Vaginoplasty Research Articles

Report of the first live birth after uterus transplantation in People’s Republic of China

To present the first live birth after uterine transplantation (UTx) in the People's Republic of China. Case study. University hospital. A 22-year-old woman with Mayer-Rokitansky-Kuster-Hauser syndrome and previous surgery for vaginal reconstruction and UTx. Endometrial preparation, frozen embryo transfer, pregnancy follow-up, and cesarean section. Results of invitro fertilization, frozen embryo transfer, ultrasound measurements during pregnancy, rejection diagnosis and treatment, delivery, live birth, and histology of uterus. Frozen embryo (cleavage stage) transfer started 1.5 years after UTx. The first embryo transfer (n = 2) resulted in a biochemical pregnancy. The second, third, and fourth embryo transfer (n = 2, 2, 3) did not result in pregnancy. The fifth embryo transfer (n = 3) resulted in pregnancy with two gestational sacs, but with spontaneous disappearance of one in early pregnancy. During early pregnancy three episodes of vaginal bleedings occurred (gestational weeks 6 + 2, 13 + 1, and 16 + 3), with a spontaneously resorbing subchorionic hematoma diagnosed at the last bleeding episode. Bleeding episodes were treated with corticosteroids and tacrolimus. During pregnancy, blood flow velocity waveforms and fetal growth parameters were normal. A subacute cesarean section was performed at gestational week 33 + 6 due to uterine contraction pattern suggesting imminent labor. A healthy boy (2,000 g) with Apgar scores of 10, 10, 10 was delivered. The uterus was kept for a possible second pregnancy. The first live birth after UTx in the People's Republic of China is reported and this occurred after a robotic-assisted laparoscopic uterus retrieval from the mother.

Safety and Efficacy of Total Vaginal Reconstruction in Elderly Women with Medical Co-Morbidities

Safety and Efficacy of Total Vaginal Reconstruction in Elderly Women with Medical Co-Morbidities

Donor Site Morbidity of Patients Receiving Vertical Rectus Abdominis Myocutaneous Flap for Perineal, Vaginal or Inguinal Reconstruction

BackgroundManagement of donor site closure after harvesting a vertical rectus abdominis myocutaneous (VRAM) flap is discussed heterogeneously in the literature. We aim to analyze the postoperative complications of the donor site depending on the closure technique.MethodsDuring a 12-year period (2003–2015), 192 patients in our department received transpelvic VRAM flap reconstruction. Prospectively collected data were analyzed retrospectively.Results182 patients received a VRAM flap reconstruction for malignant, 10 patients for benign disease. The median age of patients was 62 years. 117 patients (61%) received a reconstruction of donor site by Vypro® mesh, 46 patients (24%) by Vicryl® mesh, 23 patients (12%) by direct closure and 6 patients (3%) by combination of different meshes. 32 patients (17%) developed in total 34 postoperative complications at the donor site. 22 complications (11%) were treated conservatively, 12 (6%) surgically. 17 patients (9%) developed incisional hernia during follow-up, with highest incidence in the Vicryl® group (n = 8; 17%) and lowest in the Vypro® group (n = 7; 6%). Postoperative parastomal hernias were found in 30 patients (16%) including three patients with simultaneous hernia around an urostomy and a colostomy. The highest incidence of parastomal hernia was found in patients receiving primary closure of the donor site (n = 6; 26%), the lowest incidence in the Vypro® group (n = 16; 14%).ConclusionThe use of Vypro® mesh for donor site closure appears to be associated with a low postoperative incidence of complications and can therefore be recommended as a preferred technique.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap

IntroductionAfter extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap. MethodPatients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed. ResultsThirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap. ConclusionThis long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.

Влагалищный доступ в хирургическом лечении пролапса тазовых органов

A review of current literature on the results of surgical treatment of patients with pelvic organ prolapse by vaginal approach is presented in the article. The relevant issues are the safety and efficiency of using mesh implants for the surgical correction of pelvic organ prolapse. Most experts recognize a need for further improvement of vaginal reconstruction techniques using synthetic meshes, however, current restrictions in a number of countries significantly impact on the respective studies. Despite the many scientific works and various publications, to date there is no single concept of the pelvic organ prolapse. It is necessary to conduct multicenter clinical studies in order to further develop clinical guidelines and to determine a place of these operations in the surgical treatment of pelvic organ prolapse.

