Recurrence of high-grade squamous intraepithelial neoplasia in neovagina: case report and review of the literature

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction

PURPOSE

Various techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts.

METHODS

Thirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed.

RESULTS

Age at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion.

CONCLUSIONS

We conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Retrospective Study.

Microinvasive squamous carcinoma of neovagina created with peritoneal flap (Davidov): Case report and literature review

Carcinoma of the vagina is a rare disease, and it is even more rare when it appears in a neovagina, having its incidence and optimum treatment constantly discussed. The aim of this article was to review the cases described in the currently available literature and describe the second documented case of carcinoma in a neovagina created with peritoneal flaps, and also list the possible pathways and risk factors for its development. The case we present is a 49-year-old female who after undergoing a laparoscopic colpectomy of the upper two-thirds of the vagina, with an immediate reconstruction with peritoneal flaps by laparoscopy, at a 4 months follow up presented a focal microinvasive squamous carcinoma in the vault of the neovagina. After reviewing the literature, we conclude that excisional treatment is the preferable option to avoid the progression to an invasive carcinoma. However, this case demonstrates the importance of the necessity to do regular cito-vulvovaginoscopic examinations after the complete surgical treatment because of the chance of persistent or recurrent lesions on the transplanted tissue.

Lesions of the Neovagina--A Review

Creation of a neovagina is uncommon, but it may be performed for congenital absence or anomaly, after exenterative cancer surgery, or in male-to-female transsexuals. A variety of tissues may be used to create the neovagina. Lesions of the neovagina are uncommon and probably not well known to most practitioners. A review of these lesions will be helpful if such a patient presents.

Squamous papilloma with hyperpigmentation in the skin graft of the neovagina in Rokitansky syndrome: literature review of benign and malignant lesions of the neovagina

BACKGROUND

It is rare for a benign or malignant neoplasm to develop in a neovagina.

CASE

This is the first report of a squamous papilloma with hyperpigmentation which developed in the neovagina 12 years after a McIndoe procedure was done with a split-thickness skin graft from the patient's buttock. The patient had congenital absence of the vagina and uterus (Rokitansky syndrome, Mayer-Rokitansky-Küster-Hauser syndrome, MRKH syndrome). It presented as post-coital blood spotting for 3 months.

CONCLUSION

As a routine, all cases of vaginal construction regardless of the reason for the surgery or the lining of the neovagina should have a continuous annual examination and careful inspection of the entire vagina. Biopsy of any unusual finding should be done. Despite the dark color of the vaginal lesion, bleeding and rapid appearance our patient had a benign tumor. Radiation therapy to the neovagina and prolonged treatment with podophyllin and cauterization should be avoided.

Cancer of the neovagina

OBJECTIVE

Cancer of the neovagina has been documented, and found to occur at younger ages than cancer of the native vagina. A review of the world literature was performed to evaluate risk based on type of tissue used for replacement or reconstruction of the vagina, as well as signs and symptoms of tumor occurrence and follow-up possibilities for early detection/screening for cancer and precancerous changes.

METHOD

Comprehensive review of relevant published literature.

RESULTS

Creation of a neovagina is infrequently performed with no established follow-up pattern. Neovaginal construction uses a variety of tissues: bowel, skin graft, vulvar skin flaps, rectus abdominus (myocutaneous) flaps, inverted penile skin. When exogenous tissue is used, tissue dysplasia can be expected because the tissue is suddenly subjected to new contacts/stresses. Pathological criteria of abnormality in epithelium transplanted to a vaginal location are not well established. Case reports suggest that squamous cell cancers occur in skin-graft vaginal constructions and adenocarcinomas occur in vaginas constructed of bowel. Clear or bloody discharge and postcoital bleeding are the most frequent first symptoms. Endoscopy and biopsy are needed for diagnosis.

CONCLUSION

Although considered rare, many cases of cancer of the neovagina are documented in the literature. Careful follow up of patients who have undergone neovagina construction is important.