Vaginal Stent Research Articles

Polycaprolactone-based shape memory foams as self-fitting vaginal stents

There is an urgent critical need for a patient-forward vaginal stent that can prevent debilitating vaginal stenosis that occurs after pelvic radiation treatments and vaginal reconstruction. To this end, we developed a self-fitting vaginal stent based on a shape-memory polymer (SMP) foam that can assume a secondary, compressed shape for ease of deployment. Upon insertion, the change in temperature and hydration initiates foam expansion to shape fit to the individual patient and restore the lumen of the stent to allow egress of vaginal secretions. To achieve rapid actuation at physiological temperature, we investigated the effect of architecture of two photocurable, polycaprolactone (PCL) macromers. Star-PCL-tetraacrylate displayed a reduced melting temperature as compared to a linear-PCL-diacrylate. Upon fabrication into high porosity foams with emulsion-templating, both compositions displayed shape fixity (>90 %) in a crimped, temporary shape. However, only the PCL star-foams displayed shape recovery (∼84 %) at 37 °C with expansion back to its permanent shape. A custom mold and curing system were then used to fabricate the PCL star-foams into hollow, cylindrical stents. The stent was crimped to its temporary insertion shape (50 % reduction in diameter, OD ∼ 11 mm) with a custom radial crimper and displayed excellent shape fixity for deployment (> 95 %) and shape recovery (∼ 100 %). To screen vaginal stents, we developed a custom benchtop pelvic model that simulated vaginal anatomy, temperatures, and pressures with an associated computational model. The crimped SMP vaginal stent was deployed in the model and expanded to walls of the canal (∼70 % increase in cross-sectional area) in less than 5 min after irrigation with warm water. The vaginal stent demonstrated retention of vaginal caliber with less than 10 % decrease in cross-sectional area under physiological pressures. Collectively, this work demonstrates the potential for SMP foams as self-fitting vaginal stents to prevent stenosis and provides new open-source tools for the iterative design of other gynecological devices. Statement of significanceVaginal stenosis, a painful narrowing of the vaginal canal, is a common complication after pelvic radiation therapy or reconstructive surgery. To address this clinical need, we have created a self-fitting vaginal stent from a shape-memory polymer foam. The stent compresses for easy insertion and then expands to adapt to each patient's anatomy to maintain an open vaginal canal and prevent stenosis. This innovative stent provides a patient-friendly solution that could make a significant difference for women undergoing pelvic treatments by reducing pain, aiding recovery, and improving quality of life.

Troubleshooting Vaginal Stents: A Critical Review of Common Problems and Solutions.

This review aims to examine the use of vaginal stents in clinical practice, specifically for treating vaginal agenesis and related complications and problem associated with vaginal stents. Vaginal agenesis, also known as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, is a congenital disorder characterized by the uterusnot developing or developing only partially. Vaginal stents are medical devices that preserve the structural integrity and patency of the vaginal canal after trauma or surgery. They playan important part in gynecological treatments such as post-radiation therapy, reconstructive surgery, and vaginal stenosis management. The review also discusses the primary applications of vaginal stents, such as preventing adhesions, healing mucosa, and maintaining patency. It also investigates frequent concerns associated with stent use, such as complications and the need for better designs. Vaginal stents are essential in a variety of therapeutic settings, providing major benefits in maintaining vaginal tissue and function. However, their use is fraught with complications, including the risk of infection, discomfort, and the possibility of inappropriate placement.

Understanding Physician Practices and Preferences Using Vaginal Stents to Prevent Postoperative Vaginal Stenosis in Pediatric and Adolescent Patients

Study ObjectiveThe purpose of this study is to describe practices to prevent vaginal stenosis in pediatric and adolescent patients and to evaluate the strengths and weaknesses of available vaginal stents. MethodsAn online survey was distributed to North American Society for Pediatric and Adolescent Gynecology (NASPAG) members with an optional follow up focus group. Quantitative and qualitative data were synthesized to highlight physician practices and preferences using vaginal stents, strengths and weakness of stents, and ideal stent properties. ResultsTwenty physicians completed at least 50% of the survey and 4 participated in the focus group. Most were pediatric and adolescent gynecology (PAG) specialists (95%) with fellowship training (60%) and experience in managing Müllerian anomalies (80%). Physicians reported they “always” used a vaginal stent when performing vaginoplasty for distal vaginal agenesis with a graft (62.5%) or without a graft (37.5%), and for transverse vaginal septa (57.1%). The most common type of stents used were packed condoms (60%), tracheobronchial stents (40%), Foley catheters (35%), and custom stents (35%). Participants described an ideal vaginal stent as something that would stay in place, cause little discomfort, expand, and come in a variety of lengths. ConclusionsThere are limited vaginal stent options for the PAG population. Participants reported variability in stents used to prevent vaginal stenosis with commonly used vaginal stents having significant weaknesses. Future efforts are needed to identify and develop post-operative clinical guidelines to prevent vaginal stenosis.

