Vesicovaginal fistula (VVF) is rare in children and is most commonly associated with retained vaginal foreign bodies. Surgical repair is technically demanding and carries a significant risk of recurrence, which has limited the application of minimally invasive approaches. We report the first pediatric case of robot-assisted laparoscopic transvesical repair of a VVF. A 14-year-old girl presented with longstanding urinary incontinence, malodorous vaginal discharge, and recurrent urinary tract infections, since early childhood. Initial imaging revealed a 30-mm bladder stone. Cystoscopy identified a large infratrigonal VVF associated with the stone, which had formed around a retained plastic ring. The foreign body and stone were removed through a suprapubic cystotomy. As spontaneous fistula closure did not occur after 1 year, definitive repair was undertaken. A robot-assisted laparoscopic transvesical approach was performed following cystoscopic identification of the ureteral orifices and placement of bilateral double-J stents. The fistula was closed in two watertight layers, with separate closure of the vaginal and bladder defects using absorbable sutures ( Video 1 ). No intraoperative or postoperative complications occurred. The patient was discharged on postoperative day 2. At 1-year follow-up, she remained asymptomatic, with complete fistula closure, normal urinary continence, and normal uroflowmetry findings. Robot-assisted transvesical repair provides excellent visualization and precise suturing within the confined pelvic space, representing a promising minimally invasive option for the management of complex pediatric VVF.

Objective Among those with a prior cesarean, Black individuals are more likely to have labor after cesarean compared to White individuals, but have lower rates of vaginal birth after cesarean following labor. However, little is known about indications for cesarean among these patients. We examined whether indication for unplanned cesarean delivery varied by race and ethnicity among individuals with one prior cesarean. Study Design Using linked Massachusetts birth certificate and hospital discharge data (2012-2022), we identified individuals with one prior cesarean who labored and subsequently had an unplanned cesarean. Indications were categorized as nonreassuring fetal status, labor dystocia/arrest, or other. A multilevel multinomial logit model assessed associations between race and ethnicity and cesarean indication, adjusting for covariates. Results Overall, 41% had cesarean for nonreassuring fetal status, 16% for labor dystocia/arrest, and 43% for other indications. Nonreassuring fetal status was the indication for 59% of Black patients versus 36% of White patients. In adjusted analyses, Black individuals had a 42% higher relative risk of having a cesarean for an indication of nonreassuring fetal status, compared to White individuals and compared to having a cesarean for an indication of labor arrest/dystocia (Relative Risk Ratio [RRR] 1.42, 95% Confidence Interval [CI]: 1.14-1.76). Black and Latinx individuals had a lower relative risk of having a cesarean for other indication, compared to White individuals and compared to cesarean for an indication of labor arrest/dystocia. Conclusions Racial and ethnic differences exist in indications for unplanned cesarean after labor among those with one prior cesarean, mirroring disparities reported for primary cesarean indications.

Endometrial ossification, also described as endometrial osseous metaplasia (EOM), is a rare benign condition characterized by the presence of bone tissue within the endometrium. Its exact etiopathogenesis remains unclear, although the metaplasia of endometrial stromal cells into osteoblast-like cells has been proposed as the most accepted mechanism. Clinically, it may present with infertility, abnormal uterine bleeding, or pelvic discomfort and, in rare situations, may mimic more serious gynecological pathology. We report the case of a 60-year-old postmenopausal woman who presented with persistent vaginal bleeding, vaginal discharge, and a protruding vaginal mass causing discomfort. She had a long history of recurrent postmenopausal bleeding (PMB) and previously diagnosed benign endometrial polyps managed with hysteroscopic polypectomy. Imaging revealed a markedly thickened, inhomogeneous endometrium with multiple polypoidal lesions and calcifications, raising suspicion for endometrial malignancy with possible cervical involvement. Due to persistent symptoms, suspicious imaging findings, and the patient's multiple comorbidities, a robotic total hysterectomy with bilateral salpingo-oophorectomy was performed. Histopathological examination unexpectedly revealed the ossifying cartilaginous metaplasia of the endometrial stroma involving the endometrium and an endometrial polyp, with no evidence of malignancy. The patient had an uneventful recovery and remained asymptomatic on follow-up. This case highlights how a rare benign diagnosis can present in a complex clinical scenario mimicking malignancy. The awareness of such entities is important to avoid misdiagnosis and to emphasize the crucial role of histopathology and multidisciplinary management in achieving safe, patient-centered care.

