Native Vagina Research Articles

Reproductive and Family Building Considerations for Female Patients with Anorectal And Urogenital Malformations

BackgroundLittle is known about fertility and pregnancy outcomes in patients with anorectal malformations (ARM), particularly those with long common channel cloaca and cloacal exstrophy who may have impaired fertility. The purpose of this study is to describe pregnancy and offspring data from a cohort of patients with ARM. MethodsA retrospective review of female patients with ARM from our database, which includes patients operated on since 1980, was performed as well as a review of the literature. Demographic, operative, and self-reported fertility, obstetric, and offspring data were collected. ResultsThere were 37 females identified in our database who reported any pregnancy or having children. There were 59 pregnancies, 48 (81.3%) of which resulted in live birth. The most common mode of delivery was cesarean delivery. There were five patients with long channel cloaca (>3 cm) and one with cloacal exstrophy that reported 11 total pregnancies, eight of which resulted in live birth. Four cloaca patients in which the native vagina was pulled through were able to conceive spontaneously. Three patients with cloacal anomalies required in vitro fertilization to conceive; one was unsuccessful. No patients who underwent bowel partial vaginal replacement became pregnant. Women with ARM face many unique challenges in assisted reproduction, pregnancy, and delivery owing to their anatomy and associated anomalies. ConclusionsWomen with recto-perineal, recto-vestibular, and cloacas in which the native vagina was pulled through are capable of spontaneous pregnancy. Assisted reproduction, however, may be needed those with more complex anomalies and surgical repairs. Level of evidenceIV.

Intravaginal Mesalamine Administration: A Novel Technique for Neovaginal Diversion Colitis

Background: Vaginoplasty utilizing sigmoid colon has the advantage of spontaneous mucus production similar to a native vagina and appropriate vaginal length. Neovaginal diverting colitis, a potential side effect of sigmoid vaginoplasty, is an inflammatory process that affects the colonic tissue. Patients may present with vaginal pain, postcoital bleeding, vaginal spotting, and dyspareunia. Treatment for neovaginal diversion colitis includes a combination of intravaginal application mesalamine foam and sodium butyrate enemas.

Genital surgical procedures for feminization in gender dysphoria

The necessity and the benefits of genital approximating surgery in gender dysphoria are established, therefore the indications after careful diagnostics are indisputable. For vaginoplasty, the method of choice is penile inversion, in which the penile skin is inserted as a pedicled flap into the prepared vaginal space. Alternatively, free skin grafts or intestinal segments can be used. Lifelong bougienage of the vagina is obligatory for all methods. The spectrum of complications after vaginoplasty is broad. Of particular note, although rare, is injury to the anterior rectal wall, from which rectovaginal fistulas can result. During the course strictures of the urinary meatus or also the neovagina occur. Corrections must often be surgically undertaken but conservative measures, e.g. intensified bougienage and topical estrogen treatment, can also be successful. Neovaginal infections are treated analogously to infections of a native vagina. A special situation is inflammation of the intestinal neovagina, which must be treated with mesalazine.

Sensibility, Sensation, and Nerve Regeneration after Reconstructive Genital Surgery: Evolving Concepts in Neurobiology.

Sensory recovery following phalloplasty and vaginoplasty for gender dysphoria is essential to the overall success of gender-confirming surgery. Anecdotal evidence suggests that superior reinnervation results are seen in genitoplasty compared to other peripheral nerve repair scenarios. Despite these observed differences, the quality of available literature is poor. The authors reviewed the body of English language literature regarding sensory outcomes following genitoplasty for gender confirmation. The available body of literature discussing the basic science and clinical science aspects of sensory recovery following gender-confirming genitoplasty is small. Available data show that sensory recovery following vaginoplasty produces high rates of reported orgasmic ability, largely through the neoclitoris, and a neovagina with vibratory and pressure sensation similar to that of the native vagina. Phalloplasty sensory outcomes are variable, with the largest series reporting return of sensation in the neophallus that is slightly less than what is measured in control men. Erogenous sensation, including the ability to orgasm, is present in nearly all patients after several months. Existing series indicate that genitoplasty patients experience faster and more complete recovery than any other peripheral nerve regeneration scenarios. However, there are many potential confounding factors in assessment and reporting, and more consistent and reproducible measure endpoints measures are needed. Further research is needed to better understand both the basic science and clinical science of peripheral nerve regeneration in genitoplasty, which may change fundamental aspects of current paradigms of peripheral nerve regeneration.

