McIndoe Procedure Research Articles

McIndoe procedure for vaginal agenesis: Long-term outcome and effect on quality of life

Objective The purpose of this study was to evaluate quality of life, sexual function, and long-term outcome in women after undergoing the McIndoe procedure for vaginal agenesis. Study design This was a retrospective descriptive study of patients who were treated with the McIndoe procedure for vaginal agenesis. Participants answered a structured questionnaire to describe self-reported outcomes in quality of life, sexual function and satisfaction, and body image after the McIndoe procedure. Patient characteristics along with short- and long-term findings were abstracted from the medical record. Results Eighty-six patients responded to the questionnaire. Average age (±SD) at surgery was 21±6 years (range, 12-49 years). The mean number of years (±SD) since surgery was 23±12 (range, 2-50 years). Seventy-nine percent of the respondents stated that the McIndoe procedure improved their quality of life. Ninety-one percent of the respondents were sexually active, with 75% able to achieve orgasm. Reported self-image was improved in 55% of the women. Conclusion The McIndoe procedure improves quality of life and sexual satisfaction and provides a functional vagina with minimal complications.

Comparison of Three Surgical Procedures for Colpopoiesis in Patients with Mayer–Rokitansky–Küster–Hauser Syndrome

Mayer–Rokitansky–Kuster–Hauser (M–R–K–H) syndrome is a rare congenital anomaly of the female genital tract. A number of techniques have been described for the formation of a neovagina, however, a standardized treatment does not yet exist. To evaluate three surgical procedures for colpopoiesis in patients with M–R–K–H syndrome, we design a retrospective study based on record of clinical data in our university hospital. Eighteen patients with M–R–K–H syndrome were performed colpopoiesis by Ruge's, McIndoe's, and laparoscopically assisted Davydov's procedures. We compare with three surgical procedures in terms of operative success rate, operation time, total bleeding loss during operation, perioperative complication rate, and long-term complications. The postoperative vaginal depth showed no significant difference among the three procedures. Operation success rate was 50.0% in Ruge's procedure, 88.9% in McIndoe's procedure, and 100% in laparoscopically assisted Davydov's procedure. The duration of McIndoe's ...

Neovaginal reconstruction with the modified McIndoe technique: a review of 32 cases.

The authors reviewed 32 patients who underwent vaginal reconstruction using a modified McIndoe procedure during the past 15 years. This technique consists of the application of split-thickness skin grafts into a new cavity created between the rectum, bladder, and urethra. The grafts are placed previously on a mold of Optosil, which is a silicon-based condensation curing impression material used by dentists. The mold is kept for 3 months 24 hours each day. During the next 3 to 4 weeks it is applied 12 hours per day. Later, according to sexual activity, the mold can be removed completely. In case of no sexual activity it should be used 1 hour per week. Parameters assessed during the follow-up were mold management, grade of pseudomucinous metaplasia of the skin grafts, sensation of the neovagina, neovagina size changes, sexual satisfaction, and complications. Postoperative complications included partial take of skin grafts (N = 3), postoperative anxiety (N = 2), donor site cheloids (N = 1), and neovaginal stricture in 3 patients who used the mold for 1 month only without having any further sexual activity. Patients who managed the mold correctly or who had constant sexual activity obtained satisfactory dimensions of the neovagina in terms of length, diameter, and elasticity.

Vaginal vault prolapse after nonsurgical and surgical treatment of MÄAdullerian agenesis

BACKGROUND: Women with Mayer-Rokitansky-Küster-Hauser syndrome fail to develop müllerian ducts, present with primary amenorrhea, and an absent or rudimentary uterus and vagina. After creation of a neovagina, vaginal vault prolapse may occur because of lack of support to the artificially created vagina. CASES: The first patient presented with vaginal vault prolapse 10 years after her vagina was mechanically dilated. The second patient presented with vaginal vault prolapse 27 years after a McIndoe procedure. CONCLUSION: Women with Mayer-Rokitansky-Küster-Hauser syndrome with an artificially created neovagina by dilatation or surgical procedure with a graft are at risk for vaginal vault prolapse. They can be successfully treated with abdominal sacrocolpopexy and paravaginal repair.

Vaginal creation for müllerian agenesis

Objective: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with müllerian agenesis. Study Design: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. Results: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1 ± 7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5 ± 9.5 and 65.3 ± 18.5 months, respectively (P <.005). The mean time to successful dilation was 11.8 ± 1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5 ± 12.5 months; range, 8-33 months). Conclusion: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.(Am J Obstet Gynecol 2001;185:1349-53.)