Primary vaginal calculus in a woman with urogenital sinus anomaly: a case report

BackgroundPrimary vaginal calculus is rare and often misdiagnosed due to its low incidence. The formation of primary vaginal calculus is mainly due to the pooling and stasis of urine within the vagina, and associated with urogenital tract abnormalities.Case presentationWe present a case of a 23-year-old woman with urogenital sinus anomaly who presented with a vaginal calculus. The patient was not suspected of a calculus in the vagina until the patient suffered amenorrhea and dyspareunia. Pelvic computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the patient had urogenital sinus anomaly with vaginal calculus. For the reason, the calculus was removed by surgery, and the reconstruction of vagina and urethra was performed. The postoperative recovery and follow-up were uneventful.ConclusionsAlthough vaginal calculus and urogenital sinus anomaly are extremely rare in literature, the radiologist should be familiar with the imaging appearance of urogenital sinus anomaly, and be aware of the possibility of vaginal calculus.

Uterine Conserving Surgery in Patient With Cervicovaginal Agenesis: A Case Report

Congenital absence of the vagina with variable uterine development known as Mullerian agenesis or Mayer-Rokitansky-Kuster-Hauser syndrome. Cervicovaginal agenesis in the presence of normal uterus is very rare. Conservative surgery has recently been suggested in patients with congenital cervicovaginal atresia in order to relieve the symptoms and maintain fertility. A 13-year-old female referred to a pelvic floor clinic, because of primary amenorrhea and severe cyclic pelvic pain. Ultrasonography revealed a large amount of blood accumulation in the uterine cavity, and also, the cervicovaginal agenesis was reported. Both ovaries were normal. A neovagina was created by dissection of the space between the bladder and rectum. Under ultrasonography guidance, two Pezzer catheters were inserted between uterine ending and neovagina, so the catheters kept the canal patent, a soft mould was applied to prevent the vaginal stricture. Cervicovaginal agenesis, accompanied by normal functional endometrium, is a rare but challenging Mullerian anomaly in the case of surgical treatment. One of the successful conservative treatment in a fully educated patient is the vaginal reconstruction and uterovaginal anastomosis by stenting and continues the application of vaginal mould.

Vaginal reconstruction after pelvic exenteration with a vertical deep inferior epigastric perforator flap in 10 steps

Pelvic exenteration is a radical and challenging surgery requiring a functional reconstruction after pelvic organ resection and, to date, it remains the only treatment with curative intent in selected cases...

Prolapse repair after anterior exenteration.

This report presents our experience in performing prolapse repair after anterior exenteration. The patient had a history of invasive bladder cancer and underwent a robotically assisted laparoscopic anterior exenteration with extended bilateral pelvic lymph node dissection and creation of an Indiana pouch continent diversion. Her pelvic organ prolapse progressed over time despite multiple pessary fittings. She eventually decided to proceed with pelvic reconstructive surgery 6 years after her cancer surgery. She underwent a successful vaginal native tissue reconstruction with uterosacral ligament suspension, posterior repair and reconstruction of the anterior compartment. The patient has been followed for 16months without recurrent prolapse. Vaginal native tissue pelvic reconstruction is feasible in a patient with a history of pelvic exenteration.

Flaps versus skin grafts in neovagina creation for vaginal agenesis

Background: Women with congenital uterovaginal agenesis have normal development of all secondary sexual characteristics. They face the cruel fact of being unable to bear children and enjoy sexual satisfaction. Good neo vaginal reconstruction is important in improving functional and psycho social impacts to womanhood. The aim of the study was to compare the three commonly done surgical procedures for vaginal reconstruction.Methods: All the vaginal agenesis patients who attended Department of plastic surgery Madras Medical College, Chennai during the period from August 2004 to April 2007 were included in our study.Results: In Abbe McIndoe procedure, graft take was full in all 7 cases with good cosmetic appearance. Flaps survived in all 10 patients underwent pudendal thigh flap surgery. 2 patients underwent horse shoe shaped labia minora flaps. The cosmetic appearance was fair because of the distortion of the labia. The mean vaginal depth obtained was 8 cm and width was 2 cm.Conclusions: Cosmetic appearance was good in patients who underwent McIndoe procedure as the genitalia were not distorted. Contracture rate was more in patients who underwent McIndoe procedure especially who were irregular in using stents. Flap procedure especially pudendal thigh flaps which has the least contraction rate is the preferable treatment option for such patients.

Extracellular Matrix Stiffness and Composition Regulate the Myofibroblast Differentiation of Vaginal Fibroblasts.