Gynecologic outflow tract obstruction - Pre-operative evaluation and surgical management

Abstract Background Approximately 7% of adolescent girls have reproductive tract anomalies. Anomalies associated with complete outflow track obstruction present with primary amenorrhea and cyclic abdominal pain. Some outflow tract obstructions may be associated with renal, anorectal, vertebral, cardiac, tracheoesophageal, and limb anomalies. Outflow tract obstructions may occur at varying anatomic locations – vaginal, cervical, or uterine, each requiring different surgical management. Methods We present the preoperative evaluation and surgical management of three different gynecologic outflow tract obstructions. Results Physical exam, ultrasound, and MRI were obtained for each patient. The first obstruction was a transverse vaginal septum, which was treated with transperineal resection to allow menstrual egress. The second obstruction was identified as distal vaginal atresia and managed with operative pull-through of her native vagina. The third obstruction was found to be cervico-vaginal atresia and required hysterectomy and salpingectomy with preservation of the ovaries. Conclusions Preoperative examination of the perineum and imaging with accurate interpretation is crucial to identify subtle but important distinctions in diagnosis, which can result in markedly different interventions ranging from transperineal resection of a transverse vaginal septum, vaginal pull-through procedure, to hysterectomy. The location of the gynecologic outflow obstruction dictates the proper surgical treatment of these patients.

Novel three-dimensional autologous tissue-engineered vaginal tissues using the self-assembly technique

Many diseases necessitate the substitution of vaginal tissues. Current replacement therapies are associated with many complications. In this study, we aimed to create bioengineered neovaginas with the self-assembly technique using autologous vaginal epithelial (VE) and vaginal stromal (VS) cells without the use of exogenous materials and to document the survival and incorporation of these grafts into the tissues of nude female mice. Epithelial and stromal cells were isolated from vaginal biopsies. Stromal cells were driven to form collagen sheets, 3 of which were superimposed to form vaginal stromas. VE cells were seeded on top of these stromas and allowed to mature in an air-liquid interface. The vaginal equivalents were implanted subcutaneously in female nude mice, which were sacrificed after 1 and 2weeks after surgery. The invitro and animal-retrieved equivalents were assessed using histologic, functional, and mechanical evaluations. Vaginal equivalents could be handled easily. VE cells formed a well-differentiated epithelial layer with a continuous basement membrane. The equivalent matrix was composed of collagen I and III and elastin. The epithelium, basement membrane, and stroma were comparable to those of native vaginal tissues. The implanted equivalents formed mature vaginal epithelium and matrix that were integrated into the mice tissues. Using the self-assembly technique, invitro vaginal tissues were created with manyfunctional and biological similarities to native vagina without any foreignmaterial. They formed functional vaginal tissues after invivo animal implantation. Itis appropriate for vaginal substitution and disease modeling for infectious studies,vaginal applicants, and drug testing.

Bone marrow mesenchymal stem cells could acquire the phenotypes of epithelial cells and accelerate vaginal reconstruction combined with small intestinal submucosa.

Grafting material for vaginal reconstruction commonly includes the bowel, peritoneum, skin, and amniotic membrane. Bone marrow mesenchymal stem cells (MSCs) have the potential of multilineage differentiation into a variety of cells and have been widely explored in tissue engineering. In the current study, we examined whether MSCs could be differentiated to vaginal epithelial cells (VECs) upon co-culturing with VECs. We also examined whether Wnt/β-catenin signaling pathway is implicated in such differentiation. Co-culture of MSCs with VECs using a transwell insert system (with no direct contact) induced the expression of VECs marker AE1/AE3 in MSCs. MSCs combined with small intestinal submucosa (SIS) scaffold were implanted in place of the native vagina in rats to observe the implications for vaginal reconstruction in vivo. Anatomic repair of neovagina was assessed by histological staining for H/E and Masson's Trichrome. GSK-3β and β-catenin, main members of Wnt/β-catenin signaling pathway, in MSCs were increased upon co-culturing with VECs. Exposure of co-cultured MSCs to a Wnt/β-catenin signaling activator, lithium chloride (LiCl, 20 µM) increased phosphorylated GSK-3β and β-catenin and enhanced expression of AE1/AE3. In vivo-grafted cells displayed significant matrix infiltration and expressed epithelial markers in neovagina. These findings suggest that MSCs could acquire the phenotype of VECs when co-cultured with VECs, possibly via activation of Wnt/β-catenin signaling. MSCs provide an alternative cell source for potential use in vaginal tissue engineering.

