Percutaneous obstructed hemivagina access (POHVA) to the difficult obstructed hemivagina in the OHVIRA syndrome: a novel minimally invasive technique

Abstract

OBJECTIVE: To illustrate a novel minimally invasive technique for the identification and safe entry to the hematocolpos associated with obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome. DESIGN: Surgical technique. MATERIALS AND METHODS: Retrospective review from 2005-2010 of OHVIRA syndrome cases in which POHVA was employed. Preoperative evaluation consisted of a thorough history, physical examination and a pelvic MRI. At exam under anesthesia, vaginoscopy is performed to identify the hematocolpos and unobstructed cervix. To avoid blind dissection, a 10 Fr Council tip Foley catheter and a percutaneus vascular catheter introducer set, containing an 18 gauge × 7 cm needle, a 16 Fr introducer with peel-away sheath and a 50 cm guide wire, are used in the POHVA technique. The hematocolpos is needled until old menses is aspirated, otherwise placement is confirmed under fluoroscopic guidance. Through the needle, the wire is then inserted and followed with the introducer and peel-away sheath. The introducer is then removed and the Foley catheter is inserted over the wire. After Foley inflation, the wire and sheath are removed. The hematocolpos is completely drained, the septum is widely resected and sutured to prevent reobstruction. RESULTS: From 2005-2010, ten patients with cyclical pain were found to have OHVIRA syndrome and 4 had difficult access to the obstructed hemivagina. The POHVA technique was successfully performed in all 4 cases, with rapid identification and access to the difficult obstructed hemivagina without need of concomitant laparoscopy. There were no intraoperative complications. One patient required repeat POHVA and vaginoplasty secondary to restenosis. CONCLUSION: Single-stage vaginoplasty in girls with OHVIRA syndrome can be challenging when due to a small vaginal caliber, a less accessible and high lateral vaginal bulge, and chronic inflammation. The POHVA technique uses a widely available vascular catheter introducer set, permitting a controlled entry with good early results.