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.     

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.     

A new method of neovagina in Rokitansky's syndrome. A review of the literature and description of a series

BACKGROUND: The absence or hypoplasia of the vagina is a frequent finding in Rokitansky-Mayer-Küster-Hauser syndrome. METHODS: A group of 13 patients with Rokitansky-Mayer-Küster-Hauser syndrome were treated between 1982 and December 2001 at the Plastic Surgery Department of C.T.O. (Turin) and the 2nd Obstetrics-Gynecology Clinic of Turin University. Surgery was the proposed therapy in all patients, using a modified version of the McIndoe technique. RESULTS: In this series, the cytological tests of neovaginal tissue carried out one year after surgery showed a syndrome of slight atrophy in 8 cases, but this was not sufficient to impede the sexual activity of these patients. Two patients were lost in the follow-up; 3 patients declared that they were reasonably satisfied with their sex life, whereas the remaining 8 reported a normal sex life. CONCLUSIONS: The treatment of choice for complete vaginal agenesia is a neovagina using the skin graft method. This technique produces excellent anatomical results, especially in young patients, even without regular dilatation or frequent sexual relationships. The only drawback of this method is that the vagina tends to retract in some patients, a problem that has been largely solved by the most recently proposed surgical variants.     

Sigmoid neovagina by combined laparoscopic-perineal route for Rokitansky syndrome

OBJECTIVE: To evaluate the feasibility of a combined laparoscopic-perineal procedure to create a neovagina. PATIENTS AND METHODS: We reported four cases of patients with a Mayer-Rokitansky-Küster-Hauser syndrome. The surgical procedure was the same for all patients. The results have been evaluated on the operative time, the intra and postoperative complications, the first day haemoglobin drop, the antalgic drugs consumption, the transit recovery, the hospital stay, and the neovagina length. RESULTS: The mean operative time was 311 minutes. The mean haemoglobin drop was 2.3 g/dl. The mean paracetamol, nonsteroidal anti-inflammatory (NSAID), and morphine consumption were: 16 g, 216.7 mg, and 12.6 mg, respectively. The mean transit recovery, and hospital stay were: 2.3 days, 6.5 days, respectively. No intra or postoperative complication occurred. The mean neovagina length evaluated at one month follow-up visit was 12 cm. DISCUSSION AND CONCLUSION: This surgical technique appeared feasible and reproducible for teams having an adequate experience in laparoscopic gynaecologic and digestive surgery. This technique allowed to obtain a neovagina with enough length and without any shrinkage. Laparoscopy reduces the psychological and aesthetic consequences of surgery, especially for these young patients already distressed by their malformation.     

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.     

Surgical Video Tutorial: Treatment of Congenital Vaginal Agenesis: Laparoscopic Modified Davydov in 8 Steps

ObjectiveTo describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches.DesignProduction of a step-by-step surgical video tutorial with narrative video footage.SettingUterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1]. Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as “covering” tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2].InterventionsWe treated an 18-year-old patient with Mayer-Rokitansky-Küster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners.ConclusionThe Davydov technique is less invasive than other surgical techniques and allows good outcomes [3,4] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.     

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.     

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 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.     

Laparoscopy-assisted Ruge procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To describe the successful use of a laparoscopy-assisted Ruge procedure for the reconstruction of a vagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome. DESIGN: Case report. SETTING: A university hospital. PATIENT(S): A 19-year-old Japanese woman with Mayer-Rokitansky-Küster-Hauser syndrome. INTERVENTION(S): Creation of a neovagina by a laparoscopy-assisted Ruge technique. MAIN OUTCOME MEASURE(S): Clinical examinations were performed during the follow-up period. The depth and diameter of the neovagina were measured by vaginography. Patient satisfaction also was determined. RESULT(S): The neovagina was 12 cm in length and 4 cm in diameter. The mucosa of the neovagina was pinkish and had a moist surface. No intraoperative or postoperative complications were observed. CONCLUSION(S): The use of an isolated segment of the sigmoid colon for vaginal construction has the advantages of providing a sufficient length of neovagina and not requiring immediate postoperative self-dilatation. We believe that our procedure has various advantages in addition to those of the original Ruge method, including its minimally invasive nature and excellent cosmetic results. Further, a laparoscopy-assisted operation allows for the diagnosis of uterine defects and the creation of a neovagina at the same time.     

Creation of a neovagina according to Wharton-Sheares-George in patients with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE: To introduce a simple and quick surgical alternative for creating a neovagina in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome that offers good anatomic and functional results. DESIGN: Historical report. SETTING: Tertiary center for gynecologic endocrinology. PATIENT(S): Three patients with MRKH syndrome. INTERVENTION(S): The creation of a neovagina according to Wharton-Sheares-George in patients with MRKH syndrome. MAIN OUTCOME MEASURE(S): Axis, length, and width of neovagina. RESULT(S): The George modification of the Wharton-Sheares neovaginoplasty was successfully performed in three patients. The results were excellent (normal axis and adequate length and width of neovagina), and there were no major complications. CONCLUSION(S): The George modification of the Sheares technique represents a simple, safe, and effective surgical option for creating a neovagina. The procedure is not highly complex and is therefore easy to learn and perform; no special surgical equipment is needed. Anatomic and functional results are very satisfying. Short-term hospitalization, accelerated recovery, and a rapid return to everyday life are important benefits for these young patients. These benefits also result in lower surgery-related expenses and therefore reduce the strain on the hospital's budget compared with other therapeutic options. The creation of a neovagina according to Wharton-Sheares-George might provide a satisfactory alternative for the surgical management of vaginal aplasia in patients with MRKH syndrome.     