Vaginal Reconstruction in Female Cloacal Exstrophy Patients

To present our experience of vaginal reconstruction in female cloacal exstrophy patients. The records of 7 postpubertal female cloacal exstrophy patients (median age, 17 years; range, 11-26 years) were retrospectively reviewed. Complete duplication of the uterus and vagina was noted in all patients. All of them underwent various types of vaginoplasty at the time of urinary tract reconstruction. When a pull-through vaginoplasty was difficult, the native vagina was anastomosed to the neovagina using the large or small bowel. Alternatively, the native bladder remaining connected to the vagina was used as a neovagina with simultaneous construction of the gastroileal composite reservoir. The median age at vaginoplasty was 6 years (range, 5-8 years). The techniques were pull-through vaginoplasty in 1 patient, intestinal vaginoplasty in 2 patients, and vaginoplasty using the native bladder in 4 patients. Five patients required revision surgery for hematometrocolpos after the onset of puberty (median age, 14 years; range, 11-16 years). Three patients underwent an end-to-side reanastomosis of the uterus to the neovagina using the bowel or the native bladder, whereas 2 patients received a side-to-side anastomosis of the uterus to the neovagina using the native bladder. No patient developed recurrence of hematometrocolpos after the revision surgery, with a mean follow-up of 71 months. Our recent approach to vaginoplasty can be an alternative for female cloacal exstrophy patients. A side-to-side anastomosis of the uterus to the neovagina is a technically easy procedure in surgical management of hematometrocolpos.

Experimental study on vagina reconstruction with tissue-engineering biological material.

To investigate the effect of vagina reconstruction using tissue-engineering biological material (acellular dermal matrix) in an animal model. Vagina excision and vagina reconstruction with tissue-engineering biological material were performed in 12 Chinese experimental miniature pigs. The control group was matched with two of normal vagina specimens resected. At week 1, 2, 4, 6, 8, 12 after surgery, the animals were sacrificed, respectively, and the neovaginas were prepared for immunohistochemical and Van Gieson (VG) staining to evaluate the status of various layer growth of vagina. Epithelial broad spectrum of monoclonal antibodies of AE1/AE3 and alpha-actin were used to test the existence of epithelial and smooth muscle tissue by immunohistochemical staining. The ultrastructure of neovagina was studied by transmission electron microscope at week 1 and 12 after surgery. Contractile function of isolated smooth muscle of neovagina was evaluated by chemical and electronic stimulation after 12 weeks' reconstruction. (1) Epithelization of 2/3 neovaginal mucosa was observed within 1 week. Only 1 - 2 layer epitheliums were observed under the light microscopy and epithelial cells with characteristics of loose and disarrangement were shown with the electron microscopy. Within 4 - 6 weeks, epithelization in mucosa of neovaginal canal was intensified to 4 - 5 layers. After 12 weeks, the differences between the neovagina and the native vagina were harldy noted either in the gross or microscopically. (2) After 4 weeks, a few smooth muscle cells were observed with VG and immunohistochemical staining, and homogeneous muscle bundle was formed. (3) After 12 weeks, similar contractile responses between neovagina and native vagina were observed when KCl and electrical stimulation with different frequency and voltage were given [(2.96 +/- 0.29) g vs. (3.14 +/- 0.30) g, (3.43 +/- 0.34) g vs. (4.65 +/- 0.73) g, (4.92 +/- 0.38) g vs. (4.89 +/- 0.44) g]. The tissue-engineering biological material might be an ideal graft used in the reconstruction of vagina.

Bowel Vaginoplasty Associated with Complex Anorectal Malformations: A Retrospective Review of 131 Cases

Background: The association of reproductive anomalies with anorectal malformations has been well established. Due to the complex nature of these malformations, vaginal reconstruction is performed during the definitive surgical repair of the malformation. Creation of a neovagina is indicated in cases of agenesis of the vagina, or an interposition graft may be necessary if the native vagina cannot be adequately mobilized to the perineum. Various grafts have been utilized, including small bowel, rectum, descending colon and sigmoid colon, for vaginal reconstruction; however, complications such as stricture, prolapse, mucus and fistulas have all been reported.

