Neovaginal Construction Research Articles

SIGMOID RECONFIGURED VAGINAL CONSTRUCTION IN CHILDREN

We present a modified technique of sigmoid neovaginal construction in children that protects the sigmoid pedicle from traction, allows easy adjustment of caliber and reorients the mucosal fold in a longitudinal direction. From 1997 to 2000, 10 genetically male (46 XY) children 1 to 13 years old underwent construction of a neovagina with sigmoid, incorporating the Yang-Monti concept of intestinal reconfiguration. The diagnosis was androgen insensitivity in 7 patients, congenital adrenal hyperplasia in 2 due to 17 alpha-hydroxylase deficiency and 3 beta-hydroxysteroid dehydrogenase deficiency, respectively, and bladder exstrophy in 1 who required sex reassignment. Eight children had an adequate caliber neovagina after an initial period of systematic dilation. In 1 case a relevant stricture required reoperation using the same technique and the outcome was good. In another child a stricture developed in the middle of the reconfigured sigmoid segment and a regular dilation schedule is still being followed after 23 months of followup. The new sigmoid reconfiguration technique enables the use of smaller dimension intestinal segments and construction of a long vaginal conduit of adequate caliber. Its optimal adequacy for penetration must be assessed in the future after these patients begin sexual activity.

Neovaginal construction in vaginal aplasia and sex-reassignment surgery.

During the period 1984-1994 33 patients were admitted to the department of plastic surgery for the purpose of neovaginal construction. They comprised 22 patients with vaginal agenesis or aplasia and 11 transsexual men. In most cases neovaginal construction was done by blunt dissection and lining with a split thickness skin graft from the thigh, and in the cases of sex-reassignment surgery genital skin was also used. The two groups differed as the patients with vaginal agenesis or aplasia had remarkably few complications compared with the transsexual group. The most common complications were defects in the skin grafts and vaginal stenosis. The transsexuals therefore had an extended recovery period including several admissions and visits to the outpatient clinic. The difference in genotype does not explain the high complication rate in the transsexual group as eight in the vaginal agenesis or aplasia group had Morris syndrome (testicular feminisation (XY)). However, the phenotype may be of importance in vaginal construction as the male (transsexual) pelvis is narrow and the levator muscles are stronger than those in the female pelvis.

Female gender reconstruction surgery for ambiguous genitalia in children and adolescents

This review summarizes the principles of diagnosis in patients with ambiguous genitalia and surgical reconstruction for a female gender assignment. Common goals of corrective surgery are to reduce clitoral size, to create or reshape labia majora, to exteriorize or create a vagina, and to remove potentially malignant gonads. A one-stage clitorovaginoplasty was performed on four children with congenital adrenal hyperplasia (Passerini-Glazel et al., J Urol 1989, 142:565-568). The technique preserved the clitoral glans, used the skin of the urogenital sinus to line the introitus and form the distal vagina, and reshaped the labioscrotum. Early follow-up found minimal vaginal stenosis. A postpubertal vaginoplasty for undermasculinized genetic males or for patients with a flat perineum is described. All 15 patients had functional success, and 93% had anatomic success (Rock and Jones, Am J Obstet Gynecol 1989, 160:845-853). Early gender assignment helps stabilize gender identity, and neonatal reconstructive surgery of the external genitalia appears to be safe. Neovaginal construction is often performed postpubertally but should be individualized to the anomaly and the patient.

Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery

The short gracilis myocutaneous flap derives its blood supply from terminal branches of the obturator artery, and the vascular pedicle derived from the medial femoral circumflex artery is sacrificed. Twenty-one short gracilis myocutaneous flaps were used for vulvovaginal reconstructions in 11 patients undergoing radical pelvic surgery: bilateral flaps in nine patients for neovaginal construction after pelvic exenterations, bilateral flaps in one patient for vulvovaginal reconstruction after radical vulvovaginectomy, and a unilateral flap in one patient for vulvovaginal reconstruction after radical vulvectomy with partial vaginectomy. Major complications consisted of bilateral flap necrosis occurring in one patient who had received preoperative irradiation to the vulva and groin combined with chemotherapy. Minor degrees of necrosis (less than 5%) and/or separation of vaginal suture lines occurred in five patients without marked loss of the flaps. Vaginal caliber and depth are excellent in ten patients (91%) after follow-up of 1-22 months. The short gracilis flap is an excellent alternative to the more bulky gracilis flap, which derives its blood supply from perforating branches of the femoral artery. Based on our experience, the short gracilis flap provides adequately vascularized tissue for vulvovaginal reconstruction in patients after radical pelvic surgery, but should not be used in patients who have received extensive groin irradiation.