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A septum is not always a septum: diagnosis and management of vaginal longitudinal septums via a video presentation

      The landmark study by Buttram and Gibbons (
      • Buttram Jr., V.C.
      • Gibbons W.E.
      Müllerian anomalies: a proposed classification. (An analysis of 144 cases).
      ) in 1979 recognized that the classification of müllerian anomalies is critically important for patient care yet challenging to refine. Since that publication, there have been ongoing attempts to produce clinically relevant classification systems (
      • Grimbizis G.F.
      • Gordts S.
      • Di Spiezio Sardo A.
      • et al.
      The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies.
      ,
      • Grigoris G.F.
      Clinical approach for the classification of congenital uterine malformations.
      ). However, to this day no one system is universally accepted. Although there are excellent reviews guiding surgical interventions for müllerian anomalies, to provide optimal care for their patients, clinicians must ultimately depend on a reliable method of assessment and categorization (
      • Skinner B.
      • Quint E.H.
      Nonobstructive reproductive tract anomalies: a review of surgical management.
      ).
      Supplementing our traditional written publications, peer-reviewed video submissions are a relatively new addition to our academic journals and occupy a unique educational niche. In this issue of Fertility and Sterility, Ludwin et al. (
      • Ludwin A.
      • Lindheim S.
      • Bhagavath B.
      • Martins W.
      • Ludwin I.
      Longitudinal vaginal septum: a proposed classification and surgical management.
      ) deliver an outstanding video demonstrating their proposed classification system and surgical management of longitudinal vaginal septums. The key strengths of this presentation include a huge case series (121 women), authors who have both robust clinical experience and prior publications demonstrating a comprehensive understanding of these uncommon findings, and an exceptional video combining drawings, photos, and surgical videos.
      In addition to its elegant and clear editing, this work has several distinguishing features compared with other classification systems published in major journals. First, it offers a detailed descriptive system on longitudinal vaginal septums, which previously have not been an area of concentration. Second, in addition to the proposed classification system, the authors provide their recommendations for management, which is not typically included alongside proposed classification systems. The video is especially helpful in demonstrating the distinguishing features within each subcategory as the relevant anatomy and differences are clearly labeled and easily understood. Importantly, the authors describe the pros and cons of the various treatment options with their associated healing times and postoperative management. The comprehensive collection of images represents the most thorough representation of the full range of longitudinal vaginal septal anomalies that I have personally seen.
      I would also draw attention to the use of speculoscopy in conjunction with ultrasonography over magnetic resonance imaging (MRI) for the authors’ workup. Although MRI remains an invaluable adjuvant in the evaluation of müllerian anomalies, Ludwin and colleagues’ experience with two-dimensional and three-dimensional ultrasound allows them to use their understanding of the variations in the presentation of these conditions when performing and interpreting their studies. This knowledge and experience may or may not be present with a radiologist’s reading; ultimately, this approach increases their ability to establish a diagnosis for the patient in a single visit.
      In their conclusion the authors acknowledge the need for large, well-designed randomized controlled trials. Given that these may never be available, even if the proposed classification system is ultimately not adopted, the stepwise logical approach offered for the evaluation and treatment of the different types of longitudinal vaginal septum is invaluable, and this video presentation should be considered required “reading.”

      References

        • Buttram Jr., V.C.
        • Gibbons W.E.
        Müllerian anomalies: a proposed classification. (An analysis of 144 cases).
        Fertil Steril. 1979; 32: 40-46
        • Grimbizis G.F.
        • Gordts S.
        • Di Spiezio Sardo A.
        • et al.
        The ESHRE/ESGE consensus on the classification of female genital tract congenital anomalies.
        Hum Reprod. 2013; 28: 2032-2044
        • Grigoris G.F.
        Clinical approach for the classification of congenital uterine malformations.
        Gynecol Surg. 2012; 9: 119-129
        • Skinner B.
        • Quint E.H.
        Nonobstructive reproductive tract anomalies: a review of surgical management.
        J Minim Invasive Gynecol. 2017; 24: 909-914
        • Ludwin A.
        • Lindheim S.
        • Bhagavath B.
        • Martins W.
        • Ludwin I.
        Longitudinal vaginal septum: a proposed classification and surgical management.
        Fertil Steril. 2020; 114: 899-901

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