Main Findings
The present clinical research showed that vaginal outlectomy is a simple obstetrical procedure with a short learning curve, negligible blood loss, mild postpartum perineal discomfort, and no dyspareunia. Approximately 1,5 cm V-shape excision is made on the vaginal outlet (the hymeneal membrane, hymeneal ring, and continued within the hymeneal plate). It was enough to reduce tissue resistance forces on the fetal head at birth. During a fetal head delivery, the perineal muscle would naturally be stretched by the forces of uterine contractions and progressing fetal head that compresses the crotch from inside; therefore, the posterior perineum has limited contribution in widening vaginal outlet and will not require to be included into vaginal outlectomy. Thus, the too-tight vaginal outlet is the cause that inhibits the fetal head from passing through the vaginal outlet and removes this tissue’s natural resistance by small excision of the fragment of the transitional skin, hymeneal ring, hymeneal plate without perineal muscles incisions will overcome the resistance force.
Garner et al. developed the injury risk map during parturition and determined that the posterior perineum was at low risk for trauma during fetal head vaginal delivery.11 Therefore, the posterior perineal incision is not necessary to perform for the birth of a fetus. In addition, not including the posterior perineum in vaginal outlectomy prevents significant bleeding related to episiotomy during parturition, postpartum moderate to severe perineal pain, and, later on, superficial dyspareunia.
The vaginal outlectomy estimated bleeding is minimal, Fig. 5. Furthermore, closing the surgical defect of vaginal outlectomy (outlectorrhaphy) requires only two or three sutures. Compared to episiorrhaphy, Ostrzenski’s vaginal outlectomy significantly reduces clinical training and using suturing materials. After healing, the fine-scare, almost invisible, provides a very appealing esthetic look, and the vaginal outlet is not gapping postpartum, Fig. 4. In one case out of eighteen, vaginal outlectomy extension occurred in this study group. The extension included the perineal skin, perineal fascia, right bulbospongiosus muscle (the second degree), Fig. 5 B. However, the vaginal wall, corrugator muscle, and external anal sphincter were intact. Thus, the vaginal outlet extension did not progress towards the anal sphincter. Estimated vaginal outlectomy extension bleeding was heavier when compared to uncomplicated vaginal outlectomy, Fig. 2 and Fig. 5. Additionally, the woman who experienced vaginal outlectomy extension reported moderate postpartum perineal pain that lasted for five days and required pain medication (NRS was 5 pain perception intensity). At three months postpartum follow-up, the subjects did not report superficial dyspareunia. Therefore, this case demonstrates that vaginal outlectomy extension can occur and obstetrical injury of the bulbospongiosus muscle causes heavier bleeding than uncomplicated vaginal outlectomy, Fig. 2 and Fig. 5, and moderate postpartum perineal pain.
Strengths and Limitations
The present study shows that the posterior perineal musculature does not significantly affect the vaginal outlet resistance force on a fetal head during birth. Instead, the most substantial contribution to resistance is the vaginal outlet. Thus, Ostrzenski’s vaginal outlectomy eliminates incision of the posterior perineum, decreases post vaginal outlectomy bleeding, reduces using surgical suturing materials, re-establishes the natural esthetic look of vaginal orifice without gapping, eliminates moderate or severe postpartum perineal pain perception, abolishes post-birth superficial dyspareunia, and significantly reduces the length of traditional episiotomy scar. Additionally, the learning curve is short and does not require as intense training as the traditional episiotomy. Esthetically, vaginal outlectomy provides impressive results, creates an almost invisible scar, and eliminates postpartum vaginal gapping. Furthermore, vaginal outlectomy reduces the time of repairing the excision site and cuts on using surgical suture materials (2-3 stitches are needed).
The current study’s limitation is the small number of subjects to draw general conclusions or determine the safety and effectiveness of vaginal outlectomy. Still, this number was sufficient to decide on the clinical implementation of a vaginal outlectomy. Also, the weakness of this clinical investigation is the absence of standardization when a vaginal outlectomy should be performed, and the indication for performing vaginal outlectomy was adopted from the existing practice mode for selective episiotomy and not established for Ostrzenski’s vaginal outlectomy, Tabl. 1 Furthermore, this obstetrical procedure was not used at the time of operative vaginal delivery, and whether a vaginal outlectomy will reduce the development of obstetrical anal sphincter injuries - OASIS, particularly in forceps or vacuum delivery, abnormal fetal presentations, or primiparity.
