Vaginoplasty:

Laparoscopic Sigmoid Vaginoplasty for the Treatment of Mayer-Rokitansky-Kuster-Hauser Syndrome in a Single Center: 20 years' Experience

INTRODUCTION AND HYPOTHESIS

We investigate the feasibility, safety, and clinical therapeutic effect of laparoscopic sigmoid vaginoplasty in women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.

METHODS

We performed a retrospective case review cohort study of 56 patients with MRKHs undergoing laparoscopic sigmoid vaginoplasty in Wuhan Union Hospital between 2000 and 2020, and all patients were followed up.

RESULTS

The median operating time was 165 min (120-420 min). The median hospital stay was 10 days (rang 7-15 days). A functional neovagina was created 11-15 cm in length and two fingers in breadth in all patients. No introitus stenosis was observed. No intra- or post-operative complications occurred. Two patients were lost to follow-up after 3 months of outpatient visits. Six patients had no intercourse and were required to wear a vaginal mold occasionally. None of the patients had complained of local irritation or dyspareunia. Patients who had post-surgery sexual intercourse were satisfied with their sexual life and the mean total Female Sexual Function Index (FSFI) score was 25.17 ± 0.63. The cosmetic results were excellent.

CONCLUSIONS

The laparoscopic sigmoid vaginoplasty can achieve the goal of making a functional neovagina. The main advantage of this surgical technique is that it is minimally invasive and that there are fewer complications post-operation. It is an acceptable procedure for patients with MRKH syndrome.

Vaginal stenosis treatment using computed tomography and fluoroscopy guidance

INTRODUCTION

Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis.

CASE

We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation.

INTERVENTION

A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency.

CONCLUSION

This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.

Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction)

OBJECTIVE

To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment.

SUMMARY OF BACKGROUND DATA

Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress.

METHODS

A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes.

RESULTS

Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications.

CONCLUSIONS

Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.

Refinement of recto-sigmoid colon vaginoplasty using a three-dimensional laparoscopic technique

To investigate the feasibility, safety, and outcomes of three-dimensional (3D) laparoscopic vaginoplasty with a rectosigmoid colon flap for vaginal reconstruction.Following appropriate preoperative patient counseling, 17 consecutive patients underwent vaginoplasty using a 3D laparoscopic system. Perioperative and postoperative outcomes were retrospectively evaluated.Between September 2016 and February 2020, 17 patients underwent 3D laparoscopic vaginoplasty with a rectosigmoid colon flap. Of them, 15 (88%) were transgender female patients, and 2 (12%) were cisgender female patients with congenital deformities. Among the 15 transgender patients, 12 (80%) underwent de novo surgeries and 3 (20%) underwent re-do surgeries. The mean age at the time of operation was 33.0 years, and the mean total operation time was 529 ± 128 minutes. The initial intraoperative mean vaginal depth was 15.2 ± 1.3 cm, and the 30-day readmission rate was 5.9% (1/17 cases). The mean follow-up duration was 24.8 months.Perioperative and postoperative outcomes suggest that 3D laparoscopic rectosigmoid colon vaginoplasty is a potentially acceptable, effective, and safe method for vaginal reconstruction.

Double Pedicle Artery Rotation Sigmoid Vaginoplasty for Vaginal Aplasia Management

Sigmoid vaginoplasty has been popular for neovagina reconstruction in vaginal aplasia. The most common surgical complication was vaginal stenosis caused by inadequate vascularization and tension because of graft length. Therefore, ischemia ensued and disrupted wound healing. The selection of double pedicle artery rotation sigmoid vaginoplasty is expected to reduce this problem. Five patients from April to December 2016 were diagnosed with vaginal aplasia; 4 had history of neovagina stenosis. These patients underwent sigmoid vaginoplasty with double pedicle artery rotation. No complications occurred during or after the procedure. Assessment postsurgery was conducted at 1 year. These results suggest that double pedicle artery rotation sigmoid vaginoplasty is a safe and acceptable technique for management of vaginal aplasia. The procedure decreased tension inside vascular pedicles as a result of maintaining abundant vascularization supply. Consequently, this procedure could avert graft necrosis, leakage, and severe stenosis. All of the patients exhibited regular menstrual cycle and satisfactory sexual activity. The outcomes were excellent with remarkable anatomical and functional results.

