Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer-Rokitansky-Küster-Hauser syndrome.

OBJECTIVE: Evaluation of the Creatsas modification of Williams vaginoplasty for the creation of neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome). DESIGN: Record of perioperative and postoperative results and complications. Follow-up evaluations of patients yearly after the operation. SETTING: Division of Pediatric-Adolescent Gynecology and Gynecologic Corrective Surgery, University of Athens (tertiary referral center). PATIENT(S): One hundred eleven patients with MRKH syndrome. INTERVENTION(S): Surgical creation of neovagina using the Williams vaginoplasty technique (group A: 10 patients) or the Creatsas modification of the previous method (group B: 101 patients). MAIN OUTCOME MEASURE(S): Length and width of the neovagina, and the quality of sexual life postoperatively. RESULT(S): A functioning vagina of 10 to 12 cm depth and 5 cm width was created in eight of the patients in group A (80%) and in 98 of those in group B (97.02%). A vagina of 7 to 9 cm depth and 2 to 3 cm width was created in the rest of the patients in both groups. In group A, two wound openings were reported (20%); in two of the patients hemorrhage occurred during the first intercourse, compared to none in group B. A satisfactory sexual life was reported from 94.4% of the patients and an adequate one from 4.16% of them. CONCLUSION(S): The Creatsas modification of Williams vaginoplasty is a simple and effective technique for the creation of a functioning neovagina in young women with vaginal aplasia.     

Ultrasound imaging to evaluate Creatsas vaginoplasty.

OBJECTIVE: To present a new imaging technique for the evaluation of the functional effectiveness of Creatsas vaginoplasty. METHOD: Eighteen women with Mayer-Rokitansky-Kuster-Hauser syndrome underwent a transabdominal and transperineal ultrasound examination 4 weeks and 6 months after the surgical creation of a neovagina, and then yearly, with a condom filled with water as a distending and imaging medium. The functional length and width of the neovagina and its axis deviation were assessed, as well as the postoperative quality of the women's sexual life. RESULTS: A functional vagina 10 to 12 cm in length and 4 to 5 cm in width was observed; its axis deviation, which was similar to the anatomic deviation, was easily determined; and 94.5% of the women reported a satisfactory while 5.5% reported an adequate sexual life. CONCLUSION: This new imaging technique is a simple and effective alternative for the evaluation of the postoperative effectiveness of colpopoiesis.     

Application of Creatsas Vaginoplasty after Radical Surgical Treatment of Sarcoma Botryoides

BackgroundSarcoma botryoides of the female genital tract is a rare malignancy. For many years, treatment consisted of radical procedures involving removal of the vagina, cervix, and uterus. Reconstructive surgery is essential for these patients, in order to achieve vaginal penetrative sexual intercourse.CaseA 17-year-old adolescent, with medical history of surgical excision of uterus and vagina at the age of 2, due to sarcoma botryoides, underwent Creatsas vaginoplasty. A neovagina with adequate dimensions to allow comfortable sexual intercourse was created, without the need for postoperative dilations and without any complications.Summary and ConclusionsCreatsas vaginoplasty can be safely performed in patients with medical history of radical pelvic surgery, while other more invasive techniques may carry an increased risk of intra- or postoperative complications.     

Use of acellular human dermal allograft for vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome: a case report

BACKGROUND: Both autologous and synthetic tissue have been used to create a neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome. Despite reports on many different techniques, the ideal method of vaginoplasty has not been firmly established. CASE: A 33-year-old woman with Mayer-Rokitansky-Küster-Hauser syndrome had been unsuccessful in using vaginal dilators for the creation of a functional vagina with the Frank technique due to pain and vulvar lichen sclerosis. She thus elected to undergo vaginoplasty by a modified McIndoe procedure using acellular human dermal allograft material. Both the surgery and immediate postoperative course were uncomplicated. Vaginal apex stenosis resulted from inadequate dilatation in the weeks following surgery since the patient experienced pain with dilator use. CONCLUSION: The use of dermal allograft material instead of a split-thickness autologous skin graft is a simple and less invasive method of constructing a neovagina. Due to the many potential advantages of this technique, further investigation is warranted to optimize long-term outcomes of vaginoplasty using this method.     

Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques

IntroductionGender reassignment surgery is the keystone of the treatment of transgender patients. For male-to-female transgenders, this involves the creation of a neovagina. Many surgical methods for vaginoplasty have been opted. The penile skin inversion technique is the method of choice for most gender surgeons. However, the optimal surgical technique for vaginoplasty in transgender women has not yet been identified, as outcomes of the different techniques have never been compared.AimWith this systematic review, we aim to give a detailed overview of the published outcomes of all currently available techniques for vaginoplasty in male-to-female transgenders.MethodsA PubMed and EMBASE search for relevant publications (1995–present), which provided data on the outcome of techniques for vaginoplasty in male-to-female transgender patients.Main Outcome MeasuresMain outcome measures are complications, neovaginal depth and width, sexual function, patient satisfaction, and improvement in quality of life (QoL).ResultsTwenty-six studies satisfied the inclusion criteria. The majority of these studies were retrospective case series of low to intermediate quality. Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization.ConclusionsThe penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data. Horbach SER, Bouman M-B, Smit JM, Özer M, Buncamper ME, and Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med 2015;12:1499–1512.     

Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients

IntroductionThe “traditional” method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion.AimThe aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion.MethodsThis is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups.Main Outcome MeasurePatient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina.ResultsOur findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance).Clinical ImplicationsThe use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty.Strength & LimitationsThis study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction.ConclusionThis study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar.di Summa PG, Watfa W, Krähenbühl S, et al. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med 2019;16:2030?2037.     

Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in vaginal agenesis

OBJECTIVE: The purpose of this study was to present our experiences of an innovative surgical approach for vaginal agenesis with the use of Interceed absorbable adhesion barrier (Ethicon) to achieve a satisfactory neovagina. STUDY DESIGN: The current study involved 10 subjects who were diagnosed with vaginal agenesis. After the creation of a vaginal tunnel, a mold that had been wrapped with Interceed was placed in the neovagina. RESULTS: No operative and postoperative complications were encountered. The duration of the operation was < or =30 minutes, and blood loss was minimal. The postoperative hospital stay was only 2 days. Epithelialization of the neovagina was achieved 1 to 4 months after the operation, and all patients were satisfied with the outcome. The neovagina that was created with this procedure was not much different from the normal adult vagina as far as histologic and physiologic conditions are concerned. CONCLUSION: This innovative surgical procedure may be a potential alternative approach for the therapy of vaginal agenesis with the use of the absorbable adhesion barrier Interceed with excellent results.     

Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified vascularized pedicled sigmoid

Between 1995 and 2002, 53 primary sex reassignments in male to female transsexuals were performed at our division. The objective of this procedure is to mimic the female external and part of the internal genitalia both esthetically and functionally. In 11 of the 53 patients, a secondary vaginal lengthening had to be performed due to a short neovagina. This was achieved using a pedicled sigmoid segment, with an open approach in the first 2 patients and using a laparoscopic method in the following 9. This paper focuses on the laparoscopic technique, its benefits and potential complications. Where a primary vaginoplasty, combining inversion of the penile and scrotal skin flaps, yields unsatisfactory functional results, a secondary vaginoplasty using the pedicled sigmoid represents an elegant means to achieve functional improvement. Furthermore, we report a modified surgical approach to the conventional sigmoid transition.     

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.     

A case of vaginoplasty without grafting

BackgroundMany techniques have been used to create a neovagina in patients with vaginal agenesis, and several surgical procedures involve the use of a graft. Grafting techniques are associated with intraoperative and postoperative morbidity and complications, at both the donor and the recipient site.CaseA 17-year-old patient with Mayer-Rokitansky-Kuster-Hauser syndrome complicated by unilateral pelvic kidney underwent successful vaginoplasty without the use of a graft, followed by insertion of a vaginal stent for 12 weeks. She had a functional, well-healed, and fully epithelialized neovagina by 6.5 months postoperatively.ConclusionPatients undergoing surgical vaginoplasty may benefit from this simple surgical technique, thereby avoiding the morbidity associated with the alternative grafting techniques commonly used in practice.     

