Laparoscopic Vecchietti Research Articles

Laparoscopic Vecchietti procedure: pearls for success

To present an effective strategy for optimizing the care of patients with Müllerian agenesis who desire surgical management for the creation of a neovagina with the laparoscopic Vecchietti procedure. This video provides a framework for patient evaluation and selection, surgical strategy, and postoperative care regimen to provide optimal postprocedural outcomes. Academic Hospital. This is a 22-year-old patient with Müllerian agenesis who was unsuccessful with conservative strategies for vaginal lengthening and sought care for neovagina creation. The patient underwent preoperative pelvic floor physical therapy and vaginal dilation, both of which were ineffective in producing adequate vaginal lengthening. We then performed a laparoscopic Vecchietti procedure. The procedure occurred at a large academic institution with two obstetrics-gynecology subspecialty surgeons providing perioperative care. A vaginal length of 7 cm was achieved, which was sustained at >12 months. The patient was managed by a multidisciplinary team using our established care regimen, with follow-up demonstrating a sustained positive treatment outcome. The vaginal length at more than 1 year after the procedure measured 7 cm. Using a methodological, patient-focused approach and an experienced multidisciplinary team can optimize immediate- and long-term surgical outcomes for patients with Müllerian anomalies who do not have acceptable success with conservative methods.

Comparison of the modified laparoscopic Vecchietti and Davydov colpoplasty techniques in Mayer‐Rokitansky‐Küster‐Hauser syndrome: A long‐term follow‐up analysis

To introduce and compare the modified laparoscopic Vecchietti and Davydov techniques for vaginoplasty in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Moreover, the long-term treatment of vaginal agenesis was followed-up. This comparative retrospective cohort study enrolled a total of 53 women with MRKH syndrome. The patients underwent surgical creation of a neovagina including 32 patients who underwent the modified laparoscopic Vecchietti technique, and 21 patients who underwent the modified laparoscopic Davydov technique from January 2009 to February 2019. The perioperative parameters, complications, anatomical, and functional outcomes of the two groups were compared. Patients' sexual functions were evaluated over a long-term follow-up using the female sexual function index (FSFI) and the revised female sexual distress scale (FSDS-R). The medians (25th-75th) of the surgery duration for modified Vecchietti procedures was 50.0 (40.0-59.0) minutes, comparing to 135.0 (117.5-162.5) min for Davydov procedures (p < 0.001). The intraoperative blood loss was 20 (7.5-20.0) mL versus 50.0 (50.0-100.0) mL using the modified Vecchietti and Davydov approaches (p < 0.001), respectively. In the 39 follow-up cases, the lengths of the neovagina of the patients for Vecchietti group versus Davydov group were 7.9 ± 1.0cm versus 8.6 ± 1.2cm at 6months after the vaginoplasty and 8.3 ± 0.7cm versus 8.5 ± 0.9cm after 2 years. There was no statistical difference in the FSFI and FSDS-R scores between the two groups. Both the modified Davydov and Vecchietti laparoscopic procedures successfully achieved optimal anatomic and functional outcomes in treatments of vaginal agenesis. The modified Vecchietti technique is relatively simpler than the modified Davydov technique.

Agenesis of female internal reproductive organs, the Mayer- Rokitansky-Küster-Hauser syndrome

