Intestinal vaginoplasty: seven years' experience of a tertiary center

Postoperative outcomes of sigmoid colon vaginoplasty for vaginal agenesis: A randomized controlled trial

Objective

Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is a rare disorder in women that is associated with vaginal agenesis and hypoplasia or loss of uterus. In this study we aim to study the outcome of sigmoid colon vaginoplasty among MRKH patients with vaginal agenesis.

Methods

In this randomized clinical trial study, from 2017 to 2021, 39 patients were reported to our center with vaginal agenesis as a result of MRKH. Patients were treated with sigmoid colon vaginoplasty and postoperative outcomes such as Female sexual function index (FSFI), depth of vaginal cavity, and postoperative complications were evaluated.

Results

The mean age of the patients was 32.3 ± 2.3 years. 18 patients (46.2%) were diagnosed using MRI whereas 21 patients (53.8%) were diagnosed with exploratory laparoscopy. The mean vaginal depth before and after the surgery was 2.8 cm and 17.3 cm, respectively. One patient (2.6%) developed fistula, and peritonitis due to perforation of the vagina, 26 months after surgery, respectively. Of 10 patients who were sexually active after the surgery, all of these patients were sexually satisfied. The FSFI was 32 ± 3.9.

Conclusion

The postoperative complications after sigmoid colon vaginoplasty were minimum and all the sexually active patients were sexually active. This method appears to be an effective for surgical treatment of vaginal agenesis.

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Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is a rare disorder in women.

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That is associated with vaginal agenesis and hypoplasia or loss of uterus.

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Sigmoid colon vaginoplasty were minimum and all the sexually active patients were sexually active.

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This method appears to be an effective for surgical treatment of vaginal agenesis.

Prevalence of urinary, prolapse, and bowel symptoms in Mayer-Rokitansky-Küster-Hauser syndrome

BACKGROUND

Müllerian agenesis, or Mayer-Rokitansky-Küster-Hauser syndrome, occurs in 1 in 4500 to 5000 individuals assigned female sex at birth. Pelvic floor symptoms among individuals with Mayer-Rokitansky-Küster-Hauser syndrome have not been well studied, and it is unknown how vaginal lengthening treatments affect these symptoms.

OBJECTIVE

This study aimed to assess urinary, prolapse, and bowel symptoms in individuals with Mayer-Rokitansky-Küster-Hauser syndrome and to determine whether symptoms vary by vaginal lengthening treatment.

STUDY DESIGN

We conducted a cross-sectional study in 2019 using an online survey distributed by the Beautiful You MRKH Foundation via social media to individuals with Mayer-Rokitansky-Küster-Hauser syndrome. Demographics, age at and timing of diagnosis, information about vaginal lengthening treatment, urinary symptoms (Michigan Incontinence Symptom Index), prolapse symptoms (Pelvic Organ Prolapse Distress Inventory short-form version), and bowel symptoms (Bristol Stool Form Scale) were obtained. The inclusion criteria included self-reported diagnosis of müllerian agenesis and female sex. Respondents with a history of renal transplant or dialysis, completion of <85% of the survey, and non-English survey responses were excluded. Descriptive analyses were used to describe the sample population. Logistic regression, Kruskal-Wallis, and Fisher exact tests were used to compare the prevalence of pelvic floor symptoms and vaginal lengthening treatments. Associations between age and genitourinary symptoms were investigated with Spearman correlations.

