The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study

Vaginal Stenosis After Gender-affirming Vaginoplasty: A Systematic Review

OBJECTIVE

To review the literature and report the incidence of vaginal stenosis (VS) after vaginoplasty and compare the incidence rates by surgical technique and follow-up duration.

METHODS

We performed a systematic literature review according to PRISMA guidelines. Original research on primary vaginoplasty was included. Exclusion criteria included non-English studies, mixed cohorts without subgroup analysis, revision vaginoplasty, and papers without stenosis rates. The search was ran in Pubmed, Embase, Scopus, and Cochrane on September 9, 2022. Stenosis rates were compared with descriptive statistics using SPSS.

RESULTS

Fifty-nine studies with a cumulative 7338 subjects were included. The overall incidence of VS was 5.83% (range 0%-34.2%). Combining VS with introital stenosis (IS) and contracture results in a cumulative incidence of 9.68%. The rate of VS in the penile inversion vaginoplasty subgroup (PIV) was 5.70%, compared to 0.20% in primary intestinal vaginoplasty. The rate of IS in the PIV group was 3.13% and 4.7% in the intestinal vaginoplasty subgroup.

CONCLUSION

The overall rate of VS was 5.83%, which is lower than previously documented. This may be related to the inclusion of more recent studies and analysis limited to primary vaginoplasty. The similar rate of IS in PIV and intestinal vaginoplasty subgroups may be secondary to multiple suture lines and the need for dilation through this anastomosis. Our research demonstrates a need for a standardized definition of VS.

Are transgender people satisfied with their lives?

BACKGROUND

Our goal was to examine the proportion of transgender people satisfied with their lives (i.e., cognitive evaluation of life as a whole) and the determinants of life satisfaction level among transgender individuals.

METHODS

Data were taken from the HH-TPCHIGV study. Included were 104 transgender people who had joined self-help groups to get and share information about the gender-affirming surgeries performed at the Division of Plastic, Reconstructive and Aesthetic Surgery at the University Medical Center Hamburg-Eppendorf. The established Satisfaction with Life Scale was used to quantify life satisfaction. Sociodemographic-, lifestyle-related and health-related determinants were included in multiple linear regressions. In regression analysis, life satisfaction served as outcome measure and in a robustness check ordered probit regressions were used.

RESULTS

Among transgender people, 12.9% can be classified as "extremely dissatisfied", 18.3% can be classified as "dissatisfied", 12.9% can be classified as "slightly dissatisfied", 7.5% as "neutral", 30.1% as "slightly satisfied", 17.2% as "satisfied" and 1.1% as "extremely satisfied". Higher levels of life satisfaction were associated with higher age (β = .15, p < .05), higher school education (β = 5.54, p < .001), and favorable self-rated health (β = 2.20, p < .001).

CONCLUSIONS

Nearly half of the transgender people were at least "satisfied" with their lives. Knowledge about the correlates of life satisfaction may assist in addressing unsatisfied individuals.

Principles and outcomes of gender-affirming vaginoplasty

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review

BACKGROUND

Many transgender women and men undergo gender-affirming surgeries. Existing work shows that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive quality of life outcomes. Less work, however, examines these outcomes in the longer-term.

AIMS

To conduct a systematic literature review into the longer-term (i.e., ≥ 1 year) surgical satisfaction and quality of outcomes following various forms of gender-affirming surgery in transgender populations. Specifically, we aim to examine research on such outcomes at least one-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries.

METHODS

Studies were identified through Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. We considered all studies published until October 2021. Two reviewers extracted data from suitable studies using Covidence. Both reviewers also independently assessed the identified studies' risk of bias and strength of evidence.

RESULTS

Seventy-nine low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggest that most transgender patients are satisfied with surgical outcomes when assessed at least one-year post-surgery. Low quality research also indicates that transgender women and men typically report positive psychological and sexual wellbeing post-surgery, and similar wellbeing outcomes as those who have not had surgery.