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the most common cause of uterine and uterine tubes absence/underdevelopment and the second most common cause of primary amenorrhea. It is characterized by a congenital agenesis of the uterine tubes, uterus, cervix, and upper part of the vagina. This study presents our 10 years of experience with the diagnostics and therapeutic management of patients with MRKH syndrome. We also focused on the description of anatomical deviations of the female reproductive organs. We studied a cohort of 16 patients hospitalized with MRKH syndrome between 2011-2020. We analysed the age at diagnosis, clinical signs and symptoms, diagnostic techniques, methods of neovagina creation, and anatomical anomalies of the female reproductive organs. The mean age of our patients at the time of diagnosis was 16.75 years. The most frequent clinical manifestations were primary amenorrhea (56.25 %), pelvic pain (31.25 %) and coitus-associated problems. We used two methods of neovagina creation. In six patients we used the non-surgical Frank's dilators method. The vaginal length at the beginning of the dilation was 1.5-2 cm. In 4 patients the vaginal length was under 1 cm, so we performed surgical neovagina creation using the laparoscopic Vecchietti method. An-other two patients could create the vagina via regular sexual intercourse. Based on magnetic resonance imaging and ultrasound examination, the following anomalies were observed: complete agenesis of the uterus (50 % of cases), fibrous band (25 %) and rudimentary uterus (25 %). Satisfactory results in the attempt to create a neovagina can be obtained by both non-surgical and surgical methods. Modern medicine provides many therapeutic measures, which make it possible for the affected women to have a normal sexual life (Tab. 1, Fig. 3, Ref. 37).

Urinary Incontinence in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome Is Independent of Treatment Strategy

<h3>Study Objective</h3> Evaluate the level of distress secondary to urinary incontinence in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and assess if it differs based on treatment strategy. <h3>Design</h3> Cross-sectional. <h3>Setting</h3> Online support communities for patients with MRKH. <h3>Patients or Participants</h3> Patients with MRKH aged ≥18 years who consented to participate. <h3>Interventions</h3> The participants answered an online-based survey in which demographic and clinical information was collected. Additionally, a section with adapted versions of the Urinary Distress Inventory-6 (UDI-6) and the Incontinence Impact Questionnaire-7 (IIQ-7) was incorporated to evaluate for urinary symptomatology and its impact on quality of life. <h3>Measurements and Main Results</h3> 65 patients with a median age of 32 years (range: 18-63) answered the survey. 27 (41.5%) had not undergone any procedure, 24 (36.9%) underwent vaginal dilation, 8 (12.3%) McIndoe vaginoplasty and 6 (9.2%) laparoscopic Vecchietti vaginoplasty. Overall, 53.8% reported symptoms of irritative incontinence, 63% of stress incontinence and 69.2% obstructive/discomfort symptoms. Furthermore, 32.3% of patients reported that urinary symptoms impacted their emotional health to some extent. Mean scores of the UDI-6 and IIQ-7 did not differ between treatment groups, even when non-invasive and invasive procedures were compared (<i>p</i>=0.96). <h3>Conclusion</h3> In this study, MRKH patients with four different treatment strategies did not have statistically significant differences in the severity of urinary symptoms or their effect on quality of life.

META-ANALYSIS : COMPARISON OF NEOVAGINA SUCCESS RATE WITH VECCHIETTI'S LAPAROSCOPIC METHOD AND DAVYDOV'S LAPAROSCOPIC METHOD IN MAYER-ROKITANSKY-KUSTER-HAUSER SYNDROME (MRKH) PATIENTS

ABSTRACT&#x0D; &#x0D; Background&#x0D; Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH) is caused by an embryological growth disorder of the mullerian duct. Laparoscopic Vecchietti and Davydov are laparoscopic surgery techniques that are often used for neovaginal surgery&#x0D; &#x0D; Objective&#x0D; This paper aims to compare the success rate of neovagina with the Vecchietti laparoscopic method and Davydov's laparoscopic method in patients with Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH)&#x0D; &#x0D; Methods: A systematic data search was performed on a medical database (PUBMED, MEDLINE, Cochrane Database, Google Scholar). Inclusion criteria: (1) randomized randomized study of the Vecchietti Laparoscopic Method with Davydov’s Laparoscopy, (2) all inclusive papers can be accessed completely, and (3) the data obtained can be accurately analyzed&#x0D; &#x0D; Data acquisition and analysis: We searched for a random blind study (RCT) with the following keywords: (1) Vecchietti Laparoscopy [title] AND (2) Davydov’s Laparoscopy [title] AND Mayer-Rokitansky-Kuster-Hauser syndrome [title]&#x0D; &#x0D; Results: Three RCTs comparing neovaginal success with the Vecchietti laparoscopic method and Davydov's laparoscopic method a total of 122 patients were analyzed. Average vaginal length (mean difference [MD] -0.70, and 95% [CI] -0.99 to -0.41 (P &lt;0.00001), Average number of Female Sexual Function Index scores (mean difference [MD] -1.34, and 95% [CI] -1.71 through -0.96. (P &lt;0.00001)&#x0D; &#x0D; Conclusion&#x0D; This meta-analysis concludes that Davydov’s Laparoscopic Method is better in terms of postoperative vaginal length and the Female Sexual Function Index Score&#x0D; &#x0D; Keywords&#x0D; Mayer-Rokitansky-Kuster-Hauser Syndrome,Laparoscopic Davydov,Laparoscopic Vecchietti,Vaginal Length,FSFI Score

