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

Neovagina in Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome: Vaginoplasty Using Ileal Flap

INTRODUCTION

Surgical treatment of patients with malformations of the female genital tract is a complex problem and there are different techniques described in the literature. The goal of all these techniques is the reconstruction of a neovagina that is anatomically similar to a vagina, with adequate length to facilitate sexual functioning and with the lowest risk of possible complications. The aim of this study is to describe the surgical technique for the reconstruction of a neovagina from an ileal segment without a vascular pedicle.

MATERIAL AND METHODS

Description of a surgical technique developed in our tertiary university center in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

RESULTS

The vaginoplasty surgery using ileal flap was performed in three steps. In the first part of the intervention a laparoscopic hysterectomy with bilateral salpingectomy was performed. The second step consisted of isolating the ileal segment, ileal anastomosis and preparing the ileal segment. After the isolated segment was prepared, it was repositioned in a vagina mold to configure the neovagina. Finally, the third step included the adaptation of the vaginal mold with the ileal mucosa to the vesicorectal space.

CONCLUSION

Ileal vaginoplasty without a vascular pedicle is an option that can be used to reconstruct the vagina, because it provides an excellent tissue for vaginal replacement. This technique can be used in patients with genital malformations of the genital tract with absence or vaginal hypoplasia.

Usefulness of Endoscopy for Female Genital Plastic Surgery: A Series of 4 Cases with Genital Malformations

BACKGROUND Female genital plastic surgery is rare and requires specific patient anatomical information to successfully carry out the appropriate procedure for each female genital malformation. Performing endoscopic surgery can increase the amount of information intraoperatively. We report on our experience of proactively using endoscopy to obtain additional intraoperative information to perform the appropriate surgical procedure suited to each female genital malformation, and evaluate the usefulness of concurrent endoscopy for improved surgical outcomes. CASE REPORT In Case 1, an 18-year-old woman underwent colpoplasty for Mayer-Rokitansky-Küster-Hauser syndrome using the laparoscopic Davydov procedure, wherein the pelvic peritoneum was precisely dissected using light from a laparoscope as a guide. In Case 2, a 25-year-old woman presented with suspected Wunderlich syndrome. Since the junction of the affected uterus with the normal uterus was unclear on preoperative imaging, we performed total hysterectomy of the affected uterus after identifying the anatomical structure by hysteroscopy. In Case 3, a 12-year-old girl with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome underwent transvaginal fenestration of the obstructed vaginal wall to prevent future menstrual molimen. Simultaneous hysteroscopy and laparoscopy allowed us to determine the location of a unilateral vaginal wall cyst and drain it safely. In Case 4, a 29-year-old woman had OHVIRA syndrome, and we conducted a laparoscope-based fenestration of the cervical canal safely and accurately. CONCLUSIONS Our series showed how, even for gynecological malformations without established standards for surgical procedure, a safe and minimally invasive surgery can be ensured if the amount of anatomical information is increased via endoscopy.

A case of neovagina surgical creation using the uterine cervix remnant in a patient with Mayer-Rokitansky-Küster-Hauser syndrome

OBJECTIVE

To study the efficacy of a novel approach to vaginoplasty in a patient with vaginal aplasia and a preserved cervix.

DESIGN

We present the case of a 28-year-old patient who was referred with a history of absent menstruation and vaginal intercourse was absent as well as abnormal development of the internal genitals. The patient underwent a laparoscopic cystectomy in 2012 because of an ovarian cyst and later that year underwent laparotomic supracervical hysterectomy with bilateral salpingectomy because of severe pain caused by a hematometra in their uterine remnant. In the period from 2013 to 2016, multiple pelvic ultrasound examinations revealed a fluid structure in the pelvis. By 2020, the size of the lesion had increased to 10 cm on average. A computed tomography scan and magnetic resonance imaging showed a mucinous lesion in the lower part of the patient's pelvis resembling the cervical origin. No pathology of the urinary tract was found. A laparoscopic approach was chosen to achieve the two main goals of the patient-the possibility of vaginal intercourse and the treatment of the intraabdominal lesion. The procedure started with a vaginal step when the neovagina dissection was performed as in the classical Davydov technique up to the beginning of the dilated cervical remnant. Bilateral ureterolysis was performed laparoscopically to prevent ureteral injury. The peritoneum was widely dissected from both the anterior and posterior surfaces of the uterine cervix, which appeared as a large structure filled with typical cervical mucus. Partial dissection of the sacrouterine and ovarian ligaments on both sides was performed to mobilize the cervix. A transverse incision of the cystically dilated cervix in the cranial part was performed and the edges of the incision were brought down to the introitus of the vagina. The cervicovulvar anastomosis was fixed by separate sutures with Vicryl 2-0.

