Mayo Clinic Experience With Modified Vecchietti Procedure for Vaginal Agenesis: It is Easy,Safe, and Effective

ObjectiveTo evaluate the surgical outcome and the anatomic and sexual function in 10 women with Rokitansky syndrome who underwent the laparoscopic Vecchietti procedure at our center.DesignRetrospective analysis.MethodsData were analyzed on the basis of short-term and long-term surgical outcome and sexual function. All patients underwent clinical follow-up at 1, 2, and 6 months after surgery.Measurements and Main ResultsIn all 10 patients, the procedure produced anatomic and functional success.ConclusionThe laparoscopic Vecchietti technique is safe, simple, and effective for treatment of vaginal agenesis. Results are comparable to those of all European studies, and the procedure should gain more popularity in North America.     

Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases

OBJECTIVE: To evaluate the surgical feasibility and the long-term anatomic and functional results of a new procedure that uses the endoscopic approach to treat uterovaginal agenesis, known as Rokintansky syndrome. DESIGN: Evaluation of surgical feasibility and recording of clinical data over a 12-month follow-up. SETTING: Tertiary referral center for the treatment of female genital malformations. PATIENT(S): Fifty-two patients with vaginal agenesis. Intervention(s): The laparoscopic version of the Vecchietti method was used to create a neovagina. MAIN OUTCOME MEASURE(S): Anatomic success was defined as a neovagina >/=6 cm long, allowing easy introduction of two fingers, within 6 months after corrective surgery. Functional success was considered achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. RESULT(S): The surgical procedure was performed with no major complications and with 100% anatomic success; functional success was obtained in 98.1% of the study population. CONCLUSION(S): In patients with Rokitansky syndrome, the laparoscopic approach for creating a neovagina by the Vecchietti method is simple, safe, and effective.     

Creación de neovagina por laparoscopia en el síndrome de Rokitansky. Análisis de nuestros casos

ObjectiveVecchieti's principles were applied to laparoscopic construction of a neovagina in patients with Rokitansky syndrome.Patients and methodSixteen patients with a diagnosis of Rokitansky syndrome were treated with a modified Vecchietti method by laparoscopic approach.ResultsA satisfactory result was defined as a neovagina of at least 8 cm long on the final follow-up visit and was found in 15 patients. The result was much less satisfactory in the 16th patient in whom the vagina was discovered to be shortened from 12 cm to 6 cm at 2 years’ follow up as she had not followed the postoperative treatment.ConclusionsLaparoscopic creation of a neovagina is a safe, minimally invasive treatment with few risks and good functional results.     

The laparoscopic Vecchietti technique for vaginal agenesis.

OBJECTIVE: To evaluate surgical, long-term anatomic and functional results of the laparoscopic Vecchietti procedure to treat women with vaginal agenesis. METHODS: Retrospective analysis of 86 women treated at the Department of Gynecology and Obstetrics at the University of Verona, Italy. Data were analyzed based on surgical results and postoperative sexual satisfaction. Depth and diameter of the neo-vagina was determined. The characteristics of the neo-vaginal mucosa were investigated by vaginoscopy. Patients reported frequency, satisfaction, and any difficulties found at intercourse. RESULTS: Functional success was obtained in 98.1% and anatomic success in 100%. In all patients, at 1 year, the mucosa was pink, trophic, and moist. Two fingers were introduced easily into the neo-vagina in all cases. All patients, which decided to have sexual intercourse, defined these as satisfying within 6 months. CONCLUSIONS: Laparoscopic procedure used in this study is simple, safe, and effective. Anatomical and functional results obtained suggest this laparoscopic procedure as the treatment of choice for this syndrome.     

A simple and effective traction device for laparoscopic formation of a neovagina using the Vecchietti technique

We sought to present a simple new traction device that was used with success in 4 cases of laparoscopic creation of a neovagina using a modified Vecchietti technique. Four patients were treated with laparoscopic creation of a neovagina. All women had Rokitansky-Küster-Hauser syndrome and no more than a 1-cm vestibule dimple. A 3-cm diameter and 10-cm long plastic tube (mold) was used for traction. We developed 2 independent wood traction devices. They were based on tuning pegs of a guitar. The 1-cm demarcation in the external face of the mold allowed easy observation of the effects of traction. The patients were hospitalized from 7 to 10 days and the postoperative courses were uneventful. One patient was lost after 3 months of follow-up. After a year, the other 3 patients were having intercourse and were satisfied with the results. The laparoscopic technique has several advantages: it does not need grafts, it does not need a dissection of the space between the bladder and the rectum, it uses the mucous membrane of the vestibular area, the time of hospitalization is relatively short, and it possesses good long-term results.     