RESULTS

Of 808 respondents, 615 met the inclusion criteria, representing 40 countries. 81% of respondents identified as white. The median age of the participants was 29 years (interquartile range, 24-36), with a median age at diagnosis of 16 years (interquartile range, 15-17). Among the 614 respondents, 331 (54%) had vaginal lengthening treatment, 130 of whom (39%) had undergone surgical vaginal lengthening. Of individuals with Mayer-Rokitansky-Küster-Hauser syndrome, 428 of 614 (70%) reported having had one or more urinary symptoms, and 339 of 428 (79%) reported being bothered by these symptoms. Urinary symptoms included urinary incontinence (210 of 614 [34%]), urinary frequency (245 of 614 [40%]), urinary urgency (248 of 614 [40%]), pain with urination (97 of 614 [16%]), and recurrent urinary tract infections (177 of 614 [29%]). Prolapse symptoms included lower abdominal pressure (248 of 612 [41%]), pelvic heaviness or dullness (177 of 610 [29%]), and vaginal bulge (68 of 609 [11%]). In addition, constipation was reported by 153 of 611 respondents (25%), and anal incontinence was reported by 153 of 608 (25%) respondents. Beside recent urinary incontinence (P=.003) and anal incontinence (P<.001), the prevalence of pelvic floor symptoms (P>.05) did not differ significantly between those with and without vaginal lengthening. Among those with surgical vaginal lengthening, symptomatic vaginal bulge was highest in individuals who underwent a bowel vaginoplasty procedure.

CONCLUSION

Urinary, prolapse, and bowel symptoms are common among individuals with Mayer-Rokitansky-Küster-Hauser syndrome and should be evaluated in this population. Overall, compared with no vaginal lengthening treatment, having vaginal lengthening treatment is not associated with substantial differences in the prevalence of pelvic floor symptoms, with the exception of recent urinary incontinence and anal incontinence. Our data suggested that bowel vaginoplasty may be associated with greater symptoms of vaginal bulge. More robust studies are needed to determine the impact of various vaginal lengthening treatments on pelvic floor symptoms.

Vaginoplasty with Oxidized Cellulose in Mayer-Rokitansky-Küster-Hauser Syndrome

Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) is the major cause of vaginal agenesis. Vaginoplasty with oxidized cellulose has been used by gynecologists as a surgical option in vaginal agenesis; however, it is not very widespread among pediatric surgeons. A case of MRKHS who underwent vaginoplasty with oxidized cellulose is reported here.

Vaginoplasty With Mesh Autologous Buccal Mucosa in Vaginal Agenesis: A Multidisciplinary Approach and Literature Review

BACKGROUND

Vaginal agenesis, a rare condition, is treated by various surgical techniques to achieve neovaginal reconstruction. The main difference between the approaches lies in the graft material used to cover the newly formed cavity.

OBJECTIVES

The purpose of this retrospective study was to describe the surgical procedure and outcomes of autologous buccal mucosal grafting in neovaginal reconstruction.

METHODS

Sixteen patients with vaginal agenesis admitted to our department between January 2016 and January 2019 were included in our study. A reconstruction procedure, described in detail here, involving autologous buccal mucosa as graft material was successfully conducted in all of the patients. Long-term anatomic and functional outcomes were evaluated.

RESULTS

The blood loss during operation was estimated to be 15 to 20 mL in all cases. No rectal or bladder injury occurred. The buccal mucosal wound completely healed 10 to 14 days after the operation. All patients had a well-formed neovagina 8 to 10 cm in length, with a mean diameter of >3 finger-breadths.

CONCLUSIONS

The application of autologous buccal mucosa in neovaginal construction is a simple procedure. Autologous buccal mucosa is an ideal material to achieve excellent cosmetic and functional results in patients with vaginal agenesis.

LEVEL OF EVIDENCE: 4

Application of mesocolon rotation and reverse puncture in total laparoscopic sigmoid vaginoplasty