DISCUSSION

To the best of our knowledge, this literature review is the first to critically summarize and evaluate all published studies on the longer-term quality of life outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. While the results suggest promising surgical satisfaction and quality of life outcomes following surgery, many studies only draw on small samples, and most studies do not allow for causal conclusions. Further, few studies have compared surgical outcomes between transgender women and men. We conclude by offering concrete suggestions for future research.

Altered Expression of Candidate Genes in Mayer-Rokitansky-Küster-Hauser Syndrome May Influence Vaginal Keratinocytes Biology: A Focus on Protein Kinase X

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare and complex disease defined by congenital aplasia of the vagina and uterus in 46,XX women, often associated with kidney and urinary tract anomalies. The aetiopathogenesis of MRKH syndrome is still largely unknown. Herein, we investigated the role of selected candidate genes in the aetiopathogenesis of MRKH syndrome, with a focus on PRKX, which encodes for protein kinase X. Through RT-qPCR analyses performed on vaginal dimple samples from patients, and principal component analysis (PCA), we highlighted a phenotype-related expression pattern of PRKX, MUC1, HOXC8 and GREB1L in MRKH patients. By using an in vitro approach, we proved that PRKX ectopic overexpression in a cell model of vaginal keratinocytes promotes cell motility through epithelial-to-mesenchymal transition (EMT) activation, a fundamental process in urogenital tract morphogenesis. Moreover, our findings showed that PRKX upregulation in vaginal keratinocytes is able to affect transcriptional levels of HOX genes, implicated in urinary and genital tract development. Our study identified the dysregulation of PRKX expression as a possible molecular cause for MRKH syndrome. Moreover, we propose the specific role of PRKX in vaginal keratinocyte biology as one of the possible mechanisms underlying this complex disease.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

Protein-protein interaction network analysis applied to DNA copy number profiling suggests new perspectives on the aetiology of Mayer-Rokitansky-Küster-Hauser syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare disease, characterised by the aplasia of vagina and uterus in women with a 46,XX karyotype. Most cases are sporadic, but familial recurrence has also been described. Herein, we investigated an Italian cohort of 36 unrelated MRKH patients to explore the presence of pathogenic copy number variations (CNVs) by array-CGH and MLPA assays. On the whole, aberrations were found in 9/36 (25%) patients. Interestingly, one patient showed a novel heterozygous microduplication at Xp22.33, not yet described in MRKH patients, containing the PRKX gene. Moreover, a novel duplication of a specific SHOX enhancer was highlighted by MLPA. To predict the potential significance of CNVs in MRKH pathogenesis, we provided a network analysis for protein-coding genes found in the altered genomic regions. Although not all of these genes taken individually showed a clear clinical significance, their combination in a computational network highlighted that the most relevant biological connections are related to the anatomical structure development. In conclusion, the results described in the present study identified novel genetic alterations and interactions that may be likely involved in MRKH phenotype determination, so adding new insights into the complex puzzle of MRKH disease.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Male-to-Female Reassignment Surgery

BACKGROUND

Plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells.

PURPOSE

The aim of this study is to compare the results of amnion grafts with amnion seeded with autograft fibroblasts.

MATERIALS AND METHODS

Over 8 years, we compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction. Sixteen patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding.

RESULTS

The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed up from 30 months to 8 years, (mean 36 ± 4) after surgery. The depth of the vaginas for group A was 14-16 and 13-16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34-38 mm in group A and 33-38 cm in group B. We only had two cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina. Seventy-five percent of patients had sexual experience and of those, 93.7% in group A and 87.5% in group B expressed satisfaction.

CONCLUSION

The creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7% of patients had satisfaction with sexual intercourse. Amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a two-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Autologous Buccal Micro-Mucosa Free Graft combined with Posterior Scrotal Flap Transfer for Vaginoplasty in Male-To-Female Transsexuals: A Pilot Study

BACKGROUND

The inverted peno-scrotal flap method is considered the standard method of vaginoplasty in male-to-female genital reassignment surgery. Though with numerous advantages, the method has its limitations regarding skin texture, lack of inherent lubrication, and that the tissues for creating the labia depend on the amount of tissues remaining after vaginoplasty. Our purpose was to describe the procedure and outcome of vaginoplasty applying a new technique: autologous buccal micro-mucosa free graft combined with posterior scrotal flap transfer, which could solve some of the problems the previous methods had.

