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.