Laparoscopically Assisted Vaginal Pull-Through in 7 Cases of Congenital Adrenal Hyperplasia with High Urogenital Sinus Confluence: Early Results.

Abstract

Surgical management of the high urogenital sinus (UGS) is challenging. Presence of a short urethra is a contraindication for UGS mobilization as this is likely to affect urinary continence. In addition, vaginal reconstruction of the high suprasphincteric confluence is complex and prone to complications and failure. This study included 7 girls who underwent a laparoscopically assisted vaginal pull-through in the past 2 years. All cases included were diagnosed with congenital adrenal hyperplasia (CAH), with a high UGS, and a short urethra of ≤15 mm above the confluence. Patients were preoperatively assessed by genitography. Mobilization of the vagina was pursued until the confluence became visible and the vaginal caliber tapered off at its junction with the urethra. The connection was sutured or clipped and divided. Uterine round ligaments were divided to allow delivering the vagina to the perineum with minimum tension. The tract for the pull-through was created and the vagina was pulled outside and sutured to the perineal skin. Good vaginal mobilization allowed a direct perineal anastomosis without skin flap augmentation of the vaginal wall. Clitoroplasty and labiaplasty were deferred. Mobilization of the vagina was possible in all cases attempted, without injuries to the adjacent pelvic structures. Calibration and dilatation started 2 weeks postoperatively. At 12-month follow-up, all the patients had a patent vagina with good caliber, and were able to retain urine without dribbling. The laparoscopically assisted vaginal pull-through approach provides optimal exposure, facilitates vaginal dissection, separation from the urethra, and avoids injuries to the urinary structures. This allows vaginal reconstruction without tension.