METHODS

Nine male-to-female transsexual patients received our new method of vaginoplasty from July 2010-October 2015. We described the details of the surgical procedure and evaluated the long-term anatomical and functional outcomes.

RESULTS

In a mean clinical follow-up period of 25.3 months and phone interview follow-up of 50.3 months, we observed that the neovaginas in the nine cases were all of sufficient volume, lined with mucosa, with natural mucosal discharge. The oral donor sites resulted in no visible scars or malfunction. Eight patients experienced uneventful postoperative periods, while one patient suffered from scrotal flap prolapse. All the patients were sexually active and reported sexual satisfaction, with no need of lubrication.

CONCLUSION

The reported technique achieves the outcomes of creating a neovagina of sufficient volume, without serious stenosis in long-term follow-up. The neovagina is lined with mucosa and has appropriate lubrication as well as good sexual sensation. The reported method is easy and economical to perform and retains enough tissues for vulvoplasty to achieve a superior cosmetic appearance, with rare risk of complications and donor area malfunction. Additionally, this technique is feasible and advantageous to the patients who have insufficient peno-scrotal skin for neovaginal lining as well as those with unfavorable previous vaginoplasty. All of these indicate that this technique is a promising option for vaginoplasty in male-to-female transsexual surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Neovaginal Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc.

Complications of the neovagina in male-to-female transgender surgery: A systematic review and meta-analysis with discussion of management

Gender-affirmation surgery is often the final gender-confirming medical intervention sought by those patients suffering from gender dysphoria. In the male-to-female (MtF) transgendered patient, the creation of esthetic and functional external female genitalia with a functional vaginal channel is of the utmost importance. The aim of this review and meta-analysis is to evaluate the epidemiology, presentation, management, and outcomes of neovaginal complications in the MtF transgender reassignment surgery patients. PUBMED was searched in accordance with PRISMA guidelines for relevant articles (n = 125). Ineligible articles were excluded and articles meeting all inclusion criteria went on to review and analysis (n = 13). Ultimately, studies reported on 1,684 patients with an overall complication rate of 32.5% and a reoperation rate of 21.7% for non-esthetic reasons. The most common complication was stenosis of the neo-meatus (14.4%). Wound infection was associated with an increased risk of all tissue-healing complications. Use of sacrospinous ligament fixation (SSL) was associated with a significantly decreased risk of prolapse of the neovagina. Gender-affirmation surgery is important in the treatment of gender dysphoric patients, but there is a high complication rate in the reported literature. Variability in technique and complication reporting standards makes it difficult to assess the accurately the current state of MtF gender reassignment surgery. Further research and implementation of standards is necessary to improve patient outcomes. Clin. Anat. 31:191-199, 2018. © 2017 Wiley Periodicals, Inc.

Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline

OBJECTIVE

To update the "Endocrine Treatment of Transsexual Persons: An Endocrine Society Clinical Practice Guideline," published by the Endocrine Society in 2009.

PARTICIPANTS

The participants include an Endocrine Society-appointed task force of nine experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.

CONSENSUS PROCESS

Group meetings, conference calls, and e-mail communications enabled consensus. Endocrine Society committees, members and cosponsoring organizations reviewed and commented on preliminary drafts of the guidelines.

