The clinical, structural, and biological features of neovaginas: a comparison of the Frank and the McIndoe techniques

Effectiveness of non-surgical interventions to improve health and well-being in women living with Mayer-Rokitansky-Kuster-Hauser syndrome: A systematic review

AIM

The aim of this paper is to present the evidence on the effectiveness of non-surgical interventions to improve health and well-being in women living with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.

DESIGN

Systematic review guided by Preferred Reporting Items for Systematic Reviews checklist.

DATA SOURCES

The search was conducted between June and September 2022 across the following databases: CINAHL, EMBASE, Medline, PsycINFO and Cochrane. Trial registries (clinicaltrials. gov, World Health Organization International Clinical Trials Registry Platform (ICTRP), Cochrane Controlled Trials Register-CCTR), Google scholar, dissertations, conference proceedings and reference lists of included studies were also searched. Corresponding authors, formal and informal MRKH groups were contacted to obtain any significant studies or reviews.

REVIEW METHODS

Eligible were only English-language empirical studies of any time period. The review followed narrative synthesis.

RESULTS

Twenty-three studies were identified that fit the inclusion criteria which included 1540 MRKH syndrome affected women. Four studies were on psychological interventions (n = 85) and 19 studies (vaginal dilation therapy n = 897, coital dilation n = 57) focused on non-surgical vaginal dilation as a measure to vaginal agenesis in MRKH syndrome.

CONCLUSIONS

Clearly, vaginal dilation is a viable initial treatment option for women with MRKH syndrome. There is limited evidence that 'coital dilation' is an effective method of dilation for vaginal agenesis. The literature, however, supports the need for psychological intervention to improve health and well-being.

IMPACT

Women with MRKH syndrome who require dilation can receive guidance and support from their healthcare providers, particularly sexual and reproductive health nurses, clinical nurse specialists and gynaecologists. From the point of diagnosis, clinical psychologists should be involved. As much as feasible, family and partner support can be encouraged.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Anatomical and Functional Evaluation of Modified Abbe-McIndoe Vaginoplasty at a Tertiary Care Hospital

BACKGROUND

Mayer-Rokitansky-Kuster-Hauser (MRKH) Syndrome, the second important cause of primary amenorrhea, is characterized by complete mullerian agenesis in the presence of normal karyotype and normal functioning ovaries. Incidence is one in 4500 females. Treatment options include surgical and non-surgical methods. Surgical treatment by creating a neovagina between bladder and rectum is preferred as it gives immediate results.

AIM

To evaluate the anatomical and functional outcomes of modified vaginoplasty procedures conducted in our institution.

METHODS

An ambispective cohort study was conducted in the Department of Obstetrics and Gynaecology, at a tertiary care hospital and included 10 cases of MRKH syndrome, who underwent surgical treatment in our department. Postoperative outcome was noted. Sexual function was evaluated using the Female Sexual Function Index (FSFI) score.

RESULTS

The mean duration of surgery was 40 minutes. The average blood loss during surgery in patients undergoing vaginoplasty was 60 ml. The mean length of the neovagina as measured 1 month after surgery was 7.9 cms. FSFI score was >30 in eight patients. Two patients were lost to follow-up.

CONCLUSION

Modified McIndoe vaginoplasty is a simple, safe, and cost-effective procedure in the hands of experts. Only mature patients willing to follow the instructions and planning to get married soon should undergo this surgery.

Long-term Results of Sexual Function and Body Image After Vaginoplasty With Acellular Dermal Matrix in Women With Mayer-Rokitansky-Küster-Hauser Syndrome

STUDY OBJECTIVE

To describe the long-term anatomic and sexual functional results of vaginoplasty with acellular dermal matrix (ADM) in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) and to evaluate the changes in body image pre- and postoperatively in these patients.

DESIGN

A retrospective study from March 2015 to September 2021.

SETTING

A tertiary teaching hospital.

PATIENTS

Forty-two patients with MRKH syndrome who underwent vaginoplasty with ADM (the MRKH group) and 30 sexually active, nulliparous, aged-matched women (the control group).

INTERVENTION

The relevant data were retrospectively collected via our electronic medical record system and were analyzed statistically.

