Neovaginal Construction Research Articles

Ulcerative colitis in a transgender woman with a sigmoid neovagina: a case report

BackgroundSex reassignment surgery (SRS) is a necessary step in transitioning into the desired gender for male-to-female transgender individuals. This study focuses on a rare complication developed following SRS, aiming to highlight potential complications associated with this procedure.Case presentationThis report describes a 49-year-old transgender woman with a history of SRS who developed bloody diarrhea and neovaginal bleeding 10 years later. A colonoscopy revealed features compatible with ulcerative colitis, which was confirmed by a biopsy.ConclusionsThe unpredictable clinical course of this phenomenon may prompt surgeons to reconsider the use of a rectosigmoid colon to create a neovagina. This case report underscores the necessity of long-term monitoring for gastrointestinal complications in transgender women post-SRS when a rectosigmoid colon segment is utilized for neovaginal construction.

Successful Use of Acellular Small Intestinal Submucosa Graft in Vaginal Reconstruction

PurposeVarious techniques for neovaginal construction have been employed in the pediatric and adult populations, including the use of intestinal segments, buccal mucosal grafts, and skin grafts. Small intestinal submucosa (SIS) extracellular matrix grafts have been described as a viable alternative, though prior experience is limited. Our purpose was to assess operative characteristics and patient outcomes with neovaginal construction using SIS grafts. MethodsThirteen patients underwent vaginoplasty with acellular porcine SIS grafts at our institution between 2018 and 2022. Operative and clinical data, postoperative mold management, vaginal dilating length, and complications were reviewed. ResultsAge at time of repair ranged from 13 to 30 years (median 19 years). Patient diagnosis included cloacal anomalies (n = 4), Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n = 4), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n = 1). Following dissection of the neovaginal space, a silicon mold wrapped with SIS graft was placed with retention sutures and removed on postoperative day 7. Median (IQR) operative time was 171 (118–192) minutes, estimated blood loss was 10 (5–20) mL, and length of stay was 2 (1–3) days. The follow-up period ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia. Mean vaginal length on latest follow-up was 8.97 cm. All thirteen patients had successful engraftment and progressed to performing self-dilations or initiating intercourse to maintain patency. There were no cases of graft reaction or graft extrusion. ConclusionsWe conclude that acellular small intestinal submucosa grafts are effective and safe alternatives for mold coverage in neovaginal construction. Our experience demonstrates minimal perioperative morbidity, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Future study on sexual outcomes, patient satisfaction, and comparison against alternative techniques has been initiated. Level of EvidenceIV. Type of StudyRetrospective Study.

Vaginoplasty With Mesh Autologous Buccal Mucosa in Vaginal Agenesis: A Multidisciplinary Approach and Literature Review.

Vaginal agenesis, a rare condition, is treated by various surgical techniques to achieve neovaginal reconstruction. The main difference between the approaches lies in the graft material used to cover the newly formed cavity. The purpose of this retrospective study was to describe the surgical procedure and outcomes of autologous buccal mucosal grafting in neovaginal reconstruction. Sixteen patients with vaginal agenesis admitted to our department between January 2016 and January 2019 were included in our study. A reconstruction procedure, described in detail here, involving autologous buccal mucosa as graft material was successfully conducted in all of the patients. Long-term anatomic and functional outcomes were evaluated. The blood loss during operation was estimated to be 15 to 20 mL in all cases. No rectal or bladder injury occurred. The buccal mucosal wound completely healed 10 to 14 days after the operation. All patients had a well-formed neovagina 8 to 10 cm in length, with a mean diameter of >3 finger-breadths. The application of autologous buccal mucosa in neovaginal construction is a simple procedure. Autologous buccal mucosa is an ideal material to achieve excellent cosmetic and functional results in patients with vaginal agenesis.