SETTING

The surgery was performed in an inpatient setting equipped with conventional laparoscopic instruments, a 30-degree laparoscope, a high-definition video system, xenon light source, insufflator, irrigator, and bipolar and monopolar energy sources.

PATIENT(S)

A single patient, mentioned previously.

INTERVENTION(S)

Surgical vaginoplasty using the preserved cervix. The details are explained in the Design section.

MAIN OUTCOME MEASURE(S)

Restoration of the normal vaginal anatomy and function.

RESULT(S)

In the postoperative period, the patient did not have any postoperative complications. The urinary catheter was removed on the first postoperative day. From day 1, the patient was taught to make daily vaginal dilations with a vaginal dilator to maintain normal vaginal depth and width. The patient was discharged on day 3 after surgery. In a 3-month follow-up visit, the patient's vagina appeared normal in size with transverse folds and was very well lubricated because of the natural secretions of the cervical mucosa. The patient had been sexually active by the time of the follow-up visit.

CONCLUSION(S)

According to a literature search, this was the first published case of a successful neovagina creation through cervicovulvar anastomosis. Although different surgical approaches were widely discussed in previous publications of Fertility and Sterility, such as "Laparoscopic uterovaginal anastomosis in Mayer-Rokitansky-Küster-Hauser syndrome with functioning horn", "Laparoscopy-assisted Ruge procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome", and "Evaluation of amnion in creation of neovagina in women with Mayer-Rokitansky-Küster-Hauser syndrome", which were all variants of vaginoplasty with allograft, vaginal distention (Vecchietti procedure), or the use of native tissues (Davydov technique), our approach could be more feasible in the rare cases of preserved distended cervix because of less induced trauma when compared with that of cervical removal. This is because of the strong and lubricated nature of the cervical epithelium, which is already present and does not require time for epithelization.

Sexual function after modified laparoscopic Vecchietti's vaginoplasty

STUDY OBJECTIVE

To report on minor modification of laparoscopic Vecchietti vaginoplasty and to examine the quality of sexual life after the operation.

DESIGN

A retrospective study to examine the role of minor modification during laparoscopic Vecchietti operation to prevent injuries and to evaluate the sexual function of patients with neovagina.

SETTING

Department of Obstetrics and Gynecology, University of Pécs, Faculty of Medicine, a tertiary supply center in Hungary. PATICIPANTS: Twenty-three adolescents or young adults, ages 16 to 26 with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) were operated. Twenty-five sexually active patients with matched age served as controls.

INTERVENTIONS

Laparoscopic Vecchietti operation was modified with the use of endovaginal ultrasound transducer to visualize the narrow vesico-rectal space. The quality of sexual life 2-11 years after the operation was measured by the Female Sexual Function Index (FSFI).

MAIN OUTCOME MEASURES

Complications occurring during operations; desire, arousal, orgasm, satisfaction, lubrication, and pain during sexual intercourse.

RESULTS

The technical modification of the operation, with endovaginal transducer, improved the method. Serious injuries of the bladder or rectum could be avoided. Anatomic and functional results shown by the total FSFI scores did not differ from that of the control group. Desire, arousal, orgasm, and satisfaction of the operated patients were similar to controls; however, patients with neovagina tended to have less lubrication and more pain during sexual intercourse.

CONCLUSIONS

Laparoscopic Vecchietti operation modified by the use of endovaginal transducer is a safe procedure to create a neovagina, which guarantees good quality of sexual life with high satisfaction for patients.

Laparoscopically assisted sigmoid colon vaginoplasty in women with Mayer-Rokitansky-Kuster-Hauser syndrome: feasibility and short-term results

OBJECTIVES

To evaluate the technical feasibility and anatomical and functional outcomes of laparoscopically assisted sigmoid colon vaginoplasty (LASV) in women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.

DESIGN

A retrospective review of prospectively collected data.

SETTING

Shanghai First People's Hospital, Shanghai Jiao Tong University.