Laparoscopic Davydov Correction of a Failed Gracilis Flap Neovagina in a Patient With Mayer-Rokitansky-Kuster-Hauser Syndrome With a Pelvic Kidney

The laparoscopic Davydov procedure is a surgical technique for creation of a neovagina in patients with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) or vaginal agenesis. Herein we report its use in creating a neovagina after failure of a previous surgical attempt in a patient with a pelvic kidney, which has not been described to date. The patient, a 28-year-old woman with MRKH in whom creation of a neovagina using bilateral gracilis flaps had been attempted, was unable to have intercourse because of a shortened and scarred vagina. We successfully used the laparoscopic Davydov procedure to create a functional neovagina despite the previous surgery and the presence of a pelvic kidney. The Davydov procedure is an option for use in patients with MRKH with history of unsuccessful neovaginal surgery and can be performed in the presence of a pelvic kidney.     

Laparoscopic vaginoplasty: alternative techniques in vaginal reconstruction

Construction of a neovagina is the next step for women with an absent vagina who have failed vaginal dilator therapy. Traditional operative techniques such as skin grafting or intestinal substitution have major disadvantages including prolonged recovery time and significant scarring. Laparoscopic vaginoplasty is performed widely throughout Europe but has not been available in the UK until now. We report on five women who underwent laparoscopic vaginoplasty. Three women underwent a laparoscopic Vecchietti procedure and two underwent a laparoscopic Davydov procedure. Details were recorded on preoperative features, perioperative problems and early postoperative outcome. Laparoscopic vaginoplasty is a safe treatment for vaginal agenesis, and short-term results are encouraging.     

Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases

IntroductionThere are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue.AimTo evaluate the anatomical and functional results of sigmoid vaginoplasty and long‐term sexual and psychological outcomes in 86 patients with vaginal absence.MethodsBetween April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis.Main Outcome MeasuresSexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires.ResultsFollow‐up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%).ConclusionsRectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery. Djordjevic ML, Stanojevic DS, and Bizic MR. Rectosigmoid vaginoplasty: Clinical experience and outcomes in 86 cases. J Sex Med **;**:**–**.     

阴股沟皮瓣阴道再造术12例分析

目的　对应用阴股沟皮瓣进行阴道再造的经验进行总结。方法　以阴唇后动脉外侧支为血管蒂 ,在两侧阴股沟区掀起阴股沟皮瓣 ,皮瓣 9cm× 4cm～ 14cm× 5cm ,通过大阴唇皮下隧道转移至阴道前庭 ,相对缝合形成皮管 ,推入尿道、直肠间隙的腔穴中形成阴道。共为 12例患者实施阴道再造。结果　 1例因术中造穴时损伤直肠导致阴道直肠瘘 ,1例因感染致一侧皮瓣坏死 ,二期修复成功。其余 2 3个皮瓣全部成活 ,随诊 3个月至 8年 ,再造阴道光滑、无缩窄 ,横向可容纳两指 ,深度约9～ 10cm。结论　应用阴股沟皮瓣进行阴道再造 ,具有皮瓣血运丰富 ,解剖简便易行 ,再造阴道无继发挛缩并带有会阴部感觉 ,供区较隐蔽 ,术后少有继发瘢痕畸形的优点。     

Laparoscopic promontofixation for the treatment of recurrent sigmoid neovaginal prolapse: case report and systematic review of the literature

Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest. A 34-year-old woman with vaginal agenesis underwent vaginoplasty using sigmoid colon. Almost 6 years after the initial operation, she started complaining of a bearing-down sensation and an increase in vaginal discharge. She underwent 2 open surgeries and one vaginal surgery to treat the prolapse with no success. She came to our service and at vaginal examination the neovagina protruded approximately 5 cm beyond the hymen. The prolapse was treated successfully using a laparoscopic approach to suspend the neovagina to the sacral promontory (laparoscopic promontofixation). Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Laparoscopy may be an alternative approach to restore the neovagina without compromising its function.     