Reconstrucción vaginal mediante la técnica de McIndoe

ObjectiveWe analyze our experience with the use of the McIndoe procedure Subjects and MethodsVaginal agenesis has an incidence of 1/5,000 female newborns. Hereby, we analyze our experience with the use of the McIndoe procedure, in 25 cases done in our institution, during a 17 year period. We analyze the diagnostic techniques used, the patient complaints, the surgical procedure and its short and long term complications, and the evolution of these 25 patients ResultsThe most of patients (99%) have satisfactory sexual relationships. We think that the McIndoe procedure is the election technique for its simplicity and good outcome

Neovagina with cultured allogenic epidermal sheets

Several materials have been used in neovagina construction, but most of them show some kind of drawback. This is the report of a case in which cultured allogenic epidermal sheets were used instead of skin grafting for a McIndoe procedure.

Agenesis of the vagina

In the last 10 years we treated ten patients with the diagnosis of vaginal agenesia. The reconstruction was performed according to the McIndoe procedure. The medical records of these patients were retrospectively reviewed in what concerns the diagnosis (Mayer-Rokitansky S.-7, Androgenital S.-1, Testicular feminization S.-1), classification, treatment, complications, and outcome. It is the authors' opinion that the McIndoe method is the most appropriate for the treatment of vaginal agenesia, because of its simplicity, low morbidity and absence of mortality.

Sigmoid colon vaginoplasty: a modified method.

To assess the technical feasibility and functional results of sigmoid colon vaginoplasty using a modified technique. Retrospective descriptive analysis. Referral centre. A method for creating an artificial vagina was applied in 13 women for the following indications: true hermaphrodite (n = 1), gender dysphoria (n = 2), Müllerian dysgenesis (n = 10). A method for sigmoid vaginoplasty was devised whereby transection of the inferior mesenteric artery proximal to the first sigmoid branch provides immediate mobility for the sigmoid colonic segment to reach the introitus (with adequate nourishment from the middle and inferior rectal vascular systems). Assessment of sexual function after a follow up period of 1 to 19 years. Twelve women reported a satisfactory result. Three of these were lost to follow up after one year, and the others report for regular assessment. Mild stenosis at the muco-cutaneous anastomosis, which may occur after failed perineal procedures, appears to be amenable to daily dilatations until the women become sexually active. In one woman the prosthesis had to be removed on account of severe pelvic floor fibrosis as a result of previous abdomino-perineal surgery at the age of seven. Another woman presented with a postcoital vesico-vaginal fistula after a previous McIndoe procedure; the tear at the base of the bladder was repaired and buttressed with a sigmoid vagina which is now functioning satisfactorily after 19 years. The creation of a sigmoid vagina which is vascularised by the middle and inferior rectal arterial systems appears to be an acceptable procedure for vaginal agenesis, acquired vaginal loss or sexual reassignment.

Congenital absence of the vagina — results of conservative treatment

To assess the efficacy of a combination of Frank's mold therapy with intercourse as a treatment for congenital vaginal aplasia. From 1973–1993, thirty-three patients with congenital aplasia of vagina and uterus were seen by one gynecologist. Patients with a partner were instructed how to create a functional vagina by a modified form of coitus (‘interfemoral intercourse’). Mold therapy (using modified molds) was used as a primary treatment when patients had no partner (n = 9) or added to the treatment of nine patients in whom interfemoral intercourse alone had failed. In case of failure of conservative treatment, the surgical creation of a neovagina (McIndoe procedure) was offered. Conservative therapy in patients with a stable sexual relationship (n = 24) gave significantly better (p = 0.0104) results than when patients were single. In the former, a vaginal depth of > 8 cm was reached within six months at most with intercourse alone and four months if combined with mold therapy. With molds alone, 3 out of 9 obtained a satisfactory vagina. Treatment failures occurred (with one exception) only in patients who had no or unstable sexual relationships. Intercourse as a treatment of vaginal atresia can be very successful, especially if practised together with modified mold therapy. A stable sexual relationship — implying a healthy self-concept — appears to be an important determinant of treatment outcome.

