At the time of exploration

At the time of exploration, vaginoscopy demonstrated irregular fibrous tissue at the Phenyl sulfate and normal-appearing vaginal mucosa in the distal two-thirds of the vagina. A Pfannenstiel incision was made, and gross inspection of the pelvis did not identify any lymphadenopathy or local spread. The mass was palpable at the cervix in continuation with the proximal vagina. The left ovary was congenitally absent. The right ovary was adherent to the posterior aspect of the uterus. A right oophorectomy, total abdominal hysterectomy, and proximal vaginectomy were performed, knowing this would render the patient infertile and reliant on hormone replacement therapy. The remaining vaginal cuff was biopsied, and the frozen section was negative for malignancy. The majority of her vagina was preserved (Fig. 2C). Final pathology showed fibrous scar tissue and a nonviable focus of tumor without evidence of teratomatous elements within the uterus and right ovary (Fig. 2B). Her postoperative AFP level was 7 ng/mL.

Vaginal bleeding in young girls poses a challenge. Striegel et al recommend the routine use of examination under anesthesia, cystoscopy, and vaginoscopy to fully elucidate the etiology of vaginal bleeding. The sensitivity of diagnosis of malignancy by noninvasive imaging alone was just 33% compared with 100% with examination under anesthesia, cystoscopy, and vaginoscopy. Any young girl with vaginal bleeding must undergo further investigation, and a failure to include YSTs in the differential can lead to excessive morbidity and delayed treatment.
Cisplatin-based chemotherapy was introduced in the 1980s and has improved survival in children with GCTs at all anatomic sites. Initial management was with vincristine, actinomycin, and cyclophosphamide chemotherapy, but this has been replaced with BEP owing to less toxicity. A 2003 study by Rescorla et al identified 12 girls diagnosed with YST of the vagina with biopsy or subtotal resection followed by BEP treatment. The goal was vaginal preservation. Nine patients underwent secondary surgical resection after 4 cycles of chemotherapy for the presence of residual tumor. Three girls in the standard dose arm and no girls in the high-dose chemotherapy arm developed progressive disease or relapse over 4 years. Excellent results were seen with high-dose cisplatin. This is consistent with studies of BEP for GCTs of other sites. They reported a 2-year survival rate for vaginal GCTs of 70%. There is a paucity of data for uterine or cervical YSTs, and these are typically treated in the same manner as vaginal YSTs.
Growing teratoma syndrome is a recognized outcome after chemotherapy for GCTs. Patients with mixed GCTs with known teratomatous elements would be most likely affected by this clinical entity. In the pediatric population, mixed GCTs most commonly occur in the ovary, and growing teratoma syndrome has been described in a 4-year-old girl previously treated for ovarian mixed GCT. There are no reports of mixed GCTs arising from the vagina or uterus, although this is not unsuspected with the rarity of this entity, overall. In this particular case, there was a large tumor with only a relative percentage of it sampled via transvaginal biopsy, leaving occult mixed elements a possibility. When a complete response was not achieved with chemotherapy, the possibility of residual teratoma was entertained and should be included in the differential for residual disease in this complex and rare entity.


Urethral stricture disease can cause men to experience a host of problems including lower urinary tract symptoms, pain, and ejaculatory and bladder dysfunction. Urethral stricture disease is common and accounted for an estimated 1.2 million office visits in the United States between 2002 and 2007. Urethroplasty remains the gold standard treatment for urethral strictures. Because most published outcomes on urethroplasty is derived from individual surgeon case series, there is a lack of national level data reporting trends in the type of urethroplasty performed, patient and hospital characteristics, and perioperative outcomes and complications of urethroplasty.