POPULATION

Twenty-six women with MRKH syndrome.

METHODS

A record was made of mean operating time, length of hospital stay, perioperative complications and the anatomical and functional outcomes of surgery.

MAIN OUTCOME MEASURES

The perioperative results, complications and anatomical and functional outcomes of LASV (with median 20 months follow up, range 5-48 months).

RESULTS

The mean operating time and hospital stay were 238 minutes and 9.8 days, respectively. The mean fall in haemoglobin was 2.0 g/dl. The only significant perioperative complications were one case with blood transfusion and three cases with infection (one with urinary tract and two with adjunctive incision). A functioning vagina 10 to 15 cm in length and 4 cm in width was created in all women. Introital stenosis occurred in only two women (2 months later). Twenty-two women subsequently had intercourse and 20 women (91%) were satisfied with the surgery and subsequent sexual activity.

CONCLUSIONS

LASV is an effective approach for women with MRKH syndrome. Both the anatomical and functional outcomes are satisfactory.

Transverse Retubularized Ileal Vaginoplasty: A New Application of the Monti Principle—Preliminary Report

OBJECTIVE

The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. Herein we present our successful experience with vaginal reconstruction by the use of a modified ileal segment according to the Monti principle.

METHODS

Six patients aged from 23 to 41 years (mean 33 years) were referred to our institution for vaginal stenosis. In our series, ileum has been used to create the neovagina: the isolated segment has been longitudinally detubularized and transversally retubularized in order to configure the roof of the neovagina.

RESULTS

The mean operating time was 220 min. No intra-operative complication occurred. The mean follow-up of this series was 16 months. At the latest follow-up, all patients had patent moist neovaginas, but excessive vaginal mucous was not a problem in any patient in our series.

CONCLUSIONS

Neovaginal creation using isolated ileal segments according to the Monti channel principle provide excellent tissue for vaginal replacement, providing excellent patient satisfaction and relatively low morbidity. Cosmetic, functional and anatomical results were encouraging. In our opinion our technique may be indicated for all cases of vaginal absence: congenital abnormalities in the pediatric population, vaginal stenosis after treatment of pelvic tumors, severe vaginal scarring secondary to chronic inflammatory disease or in case of secondary correction after failure gender surgery.

Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals

OBJECTIVES

To describe 3 cases of successful laparoscopically assisted vaginal reconstruction using an ileal segment in patients with complete neovaginal stenosis.

METHODS

We evaluated 5 male-to-female transsexual patients who required laparoscopic-assisted vaginal replacement for complete neovaginal stenosis after sex reassignment surgery. We performed complete laparoscopic vaginal isolation and mobilization, external configuration of the vagina, and laparoscopic-assisted vaginal anastomosis.

RESULTS

No intraoperative complications occurred, and laparotomy conversion was not necessary. The mean length of the neovagina at the first postoperative visit was 13 cm. At a mean follow-up of 14 months, all patients were sexually active and completely satisfied with the operation.

CONCLUSIONS

Our results have confirmed the feasibility of laparoscopic perineal neovagina construction by ileal colpoplasty. The cosmetic, functional, and anatomic results were encouraging. Isolated ileal segments provided excellent tissue for vaginal replacement, resulting in excellent patient satisfaction and relatively low morbidity. Furthermore, we report a modified surgical approach to conventional ileal vaginoplasty according to the Monti channel principle.

Total Endoscopic Vaginal Reconstruction in a Case of Mayer-Rokitansky-Kuster-Hauser Syndrome

The congenital absence of the vagina is an uncommonly encountered malformation, known as Rokitanski- Kuster-Hauser syndrome. These patients may enjoy an improved quality of sexual life once a neovagina is constructed. Surgical and nonsurgical (Frank's autodilatation) methods of creating a neovagina by recurrent dilatations require long and often embarrassing self-catheterization which is often painful, and yield a vagina with limited length. The developing ability to perform complicated surgery by laparoscopy has revived interest in colonic and ileal interposition procedures for formation of a neovagina. We report a case of sigmoid colpoplasty for neovagina creation in a 15-year-old girl, performed completely by laparoscopy, with a favorable outcome and an easier recovery.

Le Davydov cœlioscopique ou transposition cœlioscopique du colpopoiesis péritonéal pelvien décrit par Davydov pour le traitement des agénésies congénitales du vagin : la technique et son évolution

INTRODUCTION

The laparoscopic Davydov is described. The data concerning the surgery and the postoperative course are reported at the same time as the data concerning the anatomical and sexological results.