Neovagina Creation: A Novel Improved Laparoscopic Vecchietti Procedure in Patients with Mayer-Rokitansky-Küster-Hauster Syndrome

To report a new improved laparoscopic Vecchietti vaginoplasty in patients with congenital vaginal agenesis and to investigate its efficacy and safety. A retrospective descriptive and case-control study. Single academic institution. Women who were diagnosed with Mayer-Rokitansky-Küster-Hauster (MRKH) syndrome and underwent our new improved laparoscopic Vecchietti procedure from July 2010 to June 2019 were selected as the study group. The eligible participants had congenital vaginal agenesis with normal 46,XX karyotype and ovarian function. Age-matched, nulliparous, sexually active women were selected as the control group. Women with MRKH syndrome in the study group underwent the novel improved laparoscopic Vecchietti procedure. All participants in both groups were required to complete Female Sexual Function Index and Female Genital Self-Image Scale questionnaires. The effects of our procedure, including the anatomic and functional efficacy of the neovagina, were the primary outcomes. The secondary outcomes consisted of the perioperative complications, surgical morbidities, and long-term postoperative discomfort. A total of 79 patients with MRKH syndrome underwent our new improved Vecchietti vaginoplasty, of whom 44 (55.7%) were diagnosed as Type I MRKH syndrome, whereas 35 (44.3%) were Type II MRKH syndrome. At a 30-month follow-up after surgery, an anatomic neovagina measuring 10.44 cm in length and 1.30 cm in width was achieved. All 79 patients obtained anatomic success with 92.41% of functional efficacy. Compared with 81 age-matched, nulliparous women in the control group, there was no statistical difference regardless of individual measure or total Female Sexual Function Index scores (p >.05). The Female Genital Self-Image Scale assessment showed a significantly lower score in patients undergoing the vaginoplasty (20.14 ± 3.05 vs 22.95 ± 2.12; p <.001). There were no severe perioperative complications except 1 mild bladder injury and 1 transient fever. Our novel improved laparoscopic Vecchietti vaginoplasty is a relatively safe and effective method for surgical treatment of congenital vaginal agenesis. It may be an alternative to neovagina creation for reaching satisfying anatomic and functional efficacy and improving patients' sexual function.

Laparoscopic Vecchietti - Minimally Invasive Treatment for Vaginal Agenesis

Video Objective To describe the surgical steps and postoperative care utilized when performing a laparoscopic Vecchietti procedure for the treatment of complete vaginal agenesis. Setting 21 year old female with complete vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) who desires surgical management and creation of a neovagina. Interventions The laparoscopic Vecchietti procedure is a simple, minimally-invasive technique for the creation of a neovagina in patients with complete vaginal agenesis. Unlike other vaginoplasty techniques, this method does not rely on the use of grafts or surgical flaps. Instead, this procedure creates a neovagina through continuous invagination of the vaginal dimple by an olive-shaped vaginal dilator. The vaginal “olive” is connected to a spring-loaded tensioning device on the patient's abdomen via laparoscopically placed sub-peritoneal sutures. Following placement of the system in the operating room, the sutures are tensioned by 1 to 2 cm each day and a 10 cm neovagina is created over the course of 7 to 10 days. The vaginal olive and sutures are removed in the office, and the patient is instructed to perform daily vaginal dilation using handheld dilators to prevent shortening and stenosis of the neovagina. Conclusion The laparoscopic Vecchietti is a simple and effective procedure to treat complete vaginal agenesis using a minimally-invasive approach.