Congenital vaginal agenesis, davydov procedure: A case report and review of literature

Congenital vaginal agenesis, also called Mullerian agenesis or Rokitansky–Mayer–Kuster–Hauser syndrome, is a rare anomaly of the female genital tract. The affected individuals present with primary amenorrhea, varying degree of uterovaginal anomalies, infertility, and other associated renal, spine, and skeletal malformations. Embryologically, the vagina is formed from the fusion of the two embryonic structures: the upper part from the Mullerian duct system and the lower third from the urogenital sinus. Mullerian agenesis is caused by embryologic underdevelopment of the Mullerian duct, with resultant agenesis or atresia of the vagina, uterus, or both. We report the case of a 25-year-old woman who presented with complaints of delayed onset of menses and inability to have sexual intercourse with her partner. She had well-developed secondary sexual characteristics. She had never experienced penetrative sexual intercourse despite being married for 2 years. A general physical examination revealed a young woman of normal stature. She had well-developed breast (Tanner stage 5). The clitoris and pudendal cleft were normal. There was normal external urethral meatus with blind ended vagina of 2 cm long. A digital rectal examination revealed good sphincteric tone with no uterus or cervix palpated. A diagnosis of congenital uterovaginal anomaly was made. A buccal smear done revealed XX karyotype. She was counseled about her condition. Consents for surgery and media release were sought and obtained. A Davydov procedure for neovaginal construction was made and her postoperative condition was satisfactory. Congenital vaginal agenesis is a rare condition with profound effects on the affected individuals. Therefore, proper counseling on future fertility options and the need for neovaginal construction for improved sexual satisfaction should never be overemphasized among others.

Augmentation vaginoplasty with buccal mucosa for the surgical revision of postreconstructive vaginal stenosis: a case series

Vaginal stenosis is a common consequence of vaginal reconstruction in childhood. Significant scarring can make dilation ineffective, and there maybe a paucity of skin to create perineal skin flaps. Numerous vaginoplasty techniques exist, including perineal skin flaps for distal stenosis and intestinal vaginoplasty requiring laparotomy and bowel anastomosis. Buccal mucosa graft is widely used in urethroplasty and has been reported in neovaginal construction. It is easily accessible with minimal graft site morbidity and provides a close functional replica to vaginal mucosa. The aim was to describe the use of buccal mucosa grafts for the surgical revision of postreconstructive vaginal stenosis. The study setting was a tertiary centre for congenital gynaecological anomalies. Buccal mucosa grafting was provided to women with vaginal stenosis unsuitable for perineal skin flaps and in whom intestinal vaginoplasty was the next option. Four cases have been performed, and the medical notes were reviewed for clinical data. Mean age at buccal mucosa vaginoplasty was 21 years (range 18-26 years). Two patients had a cloacal anomaly, one had mosaic Turner syndrome and one had postradiation vaginal stenosis. All four had undergone previous vaginal reconstruction. In all cases, there was a tight band of vaginal stenosis either too proximal or with insufficient perineal tissue to allow a perineal flap vaginoplasty. There were no immediate complications. Mean clinic follow-up was 16 months (3 months-4 years). Two patients were able to have penetrative sexual intercourse, and two were using vaginal dilators successfully. Patients have an email contact for the teamnurse specialist and therefore are able to contact before clinical review if they develop concerns. The use of buccal mucosal grafts for vaginoplasty is increasingly reported. This is the first detailed case series describing its use for augmentation vaginoplasty with postreconstructive/stenosis. All patients had a successful outcome with a normal capacity vagina, and two were able to have penetrative intercourse. This suggests that buccal mucosal graft vaginoplasty is a safe and effective alternative for women with previous vaginal reconstruction requiring surgery for vaginal stenosis.

Use of infragluteal folds as a full‐thickness skin graft donor site for construction of the neovagina in cases of Mullerian agenesis

The aims of this study were to present the results of using infragluteal folds as a skin graft donor site in cases of Mullerian agenesis undergoing full-thickness skin graft vaginoplasty and to evaluate the outcomes of the surgical technique. Demographics and clinical parameters of 24 consecutive Mullerian agenesis patients refusing any dilatational procedure and undergoing neovaginal construction using infragluteal folds skin grafts from May 2004 to July 2015 were analyzed. The mean age of the patients was 21.5 ± 5.7 years. Five patients had nonfunctional rudimentary uterus, one patient had unilateral ovarian agenesis, one patient had unilateral renal agenesis, and one had undergone a previous vaginoplasty. There were no serious complications needing surgical or medical intervention. The depth of the neovagina in patients with a follow-up period of more than 6 months (n = 17) varied from 7 to 12 cm. Of these patients, the sexually active ones (n = 8) did not complain of dyspareunia or vaginal dryness during sexual intercourse. The resulting scars were satisfactory and acceptable for all patients. It has been our practice to use infragluteal folds as a skin graft donor site for full-thickness skin graft vaginoplasty. We believe that the results of this study demonstrate that this area is versatile and an excellent alternative to the groins and lower abdomen. Further clinical and histomorphological investigations are necessary for strong statements and results.

