorrhea with findings of hematocolpos on
imaging (Figure 29.6).34 There may be a dimple present at
the location of the vaginal introitus. Treatment for this is
surgical and typically timed with adequate hematocolpos
to distend the upper vaginal canal.
A transverse incision should be made at the perineum
at the location of the vaginal dimple approximately 2 cm
in length. Using a scalpel, the incision is continued until
the bulging hematocolpos is reached. Care should be
taken to remain in the same plane while creating the
incision at the perineum to avoid injury to the urethra,
bladder, or rectum. We recommend placement of a Foley
catheter prior to incision to adequately show and palpate
the location of the urethra throughout the procedure.
A rectal exam should also be performed initially to pal-
pate the hematocolpos location and then again at the end
of the procedure to ascertain that no injury was incurred
to the rectum. Once the hematocolpos has been reached
and evacuated, vaginal epithelium can be seen. The vagi-
nal epithelium should then be grasped with atraumatic
clamps, such as an Alis clamp, at four corners and then
pulled out to the level of the perineum to begin to create
an introitus. The four corners of the vaginal epithelium
can then be secured to the perineum using interrupted
Figure 29.4 Isolated vaginal agenesis. (From Jessel RH, delayed absorbable sutures such as 2-0 polygalactin 910.
Laufer MR, J Pediatr Adolesc Gynecol. 2013;26(1):e21-3. With Additional sutures may be added along the perimeter of
permission.) the neointroitus.34

Figure 29.5 Surgical management of cervical agenesis. (From Fedele L, et al., Fertil Steril. 2008;89(1):212-16. With permission.)

(a)
(d)
Figure 29.6 Cervical agenesis. (From Kriplani A, et al., J Minim Invasive Gynecol. 2012;19(4):477-84. With permission.)
This tract can allow for additional drainage of any remain­
ing hematometria or hematosalpinx. Postoperatively,
patients should be told to expect o ­ngoing chocolate-­
colored discharge until adequate drainage of the tract has
occurred; visualization of the next menses will confirm
the patency of the tract. Cases of vaginal stricture have
been noted postoperatively where the vaginal epithelium
was pulled out more than 3 cm.35 There has been no good
evidence to support the use of vaginal stents or molds fol-
lowing the pull out method.
Cervical agenesis (CONUTA C3 [unilateral aplasia]
or C4 [cervical aplasia])
Isolated cervical hypoplasia or agenesis is extremely rare,
with the actual incidence unknown.15,32,36 The coexistence
with vaginal agenesis has been estimated to be about 25%
based on cases reported in the literature.36 Much of the
available evidence is derived from case reports and very
small series, a circumstance that makes it difficult to gener-
alize recommendations. Reconstruction based on the con-
cept of uterovaginal anastomosis has been described and
rarely reported to result in successful spontaneous preg-
nancy.37–42 In the past, the procedures typically included
a uterovaginal graft as part of the accompanying vagino-
plasty that was required for the commonly encountered
patients with vaginal agenesis. This approach has also been
associated with tragic outcomes, including infection and
even death related to endomyometritis, reobstruction, and
death secondary to sepsis.40,43
More recently a different laparoscopically directed tech-
nique has been described that does not require a graft,
involving mobilization of the uterus with dissection of the
vesicouterine and rectouterine spaces and by dividing the
Müllerian anomalies affecting the uterus 439
(b) (c)
(e) (f )
round ligaments.42 Then, a probe is passed into the endo-
metrial cavity through a small midline fundal hysterotomy.
This probe is then applied to the cervical plate, displacing
the uterus caudally. From below, an “H” incision is made
in the retrohymenal dimple, and blunt and sharp dissec-
tion is carefully performed until the caudal end of the cor-
pus is reached. After stabilizing the corpus, incisions are
made over the probe entering the cavity, and the corpus is
attached to the flaps of the “H” incision, thereby creating
a neovaginal canal. A mold can be left in place and then
inserted and reinserted. A series of 12 such patients has
been reported, with long-term maintenance of vaginal cali-
ber, and all who had attempted vaginal sexual function had
done so successfully; no pregnancies had been attempted.42
For those with cervical hypoplasia, but with a patent
canal without hematocolpos, ART.approaches include
zygote intrafallopian transfer44,45 and image-guided trans-
myometrial transfer of embryos to the endometrial cavity
to bypass cervical passage can be considered.46,47
Unicornuate uterus (rAFS Class II; CONUTA U4-C3)
As mentioned in Chapter 11, there is no evidence to sup-
port surgical treatment of a unicornuate uterus with con-
tralateral agenesis. No surgical intervention is deemed
necessary unless the Class II anomaly is associated with a
contralateral uterine horn with functional endometrium
and outflow tract obstruction (rAFS Class II b; CONUTA
U4a-C3).
Class II b anomalies are associated with a higher inci-
dence of endometriosis, in addition to premature labor
and malpresentation. A spontaneous abortion rate of 37%,
preterm delivery rate of 16%, term delivery of 45%, and
live birth rate of 54% have been reported.48,49
440 Surgery for congenital anomalies
Surgical intervention of an obstructed uterine horn
requires assessment of the renal system, as anomalies may
include either agenesis or distortion of anatomy, such as
the course of the ureter. If a decision is made to excise
the involved uterine remnant, this can usually be accom-
plished laparoscopically (Video 29.4). Following position-
ing of the laparoscopic ports, and with confirmation of the
anatomy including the location of the ureter or ureters, the
dilated and obstructed horn is identified. Adhesions are
lysed as appropriate with scissors or an appropriate energy
source. The pedicle comprising the round ligament, the
fallopian tube, and the ovarian artery (“triple pedicle”) is
identified and transected after coagulating the tissue with
RF or ultrasonic energy. The pedicle is transected and the
leaves of the broad ligament opened and then divided,
exposing the vascular supply to the horn, usually from
the ipsilateral uterine artery. It is advisable to extend the
peritoneal incision to the vesicovaginal fold isolating the
bladder from the area of dissection. Then the blood sup-
ply can be sealed and transected. Attention can then be
turned to separation of the horn from the “normal” corpus
in a way that preserves optimal myometrial caliber. This is
usually performed with an RF needle or blade electrode
or an ultrasonic scalpel or shears. The dissection is con-
tinued until it meets that from the lateral side when the
blind horn can be removed. Removal from the peritoneal
cavity can be accomplished with an appropriate morcella-
tion technique (Chapter 4). Suture reapproximation of the
detached round, broad, and uteroovarian ligaments to the
“normal” horn can be performed using running or inter-
rupted delayed absorbable 2-0 sutures.
Didelfic uterus (rAFS Class III; CONUTA U3b-C2)
Generally, there is no indication for surgical intervention
except for excision of an associated symptomatic vaginal
septum, i.e., hemi-vagina with associated hematocolpos.
Overall the spontaneous abortion rate is 32%, preterm
birth rate is 28%, term delivery is 36%, and live birth rate
is 56%.48,49 Controversy remains regarding the role of
Strassman metroplasty in women with recurrent preg-
nancy loss, especially those that occur in the second tri-
mester. Unification of the uterine cavities (described below
with Class IV anomalies) can be accomplished via lapa-
rotomy or with minimally invasive techniques; following
laparotomy, outcomes describing an 80% live birth rate
have been reported.50 However, overall, the available evi-
dence does not support this type of unification procedure.51
OHVIRA (obstructed hemivagina and ipsilateral renal
agenesis) is one of the more common Müllerian anomalies
associated with obstruction (CONUTA U2/U3b-C2-V2).
Resection of the wall between the patent and obstructed
hemi-vagina on the involved side results in relief of pain
in association with retained menstrual fluid. Ideally,
management includes a single stage approach that entails
vaginally directed resection of the hemi-vagina aided by
intraoperative ultrasound and laparoscopy as appropri-
ate. Upon resection, a hematocolpos is usually noted, and
thus creation of an outflow tract relieves the unilateral
obstruction. Care must be taken to widely excise the sep-
tum, and in a manner similar to that for transverse vagi-
nal septum resection, the vaginal epithelium is then well
approximated (see Chapter 11).
Bicornuate uterus (rAFS Class IV; CONUTA
U3a, b, and c-C0)
Surgical reconstruction can be considered in the patient
with recurrent pregnancy loss and an rAFS Class IV
anomaly. Outcome data are variable with pre-operative
live birth rates ranging from 2%–21% to post-surgical suc-
cess at 60%–86%.51–53 The spontaneous abortion rate has
been reported to be 36%, the preterm rate 23%, term deliv-
ery rate 41%, and live birth rate 55%.16
One option, as noted for Class III/U3b anomalies, is the
Strassman metroplasty, a procedure that results in unifica-
tion of the two uterine horns after the creation of a trans-
verse fundal incision. Following access to the peritoneal
cavity, the procedure starts with use of dilute vasopressin
(concentration varies, e.g., 1 unit diluted with 30 ml normal
saline) injected into area of planned uterine incision. The
myometrium is incised with a monopolar RF blade or needle
electrode using a low voltage (“cutting”) waveform at about
30 watts (depending on the design of the electrode); the inci-
sion is made from the superomedial aspect of each uterine
horn with care being taken not to disturb the cornual aspects
on each side of the uterus. The incision is extended down
to the endometrial cavity. This is followed by transposing
the incision to a vertical orientation and then approximat-
ing the myometrial edges with interrupted 0-polygalactin
910 (Vicryl), or equivalent delayed absorbable sutures. The
serosa is reapproximated with a 3-0, delayed absorbable
suture. The result resembles the appearance of the repaired
incision associated with a classical Cesarean section.32,54
Cervical cerclage has also been reported to reduce the
risk of second trimester pregnancy loss and preterm birth;
however, available comparative evidence suggests that
expectant management appears to be of equal efficacy.48
Septate (rAFS Class V; CONUTA U2-C0/1)
As previously mentioned, there is a large body of evidence
to support the surgical management of a septate uterus
to improve pregnancy-related outcomes in patients with
a history of recurrent pregnancy loss.55–57 Additionally,
Chapter 11 addressed the argument for prophylactic tran-
section of the septate uterus in patients with primary
infertility.
The question of septum management prior to in vitro
fertilization overall seems most supportive of septum
transection.58 This question has been addressed in a series
reflecting IVF outcomes before and after hysteroscopic
septum transection. In patients with a large septum (rAFS
Va; CONUTA U2b) that was left intact, the spontaneous
abortion rate was 83.3% and with a small septum (rAFS
Vb; CONUTA U2a), 28.9%. This was in comparison to
patients for whom a larger septum was removed, where the
miscarriage rate was found to be 30.6% while with small
septum transection it was reported as 28.1%.58

