Vecchietti Operation Research Articles

Psychosexual and social consequences in a woman with undiagnosed Mayer-Rokitansky-Küster-Hauser syndrome

Purpose: To report a woman with devastating psychosexual and social consequences as a result of undiagnosed Mayer-Rokitansky- Küster-Hauser syndrome (MRKH) syndrome. Materials and Methods: An 18-year-old woman was referred after being divorced for “absent vagina and uterus”. On examination, secondary sexual characteristics were normal. Vaginal and rectal examinations revealed absent vagina and uterus. Investigations showed normal hormonal profile, 46 XX karyotype, and normal intravenous pyelography. Pelvic ultrasonography and magnetic resonance imaging (MRI) confirmed the absence of the uterus and presence bilateral ovaries. Results: A diagnosis of MRKH syndrome was made and she underwent successful modified laparoscopic Vecchietti operation for creation of a new vagina. Vaginal dilators were used after the surgery. Two years of follow up confirmed that vaginal length was about ten cm. Conclusion: The proper diagnosis, counseling, and prompt treatment of MRKH syndrome can prevent tragic consequences.

Single-incision mesh repair for the treatment of neovaginal prolapse

The MayereRokitanskyeKustereHauser syndrome is a congenital disorder characterized by the absence of the uterus and the upper two thirds of the vagina, but with normal ovarian function and karyotype. The incidence rate of this disorder is estimated to be one in 4000e5000 female live births [1]. These patients present with primary amenorrhea and seek medical consultation when they become adolescents. At present, nonsurgical vaginal dilator therapy is the treatment of choice recommended by the American College of Obstetricians and Gynecologists. The treatment has a reported success rate of approximately 86% in creating a functional vagina [2]. Several surgical techniques have been developed for patients who had unsuccessful passive vaginal dilatation. Some of the surgical procedures useful in this regard are the surgical creation of a neovaginal space, vulvovaginoplasty, bowel vaginoplasty, and the Vecchietti operation. However, whether a neovagina is created by passive dilatation or surgery, it is not apically or laterally suspended by endopelvic fascial attachments. The absence of these anatomical supports, or a defect in their normal functioning, increases the risk of prolapse. The Anterior Elevate system (American Medical Systems, Minnetonka, MN, USA) is one of the single-incision mesh kits available, and is reported to have favorable outcomes and acceptable adverse events for the treatment of prolapse [3,4]. To eliminate the recurrence of prolapse and reinforce the weakness of the native tissue, the mesh is put in place for the correction of cystocele and rectocele. Because of its efficacy and efficiency, synthetic meshes are being increasingly used worldwide. To date, very limited data are available on the treatment of neovaginal prolapse. We herein

Sexual Function after Modified Laparoscopic Vecchietti’s Vaginoplasty

Study Objective To report on minor modification of laparoscopic Vecchietti vaginoplasty and to examine the quality of sexual life after the operation. Design A retrospective study to examine the role of minor modification during laparoscopic Vecchietti operation to prevent injuries and to evaluate the sexual function of patients with neovagina. Setting Department of Obstetrics and Gynecology, University of Pécs, Faculty of Medicine, a tertiary supply center in Hungary. Paticipants Twenty-three adolescents or young adults, ages 16 to 26 with vaginal agenesis (Mayer-Rokitansky-Küster-Hauser syndrome) were operated. Twenty-five sexually active patients with matched age served as controls. Interventions Laparoscopic Vecchietti operation was modified with the use of endovaginal ultrasound transducer to visualize the narrow vesico-rectal space. The quality of sexual life 2–11 years after the operation was measured by the Female Sexual Function Index (FSFI). Main Outcome Measures Complications occurring during operations; desire, arousal, orgasm, satisfaction, lubrication, and pain during sexual intercourse. Results The technical modification of the operation, with endovaginal transducer, improved the method. Serious injuries of the bladder or rectum could be avoided. Anatomic and functional results shown by the total FSFI scores did not differ from that of the control group. Desire, arousal, orgasm, and satisfaction of the operated patients were similar to controls; however, patients with neovagina tended to have less lubrication and more pain during sexual intercourse. Conclusions Laparoscopic Vecchietti operation modified by the use of endovaginal transducer is a safe procedure to create a neovagina, which guarantees good quality of sexual life with high satisfaction for patients.

Should Progressive Perineal Dilation be Considered First Line Therapy for Vaginal Agenesis?