Müllerian dysgenesis: a review of recent outcomes at Royal Hospital for Women

BACKGROUND: Müllerian dysgenesis occurs in approximately 1 in 5000 live-born females. There have been many methods described for creation of a functionally useful vagina in cases of Müllerian dysgenesis. Given the number of available methods and the infrequency of the condition, outcome data can be difficult to obtain. AIM: To perform a retrospective review of presentation, treatment and outcomes in cases of Müllerian dysgenesis seen at the adolescent gynaecology unit at the Royal Hospital for Women, Sydney. METHODS: Thirty women with Müllerian dysgenesis were identified between January 2000 and December 2004. Of these, 23 had Müllerian agenesis and seven had partial vaginal agenesis. As this audit and review conform with the standards established by the National Health and Medical Research Council for ethical quality review, ethics approval was not sought. RESULTS: Dilator therapy under the guidance of a trained clinical nurse educator was successful in creating a functionally useful vagina and was well tolerated in all cases of Müllerian agenesis. Patients suffering from segmental vaginal agenesis all had surgical creation of a neovagina with the aid of an amnion vaginoplasty. All patients who were referred following surgical drainage of their haematocolpos outside the unit became infected and needed to undergo further surgery prior to creation of a neovagina. Fibrotic vaginal bands developed only in these patients. CONCLUSION: The outcomes reinforce the TASPAG guidelines of management for Müllerian dysgenesis, which suggest that dilators are generally effective in creating a functionally useful vagina, and if surgery is required, the primary operation should be definitive and performed by well-trained experts.     

Creation of neovagina using oxidized cellulose (surgicel) as a surgical treatment of vaginal agenesis

Objective Our goal was to analyze the safety and efficacy of the use of oxidized cellulose in the creation of neovagina. Methods A total of 10 women with vaginal agenesis attending gynaecology clinic of AIIMS between July 2003 to March 2005 underwent vaginal reconstructive surgery using oxidized cellulose were recruited in this retrospective study. The age of patients ranged from 17 to 22 years (mean age 19 years). Using a transverse incision at introitus, a 10 × 4 cm space was created and a vaginal mould covered with oxidized cellulose was put in the neovagina. Results The age ranged from 16 to 22 years (mean 19.5 years). Out of 10 patients, who had undergone vaginoplasty, all were sexually active; 8 had satisfactory intercourse, 1 chronic mild dyspareunia due to partial stenosis and 1 was lost to follow up. 2 out of 10 had inflammatory reaction and 1 had psychological problems. Conclusion Vaginal reconstruction using oxidized cellulose appears to be a safe and effective procedure with minimum complications, morbidity and discomfort with high success rates.     

Inverted balloon vaginoplasty: an obstructed upper vaginal pouch was pulled downward to form a neovagina

Inverted balloon vaginoplasty technique was performed for a case with segmental vaginal aplasia and upper hematocolpos within 50 min operative time without any complications. The neovagina was naturally covered, 11 cm in depth and communicated with dimple at hymen's site. Regular painless menstruations were reported.     

Sexuality after Laparoscopic Peritoneal Vaginoplasty in Women with Mayer-Rokitansky-Kuster-Hauser Syndrome

ObjectiveTo evaluate anatomic and sexual outcomes in women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome after laparoscopic Davydov (laparoscopic peritoneal vaginoplasty).DesignProspective follow-up study of patients with MRKH syndrome after vaginoplasty (Design classification: II-2).SettingAcademic hospital.PatientsPatients with MRKH syndrome and frequency-matched age-comparable healthy controls.InterventionThirty-one patients with MRKH syndrome underwent surgery with the procedure, and their clinical, surgical, and follow-up data were recorded. A Female Sexual Function Index (FSFI) questionnaire was administrated to evaluate sexual functions of patients who became sexually active and compared them with 50 randomly selected, age-matched healthy women.MeasurementsFSFI scores in women with MRKH syndrome and in control subjects. Clinical and anatomic measurements of neovagina.Main ResultsThe laparoscopic Davydov was successfully completed in all 31 cases, with 24 patients monitored. The mean length of the neovagina was 6.27±1.25 cm. There was no statistical difference in the total FSFI score between the case and control groups. There is indication that shorter neovaginal length, especially of<7 cm, appears to be associated with lower total FSFI scores.ConclusionLaparoscopic Davydov is a safe, effective treatment of Mayer-Rokitansky-Kuster-Hauser syndrome with minimal invasion and a relatively low complication rate.