12: Vaginal agenesis and the modified laparoscopic Vecchietti procedure

To demonstrate our experience with the modified laparoscopic Vecchietti procedure in treating vaginal agenesis. This video details the case of a 17 year old woman who was referred to our office for evaluation of vaginal agenesis. Management options were reviewed with the patient and her parents extensively and following counseling, the patient and her parents chose to proceed with surgical management with a modified laparoscopic Vecchietti procedure. In this video, we detail the modified laparoscopic Vecchietti procedure and subsequent postoperative care. The modified laparoscopic Vecchietti procedure is a feasible and effective technique to surgically treat vaginal agenesis.

Sexual Life of Women With Rokitansky Syndrome After Laparoscopic Vecchietti’s Vaginoplasty

Adequate anatomy and physiology functions of genitalia are fundamental pre-requisites for sexual well-being and reproduction. Mayer-Rokitansky-Küster-Hauser Syndrome (MRKHS) compromises female sexual life and makes reproduction impossible. The aim of this study is to evaluate the psycho-sexual results of vagina reconstruction in patients with MRKHS using laparoscopic Vecchietti’s technique, to determine their impact on reproductive choices. This study included 42 patients with MRKHS who underwent laparoscopic Vecchietti’s vaginoplasty. Their partners were also interviewed. Forty-five age matched healthy sexual active women as a control group were examined during the same period. A gynecological examination was performed to determine the anatomical outcome. Psycho-sexual functioning was evaluated with the revised Female Sexual Distress Scale-Revised (FSDS-R), the Female Sexual Function Index (FSFI) and semi-structured interview. Genital self-image was evaluated using the Female Genital Self-Image Scale (FGSIS). Average length of neovagina (7.0 ± 9.6 cm) for study group with MRKHS was significantly shorter than that of the control group (9.3 ± 2.5 cm). Sexual function in neovagina women was satisfactory (FSFI score 29 ± 2.7) not significantly different from the control group (P < .05) but they had significantly higher levels of stress (FSDS-R scores 14.5 ± 6.5) and were not satisfied with their genital (FGSIS scores 22.0 ± 2.4) compared to the control group. 95% of patients wish to have their own baby. Surrogate motherhood would be accepted only by 35% of women and 83% of women would think about adoption. Uterus transplantation would be accepted by 90% women and 26% of them consider it as the last option.

Sexual Life of Women With Mayer-Rokitansky-Küster-Hauser Syndrome After Laparoscopic Vecchietti Vaginoplasty.

IntroductionAdequate anatomic and physiologic functions of the genitalia are fundamental prerequisites for sexual well-being and reproduction. Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) compromises female sexual life and makes reproduction impossible.AimTo assess the psychosexual effect of vaginal reconstruction using the laparoscopic Vecchietti technique in patients with MRKHS.MethodsForty-two patients with MRKHS who underwent laparoscopic Vecchietti vaginoplasty were included. Their partners also were interviewed. A control group of 45 age-matched, childless, sexually active women were examined during the same period.Main Outcome MeasuresA gynecologic examination was performed to determine the anatomic outcome. Psychosexual function was evaluated with the Female Sexual Distress Scale–Revised (FSDS-R), the Female Sexual Function Index (FSFI), and a semistructured interview. Genital self-image was evaluated using the Female Genital Self-Image Scale (FGSIS).ResultsAverage neovagina length (7.0 ± 9.6 cm) in the MRKHS group was significantly shorter than the vaginal length in the control group (9.3 ± 2.5 cm). Women with a neovagina reported satisfactory sexual function (FSFI score = 29 ± 2.7) that was not significantly different from the control group (P < .05); however, they also had significantly higher levels of distress (FSDS-R score = 14.5 ± 6.5) and were not satisfied with their genitals (FGSIS score = 22.0 ± 2.4) compared with the control group.ConclusionSexual function in women with MRKHS can be restored successfully by vaginoplasty; however, they have higher rates of distress and are less satisfied with their genitals.Pastor Z, Fronĕk J, Nováčková M, Chmel R. Sexual Life of Women With Mayer-Rokitansky-Küster-Hauser Syndrome After Laparoscopic Vecchietti Vaginoplasty. Sex Med 2017;5:e106–e113.