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.

Early cervical cancer impact of peritoneal vaginoplasty combined with laparoscopic radical hysterectomy improved sexual function

OBJECTIVE

We investigated the impact of laparoscopic radical hysterectomy (LRH) in combination with peritoneal vaginoplasty (PV) in improving sexual function after radical hysterectomy (RH) in patients with early cervical cancer.

METHODS

A total of 79 patients with early-stage cervical cancer younger than 45 years were assigned to receive LRH in combination with PV (the LRH-PV group; n = 31) or LRH alone (the LRH group; n = 48). Other 40 healthy females were selected as controls (the control group). The sexual function was assessed with Female Sexual Functioning Index (FSFI). The FSFI scores and sexual function in the postoperative 1 year were compared between the LRH-PV and LRH groups, LRH-PV and control groups, and LRH and control groups, respectively.

RESULTS

Patients with LRH-PV showed significantly higher scores in sexual satisfaction, lubrication, pain, and total score than those with LRH alone (P < 0.05) but were not statistically different in scores regarding sexual desire, arousal, and orgasm (P > 0.05). Healthy controls showed the highest in total scores and 6 domains among all subjects. In addition, the FSFI total scores in the LRH-PV group, LRH group, and LRH-PV + LRH group were significantly decreased compared with the control (P < 0.05).

CONCLUSIONS

Peritoneal vaginoplasty to lengthen the vagina improves sexual function of patients with early cervical cancer receiving LRH in sexual satisfaction, lubrication, and pain.

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.

Oestrogen receptor alpha expression in neovaginal tissue of women following modified Abbé-McIndoe technique and in premenopausal women

The aim of the study was to compare the expression of oestrogen receptor alpha (ERα) in neovaginal tissue of patients with vaginal agenesis following neovaginoplasty using regenerated, oxidised cellulose in premenopausal women. A prospective, observational case-control study was performed on eight patients with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty and 10 control premenopausal women following benign gynaecologic surgery. 6F11 monoclonal antibody was used to determine ERα expression in the vaginal mucosa. Quantitative and qualitative evaluations were performed, respectively, in vaginal epithelium and stroma. The thickness of the vaginal epithelium was determined as the vertical distance between the basal layer cells and the apical surface of the superficial layer. The percentage of ERα-expressing cells was higher in the control group, except in the superficial zone of the epithelium. In the stromal tissue, ERα was detected in only one patient from the neovagina group compared with nine women in the control group. The neovagina group had a statistically thinner epithelium. Our study suggests that women with vaginal agenesis following modified Abbé-McIndoe neovaginoplasty using regenerated oxidised, cellulose experience relatively local hypo-oestrogenism in the first year after surgery, with repercussion in vaginal trophism.

Comparison of improved laparoscopic peritoneal vaginoplasty and gasless laparoscopic ileal vaginoplasty in treatment of androgen insensitivity syndrome

PURPOSE

To investigate a better approach for androgen insensitivity syndrome (AIS) treatment using laparoscopic peritoneal or ileal vaginoplasty.

METHOD

Improved laparoscopic peritoneal vaginoplasty and gasless laparoscopic ileal vaginoplasty were, respectively, applied to AIS patients in vaginal reconstruction. The operation condition and surgical results were summarized and follow-up was performed from the 5th week after operation, then once a month. The sexual function was scored by Female Sexual Function Index (FSFI), and FSFI score >30 represented a very good sexual function, 25-30 as good, and <25 as bad.

RESULT

The operation time (including gonadal resection and genital plastic surgery) of improved laparoscopic peritoneal vaginoplasty was 77.2 ± 18.9 (55-105) min, while of ileal vaginoplasty was 183.3 ± 30.1 (155-215) min, longer than peritoneal vaginoplasty, and the bleeding amount was 7.2 ± 13.0 (5-30) versus 50.0 ± 30.0 (20-80) mL, respectively. The surgery was successful in all 12 cases without complications. During 1 month to 7 years follow-up, the depth of artificial vagina was approximately 8-12 cm after peritoneal vaginoplasty, while 6-11 cm after ileal vaginoplasty. The vaginal mucosa appeared as normal in all cases. Besides, 4/9 cases had normal FSFI score after peritoneal vaginoplasty while only 1/3 case after ileal vaginoplasty.