UTERUS AND VAGINAL APLASIA AND PELVIC KIDNEY - MANAGEMENT AND SURGICAL POSSIBILITY IN CONGENITAL ANOMALY CORRECTION

Objective. To clarify the possibilities and peculiarities of neovagival creation among the patients with MRKX syndrome and pelvic kidney. Subject and methods. Examination and surgical treatment were conducted in 3 patients with MRKX syndrome and pelvic kidney, including total laparoscopic colpopoiesis in 2 patients. Results. After surgical correction of vaginal and uterus aplasia in patiets with MRKX syndrome and pelvic kidney neovagina were created. In one patients neovagina were restore after previous surgery by vaginal approach because of extensive adhesions and high risk of laparoscopic surgery. In 2 patients - total laparoscopic colpopoiesis were perform without complications. Conclusion. Our clinical observations of surgical treatment in patients with MRKX syndrome and pelvic kidney shows possible surgical approaches of neovaginal creation depending of previous surgery and pelvic kidney localization, established during laparoscopy. Improvement of endoscopic technique and new modifications of neovaginal construction let us to increase the indications and possibilities of neovaginoplasty in patients with MRKX syndrome and pelvic kidney.

Neovaginal Construction with Pelvic Peritoneum: Reviewing an Old Approach for a New Application.

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc.

Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery.

Gender reassignment surgery due to transsexualism (International Classification of Diseases, Tenth Revision: F64.0) is a procedure becoming increasingly common worldwide as a result of a significant increase in diagnostic incidence. Several methods have been described for this complex surgery, but no internationally agreed upon gold standard exists, in particular with regard to which methods allow for creating a sufficient neovaginal depth. We use a 2-stage technique using solely penile skin for creating a neovaginal cavity and present the long-term outcome in terms of measured neovaginal depth. Eighty patients were included. Patients' neovaginal depth was measured in a standardized fashion 6 months or more after initial surgery. Results were compared with published data on female anatomy. The average neovaginal depth achieved was 10.2 cm. Having had a postoperative complication and noncompliance to neovaginal dilatation were both negatively correlated with neovaginal depth, whereas higher body mass index was not. Most patients received a neovaginal depth sufficient for penetrative intercourse and within the range for biological women. Using solely penile skin for the vaginal lining is a satisfactory surgical method to achieve adequate vaginal depth, provided that the postoperative dilatation regimen is followed. This holds true regardless of age or body mass index.

FRI-09 THE CREATION OF THE NEOVAGINA: A HISTORY OF VAGINAL RECONSTRUCTION

INTRODUCTION AND OBJECTIVES: After Realdus Colombus described congenital vaginal agenesis in the 16th century, vaginal reconstruction became of interest to urologists, plastic surgeons, and gynecologists. We will review the evolution of neovaginal reconstruction as it’s indications expanded from treatment of congenital disease, to restoration of normal function following radical surgery and finally to elective gender reassignment surgery. METHODS: A comprehensive literature review (PubMed, Clinical Key) was performed to elucidate relevant historical and clinical information. RESULTS: Early reports of surgical vaginal reconstruction attempted to use the labia majora for vaginoplasty, however the first use of extravaginal tissue came in 1898 when Dr. Abbe described the construction of a neovagina using skin grafts. The technique was largely abandoned until McIndoe refined the procedure in 1938. Although the procedure was successful in over 133 reported cases by 1948, patients developed scarring and subsequent stenosis. Techniques in reconstruction expanded as the indications for neovaginal reconstruction began including patients with large defects following radical pelvic surgery. In the 1950’s Conway and Stark popularized the use of bowel similar to their predecessors at the turn of the century, however this approach proved to be afflicted with complications. The use of regional tissue transposition began with McGraw in 1976 that utilized a gracilis myocutaneous flap. For larger defects following pelvic exenteration, Tobin described the use of a rectus abdominis myocutaneous flap in 1988. Alternatively, in 1974 Davydov described a procedure using peritoneum from the pouch of Douglas to reconstruct upper vaginal defects. A new interest has currently been taken in this procedure as it is now being performed laparoscopically. The vaginal reconstructive techniques described for treating patients with vaginal atresia helped form the foundation for neovaginal construction in male-to-female transgender surgery which became popularized in the late 1960’s. Although penile disassembly and inversion vaginoplasty remains the preferred surgical technique, nongenital flaps and intestinal interposition remain suitable options as primary or revision vaginoplasty. CONCLUSIONS: Techniques in vaginoplasty have evolved since their original descriptions in the turn of the century and their contemporary applications are used for numerous indications.