Fibroblast to myofibroblast differentiation is a key feature of wound-healing in soft tissues, including the vagina. Vaginal fibroblasts maintain the integrity of the vaginal wall tissues, essential to keep pelvic organs in place and avoid pelvic organ prolapse (POP). The micro-environment of vaginal tissues in POP patients is stiffer and has different extracellular matrix (ECM) composition than healthy vaginal tissues. In this study, we employed a series of matrices with known stiffnesses, as well as vaginal ECMs, in combination with vaginal fibroblasts from POP and healthy tissues to investigate how matrix stiffness and composition regulate myofibroblast differentiation in vaginal fibroblasts. Stiffness was positively correlated to production of α-smooth muscle actin (α-SMA). Vaginal ECMs induced myofibroblast differentiation as both α-SMA and collagen gene expressions were increased. This differentiation was more pronounced in cells seeded on POP-ECMs that were stiffer than those derived from healthy tissues and had higher collagen and elastin protein content. We showed that stiffness and ECM content regulate vaginal myofibroblast differentiation. We provide preliminary evidence that vaginal fibroblasts might recognize POP-ECMs as scar tissues that need to be remodeled. This is fundamentally important for tissue repair, and provides a rational basis for POP disease modelling and therapeutic innovations in vaginal reconstruction.

Vaginal Reconstruction in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome-One Centre Experience.

Background and Objectives: The Mayer–Rokitansky–Küster–Hauser syndrome is a congenital condition in which patients are born with vaginal and uterus agenesis, affecting the ability to have a normal sexual life and to bear children. Vaginal reconstruction is a challenging procedure for plastic surgeons. The aim of this study is to report our experience in the management of twelve patients with congenital absence of the vagina due to the MRKH syndrome. Materials and Methods: We performed a retrospective study on 12 patients admitted to the Plastic Surgery Department of the Clinical Emergency Hospital “Prof. Dr. Agrippa Ionescu”, Bucharest, Romania, for vaginal reconstruction within a period of eleven years (January 2009–December 2019). All patients were diagnosed by the gynaecologists with vaginal agenesis, as part of the Mayer–Rokitansky–Küster–Hauser syndrome. The Abbe‘–McIndoe technique with an autologous skin graft was performed in all cases. Results: The average age of our patients was 20.16 (16–28) years. All patients were 46 XX. The average surgical timing was 3.05 h (range 2.85–4h). Postoperative rectovaginal fistula was encountered in 1 patient. Postoperative average vaginal length was 10.4 cm (range 9.8–12.1 cm). Regular sexual life was achieved in 10 patients. Conclusion: Nowadays, there is no established standard method of vaginal reconstruction. In Romania, the McIndoe technique is the most applied. Unfortunately, even if the MRKH syndrome is not uncommon, less and less surgeons are willing to perform the procedure to create a neovagina.

Long Term Anatomical and Functional Results of Modified McIndoe Vaginoplasty with Amnion Graft in Patients with Congenital Vaginal Aplasia Compared with a Control Group

Background: Vaginal aplasia is a rare congenital anomaly with different surgical techniques suggested for vaginal reconstruction.McIndoe vaginoplasty is an easy one of these surgical methods with a low morbidity rate, but its long-term results need to be further investigated. Therefore, the female genital anatomy and sexual function was examined after performing McIndoe vaginoplasty in patients with mullerian anomaly or androgen insensitivity syndrome. Materials and Methods: In this historical cohort study, the data of 25 patients undergoing McIndoe vaginoplasty with amniotic graft from 2006 to 2017 at four selected hospitals of Shiraz affiliated with Shiraz University of Medical Sciences in Iran were extracted from medical records. Then, the patients were called to refer for physical examination and fill the Female Sexual Function Index (FSFI) questionnaire. In addition, 31 women of the same age range and without a sexual problem, vaginal surgery, or delivery were selected as the control group. Finally, the results of vaginal measurements and FSFI scores of the two groups were compared together. Results: Theaverage vaginal length of the case and control groups were 5.60±2.38 and 8.47±1.31 cm, respectively. Furthermore, the mean proximal vaginal diameter in case and control groups were measured 2.94±0.92, and 4.12±0.70 cm, respectively (P<0.001). The mean FSFI score of the case group was 12.81±7.87, and 24.19±2.90 for the control group (P<0.001). The vaginal indices and FSFI of the patients using mold routinely were still lower than the control group (P<0.05) although theyhad a larger vagina (P<0.001). Conclusion: Vaginal reconstruction using McIndoe vaginoplasty with amniotic graft failed to provide normal vagina function and anatomy for patients with congenital vaginal aplasia in long-term follow-up.

Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note

Immediate vaginal reconstruction is usually offered following pelvic exenteration for recurrent cervical cancer in women previously treated with radiotherapy or with severe radiation-induced fistulae. Introduction of muscle-sparing flaps, such as the pedicled vertical deep inferior epigastric perforator (DIEP) flap, provides viable tissues for vaginal reconstruction and is associated with reduced donor-site morbidity. This report describes the surgical technique, which is one of the procedures of choice for vaginal reconstruction. It is safe and beneficial, especially for women with gynecologic cancer who have undergone pelvic exenteration after failed radiation therapy.

Interdisciplinary Surgical Approaches in Vaginal and Perineal Reconstruction of Advanced Rectal and Anal Female Cancer Patients.

Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy—and in case of a relapse a second irradiation—rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (tpVRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.

Reconstruction of Intrapelvic Defects Using the Free Anterolateral Thigh Flap: Expanding the Traditional Algorithm.

Reconstruction of intrapelvic soft tissue defects traditionally relies on regional pedicled myocutaneous flaps. However, there remain situations in which local options are unavailable. We review our experience treating intrapelvic defects with the anterolateral thigh (ALT) microvascular free flap. A retrospective, institutional review was conducted from 2014 to 2018 of patients undergoing microvascular ALT flap reconstruction of intrapelvic defects. Four patients were identified in this cohort out of 92 total pelvic reconstruction cases. All patients underwent abdominoperineal resection (APR) for rectal cancer treatment. In the two male patients, pelvic abscesses and bladder leak necessitated soft tissue reconstruction after radiation and APR. In both, regional tissue options were unavailable, and a buried ALT free flap was used for soft tissue reconstruction. Both female patients developed rectovaginal fistulas secondary to their tumor burden, necessitating posterior vaginal wall resections. Prior surgical scars and ostomies made abdominal wall tissue unavailable; thus, free ALTs were used to eliminate intrapelvic dead space and reconstruct the posterior vaginal wall. In all cases, recipient vessels were the deep inferior epigastric artery and vein. Flap survival was 100%. Pelvic reconstruction has traditionally been addressed with local/regional pedicled flaps. In cases where these are unavailable, the free ALT flap is a versatile option when buried for intrapelvic reconstruction or posterior vaginal wall lining. We also propose updating Cordeiro et al.'s classic vaginal defect reconstruction algorithm to include the free ALT flap for type IB cases in which the rectus abdominis is unavailable.

Prevascularized Tissue-Engineered Human Vaginal Mucosa: In Vitro Optimization and In Vivo Validation.

Tissue engineering offers novel therapies for vaginal reconstruction in patients with congenital vaginal agenesis such as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. This study aims to reconstruct a prevascularized tissue-engineered model of human vaginal mucosa (HVM) using the self-assembly approach, free of exogenous materials. In this study, a new cell culture method was used to enhance microcapillary network formation while maintaining sufficient biomechanical properties for surgical manipulation. Human vaginal fibroblasts were coseeded with human umbilical vein endothelial cells (HUVECs). Transduction of HUVEC with a vector that allows the expression of both green fluorescent protein (GFP) and luciferase allowed the monitoring of the formation of a microvascular network in vitro and the assessment of the viability and stability of HUVEC in vivo. Two reconstructed vaginal mucosa grafts, a prevascularized, and a nonvascularized control were implanted subcutaneously on the back of 12 female nude mice and monitored for up to 21 days. Prevascularized grafts demonstrated signs of earlier vascularization compared with controls. However, there were no differences in graft survival outcomes in both groups. The finding of mouse red blood cells within GFP-positive capillaries 1 week after implantation demonstrates the capacity of the reconstructed capillary-like network to connect to the host circulation and sustain blood perfusion in vivo. Furthermore, sites of inosculation between GFP-positive HUVEC and mouse endothelial cells were observed within prevascularized grafts. Our results demonstrate that the addition of endothelial cells using a hybrid approach of self-assembly and reseeding generates a mature capillary-like network that has the potential to become functional in vivo, offering an optimized prevascularized HVM model for further translational research. Impact statement This study introduces a prevascularized tissue-engineered model of human vaginal mucosa (HVM), which is adapted for surgical applications. The prevascularization of tissue-engineered grafts aims to enhance graft survival and is an interesting feature for sexual function. Various scaffold-free cell culture methods were tested to reconstruct a mature microcapillary network within HVM grafts while meeting biomechanical needs for surgery. Moreover, this animal study assesses the vascular functionality of prevascularized grafts in vivo, serving as a proof of concept for further translational applications. This research underlines the continuous efforts to optimize current models to closely mimic native tissues and further improve surgical outcomes.