The aim of the present study was to explore the clinical efficacy of mesocolon rotation and reverse puncture in total laparoscopic sigmoid vaginoplasty (LSV). The clinical data of 11 patients (unmarried, n=4; married, n=7) with congenital absence of a vagina who underwent treatment of total laparoscopic sigmoid vaginoplasty at the First Affiliated Hospital of Xinjiang Medical University (Urumqi, China) between March 2013 and March 2016 were retrospectively analyzed. In all patients, the surgical method included sigmoid mesocolon rotation and reverse puncture. The vaginal depth, the first sexual intercourse time and female sexual function indexes were recorded. The average operation time was 187±19 min, the average intra-operative blood loss was 132±24 ml, the time to the first meal after surgery was 4.3±1.1 days, the average post-operative hospital stay was 7.5±1.2 days, the post-operative short-term complication rate was 36.3% and the time to the first sexual intercourse was 3.0±0.3 months. The post-operative follow-up results indicated that the anatomical standard was reached in all of the 11 patients. Among the seven married patients, five patients were satisfied with their sex lives after the operation. In terms of psychosexual desire, only one married patient felt no sexual arousal. The other married patients had good sexual relations, function and satisfaction. In conclusion, the application of mesocolon rotation and reverse puncture in total LSV is safe and feasible.

Bowel vaginoplasty: a systematic review

Among surgical procedures for constructing a neovagina, positive outcomes are reported in literature for bowel vaginoplasty for male-to-female transgenders and patients with vaginal aplasia. This systematic review shows outcomes of bowel vaginoplasty procedures, and rates the quality of evidence of the included studies. A search of the literature was performed in PubMed, Medline, Cochrane Library and SveMed+, in accordance with the PRISMA statement, between January 2016 and February 2018. The PICOS (patients, intervention, comparator, outcomes and study design) approach was used as inclusion criteria. Among 251 analyzed studies only 34 met inclusion criteria. Quality of evidence and methodology were rated according to GRADE and MINORS, respectively. Data from the included studies were extracted based on study characteristics, participants? specifics, type of intervention/treatment and type of outcome measures into data extraction forms. All studies were non-randomized with a high risk of bias and very low quality of evidence according to GRADE. Vaginal reconstruction with isolated bowel segments provides a self-lubricating neovagina with low rates of failure and revision, and without routine dilatation need. Furthermore, the use of laparoscopic techniques offers a better postoperative cosmetic appearance of the abdomen and a shorter hospital stay. Vaginoplasty using bowel segment is a safe and effective procedure that obtains excellent long-term results as reported by the included studies. Despite that further researches are needed improving methodology with larger populations, retrospective qualitative studies and report of outcome measurements using standardized evaluation tools as the Female Sexual Function Index.

Local control for vaginal botryoid rhabdomyosarcoma with pre-rectal transperineal surgical resection and autologous buccal graft vaginal replacement: A novel, minimally invasive, radiation-sparing approach

PURPOSE

Localized vaginal rhabdomyosarcoma (RMS) is associated with a favorable prognosis, but strategies for local control remain controversial. The use of radiotherapy (RT) can have important long-term sequelae, while traditional resection involves major reconstructive surgery. We describe a new surgical approach employing a minimally-invasive resection and immediate reconstruction.

MATERIALS AND METHODS

Records from 4 consecutive patients with localized vaginal RMS managed in 4 major pediatric referral centers were reviewed. All cases were performed with a standardized technique.

RESULTS

Patients were diagnosed at a median age of 24months. Each underwent a total/subtotal vaginectomy with autologous buccal graft vaginal replacement. Final margins were focally positive in one patient and negative in three. None received radiotherapy. To date, all patients have patent buccal neovaginas, enjoy a favorable aesthetic result, and remain disease-free at a median follow-up of 35months.

CONCLUSIONS

We report 4 cases of localized vaginal RMS successfully treated with a minimally invasive surgical approach. All patients have avoided radiation and remain disease-free. Our initial data suggest that surgical local control and immediate reconstruction are feasible and can spare these patients the long-term complications of RT. Longer follow-up is critical to ensure disease-free survival with a functional, successfully reconstructed neovagina.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

Level IV.

Evaluation of amnion in creation of neovagina in women with Mayer-Rokitansky-Kuster-Hauser syndrome

OBJECTIVE

To assess the outcome of amnion vaginoplasty in cases of vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome managed at the authors' institution.