Plastic neo-vaginal construction in Mayer-Rokitansky-Küster-Hauser syndrome: an expert opinion paper on the decision-making treatment process.

Vaginal agenesis is a congenital anomaly that affects the life of one of each four thousand women around the world. There is a trend that patients request immediate surgical correction, instead of passive vaginal dilatation. Therefore a differentiated counselling should be provided. We present a comparative chart, based on published evidence, with aspect to the available techniques, which will facilitate the decision-making process in the clinical practice. From our point of view, the best results are achieved with techniques that combine the advantages of the minimal-invasive surgery with those derived of the use of peritoneum as covering tissue of the neovagina. Nevertheless there is a lack on interdisciplinary consensus about the best option to restore the physical and sexual quality of life.

Full-Thickness Skin Grafts for Neovaginal Construction in Mayer–Rokitansky–Küster–Hauser Syndrome

Abstract Background: Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome is characterized by vaginal agenesis, the treatment of which typically involves neovaginal construction using split-thickness skin grafts. While successful in many patients, this method may result in vaginal contracture or foreshortening. Neovaginal construction using full-thickness skin grafts (FTSGs) is an underutilized surgical technique associated with decreased rate of contracture and improved functional outcomes. Cases: FTSGs were used for neovaginal construction in 5 patients with MRKH syndrome. This report describes the surgical technique and the current authors' experience when using it. There was a mean follow-up time of 39.4 months (range: 9–111 months). Results: All 5 grafts have remained patent, and all of the patients who desired vaginal intercourse are now capable of achieving this. None of the 5 patients had vaginal contraction or foreshortening. Conclusions: Neovaginal construction using FTSGs is an underutilized and unde...

Surgical Reconstruction for Male-to-Female Sex Reassignment

BackgroundThe primary challenge of male-to-female reassignment surgery is to create natural-appearing female genitalia with neovaginal dimensions adequate for intercourse, neoclitoris sensitivity, and minimal risk of complications. Surgical positioning is an important component of the procedure that successfully minimizes the risk of morbidity. ObjectiveWe modified various vaginoplasty techniques to better position the urethral neomeatus in the proper anatomic location to minimize the chance for complications and enhance aesthetic satisfaction. Design, setting, and participantsWe retrospectively reviewed data stored in a prospective database for 24 consecutive patients who underwent male-to-female gender reassignment at a German university clinic between January 2007 and March 2011. Surgical procedureFirst, orchiectomy and penile disassembly are performed with the patient in the supine position. Both corpora cavernosa are resected with the patient in the lithotomy position, and neovaginal construction is accomplished with the incorporation of the penile urethra into the penile shaft skin. The glans is preserved and resized to form the neoclitoris. The assembled neovagina is inverted, inserted into the expanded rectoprostatic space, and secured to the sacrospinous ligament. Scrotal skin is tailored to create the labia. Outcome measurements and statistical analysisComplications and patient satisfaction with neovaginal depth, appearance, neoclitoral sensation, and capacity for sexual intercourse were evaluated. Results and limitationsThe mean neovaginal depth was 11cm (range: 10–14cm); median follow-up was 39.7 mo (range: 19–69 mo). All patients reported satisfactory vaginal functionality. One patient noted stenosis after 4 yr that was histologically confirmed as lichen sclerosus. Neoclitoral sensation was good or excellent in 97% of patients; 33% reported regular intercourse. No major complications were observed. Because this is a retrospective review to describe a complex reconstructive surgery and illustrate these techniques in the accompanying intraoperative surgery-in-motion video, no control group was undertaken. ConclusionsGender reassignment can be performed with minimal complications using penile skin with incorporated penile urethra and intraoperative repositioning of the patient to achieve adequate neovaginal dimensions for intercourse and neoclitoral sensation.