Variability in Design and Materials of Vaginal Stent or Moulds for Vaginal Agenesis - A Systematic Review

Background: Vaginal stents play a crucial role in both non-surgical and surgical management of vaginal agenesis. Different types of stents with variable designs and materials have been described in the literature. However, a summary of various stents described in the existing data and their outcome measures needs to be studied. Objectives: The objective of the study was to identify and summarise different types of vaginal stents used for patients with vaginal agenesis, to identify the design and material of different vaginal stents and to assess the benefit of using that specific vaginal stent. Materials and Methods: The literature search was conducted in the PubMed database for articles from 2000 to 2024 in the English language. An exploration of grey literature was also included through Google Scholar. The articles were included only if they clearly described vaginal stent, its material, design and advantage of using that particular stent, and any study not directly related to the research question or in which vaginal stent was used for cases other than vaginal agenesis/Mayer–Rokitansky–Kuster–Hauser syndrome/Mullerian aplasia or agenesis were not included in this study. Risk of bias assessment was done using an eight-item tool that included domains of selection, ascertainment, causality and reporting. Results: A total of 133 abstracts appeared in PubMed, of which, 26 titles/abstracts were related to the research question. Based on inclusion and exclusion criteria, seventeen articles were selected for the review. A total of 905 articles were identified from Google Scholar, of which, 7 were chosen to be included. The literature reports the usage of variable vaginal stents which can be hard, soft, solid or hollow with the option of customisation available. Interpretation: Based on the results of this review, soft stents are better than rigid stents due to increased patient compliance, a critical factor contributing to the success of the treatment. The resilient nature, comfort and lightweight of the silicone material are more suitable than commonly used acrylic material. However, the choice in a particular case may vary. Limitations: The majority of articles included in this review were case reports. As the duration and frequency of usage of stents affect the outcome, studies need to be done to evaluate the effectiveness of different types of stents to come to identify the best design and material for vaginal stents. PROSPERO Registration: CRD42024554676.

Sustained vaginal stent placement in the surgical management of shortened vaginal length

Sustained vaginal stent placement in the surgical management of shortened vaginal length

A NOVEL FABRICATION TECHNIQUE OF PROSTHETIC HOLLOW VAGINAL STENT FOR A CASE OF MAYER–ROKITANSKY–KUSTER–HAUSER SYNDROME

Vaginal stents are most widely employed in the management of maintaining the patency of neovagina in patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Although several methods are available for the fabrication of vaginal stents, hardly any techniques are described in the literature to date to make the vaginal stent prosthesis hollow. This article presents a novel simple and cost-effective technique for fabricating custom hollow vaginal stent prostheses for patients with MKRH syndrome. This dental technique offers a convenient removable treatment option for maintaining the patency of the neovagina and is a very straightforward, reasonably simple, and cost-effective method for making vaginal stents.

Experience of surgical correction of the urogenital sinus of the girl using an individual vaginal stent

Experience of surgical correction of the urogenital sinus of the girl using an individual vaginal stent

Star-PCL shape memory polymer (SMP) scaffolds with tunable transition temperatures for enhanced utility.