MEASUREMENTS AND MAIN RESULTS

Vaginal length was assessed using a 3-cm-diameter mold. The Chinese version of the Female Sexual Function Index questionnaire was used to evaluate sexual function. The Chinese version of the modified body image scale was applied to evaluate body image. The median follow-up time was 57 months (range, 13-91 months). Granulomatous polyps in the neovagina were the most common postoperative complication (7 of 42, 16.7%). Patients with MRKH syndrome can achieve long-term satisfactory outcomes both anatomically and functionally after vaginoplasty with ADM, comparable with those of healthy control women. The vaginal length in the MRKH group was comparable to that in the control group ( 8.04 ± 0.51 cm vs. 8.15 ± 0.46 cm, respectively). The FSFI scores were similar between the MRKH (26.54 ± 3.44) and control (26.80 ± 2.23) groups. The modified body image scale score was significantly decreased after vaginoplasty with ADM.

CONCLUSION

Vaginoplasty with ADM is a minimally invasive and effective procedure for patients with MRKH syndrome.

Neovaginoplasty With Nile Tilapia Skin: Cytological and Microbiota Evaluation

OBJECTIVES

To study the clinical, cytological, and vaginal microbiota findings in patients with Mayer-Rokitansky-Küster-Hauser syndrome who underwent neovaginoplasty using Nile tilapia fish skin.

METHODS

This is a cross-sectional study with 7 cisgender women with Mayer-Rokitansky-Küster-Hauser syndrome who had previously undergone neovagina reconstruction using Nile tilapia fish skin at a university hospital. Local institutional review board approval and written permission from the patient were obtained. Between August 2019 and November 2021, within 12 to 24 months after surgery, vaginal specimens were obtained for conventional oncotic and hormonal cytology, and for Gram staining. The Nugent scores were calculated. Colposcopy was also performed.

RESULTS

Squamous cells without atypia were found in all patients. Five patients had intermediate vaginal microbiota (Nugent score of 4), which was determined by the presence of few lactobacilli on Gram staining. In hormonal cytology, 4 patients presented with findings compatible with menacme. No colposcopic change was observed. When postsurgical dilation was performed correctly, a mean vaginal length of 8.3 cm was maintained after 1 year of follow-up.

CONCLUSIONS

Squamous cells without atypia were present in neovaginas with Nile tilapia fish skin. Most vaginal contents revealed intermediate microbiota and hormonal results compatible with menacme. Studies with a greater number of patients are necessary for a more comprehensive understanding of the microbiome in neovaginas with this new technique, thereby providing support for the treatment and prevention of associated pathologies.

Systematic Review: The Neovaginal Microbiome

OBJECTIVE

To review neovaginal colonization and inflammatory patterns, and factors that may impact this.

METHODS

A systematic review of the neovaginal microbiome was conducted in concordance with PRISMA guidelines through October 2021.

RESULTS

Thirteen articles were included, totaling 458 patients. Neovaginal constructions were most commonly performed with penile and scrotal skin grafts, sigmoid segments, and peritoneal grafts. The neovaginal microflora identified were generally polymicrobial and shared similarities with the native tissue. Nine studies identified Lactobacillus: 5/6 for penile skin, 1/3 for sigmoid, 1/1 for peritoneum, and 2/3 for other graft types, suggesting that the neovagina may support Lactobacillus either innately, via rectal migration or oral probiotic supplementation. A polymicrobial, bacterial vaginosis-like environment was found in nine studies. Inflammatory markers were also described: 2/6 for penile skin, 2/3 for sigmoid, 0/1 for peritoneum, and 1/3 for other graft types. Scant data were available on the impact of postsurgical duration, oral hormones, dilating, sexual practices, or douching on the neovaginal microbiome.

CONCLUSION

Understanding and optimizing the polymicrobial neovaginal microenvironment may improve surgical outcomes, specifically inflammatory, pain, and infectious. Future research should focus on standardizing testing and classification systems, and treating neovaginal dysbiosis.

Diagnosis and treatment of müllerian malformations

Anomalies in the müllerian ducts are congenital alterations with more prevalence than it is imagined, varying from 0.5 to 6.7% in the general population and up to 16.7% in women with recurrent miscarriage. The main findings are primary amenorrhea, dysmenorrhea, pelvic pain, endometriosis, sexual difficulties and low self-esteem. The major impact on the quality of life in women stricken by these problems justifies this study, whose objective is to analyze their most important aspects such as etiopathogeny, classification, diagnostic methods and proposed treatments. The research was performed on the Medline-PubMed database from 1904 to 2018. The American Fertility Society, European Society of Human Reproduction and Embryology, and the European Society of Gynaecological Endoscopy classify malformations as: Class 1/U5bC4V4: agenesis or hypoplasia of uterus and vagina; Class 1/U5aC4V4: cervical hypoplasia, associated with total or partial vaginal agenesis; Class 2/U4: unicornuate uterus; Class 3/U3bC2V1 or Class3/U3bC2V2: uterus didelphys; Class 4/U3C0: bicornuate uterus; Class 5/U2: septate uterus; Class 6: arcuate uterus; Class 7/U1: induced by diethylstilbestrol, represented by a T-shaped uterus; and V3: transverse vaginal septum. The diagnostic methods are the two-dimensional or three-dimensional ultrasound, MRI, hysterosalpingo-contrast-sonography, X-ray hysterosalpingography, hysteroscopy and laparoscopy. Some müllerian malformations are healed with surgery and/or self-dilatation. For vaginal agenesis, dilatation by Frank technique shows good results while malformations with obstruction of the menstrual flow need to be rapidly treated by surgery.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: a comprehensive update