DESIGN

Retrospective study.

SETTING

Tertiary care hospital.

PATIENT(S)

Fifty women with MRKH who underwent neovaginoplasty.

INTERVENTION(S)

Modified McIndoe's vaginoplasty was done in all the patients, using human amnion graft.

MAIN OUTCOME MEASURE(S)

Functional status assessed by Female Sexual Function Index, anatomic status (length and width of neovagina), and epithelialization of vagina.

RESULT(S)

Mean (±SD) vaginal length after surgery was 8.2 ± 1 cm. Mean vaginal length at 6-month follow-up in sexually active patients was significantly longer as compared with the patients who were not sexually active after surgery (8.4 ± 1.04 cm vs. 6.6 ± 2.4 cm). Mean Female Sexual Function Index score was 30.8 ± 2.1. Vaginal biopsy showed complete epithelialization of vaginal mucosa.

CONCLUSION(S)

In a developing nation like India, McIndoe's method with amnion graft seems to be a promising option owing to its low cost, easy availability, and safety, ease of the procedure not requiring any special instrument, physiologic outcome with respect to epithelialization of the vagina without hair growth, and satisfying functional outcome.

Surgical Management of the Constricted or Obliterated Vagina

Management of the constricted or obliterated vagina demands an understanding and recognition of the potential etiologies leading to this presentation. A thorough and comprehensive medical and surgical review is required to arrive at an accurate diagnosis, which then will guide medical or surgical intervention. It is paramount to recognize when underlying medical conditions are contributing to these conditions and to begin medical therapy; failure to do so will often yield suboptimal results. When these conditions arise after surgical interventions, compensatory surgical techniques that correct upper and lower vaginal strictures or obliteration include incision through the stricture, vaginal advancement, Z-plasty, skin grafts, perineal flaps, and abdominal flaps and grafts. Postoperative surveillance and dilation are critical to optimize long-term success.

Nonobstructive Reproductive Tract Anomalies: A Review of Surgical Management

Müllerian anomalies include a spectrum of anatomic variants of the genital tract arising from abnormal embryologic development, ranging from incomplete resorption of uterine septa to complete vaginal agenesis. Nonobstructive anomalies are often recognized later than obstructive anomalies, because women do not present with pain. However, nonobstructive anomalies frequently have a negative impact on sexual and reproductive health, and careful evaluation and management of these disorders is warranted. This review focuses on the surgical management of nonobstructive Müllerian anomalies.

Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia: A Prospective Cohort Study of Surgical Outcomes and Follow-Up of 42 Patients

BACKGROUND

In young transgender women previously treated with puberty-suppressing hormones, penoscrotal hypoplasia can make penoscrotal inversion vaginoplasty unfeasible. The aim of this study was to prospectively assess surgical outcomes and follow-up of total laparoscopic sigmoid vaginoplasty as primary reconstruction in a cohort of transgender women with penoscrotal hypoplasia.

METHODS

Baseline demographics, surgical characteristics, and intraoperative and postoperative complications of all performed total laparoscopic sigmoid vaginoplasty procedures were prospectively recorded.

RESULTS

From November of 2007 to July of 2015, 42 transgender women underwent total laparoscopic sigmoid vaginoplasty as primary vaginal reconstruction. The mean age at the time of surgery was 21.1 ± 4.7 years. Mean follow-up time was 3.2 ± 2.1 years. The mean operative duration was 210 ± 44 minutes. There were no conversions to laparotomy. One rectal perforation was recognized during surgery and immediately oversewn without long-term consequences. The mean length of hospitalization was 5.7 ± 1.1 days. One patient died as a result of an extended-spectrum beta-lactamase-positive necrotizing fasciitis leading to septic shock, with multiorgan failure. Direct postoperative complications that needed laparoscopic reoperation occurred in three cases (7.1 percent). In seven cases (17.1 percent), long-term complications needed a secondary correction. After 1 year, all patients had a functional neovagina with a mean depth of 16.3 ± 1.5 cm.