The technique is NOT septum resection but hystero-
scopic transection. This approach appears to result in an
“almost normal prognosis for pregnancy outcomes and
term delivery rates.”48 If the septum reaches the level of the
exocervix (CONUTA U2b-C1), there has been some con-
troversy regarding management—some suggesting that
the cervical component be left intact, while others remove
the cervical septum in its entirety.59 If there is uncertainty
regarding the diagnosis—i.e., the distinction between a
rAFS Class IV and Class V anomaly—it is most appropri-
ate to perform the procedure in the operating room under
laparoscopic guidance. However, when 3-D TVUS or MRI
is available this should not be necessary.
There does not appear to be any uniform approach to
pre-op endometrial suppression with progestins, danazol,
or Gonadotrophin-releasing hormone agonists, but it is
apparent that they avoid the specter of endometrial frag-
ments obscuring visualization and potentially clogging
the flow channels of the hysteroscope.
At least for rAFS Va (CONUTA U2b) anomalies, the
technique can be performed under local anesthesia as an
office procedure using no or, preferably, local anesthesia;60
it can also be performed under conscious sedation (see
Chapter 7). All that is necessary is a hysteroscope placed
within a 5 or 5.5 mm OD continuous flow operative sheath
with a 5 Fr operating channel and either 5 Fr hysteroscopic
scissors or an RF needle. Such an approach may be associ-
ated with reduced operating time and complications but
equivalent outcomes.61 Usually, the selected hysteroscope
has an oblique lens, either 12°–15° or 25°–30°. When mechan-
ical or bipolar RF instruments are used, the distending
media should contain electrolytes such as a normal saline
solution. Nonelectrolytic media such as sorbitol, glycine,
or mannitol are used for uterine distention when monopo-
lar RF instrumentation is selected. The fluid deficit should
be monitored throughout the procedure as described
in Chapter 7 with maximum deficits of 1000 mL with
non-electrolyic solutions and 2000–2500 mL with saline
media, each signaling termination of the procedure. For
more details regarding hysteroscopic distending media,
see Chapters 7 and 10 and the AAGL Practice Report on
management of hysteroscopic distending media.62
The specific approach utilizing hysteroscopic scissors,
laser energy, or RF monopolar or bipolar devices is, in
large part, operator choice. If the surgeon is confident of
the diagnosis based on MR imaging or prior laparoscopic
evaluation, and the septum is confined to the endometrial
cavity, it is rather simple and safe to perform in an office
setting. After obtaining appropriate local anesthesia (see
Chapter 7) (Video 29.5) the cervix is dilated as necessary
to accommodate the outer diameter of the hysteroscopic
system to be used in the procedure. After accessing the
cervical canal, the septum is identified with the two “tun-
nels” that represent the endometrial cavities on each side.
In such instances, additional anesthesia may be provided
with hysteroscopically directed injection of 0.5% lidocaine
(or mepivacaine), with 1/200,000 adrenaline into the sep-
tum with a suitable needle passed through the operating
Müllerian anomalies affecting the uterus 441
channel of the hysteroscope. Examples include an oocyte
retrieval needle or a 5 Fr Williams needle. Then the scis-
sors or, preferably, a bipolar needle is passed through the
operating channel of the operative sheath. Transection of
the septum can start with the most caudal portion divid-
ing the tissue while continually ensuring that the plane of
transection is midway between the anterior and posterior
aspects of the endometrial cavity. In general, this plane
will be relatively avascular—if bleeding is encountered, it
is possible that the dissection has deviated off plane. The
surgeon should also be aware of the cephalic extent of dis-
section with the end point being the observation of muscu-
lar tissue, bleeding, and/or the transection reaching a plane
that is approximately level with the cornua.61 It is better to
leave a small amount of the septum than to go too far.
If the procedure is performed under laparoscopic guid-
ance, the laparoscopic light source can be turned off while
viewing the uterus to visualize uniformity of hystero-
scopic resection. In this case, the uterus seen through the
laparoscope takes on the appearance of a “jack-o’-lantern”
when uniform hysteroscopic transect is accomplished.
For Class Va anomalies that reach the level of the exo-
cervix (CONUTA U2, C1), the approach changes some-
what, as there is controversy regarding the propriety of
removing the cervical component of the septum.
Advocates for preservation of the cervical septum at the
time of metroplasty propose a hypothetical risk of iatro-
genic cervical incompetence in subsequent pregnancies.
To transect the septum in the uterine corpus while pre-
serving the cervical component of the septum, a pediatric
#8 Foley catheter or metal probe is inserted into one hemi-
cervix. A resectoscope or operative rigid hysteroscope is
then placed in the contralateral hemicervix and the other
hemicervix is distended with fluid media. The septum is
then incised with hysteroscopic scissors or with a needle
or blade electrode just above the internal cervical os until
the Foley bulb or metal rod is visualized. Transection of
the septum is continued in a cephalad direction until both
tubal ostia are visualized and the hysteroscope can move
free about the cavity.
Proponents of cervical septum transection have postu-
lated that removal of the septum allows for an easier and
safer hysteroscopic metroplasty. One randomized con-
trolled trial comparing those women with cervical septum
transection versus retention found that in the transection
group, total operative time was reduced owing to improved
visibility and ease of initial uterine septum incision during
hysteroscopy.63 The use of distending media was reduced
in the cervical transection group. No difference was found
in subsequent pregnancy rates, first trimester abortions,
the need for cerclage, or the proportion of preterm deliv-
eries. The group with cervical septum retention had a sig-
nificantly higher number of cesarean sections.
Transection of the septum can be performed by first plac-
ing two single tooth tenacula on the anterior aspect of the
cervix. Then the two cervical canals can be dilated one at a
time to 6 mm. Next, using Metzenbaum scissors, the cervi-
cal septum can be incised to the level of the cervical canal
442 Surgery for congenital anomalies
Table 29.1 Complications of vaginoplasty.
Urinary Complaints and Bleeding 1%
Bladder Trauma 2%
Rectum or Bladder Perforation 1%–4%
Long-term UTI 4%–7%
Vaginal Stricture or Contracture 4%–9%
Vesicovaginal/Rectovaginal Fistula 1%–3%
Skin Graft Necrosis 1%–3.5%
Persistent Vaginal Discharge 3%
Vaginal Prolapse 3%
Source: Adapted from Callens N, et al., Hum Reprod Update.
2014;​20(5):775-801.
sufficient to allow adequate distension following placement
of an operative hysteroscope or resectoscope. Then, with
hysteroscopic scissors, or a suitable needle electrode, the
surgeon can transect the remaining portion of the septum
in the cervix and the uterine corpus (see Table 29.1).
Concurrent laparoscopy may be used to monitor for
perforation of the corpus or cervix; however, with prepro-
cedure imaging, good hysteroscopic visualization, and, if
necessary, intraoperative transabdominal ultrasound, this
step is usually unnecessary. The procedure should be per-
formed either in the follicular phase of the menstrual cycle
or following preoperative treatment with progestins to thin
the endometrium and improve hysteroscopic visibility.
There is some controversy regarding the utility of
postoperative intrauterine stents or barriers. Estrogens,
progestins, and stents, including intrauterine devices
and pediatric Foley catheters, are used by many without
abundant evidence of value.64 A randomized clinical trial
was conducted to address the utility of an intrauterine
device (IUD) placed postoperatively vs. no placement of
an IUD upon completion of hysteroscopic metroplasty. All
patients received postoperative conjugated equine estro-
gens at 1.2 mg twice daily for 30 days with the addition of
medroxyprogesterone acetate 10 mg daily on days 26–30.
The researchers concluded the use of an IUD with hor-
monal therapy did not seem to be efficacious.65 Moreover,
additional trials have shown that the use of neither post-
operative estrogen, copper IUD, nor intrauterine balloon
had any benefit in the prevention of postoperative adhe-
sion formation following metroplasty.
Other approaches, not necessarily recommended in
light of the advances in hysteroscopically directed sur-
gery, include abdominal metroplasty, which requires
laparotomy, or laparoscopy for septum resection, exam-
ples of such include Jones metroplasty, where a cuneiform
portion of fundal myometrium is resected, and the Bret–
Tompkins metroplasty, in which an anteroposterior inci-
sion is made into the uterus, the septum is incorporated
into the myometrium, and uterine muscle closure occurs
without removal of any tissue.64 In addition, El Magoub
reported approaching the fundus with a small transverse
incision along the septum through which the septum is
removed.66
Arcuate (rAFS Class VI; CONUTA-No categorization)
The arcuate uterus is “a variant of normal”; patients with
Class VI lesions should not be advised to undergo surgery.
As described in Chapter 11, and by definition, the arcuate
uterus equates with a septum measurement of less than 1 cm
in length. The reported reproductive outcomes reported
are similar to those of “historical controls.”20–23,52,54,67,68
Diethylstilbestrol (DES)-related anomalies (rAFS
Class VII)(CONUTA U1)
Until 1971, DES was given to help prevent miscarriage in
women with a prior history of spontaneous abortions. The
relationship of DES to uterovaginal anomalies is a subject
discussed in Chapter 11. There has been no good evidence
to suggest metroplasty or other corrective surgeries as
being efficacious.10 If genetic progeny are desired, then
the individual or couple can consider controlled ovarian
hyperstimulation, IVF, and subsequent gestational carrier.
Possible infertility with cervical hoods, collars, or vaginal
adenosis may be overcome with intrauterine insemina-
tion. Again, there is no good evidence to suggest that sur-
gical intervention is warranted here.
VIDEOS
Video 29.1 Transection of longitudinal vaginal septum.
https://youtu.be/jXK_AvILhVQ
Video 29.2 Laparoscopic Vecchietti procedure. https://
youtu.be/0IGbkMYZwA8
Video 29.3 Laparoscopic Davydov procedure. https://
youtu.be/pJLCHZhl7lc
Video 29.4 Laparoscopic removal of uterine horn. https://
youtu.be/Mc_TVO14C4M
Video 29.5 Hysteroscopic metroplasty rAFS Va septum.
https://youtu.be/uJ1RBeDdPBs