PATIENTS AND METHODS

The surgery includes three steps: (i) cleavage under laparoscopic guidance, (ii) peritoneovestibular stitch by perineal approach, (iii) making the vaginal vault with the laparoscope. The cleavage can be performed in front of the fascia interposed between the bladder and the rectum or behind it. A nymphoplasty can be added to the colpopoeisis.

RESULTS

Between February 1996 and March 2003 we operated on 28 patients affected by congenital vaginal agenesis using the laparoscopic Davydov technique. Two peroperative complications occurred (urinary tract injuries during the first step: laparoscopic management) and two postoperative complications (intraperitoneal migration of the mould and vesicovaginal fistula managed successfully with the laparoscope for the first one and trough laparotomy for the second one). Four re-operations (incision and dilation) were necessary. The length of the neovagina was, at the last assessment, 7.2 +/- 1.3 cm. The Female Sexual Function Index was 26.5 +/- 5.6 vs. 27.9 +/- 4.5 in a control cohort. In the patients whose cleavage was performed behind the fascia (13 cases vs. 15) no complication occurred, no re-operation was necessary, the length of the neovagina was 7.0 +/- 0.7 cm and the FSFI was 26.3 +/- 5.9.

DISCUSSION AND CONCLUSION

The laparoscopic Davydov is, if the dorsal approach is used for the cleavage, an easy to make operation (operating time: 90 +/- 29 minutes) with a short hospital stay. The postoperative care is simple (vaginal mould useless). Heterosexual activity with penile penetration can start early (6 to 8 weeks). The level of satisfaction is high. Laparoscopic Davydov procedure may be considered a good alternative to the more complex ones (as Vecchietti's technique) or to the more dangerous ones (sigmoid colpoplasty).

LAPAROSCOPIC VAGINAL RECONSTRUCTION USING A SIGMOID COLON SEGMENT: A PRELIMINARY REPORT

PURPOSE

Sigmoid vaginoplasty is an alternative technique for vaginal replacement. We describe the successful use of laparoscopy for reconstruction of a vagina in patients with the Mayer-Rokitansky-Kuster-Hauser syndrome.

MATERIALS AND METHODS

Laparoscopic surgery was performed in 5 girls with a mean age of 17 years and 5 months. We used 4 ports, the first of which was inserted supraumbilically by the Hasson technique. The next 10 mm port was introduced through the right lower quadrant under visual control. Then 5 and 15 mm ports were inserted at the left lower quadrant. The scope was introduced through the supraumbilical port. After isolating a segment of the sigmoid using 2 endoscopic staplers an incision was made in the deepest part of the vestibule. Performing a blunt dissection a 2-finger wide space was created between the urethra, bladder and rectum. In the top of the space the peritoneum was incised under laparoscopic control, which allowed passage of the forceps from the perineum and enabled descent of the isolated sigmoid segment. The graft was fixed to the mucosa of the vaginal vestibule using a single suture. The continuity of the intestinal tract was restored using a circular mechanical suture through the rectum.

RESULTS

Average operative time was 5 hours. None of the cases needed conversion to open surgery. No significant blood loss or any other complication was noted. Average postoperative stay was 7 to 9 days.

CONCLUSIONS

This preliminary report suggests that laparoscopic sigmoid vaginal replacement is feasible and safe, and may be used as an alternative to open surgery.

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.

[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.

Neovagina construction by combined laparoscopic-perineal sigmoid colpoplasty in a patient with Rokitansky syndrome

We created a neovagina by sigmoid colpoplasty using a combined laparoscopic-perineal approach in a 19-year-old woman with Rokitansky syndrome. Operating time was 4 hours and 45 minutes. No perioperative or postoperative complications occurred. Hemoglobin level fell by 1 g/dl. Total doses of morphine, nonsteroidal antiinflammatory drugs (NSAIDs), and paracetamol were 20 mg, 350 mg, and 28 g, respectively. Hospital stay was 7 days. The length of the neovagina was 12 cm. By comparison, in the three reported cases of laparotomic-perineal sigmoid vaginoplasty, mean operating time was 5 hours and 40 minutes; 24-hour fall in hemoglobin was 3.2 g/dl (range 2.1-4.3 g/dl); mean doses of morphine, NSAIDs, and paracetamol were 42.6 mg, 300 mg, and 40 g, respectively; mean hospital stay was 11.3 days; and length of neovaginas was 10, 12, and 12 cm. Although sigmoid colpoplasty is a reliable and reproducible technique, it requires experience in laparoscopic colonic surgery. The combined laparoscopic-perineal approach is associated with less analgesic requirement, shorter hospital stay, and similar anatomic results compared with the laparotomic-perineal approach.