In women with vaginal agenesis progressive perineal dilation provides a minimally invasive method to create a functional vagina without the attendant risks or complications of traditional surgical options. We report our 12-year experience with this technique. Patients with vaginal agenesis treated at our institution were analyzed retrospectively and followed prospectively using case report forms and semistructured interviews. Patients diagnosed with vaginal agenesis were counseled on vaginal reconstruction options. Those electing progressive perineal dilation were instructed on the proper use of vaginal dilators by one of us (MRL) and advised to dilate 2 or 3 times daily for 20 minutes. All patients received physician, nursing and social work education and counseling. Parameters reviewed included primary diagnosis, start and end of vaginal dilation, dilation frequency, dilator size, sexual activity and whether the patient experienced pain or bleeding with dilation or sexual activity. Functional success was defined as the ability to achieve sexual intercourse, vaginal acceptance of the largest dilator without discomfort or a vaginal length of 7 cm. Univariate and multivariate analysis was performed to identify factors associated with successful neovaginal creation. From 1996 to 2008 we enrolled 69 females with vaginal agenesis in a progressive perineal dilation program. The primary diagnosis was Mayer-Rokitansky-Küster-Hauser syndrome in 64 patients. Mean age at the start of vaginal dilation was 17.5 years (range 14 to 35) Mean followup was 19 months (range 0 to 100). Four patients (5.7%) were lost to followup. In 7 of the remaining 65 patients (12%) treatment failed due to noncompliance and 50 (88%) achieved functional success at a median of 18.7 months. Patients who dilated frequently (once daily or greater) achieved a functional neovagina at a mean +/- SD of 4.3 +/- 2.4 months. Functional success correlated positively with frequent (once daily or greater) dilation and the initiation of sexual activity. Complications were minor. Three patients reported infrequent pain and 2 reported a single episode of bleeding with dilation. A total of 18 sexually active patients reported satisfactory intercourse without dyspareunia. Progressive perineal dilation for neovaginal creation is a valuable, minimally invasive therapy to create a functional vagina with a high success rate and a much lower complication rate than that in published surgical series. Given these findings, progressive perineal dilation should be offered as first line therapy in adolescents with a congenitally absent vagina.

The application of ‘endovaginal’ sonography during a laparoscopy‐assisted Vecchietti operation

Many types of operations are described to create a neovagina in a patient with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, that sometimes result in injury of the surrounding organs. Many trials are detailed in the literature to avoid these complications. Our goal was to examine the benefit of 'endovaginal' sonography during a laparoscopy-assisted Vecchietti operation to avoid bladder injuries. A neovagina was created in 15 women with MRKH syndrome by the method of Vecchietti assisted by laparoscopy. The method was modified with the use of‘endovaginal' sonography, in order to reduce bladder and rectal injuries. The vaginal ultrasound transducer, placed in front of the vaginal dimple, can guide penetration from the perineum into the peritoneal cavity. With this technique, the narrow space between the bladder and rectum can be well identified. All operations were successful, without any complication, forming a well-functioning 8-10 cm long neovagina, allowing easy introduction of two fingers in all cases, and with good quality of sexual life for the couples. Creation of a neovagina by any method in MRKH syndrome may sometimes result in injury of the bladder or rectum due to the narrow space between the bladder and rectum. The placement of the endovaginal ultrasound transducer in front of the vaginal dimple seems to be a promising method to avoid these complications during a laparoscopy-assisted Vecchietti operation.

Laparoscopic creation of a neovagina with the laparoscopic Vecchietti operation: comparison of two instrument sets

To compare safety and effectiveness of two different instrument sets for the laparoscopic Vecchietti operation for the creation of a neovagina. Descriptive study. Tertiary referral center. Twenty-six women with Rokitansky syndrome. Twelve consecutive patients had surgery with the kit recently developed by Storz (group 1) and 14 consecutive patients had surgery with the original kit of Vecchietti (group 2). Laparoscopic Vecchietti operation and clinical and instrumental follow-up for all patients. All the parameters reflecting safety, effectiveness, and compliance that were systematically measured for all patients. Patients in group 1 had a wider vagina at device removal and experienced less vaginal bleeding than patients in group 2, and the removal of the device was simpler. Patients in group 1 had a shorter vagina at device removal and retained the device and the Foley catheter for a longer period than patients in group 2. Diameter and length of neovagina at 1-month follow-up were comparable in the two groups. The availability of this new instrument set represents a small but significant improvement in the creation of a neovagina by the laparoscopic Vecchietti operation in women with Rokitansky syndrome.