V1548 COMBINED ROBOT ASSISTED AND PURE LAPAROSCOPIC ILEAL NEOVAGINA CREATION UTILIZING ROBOT SIDE DOCKING AND LAPAROSCOPIC PERINEAL PORT PLACEMENT

You have accessJournal of UrologyReconstruction1 Apr 2010V1548 COMBINED ROBOT ASSISTED AND PURE LAPAROSCOPIC ILEAL NEOVAGINA CREATION UTILIZING ROBOT SIDE DOCKING AND LAPAROSCOPIC PERINEAL PORT PLACEMENT James Brien, Britton Tisdale, Jeremy Tonkin, Michael Fabrizio, and Gerald Jordan James BrienJames Brien More articles by this author , Britton TisdaleBritton Tisdale More articles by this author , Jeremy TonkinJeremy Tonkin More articles by this author , Michael FabrizioMichael Fabrizio More articles by this author , and Gerald JordanGerald Jordan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1300AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome affects at least 1 out of 4500 women, and is characterized by varying degrees of vaginal aplasia, as well as other malformations. Neovaginal construction is possible using several techniques, although no single method is considered ideal. Use of ileum for neovaginal construction is well described, although challenging to accomplish using minimally invasive techniques. We present a case of combined robotic assisted and pure laparoscopic ileal neovagina creation in a MRKH female with complete vaginal agenesis and a solitary pelvic kidney. METHODS Patient positioning was in low lithotomy. After mobilization of ascending colon and terminal ileum, The da Vinci robot was docked on the left side of the patient to allow for simultaneous laparoscopy and perineal access. After dissection of the vaginal plate, a 10-12mm port was placed through the area corresponding to the neovaginal hiatus. The perineal port was useful in the selection and dissection of the ileal segment identified for creation of the neovagina, transilluminating mesentery vascular arcades prior to division, and facilitating construction of the ileal-ileal reanastomosis. The neovaginal ileal segment was transposed to the perineum and matured with interrupted sutures after pull through to the neovaginal hiatus. RESULTS Total operative time was 7 hours 24 minutes and estimated blood loss was 100cc. The patient experienced no significant post-operative complications and was discharged on post operative day 7. Neovaginal cosmesis was good. Hiatus of neovagina was of good caliber and depth of the vaginal limb was sufficient. CONCLUSIONS Combined pure laparoscopy and robotic assisted laparoscopy with robot side docking and placement of a perineal intraperitoneal port is an alternative minimally invasive option for creation of an ileal neovagina while avoiding the morbidity of a laparotomy. Norfolk, VA© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e596-e597 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information James Brien More articles by this author Britton Tisdale More articles by this author Jeremy Tonkin More articles by this author Michael Fabrizio More articles by this author Gerald Jordan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Neo-vaginal construction with subcutaneously based gluteal-fold flaps: a case report

A 16-year-old girl with vaginal aplasia had a 1-cm long vaginal pouch and complete absence of uterus. Bilateral subcutaneous based flaps were raised horizontally from the gluteal folds and transposed into the created vaginal cavity. At 12 months follow-up, she had successfully engaged in intercourse and at no time had been mechanically using dilation. At clinical examination, the neo-vagina maintained both adequate length and width.