V09-10 ROBOT ASSISTED VAGINOPLASTY WITH A COMBINED ABDOMINAL AND PERINEAL APPROACH IN A PEDIATRIC PATIENT WITH DISTAL VAGINAL ATRESIA

INTRODUCTION AND OBJECTIVE:Historically, vaginal reconstruction for atresia has been managed by a variety of different procedures involving the use of muscle flaps, peritoneum, and bowel to augment...

MP05-15 8 YEARS PROSTHETIC VAGINAL PELVIC ORGAN PROLAPSE REPAIR IN ULTRA-HIGH-VOLUME CENTER: 4487 PATIENTS, 250 CASES PER SURGEON ANNUALLY AND NO EVIDENCE FOR MESH BAN

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (MP05)1 Apr 2020MP05-15 8 YEARS PROSTHETIC VAGINAL PELVIC ORGAN PROLAPSE REPAIR IN ULTRA-HIGH-VOLUME CENTER: 4487 PATIENTS, 250 CASES PER SURGEON ANNUALLY AND NO EVIDENCE FOR MESH BAN Shkarupa Dmitry*, Shkarupa Andrey, Kubin Nikita, Shulgin Andrey, Staroseltseva Olga, Vostrikova Evgenia, and Ustinova Anna Shkarupa Dmitry*Shkarupa Dmitry* More articles by this author , Shkarupa AndreyShkarupa Andrey More articles by this author , Kubin NikitaKubin Nikita More articles by this author , Shulgin AndreyShulgin Andrey More articles by this author , Staroseltseva OlgaStaroseltseva Olga More articles by this author , Vostrikova EvgeniaVostrikova Evgenia More articles by this author , and Ustinova AnnaUstinova Anna More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000819.015AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: At the moment, there is no universal approach to the treatment of patients with pelvic organ prolapse (POP). Native tissue repair is characterized with the lack of effectiveness in advanced cases however the use of synthetic materials can lead to a number of specific complications. The objective was to assess the evolution in POP-mesh surgery based on tertiary center experience. METHODS: The database of 4487 patients operated for POP with the use of mesh implants during 2012-2019 was analysed retrospectively. The type of performed surgery and indicators characterizing its safety and effectiveness were evaluated. RESULTS: According to the results, it was possible to retrace distinctly how the techniques for pelvic floor reconstruction have been changed basing on clinical experience and global trends. First, there were two “big” meshes: one for each compartment. Then, there was a total exclusion of mesh implantation in posterior compartment in favor of native tissue repair. Further, the fixation of implant to arcus tendinius was replaced for sacrospinous. Meanwhile, the transition from trocar technique to anchor fixation took place. Subsequently, the anchor fixation was changed again for trocar and a “big” implant was replaced by apical sling which was put bilaterally in sacrospinous ligaments and the anterior compartment was repaired via original subfascial colporrhaphy. Then the bilateral fixation was replaced by the unilateral apical sling. Finally, the technique described above was combined with posterior colpoperineoplasty for the hybrid three-level reconstruction of the pelvic floor. The results of all listed techniques are presented in the table. It is important that with the decrease of the implanted mesh material amount and decrease of fixation points, the technique’s safety rises while retaining its high effectiveness. CONCLUSIONS: The keystone of the improvement of technologies in vaginal reconstruction of the pelvic floor for 8 years was to reduce the amount of synthetic material and the number of fixation points of mesh implant together with pathogenetically substantiated native tissue repair. In high-volume center where every doctor performs at least 250 surgeries annually, the number of complications is more than acceptable. Source of Funding: no © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e47-e47 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Shkarupa Dmitry* More articles by this author Shkarupa Andrey More articles by this author Kubin Nikita More articles by this author Shulgin Andrey More articles by this author Staroseltseva Olga More articles by this author Vostrikova Evgenia More articles by this author Ustinova Anna More articles by this author Expand All Advertisement PDF downloadLoading ...

The use of previously irradiated pedicled flaps for vaginal reconstruction

The use of previously irradiated pedicled flaps for vaginal reconstruction