Minimally invasive methods to create a neovagina

There are several methods to construct a vagina in case of a congenital vaginal agenesis. The significance of minimal-invasive technics, especially the laparascopian Vecchietti operation, increases continuously. The sigmoid neovagina was performed up to now per laparotomiam only. By performing it endoscopically, the postoperative discomfort for the patient was reduced in comparance to laparatomian operation. Some disadvantages of the laparoscopy Vecchietti operation and advantages of the sigmoid neovagina convinced us to support and develop this endoscopic method.

ULTRASOUND-ASSISTED LAPAROSCOPIC CREATION OF A NEOVAGINA BY MODIFICATION OF VECCHIETTIʼS OPERATION

In performing Vecchietti's operation laparoscopically, it is important to ensure bladder and rectum integrity. We report new techniques of ultrasonography and suture retrieval that simplify and improve the ease and speed of this operation. The pneumoperitoneum is emptied and the bladder filled with 200 mL of sterile water. The ultrasound probe is placed on the suprapubic wall for a sagittal image. The needle progresses medially through the vesicorectal space, with ultrasound guidance, and its emergence into the pelvis is controlled with laparoscopy. The nylon sutures carrying the dilation ball are threaded through the needle and brought back through the abdominal wall. Seven patients with vaginal aplasia had this procedure. There were no complications, and the mean operative time was 43 minutes (range 35-55). Mean vaginal length was 7 cm (range 6-10). Four women defined sexual intercourse as very satisfying and two as moderately satisfying. This original technique was used for easy, safe, and rapid creation of neovaginas.

The Vecchietti operation for constructing a neovagina: Indications, instrumentation, and techniques

The Vecchietti method is a surgical technique for the treatment of vaginal agenesis that constructs a dilation-type neovagina in 7-9 days. We have performed the Vecchietti operation on six patients. The method was applied to create a primary neovagina, to lengthen a surgically foreshortened vagina, and to reconstruct an obliterated neovagina with or without the presence of a uterus. Two patients underwent the conventional transabdominal approach, and four, laparoscopy. Follow-up was 7-39 months, and neovaginal depth was 8.0-10.6 cm. The anatomic and functional results in all patients were excellent.

Does it make sense to carry out a Vecchietti intervention pelviscopically?

The Mayer-Rokitansky-Küster syndrome is the most frequent cause of vaginal aplasia. There are several operations that can correct this malformation; the most important is that of Vecchietti. The rapid development of the laparoscopic know-how in the last years enables a pelviscopic approach of the laparotomic part of the Vecchietti operation. The question remains whether there are real advantages or whether the choice between laparotomy and laparoscopy should depend exclusively on the personal experience of the surgeon.

Laparoscopic-ultrasonographic combined technique for the creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome

To create a neovagina using a combined laparoscopic and ultrasonographic technique in Mayer-Rokitansky-Kuster-Hauser syndrome by modification of Vecchietti's operation. Case report. Division of Physiopathology of Reproduction, University of Palermo, Palermo, Italy. The advancement of the needle from the pseudohymen, through the vesicorectal space using a triple contrast ultrasonographic technique. The ultrasonographic scanning guides the accurate transit from external genitalia to the peritoneal cavity. This original approach allowed a safe and rapid creation of a neovagina in a case of Mayer-Rokitansky-Kuster-Hauser syndrome.

Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modification of Vecchietti's operation

A neovagina was created by a laparoscopic modification of Vecchietti's operation in two women with Mayer-Rokitansky-Kuster-Hauser syndrome. A plastic olive was applied to the vaginal dimple and pulled upward by two threads passed through the potential neovaginal space at laparoscopy, without the need for laparotomy or dissection of the vesicorectal space. In both cases we obtained very good results in anatomic and sexual functional terms.

Vecchietti's operation for the formation of a neovagina: technic and results

We performed Vecchietti's operation in 10 patients with absence of the vagina (8 Rokitansky-Küster-syndrome, 1 testicular feminization, 1 occlusion of the vagina after radiotherapy). There were no intra- or postoperative complications; on discharge the neovagina was patent for 2 fingers in all cases. On follow-up examinations 2 to 20 months postoperatively the neovagina was no longer patent in the patient after radiotherapy, all other patients had neovaginas with a length ranging from 5 to 9 cm and reported satisfactory coitus without dyspareunia. According to our experience the conditions for successful surgical formation of a neovagina are: good psychosocial adjustment, some preoperative sexual experience, higher age, preoperative counselling, and longterm follow-up.