Creation of a Neovagina by Laparoscopic Modified Vecchietti Technique: Anatomic and Functional Results.

Purpose To evaluate the anatomic and functional results of a laparoscopic modified Vecchietti technique for the creation of a neovagina in patients with congenital vaginal aplasia. Methods Retrospective study of nine patients with congenital vaginal aplasia submitted to the laparoscopic Vecchietti procedure, in our department, between 2006 and 2013. The anatomical results were evaluated by assessing the length, width and epithelialization of the neovagina at the postoperative visits. The functional outcome was evaluated using the Rosen Female Sexual Function Index (FSFI) questionnaire and comparing the patients' results to those of a control group of 20 healthy women. The statistical analysis was performed using SPSS Statistics version 19.0 (IBM, Armonk, NY, USA), Student t-test, Mann-Whitney U test and Fisher exact test. Results The condition underlying the vaginal aplasia was Mayer-Rokitansky-Küster-Hauser syndrome in eight cases, and androgen insensitivity syndrome in one case. The average preoperative vaginal length was 2.9 cm. At surgery, the mean age of the patients was 22.2 years. The surgery was performed successfully in all patients and no intra or postoperative complications were recorded. At the first postoperative visit (6 to 8 weeks after surgery), the mean vaginal length was 8.1 cm. In all cases, the neovagina was epithelialized and had an appropriate width. The mean FSFI total and single domain scores did not differ significantly from those of the control group: 27.5 vs. 30.6 (total); 4.0 vs. 4.2 (desire); 4.4 vs. 5.2 (arousal); 5.2 vs. 5.3 (lubrication); 4.2 vs. 5.0 (orgasm); 5.3 vs. 5.5 (satisfaction) and 4.4 vs. 5.4 (comfort). Conclusions This modified laparoscopic Vecchietti technique is a simple, safe and effective procedure, which allows patients with congenital vaginal aplasia to have a satisfactory sexual activity, comparable to that of normal controls.

Failure of laparoscopic Vecchietti procedure in a woman with androgen insensitivity syndrome

The authors describe a case with androgen insensitivity syndrome (AIS) who underwent the laparoscopic Vecchietti procedure for creation of a neovagina. Postoperatively, the patient achieved anatomic success, with a vaginal length of about eight cm, and she was advised to use vaginal dilators after discharge. The patient reported improved sexual function, but presented about six months later for shortening of her vagina and difficult vaginal intercourse. Physical examination revealed an obliterated vaginal canal about two cm long. Further examination revealed lack of vaginal epithelization. The patient was instructed to continue using vaginal dilators in combination with estrogen cream; however, the patient did not achieve a vaginal length > two cm. The authors believe that the laparoscopic Vecchietti procedure may not be appropriate for women with AIS due to lack of epithelization.

Optimizing the modified laparoscopic Vecchietti procedure

Objective: To enhance the modified laparoscopic Vecchietti procedure. Materials and Methods: A case series of five women with Mayer-Rokitansky-K&#x00FC;ster-Hauser syndrome at the Department of Obstetrics and Gynecology, King Abdulaziz University Hospital, Jeddah, Saudi Arabia underwent the modified laparoscopic Vecchietti procedure with intraperitoneal placement of sutures. This involved perforation of the vaginal dimple by a straight thread guide with two threads attached to the olive followed by pulling the two threads intra-peritoneally and through the abdominal wall to the traction device by grasping instruments under laparoscopic control. Results: Intraperitoneal placement of the sutures was easily done without complications in all five women. The operative time was 50 &#x00B1; 10 (mean &#x00B1; SD) minutes. After five postoperative days, the average vaginal length was seven to 7.5 cm. Two women were able to have vaginal intercourse without problems. After six months to one year of follow up, the vaginal length was at least ten cm and no postoperative complications occurred. Conclusions: Intraperitoneal placement of sutures makes the modified laparoscopic Vecchietti procedure easy and appealing. Furthermore, it avoids potential damage to the vital structures at the pelvic side walls.