Thermoresponsive shape memory polymers (SMPs) prepared from UV-curable poly(ε-caprolactone) (PCL) macromers have the potential to create self-fitting bone scaffolds, self-expanding vaginal stents, and other shape-shifting devices. To ensure tissue safety during deployment, the shape actuation temperature (i.e., the melt transition temperature or Tm of PCL) must be reduced from ∼55 °C that is observed for scaffolds prepared from linear-PCL-DA (Mn ∼ 10 kg mol-1). Moreover, increasing the rate of biodegradation would be advantageous, facilitating bone tissue healing and potentially eliminating the need for stent retrieval. Herein, a series of six UV-curable PCL macromers were prepared with linear or 4-arm star architectures and with Mns of 10, 7.5, and 5 kg mol-1, and subsequently fabricated into six porous scaffold compositions (10k, 7.5k, 5k, 10k★, 7.5k★, and 5k★) via solvent casting particulate leaching (SCPL). Scaffolds produced from star-PCL-tetraacrylate (star-PCL-TA) macromers produced pronounced reductions in Tm with decreased Mnversus those formed with the corresponding linear-PCL-diacrylate (linear-PCL-DA) macromers. Scaffolds were produced with the desired reduced Tm profiles: 37 °C < Tm < 55 °C (self-fitting bone scaffold), and Tm ≤ 37 °C (self-expanding stent). As macromer Mn decreased, crosslink density increased while % crystallinity decreased, particularly for scaffolds prepared from star-PCL-TA macromers. While shape memory behavior was retained and radial expansion pressure increased, this imparted a reduction in modulus but with an increase in the rate of degradation.

Surgical Management of OHVIRA and Outcomes

Study ObjectiveObstructed hemivagina and ipsilateral renal anomaly (OHVIRA) includes uterine didelphys, unilateral obstructed hemivagina, and ipsilateral renal anomaly. Surgical management of this condition relies on accurate diagnosis to excise the obstructed longitudinal vaginal septum (OLVS). Vital considerations involve identifying the side affected, ipsilateral renal anomaly (IRA), thickness of the septum (TS), septal axis (SA), and distance of the septum to perineum (DSP). The study aimed to evaluate the preoperative characteristics, imaging findings, and surgical outcomes of OHVIRA. MethodsInstitutional review board approval was obtained for this retrospective chart review. ICD-10 codes identified OHVIRA cases between 2012 and 2019 at a single children's hospital. Patient demographic characteristics, magnetic resonance imaging findings, surgical management, outcomes, and complications were reviewed. Descriptive statistics were utilized. ResultsTwenty-six patients met inclusion criteria. Most were diagnosed at puberty (92%). Abdominal pain (50%) was the most common presenting complaint. The mean age of diagnosis was 13.2 years overall and 11.2 years for those with regular cycles vs 13.4 years for those with irregular cycles. Preoperative imaging showed predominant right-sided OLVS (50%), IRA (77%), and oblique SA (65%). All patients underwent vaginoscopy, septum resection, and vaginoplasty, except 1 who was managed with an abdominal drain as a neonate. Four required postoperative vaginal stent or Foley, with DSP greater than 5 cm in all cases. One intraabdominal abscess complication occurred. No instances of hematocolpos re-accumulation or reoperation were observed during the 3-year follow-up period. ConclusionThis study demonstrates that detailed preoperative planning and a systematic surgical approach lead to favorable outcomes in OHVIRA irrespective of the OLVS laterality, TS, SA, or DSP.

Adolescent and Young Adult Patients with Vaginal Graft-vs-Host Disease and Hematocolpos Managed with Vaginal Stents: A Case Series

Vaginal stenosis can be acquired as a result of vaginal graft-vs-host disease (GVHD) in patients who have undergone hematopoietic stem cell transplant (HSCT). Little data exist to guide the management of vaginal GVHD, particularly in adolescent and young adult patients. The objective of this study was to detail the management of vaginal stenosis with lysis of adhesions and vaginal stent placement in 3 young patients with vaginal GVHD. A retrospective chart review was done for 3 patients with vaginal GVHD causing vaginal stenosis with hematometrocolpos. All 3 were treated using vaginal stent placement. Additionally, a literature review was conducted through PubMed and Google Scholar to identify 21 case reports (with a total of 35 patients) of menstrual obstruction due to GVHD. Obstructive vaginal stenosis secondary to vaginal GVHD occurred in our patients at ages 15, 16, and 24 years. Resolution of hematocolpos was obtained with lysis of vaginal adhesions with vaginal stent placement in all patients, with varying regimens of systemic and topical hormones, topical corticosteroids, and dilator therapy. Vaginal stenosis secondary to vaginal GVHD should be considered in patients with a history of allogeneic HSCT presenting with amenorrhea, especially those with a diagnosis of primary ovarian insufficiency. The use of vaginal stents, along with postoperative medical and dilator management as appropriate, may prevent re-stenosis, although more information is needed regarding the efficacy of treatments.

