82: The treatment of vaginal shortening with autologous buccal mucosa graft augmentation without vaginal mold

Abstract

To present a case in which vaginal shortening after hysterectomy was treated with an autologous buccal mucosa graft augmentation without vaginal mold. A 61-year-old woman 5 years status post robotic-assisted hysterectomy with foreshortened vagina and vaginal stricture sought care secondary to dyspareunia and limited ability to have sexual intercourse. Gynecologic examination revealed a narrow vaginal introitus and 4cm vagina, surgically absent cervix and uterus, normal reflexes and external and rectal examination. MRI revealed an additional 3cm of scarred vagina proximal to the 4cm of patent vagina. The patient was counselled on potential treatment option including progressive vaginal dilation, surgical exploration, creation of neovagina with bowel or skin, and novel autologous buccal mucosal placement without the use of mold. This technique avoided the traditional 5-7 days of bedrest required when a vaginal mold is used. She consented and was taken to the operating room where blunt and sharp dissection were used to prepare the vagina for graft. Bilateral buccal mucosa grafts were harvested with careful attention was used in identifying the Stenson duct and buccinator muscle (Figure 1). Both buccal mucosal grafts were then prepared and defatted. To obtain optimal size of each graft, and to prevent hematoma/seroma accumulation, the grafts were meshed using a 3:1 mesher. The buccal mucosa was then attached to the underlying posterior fibromuscularis region using 2-0 PDS interrupted suture. A 60-degree Z-plasty was performed at the perineal body allowing the vaginal opening to admit 3 fingerbreadths. The vagina was then packed with estrogen cream. Post-operatively, the patient’s pain was well controlled on by-mouth pain medications and chlorhexidine mouthwash, and was discharged home on postoperative day 1. She was given strict pelvic rest precautions. She was instructed to follow up twice weekly for 4 weeks post operatively for peroxide vaginal irrigation and 4 grams of estrogen cream application under direct visualization. By her 1 week follow up she denied significant vaginal tenderness and by her 4-week postoperative visit, the incisions in her mouth were completely healed. She continued 4 grams of estrogen cream per vagina twice weekly. At 8-weeks post-op her vagina was 8 cm long and able to admit 3 fingerbreadths comfortably. She reported being very satisfied with the result. Vaginal shortening after hysterectomy can be repaired using autologous buccal mucosal grafting without the need for a vaginal mold or 5-7 days of bedrest. Hysterectomy can lead to significant vaginal shortening which can decrease patient quality of life and impede penetrative intercourse. Buccal mucosa can be harvested and used without a vaginal mold or multiday bedrest for patients with vaginal foreshortening. Care for patients with vaginal shortening requires a multidisciplinary approach given the complex anatomy of these patients.