McIndoe procedure for congenital vaginal agenesis : complications and results

In the period 1972–1992, 26 women had surgery for congenital vaginal agenesis, with a modified McIndoe's technique, in Aarhus University Hospital. Their medical records were reviewed and 23 of the patients were evaluated clinically. Complications comprised lack of skin graft take, bleeding, urethrovaginal fistula, perforation of the rectum, rectovaginal fistula and vaginal stricture. All complications were treated and the final results were satisfactory, i.e. complete graft take, satisfactory dimensions of the vagina and no strictures or fistulas giving symptoms. Of 23 patients reviewed, 18 reported satisfactory sexual relationships and vaginal intercourse was anatomically possible in a further 3 patients. We conclude that the McIndoe procedure is simple and, though the course of treatment is often protracted, serious complications are few and the final results are good.

Bicornuate nonfused rudimentary uterine horns with functioning endometria and complete cervical-vaginal agenesis: magnetic resonance diagnosis

A case is reported of a 16-year-old adolescent with cryptomenorrhea. The patient had a congenital anomaly of a bicornuate, nonfused, separate rudimentary blind uterine horns with functioning endometria, and complete cervical-vaginal agenesis. Ultrasound, laparoscopy, and minilaparotomy for unilateral salpingectomy failed to accurately identify the exact classification of the anomaly. Magnetic resonance imaging, however, accurately correlated with operative findings of exploratory laparotomy and McIndoe procedure.

Intestinal vaginoplasty for congenital absence of the vagina

Congenital absence of the vagina is rare and occurs as a result of aplasia of the Müllerian ducts (46,XX) or complete androgen insensitivity syndrome (AIS—46,XY). Both syndromes are associated with normal female external genitalia and these patients are raised as females. These children are usually treated during adolescence with chronic dilatation of the shallow vaginal introitus (pressure tube technique) or by skin graft vaginoplasty (Mcindoe procedure). Neither of these procedures is entirely satisfactory, as both may lead to neovaginal stenosis, inadequate length, poor lubrication, or all three. We have recently modified the operation first described by Baldwin in which a loop of sigmoid colon or small bowel is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and anastomosed to the hymenal ring. We have performed this operation on four adolescents (mean age, 15 years) and two infants (aged 4 days and 14 months) with excellent results (mean follow-up, 7.5 years for the adolescents and 1.8 years for the infants). The advantages of a bowel segment in contrast to a skin graft are: (1) minimal likelihood of “poor take” or later contraction because a vascularized epithelial-lined tube is used; (2) patency and depth can be maintained without a mold and with minimal dilatation; (3) spontaneous mucus production matches that of the normal vagina and facilitates sexual intercourse; (4) dysparenunia frequently seen with skin grafts is avoided by the ability of the intestinal segment to withstand local trauma; and (5) the use of an intestinal segment offers the option of performing a bowel interposition vaginoplasty during infancy at the time of surgical correction of more complex associated caudal anomalies. The sigmoid colon is the best choice for interposition vaginoplasty because of size, location, and ease of preserving blood supply.

Urinary Calculi: ESWL, Endourology, and Medical Therapy

The presentation of the material could have been better organized. The text begins with an appropriate review ofthe pelvic anatomy (one of the outstanding chapters in the book), followed by a chapter on reduction of maternal injuries associated with childbirth. The next few chapters discuss appropriate selection of operative procedures. The eighth chapter reviews instruments and sutures, and the ninth is devoted to minor ambulatory operations. These last two chapters should be located either at the beginning or at the end of the text, rather than in the middle of the material on basic vaginal procedures. Similarly, the chapters on urinary incontinence belong in the same section as those on diverticulum and fistula formation of the urinary tract, and the chapters devoted to lacerations of the perineum should be grouped with those that address rectovaginal fistula and retrorectal levatorplasty. The chapter that reviews operations for stress incontinence is incomplete, and only 4 of the 44 references were published during the past 10 years. In contrast, the chapter on vaginal hysterectomy is outstanding, including excellent illustrations and numerous points that reflect the vast experience of the authors. Alternative means of morcellating a large uterus are well illustrated, and a thorough discussion of appropriate reconstruction of the pelvis is presented. Dr. Nichols is known worldwide for his revival of the technique of sacrospinous ligament fixation for massive inversion of the vagina. The color illustrations of this procedure clearly demonstrate the placement of this suture within the ligament. The authors emphasize practical points that will help ensure excellent results and minimize potential complications. The chapters devoted to urethral diverticuIurn and vesicovaginal and rectovaginal fistulas are well illustrated and informative. The section on creation of a neovagina is thorough, but the McIndoe procedure is inadequately illustrated and incompletely reviewed. The bibliographies in these chapters are incomplete. In general, this is a well-written, easy to read text. Because it covers areas that are often poorly understood by clinicians, I recommend it Mayo Cltn Proc, June 1990, Vol 65