V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP)

You have accessJournal of UrologyCME1 Apr 2023V09-05 ROBOTIC-ASSISTED VAGINOPLASTY WITH PERITONEAL COVERAGE (COMPLETE APICAL GRAFT CLOSURE VS. PERITONEAL CAP) Arman Walia, Vi Nguyen, Aditya Bagrodia, and Jennifer Anger Arman WaliaArman Walia More articles by this author , Vi NguyenVi Nguyen More articles by this author , Aditya BagrodiaAditya Bagrodia More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.05AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Penile inversion vaginoplasty is a common technique for feminizing gender-affirming surgery in which a vaginal canal can be created from full thickness scrotal skin graft. Based on surgeon preference or when scrotal skin is limited, the Davydov technique described for patients with vaginal agenesis can be used (Zhao et al). In this approach, the proximal canal is formed from peritoneum as a peritoneal cap. However, a peritoneal cap may not necessary in those with adequate graft length. Here we demonstrate a modified Davydov technique is which the apex of the vaginal canal is closed and peritoneal flaps are utilized for coverage and blood supply only, rather than inclusion as the neovaginal apex. METHODS: We utilized a standard pelvic robotic port placement using the Da Vinci Xi. Side docking allows for perineal dissection and penile disassembly. Posterior dissection is performed similar to robotic prostatectomy. The peritoneum is incised and Denonvillier’s followed. The perineal surgeon directs the robotic surgeon in avoiding the rectum. Under vision from above the perineal surgeon enters the dissected space. With guidance from below, the robotic surgeon separates the lateral levator muscle until the opening is calibrated to vaginal stent diameter. Vaginal packing can be placed to facilitate remaining perineal work. The lateral peritoneal flaps are created by incising peritoneum over the external iliac artery distally. Flap length is assessed to avoid constriction over the sigmoid, and further released as needed. After confirming adequate length, the canal is delivered from below. The apex can be closed prior to delivery or robotically. The anterior peritoneal flap is harvested by continuing the lateral dissections in an inverted "U". The lateral flaps are then secured to the canal with barbed suture. Depending on patient anatomy, the anterior flap can be rotated for coverage or simply advanced posteriorly. The anterior and posterior peritoneal flaps are then approximated over the canal apex to provide blood supply to the graft. RESULTS: The above technique has been applied to our last 5 penile inversion vaginoplasty patients. Each had an unremarkable postoperative recovery and is doing well at follow up. CONCLUSIONS: Gender-affirming surgery is a growing field with evolving techniques. A robotic-assisted approach provides additional visibility and maneuverability. A modified Davydov technique for peritoneal coverage can be added to our surgical repertoire for patients with adequate canal length so that the vaginal graft can be fully closed at the apex. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e838 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Arman Walia More articles by this author Vi Nguyen More articles by this author Aditya Bagrodia More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...

42. Self-fitting Vaginal Stents from Biodegradable, Shape Memory Polymers

42. Self-fitting Vaginal Stents from Biodegradable, Shape Memory Polymers

Management of Hematometra and Hematocolpos in Obstructive Mullerian Anomalies by Image-Guided Drainage with Interventional Radiology: A Multi-Institutional Case Series

Study ObjectiveTo describe cases of image-guided drainage of symptomatic hematometrocolpos from obstructive Müllerian anomalies as a temporizing measure to manage acute pain symptoms and delay definitive management of the obstructive Müllerian anomalies that require complex reconstruction MethodsInstitutional Review Board exemption from all included institutions was obtained. A retrospective case series from 3 academic children's hospitals of 8 females under the age of 21 with symptomatic hematometrocolpos due to obstructive Müllerian anomalies drained by image-guided percutaneous transabdominal vaginal or uterine drainage with interventional radiology was reviewed and described. ResultsEight pubertal patients with obstructive Müllerian anomalies (6 patients with distal vaginal agenesis, 1 patient with an obstructed uterine horn, and 1 patient with a high obstructed hemi-vagina) and symptomatic hematometrocolpos are reported. All patients with distal vaginal agenesis had greater than 3 cm lower vaginal agenesis, which would usually require complex vaginoplasty and use of postoperative stents. Given their immaturity and inability to use stents or dilators postoperatively or medical complexity, they subsequently underwent ultrasound-guided drainage of hematometrocolpos with interventional radiology to relieve pain symptoms, followed by menstrual suppression. The patients with obstructed uterine horns had complex medical and surgical histories requiring perioperative planning; they also underwent ultrasound-guided drainage of hematometra as a temporizing measure to manage acute symptoms. ConclusionPatients presenting with symptomatic hematometrocolpos due to obstructive Müllerian anomalies might not be psychologically mature enough to undergo definitive complex reconstruction, which requires vaginal stent or dilator use postoperatively to prevent stenosis and other complications. Image-guided percutaneous drainage of symptomatic hematometrocolpos serves as a temporizing measure by offering pain relief until patients are ready to undergo surgical management and/or to allow time for complex surgical planning.