CONCLUSION

Gender affirmation is multidisciplinary treatment in which endocrinologists play an important role. Gender-dysphoric/gender-incongruent persons seek and/or are referred to endocrinologists to develop the physical characteristics of the affirmed gender. They require a safe and effective hormone regimen that will (1) suppress endogenous sex hormone secretion determined by the person's genetic/gonadal sex and (2) maintain sex hormone levels within the normal range for the person's affirmed gender. Hormone treatment is not recommended for prepubertal gender-dysphoric/gender-incongruent persons. Those clinicians who recommend gender-affirming endocrine treatments-appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)-should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition. We recommend treating gender-dysphoric/gender-incongruent adolescents who have entered puberty at Tanner Stage G2/B2 by suppression with gonadotropin-releasing hormone agonists. Clinicians may add gender-affirming hormones after a multidisciplinary team has confirmed the persistence of gender dysphoria/gender incongruence and sufficient mental capacity to give informed consent to this partially irreversible treatment. Most adolescents have this capacity by age 16 years old. We recognize that there may be compelling reasons to initiate sex hormone treatment prior to age 16 years, although there is minimal published experience treating prior to 13.5 to 14 years of age. For the care of peripubertal youths and older adolescents, we recommend that an expert multidisciplinary team comprised of medical professionals and mental health professionals manage this treatment. The treating physician must confirm the criteria for treatment used by the referring mental health practitioner and collaborate with them in decisions about gender-affirming surgery in older adolescents. For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient. We suggest maintaining physiologic levels of gender-appropriate hormones and monitoring for known risks and complications. When high doses of sex steroids are required to suppress endogenous sex steroids and/or in advanced age, clinicians may consider surgically removing natal gonads along with reducing sex steroid treatment. Clinicians should monitor both transgender males (female to male) and transgender females (male to female) for reproductive organ cancer risk when surgical removal is incomplete. Additionally, clinicians should persistently monitor adverse effects of sex steroids. For gender-affirming surgeries in adults, the treating physician must collaborate with and confirm the criteria for treatment used by the referring physician. Clinicians should avoid harming individuals (via hormone treatment) who have conditions other than gender dysphoria/gender incongruence and who may not benefit from the physical changes associated with this treatment.

Autophagy activation is required for myofibroblast differentiation during healing of oral mucosa

AIM

It is known that periodontal tissues heal faster that skin, and gingiva in particular heal without scar formation. The mechanisms regulating this behaviour are still unclear. The aim of our work was to compare wound healing in oral mucosa and gingiva, investigating the role of α-smooth muscle actin (αSMA)-expressing myofibroblasts and autophagy.

MATERIALS AND METHODS

Biopsies were obtained from seven patients immediately before and 24 hr after vertical releasing incision in oral mucosa and attached gingiva. Both whole biopsies and primary cultures of fibroblasts derived from the same tissues were subjected to immunofluorescence, Western blot and quantitative real-time PCR analyses.

RESULTS

We demonstrated that in oral mucosa, characterized by partially fibrotic outcome during repair, the activation of autophagy determined an increase in αSMA and collagen 1a1 production. Conversely, wound healing did not stimulate autophagy in attached gingiva, and subsequently, no increase in myofibroblast differentiation and collagen deposition could be seen, thus justifying its scarless outcome.

CONCLUSIONS

The elucidation of the differential regulation of autophagy in periodontal tissues and its correlation with myofibroblast differentiation and fibrotic outcome could allow the identification of new molecules involved in periodontal healing and the development of new surgical approaches for periodontal treatment that could improve the outcome of postoperative wounds.

An Update on the Surgical Treatment for Transgender Patients

INTRODUCTION

As gender dysphoria is becoming increasingly accepted in the general population, the number of patients seeking gender reassignment surgery is increasing. Although not every patient with gender dysphoria requires surgery, medical practitioners taking care of these individuals should be aware of the different surgical options.

AIM

To review current gender reassignment surgical techniques and update the clinician.

METHODS

A review of the literature was performed focusing on the most recent techniques of gender reassignment surgery.

MAIN OUTCOME MEASURES

Main outcomes included a historical review of gender confirmation surgery leading to the techniques of choice in different divisions. For the vaginal lining, penile-scrotal skin flaps remain the technique of choice, and the gold standard for a phalloplasty remains the radial forearm flap.

RESULTS

Surgical techniques for male-to-female gender reassignment consist of facial feminization surgery, voice surgery, breast augmentation, orchiectomy, and vaginoplasty. Female-to-male gender reassignment surgery includes facial masculinization surgery, subcutaneous mastectomy, and phalloplasty procedures.