InterpretationThe vaginal outlectomy eases the passage of a fetal head during vaginal delivery by reducing the vaginal outlet tissue resistance force created by a belt-like structure embracing the fetal skull—the belt-like consists of the transitional vulvar skin, hymeneal ring, and hymeneal plate. V-shaped excision in the most distended belt area is enough for successful fetal head and body delivery.
Histology of the excised vaginal outlet showed no perineal muscle skeletal muscle present in the excised specimens and verified anatomical findings of three distinctive layers: the hymeneal membrane, ring, and plate, Fig. 1C. The absence of the perineal muscle within the excised V-shape tissue helps understand the mechanism of posterior postpartum pain and, later on, superficial dyspareunia. Therefore, the present study shows that the posterior perineal musculature is unnecessary to cut for widening the vaginal outlet to deliver a fetal head.
The surgical concept of Ostrzenski’s vaginal outlectomy is how to minimize the “belt-like” tissue resistance force on a fetal head being entrapped by the vaginal outlet and not by the posterior perineum. This procedure is easy to learn and execute with only negligible blood loss and minimal postpartum perineal discomfort and does not produce superficial dyspareunia.
A traditional mediolateral episiotomy incorporates into the incision several anatomical structures: the posterior-distal vaginal, perineal body, hymeneal membrane, hymeneal ring, vaginal plate, inferior labium minus, perineal skin, posterior perineal fascia, superficial transverse perineal muscle, bulbospongiosus muscle, dorsal perineal membrane, urethrovaginal sphincter muscle, the pubovaginalis muscle (the fragment of the levator ani muscle), and superficial external sphincter muscle. A midline episiotomy includes anatomical structures: the posterior-distal vaginal wall, perineal body, vaginal outlet, fossa navicularis, fourchette, posterior perineal skin, perineal fascia, the central point of the posterior perineum, superficial external sphincter muscle, and distal rectovaginal septum.12 These episiotomy techniques were developed to prevent posterior perineum damages, including anal sphincters, pelvic floor dysfunction, and the fetus from either intracranial hemorrhage or intrauterine asphyxia. None of these suppositions were validated by clinical-scientific studies, and traditional episiotomies are responsible for severe complications.13 Unfortunately, episiotomy does not prevent damages but does create damages of the posterior perineum in women,
Estimated blood loss associated with traditional episiotomy exceeds the amount observed at cesarean section.14 The immediate postpartum severe posterior perineal pain followed traditional episiotomy often lasts for several weeks.15,16Episiotomy extension to the external and internal anal sphincter causes more pain for several weeks after birth and requires strong pain medication.17 Additionally, an episiotomy or other obstetrical perineal trauma can cause transient or prolonged, or permanent superficial dyspareunia, which plays a significant role in female sexual dysfunction.18 Also, episiotomy, particularly midline episiotomy, can lead to debilitating urinary or fecal incontinence, or both due to injuries of the perineal body.19-23 Furthermore, an obstetrician’s or midwife’s skill to perform episiorrhaphy is very often inappropriately done. The method of repair techniques increases short- and long-term women morbidity and negatively influences the quality of life, Fig. 4D.18, 21, 24
Future Research
The present study’s findings showed that vaginal outlectomy has the potential for obstetrical use in everyday practice. However, there is a need for additional clinical-scientific research to assess vaginal outlectomy further since the current study design could not answer the safety and effectiveness of vaginal outlectomy or whether vaginal outlectomy can be applied in the form of a restrictive or routine use. If the restrictive use would be preferable, what are the indications for vaginal outlectomy? In addition, how vaginal outlectomy will assist during vaginal instrumental delivery should also be studied.
Conclusions The vaginal outlet is responsible for resistance force on a fetal head passing through it and not the posterior perineum that only supports the vaginal outlet. Ostrzenski’s vaginal outlectomy widens the vaginal outlet sufficiently for a fetal vaginal birth and eliminates postpartum perineal pain and dyspareunia.