BACKGROUND

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, also referred to as Müllerian aplasia, is a congenital disorder characterized by aplasia of the uterus and upper part of the vagina in females with normal secondary sex characteristics and a normal female karyotype (46,XX).

MAIN BODY

The diagnosis is often made during adolescence following investigations for primary amenorrhea and has an estimated prevalence of 1 in 5000 live female births. MRKH syndrome is classified as type I (isolated uterovaginal aplasia) or type II (associated with extragenital manifestations). Extragenital anomalies typically include renal, skeletal, ear, or cardiac malformations. The etiology of MRKH syndrome still remains elusive, however increasing reports of familial clustering point towards genetic causes and the use of various genomic techniques has allowed the identification of promising recurrent genetic abnormalities in some patients. The psychosexual impact of having MRKH syndrome should not be underestimated and the clinical care foremost involves thorough counselling and support in careful dialogue with the patient. Vaginal agenesis therapy is available for mature patients following therapeutical counselling and education with non-invasive vaginal dilations recommended as first-line therapy or by surgery. MRKH syndrome involves absolute uterine factor infertility and until recently, the only option for the patients to achieve biological motherhood was through gestational surrogacy, which is prohibited in most countries. However, the successful clinical trial of uterus transplantation (UTx) by a Swedish team followed by the first live-birth in September, 2014 in Gothenburg, proofed the first available fertility treatment in MRKH syndrome and UTx is now being performed in other countries around the world allowing women with MRKH syndrome to carry their own child and achieve biological motherhood.

CONCLUSION

Several advances in research across multiple disciplines have been made in the recent years and this kaleidoscopic review provides a current status of various key aspects in MRKH syndrome and provides perspectives for future research and improved clinical care.

Use of infragluteal folds as a full-thickness skin graft donor site for construction of the neovagina in cases of Mullerian agenesis

AIM

The aims of this study were to present the results of using infragluteal folds as a skin graft donor site in cases of Mullerian agenesis undergoing full-thickness skin graft vaginoplasty and to evaluate the outcomes of the surgical technique.

METHODS

Demographics and clinical parameters of 24 consecutive Mullerian agenesis patients refusing any dilatational procedure and undergoing neovaginal construction using infragluteal folds skin grafts from May 2004 to July 2015 were analyzed.

RESULTS

The mean age of the patients was 21.5 ± 5.7 years. Five patients had nonfunctional rudimentary uterus, one patient had unilateral ovarian agenesis, one patient had unilateral renal agenesis, and one had undergone a previous vaginoplasty. There were no serious complications needing surgical or medical intervention. The depth of the neovagina in patients with a follow-up period of more than 6 months (n = 17) varied from 7 to 12 cm. Of these patients, the sexually active ones (n = 8) did not complain of dyspareunia or vaginal dryness during sexual intercourse. The resulting scars were satisfactory and acceptable for all patients.

CONCLUSION

It has been our practice to use infragluteal folds as a skin graft donor site for full-thickness skin graft vaginoplasty. We believe that the results of this study demonstrate that this area is versatile and an excellent alternative to the groins and lower abdomen. Further clinical and histomorphological investigations are necessary for strong statements and results.

Androgen insensitivity syndrome: a review

Androgenic insensitivity syndrome is the most common cause of disorders of sexual differentiation in 46,XY individuals. It results from alterations in the androgen receptor gene, leading to a frame of hormonal resistance, which may present clinically under 3 phenotypes: complete (CAIS), partial (PAIS) or mild (MAIS). The androgen receptor gene has 8 exons and 3 domains, and allelic variants in this gene occur in all domains and exons, regardless of phenotype, providing a poor genotype - phenotype correlation in this syndrome. Typically, laboratory diagnosis is made through elevated levels of LH and testosterone, with little or no virilization. Treatment depends on the phenotype and social sex of the individual. Open issues in the management of androgen insensitivity syndromes includes decisions on sex assignment, timing of gonadectomy, fertility, physcological outcomes and genetic counseling.