CONCLUSION

Penile-scrotal skin flaps remain the technique of choice for the vaginal lining, although indications for a vaginoplasty with intestinal transfer are becoming more common. The gold standard for a phalloplasty remains the free radial forearm flap.

Improvement of Mouth Functional Disability in Systemic Sclerosis Patients over One Year in a Trial of Fat Transplantation versus Adipose-Derived Stromal Cells

Background. Systemic sclerosis (SSc) is a multisystem disease characterized by cutaneous and visceral fibrosis. Face and mouth changes include telangiectasia, sicca syndrome, and thinning and reduction of mouth width (microcheilia) and opening (microstomia). We applied autologous fat transplantation compared with autologous adipose-derived stromal cells (ADSCs) injection to evaluate the clinical improvement of mouth opening. Methods. From February to May 2013 ten consecutive SSc patients were enrolled from the outpatient clinic of Plastic Surgery Department of Sapienza University of Rome. Patients were divided into two groups as follows: 5 patients were treated with fat transplantation and 5 patients received infiltration of ADSCs produced by cell factory of our institution. To value mouth opening, we use the Italian version of Mouth Handicap in Systemic Sclerosis Scale (IvMHISS). Mouth opening was assessed in centimetres (Maximal Mouth Opening, MMO). In order to evaluate compliance and physician and patient satisfaction, we employed a Questionnaire of Satisfaction and the Visual Analogic Scale (VAS) performed before starting study and 1 year after the last treatment. Results and Conclusion. We noticed that both procedures obtained significant results but neither one emerged as a first-choice technique. The present clinical experimentation should be regarded as a starting point for further experimental research and clinical trials.

Peritoneal vaginoplasty by Luohu I and Luohu II technique: a comparative study of the outcomes

BACKGROUND

Surgical vaginoplasty is the standard treatment for women suffering from Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. This study compares the advantages and disadvantages of Luohu I technique or its modification, Luohu II technique.

METHODS

Women with MRKH syndrome undergoing laparoscopic peritoneal vaginoplasty using either the Luohu I (N = 145) or Luohu II (N = 155) technique were recruited. We compare the effectiveness of the Luohu II and one of Luohu I. Sexual satisfaction was checked by Female Sexual Function Index.

RESULTS

There was no significant difference in the mean operation time, volume of intraoperative blood loss, time for the first passage of gas, sexual satisfaction (and hospital stay for patients in either group (P > 0.05). But patients in the Luohu II group had a significantly lower incidence of complications than patients in the Luohu I group. All patients had vaginal depths more than 9 cm over 3 months post-surgery.

CONCLUSIONS

Compared with the traditional Luohu I laparoscopic peritoneal vaginoplasty, the Luohu II operation is easier to perform and causes less damage to the bladder and rectum. The physiological and anatomical features of the artificial vagina resemble the normal vagina in both techniques.

Iatrogenic rectovaginal fistula repair by trans-perineal approach and pubo-coccygeus muscle interposition

INTRODUCTION

Rectovaginal fistula (RVF) is a rare but debilitating complication of a variety of pelvic surgical procedures.

PRESENTATION OF CASE

We report the case of a 45-year-old female who underwent the STARR (Stapled Trans Anal Rectal Resection) procedure, that was complicated by a 30mm rectovaginal fistula (RVF). We successfully repaired the fistula by trans-perineal approach and pubo-coccygeus muscle interposition. Seven months later we can confirm the complete fistula healing and good patient's quality of life. We carefully describe our technique showing the advantages over alternative suturing, flap reconstruction or resection procedures.

DISCUSSION

This technique is fairly easy to perform and conservative. The pubo-coccygeus muscle is quickly recognizable during the dissection of the recto-vaginal space and the tension-free approximation of this muscle by single sutures represents an easy way of replacement of the recto-vaginal septum.

CONCLUSION

In our experience the use of pubo-coccygeus muscle interposition is an effective technique for rectovaginal space reconstruction and it should be considered as a viable solution for RVF repair.