Surgical and functional outcomes of sigmoid vaginoplasty among patients with variants of disorders of sex development

Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature

BACKGROUND

Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults.

AIM

This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transitional disorders/differences of sex development team of pediatric surgeons and gynecologists.

METHODS

A retrospective analysis was carried out on adult and female identified disorders/differences of sex development patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revision of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished.

OUTCOMES

To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse.

RESULTS

Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persistent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership.

CLINICAL IMPLICATIONS

Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vaginoplasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina.

STRENGTHS & LIMITATIONS

The strength of this study is the detailed description of several cases while the retrospective character is a limitation.

CONCLUSION

In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Ellerkamp V, Rall KK, Schaefer J, et al. Surgical Therapy After Failed Feminizing Genitoplasty in Young Adults With Disorders of Sex Development: Retrospective Analysis and Review of the Literature. J Sex Med 2021;18:1797-1806.

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.

Long-term outcomes of sigmoid vaginoplasty in patients with disorder of sexual development - our experience

Introduction

To report our experience with sigmoid vaginoplasty in patients with different forms of disorder of sexual development and their long-term follow-up.

Materials and Methods

This is a retrospective study of patients who underwent sigmoid vaginoplasty between July 2004 and June 2015 at our center. Follow-up included a physical examination to assess vaginal length and width, cosmetic appearance of the neovagina, and occurrence of any complications.

Results

The current study included eight patients with mean age 19.5 years. The mean operative time was 164 min. No significant intraoperative or immediate postoperative complications occurred. Follow-up period ranges from 21 months to 12 years with mean of 7.5 years. In all patients, the neovagina was found to have a satisfactory cosmetic appearance. Seven patients are sexually active and satisfied.

Conclusion

Sigmoid vaginoplasty is safe and acceptable procedure in patients having vaginal agenesis. Sigmoid vaginoplasty has acceptable cosmetic results and complication rate.

Follow-up of psychological outcomes of interventions in patients diagnosed with disorders of sexual development: A systematic review

The objective of this study was to perform a systematic review of articles that followed up the psychological outcomes of interventions in patients with disorders of sexual development. The analysis focused on the methodological quality of the studies and the assumptions on the evaluation of the intervention outcomes. The review signaled the need for better consideration about the complexity of intersexuality and for a shift from the anatomical/functional/aesthetic to the subjective outcomes related to patient’s quality of life. Furthermore, it is suggested that the interventions should be better investigated, given the lack of evidence for the necessity of early procedures.

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.

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.

Perforation of the neovagina in a male-to-female transsexual: a case report

Introduction

There are several techniques for creation of a neovagina in male-to-female reassignment surgery. Although vaginoplasty with the sigmoid colon is not a common procedure, it is becoming more common. Perforation of the recto-sigmoid neovagina after sex reassignment surgery is very rare. We hereby report a case of perforation of the neovagina that presented as acute peritonitis, with a massive abscess in the intra-abdominal cavity.

Case presentation

This case report describes a 33-year-old Asian woman presenting with mild persistent abdominal pain, nausea, and vomiting who had undergone male-to-female sex reassignment surgery four years prior. Physical examination revealed mild abdominal pain without rebound tenderness. An abdominal computed tomography scan showed a massive abscess that occupied a significant portion of the intra-abdominal cavity. Perforation of the neovagina was confirmed by exploratory laparotomy and surgical drainage with primary closure was performed without any complications.

Conclusion

This is a rare case involving perforation of the neovagina that was successfully treated with surgical intervention. This case emphasizes the importance of taking a detailed medical history and to make physicians and patients aware that bowel vaginoplasty can result in a weak vagina.

Thirty-six vaginal constructions: lessons learned

OBJECTIVES

The use of bowel for vaginal construction is a well-established procedure. In this paper, the lessons learned from 36 vaginoplasties over a 34-year period are discussed.

METHODS

Between 1980 and 2013, 36 patients between 1 and 21 years of age underwent vaginal construction. In 27 of the 36 patients, an inverted V-shaped perineal skin flap was incorporated into the posterior wall of the neovagina, and, when required, a detubularized pouch was used to avoid traction on the vascular pedicle. In nine patients, the sigmoid colon was anastomosed, in a circumferential manner, to the short blind-ending vaginal dimple.

RESULTS

Two of the nine sigmoid vaginas, where the perineal skin flap was omitted, developed introital stenosis. None of the sigmoid neovaginas that included the perineal flap developed stenosis. One patient with ileal segment vagina, at the onset of puberty, developed introital stenosis after 10 years; this was successfully corrected. Nineteen out of 28 patients available for long-term follow up were sexually active and reported no dyspareunia.

CONCLUSIONS

Detubularization and reconfiguration to form a pouch reduces the traction on the mesentery of the bowel segment, which ensures adequate blood supply to the distal entero-cutaneous junction. The inverted V-shaped perineal skin flap should be incorporated in the anastomosis to avoid circumferential suture line and introital stenosis.