Construction of a neovagina for patients with a flat perineum

Vaginal dilatation affords an acceptable functional success rate for women with vaginal agenesis, provided there is an introitus with a pouch or dimple. In contrast, women with a flat perineum who lack labia majora, labia minora, and vaginal introitus have no alternative to development of a vagina-like orifice other than surgical vaginoplasty. This study addresses the anatomic and functional success rate of these women after undergoing modified McIndoe technique. Thirty-four patients with microphallus were assigned the female gender as the sex of rearing at the Johns Hopkins Hospital between 1951 and 1987. A majority of patients underwent surgical revision of the external genitalia and gonadectomy before 2 years of age. Family counseling was begun at birth. Of these patients, 15 (17 to 25 years old) who requested the ability to have sexual relations underwent modified McIndoe vaginoplasty. All 15 of these women have experienced satisfactory coitus. All but one patient have an adequate size vagina. Results of this group indicate that patients with ambiguous genitalia as a result of male hermaphroditism or microphallus can achieve functional success after vaginal creation with a modified McIndoe technique despite the presence of a flat perineum.     

Laparoscopic findings and pelvic anatomy in Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To describe analytically the anatomic variety and laparoscopic findings observed in patients with Rokitansky syndrome throughout an 11-year span. METHODS: We analyzed the laparoscopic and chart records of 106 consecutive patients who underwent surgery for the creation of a neovagina, according to the modified laparoscopic Vecchietti procedure. RESULTS: A hypoplastic vagina was observed in 61 women. Müllerian remnants, laterally displaced in the pelvis, were identified in 92 cases; 42 (25.9%, 95% confidence interval [CI] 19.2-33.3) of 162 müllerian remnants were cavitated and contained endometrial mucosa. Ovaries were extrapelvic in 17 (16.0%, 95% CI 9.6-24.4) cases. Anomalies of the urinary tract were identified in 32 (30.2%, 95% CI 21.7-39.9) patients; unilateral renal agenesis was the most frequent finding (18 cases; 18%, 95%CI 10.4-25.5). CONCLUSION: Rokitansky syndrome has a wide variability of anatomic presentations, and, as the do other congenital anomalies of the female genital tract, it represents a continuum of embryonic malformations, which occur at different stages of development.     

New Laparoscopic Vaginoplasty Procedure With a Modified Peritoneal Pull-Down Technique in Four Patients With Mayer−Rokitansky−Küster−Hauser Syndrome

BackgroundVarious vaginal reconstructive procedures have been described for patients with Mayer?Rokitansky?Küster?Hauser (MRKH) syndrome. We describe the success of a novel laparoscopic vaginoplasty procedure using an anteroposterior peritoneal pull-down technique.CaseFour patients with MRKH syndrome underwent a modified laparoscopic Davydov procedure using an anteroposterior peritoneal pull-down technique with a transverse laparoscopic incision below the strand. Anatomical success was achieved in all patients, allowing easy introduction of 2 fingers, an epithelialized neovagina, and a mean length of 8.0 cm (range 7.0-9.0cm). All 3 patients who attempted sexual intercourse were successful, and neovagina size was adequately maintained at the long-term follow-up in the remaining patient.Summary and ConclusionThis novel procedure presents as a feasible and an effective approach for vaginal reconstruction in patients with MRKH syndrome.     