REFERENCES
1. Vaughan ED, Jr., Middleton GW. Pertinent genito-
urinary embryology: review for practicing urologist.
Urology. 1975;6(2):139-49.
2. Lemaine V, Simmons PS. The adolescent female:
breast and reproductive embryology and anatomy.
Clin Anat. 2013;26(1):22-8.
3. Practice Committee of the American Society for
Reproductive M. Current evaluation of amenorrhea.
Fertil Steril. 2006;86(5 Suppl 1):S148-55.
4. Williams CE, Nakhal RS, Hall-Craggs MA, Wood D,
Cutner A, Pattison SH, et al. Transverse vaginal sep-
tae: management and long-term outcomes. BJOG.
2014;121(13):1653-8.
5. Rock J. Anomalous development of the vagina.
Semin Reprod Endocrinol. 1986;4:13-31.
6. Wierrani F, Bodner K, Spangler B, Grunberger W.
“Z”-plasty of the transverse vaginal septum using
Garcia’s procedure and the Grunberger modifica-
tion. Fertil Steril. 2003;79(3):608-12.
7. Sanfilippo JS, Wakim NG, Schikler KN, Yussman
MA. Endometriosis in association with uterine
anomaly. Am J Obstet Gynecol. 1986;154(1):39-43.
8. Quint EH, McCarthy JD, Smith YR. Vaginal sur-
gery for congenital anomalies. Clin Obstet Gynecol.
2010;53(1):115-24.
9. Morcel K, Lavoue V, Jaffre F, Paniel BJ, Rouzier R.
Sexual and functional results after creation of a neo-
vagina in women with Mayer-Rokitansky-Kuster-
Hauser syndrome: a comparison of nonsurgical and
surgical procedures. Eur J Obstet Gynecol Reprod
Biol. 2013;169(2):317-20.
10. Epelboin S. [Diethylstilbestrol exposure in utero.
Polemics about metroplasty. The cons]. Gynecol
Obstet Fertil. 2007;35(9):832-41.
11. Oppelt PG, Lermann J, Strick R, Dittrich R, Strissel
P, Rettig I, et al. Malformations in a cohort of 284
women with Mayer-Rokitansky-Kuster-Hauser
­syndrome (MRKH). Reprod Biol Endocrinol.
2012;10:57.
12. Frank R, Geist D. The formation of an artificial
vagina without operation. Am J Obstet Gynecol.
1938;14:712-18.
13. Committee on Adolescent Health C. Committee
opinion: no. 562: Mullerian agenesis: ­ diagnosis,
management, and treatment. Obstet Gynecol.
2013;121(5):1134-7.
14. Ingram JM. The bicycle seat stool in the treatment of
vaginal agenesis and stenosis: a preliminary report.
Am J Obstet Gynecol. 1981;140(8):867-73.
15. Roberts CP, Haber MJ, Rock JA. Vaginal cre-
ation for mullerian agenesis. Am J Obstet Gynecol.
2001;185(6):1349-52; discussion 52-3.
16. Callens N, De Cuypere G, De Sutter P, Monstrey S,
Weyers S, Hoebeke P, et al. An update on surgical
and non-surgical treatments for vaginal hypoplasia.
Hum Reprod Update. 2014;20(5):775-801.
References
17. Wharton LR. A simple method of constructing a
vagina: report of four cases. Ann Surg. 1938;107(5):​
842-54.
18. Walch K, Kowarik E, Leithner K, Schatz T, Dorfler
D, Wenzl R. Functional and anatomic results after
creation of a neovagina according to Wharton-
Sheares-George in patients with Mayer-Rokitansky-
Kuster-Hauser syndrome-long-term follow-up. Fertil
Steril. 2011;96(2):492-7 e1.
19. Abbe R. New method of creating a vagina in a case of
congenital absence. Med Rec. 1898;54:836-8.
20. Banister JB, McIndoe AH. Congenital absence of the
vagina, treated by means of an indwelling skin-graft.
Proc R Soc Med. 1938;31(9):105-6.
21. Mcindoe A. The treatment of congenital absence and
obliterative conditions of the vagina. Br J Plast Surg.
1950;2(4):254-67.
22. Nisolle M, Donnez J. Vaginoplasty using amniotic
membranes in cases of vaginal agenesis or after vagi-
nectomy. J Gynecol Surg. 1992;8(1):25-30.
23. Noguchi S, Nakatsuka M, Sugiyama Y, Chekir C,
Kamada Y, Hiramatsu Y. Use of artificial dermis
and recombinant basic fibroblast growth factor
for creating a neovagina in a patient with Mayer-
Rokitansky-Kuster-Hauser syndrome. Hum Reprod.
2004;19(7):1629-32.
24. Vecchietti G. [Creation of an artificial vagina in
Rokitansky-Kuster-Hauser syndrome]. Attual Ostet
Ginecol. 1965;11(2):131-47.
25. Brucker SY, Gegusch M, Zubke W, Rall K, Gauwerky
JF, Wallwiener D. Neovagina creation in vagi-
nal agenesis: development of a new laparoscopic
Vecchietti-based procedure and optimized instru-
ments in a prospective comparative interventional
study in 101 patients. Fertil Steril. 2008;90(5):1940-52.
26. Fedele L, Bianchi S, Frontino G, Fontana E, Restelli E,
Bruni V. The laparoscopic Vecchietti’s modified
technique in Rokitansky syndrome: anatomic, func-
tional, and sexual long-term results. Am J Obstet
Gynecol. 2008;198(4):377 e1-6.
27. Csermely T, Halvax L, Sarkany A, Jeges S, Vizer M,
Bozsa S, et al. Sexual function after modified lapa-
roscopic Vecchietti’s vaginoplasty. J Pediatr Adolesc
Gynecol. 2011;24(3):147-52.
28. Nahas S, Yi J, Magrina J. Mayo Clinic experience
with modified Vecchietti procedure for vaginal agen-
esis: it is easy, safe, and effective. J Minim Invasive
Gynecol. 2013;20(5):553.
29. Davydov SN. [Colpopoeisis from the peritoneum
of the uterorectal space]. Akush Ginekol (Mosk).
1969;45(12):55-7.
30. Giannesi A, Marchiole P, Benchaib M, Chevret-
Measson M, Mathevet P, Dargent D. Sexuality
after laparoscopic Davydov in patients affected by
congenital complete vaginal agenesis associated
with uterine agenesis or hypoplasia. Hum Reprod.
2005;20(10):2954-7.
Surgery for congenital anomalies
31. Fedele L, Frontino G, Restelli E, Ciappina N, Motta
F, Bianchi S. Creation of a neovagina by Davydov’s
laparoscopic modified technique in patients with
Rokitansky syndrome. Am J Obstet Gynecol.
2010;202(1):33; e1-6.
32. Ozkan O, Erman Akar M, Ozkan O, Dogan NU.
Reconstruction of vaginal agenesis. Ann Plast Surg.
2011;66(6):673-8.
33. Hecker BR, McGuire LS. Psychosocial function in
women treated for vaginal agenesis. Am J Obstet
Gynecol. 1977;129(5):543-7.
34. Jessel RH, Laufer MR. Management of lower vaginal
agenesis in a patient with unicornuate uterus. J Pediatr
Adolesc Gynecol. 2013;26(1):e21-3.
35. Mansouri R, Dietrich J. Postoperative course and
complications after vaginal pull through procedures
for distal vaginal atresia. J Pediatr Adolesc Gynecol.
2013;26(2):433-6.
36. Jacob JH, Griffin WT. Surgical reconstruction of the
congenitally atretic cervix: two cases. Obstet Gynecol
Surv. 1989;44(7):556-69.
37. Zaru GS, Esposito JM, Zarou DM. Pregnancy fol-
lowing the surgical correction of congenital atresia
of the cervix. Int J Gynaecol Obstet. 1973;11(4):​143-6.
38. Fraser IS. Successful pregnancy in a patient with
congenital partial cervical atresia. Obstet Gynecol.
1989;74(3 Pt 2):443-5.
39. Hampton HL, Meeks GR, Bates GW, Wiser WL.
Pregnancy after successful vaginoplasty and cervi-
cal stenting for partial atresia of the cervix. Obstet
Gynecol. 1990;76(5 Pt 2):900-1.
40. Kriplani A, Kachhawa G, Awasthi D, Kulshrestha V.
Laparoscopic-assisted uterovaginal anastomosis in
congenital atresia of uterine cervix: follow-up study.
J Minim Invasive Gynecol. 2012;19(4):477-84.
41. Grimbizis GF, Mikos T, Papanikolaou A, Theodoridis
T, Tarlatzis BC. Successful isthmo-neovagina anas-
tomosis after Davydov’s colpopoiesis in Mayer-
Rokitansky-Kuster-Hauser syndrome patients with
a functional rudimentary uterine horn. J Minim
Invasive Gynecol. 2015;22(1):142-50.
42. Fedele L, Bianchi S, Frontino G, Berlanda N,
Montefusco S, Borruto F. Laparoscopically assisted
uterovestibular anastomosis in patients with uter-
ine cervix atresia and vaginal aplasia. Fertil Steril.
2008;89(1):212-16.
43. Casey AC, Laufer MR. Cervical agenesis: septic death
after surgery. Obstet Gynecol. 1997;90(4 Pt 2):706-7.
44. Thijssen RF, Hollanders JM, Willemsen WN, van der
Heyden PM, van Dongen PW, Rolland R. Successful
pregnancy after ZIFT in a patient with congenital cer-
vical atresia. Obstet Gynecol. 1990;76(5 Pt 2):902-4.
45. Fluker MR, Bebbington MW, Munro MG. Successful
pregnancy following zygote intrafallopian transfer
for congenital cervical hypoplasia. Obstet Gynecol.
1994;84(4 Pt 2):659-61.
46. Groutz A, Lessing JB, Wolf Y, Azem F, Yovel I, Amit
A. Comparison of transmyometrial and transcervi-
cal embryo transfer in patients with previously failed
in vitro fertilization-embryo transfer cycles and/or
cervical stenosis. Fertil Steril. 1997;67(6):1073-6.
47. Anttila L, Penttila TA, Suikkari AM. Successful
pregnancy after in-vitro fertilization and trans-
myometrial embryo transfer in a patient with con-
genital atresia of cervix: case report. Hum Reprod.
1999;14(6):1647-9.
48. Grimbizis GF, Camus M, Tarlatzis BC, Bontis JN,
Devroey P. Clinical implications of uterine malfor-
mations and hysteroscopic treatment results. Hum
Reprod Update. 2001;7(2):161-74.
49. Rackow BW, Arici A. Reproductive performance of
women with mullerian anomalies. Curr Opin Obstet
Gynecol. 2007;19(3):229-37.
50. Strassmann EO. Fertility and unification of double
uterus. Fertil Steril. 1966;17(2):165-76.
51. Lin PC, Bhatnagar KP, Nettleton GS, Nakajima ST.
Female genital anomalies affecting reproduction.
Fertil Steril. 2002;78(5):899-915.
52. Raga F, Bauset C, Remohi J, Bonilla-Musoles F,
Simon C, Pellicer A. Reproductive impact of congen-
ital Mullerian anomalies. Hum Reprod. 1997;12(10):​
2277-81.
53. Heinonen PK. Pregnancies in women with uterine
malformation, treated obstruction of hemivagina
and ipsilateral renal agenesis. Arch Gynecol Obstet.
2013;287(5):975-8.
54. Heinonen PK. Complete septate uterus with lon­
gitudinal vaginal septum. Fertil Steril. 2006;85(3):​
700-5.
55. Homer HA, Li TC, Cooke ID. The septate uterus: a
review of management and reproductive outcome.
Fertil Steril. 2000;73(1):1-14.
56. Pabuccu R, Gomel V. Reproductive outcome after
hysteroscopic metroplasty in women with septate
uterus and otherwise unexplained infertility. Fertil
Steril. 2004;81(6):1675-8.
57. Mollo A, De Franciscis P, Colacurci N, Cobellis L,
Perino A, Venezia R, et al. Hysteroscopic resection of
the septum improves the pregnancy rate of women
with unexplained infertility: a prospective controlled
trial. Fertil Steril. 2009;91(6):2628-31.
58. Ban-Frangez H, Tomazevic T, Virant-Klun I,
Verdenik I, Ribic-Pucelj M, Bokal EV. The outcome
of singleton pregnancies after IVF/ICSI in women
before and after hysteroscopic resection of a uterine
septum compared to normal controls. Eur J Obstet
Gynecol Reprod Biol. 2009;146(2):184-7.
59. Le Ray C, Donnadieu AC, Gervaise A, Frydman R,
Fernandez H. [Management of ten patients with
complete septate uterus: hystersocopic section of and
obstetrical outcome]. J Gynecol Obstet Biol Reprod
(Paris). 2006;35(8 Pt 1):797-803.

60. Bettocchi S, Ceci O, Nappi L, Pontrelli G, Pinto L,
Vicino M. Office hysteroscopic metroplasty: three
“diagnostic criteria” to differentiate between sep-
tate and bicornuate uteri. J Minim Invasive Gynecol.
2007;14(3):324-8.
61. Colacurci N, De Franciscis P, Mollo A, Litta P, Perino
A, Cobellis L, et al. Small-diameter hysteroscopy with
Versapoint versus resectoscopy with a unipolar knife for
the treatment of septate uterus: a prospective random-
ized study. J Minim Invasive Gynecol. 2007;14(5):622-7.
62. Worldwide AAMIG, Munro MG, Storz K, Abbott JA,
Falcone T, Jacobs VR, et al. AAGL practice report:
practice guidelines for the management of hystero-
scopic distending media: (Replaces hysteroscopic
fluid monitoring guidelines. J Am Assoc Gynecol
Laparosc. 2000;7:167-8.). J Minim Invasive Gynecol.
2013;20(2):137-48.
63. Parsanezhad MD, Alborzi D, Zarel A, Dehbashi S,
Shirazi LG, Rajaeefard A, Schmidt EH. Hysteroscopic
metroplasty of the complete uterine septum, dupli-
cate cervix, and vaginal septum. Fertil Steril. 2006;​
85(5):1473-7.
References
64. Valle RF, Ekpo GE. Hysteroscopic metroplasty for
the septate uterus: review and meta-analysis. J Minim
Invasive Gynecol. 2013;20(1):22-42.
65. Vercellini P, Fedele L, Arcaini L, Rognoni MT,
Candiani GB. Value of intrauterine device inser-
tion and estrogen administration after hysteroscopic
metroplasty. J Reprod Med. 1989;34(7):447-50.
66. el-Mahgoub S. Unification of a septate uterus:
Mahgoub’s operation. Int J Gynaecol Obstet.
1978;15(5):400-4.
67. Maneschi F, Marana R, Muzii L, Mancuso S.
Reproductive performance in women with bicornu-
ate uterus. Acta Eur Fertil. 1993;24(3):117-20.
68. Lin PC. Reproductive outcomes in women with
uterine anomalies. J Womens Health (Larchmt).
2004;13(1):33-9.
Surgery for vulvar disorders
HOWARD T. SHARP
30
Key points
•• Vestibulectomy is indicated for women with chronic localized provoked (NOT unprovoked) vulvodynia who do not respond
to medical therapy.
•• For vestibulectomy
– The excision should extend to Hart’s line and no further.
– The hymen is removed with the specimen.
– Vaginal tissue should be undermined to close tension-free.
– 3-0 chromic catgut is used for rapid release to minimize scarring.
•• For reduction labioplasty
– Approximately 1.5 cm of labia should remain for functional purposes.
– Measuring and marking the lines of incision aid in symmetry.
•• For Bartholin duct cyst and abscess management
– 1% lidocaine with added sodium bicarbonate can reduce infiltration pain.
– A small gauge needle (27- or 30-gauge preferably) and a small volume syringe are used.
– The skin stab wound should be only 5 to 6 mm wide to hold the Word catheter in place.
– The catheter should remain in place for four weeks.
•• For Bartholin gland excision
– The dissection can be quite vascular due to branches from the pudendal artery.
– Vascular branches should be clamped and sutured or electrodesiccated.
– A drain may be left in place if there is significant oozing through the surgery.
•• For laser ablation for VIN
– The surgeon should be familiar with the four surgical planes of the vulvar skin.
– Postoperative pain can be treated with oral analgesics as well as local measures:
– Ice
– Topical lidocaine
– Topical 1% silver sulfadiazine cream
– Sitz baths
•• For wide local excision of the vulva
– The area of excision should be an ellipse that can be closed primarily.
– The margins should be undermined 1 to 2 cm to aid in closure.

