(019) Complete Sub-Epithelial Vestibulectomy: Refinement of Surgery for Neuroproliferative Vestibulodynia

Abstract

Abstract Introduction Complete vestibulectomy (CV) was first described by Goldstein and Marinoff, detailing an excision 3 mm cephalad to the hymen and caudad to Hart’s line. A vaginal advancement flap (VAF) to cover the defect left by excised vestibule was also described. Since neuroproliferative vestibulodynia is a field disease, The CV with VAF surgery has become widely utilized practiced by sexual medicine surgeons to treat neuroproliferative vestibulodyniaby surgeons practicing sexual medicine. However, the depth of dissection for the vestibular mucosal excision (VME) was not clearly defined. To gain a better appreciation for appropriate depth of the VME during CV with VAF, we have reviewed the results of immunohistochemical staining (IHC) of excised vestibular specimens (n=564) since 2019. In all cases, tissue depth of the excess positive CD117 and PGP9.5 staining, consistent with excess mast cells and nerves respectively, were < 600 μm (0.6 mm) from the epithelial surface. Objective Our objective is to describe safety and efficacy of vestibulectomy surgical technique modifications made in 2021 based on this finding. Methods We refined the CV and VAF surgery based on the observation that the IHC pathology resides very close to the vestibular epithelium. This modification has been termed complete subepithelial vestibulectomy (CSEV). These modifications keep the VME thickness as close as possible to 1-2 mm. Liposomal bupivicaine (20 ml) is injected subcutaneously throughout the vestibule to hydrodissect the mucosa. The lateral border at Hart’s line and medial border 3 mm cephalad to the hymen is incised. The mucosal surface of the vestibule is grasped with an atraumatic vascular clamp and dissected sharply with the tissue stretched over a finger to maintain a very thin VME. Excised specimens are sent for IHC staining. Patients who underwent CSEV with VAF surgery from 2021 onward were followed for ≥ 6 months. Results A total of 13 individuals (mean age 29 ± 8yrs) underwent CSEV with VAF, with a mean follow-up of 8 ± 4 months. Photomicrographs of surgical specimen confirmed the thickness to be approximately 1-2 mm (Fig 1). Blood loss was minimal, <100 ml in 11/13. Post-operative use of narcotics was minimal with all patients reporting less than 5 oxycodone 5mg tablets used. At 6 months post-op, 10/13 reported their vestibulodynia was much better/better based on PGI-I. Conclusions We report CSEV as a refinement of the Goldstein/Marinoff procedure. The depth of dissection and thickness of VME was 1-2 mm with this new procedure. Early results in our small case series show excellent vestibulodynia resolution and reduced pain medication requirements post-operatively. To date, the success rate of CSEV is equivalent to the outcomes from previous vestibulectomy series, ~77%, with minimal less operative blood loss. Disclosure No