FREE COMMUNICATION

Several conservative and surgical methods have been proposed for patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. The technique described by Vecchietti is a combination of both dilatation and surgery. We describe a minimally invasive modification of this approach including dissection of the vesico-rectal septum and present long-term patient outcome. Eight patients who underwent surgery at our department between 1996 and 2005 for MRKH syndrome were included in the present analysis. Post-operative follow-up and a semi-structured telephone interview were performed to obtain information on neovaginal functionality, immediate and long-term post-operative outcome, sexual function and physiological and psychological well-being evaluated on a 10-point scale and by the Sintonen 15D questionnaire. After a median post-operative (median operation time: 88 min, range: 63–116 min) follow-up period of 40.3 months (range: 18–84 months) without major complications and a median post-operative stay of 13.8 days (range: 6–15 days), a functional neovagina was created in seven of eight patients. Median vaginal length at the time of discharge from the hospital ranged between 7 and 10 cm (median: 9.6 cm) and reached 11.5 cm (range: 5–15 cm) at the time of evaluation. Except for one patient who neither had regular sexual intercourse nor used the vaginal dilator, sexual intercourse was quoted as satisfactory in six cases (one patient still used the dilator only). Patients reported an improvement of quality of life (mean: 8.1, range: 5–10) and self-confidence (8.1, range: 5–10) and general well-being evaluated by the Sintonen 15D questionnaire (average score of 1.8, SD = 0.06). The laparoscopic-assisted Vecchietti procedure with dissection of the vesico-rectal septum is a safe and effective method for creation of a neovagina in MRKH patients.     

Laparoscopic-assisted Vecchietti procedure for creation of a neovagina: an analysis of five cases

The aim of this study was to review the functional and psychological outcomes of subjects with vaginal aplasia undergoing a laparoscopic creation of a neovagina (Vecchietti procedure). A semi-structured telephone interview was undertaken of five consecutive subjects who underwent the procedure in the preceding three years. Information was obtained with regard to the operation, immediate post-operative period, complications experienced, sexual function and improvements in general and psychological well-being. A functioning neovagina was formed in all subjects. All sexually active women noted satisfactory intercourse with significant improvements in self-confidence, self-esteem and general well-being up to three years post-operatively.     

The Vecchietti procedure for surgical treatment of vaginal agenesis: comparison of laparoscopy and laparotomy.

OBJECTIVE: Our goal was to describe the outcomes of women with vaginal agenesis who had surgical creation of a neovagina using the Vecchietti technique over a 20-year period. We also sought to determine whether the laparoscopic approach would result in similar outcomes as laparotomy. METHOD: Retrospective analysis of 76 women with vaginal agenesis treated at the University of Verona Hospital between 1976 and 1996 with the Vecchietti procedure. Operative and postoperative records were reviewed, and sexual histories were obtained. Data were analyzed based on surgical approach and postoperative sexual satisfaction. Continuous data were analyzed with student's t-test, and categoric data were analyzed using Fisher's exact test. RESULT: Those who underwent the Vecchietti procedure with a laparoscopic approach (N = 7) had similar complication rates (0% vs. 13.0%, P = 0.59) and postoperative neovaginal depth (74.9 mm vs. 73.7 mm, P = 0.93) as those with laparotomy (N = 69). Similar proportions of women reported inadequate vaginal lubrication (28.6% vs. 17.4%, P = 0.61) and sexual satisfaction (100% vs. 78.3%) in the laparoscopy and laparotomy groups as well. Operative complications, neovaginal depth, or degree of lubrication were not good predictors of sexual satisfaction. CONCLUSION: Outcomes in those women who underwent the Vecchietti technique via the laparoscopic approach are comparable to those who underwent laparotomy.     

Vaginal creation for müllerian agenesis

Objective: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. Study Design: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. Results: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 ± 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 ± 9.5 and 65.3 ± 18.5 months, respectively (P < .005). The mean time to successful dilation was 11.8 ± 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 ± 12.5 months; range, 8-33 months). Conclusion: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.(Am J Obstet Gynecol 2001;185:1349-53.)     