Twenty years of experience with Krzeski’s cystovaginoplasty for vaginal agenesis in Mayer‐Rokitansky‐Küster–Hauser syndrome: anatomical, histological, cytological and functional results

To evaluate the long-term anatomical results using the original method of vaginal reconstruction with a pedicled bladder flap (Krzeski's cystovaginoplasty, CVP) in women with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) and the evaluation of radiological, histological, cytohormonal and functional results of CVP. Between 1981 and 2000, 38 patients (mean age 22.5 years, range 18-40) with MRKHS underwent CVP. A physical examination was used to evaluate the anatomical results, 27 patients had vaginography, and biopsies of the neovaginal wall and cytohormonal smears were taken in two. Functional sexual and urinary results, and opinions on CVP, were evaluated by an inventory mailed to 37 patients in 2000. The anatomical result was good in 37 patients during a mean (range) follow-up of 9 (0.25-19) years; the result was good in 30 patients, but seven developed vaginal stenosis that was successfully repaired. There were two cases of post-coital vesicovaginal fistula (VVF) at 18 months after CVP. Vaginal biopsies showed epithelialization of the posterior vaginal wall and gradual metaplastic changes from urothelium to stratified nonsquamous epithelium. Cytological smears showed a normal biphasic pattern and neovaginal susceptibility to hormonal milieu. In all, 27 patients (73%) responded to the questionnaire. All had sexual partners and started sexual intercourse at a mean of 14 months after CVP; 89% experience orgasms and in 48% the vagina was the source; 40% sometimes used lubricants and seven (26%) used vaginal dilators. Lower urinary tract symptoms (LUTS) after CVP were reported by 19 (66%) of the women and in six the LUTS were persistent. One patient was not satisfied with the functional and anatomical result of CVP, 89% declared that it improved sexual life, 93% would undergo CVP again and in 92% the quality of their sexual life was improved. All patients, when asked, stated that they would recommend CVP to another patient with MRKHS. Vaginal reconstruction by CVP is characterized by good anatomical and functional results, sustained by long-term observation. The resultant epithelium is very similar to that of the native vagina in histology and function. All vaginas are functional and the level of patient satisfaction was high. The level of complications was acceptable, but in some patients LUTS can persist.

Passerini-Glazel Feminizing Genitoplasty: Modifications in 17 Years of Experience with 82 Cases

ObjectivesTo describe modifications of Passerini-Glazel feminizing genitoplasty and report on long-term functional outcome. MethodsModifications include vaginal dissection and disconnection from the urethrovaginal sinus as the initial stage of the procedure; large dissection of the neurovascular bundle on both dorsal and lateral faces of the clitoris; plication of the skin around the reduced clitoris; and suturing the lateral edge of the proximal portion of the mucocutaneous plate with the labia majora's medial edge to a plane deeper than the subcutaneous tissue. These modifications reduce bleeding and operating time, better preserve clitoral sensitivity, form the clitoral prepuce, and create labia minora. ResultsEighty-two patients underwent modified Passerini-Glazel feminizing genitoplasty. Mean operating time was 120min (range: 100–180). Forty-six patients (46 of 82, 56%) were assessed at a mean follow-up of 5 yr (range: 2–9). There were no cases of clitoral vascularization defect or urethrovaginal fistula. The urethral meatus was never hypospadic. The vaginal introitus was large and elastic in all cases. Vaginal caliber at the internal suture line was as large as the vaginal introitus and the distal native vagina in 20 (43.5%) of the 46 girls. All mothers and patients reported satisfaction with external genital appearance. ConclusionsThese long-term results suggest that our modifications of one-stage Passerini-Glazel feminizing genitoplasty facilitate the procedure and produce good cosmetic results.

PASSERINI-GLAZEL FEMINIZING GENITOPLASTY: A LONG-TERM FOLLOWUP STUDY

We report our experience with early 1-stage Passerini-Glazel feminizing genitoplasty with special emphasis on long-term results of vaginoplasty. A total of 66 patients with ambiguous genitalia underwent 1-stage Passerini-Glazel feminizing genitoplasty. Long-term followup included an outpatient visit at 1 year postoperatively and a genital assessment with the patient under general anesthesia performed before menarche courses in those operated on at age 6 months to 8 years, and at 2 years postoperatively for those operated on at 9 years or older. All patients underwent the first long-term followup evaluation and no major complications were observed. The second long-term followup evaluation was performed in 46 patients (70%). In all cases the vaginal introitus was located in the physiological position and was large and elastic. Vaginal caliber at the suture line between the tubularized flap and vaginal mucosa was the same size as the vaginal introitus and distal native vagina in 20 of 46 patients (43%), slightly smaller in 10 (22%) and stenotic in 16 (35%). Stenosis at the suture line was corrected with simple Y-V introitoplasty performed at the same followup visit. Early 1-stage Passerini-Glazel feminizing genitoplasty is a safe and effective procedure that allows total surgical correction of ambiguous genitalia in infancy and good cosmetic results. Incidence of vaginal stenosis at the suture line is high but it can be repaired with simple introitoplasty performed before menarche occurs. Good functional results are presumed.