Efficacy risks of the minimal-invasive plastic and reconstructive neovagina Vecchietti technique in Mayer-Rokitansky-Küster-Hauser syndrome.

Introduction: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital disorder clinically defined by primary amenorrhea and infertility, congenital aplasia of the uterus and upper vagina. The patients with MRKH-syndrome have a female karyotype (46, XX), normally functioning ovaries and regular development of secondary sexual characters. Generally, the initial clinical sign of the syndrome is the failure to begin the menstrual cycle. Even though the psychological impact of the disease may be overwhelming, its physiological disorder can be successfully treated, after the surgical intervention the patients being able to have a normal sexual function. Reproduction may also be possible with assisted techniques. Objective: The aim of the study was to evaluate the efficacy risks of the traditional laparoscopic Vecchietti method in the plastic and reconstructive treatment of vaginal agenesis, documenting complications, as well as anatomical and functional results by means of a prospective, single center, single arm study. Material and methods: Between 2003 and 2011, 53 patients with MRKH-syndrome were treated in the gynecological clinic of the Kochi’s Lakshmi Hospital, Kerala, India. All the patients suffered from primary amenorrhea and the karyotype was (46, XX). The clinical suspicion was confirmed sonographically and intraoperatively, showing an absent uterus or the presence of rudimentary uterine horns, with normal ovaries. All the patients received a plastic laparoscopic neovagina construction, in order to achieve a satisfactory sexual function. We adopted a combined strategy: the patients were prepared by a psychological counselling, followed by the surgical intervention and a postoperative follow-up. The surgical procedure used in this series was a laparoscopic modified Vecchietti’s technique. All the patients were dismissed with the obligation to have intercourse and/or vaginal dilation 3 times a week for 6 months. Results: The patients’ ages varied between 13 and 40 years, with a mean age of 25 years. The mean operation time was 42.3 minutes, with a range between 36 and 63 minutes. In 2 cases, an intraoperative bladder injury occurred. A good qualitative vaginal tissue was clinically achieved in all the patients. The mean follow up period of the patients was 4 years ranging from 1 to 5 years. The anatomic success was observed in 94% of the cases and functional success in 79%. Conclusion: The anatomical failures in 6% were in women not having regular intercourse or not performing vaginal dilatation postoperatively. The psychological impact of the disease in combination with the performed surgery seems responsible for the difference of 15% of the cases where the anatomical result was good, but no regular intercourse could be achieved. The minimal-invasive plastic and reconstructive neovagina Vecchietti technique in MRKH-syndrome has a high success rate. In case of an intraoperative urinary bladder injury, the repair can be performed laparoscopically during the same session. Qualitatively good vaginal tissue and anatomical reconstruction can easily be achieved. In one patient desiring assisted reproductive medicine, a transvaginal oocyte retrieval was achieved.

Psychosexual and social consequences in a woman with undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome

Purpose: To report a woman with devastating psychosexual and social consequences as a result of undiagnosed Mayer-Rokitansky- K&#x00FC;ster-Hauser syndrome (MRKH) syndrome. Materials and Methods: An 18-year-old woman was referred after being divorced for “absent vagina and uterus”. On examination, secondary sexual characteristics were normal. Vaginal and rectal examinations revealed absent vagina and uterus. Investigations showed normal hormonal profile, 46 XX karyotype, and normal intravenous pyelography. Pelvic ultrasonography and magnetic resonance imaging (MRI) confirmed the absence of the uterus and presence bilateral ovaries. Results: A diagnosis of MRKH syndrome was made and she underwent successful modified laparoscopic Vecchietti operation for creation of a new vagina. Vaginal dilators were used after the surgery. Two years of follow up confirmed that vaginal length was about ten cm. Conclusion: The proper diagnosis, counseling, and prompt treatment of MRKH syndrome can prevent tragic consequences.