Androgen-Insensitivity Syndrome: Long-Term Results of Surgical Vaginal Creation

ABSTRACT The McIndoe split thickness graft technique for vaginal creation has been used successfully in women with congenital absence of the vagina, including patients with androgen-insensitivity syndrome (AIS) and mullerian agenesis (MA). Endocrbiologically, adult AIS patients differ from women with MA in having undergone a gonadectomy at or before their vaginoplasty, requiring estrogen replacement and being resistant to androgens. The long-term result of the McIndoe procedure in 14 AIS patients, operated on between 1958 and 1976 at the Johns Hopkins Hospital, was retrospectively determined. The average age at surgery was 19.7 years, with an average follow-up time of 10.2 years. Preoperative vaginal depth averaged 2.6 cm and measured between 10 and 12 cm postoperatively. Vaginal graft take was excellent in all patients. Nevertheless, only 10/14 (72%) had fully satisfactory intercourse postoperatively, 3/14 (21%) had a partial success, complaining of mild to moderate discomfort, and 1 (7%) had severe dysp...

McIndoe Procedure for Vaginal Agenesis: Results and Complications

During the 10-year interval from 1976 through 1985, 50 patients with congenital absence of the vagina underwent McIndoe vaginoplasty at our institution. The medical records of these patients were retrospectively reviewed, and additional information was obtained through a survey of the patients. The mean duration of follow-up was 6.5 years. Two rectovaginal fistulas and one graft failure were among the complications that occurred. Five patients required additional reconstructive vaginal operations. Operative vaginoplasty was considered functionally successful by 40 of the 47 patients (85%) who responded to the survey, yet only 36 of these 40 (90%) had remained coitally active by the time of the survey. Recognizing the potential for complications, the need for long-term follow-up and care of the neovagina, and the less-than-perfect results achieved, we continue to consider the McIndoe operation as the procedure of choice for most patients with vaginal agenesis.

The fate of the split thickness skin graft in neovaginas. A pathologic study of 21 cases and a review of the literature.

Twenty-one cases of congenital absence of the vagina corrected by McIndoe's procedure were examined. The longest follow-up was 21 years (average 10.5 years). Vaginal biopsies showed a spectrum of changes, ranging from an almost normal vaginal mucous membrane to a skin-like mucous membrane. Neither hormonal status nor postoperative complication, nor the time the graft had been in place, correlated to histology, and we suggest that the varied appearance of the graft epithelium depends on the amount of corium included in the transplant.

Skin-muscle flap lower lid blepharoplasty: an easier dissection.

Most descriptions of the skin-muscle flap lower lid blepharoplasty, the so-called McIndoe technique, indicate dissection of the flap in a cephalad-to-caudad direction from near the ciliary margin toward the bony orbital rim. However, this report describes a technical variation in which counter-traction and lateral-to-medial blunt dissection "opens up" the potential anatomical space between the orbicularis oculi muscle and the tarsus and septum orbitale. This technique is easier and faster than the McIndoe procedure.

Surgery for congenital absence of the vagina.

The Counsellor modification of McIndoe's procedure was used to create a vagina in 12 of 15 patients who presented with Rokitansky-Kuster-Hauser syndrome. Eighty percent of these patients, followed postoperatively from 4 months to 8 years, report satisfactory coital function. Our experience suggests that a malleable stent fashioned to conform to the surgically created neovagina is superior to a preformed, nonmoldable stent to which the endopelvic fascial dissection must conform.

Congenital absence of the vagina: Observations on 25 cases

Twenty-five cases of congenital absence of the vagina have been reviewed. The clinical syndromes encountered include simple absence of the vagina, male pseudohermaphroditism., and Rokitansky-Küster-Hauser synrdrome. Complete physical and laparotomy data are detailed in 14 cases. The surgical procedures and their results are evaluated in 19 cases. The McIndoe procedure and its modification by Counseller are the procedures of choice in vaginal reconstruction. Laparotomy should be a routine procedure prior to vaginal reconstruction.