An Innovative Approach in the Fabrication of a Hollow Vaginal Stent Using Ice in a Gender Dysphoria Patient: A Case Report

Gender dysphoria is the term used for individuals who are unhappy with their assigned gender at birth. They experience a strong desire to have the body of the opposite gender or to be socially recognised as a person of the opposite gender. Gender dysphoria can occur in both genders, but it is more prevalent in males, ranging from 0.005% to 0.014%. In females, the prevalence rate is lower, ranging from 0.002% to 0.003%. This case report highlights the prosthetic management of a 31 years old male patient with gender dysphoria after undergoing surgical intervention to remove male genitalia and create a neovagina. The patient underwent multiple surgeries to fulfill their gender transition desires. The patient initially visited the Department of Prosthodontics before vaginoplasty, where a custom-made hollow vaginal stent was planned and fabricated using a novel technique. In addition to prosthetic treatment, the patient also required hormonal therapies and psychological counseling, both of which were provided.

Vaginal stents: what is working and what is needed to prevent vaginal stenosis in young women

Background: Vaginal stents are used to prevent vaginal stenosis in patients requiring vaginoplasty for vaginal anomalies and strictures. Providers are using a variety of medical devices including foley catheters, condoms with packing, tracheobronchial stents and custom or commercial stents as vaginal stents. The purpose of this study is to describe strengths and weaknesses of available vaginal stents as well explore characteristics for an ideal vaginal stent.

24. Peri-urethral cyst mistaken for imperforate hymen in a patient with distal vaginal agenesis

<h3>Background</h3> Imperforate hymen is the most common obstructive genital tract anomaly and typically presents in adolescence with primary amenorrhea, worsening pelvic pain, and a bulging hymenal membrane at the introitus. When the hymen is normally visualized, other obstructive anomalies should be considered, as establishing the correct diagnosis prior to making management decisions is paramount. We present a case of a peri-urethral cyst misdiagnosed as an imperforate hymen in a patient with vaginal agenesis, highlighting strategies for accurate diagnosis and options for management. <h3>Case</h3> An 11 year old premenarchal female presented to the Emergency Department (ED) with several months of worsening intermittent lower abdominal pain. In the ED, she had transabdominal pelvic imaging showing a large hematometrocolpos and per the provider an imperforate hymen external genital exam. After achieving adequate pain control, she was discharged to follow up with Pediatric and Adolescent Gynecology. At her follow up visit, examination findings were notable for an annular hymen with membranous tissue blocking the vagina immediately behind the hymen. On rectal exam, the hematocolpos was palpated approximately 4 cm from the introitus. The patient was started on menstrual suppression with depot leuprolide and norethindrone acetate. Follow up magnetic resonance imaging (MRI) confirmed a cyst near the introitus and distal vaginal agenesis. When the genitalia were re-examined under anesthesia, adequate labial traction revealed a peri-urethral cyst. Due to ongoing pain, interventional radiology placed a transuterine drain under ultrasound guidance. Tissue plasminogen activator (TPA) was used through the drain to thin the obstructed blood and facilitate drainage. Approximately 500 ml of blood was drained from uterus and vagina before the drain was removed. The patient remains asymptomatic and will continue menstrual suppression until she reaches an age when she can participate in post-operative care. <h3>Comments</h3> In this case, the diagnosis of distal vaginal agenesis was obscured by the presence of a peri-urethral cyst. The case illustrates the importance of thorough examination including rectal exam and pelvic MRI when the diagnosis is unclear. Vaginal dilation or use of a vaginal stent is usually required after definitive surgical management of distal vaginal agenesis and therefore it is important to consider age and maturity before any surgical decisions are made. Accurate diagnosis is of utmost importance and management efforts aimed at delaying definitive surgical management should be considered.