CONCLUSIONS

Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery. Primary total laparoscopic sigmoid vaginoplasty is a feasible gender-confirming surgical technique with good functional outcomes for transgender women with penoscrotal hypoplasia.

CLINICAL QUESTIO/LEVEL OF EVIDENCE

Therapeutic, IV.

Vaginoplasty with an Autologous Buccal Mucosa Fenestrated Graft in Two Patients with Vaginal Agenesis: A Multidisciplinary Approach and Literature Review

Here we describe the procedure and outcomes of a multidisciplinary approach to vaginoplasty using autologous buccal mucosa fenestrated grafts in 2 patients with vaginal agenesis. This procedure resulted in anatomic success, with a functional neovagina with good vaginal length and caliber and satisfactory sexual function capacity and well-healed buccal mucosa. There were no complications, and the patients were satisfied with the surgical results. We conclude that the use of a single fenestrated graft of autologous buccal mucosa is a simple, effective procedure for the treatment of vaginal agenesis that results in an optimally functioning neovagina with respect to vaginal length, caliber, and sexual capacity.

Is Rectosigmoid Vaginoplasty Still Useful?

BACKGROUND

The ideal vaginoplasty must be successful functionally as well as have a natural appearance, and also must retain its functionality and appearance over the long term. Conventional vaginoplasty techniques have functional limitations and are associated with recurrent complications, but rectosigmoid vaginoplasty is known to have a high satisfaction rate due to its functional similarity with the vagina. We conducted the present study to assess the usability of rectosigmoid vaginoplasty over the course of long-term follow-up.

METHODS

From March 1992 to February 2014, 84 patients were treated with rectosigmoid vaginoplasty; 44 had gender identity disorder, 29 had vaginal agenesis, 8 had female pseudohermaphroditism, and 3 had gynecologic malignancies after radical pelvic surgery. This retrospective study was based on a review of the patients' records, clinical examinations, complications, and questionnaires about appearance, function, and sexual intercourse.

RESULTS

All patients who underwent rectosigmoid vaginoplasty were discharged within 2 weeks without surgical flap loss. The early complications were partial flap necrosis, difficulty in defecation, mucous hypersecretion, and postoperative ileus. The late complications were vaginal introitus contracture, vaginal prolapse, and difficulty in urination. The mean length and diameter of the neovagina 3.4 years after rectosigmoid vaginoplasty were 13.2 cm and 3.8 cm, respectively. On questionnaires about satisfaction, 70% of patients reported excellent satisfaction, 11% good, 12% fair, and 7% poor.

CONCLUSIONS

Rectosigmoid vaginoplasty is useful, safe, and well-accepted operative method with good functional and cosmetic results, such as natural lubrication and adequate vaginal length and width obtained without requiring the use of a dilator.

Sigmoid vaginoplasty in testicular feminising syndrome: surgical technique, outcome and review of the literature

Vaginal agenesis occurs in approximately 1:5000 live female births. It results from failure of the sinovaginal bulbs to develop and form the vaginal plate. Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is the most common cause of vaginal absence followed by complete or partial androgen insensitivity syndrome. Treatment of these patients encompasses a spectrum from simple non-operative dilation to the more complicated surgical creation of a neovagina. We present a case of a patient with testicular feminising syndrome who was reared as a female and underwent bilateral gonadal excision and sigmoid vaginoplasty.

Mayer-Rokitansky-Kuster-Hauser syndrome: complications, diagnosis and possible treatment options: a review

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a disorder in women that presents as Mullerian agenesis. These patients present internal genitalia abnormalities that include the absence of a uterus and the upper two-thirds of the vagina. In this review, current diagnostic methods, accompanying complications (congenital and psychological) and non-surgical and surgical treatments are summarized. Ultrasound and MRI have been the most documented options in MRKH syndrome diagnosis. Many women with MRKH syndrome have renal, skeletal, hearing or cardiac congenital anomalies and increased levels of psychological distress. Non-surgical interventions can be used to create a sexually functional neovagina through vaginal dilation, and surgical interventions provide alternate methods of creating a neovagina. Additionally, vaginal tissue engineering and gene therapy might provide more effective approaches in solving MRKH syndrome.

