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.     

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.     

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.     

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.     

Vaginoplasty by inverted perineal and labia minora flaps-a retrospective study.

Absence of the vagina occurs most frequently in the Rokitansky-Küster-Mayer (RKM) syndrome. Since Küster has reviewed the literature in 1910 many techniques have been described to create a neovagina. We describe a technique in which both a part of the labia minora and of the perineal skin are used as flaps to cover the neovagina and report on the long-term outcome in a series of 16 patients with RKM syndrome treated with this technique. No intra-operative or immediate postoperative complications were recorded. The average depth of the neovagina was 8 cm, at the end of the operation and 1 year later. After 3 months the neovagina was completely lined with vaginal epithelium. In six out of 16 patients scar formation and polypoid formation was observed at the apex of the neovagina. This could be successfully handled by excision and coagulation in all six cases. Ten patients reported a satisfactory sexual life. The technique is simple and easy to perform. The anatomical result and sexual gratification was outstanding in two-thirds of the patients. We conclude that flaps derived from the genital region offer the most physiological tissue for construction of a neovagina.     

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.     

腹腔镜与腹腔镜辅助乙状结肠代阴道术治疗MRKH综合征

目的 :总结使用全腹腔镜和腹腔镜辅助下乙状结肠阴道成形术各成功治疗1例Mayer Rokitansky Kuster Hauser综合征 (MRKH综合征 )的经验。方法 :全腹腔镜下使用腔镜闭合切割器切断乙状结肠的近端和远端。自肛门插入腔内圆型吻合器 ,将降结肠与直肠吻合。经会阴于尿道膀胱与直肠之间造穴。将带血管蒂的乙状结肠牵入穴道 ,完成阴道成形。腹腔镜辅助下阴道成形中 ,腔镜闭合切割器切断乙状结肠的远端后 ,于左下腹壁做一辅助切口 ,将近端乙状结肠经此切口拉出至腹腔外。切断乙状结肠近端 ,将乙状结肠的远端开口缝合 2层 ,使之成盲端。近侧端开口置入吻合器之钉钻 ,再行荷包缝合送回腹腔 ,用吻合器行肠吻合。其余步骤同全腹腔镜手术步骤。术后根据临床检查或磁共振成像测量新成形阴道的长度和宽度。结果 :全腹腔镜手术新成形的阴道长 18cm ,宽 4cm。腹腔镜辅助手术新形成的阴道长 19cm ,宽 4cm。两例新形成的阴道黏膜湿润 ,呈粉红色。无术中和术后并发症的发生。结论 :经腹腔镜乙状结肠移植段的长度完全能达到开腹手术的要求。与开放手术比较 ,全腹腔镜乙状结肠代阴道手术在腹壁上不留手术瘢痕 ,美容效果理想。而腹腔镜辅助下阴道成形 ,虽腹壁留有小手术疤痕 ,但操作简便 ,手术时间短 ,手术费用低     

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.     

Laparoscopically assisted balloon vaginoplasty for management of vaginal aplasia.

OBJECTIVE: To report the intra-operative and post-operative results of laparoscopically assisted balloon vaginoplasty, a new technique for management of vaginal aplasia. METHODS: Eight women with vaginal aplasia due to Mullerian agenesis who were referred for apareunia, dyspareunia. All had a poor penetration score and sexual satisfaction score. A Foley's catheter was laparoscopically inserted in the space between the urethra and rectum. Gradual traction and distension were used to create a neovagina. Outcomes measured were intra-operative complications, post-operative complications, length of the neovagina and post-operative complications and sexual satisfaction score in both partners. RESULTS: Mean operative time was 25.5+/-5.5 min. No operative complications were recorded. Pain scores ranged from zero to 30 points at rest and from 30 to 60 points during dressing, traction and distension. Penetration and satisfaction scores increased significantly after the operation. CONCLUSIONS: Balloon vaginoplasty is a simple, safe and satisfactory technique for management of blind vagina.     

Vaginal Reconstruction Using the Bladder and/or Rectal Walls in Patients with Radiation-Induced Fistulas

Objective. In irreparable or recurrent vesicovaginal fistulas and cloacal defects following high-dose irradiation therapy for gynecological malignancies, urinary diversion is the last resort to achieve a socially acceptable solution. In a select group of young and tumor-free patients, additional vaginal reconstruction may be indicated. Multiple operative procedures are available, but the results are often disappointing in the previously irradiated area.Materials and methods. In six such patients with large radiogenic vesicovaginal defects (n = 5) or a cloacal fistula (n = 1), a continent reservoir using the transverse colon with an umbilical stoma was performed. At the end of the operation, the bladder was incorporated into a neovagina by incising the urethra, anterior vaginal wall, and the posterior bladder wall with electrocautery from the urethral meatus to the dome of the fistula.Results. No postoperative complications related to the vaginal reconstruction occurred. After a mean follow-up of 4.7 years, all patients had a capacious vagina and a wide introitus; the neovagina measured a mean of 18 cm in length. Five patients with a partner reported a normal sexual life. No dyspareunia or discomfort from bladder or urethral mucosa during intercourse was reported.Conclusions. Following continent urinary diversion due to irreparable vesicovaginal fistulas, a neovagina can be created by simple dissection of the posterior bladder and anterior vaginal wall. When a colostomy is present, the neovagina can additionally be augmented with a bowel flap of the Hartmann stump or by incising the rectovaginal septum. The technique affords good functional and cosmetic results.     

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.     

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.     

Laparoscopic Sacrocolpopexy With a Mesh for Sigmoid Neovaginal Prolapse: A Case Report

BackgroundCreating a functional neovagina is a practical therapeutic intervention for women with congenital vaginal agenesis and sexual needs. Although the incidence of neovaginal prolapse (NP) is low, it is inconvenient for patients and is a challenging problem for gynecologists.CaseA 32-year-old woman who had undergone transabdominal sigmoid vaginoplasty 10 years previously at another hospital visited our clinic for evaluation and treatment of NP. Gynecological examination showed exstrophy of the vaginal apex, 4 cm beyond the hymen. Laparoscopic sacrocolpopexy was performed using a mesh. The mesh was sutured at the anterior wall and apex of the neovagina and suspended in the anterior sacral region without blood vessels.Summary and ConclusionLaparoscopic sacrocolpopexy might be an effective and safe treatment for NP.     

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.     

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.     

Expert opinion: vaginal aplasia: creation of a neovagina following the Creatsas vaginoplasty

Vaginal aplasia is an uncommon congenital anomaly which is usually diagnosed as part of the Mayer-Rokitansky-Kuster-Hauser syndrome. The appropriate management of the anomaly includes the creation of a neovagina, and various surgical or non-surgical techniques have been described. Among them the Creatsas modification of Williams vaginoplasty is an operative technique which involves the following surgical steps: Under general anesthesia, and after cutting the hymen with the use of diathermy, a U-shaped incision is made in the vulva extending across the perineum and up to the medial side of the labia to the level of the external urethral meatus, being 4cm lateral to it. The tissues are mobilized and a first layer of interrupted sutures is put between the inner skin margins using absorbable material with the knots lying inside the creating neovagina. A second layer of the same material is used to approximate the subcutaneous fat and the perineal muscles and finally, the external skin is sutured with absorbable interrupted stitches. The Creatsas vaginoplasty is simple, safe and highly effective, as its application in a large number of patients has been followed by excellent results, with the creation of a satisfactory neovagina (length 10-12 cm, width 5 cm) in 98% of patients.     

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.     

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.