Vaginal construction using sigmoid colon in children and young adults

Authors from Denver describe their experience in neovaginal construction using sigmoid colon in young adults. They outline potential difficulties, particularly with patients having an android pelvis, but feel that the isolated sigmoid neovagina construction is widely applicable and can be used at any age. However, they point out that the long-term satisfaction for intercourse needs long-term evaluation. The impact of early screening for reflux in siblings of those with VUR is evaluated by authors from Montreal. They found that screening at an early stage (<2 years) was more protective against renal damage than screening at a later stage. They suggested that the optimal way to proceed was early screening in asymptomatic siblings to detect VUR before it becomes clinically significant. OBJECTIVE To evaluate the age at which patients who required vaginal replacement (an uncommon procedure in children) were diagnosed, and the cause of their anomaly, and to relate these variables to the surgical outcome. PATIENTS AND METHODS Patients who had vaginal replacement at the author's institution between 1990 and 2002 were reviewed retrospectively. Depending on the age at reconstructive surgery, patients were divided into pre- and postpubertal groups. RESULTS A neovagina was constructed in 23 patients during the study period; sigmoid colon was used in 20 but not in two patients with cloacal exstrophy and in one with Mayer-Rokitansky-Kuster–Hauser syndrome (MRKHS). These cases were excluded from the analysis of outcomes and complications. Group 1 comprised patients diagnosed and treated before puberty and group 2 those diagnosed and/or treated afterward. In group 1 the presenting diagnoses included androgen insensitivity syndrome (AIS) in six patients, MRKHS in two, cloacal exstrophy in two, vaginal tumour in one, Mullerian duct renal aplasia cervicothoracic somite dysplasia, vertebral abnormalities, anal atresia, cardiac anomalies, tracheo-oesophageal fistula, and/or oesophageal atresia, renal abnormalities and limb defects syndromes in one each. In group 2 the presenting diagnoses included MRKHS in seven, AIS in two, and congenital adrenal hyperplasia in one. Complications included superficial wound infection (two patients), recurrent introital stenosis, and blind loop mucocele, complete stenosis of perineal neovaginal opening (one each) and dyspareunia in three. Neither age nor pelvic habitus (android vs gynaecoid) influenced the outcome, and the cosmetic results were excellent in all the patients. CONCLUSION Isolated sigmoid neovaginal construction appears to be applicable to many diagnoses and in patients at any age. Although an android pelvis can present technical challenges, in this experience it was not associated with a greater complication rate. The long-term satisfaction with the sigmoid neovagina for intercourse, especially in those constructed before puberty, still requires long-term evaluation.

Vaginal construction using sigmoid colon in children and young adults.

To evaluate the age at which patients who required vaginal replacement (an uncommon procedure in children) were diagnosed, and the cause of their anomaly, and to relate these variables to the surgical outcome. Patients who had vaginal replacement at the author's institution between 1990 and 2002 were reviewed retrospectively. Depending on the age at reconstructive surgery, patients were divided into pre- and postpubertal groups. A neovagina was constructed in 23 patients during the study period; sigmoid colon was used in 20 but not in two patients with cloacal exstrophy and in one with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS). These cases were excluded from the analysis of outcomes and complications. Group 1 comprised patients diagnosed and treated before puberty and group 2 those diagnosed and/or treated afterward. In group 1 the presenting diagnoses included androgen insensitivity syndrome (AIS) in six patients, MRKHS in two, cloacal exstrophy in two, vaginal tumour in one, Müllerian duct renal aplasia cervicothoracic somite dysplasia, vertebral abnormalities, anal atresia, cardiac anomalies, tracheo-oesophageal fistula, and/or oesophageal atresia, renal abnormalities and limb defects syndromes in one each. In group 2 the presenting diagnoses included MRKHS in seven, AIS in two, and congenital adrenal hyperplasia in one. Complications included superficial wound infection (two patients), recurrent introital stenosis, and blind loop mucocele, complete stenosis of perineal neovaginal opening (one each) and dyspareunia in three. Neither age nor pelvic habitus (android vs gynaecoid) influenced the outcome, and the cosmetic results were excellent in all the patients. Isolated sigmoid neovaginal construction appears to be applicable to many diagnoses and in patients at any age. Although an android pelvis can present technical challenges, in this experience it was not associated with a greater complication rate. The long-term satisfaction with the sigmoid neovagina for intercourse, especially in those constructed before puberty, still requires long-term evaluation.