80. Vaginal healing research: from bench to bedside and beyond

<h3>Background</h3> Adolescents undergoing vaginal surgery are often left with scaring and lifelong sequelae that can interfere with their daily lives, including retained menstruation and painful vaginal exams and dyspareunia. While vaginal stents are known to aid in healing, there are no current stents available for young patients and furthermore, we do not fully understand why some girls scar while others do not. It is our goal to understand vaginal healing at the mechanistic level in order to prevent scaring while at the same time provide solutions in the clinic. <h3>Methods</h3> To elucidate fundamental mechanisms of vaginal healing, both in vitro and in vivo methods were developed. Using primary murine fibroblasts, the expression of hyaluronan (HA) related genes and cell migration in response to estrogen and mechanical stretch were evaluated. To model the interplay between vaginal layers, a vagina-on-a-chip is being designed. Murine models, including full thickness wounds and bleomycin instillation plus vaginal trauma, were developed to study regenerative vaginal healing and fibrosis, respectively. In combination with oophorectomy, histologic and gene expression changes were evaluated at various time points after insults. Clinically, vaginal stents were designed and validated in a porcine model and review panels. Virtual reality (VR) technology and 3D imaging is being used for pre-operative training. <h3>Results</h3> We have successfully isolated and rapidly expanded murine primary vaginal fibroblasts, and our ongoing in vitro work suggests that estrogen influences HA via upregulation of HA synthesis genes. Full thickness murine vaginal wounds result in complete epithelial layer closure and resolution of inflammatory changes by 72 hours, which is altered in oopherectomized mice. Bleomycin instillation alone did not lead to fibrosis, but in combination with wire brush trauma led to disrupted collagen organization. The design criteria for a vagina-on-a-chip has been established including sustaining 3D cell culture and matching biomechanical properties. Physical vaginal stent designs to improve retention and patient comfort were validated and two designs were chosen for further benchtop testing in a novel pressurized 3D-printed model and a funded Phase I clinical trial. Resorbable stents were designed with polycaprolactone-based shape memory foams to provide sufficient radial force to maintain vaginal caliber over a target healing time of 4 weeks. Lastly, we are improving clinical training with 3D imaging and VR modeling. <h3>Conclusions</h3> We are advancing vaginal healing research by translating clinical problems into basic science questions and closing the loop ultimately back to bedside improvements.

85. Hematometrocolpos due to Graft versus Host Disease in Two Young Patients: Case Reports and a Review of the Literature

<h3>Background</h3> The differential diagnosis of primary or secondary amenorrhea includes obstructive pathologies such as vaginal stenosis. Vaginal stenosis can be acquired as a result of vaginal graft versus host disease (GVHD) in patients who have undergone hematopoietic stem cell transplant (HSCT). The true prevalence of vaginal GVHD is unknown, and young patients in particular are at risk for missed or delayed diagnosis, with the potential for severe complications such as vaginal stenosis and secondary hematometrocolpos. This case report demonstrates the potential for blunt dissection of vaginal adhesions along a tissue plane in cases of vaginal stenosis secondary to vaginal GVHD, and underscores the importance of increased physician awareness of vaginal GVHD in adolescents and increased screening for vaginal GVHD in at-risk adolescent patients. <h3>Case</h3> We report two cases of vaginal adhesions and hematometrocolpos secondary to vaginal GVHD in a 14-year-old patient and a 24-year-old patient, both with histories of allogeneic HSCT. Resolution of hematocolpos was obtained with surgical lysis of vaginal adhesions and temporary vaginal stent placement in both patients, followed by systemic and topical hormone therapy and, in the 24-year-old, dilator therapy. Future vaginal dilator versus surgical therapy is planned for the 14 year-old patient. <h3>Comments</h3> Vaginal stenosis secondary to vaginal GVHD must be considered with patients with a history of allogeneic HSCT who present with primary or secondary amenorrhea. Surgical management may be able to identify a residual plane of the normal vaginal canal, which may avoid the need for vaginal replacement and restore normal anatomy. The use of vaginal stents can facilitate attempts to restore normal anatomy and prevent restenosis, along with adequate postoperative medical and dilator management as appropriate. This complex diagnosis warrants careful treatment and surveillance that are bolstered by a strong physician-patient relationship and patient motivation to participate in care. These cases demonstrate that a tissue plane can be identified even in cases where the vagina appears completely stenotic. As HCST transplant success rates continue to increase, the occurrence of GVHD and vaginal GVHD in adolescents and young adults is anticipated to rise. The increasing incidence of vaginal GVHD and the potential for underdiagnosis supports a need for routine screening and education in adolescent and young adult patients who are at risk for vaginal GVHD.