Novel Minimally Invasive Technique of Neovaginoplasty Using an Absorbable Adhesion Barrier

Our objective was to provide a minimally invasive neovaginoplasty technique to construct a nearly physiologic vagina to facilitate sexual functioning and appropriate vaginal length in patients with congenital vaginal agenesis. This retrospective study at a tertiary care hospital comprised 52 patients with congenital vaginal agenesis because of Mayer-Rokitansky-Küster-Hauser syndrome or androgen insensitivity syndrome presented for vaginal reconstruction. Modified McIndoe vaginoplasty was done in all patients between 2010 and 2018 using a vaginal mold created with glove, nonadherent petroleum gauze, and Interceed absorbable adhesion barrier (Ethicon, Johnson & Johnson, Somerville, NJ) that was placed in the neovagina space created between the bladder and rectum for 7 days. Operative details, complications, length and width of the neovagina, and functional outcome were evaluated. The mean operation time was 35 minutes. The mean length of the constructed neovagina was 8.4 cm × 3.4 cm at 6 weeks follow-up. Epithelialization was completed by 4 to 6 months. All patients reported satisfactory sexual activity with no pain and good mucosal sensitivity. This modified neovaginoplasty technique is easy to perform, involves painless postoperative dilatations as the cornerstone of treatment, and results in adequate secretion, allowing lubrication and acceptable physiologic results.     

Late postoperative urinary stress incontinence after a laparoscopic-assisted Vecchietti procedure for neovagina creation in a patient with Rokitansky syndrome: successful treatment with the TVT-O technique

A case report of urinary stress incontinence after surgery in a 20-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome is presented. A neovagina was successfully created with a laparoscopic-assisted Vecchietti procedure. Fifteen months later, after normal and satisfactory sexual intercourse, the patient was seen for stress urinary incontinence. A second surgery consistent with the transobturator tension-free vaginal tape (TVT) system with nonelastic polypropylene suburethral TVT allowed full correction of the urinary symptoms.     

Vaginal creation for müllerian agenesis.

OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 +/- 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 +/- 9.5 and 65.3 +/- 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 +/- 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 +/- 12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.     

Long-Term Follow-Up after Laparoscopic Uterovestibular Anastomosis in Patients with Cervical Atresia and Complete Absence of the Vagina

BackgroundThe surgical treatment of girls with cervical atresia and complete absence of the vagina remains a problem because of the rarity of cases and the controversial study results.ObjectiveTo describe the surgical technique and long-term results of laparoscopically assisted uterovestibular anastomosis in patients with cervical atresia and complete absence of the vaginaStudy DesignSixteen consecutive patients with cervical atresia and complete absence of the vagina were conservatively treated with laparoscopically assisted uterovestibular anastomosis in 2 tertiary care referral centers. The follow-up assessments included clinical examination, determination of the presence and quality of sexual intercourse, and vaginoscopy.ResultsAll patients underwent laparoscopically assisted uterovestibular anastomosis. No perioperative complications occurred. The mean follow-up period was 8 ± 3.2 years. In all patients, the length of the neovagina was greater than 4 cm at 1 year after the surgery and approximately 6 cm after 2 years. After the start of sexual intercourse, the neovagina exceeded 7 cm in length in 2 of the 11 sexually active patients. At 12 months after the surgery, iodine-positive epithelium was present in all patients and was maintained over time. The continuity of the neovagina, neocervix, and uterine body was maintained without further interventions in 15 of the 16 patients. During the follow-up, 11 patients were sexually active, 5 were married, 4 were seeking conception, and 2 had spontaneous pregnancy.ConclusionsLaparoscopically assisted uterovestibular anastomosis seems to be a safe and effective treatment for patients with cervical atresia and complete absence of the vagina, at least in terms of the recovery of menstrual function and sexual activity.     

Plastie vaginale par technique de Vecchietti cœlioscopique : résultats anatomiques et fonctionnels

ObjectivesTo evaluate vaginoplasty by Vecchietti technique adapted to laparoscopy and the anatomical and functional long term outcomes.Patients and methodsWe retrospectively studied the patients with vaginal agenesis (a Mayer-Rokitansky-Küster-Hauser syndrome for seven of young adults) operated from 1997 to 2011. The data of eight patients with a median age of 18 years old was collected. Surgical complications were analysed. The functional outcomes were compared to a control group with the Female Sexual Function Index (FSFI).ResultsNo major complication occurred during surgery. The postoperative mean vaginal measurement was 7.2 cm (4.4–10). The total FSFI scores did not differ from that of the control group (19.2 versus 18 p = 0.82). Desire, arousal, lubrication, orgasm, satisfaction, and pain of the patients were similar to controls.Discussion and conclusionLaparoscopic Vecchietti technique is a fast, simple and safe procedure to create a neovagina, and guarantees good anatomic and functional results.