Invited Discussion: Experience With Neovaginal Construction Using the Full-Thickness Skin Graft in Vaginal Agenesis

Dr. Selcuk Akin has written a great paper contributing to our knowledge of vaginal construction and to our knowledge of wound healing. The surgeon in this world who has performed as many full-thickness skin grafts (FTSG) for neovaginal construction (neocolporrhaphy) as anybody is Professor Charles Horton of the Medical College of Eastern Virginia. I have therefore contacted him directly. He reports that these operations do work well. It is his opinion, and it is my own opinion, that FTSG for surgical treatment of Mullerian agenesis (mesodermal agenesis of the vagina) works well. The most important factor is that the FTSG contracts very little (ie, not to any significant amount or any perceptible amount). In contradistinction, a split-thickness skin graft vagina does contract; it is an ongoing “battle” to control the contraction with mechanical means (a stent worn for intermediate to long term). The technical strategy includes methods to achieve freedom from infection and freedom from hematoma, and freedom from either a straight-line longitudinal scar or a circular “purse string” scar at the graft-skin junction. Methods to control these factors are as follows: freedom from infection is reduced with skin preparation to reduce the number of bacteria in the skin appendages (glands); antibiotics parenterally administered and topically administered in solution (for example, a silicon tube through the center of the stent, as in a Mentor stent), suction to prevent hematoma, and a rather huge dart flap at the introitus (eg, 4 2.5 cm) will help prevent introital stenosis. Introital stenosis will occur whenever this flap is not used. If the stent had been left in place for 10 days, better healing would have occurred, but the foreign body may cause a generous amount of serosanguinous drainage (almost a state of preinfection). The results are indeed excellent, and they reflect a superior class of surgical and postoperative management. The 10-cm length is of course sufficient. Many patients, however, desire a longer vaginal length, and they hope to achieve that with aggressive application of the stent. And this “deficiency” in length is more than compensatory because the FTSG is much more elastic than the thick-split thickness skin graft. The donor site is the glabrous skin of the groin, with the unique aspect being the relaxing incisions of the lower abdomen to help close the donor site with a well-healing scar line. The competitive procedure is the Singapore Flap, one of many names applied to the fasciocutaneous flaps of the groin. These flaps are taken from the same area as the skin grafts. The flaps are fortunately thin and well-vascularized by a branch of the internal pudendal artery lying on top of the fascia and usually consisting of 12.5 cm of usable length in the form of an island flap. Professor Ted Huang of Galveston and others popularized that procedure. The algorithm for vaginal construction now consists of: 1) in cases of Mullerian agenesis, the FTSG or perhaps the fasciocutaneous flaps of the groin 2) for gender dysphoria, rectosigmoid flap, or perhaps penile inversion 3) to reconstruct after cancer extirpation, the rectus abdominis musculocutaneous free flap.

Experience with neovaginal construction using the full-thickness skin graft in vaginal agenesis.

The correction of vaginal agenesis requires the creation of a neovaginal cavity that is dissected between the bladder and the rectum. To protect the length of the cavity, it is necessary to ensure the complete epithelialization of the apex of the neovaginal cavity. The author prefers to tailor 2 pieces of full-thickness skin grafts longitudinally on a vaginal stent that is molded into bullet shape. Six girls with vaginal agenesis underwent neovaginal construction using this method. The apex of the neovaginal cavity was perfectly epithelialized using this vaginal stent. The length of the neovaginal cavity that is dissected during the operation was protected. The follow-up period ranged from 24 to 93 months (median, 57.2 months). Postoperative stricture or contracture of the neovagina did not occur in all patients. As a result, full-thickness skin graft is an efficient method for vaginal construction in patients with vaginal agenesis.

Neovaginal construction with buccal mucosal grafts.

Several surgical techniques have been designed to construct a neovagina that will be satisfying in appearance, function, and feeling when the vagina is congenitally absent. However, no method has yet been approved as a perfect solution. With the aim of solving the problems with conventional methods, the authors describe a new surgical technique that is simple and safe for treating vaginal agenesis. This technique consists of creating a mucosal lining of the neovaginal cavity using multiple full-thickness buccal mucosal patch grafts. Four patients with congenital absence of the vagina treated with this technique are presented. This surgical procedure created a mucus-providing lining inside the neovagina. Selecting the donor site in the oral region resulted in an inconspicuous donor-site scar. Histologically, the neovaginal lining was confirmed as mucosal, and the cream-colored viscous fluid found in the neovaginal cavity was confirmed as mucus. At a mean follow-up period of 15 months, the neovagina remained adequate in depth and width. All of the patients were interviewed to evaluate the function of the neovagina. Each patient reported having regular sexual intercourse and that the neovagina had felt normal to their partners. The encouraging results obtained in four cases suggest that this new technique deserves further application.