There are several vulvar conditions that may be associated
with pain and reduced vulvar and vaginal function. Many
of these conditions can be treated successfully with con-
servative medical therapy. When contemplating vulvar
surgery, it is important to establish a diagnosis and to try
conservative management when indicated. Many surger-
ies performed on vulvar tissues include surgery for malig-
nancy and surgery for aesthetic purposes. This chapter
will focus primarily on benign and premalignant vulvar
conditions for general gynecologic surgeons. Aesthetic
surgery is not covered in this chapter.
VESTIBULECTOMY
Vestibulectomy may be performed for localized, provoked
vulvodynia (LPV), previously referred to as vulvar vestibu-
litis (see Chapter 23). Before performing vestibulectomy, it is
important to make an accurate diagnosis and to distinguish
this from unprovoked vulvodynia, and other conditions
that may mimic provoked vulvodynia (Table 30.1). Failure
of conservative therapies should be confirmed. One of the
key features associated with LPV is the characteristic of
vestibular pain when provoked, usually with tampon inser-
tion, or vaginal intercourse. The presence of constant pain or
burning should be a red flag for a different diagnosis, falling
under the unprovoked vulvodynia category, which typically
does not respond to surgery. There is no absolute consen-
sus for making the diagnosis of LPV, though Friedrich sug-
gested three criteria: (1) vestibular pain with direct contact
(a cotton tipped applicator is often used), (2) erythema at the
minor vestibular gland openings, and (3) pain with pressure
at the vestibule, occurring for at least three to six months
duration.1 Biopsy should be considered when in doubt, as
other medically treatable conditions are often identified
when a biopsy is evaluated by a dermatopathologist.2
Informed consent
The risks associated with vestibulectomy include bleeding/
hematoma, infection, skin breakdown, scarring, and for-
mation of Bartholin cysts that may require additional ther-
apy. There is also the possibility that the surgery will not
render the patient pain-free. The patient should be aware
that the recovery is usually acute for one to two weeks

443
444 Surgery for vulvar disorders

Table 30.1 Conditions mimicking provoked vulvodynia.
Vulvovaginal candidal infection
Desquamative inflammatory vaginitis
Dermatitis (irritant, allergic)
Dermatoses
Vulvar intraepithelial neoplasia
Atrophic vaginitis
Levator ani tension myalgia
Sensitive skin syndrome
Psychosexual causes
where sitting will be painful, and movement will be some-
what limited due to pain. Most patients can return to work
within two weeks, if their work does not require strenu-
ous activity. Sexual intercourse is usually not advised for
six to ten weeks. If there is a significant degree of levator
ani tension myalgia present, the patient may need physical
therapy of the pelvic floor postoperatively.
Performing a complete vestibulectomy
I prefer to use high lithotomy under general or regional
anesthesia in the operating room for maximal exposure
to the vestibule (Video 30.1). There are no high-quality
studies supporting the use of prophylactic antibiot-
ics. The vulvar vestibule is traced with a sterile pen to
outline the margins of dissection. I mark the patient’s
left anterior apex, just cephalad to the Skeen’s glands
and trace along Hart’s line to the posterior fourchette
(Figure 30.1a). The left medial border starts at the apex
above Skeen’s glands and usually borders the urethra
(within 3 mm or so) and then connects with the vaginal
skin just cephalad to the hymen, to include the entire
hymen in the dissection.
The dissection area is infiltrated with 0.5% bupivicaine
without epinephrine. I do not use epinephrine for two rea-
sons. The first is out of concern for potential infection risk
with vasoconstriction, and the second is to be sure all bleed-
ing is adequately sutured at the end of the case, to avoid
hematoma risk after the epinephrine has worn off. To make
the dissection easier, I use an Allis clamp at the apex of the
dissection (Skeen’s glands), at 1 and 11 o’clock. Allis–Adair
clamps are placed at the 3, 6, and 9 o’clock positions. While
an assistant holds the clamps at 1, 3, and 6 o’clock, the scal-
pel is used to trace the lateral dissection along Hart’s line
to the posterior fourchette. The same is carried out on the
contralateral side, holding the clamps at 6, 9, and 11 o’clock.
The dissection is made much easier if the incision is made
deep enough to remove the entire vestibule (3 to 4 mm
deep). With the same clamps held, the medial incision is
made hugging the hymen in a semi-circumferential man-
ner, to be sure that the entire hymen will be removed. Once
the medial and lateral borders of the dissection are incised,
Metzenbaum scissors are used to remove the skin as both
incisions are straddled. I often perform a small relaxing
skin incision at the midline to overcome the potential tight-
ening that may occur during healing.
The most challenging aspect of this surgery is the
closure. It is important that the skin be closed with-
out tension and with an optimal cosmetic result,
while maintaining good hemostasis. I do not use any

1
4
Hart’s 2 3
line

Before After

(a) (b) (c) (d)

Figure 30.1 Vestibulectomy. (a) The vulvar vestibule is marked to include Hart’s line, which can be seen as the transition of
smooth to a rougher epithelium. Inside the hymen is not marked, but by placing an Allis–Adair clamp on the hymen, the area is more
easily visualized. (b) The vaginal epithelium is undermined to avoid closure on tension. (c) The figure of X stitch. The stitch is placed
high on the lateral skin (vulva) to low on the medial (vagina) and then low on the lateral skin to end up high on the vaginal skin,
forming an X. (d) When closing the vestibule with interrupted stitches of 3-0 chromic catgut, the area near the urethra is closed first,
then the rest of the vestibule is divided into quadrants.

electrosurgical hemostasis, to avoid poor healing and
scarring. The vaginal skin should be undermined care-
fully such that the closure is tension free (Figure 30.1b).
This is performed by grasping the vaginal epithelium
with an Allis–Adair clamp and making a delicate
releasing incision with a Metzenbaum scissor along the
vaginal border.
The urethral portion of the incision is closed first.
This usually requires two interrupted 3-0 chromic cat-
gut sutures. I prefer chromic catgut suture as it dissolves
quickly, around ten to 14 days, with a very low risk of
the scarring than can sometimes occur with suture that
remains for several weeks. It also precludes the need to
remove sutures in the clinic, a process that can be pain-
ful in this delicate region. An interrupted stitch is placed
at 6, 3, and 9 o’clock to best ensure a symmetrical closure,
and to divide the closure into quadrants. Each quadrant is
then closed with three to four interrupted sutures, approxi-
mately 3 to 4 mm apart. I try to avoid figure of eight stitches,
which, though hemostatic, are not anatomic, and can cause
narrowing of the introitus. I find that if the interrupted
stitch is carefully placed by ensuring that the needle tra-
verses the entire depth of the resection, the area is unlikely
to bleed or develop a hematoma. The medial aspect is much
more prone to bleed. On occasion when the area is bleeding
to the point that an interrupted suture is ineffective, I will
use the figure of X stitch, which is hemostatic, yet cosmetic.
The stitch is placed high on the lateral skin (vulva) to low
on the medial (vagina) and then low on the lateral skin to
end up high on the vaginal skin (Figure 30.1c). At the end
of the case, no dressing is placed, and hemostasis should be
complete (Figure 30.1d). See Video 30.1.
Postoperative care
Patients are sent home after they can void, drink, and
have adequate pain control with oral analgesics. To pro-
vide comfort I offer oral narcotics, and NSAIDs, as well
as a donut type cushion and advise liberal baths/sitzbaths
in warm water. I encourage them to lie down rather than
sit, and see them back in clinic in two weeks and then
four weeks after that to assess the need for dilator ther-
apy. At six weeks, most patients can use a small dilator
and progress to a medium and then a large within an
additional two to four weeks. If the levator ani muscles
are still painful, physical therapy of the pelvic floor is
recommended.
HYMENECTOMY
The hymen is a membrane consisting of fibrous con-
nective tissue attached to the vaginal wall. The hymen
usually ruptures before birth due to degeneration of the
central epithelial cells. Typically, a thin mucous fold
persists around the vaginal introitus. Hymenal abnor-
malities occur when the central portion of the hymen is
incompletely degenerated. If conservative therapies of
manual dilatation or dilator therapy have failed, or if the
patient is unable to tolerate conservative therapy, hyme-
nectomy may be offered.
Hymenectomy 445
Informed consent
The risks associated with hymenectomy include bleeding/
hematoma, infection, skin breakdown, and scarring. The
patient should be aware that the recovery is usually acute
for one to two weeks where sitting will be painful, and
movement will be somewhat limited due to pain. Most
patients are able to return to work that does not require
significant physical activity within two weeks. Sexual
intercourse should be avoided for six to ten weeks depend-
ing upon their healing and degree of tenderness.
Performing hymenectomy
In cases where minimal tissue resection is needed, and if
the patient is motivated, the procedure can be performed in
the office under local anesthesia. I prefer to perform more
involved hymen excisions in the operating room under con-
scious sedation with local anesthesia, or regional, or general
anesthesia. I use a longer-acting local anesthesia for post-
operative pain relief. I do not use prophylactic antibiotics.
The hymen is injected circumferentially with 0.5%
bupivicaine, using approximately 5 to 10 mL in total.
Bupivicaine lasts approximately four times longer than
lidocaine; hence, it is preferred. I do not use epinephrine
to avoid delayed postoperative bleeding and infection com-
plications. Before making an incision, the urethra should
be identified to be sure it is avoided. I do not use a urethral
catheter, but have the patient void just prior to being taken
to the operating room. This allows the patient to void ear-
lier and be able to go home earlier, and lessens the risk for
urinary tract infection.
The center of the hymen is grasped with an Allis clamp,
and if there is a perforation, the perforation is opened lat-
erally at the 3 or 9 o’clock position (Figure 30.2a) to avoid
coming in contact with the urethra or rectal sphincter.
Once the hymen is opened sufficiently (2 cm), the addi-
tional edges are grasped with Allis clamps and the border
of the hymen can see both seen and felt. The hymen is cut
to its base with a scalpel or Metzenbaum scissors and then
trimmed circumferentially until it is removed. I do not use
any electrosurgical hemostasis to avoid delay in healing or
scarring. For hemostasis, I use interrupted sutures of 3-0
chromic catgut at approximately 4 mm intervals (Figure
30.2b), which will absorb or release by ten to 14 days.
After hymenectomy, and while in the operating room
under anesthesia, it is good practice to view the cervix for
associated anatomic anomalies which may be associated
with Müllerian anomalies.
Postoperative care
Patients are sent home after they are able to void, drink,
and have adequate pain control with oral analgesics. I offer
oral narcotics, and NSAIDs, as well as a donut type cush-
ion and advise liberal baths/sitz baths in warm water for
comfort measures. I encourage them to lie down rather
than sit, and see them back in clinic in two weeks and then
four weeks after that to assess the need for dilator therapy.
At six weeks, most patients are able to use a small dilator
446 Surgery for vulvar disorders
(a) (b)
Figure 30.2 Hymenectomy. (a) Incising the hymen with
a scalpel while maintaining traction with an Allis clamp.
(b) The hymen is closed with interrupted 3-0 chromic catgut
sutures, which dissolve rapidly.
and to progress to a medium and then a large within an
additional two to four weeks.
Reduction labiaplasty for labia minora hypertrophy
Enlargement of the labia minora can be painful and inter-
fere significantly with sports, daily activities, and sexual
intercourse. Hypertrophic labia minora are often associ-
ated with lymphedema.3 These symptoms may lead women
to opt for surgical management. When counseling patients
about reduction labiaplasty, it is important to remember
that the labia minora function to protect the urethra and
vaginal introitus; hence, complete removal is not advised.
The goal is to restore normal anatomy and function. I tend
to measure the labia from the medial aspect to assess the
longest span of each labium from mid tip to the hymen
base. Normal length is not clearly defined; however, in my
experience, this is rarely an issue in patients with labia
under 2 cm from the hymen to the distal central curva-
ture. In women who opt for surgical correction, most labia
minora are in the 2.5 to 5 cm range.
Informed consent
The risks associated with reduction labiaplasty include
bleeding/hematoma, infection, skin breakdown, scarring,
and asymmetrical labia. They may have decreased sen-
sation over the sutured skin, and the labia may be asym-
metrical after surgery (as they are often before surgery).
Complications are rare. I have not found scarring to be an
issue with this technique; however, other surgeons may pre-
fer to use a W-shaped excision.4 There are no comparative
trials to date. The patient should be aware that the recov-
ery is usually acute for one to two weeks, where sitting will
be painful, and movement will be somewhat limited due
to pain. Most patients can return to work, provided it does
not require significant physical activity within two weeks.
Sexual intercourse is usually not advised for six to ten weeks.
Performing reduction labiaplasty of the labia
minora—curvilinear technique
It is important to understand that the labia minora ema-
nate from the clitoral hood and extend to the posterior
fourchette. The mid portion of the distal labial curvature
is between these two points, and is the area that I mea-
sure for reference length. It is important to mark the area
for excision before making an incision, after performing
the surgical prep. I prefer to leave 1.5 cm of tissue at the
midpoint for adequate coverage of the vaginal introitus.
The line is tapered toward the posterior fourchette and
toward the clitoral hood (Figure 30.3a). I prefer to stay
as far away from the base of the clitoral hood as is fea-
sible (1 to 2 cm) to avoid any decrease in sensation to the
clitoral region. I mark the medial side of the first labia
minora with a sterile surgical marking pen, then find the
contralateral point at the 1.5 cm midway point, and bring
the labia to the middle such that they touch, causing the
mark from the initial marking to transfer a faint line to
the contralateral side. This will help for symmetry. Fine
adjustment can be made afterward with a marking pen.
I also measure the lateral labial curvature, based upon
the area that will be removed on the original medial bor-
der measurements.
Once both labia minora have been measured and
marked on the medial and lateral sides, 0.5% bupivicaine
without epinephrine is injected with a 25-gauge needle,
using 5 to 10 mL in total. The labium minora is grasped
with three or four Allis–Adair clamps and held by an
assistant, while a Metzenbaum scissor is used to care-
fully excise the distal curvature of the labium. The scissors
(a) (b)
Figure 30.3 Reduction labiaplasty of the labia minora.
(a) The incision borders are drawn on the medial aspect of
the labia minora. There should be adequate distance from
the clitoral region, and approximately 1.5 cm from the hymen
to allow for proper labia minora function. (b) The incision is
closed with interrupted 3-0 chromic catgut sutures. A figure of
X stitch can be used for hemostasis if needed.
 Hymenectomy 447