Intravaginal progesterone sponges have been widely utilized to synchronize estrus in goats; however, extended use may be accompanied by vaginal microbial imbalance, vaginal discharge abnormalities, and diminished reproductive performance. Intravaginal probiotics have been suggested as an alternative to antibiotics for addressing vaginal dysbiosis, but their effects across varying synchronization durations have not been thoroughly studied in goats. The current study was conducted to assess the effect of intravaginal probiotic use in association with various progesterone sponge durations on vaginal microbiota and reproductive efficiency in Black Iraqi goats. Forty-four adult goats (2-5 years) were randomly assigned to four groups (n = 11) for 7 and 14 days of treatment with a progesterone sponge alone or in combination with probiotics. Two strains of Lactobacillus (L. plantarum and L. acidophilus) were used in a lyophilized product (2 × 10[9] CFU/sponge). The following were assessed: cultivable vaginal bacteria (total bacteria, Enterobacteriaceae, Lactobacillus), score of vaginal discharge, onset of estrus and duration of estrus, and early pregnancy rate. Larger Enterobacteriaceae and total bacterial counts, and lower Lactobacillus counts, were observed with prolonged retention (14 days) compared to the short-duration protocol (p < 0.05). Probiotic treatment showed significantly higher Lactobacillus counts (2.75 ± 0.69 vs. 0.44 ± 0.25 log CFU/mL) (p < 0.001) and significantly lower Enterobacteriaceae and total counts, especially in the long protocol (Enterobacteriaceae 4.37 ± 0.36 vs. 5.20 ± 0.44; total 5.26 ± 0.43 vs. 6.14 ± 0.44 log CFU/mL), with a significantly earlier onset of estrus (29.82 ± 0.66 vs. 33.00 ± 1.18 h), longer duration of estrus (29.91 ± 0.79 vs. 24.73 ± 0.84 h), and milder discharge (Fisher's exact test, p = 0.01-0.03) than controls. The early pregnancy rate was numerically higher in the probiotic-treated groups but not statistically significant (p > 0.05). Overall, the duration of sponge use was associated with vaginal health and reproductive responses, with short-sponge duration protocols with high-dose Lactobacillus associated with decreased dysbiosis and enhanced vaginal health, suggesting a non-antibiotic strategy that warrants testing in larger studies for its potential role in conception.

Vulvovaginal candidiasis (VVC) is a common opportunistic fungal infection of the female genital tract, primarily associated with Candida overgrowth influenced by host factors, hormonal changes, microbial imbalance, and environmental conditions. This study examined the prevalence, antifungal susceptibility, and virulence factors of Candida species in 440 pregnant women (ages 18-55) with vulvovaginitis and vaginal discharge at a Saudi Arabian hospital. The study was conducted from March 2022 to February 2023 at a tertiary hospital in Hail, Saudi Arabia, including 440 pregnant women with vaginitis. Vaginal swabs were cultured for Candida, with species identification and antifungal susceptibility testing performed using the Vitek-2 Compact system against five antifungals. Multiplex PCR was used to detect virulence genes (Hwp, Als, Sap, Hlp). Among them, 114 (25.9%) tested positive for Candida species, with Candida albicans being most prevalent (42.1%), followed by C. glabrata (19.3%) and C. tropicalis (12.3%). Most cases occurred during the second trimester (67%), with an average age of 27 years. Antifungal susceptibility testing showed that nystatin exhibited 49.1% susceptibility, 19.3% susceptible-dose dependence (SDD), and 31.6% resistance. Clotrimazole demonstrated 40.4% susceptibility, 26.3% SDD, and 33.3% resistance. Itraconazole showed 50.9% susceptibility, 28% SDD, and 21.1% resistance. Fluconazole exhibited 43.8% susceptibility, 8.8% SDD, and the highest resistance rate (47.4%). Voriconazole was the most effective antifungal agent, with 93% susceptibility, 3.5% SDD, and 3.5% resistance. Virulence analysis showed C. albicans had high Hwp (91.7%) and Sap (54.2%) gene detection, while C. glabrata and C. tropicalis exhibited elevated Hlp and Als levels, respectively. This study highlights the high prevalence of VVC in the second trimester and emphasizes the importance of virulence factors in pathogenicity. Voriconazole emerges as the most effective treatment, emphasizing the need for targeted diagnostics and therapies.

A 7-year-old female spayed Labrador retriever was presented for a 3-year history of progressive hemorrhage from the vulva. The dog previously underwent cystourethroscopy and vaginoscopy 1 year prior, and a small, raised hemorrhagic lesion was identified in the caudal vaginal wall. Following pinch biopsies of the lesion, bleeding ceased during the remainder of the procedure but recommenced within a week following discharge from the hospital. Histopathology of the vaginal biopsy revealed chronic neutrophilic and lymphoplasmacytic vaginitis. One year later, the dog was reevaluated for persistent and progressive bleeding from the vulva. At that time, dual phase abdominal computed tomography identified a focal, 0.5 cm x 1.0 cm region of asymmetric contrast enhancement within the vaginal wall. Cystourethroscopy and vaginoscopy identified a progressively enlarged bleeding polypoid mass lesion in the caudodorsal vaginal wall. Biopsy of the lesion followed by monopolar electrocautery ablation of the proliferative tissue was performed. Histopathology revealed hemorrhage lined by a layer of stratified squamous epithelium and neutrophilic exocytosis with no neoplastic cells identified. The underlying etiology of the lesion was not definitively determined. Vulvovaginal bleeding resolved following the procedure and remains resolved at the time of writing 7 months later. This case report describes successful endoscopic-guided electrocautery ablation of a vaginal hemorrhagic lesion in a dog.