English

Certain rare congenital defects can occur during the prenatal development of the female reproductive system, resulting in an abnormal or absent vagina.1 It is a part of the female genital tract. It is muscular and an elastic organ with a soft epithelial lining making it susceptible to disruption during crucial times of organogenesis.1,2 There are different malformations that occur in the female genital organ, many of which are classified under the broader term “Müllerian duct anomalies”. 1,2 Müllerian agenesis is also referred to as congenital absence of the uterus and vagina (CAUV), müllerian aplasia (MA), genital renal ear syndrome (GRES), and Mayer-Rokitansky-KüsterHauser syndrome (MRKH). It has been considered as a sporadic anomaly, but the increase in familial cases now supports the hypothesis of a genetic cause characterised by a failure of the Müllerian ducts to develop, resulting in a missing uterus and variable malformations of the vagina.1-7 According to scientific data, its incidence is reported to be 1 in 4,000 to 10,000 females occurring due to a heterozygous transformation of WNT4 gene on chromosome 1p36.1-7 Additionally, traumatic vaginal injury in females, which is not uncommon, results in vaginal stenosis.5 This results in formation of scar tissue causing stricture of the vagina.5 Based on the family history, the patient must undergo medical examination supported by gynaecologic assistance to provide a sensitive and specific means of diagnosis.1,2 It is essential for the patients and their families to attend counselling before proceeding for treatment as this syndrome can cause severe psychological stress in a young woman. Patients with vaginal agenesis in MRKH syndrome can be treated by both surgical and non-surgical procedures and there has been no evidence of the superiority of one technique over another.6,11 Abbe–McIndoe operation is a common surgical method using split thickness skin graft for reconstruction and Frank’s dilators is a common nonsurgical method for the creation of neovagina.3,7 Frank's initial technique used hand-held vaginal dilators in the lithotomy position and had technical limitations such as uncomfortable positioning, loss of time spent during the process of dilation, and fatigue of patient's hands. Ingram's method overcame these difficulties by using the sitting position to take advantage of the patient's body weight.8,9 This method used vaginal dilators mounted on a specially designed bicycle seat stool that provided perineal pressure via the narrow and elevated anterior portion of the bicycle seat.10 Despite the favourable clinical outcome of this method, there were some practical difficulties in making and handling these in an outpatient clinic. However, irrespective of the procedure opted, prosthetic vaginal dilators or long-term vaginal stents are required to prevent the possible contraction of the reconstructed neovagina, to maintain vaginal width, depth and to avoid vaginal stenosis.6

Robotic assisted ileo-vaginoplasty for vaginal atresia

Vaginal agenesis is a rare congenital disorder of female genital tract. Vaginal reconstruction using bowel segment is usually offered last when dilatation and/or prior vaginal reconstruction attempts using graft or flap has failed. Traditionally accomplished using open surgical approach, we describe here our initial experience of robotic-assisted ileo-vaginoplasty. The index patient presents to us with inadequate vaginal depth after failed buccal mucosal graft vaginoplasty. With the patient in low lithotomy position, port placement and docking of the robot was done. Isolation of ileal segment, closure at its proximal end and end-to-end bowel anastomosis was accomplished successfully. However, in view of dense adhesions the subsequent pull-down of the ileal segment into the perineum could not be done safely. The procedure was completed using combined abdomino-perineal open approach. A vaginal stent (in the ileal segment) and a catheter (in the introitus) were placed post-operatively. Post-operative recovery was uneventful. At 2-weeks, 3 months and a subsequent 1 year follow-up Cystoscopy and examination under anesthesia revealed an adequate vaginal depth with patient reporting successful vaginal dilatation. Robotic reconstruction of vagina using bowel segment in select patient, is safe and feasible, but possible with formidable surgical experience.