are held such that the curve faces the patient to allow
for straddling of both marked lines (medial and lateral).
Alternatively, a scalpel can be used along the lateral and
medial lines separately, and then the Metzenbaum scissors
can be used to make a final excision.
Interrupted sutures of 3-0 catgut are used to close the
incision (Figure 30.3b). Because the labia are fairly well
vascularized, a figure of X suture technique is sometimes
needed (see vestibulectomy, Figure 30.1c), which brings
tissue together in a symmetrical, hemostatic, and cosmeti-
cally appealing fashion compared to a figure of 8 stitch,
which causes asymmetrical tension on the skin. If a sub-
cuticular closure is used, it is important to be sure of good (a)
hemostasis to avoid hematoma formation. No dressing is
used.
Patients are sent home after they are able to void, drink,
and have adequate pain control with oral analgesics. For
comfort, I offer oral narcotics, and NSAIDs, as well as a
donut type cushion, and advise liberal baths/sitz bathes in
warm water. I encourage them to lie down rather than sit,
and see them in clinic in two and again at six weeks for
assessment.

Bartholin duct cyst and Bartholin abcess management

Bartholin glands are mucus-secreting glands providing
lubrication to the vagina. They are located within the
vulvar vestibule, with ducts external to the hymen at the
4 and 8 o’clock positions. The ducts are approximately
2.5 cm in length and can become obstructed from peri-
neal inflammation, trauma, or infection. Bartholin cysts
do not necessarily need to be treated if not symptomatic
with pain, infection, or perceived disfigurement. In gen-
eral, for symptomatic Bartholin cysts or abscesses, a con-
servative approach with Word catheter placement in the
clinic is ideal (Figure 30.4a). Marsupialization is generally
reserved for Word catheter failures. Antibiotic use is not
indicated with drainage in uncomplicated cases.5
Word catheter placement
The Word catheter is used to facilitate cyst or abscess drai­
nage, and to allow an epithelialized tract for fistula for-
mation. The key feature is to make a stab wound into the
cyst, large enough to place the catheter, but small enough
to keep it from falling out. Making a stab wound too large
is a major reason for Word catheter failure. The risks that
may be discussed for informed consent include: bleeding,
infection, cyst recurrence, scarring, dyspareunia, and dis-
tortion of anatomy.
The area of the cyst is prepped with a sterile solution,
and 1 to 2 mL of 1% lidocaine is used to infiltrate the
cyst near the hymen rather than on the vulvar surface
(Table 30.2). Due to the very sensitive nature of the area,
a 30-gauge needle is ideal for infiltration. Because these
are performed in the clinic, I use 1 mEq/mL of sodium
bicarbonate to nine parts of 1% lidocaine to decrease the
pain of infiltration, and inject at a slow rate, with a small
volume syringe (1 to 3 mL). A number 11 blade is used to
make a stab wound between 5 and 6 mm wide and 1 to
(b) (c)
Figure 30.4 Word catheter placement. (a) Word catheter
kit. Top to bottom, 3 mL syringe (fill with normal saline), num-
ber 11 scalpel blade, inflated Word catheter, non-inflated Word
catheter. (b) A relatively small incision is made with a number
11 blade to avoid a large incision that will cause the Word cath-
eter to be expelled. (c) The end of the Word catheter is tucked
into the vagina so it will not catch on clothes.
Table 30.2 Supplies for word catheter placement.
Antiseptic solution
Small gauge needle 30-gauge for local anesthesia
infiltration
1% lidocaine—1 to 2 mL (may buffer with sodium
bicarbonate)
Number 11 scalpel
Word catheter
3 mL syringe with sterile saline for Word catheter inflation
1.5 cm deep to enter the cyst (Figure 30.4b). A hemostat
may be useful if there are loculations that need to be dis-
rupted. The Word catheter is inserted into the cyst cavity
and inflated with saline. Be sure to inject the needle into
the center of the insufflation port, and insert it centrally
without deviating, or the needle can puncture the catheter
wall and render it useless. Two to 3 cc of normal saline
are injected into the catheter to inflate the distally located
balloon designed to maintain appropriate placement. The
448 Surgery for vulvar disorders
proximal end of the catheter is then tucked into the vagina
for comfort, and to reduce the chance that it becomes dis-
lodged by catching on clothing (Figure 30.4c).
The patient should be counseled that the cyst or abscess
will continue to drain, and that a peripad may be used.
She should maintain pelvic rest by avoiding vaginal inter-
course or tampon use. Baths/sitz baths and analgesics
will help with symptomatic relief. The catheter should be
maintained in place for four weeks, and then removed by
deflating the balloon in clinic. If the cyst returns, marsu-
pialization may be necessary.
Marsupialization
For recurrent, symptomatic Bartholin cysts or abscesses,
marsupialization may be necessary. Marsupialization may
often be performed in the clinic under local anesthesia,
but may also be performed in the operating room with
conscious sedation and local, regional, or general anesthe-
sia depending upon the circumstances.
The area is prepped with a sterile solution and infil-
trated with local anesthesia. I typically use 5 mL of a 0.5%
bupivicaine solution for infiltration along the line of inci-
sion if performing this with conscious sedation, but use a
sodium bicarbonate buffered 1% lidocaine solution if per-
formed under local infiltration alone. The skin incision is
typically made in a line parallel with the hymen in the vul-
var vestibule (Figure 30.5a), long enough to place several
sutures to keep it open. This is usually 3 cm in length. The
cyst wall is also incised and irrigated with normal saline.
A hemostat is used to break up any loculations if present.
The cyst wall is then everted and sutured to the vestibular
epithelium on either side of the incision with a 3-0 delayed
absorbable suture (Figure 30.5b). I prefer a suture that will
maintain tensile strength for three to four weeks, to ensure
patency, rather than the rapidly absorbing chromic catgut
sutures used in other vulvar surgeries. Follow-up is simi-
lar to that of Word catheter placement. Sutures are allowed
to dissolve.
(a) (b)
Figure 30.5 Bartholin cyst marsupialization. (a) The epi-
thelium is incised, then the cyst wall is incised in the same
direction. (b) The cyst wall is sutured to the vulvar and vaginal
epithelium with a 3-0 delayed absorbable suture to allow it to
remain patent for four weeks.
Bartholin gland excision
Bartholin gland excision is reserved for cases that are
either refractory to conservative management, or when
there is concern about malignancy. Because of its signifi-
cant blood supply from branches of the pudendal artery, it
can be associated with hemorrhage and hematoma. This
surgery is performed in the operating room under appro-
priate anesthesia with the patient in lithotomy position.
Examination under anesthesia including a rectovaginal
exam is helpful in defining the depth of the cyst. Access
and visualization are important to be maximized, as these
cysts can be deep. It is often helpful to place Allis–Adair
clamps for retraction on the labia minora and to have an
assistant gently retract laterally.
An incision is made in a line parallel with the hymen
in the vulvar vestibule, rather than the vulvar skin, long
enough to dissect the entire cyst and gland, usually 3 to 4 cm
in length, or larger depending on the domed surface exposed
(Figure 30.6a). Allis–Adair clamps are used to retract the
incised epithelium as well as the cyst wall to increase expo-
sure to the dissection plane. Metzenbaum scissors are used
to release filmy adhesions (Figure 30.6b). A “scissor spread”
technique is helpful in removing filmy adhesions and to
minimize bleeding, as this is where the branches from the
inferior pudendal artery are usually encountered. Vessels
(a) (b)
(c) (d)
Figure 30.6 Bartholin gland excision. (a) A linear incision
is made along the domed surface close to the hymen. (b) With
retraction on the cyst wall and the vulvar and vaginal epithe-
lium, Metzenbaum scissors are used to dissect the cyst wall.
(c) The bed of the cyst is sutured deeply with interrupted or fig-
ure of X stitches to close the deep space and prevent hematoma
formation. (d) The skin is closed with 3-0 delayed absorbable
interrupted sutures. A drain may be placed.