A ten year experience of cecal neovagina procedures for the restoration of sexual function on a gynecology oncology service

OBJECTIVE

We seek to describe the procedure, complications, and functional outcomes of utilizing the cecum and ascending colon for creation of a neovagina on a gynecologic oncology service.

METHODS

A search of all the cases on the gynecologic oncology service over a ten year period yielded fourteen cases of cecal neovagina. A retrospective chart review was performed. Post-operatively, each patient was evaluated at regular intervals. At each visit, they were asked standardized questions, a physical exam was performed by the same provider, and they were advised to follow a uniform regimen of physical rehabilitation.

RESULTS

Eight of the fourteen cases were performed for surgical stricture or vaginectomy, while the indication for the other six patients was radiation fibrosis. The patients were followed for a median length of 37 months. The percentage having intercourse was between 86% and 100% over the course of the first year. Thirteen of the fourteen patients reported intercourse as "comfortable", eleven of the fourteen stated that intercourse was "pleasurable", and seven patients reported having orgasms. The major reported complaint was mucusy discharge, which all patients reported as moderate to severe for the first six weeks. Over time, this improved, and only one patient required the use of pads at twelve months. There were no intestinal anastomotic leaks in the group.

CONCLUSIONS

The functional outcomes in our case series show that the cecal neovagina is a safe, uncomplicated, and viable option for those patients who have lost sexual function due to stricture formation or surgical removal of the vagina.

Management of vaginal agenesis

Rokitansky syndrome and complete androgen insensitivity syndrome are the most common causes of vaginal agenesis. Treatment should be deferred until adolescence to allow informed consent and compliance. The best treatment for vaginal agenesis remains controversial although vaginal dilation therapy is still widely considered the first line treatment because success rates are high and associated risks are low. A variety of surgical options are also available, each with enthusiastic proponents. Long-term outcome studies on most surgical techniques, however, are still lacking and until recently most studies have reported on success rate in terms of anatomical success only, without including sexual function. Moreover, the medical literature lacks prospective comparative outcome studies, meaning that current choice of surgical procedure relies greatly on the surgeon's preference and experience.

Failed vaginoplasty: a successful novel blend of minimally invasive approaches

OBJECTIVE

To evaluate outcomes of a novel blend of techniques for treating vaginal contractures secondary to previous conventional constructive surgeries.

STUDY DESIGN

Balloon vaginoplasty and scar tissue hydrolysis/hydro-disintegrations (BV/STH) were performed for three cases with vaginal scars after previously failed vaginoplasties. The outcomes measured were operative complications, vaginal depths as measured by a calibrated vaginometer, and functional outcomes as measured by changes in the penetration and satisfaction (P/S) scores on a 0-100 point visual analog scale.

RESULTS

BV/STH was performed successfully for 3 women with previously failed vaginoplasties. They included a case with a previous partial thickness skin grafting, one with previous labial flaps and one with previous amnion membrane graft. Preoperative P/S scores ranged from 20 to 30 points. Initially BV was done in addition to multiple snips of the scar tissue with a 2mm scalpel. No operative complications were reported but we failed to achieve progressive increase in vaginal depth after day 4. Scar tissue was injected with a mixture of lidocaine and normal saline. Progressive increase in depth was dramatically improved after scar hydro-disintegration. The depths of the resultant neovaginas were 10, 11 and 11.6 cm. Postoperative P/S scores increased up to 90.

CONCLUSIONS

BV/STH was successfully performed as a revision surgery for blind vaginas with fibrosis. This report highlights a wider range of possible applications of balloon vaginoplasty.