Vaginal reconstruction utilizing sigmoid colon: Complications and long-term results

BACKGROUND/PURPOSE

The use of sigmoid colon segments to repair congenital deformities of the vagina is well established. There are little data, however, on complications or functional results in these patients. The purpose of this study was to evaluate complication rates and long-term patient outcomes in the use of sigmoid segments in vaginal reconstruction for congenital anomalies.

METHODS

The authors identified 28 patients who underwent vaginal reconstruction with sigmoid colon segments between 1985 and 2000 at their institution. Patient charts were reviewed for surgical technique, complication rates, cosmetic results, functional results, and psychosocial development. Patients were recalled for physical examinations and personal interviews to assess current status.

RESULTS

Of the 28 patients, 13 had male pseudohermaphroditism, 6 had Mayer-Rokitansky-Kuster-Hauser syndrome, 2 had true hermaphroditism, 2 had mixed gonadal dysgenesis, 2 had common urogenital sinus syndrome, 2 had adrenogenital syndrome, and 1 had penile agenesis. Mean patient age was 16 years (range, 6 to 21 years). Mean follow-up was 6.2 years (range, 2 months to 15 years). Postoperative complications included introital stenosis (4 patients), mucosal prolapse (4), partial small bowel obstruction (2), perineal wound hematoma (2), superficial wound infection (2), and vaginal prolapse (1). None of the complications have affected long-term patency or cosmesis of the neovagina, nor has mucous production significantly affected quality of life. Fourteen of 16 (88%) adult patients are heterosexually active, 1 is homosexually active, and 1 is asexual. Of the 14 heterosexually active patients, 11 (79%) are "very satisfied" with their psychosexual development and 3 are "comfortable." Four patients are married, and 1 has carried a child to term. All adult patients felt that the appropriate time to undergo surgery was in adolescence.

CONCLUSIONS

Reconstruction with sigmoid segments is an effective approach for many congenital conditions requiring vaginal reconstruction. Although surgical outcomes are not perfect, appropriately timed reconstructive vaginal surgery can provide most patients with an improved quality of life. For the best long-term results, a multidisciplinary team must be available from infancy to supply comprehensive support.

Vaginal and uterine anomalies in the paediatric and adolescent patient

The past year has brought a number of interesting developments in the world of paediatric and adolescent gynaecology. These primarily relate to the genetics of the biology of sexual differentiation, which is now beginning to gain considerable understanding. A number of case reports and surgical procedures have also been described, although they have contributed only minimally to our existing understanding. Data on prevalence has always been difficult in congenital abnormalities, and some data are also now emerging to support the figures quoted in the literature.

Laparoscopic vaginoplasty: using a sliding peritoneal flap for correction of complete vaginal agenesis

In this technique of peritoneal neo-vaginoplasty, the recto-vesical space is dissected through the vulva under synchronous laparoscopic monitoring. Then the cranial limit of the pelvic peritoneum is incised circumferentially by laparoscopic approach and the two circular edges sutured sequentially. The isolated pelvic peritoneal sleeve is opened inferiorly and sutured to introital mucosal flaps.

Vaginal agenesis: an opinion on the surgical management

The management of vaginal agenesis-Mayer-Rokitanksy-Kuster-Hauser syndrome-has always been a controversial topic. Initially, the arguments centered on whether to do surgery or try passive dilation as well as at what age to intervene. As surgical techniques have recently become refined, the question is, if surgery is selected, what type of tissue should one use (bowel vs. skin graft) and, if skin graft, from what area to select. Now we are faced with new surgical techniques from the realm of pelviscopy and ask the question: Is one of these better than the other, and is this approach superior to previously established surgical techniques? Drs. Claire Templeman and S. Paige Hertweck from the University of Louisville School of Medicine, Department of Obstetrics and Gynecology here present a concise discussion of these diverse issues.