to the gland are best rendered hemostatic by clamping the
vessel with a hemostat and applying electrodessication
with “cutting” (low voltage continuous output) current.
Suture ligation may also be necessary. Once the gland is
removed, the bed of the gland is closed with interrupted or
figure of X sutures using 3-0 absorbable sutures for hemo-
stasis (Figure 30.6c). The skin is closed with 3-0 absorbable
sutures (Figure 30.6d). I prefer to use sutures that will hold
tensile strength for approximately three to four weeks.
Because of the vascular nature of this area, some surgeons
prefer to leave a small drain in place for two or three days
to avoid hematoma formation.
Patients are sent home after they are able to void, drink,
and have adequate pain control with oral analgesics. For
comfort, I offer oral narcotics, and NSAIDs, as well as a
donut type cushion and advise liberal baths/sitz baths in
warm water. I encourage them to lie down rather than sit,
and see them in clinic in two and again in six weeks.
VULVAR INTRAEPITHELIAL NEOPLASIA
The tenants of treatment for vulvar intraepithelial neopla-
sia (VIN) are to prevent the development of vulvar cancer
and relieve symptoms, while preserving normal function
and anatomy of the vulva. Therefore, the treatment of VIN
is usually individualized based upon the location and
extent of the lesion. Superficial laser therapy tends to have
a cosmetic advantage compared to skinning vulvectomy.6
Deep laser therapy often leads to scarring, with less clear
advantage over excisional techniques.
Laser vaporization of the vulva
Laser therapy is often used in patients with multifocal
lesions. The depth of treatment is directed by colposcopy.
Tissue destruction of less than 1 mm will treat VIN and
still allow rapid healing. In areas with hair distribution,
a deeper destruction is necessary to 3 mm, as the root
of the hair may contain VIN and extend to a depth of
2.5 mm. Laser vaporization to this depth is much more
destructive and may lead to scar formation. Four surgical
planes have been identified. The first surgical plane con-
sists of the epidermis down to the basement membrane,
which has a red appearance when treated with the laser.
The second surgical plane transitions into a tan appear-
ance as it extends into the papillary layer of the dermis.
The third surgical plane extends into the reticular dermis
that contains the root of a hair follicle and is identified as
grayish white fibers of collagen bundles. It is not neces-
sary to treat VIN beyond the third surgical plane. The
fourth surgical plane is complete removal of the dermis
down to fat.
Informed consent
The risks associated with laser ablation of the vulva include
bleeding, infection, scarring, and decreased sensation over
the ablated skin. They should be aware that the area will
be irritated and painful for weeks postoperatively, and full
healing will take six to eight weeks.
Vulvar intraepithelial neoplasia 449
Laser ablation procedure
If laser ablation is performed, a power density of 750–
1,250 W/cm2 is used to avoid deep coagulation injury. A
3%–5% solution of acetic acid is applied to the area while
colposcopy is used to delineate lesion margins. The area to
be treated is marked with a sterile marking pen. A hand
piece or micromanipulator with a depth gauge aids in
application of high-power density without defocusing. The
margin of normal skin should be treated. In hair-bearing
regions, the hair follicle must be treated. The first step is to
identify the tan appearance of the papillary dermis. Cold
water on a sponge may be used to help dissipate heat and
remove char to help identify the white appearance of the
third surgical plane as laser therapy proceeds.
Postoperative care
An antibacterial cream such as 1% silver sulfadiazine
cream is commonly applied once or twice daily to decrease
wound bacteria colonization, and to provide some relief
from pain. There is no evidence that there is a preferred
agent, nor is there clear evidence that these reduce infec-
tion. A 5% lidocaine gel can also be applied to aid in pain
relief. Bupivacaine 0.25% without epinephrine may be
injected into the lasered area at the end of the treatment
to deliver up to six hours of pain relief. An ice pack (or
for practical purposes, a bag of frozen peas) can be placed
against the vulva for the first 72 hours after surgery to
decease inflammation and pain. Sitz baths may be used
three times daily even on the first postoperative day, and
continued for three weeks if needed. Patients are seen at
two and six weeks postoperatively for routine follow up.
Wide local excision of the vulva
Wide local incision is appropriate when pathologic find-
ings are suggestive of cancer despite a biopsy diagnosis of
VIN for histologic confirmation. This is an option when
there are one or two focal lesions that will allow a 1 cm
margin.7 The depth should be the full thickness of the skin.
Informed consent
The risks associated with wide local excision of the vulva
include bleeding/hematoma, infection, skin breakdown,
and scarring. The patient should be aware that the recov-
ery is usually acute for two weeks where sitting will be
painful, and movement will be somewhat limited due to
pain. Full return to work may take six to ten weeks.
Wide local excision procedure
The patient is placed in the dorsal lithotomy position, and
the perineum is prepped and draped. An indwelling blad-
der catheter is placed. A marking pen is helpful to mea-
sure a margin and design an ellipse that can be closed. The
lesion is excised with an elliptical incision with a scalpel
down to the subcutaneous tissue (Figure 30.7a). Mobilizing
the skin makes closure easier, and should be undermined
fairly aggressively (1 to 2 cm). Electrosurgery is used to
achieve hemostasis. Closure is performed with two to four
Another random document with
no related content on Scribd:
them striped and splashed and dotted with puttycolor and blue and
green of camouflage paint. A man in a motorboat waved his arms.
The men in khaki slickers huddled on the gray dripping deck of the
transport begin to sing
Oh the infantry, the infantry,
With the dirt behind their ears ...
Through the brightbeaded mist behind the low buildings of
Governors Island they can make out the tall pylons, the curving
cables, the airy lace of Brooklyn Bridge. Robertson pulls a package
out of his pocket and pitches it overboard.
“What was that?”
“Just my propho kit.... Wont need it no more.”
“How’s that?”
“Oh I’m goin to live clean an get a good job and maybe get
married.”
“I guess that’s not such a bad idear. I’m tired o playin round
myself. Jez somebody must a cleaned up good on them Shippin
Board boats.” “That’s where the dollar a year men get theirs I guess.”
“I’ll tell the world they do.”
Up forward they are singing
Oh she works in a jam factoree
And that may be all right ...
“Jez we’re goin up the East River Sarge. Where the devil do they
think they’re goin to land us?”
“God, I’d be willin to swim ashore myself. An just think of all the
guys been here all this time cleanin up on us.... Ten dollars a day
workin in a shipyard mind you ...”
“Hell Sarge we got the experience.”
“Experience ...”
Apres la guerre finee
 Back to the States for me....
“I bet the skipper’s been drinkin beaucoup highballs an thinks
Brooklyn’s Hoboken.”
“Well there’s Wall Street, bo.”
They are passing under Brooklyn Bridge. There is a humming
whine of electric trains over their heads, an occasional violet flash
from the wet rails. Behind them beyond barges tugboats carferries
the tall buildings, streaked white with whisps of steam and mist,
tower gray into sagged clouds.

Nobody said anything while they ate the soup. Mrs. Merivale sat
in black at the head of the oval table looking out through the half
drawn portières and the drawingroom window beyond at a column of
white smoke that uncoiled in the sunlight above the trainyards,
remembering her husband and how they had come years ago to look
at the apartment in the unfinished house that smelled of plaster and
paint. At last when she had finished her soup she roused herself and
said: “Well Jimmy, are you going back to newspaper work?”
“I guess so.”
“James has had three jobs offered him already. I think it’s
remarkable.”
“I guess I’ll go in with the Major though,” said James Merivale to
Ellen who sat next to him. “Major Goodyear you know, Cousin
Helena.... One of the Buffalo Goodyears. He’s head of the foreign
exchange department of the Banker’s Trust.... He says he can work
me up quickly. We were friends overseas.”
“That’ll be wonderful,” said Maisie in a cooing voice, “wont it
Jimmy?” She sat opposite slender and rosy in her black dress.
“He’s putting me up for Piping Rock,” went on Merivale.
“What’s that?”
 “Why Jimmy you must know.... I’m sure Cousin Helena has been
out there to tea many a time.”
“You know Jimps,” said Ellen with her eyes in her plate. “That’s
where Stan Emery’s father used to go every Sunday.”
“Oh did you know that unfortunate young man? That was a
horrible thing,” said Mrs. Merivale. “So many horrible things have
been happening these years.... I’d almost forgotten about it.”
“Yes I knew him,” said Ellen.
The leg of lamb came in accompanied by fried eggplant, late corn,
and sweet potatoes. “Do you know I think it is just terrible,” said Mrs.
Merivale when she had done carving, “the way you fellows wont tell
us any of your experiences over there.... Lots of them must have
been remarkably interesting. Jimmy I should think you’d write a book
about your experiences.”
“I have tried a few articles.”
“When are they coming out?”
“Nobody seems to want to print them.... You see I differ radically
in certain matters of opinion ...”
“Mrs. Merivale it’s years since I’ve eaten such delicious sweet
potatoes.... These taste like yams.”
“They are good.... It’s just the way I have them cooked.”
“Well it was a great war while it lasted,” said Merivale.
“Where were you Armistice night, Jimmy?”
“I was in Jerusalem with the Red Cross. Isn’t that absurd?”
“I was in Paris.”
“So was I,” said Ellen.
“And so you were over there too Helena? I’m going to call you
Helena eventually, so I might as well begin now.... Isn’t that
interesting? Did you and Jimmy meet over there?”
 “Oh no we were old friends.... But we were thrown together a
lot.... We were in the same department of the Red Cross—the
Publicity Department.”
“A real war romance,” chanted Mrs. Merivale. “Isn’t that
interesting?”