CONCLUSION

The peritoneal vaginoplasty seems better than the ileal vaginoplasty because of the shorter operation time, less bleeding, rapid recovery, less trauma and scar, easy operating and early sexual life without mold. But the treatment should be individualized and comprehensive considering the patient anatomical characteristics and other factors.

Creatsas Modification of Williams Vaginoplasty for Reconstruction of the Vaginal Aplasia in Mayer–Rokitansky–KüSter–Hauser Syndrome Cases

Mayer–Rokitansky–Küster–Hauser syndrome has a prevalence of one in 4000 females and is the most common cause of vaginal aplasia. Management of Mayer–Rokitansky–Küster–Hauser syndrome patients includes, along with psychological support, the creation of a neovagina. Creatsas vaginoplasty is a fast and simple technique in which a perineal skin flap is used to create a perineal pouch. Initially, the hymen is cut to avoid hemorrhage during the patient's first intercourse, and a U-shaped incision is made at the perineum. Afterwards, the tissues are mobilized and the inner skin margins of the created flap are stitched together using absorbable sutures. The same material is used to approximate the perineal muscles, subcutaneous fat and outer skin margins. In our institution, the Creatsas vaginoplasty has been performed in 200 patients over the last 23 years, with excellent results.

Experimental uterus transplantation

BACKGROUND

Uterus transplantation (UTx) is developed in animal models as a future method to treat uterine factor infertility.

METHODS

All published studies in the area of UTx research were identified. Aspects relating to surgery, cold-ischemia/reperfusion, rejection, immunosuppression, pregnancy, ethics and institutional requirements were examined.

RESULTS

Uterus retrieval surgery has been solved in animals, including primates. Studies on cold-ischemia/reperfusion indicate an ischemic tolerance of >24 h. The transplantation procedure, with vascular anastomosis, has not been fully developed in animal models, indicated by frequent thrombosis formation. Pregnancies have only been reported in syngenic/auto-UTx animal models. Several ethical issues in relation to UTx, and requirements for a team that would be suitable to undertake human UTx, exist.

CONCLUSION

Much research on UTx has been performed in appropriate animal models. Several aspects of the procedure have been optimized but some remain to be solved. It is predicted that the research will soon reach a stage that could merit introduction of human UTx as an experimental procedure.

Transretropubic traction vaginoplasty for correction of vaginal aplasia

OBJECTIVE

To introduce an alternative approach to vaginoplasty using transretropubic traction (TRT).

METHODS

In this case series with 4 patients with complete vaginal aplasia, a plastic "olive" placed on the vaginal dimple was lifted by a mesh tape inserted through the space of Retzius and anchored to the anterior abdominal wall.

RESULTS

On day 8 postoperatively all patients had a reasonable vaginal size, 2.5 to 3 cm in width and 6 to 7.5 cm in length. The mean satisfaction scores were 86 points for the patients and 89 points for their husbands, who also reported a mean penetration score of 90 points.

CONCLUSION

As a minimal-access and relatively simple operation, TRT vaginoplasty could be performed by trained gynecologists. Studies with larger populations are required to support this preliminary report.

Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap

BACKGROUND

The use of the rectus abdominis myocutaneous flap in reconstruction is well documented. It can be used to fill defects in the walls of the chest, the abdomen, the groin and the perineum. In this study, details of observations on five patients who underwent vaginal reconstruction using a muscle-sparing vertical rectus abdominis myocutaneous (MS-VRAM) flap are presented.

PATIENTS AND METHODS

Between September 2006 and October 2007, five patients underwent vaginal reconstruction using a MS-VRAM flap. All patients had congenital absence of the vagina.

RESULTS

All MS-VRAM flaps survived completely. No complications occurred at the donor site of abdominal wall. In the course of 2-9 month follow-ups, the patients reported satisfaction, though they were unmarried and had no regular sexual partners. This study demonstrates that a new vagina can be created from the MS-VRAM flap and that the reconstruction is reliable, with low donor-site morbidity, easier surgical technique and shorter operation time. However, the major disadvantage of this technique is the conspicuous abdominal scar.