An update on surgical and non-surgical treatments for vaginal hypoplasia.

In women with vaginal hypoplasia, such as in Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) and in Complete Androgen Insensitivity Syndrome (CAIS), surgical vaginoplasty and non-surgical self-dilation treatments are available to lengthen the vagina and facilitate sexual intercourse, but the best treatment remains controversial. Vaginal dilation has been recommended as a first-line treatment, because of its less invasive character and high success rate. However, the exploration of factors associated with compliance and long-term outcome is incomplete, including whether psychological counselling needs to be embedded in treatment to maximize efficacy. It is not known if failed vaginal dilation therapy jeopardizes further surgical success outcomes, especially because in a number of these procedures ongoing vaginal dilation is required. In addition, if surgery is needed, there is a lack of evidence to inform physicians regarding the optimum surgical technique to use. Also, it is unclear whether maintenance dilation therapy in case of sexual inactivity is crucial to ensure functional success. In view of this ongoing debate, we performed a search of all published literature (English language only) restricted to the management of vaginal hypoplasia in patients with MRKH or CAIS from 1898 to March 2013 using Pubmed, Cochrane Library and Web of Science. Of the 6700 articles initially identified, a total of 190 studies are analysed. More specifically, by establishing the risk/efficacy profile (vaginal capacity, complications and long-term durability in terms of sexual function) of the different surgical and non-surgical reconstruction techniques, we evaluate if vaginal dilation proposed as the first-line technique is justified based on the evidence. When anatomical success was defined as a length of ≥7 cm and functional success as coitus, all vaginoplasty techniques yielded significantly higher success rates (>90 versus 75% after vaginal dilation), irrespective of underlying diagnosis or start vaginal length. When functional success was defined as 'satisfaction with sex', including non-genital sex, differences disappeared. Failed dilation therapy does not preclude anatomical (nor functional) success if vaginoplasty afterwards is necessary. Traction vaginoplasty seems to have the highest anatomical (99%) and functional success rates (96%), whereas both split- and full-thickness skin graft procedures and intestinal procedures have the lowest successful outcomes (83-95%). Overall, complication rates were significantly lower within the vaginal dilation groups when compared with the different vaginoplasty techniques. Although no randomized control data exist regarding maintenance dilation, the available evidence suggests that continued dilation is needed to maintain patency in periods of coital inactivity. Despite the expectancy that the probability of further positive outcomes is maximized with psychological counselling, this could not be confirmed. As the medical literature lacks high-quality comparative outcome studies and prospective, longitudinal studies are scarce, no evidence-based treatment guidelines can be provided. However, because of the physically low complication rate and an overall success chance of 75%, vaginal dilation as first choice treatment seems to be justified. Overall, the laparoscopic Vecchietti procedure, becoming more and more available in specialized centres, is considered an appropriate surgical option in patients who are poorly compliant and failed dilation therapy, or for those who do not want to start with vaginal dilation therapy. Future approaches need to raise a wider range of psychosexually oriented questions, elucidate the relationship between vaginal depth and satisfactory outcomes and gain additional experience concerning the format of acceptable and efficient psychological care.

The rectovaginal septum: visible on magnetic resonance images of women with Mayer-Rokitansky-Küster-Hauser syndrome (Müllerian agenesis)