“Now fellers it’s this way,” shouted Joe O’Keefe, the sweat
breaking out on his red face. “Are we going to put over this bonus
proposition or aint we?... We fought for em didnt we, we cleaned up
the squareheads, didnt we? And now when we come home we get
the dirty end of the stick. No jobs.... Our girls have gone and married
other fellers.... Treat us like a bunch o dirty bums and loafers when
we ask for our just and legal and lawful compensation ... the bonus.
Are we goin to stand for it?... No. Are we goin to stand for a bunch of
politicians treatin us like we was goin round to the back door to ask
for a handout?... I ask you fellers....”
Feet stamped on the floor. “No.” “To hell wid em,” shouted
voices.... “Now I say to hell wid de politicians.... We’ll carry our
campaign to the country ... to the great big generous bighearted
American people we fought and bled and laid down our lives for.”
The long armory room roared with applause. The wounded men
in the front row banged the floor with their crutches. “Joey’s a good
guy,” said a man without arms to a man with one eye and an artificial
leg who sat beside him. “He is that Buddy.” While they were filing out
offering each other cigarettes, a man stood in the door calling out,
“Committee meeting, Committee on Bonus.”
The four of them sat round a table in the room the Colonel had
lent them. “Well fellers let’s have a cigar.” Joe hopped over to the
Colonel’s desk and brought out four Romeo and Juliets. “He’ll never
miss em.”
“Some little grafter I’ll say,” said Sid Garnett stretching out his long
legs.
 “Havent got a case of Scotch in there, have you Joey?” said Bill
Dougan.
“Naw I’m not drinkin myself jus for the moment.”
“I know where you kin get guaranteed Haig and Haig,” put in
Segal cockily—“before the war stuff for six dollars a quart.”
“An where are we goin to get the six dollars for crissake?”
“Now look here fellers,” said Joe, sitting on the edge of the table,
“let’s get down to brass tacks.... What we’ve got to do is raise a fund
from the gang and anywhere else we can.... Are we agreed about
that?”
“Sure we are, you tell em,” said Dougan.
“I know lot of old fellers even, thinks the boys are gettin a raw
deal.... We’ll call it the Brooklyn Bonus Agitation Committee
associated with the Sheamus O’Rielly Post of the A. L.... No use doin
anythin unless you do it up right.... Now are yous guys wid me or aint
yer?”
“Sure we are Joey.... You tell em an we’ll mark time.”
“Well Dougan’s got to be president cause he’s the best lookin.”
Dougan went crimson and began to stammer.
“Oh you seabeach Apollo,” jeered Garnett.
“And I think I can do best as treasurer because I’ve had more
experience.”
“Cause you’re the crookedest you mean,” said Segal under his
breath.
Joe stuck out his jaw. “Look here Segal are you wid us or aint
yer? You’d better come right out wid it now if you’re not.”
“Sure, cut de comedy,” said Dougan. “Joey’s de guy to put dis ting
trough an you know it.... Cut de comedy.... If you dont like it you kin
git out.”
 Segal rubbed his thin hooked nose. “I was juss jokin gents, I didn’t
mean no harm.”
“Look here,” went on Joe angrily, “what do you think I’m givin up
my time for?... Why I turned down fifty dollars a week only yesterday,
aint that so, Sid? You seen me talkin to de guy.”
“Sure I did Joey.”
“Oh pipe down fellers,” said Segal. “I was just stringin Joey
along.”
“Well I think Segal you ought to be secretary, cause you know
about office work....”
“Office work?”
“Sure,” said Joe puffing his chest out. “We’re goin to have desk
space in the office of a guy I know.... It’s all fixed. He’s goin to let us
have it free till we get a start. An we’re goin to have office stationery.
Cant get nowhere in this world without presentin things right.”
“An where do I come in?” asked Sid Garnett.
“You’re the committee, you big stiff.”
After the meeting Joe O’Keefe walked whistling down Atlantic
Avenue. It was a crisp night; he was walking on springs. There was a
light in Dr. Gordon’s office. He rang. A whitefaced man in a white
jacket opened the door.
“Hello Doc.”
“Is that you O’Keefe? Come on in my boy.” Something in the
doctor’s voice clutched like a cold hand at his spine.
“Well did your test come out all right doc?”
“All right ... positive all right.”
“Christ.”
“Dont worry too much about it, my boy, we’ll fix you up in a few
months.”
“Months.”
 “Why at a conservative estimate fiftyfive percent of the people you
meet on the street have a syphilitic taint.”
“It’s not as if I’d been a damn fool. I was careful over there.”
“Inevitable in wartime....”
“Now I wish I’d let loose.... Oh the chances I passed up.”
The doctor laughed. “You probably wont even have any
symptoms.... It’s just a question of injections. I’ll have you sound as a
dollar in no time.... Do you want to take a shot now? I’ve got it all
ready.”
O’Keefe’s hands went cold. “Well I guess so,” he forced a laugh. “I
guess I’ll be a goddam thermometer by the time you’re through with
me.” The doctor laughed creakily. “Full up of arsenic and mercury
eh.... That’s it.”
The wind was blowing up colder. His teeth were chattering.
Through the rasping castiron night he walked home. Fool to pass out
that way when he stuck me. He could still feel the sickening lunge of
the needle. He gritted his teeth. After this I got to have some luck.... I
got to have some luck.

Two stout men and a lean man sit at a table by a window. The
light of a zinc sky catches brightedged glints off glasses, silverware,
oystershells, eyes. George Baldwin has his back to the window. Gus
McNiel sits on his right, and Densch on his left. When the waiter
leans over to take away the empty oystershells he can see through
the window, beyond the graystone parapet, the tops of a few
buildings jutting like the last trees at the edge of a cliff and the tinfoil
reaches of the harbor littered with ships. “I’m lecturin you this time,
George.... Lord knows you used to lecture me enough in the old
days. Honest it’s rank foolishness,” Gus McNiel is saying. “... It’s rank
foolishness to pass up the chance of a political career at your time of
life.... There’s no man in New York better fitted to hold office ...”
 “Looks to me as if it were your duty, Baldwin,” says Densch in a
deep voice, taking his tortoiseshell glasses out of a case and
applying them hurriedly to his nose.
The waiter has brought a large planked steak surrounded by
bulwarks of mushrooms and chopped carrots and peas and frilled
browned mashed potatoes. Densch straightens his glasses and
stares attentively at the planked steak.
“A very handsome dish Ben, a very handsome dish I must say....
It’s just this Baldwin ... as I look at it ... the country is going through a
dangerous period of reconstruction ... the confusion attendant on the
winding up of a great conflict ... the bankruptcy of a continent ...
bolshevism and subversive doctrines rife ... America ...” he says,
cutting with the sharp polished steel knife into the thick steak, rare
and well peppered. He chews a mouthful slowly. “America,” he
begins again, “is in the position of taking over the receivership of the
world. The great principles of democracy, of that commercial
freedom upon which our whole civilization depends are more than
ever at stake. Now as at no other time we need men of established
ability and unblemished integrity in public office, particularly in the
offices requiring expert judicial and legal knowledge.”
“That’s what I was tryin to tell ye the other day George.”
“But that’s all very well Gus, but how do you know I’d be
elected.... After all it would mean giving up my law practice for a
number of years, it would mean ...”
“You just leave that to me.... George you’re elected already.”
“An extraordinarily good steak,” says Densch, “I must say.... No
but newspaper talk aside ... I happen to know from a secret and
reliable source that there is a subversive plot among undesirable
elements in this country.... Good God think of the Wall Street bomb
outrage.... I must say that the attitude of the press has been
gratifying in one respect ... in fact we’re approaching a national unity
undreamed of before the war.”
“No but George,” breaks in Gus, “put it this way.... The publicity
value of a political career’d kinder bolster up your law practice.”
 “It would and it wouldn’t Gus.”
Densch is unrolling the tinfoil off a cigar. “At any rate it’s a grand
sight.” He takes off his glasses and cranes his thick neck to look out
into the bright expanse of harbor that stretches full of masts, smoke,
blobs of steam, dark oblongs of barges, to the hazeblurred hills of
Staten Island.
Bright flakes of cloud were scaling off a sky of crushing indigo
over the Battery where groups of dingy darkdressed people stood
round the Ellis Island landing station and the small boat dock waiting
silently for something. Frayed smoke of tugs and steamers hung low
and trailed along the opaque glassgreen water. A threemasted
schooner was being towed down the North River. A newhoisted jib
flopped awkwardly in the wind. Down the harbor loomed taller, taller
a steamer head on, four red stacks packed into one, creamy
superstructure gleaming. “Mauretania just acomin in twentyfour
hours lyte,” yelled the man with the telescope and fieldglasses....
“Tyke a look at the Mauretania, farstest ocean greyhound, twentyfour
hours lyte.” The Mauretania stalked like a skyscraper through the
harbor shipping. A rift of sunlight sharpened the shadow under the
broad bridge, along the white stripes of upper decks, glinted in the
rows of portholes. The smokestacks stood apart, the hull lengthened.
The black relentless hull of the Mauretania pushing puffing tugs
ahead of it cut like a long knife into the North River.
A ferry was leaving the immigrant station, a murmur rustled
through the crowd that packed the edges of the wharf. “Deportees....
It’s the communists the Department of Justice is having deported ...
deportees ... Reds.... It’s the Reds they are deporting.” The ferry was
out of the slip. In the stern a group of men stood still tiny like tin
soldiers. “They are sending the Reds back to Russia.” A
handkerchief waved on the ferry, a red handkerchief. People tiptoed
gently to the edge of the walk, tiptoeing, quiet like in a sickroom.
Behind the backs of the men and women crowding to the edge of
the water, gorillafaced chipontheshoulder policemen walked back
and forth nervously swinging their billies.
 “They are sending the Reds back to Russia.... Deportees....
Agitators.... Undesirables.” ... Gulls wheeled crying. A catsupbottle
bobbed gravely in the little ground-glass waves. A sound of singing
came from the ferryboat getting small, slipping away across the
water.
C’est la lutte finale, groupons-nous et demain
L’Internationale sera le genre humain.
“Take a look at the deportees.... Take a look at the undesirable
aliens,” shouted the man with the telescopes and fieldglasses. A
girl’s voice burst out suddenly, “Arise prisoners of starvation,” “Sh....
They could pull you for that.”
The singing trailed away across the water. At the end of a
marbled wake the ferryboat was shrinking into haze. International ...
shall be the human race. The singing died. From up the river came
the longdrawn rattling throb of a steamer leaving dock. Gulls
wheeled above the dark dingydressed crowd that stood silently
looking down the bay.
II. Nickelodeon

A
nickel before midnight buys tomorrow ...
holdup headlines, a cup of coffee in the
automat, a ride to Woodlawn, Fort Lee,
Flatbush.... A nickel in the slot buys chewing
gum. Somebody Loves Me, Baby Divine,
You’re in Kentucky Juss Shu’ As You’re Born
... bruised notes of foxtrots go limping out of
doors, blues, waltzes (We’d Danced the
Whole Night Through) trail gyrating tinsel
memories.... On Sixth Avenue on Fourteenth
there are still flyspecked stereopticons
where for a nickel you can peep at yellowed
yesterdays. Beside the peppering shooting
gallery you stoop into the flicker A Hot Time,
The Bachelor’s Surprise, The Stolen
Garter ... wastebasket of tornup
daydreams.... A nickel before midnight buys
our yesterdays.

R
uth Prynne came out of the doctor’s office pulled the fur tight
round her throat. She felt faint. Taxi. As she stepped in she
remembered the smell of cosmetics and toast and the littered
hallway at Mrs. Sunderlands. Oh I cant go home just yet. “Driver go
to the Old English Tea Room on Fortieth Street please.” She opened
her long green leather purse and looked in. My God, only a dollar a
quarter a nickel and two pennies. She kept her eyes on the figures
flickering on the taximeter. She wanted to break down and cry.... The
way money goes. The gritty cold wind rasped at her throat when she
got out. “Eighty cents miss.... I haven’t any change miss.” “All right
keep the change.” Heavens only thirtytwo cents.... Inside it was
warm and smelled cozily of tea and cookies.
“Why Ruth, if it isn’t Ruth.... Dearest come to my arms after all
these years.” It was Billy Waldron. He was fatter and whiter than he
used to be. He gave her a stagy hug and kissed her on the forehead.
“How are you? Do tell me.... How distinguée you look in that hat.”
“I’ve just been having my throat X-rayed,” she said with a giggle.
“I feel like the wrath of God.”
“What are you doing Ruth? I havent heard of you for ages.”
“Put me down as a back number, hadn’t you?” She caught his
words up fiercely.
“After that beautiful performance you gave in The Orchard
Queen....”
“To tell the truth Billy I’ve had a terrible run of bad luck.”
“Oh I know everything is dead.”
“I have an appointment to see Belasco next week.... Something
may come of that.”
“Why I should say it might Ruth.... Are you expecting someone?”
“No.... Oh Billy you’re still the same old tease.... Dont tease me
this afternoon. I dont feel up to it.”
“You poor dear sit down and have a cup of tea with me.
“I tell you Ruth it’s a terrible year. Many a good trouper will pawn
the last link of his watch chain this year.... I suppose you’re going the
rounds.”
“Dont talk about it.... If I could only get my throat all right.... A thing
like that wears you down.”
“Remember the old days at the Somerville Stock?”
“Billy could I ever forget them?... Wasnt it a scream?”
“The last time I saw you Ruth was in The Butterfly on the Wheel in
Seattle. I was out front....”
 “Why didn’t you come back and see me?”
“I was still angry at you I suppose.... It was my lowest moment. In
the valley of shadow ... melancholia ... neurasthenia. I was stranded
penniless.... That night I was a little under the influence, you
understand. I didn’t want you to see the beast in me.”
Ruth poured herself a fresh cup of tea. She suddenly felt
feverishly gay. “Oh but Billy havent you forgotten all that?... I was a
foolish little girl then.... I was afraid that love or marriage or anything
like that would interfere with my art, you understand.... I was so
crazy to succeed.”
“Would you do the same thing again?”
“I wonder....”
“How does it go?... The moving finger writes and having writ
moves on ...”
“Something about Nor all your tears wash out a word of it ... But
Billy,” she threw back her head and laughed, “I thought you were
getting ready to propose to me all over again.... Ou my throat.”
“Ruth I wish you werent taking that X-ray treatment.... I’ve heard
it’s very dangerous. Dont let me alarm you about it my dear ... but I
have heard of cases of cancer contracted that way.”
“That’s nonsense Billy.... That’s only when X-rays are improperly
used, and it takes years of exposure.... No I think this Dr. Warner’s a
remarkable man.”
Later, sitting in the uptown express in the subway, she still could
feel his soft hand patting her gloved hand. “Goodby little girl, God
bless you,” he’d said huskily. He’s gotten to be a ham actor if there
ever was one, something was jeering inside her all the while. “Thank
heavens you will never know.” ... Then with a sweep of his
broadbrimmed hat and a toss of his silky white hair, as if he were
playing in Monsieur Beaucaire, he had turned and walked off among
the crowd up Broadway. I may be down on my luck, but I’m not all
ham inside the way he is.... Cancer he said. She looked up and
down the car at the joggling faces opposite her. Of all those people
one of them must have it. Four Out of Every Five Get ... Silly,
that’s not cancer. Ex-lax, Nujol, O’Sullivan’s.... She put her hand
to her throat. Her throat was terribly swollen, her throat throbbed
feverishly. Maybe it was worse. It is something alive that grows in
flesh, eats all your life, leaves you horrible, rotten.... The people
opposite stared straight ahead of them, young men and young
women, middleaged people, green faces in the dingy light, under the
sourcolored advertisements. Four Out of Every Five ... A trainload
of jiggling corpses, nodding and swaying as the express roared
shrilly towards Ninetysixth Street. At Ninetysixth she had to change
for the local.