Repair of vaginal prolapse and perineal hernia after pelvic exenteration

Perineal hernias have been a significant complication of pelvic exenteration since the inception of this procedure. A variety of natural and artificial materials have been used to support the small bowel to prevent its descent into the lower pelvis with subsequent hernia and fistula formation. More recently, neovagina construction using gracilis myocutaneous flaps has provided both sexual function and support for the small bowel. A patient is presented who had prolapse of her neovagina and a perineal hernia 12 months after exenterative surgery. A technique to repair this complication is described, and a possible method of preventing it is discussed.     

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome by modification of Vecchietti's procedure

We performed a modified Fedele technique for laparoscopic creation of a neovagina by Vecchietti's method to treat vaginal aplasia in three patients with Mayer-Rokitansky-Kuster-Hauser syndrome. Three beads forming a triangle, anchored to a disposable syringe mould, were applied to the vaginal dimple and pulled upward by two polypropylene sutures, and passed through the potential neovaginal space created laparoscopically. The women sat on ordinary bicycle seats to provide pressure from below, resulting in formation of neovagina over 10 to 12 days. Good results were obtained in all three women in both anatomy and sexual function.     

Long-term results after neovagina creation in Mayer-Rokitanski-Kuster-Hauser syndrome by Vecchietti's operation

OBJECTIVES: To evaluate the long-term results after Vecchietti's operation. STUDY DESIGN: Twenty Mayer-Rokitanski-Kuster-Hauser (MRKH) syndrome patients underwent creation of a neovagina using Vecchietti's operation by laparotomy (17 cases) and laparoscopy (3 cases). RESULTS: The mean age of the patients was 21 years (16-34). After 66 months (24-156) of follow-up, the mean length x diameter of the neovagina was 8.2 cm x 2.8 cm. The neovaginal epithelium was macroscopically similar to normal vaginal mucosa, except for one patient who had subsequently undergone insertion of skin graft. Post-operative sexual behavior revealed sexual desire and pleasure (100%), lubrication (94%), clitoral orgasm (87%) and vaginal-mediated orgasm (69%). Finally, 16 patients out of 18 (89%) were completely satisfied with the results of the operation. CONCLUSION: Vecchietti's operation may be suggested as one of the choice of treatments to correct vaginal aplasia in young MRKH syndrome patients.     

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts

PURPOSE: Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study. METHOD: A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse. RESULTS: We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention. CONCLUSION: Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.     

Sexuality after sigmoid colpopoiesis in patients with Mayer-Rokitansky-Kuster-Hauser Syndrome

OBJECTIVE: To assess the functional outcome and sexuality of patients after creation of a sigmoid neovagina. DESIGN: Clinical study performed between 1992 and 2002, with a mean follow-up of 3.3 years (range, 6 months to 9 years). SETTING: Tertiary care center. PATIENT(S): Sixteen consecutive patients with Rokitansky syndrome. INTERVENTION(S): Creation of a neovagina with an antiperistaltic (n = 13) or isoperistaltic (n = 3) sigmoid graft and colovestibular anastomosis by interrupted suture (n = 11) or PCEEA forceps (n = 5). All patients had a neovaginal vault suspension (n = 16). MAIN OUTCOME MEASURE(S): Functional results were evaluated in patients 6 or more months after the operation (n = 12) by using the standardized Female Sexual Function Index (FSFI). This index assesses four domains of sexual dysfunction: desire disorder, arousal disorder, orgasm disorder, and sexual pain disorder. Lubrification and "sexual" quality of life was also evaluated. Normal patients had a mean full FSFI score of 30 +/- 5 of 36. RESULT(S): The mean full FSFI score was 28 +/- 5 (range: 22-34). Seventy-two percent of patients had vaginal intercourse at least once a week; in this subset, the mean full FSFI score was 30 +/- 3 (range: 25-34). CONCLUSION(S): Sigmoid neovagina allowed a normal sexual life in patients who had sexual relations.     

Comparison of the modified McIndoe and modified laparoscopic Vecchietti techniques for the creation of a neovagina in Rokitansky syndrome

The aim of this retrospective clinical study was to compare the effectiveness and long-term anatomic and functional results of the modified laparoscopic Vecchietti and modified McIndoe techniques used to treat Rokitansky syndrome. Neovaginas were created either with the modified laparoscopic Vecchietti technique or with the modified McIndoe technique in 21 patients with Rokitansky syndrome aged between 17 and 40 years (mean 23 years) who wished to begin sexual intercourse. Anatomic success was defined as a neovagina longer than 6 cm and the easy introduction of two fingers. Functional success was achieved if the patient reported satisfactory sexual intercourse starting from 6 months after surgery. The performance of both techniques was efficacious. However, the postoperative hospital stay and operation times of the modified laparoscopic Vecchietti technique were shorter than those of the modified McIndoe technique and the modified laparoscopic Vecchietti technique was less painful than the modified McIndoe technique.     

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.