Ongoing debate exists about whether the rectovaginal septum (Denonvilliers' fascia) is myth or reality. This study evaluates magnetic resonance images (MRI) of women with Müllerian agenesis for the presence of fascial layers between the rectum and the bladder to test the hypothesis that this layer exists in the absence of the vagina. This is a secondary analysis of a study describing MRI aspects in women with vaginal agenesis before and after laparoscopic Vecchietti procedure. Study participants (n =16) had a multiplanar pelvic MR scan. Images were evaluated independently by two investigators (MH, JOLD) for the appearance of layers separate from the bladder and rectum in the area of interest, with characteristic anatomical features of the septum. Participants' mean age was 19.4±2.6 years ± standard deviation (SD). In 12 of 16 patients (75 %) a distinct layer between rectum and bladder was identified in either the axial(4/16; 25 %) or sagittal (12/16; 75 %) scan or both. Characteristic anatomical features included lateral attachment to the levator ani muscle, cranial fusion to the cul-de-sac peritoneum,and caudal insertion into the perineal body.Conclusions Three quarters of women with Müllerian agenesis have a visible layer between bladder and rectum. As none of the participants had a vagina, these results support the existence of a rectovaginal septum, separate from a vaginal adventitia.

Mayo Clinic Experience With Modified Vecchietti Procedure for Vaginal Agenesis: It is Easy, Safe, and Effective

ObjectiveTo evaluate the surgical outcome and the anatomic and sexual function in 10 women with Rokitansky syndrome who underwent the laparoscopic Vecchietti procedure at our center. DesignRetrospective analysis. MethodsData were analyzed on the basis of short-term and long-term surgical outcome and sexual function. All patients underwent clinical follow-up at 1, 2, and 6 months after surgery. Measurements and Main ResultsIn all 10 patients, the procedure produced anatomic and functional success. ConclusionThe laparoscopic Vecchietti technique is safe, simple, and effective for treatment of vaginal agenesis. Results are comparable to those of all European studies, and the procedure should gain more popularity in North America.

Lower urinary tract symptoms in women with vaginal agenesis

Congenital vaginal aplasia is a condition with devastating implications for fertility and sexuality. However, little is known on whether urinary symptomatology is more common prior and following vaginal lengthening procedures in these women. We performed a prospective observational study of 19 women with vaginal agenesis before and after vaginal dilation treatment or a laparoscopic Vecchietti procedure. All women completed the ICIQ FLUTS questionnaire before and after treatment in order to assess incidence and changes in urinary symptomatology. Urinary symptoms were present in 53% of women prior to treatment. The majority of bladder symptoms were not significantly altered by treatment, except for incomplete bladder emptying. Women following the Vecchietti procedure had increased urinary hesitancy and a poorer steam compared with those completing dilation treatment. The longer the vaginal length, the greater the urinary frequency. Women with vaginal agenesis had significant levels of urinary symptoms and to our knowledge this has not been reported before. The majority of symptoms were not altered by treatment.

Sexual Function after Modified Laparoscopic Vecchietti’s Vaginoplasty

Study Objective To report on minor modification of laparoscopic Vecchietti vaginoplasty and to examine the quality of sexual life after the operation. Design A retrospective study to examine the role of minor modification during laparoscopic Vecchietti operation to prevent injuries and to evaluate the sexual function of patients with neovagina. Setting Department of Obstetrics and Gynecology, University of Pécs, Faculty of Medicine, a tertiary supply center in Hungary. Paticipants Twenty-three adolescents or young adults, ages 16 to 26 with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) were operated. Twenty-five sexually active patients with matched age served as controls. Interventions Laparoscopic Vecchietti operation was modified with the use of endovaginal ultrasound transducer to visualize the narrow vesico-rectal space. The quality of sexual life 2–11 years after the operation was measured by the Female Sexual Function Index (FSFI). Main Outcome Measures Complications occurring during operations; desire, arousal, orgasm, satisfaction, lubrication, and pain during sexual intercourse. Results The technical modification of the operation, with endovaginal transducer, improved the method. Serious injuries of the bladder or rectum could be avoided. Anatomic and functional results shown by the total FSFI scores did not differ from that of the control group. Desire, arousal, orgasm, and satisfaction of the operated patients were similar to controls; however, patients with neovagina tended to have less lubrication and more pain during sexual intercourse. Conclusions Laparoscopic Vecchietti operation modified by the use of endovaginal transducer is a safe procedure to create a neovagina, which guarantees good quality of sexual life with high satisfaction for patients.