Dutch Robertson sat on a bench on Brooklyn Bridge with the

collar of his army overcoat turned up, running his eye down Business
Opportunities. It was a muggy fog-choked afternoon; the bridge was
dripping and aloof like an arbor in a dense garden of
steamboatwhistles. Two sailors passed. “Ze best joint I’ve been in
since B. A.”
Partner movie theater, busy neighborhood ... stand investigation
... $3,000.... Jez I haven’t got three thousand mills.... Cigar stand,
busy building, compelled sacrifice.... Attractive and completely
outfitted radio and music shop ... busy.... Modern mediumsized
printingplant consisting of cylinders, Kelleys, Miller feeders, job
presses, linotype machines and a complete bindery.... Kosher
restaurant and delicatessen.... Bowling alley ... busy.... Live spot
large dancehall and other concessions. We Buy False Teeth, old
gold, platinum, old jewelry. The hell they do. Help Wanted Male.
That’s more your speed you rummy. Addressers, first class
penmen.... Lets me out.... Artist, Attendant, Auto, Bicycle and
Motorcycle repair shop.... He took out the back of an envelope and
marked down the address. Bootblacks.... Not yet. Boy; no I guess I
aint a boy any more, Candystore, Canvassers, Carwashers,
Dishwasher. Earn While You Learn. Mechanical dentistry is your
shortest way to success.... No dull seasons....
 “Hello Dutch.... I thought I’d never get here.” A grayfaced girl in a
red hat and gray rabbit coat sat down beside him.
“Jez I’m sick o readin want ads.” He stretched out his arms and
yawned letting the paper slip down his legs.
“Aint you chilly, sittin out here on the bridge?”
“Maybe I am.... Let’s go and eat.” He jumped to his feet and put
his red face with its thin broken nose close to hers and looked in her
black eyes with his pale gray eyes. He tapped her arm sharply.
“Hello Francie.... How’s my lil girl?”
They walked back towards Manhattan, the way she had come.
Under them the river glinted through the mist. A big steamer drifted
by slowly, lights already lit; over the edge of the walk they looked
down the black smokestacks.
“Was it a boat as big as that you went overseas on Dutch?”
“Bigger ’n that.”
“Gee I’d like to go.”
“I’ll take you over some time and show you all them places over
there ... I went to a lot of places that time I went A.W.O.L.”
In the L station they hesitated. “Francie got any jack on you?”
“Sure I got a dollar.... I ought to keep that for tomorrer though.”
“All I got’s my last quarter. Let’s go eat two fiftyfive cent dinners at
that chink place ... That’ll be a dollar ten.”
“I got to have a nickel to get down to the office in the mornin.”
“Oh Hell! Goddam it I wish we could have some money.”
“Got anything lined up yet?”
“Wouldn’t I have told ye if I had?”
“Come ahead I’ve got a half a dollar saved up in my room. I can
take carfare outa that.” She changed the dollar and put two nickels
into the turnstile. They sat down in a Third Avenue train.
“Say Francie will they let us dance in a khaki shirt?”
 “Why not Dutch it looks all right.”
“I feel kinder fussed about it.”
The jazzband in the restaurant was playing Hindustan. It smelled
of chop suey and Chinese sauce. They slipped into a booth.
Slickhaired young men and little bobhaired girls were dancing
hugged close. As they sat down they smiled into each other’s eyes.
“Jez I’m hungry.”
“Are you Dutch?”
He pushed forward his knees until they locked with hers. “Gee
you’re a good kid,” he said when he had finished his soup. “Honest
I’ll get a job this week. And then we’ll get a nice room an get married
an everything.”
When they got up to dance they were trembling so they could
barely keep time to the music.
“Mister ... no dance without ploper dless ...” said a dapper
Chinaman putting his hand on Dutch’s arm.
“Waz he want?” he growled dancing on.
“I guess it’s the shirt, Dutch.”
“The hell it is.”
“I’m tired. I’d rather talk than dance anyway ...” They went back to
their booth and their sliced pineapple for dessert.
Afterwards they walked east along Fourteenth. “Dutch cant we go
to your room?”
“I ain’t got no room. The old stiff wont let me stay and she’s got all
my stuff. Honest if I dont get a job this week I’m goin to a recruiting
sergeant an re-enlist.”
“Oh dont do that; we wouldn’t ever get married then Dutch.... Gee
though why didn’t you tell me?”
“I didn’t want to worry you Francie.... Six months out of work ...
Jez it’s enough to drive a guy cookoo.”
 “But Dutch where can we go?”
“We might go out that wharf.... I know a wharf.”
“It’s so cold.”
“I couldn’t get cold when you were with me kid.”
“Dont talk like that.... I dont like it.”
They walked leaning together in the darkness up the muddy
rutted riverside streets, between huge swelling gastanks,
brokendown fences, long manywindowed warehouses. At a corner
under a streetlamp a boy catcalled as they passed.
“I’ll poke your face in you little bastard,” Dutch let fly out of the
corner of his mouth.
“Dont answer him,” Francie whispered, “or we’ll have the whole
gang down on us.”
They slipped through a little door in a tall fence above which crazy
lumberpiles towered. They could smell the river and cedarwood and
sawdust. They could hear the river lapping at the piles under their
feet. Dutch drew her to him and pressed his mouth down on hers.
“Hay dere dont you know you cant come out here at night
disaway?” a voice yapped at them. The watchman flashed a lantern
in their eyes.
“All right keep your shirt on, we were just taking a little walk.”
“Some walk.”
They were dragging themselves down the street again with the
black riverwind in their teeth.
“Look out.” A policeman passed whistling softly to himself. They
drew apart. “Oh Francie they’ll be takin us to the nuthouse if we keep
this up. Let’s go to your room.”
“Landlady’ll throw me out, that’s all.”
“I wont make any noise.... You got your key aint ye? I’ll sneak out
before light. Goddam it they make you feel like a skunk.”
 “All right Dutch let’s go home.... I dont care no more what
happens.”
They walked up mudtracked stairs to the top floor of the
tenement.
“Take off your shoes,” she hissed in his ear as she slipped the key
in the lock.
“I got holes in my stockings.”
“That dont matter, silly. I’ll see if it’s all right. My room’s way back
past the kitchen so if they’re all in bed they cant hear us.”
When she left him he could hear his heart beating. In a second
she came back. He tiptoed after her down a creaky hall. A sound of
snoring came through a door. There was a smell of cabbage and
sleep in the hall. Once in her room she locked the door and put a
chair against it under the knob. A triangle of ashen light came in from
the street. “Now for crissake keep still Dutch.” One shoe still in each
hand he reached for her and hugged her.
He lay beside her whispering on and on with his lips against her
ear. “And Francie I’ll make good, honest I will; I got to be a sergeant
overseas till they busted me for goin A.W.O.L. That shows I got it in
me. Once I get a chance I’ll make a whole lot of jack and you an
me’ll go back an see Château Teery an Paree an all that stuff;
honest you’d like it Francie ... Jez the towns are old and funny and
quiet and cozy-like an they have the swellest ginmills where you sit
outside at little tables in the sun an watch the people pass an the
food’s swell too once you get to like it an they have hotels all over
where we could have gone like tonight an they dont care if your
married or nutten. An they have big beds all cozy made of wood and
they bring ye up breakfast in bed. Jez Francie you’d like it.”

They were walking to dinner through the snow. Big snowfeathers

spun and spiraled about them mottling the glare of the streets with
blue and pink and yellow, blotting perspectives.
 “Ellie I hate to have you take that job.... You ought to keep on with
your acting.”
“But Jimps, we’ve got to live.”
“I know ... I know. You’d certainly didn’t have your wits about you
Ellie when you married me.”
“Oh let’s not talk about it any more.”
“Do let’s have a good time tonight.... It’s the first snow.”
“Is this the place?” They stood before an unlighted basement door
covered by a closemeshed grating. “Let’s try.”
“Did the bell ring?”
“I think so.”
The inner door opened and a girl in a pink apron peered out at
them. “Bon soir mademoiselle.”
“Ah ... bon soir monsieur ’dame.” She ushered them into a
foodsmelling gaslit hall hung with overcoats and hats and mufflers.
Through a curtained door the restaurant blew in their faces a hot
breath of bread and cocktails and frying butter and perfumes and
lipsticks and clatter and jingling talk.
“I can smell absinthe,” said Ellen. “Let’s get terribly tight.”
“Good Lord, there’s Congo.... Dont you remember Congo Jake at
the Seaside Inn?”
He stood bulky at the end of the corridor beckoning to them. His
face was very tanned and he had a glossy black mustache. “Hello
Meester ’Erf.... Ow are you?”
“Fine as silk. Congo I want you to meet my wife.”
“If you dont mind the keetchen we will ’ave a drink.”
“Of course we dont.... It’s the best place in the house. Why you’re
limping.... What did you do to your leg?”
“Foutu ... I left it en Italie.... I couldnt breeng it along once they’d
cut it off.”
 “How was that?”
“Damn fool thing on Mont Tomba.... My bruderinlaw e gave me a
very beautiful artificial leemb.... Sit ’ere. Look madame now can you
tell which is which?”
“No I cant,” said Ellie laughing. They were at a little marble table
in the corner of the crowded kitchen. A girl was dishing out at a deal
table in the center. Two cooks worked over the stove. The air was
rich with sizzling fatty foodsmells. Congo hobbled back to them with
three glasses on a small tray. He stood over them while they drank.
“Salut,” he said, raising his glass. “Absinthe cocktail, like they
make it in New Orleans.”
“It’s a knockout.” Congo took a card out of his vest pocket:
MARQUIS DES COULOMMIERS
Imports

Riverside 11121
“Maybe some day you need some little ting ... I deal in nutting but
prewar imported. I am the best bootleggair in New York.”
“If I ever get any money I certainly will spend it on you Congo....
How do you find business?”
“Veree good.... I tell you about it. Tonight I’m too busee.... Now I
find you a table in the restaurant.”
“Do you run this place too?”
“No this my bruderinlaw’s place.”
“I didnt know you had a sister.”
“Neither did I.”
When Congo limped away from their table silence came down
between them like an asbestos curtain in a theater.
“He’s a funny duck,” said Jimmy forcing a laugh.
“He certainly is.”