Methods of Constructing a Vagina

Total vaginal reconstruction with combined 'Split Labia Minora Flaps' and full-thickness skin grafts

PURPOSE

Vaginal reconstruction with split-thickness skin grafts is the most common method for total vaginal reconstruction. Although it has disadvantages like contraction of the graft, foreshortening, donor site morbidity and long-lasting periods of vaginal standing; its easy surgical technique makes it popular. A new method using split labia minora (LM) flaps and full-thickness skin graft is discussed in this study.

METHOD

A 19-year-old female was presented with amenorrhea. A total absence of vagina was present and the patient underwent a total vaginal reconstruction for possible sexual intercourse.

RESULTS

We observed no contraction and no foreshortening with a patent vaginal cavity up to 11 cm and 4.5 cm width. The need for continuous standing period was as short as 4 weeks and for intermittent standing up to 4 months. Sexual intercourse was encouraged after 4 weeks. During sexual intercourse no external lubrication was reported to be needed. There was no need for further reconstructive intervention.

CONCLUSION

Vaginal reconstruction in congenital vaginal agenesis with split LM flaps and full-thickness skin grafts is a simple and effective method, which shortens the standing period and decreases the contraction in neovagina. Total vaginal reconstruction with split LM flaps could also be possible; to achieve this goal, expansion of LM flaps could be a further alternative.

The use of isolated sigmoid colon segment for vaginal replacement in young adults

PURPOSE

Vaginoplasty for congenital atresia, a component of the Mayer-Rokitansky-Kuster syndrome, or for gender confirmation, may be achieved by several techniques. This report focuses on the efficacy of rectosigmoid neocolporrhaphy (RSNC) for primary vaginal replacement.

MATERIALS AND METHODS

From 1990 to 2002 we evaluated six patients 16-33 years old (average age 23) who required vaginal replacement. The diagnoses included the Mayer-Rokitansky syndrome in two cases, classic bladder exstrophy in 1 and male pseudohermaphrodites in three cases. The vagina was reconstructed using a 15-cm isolated sigmoid segment placed between the bladder and rectum and anastomosed to the introitus in four patients. The Frank procedure was used in two patients.

RESULTS

A minimum of 1 year of followup is available in five of the six patients (mean of 32 month). Patients treated with sigmoid vaginoplasty had functional neovagina. with excellent cosmetic results and without excessive mucous production or the need for routine dilation. Stenosis at the mucocutaneous junction in one patient with a sigmoid vagina was treated with Y-V plasty. In the two patients managed by nonoperative perineal self-dilatation, there was little success noted and the two patients became surgical candidates.

CONCLUSIONS

Experience with this group of patients leads us to believe that isolated sigmoid segments provides a cosmetic, self-lubricating neovagina with low rates of failure and revision, and without the need for routine dilation.

Vaginal reconstruction

Absence of the vagina presents a challenging problem for the reconstructive urologist. This article reviews the pertinent diagnostic and pretreatment considerations and the surgical options, in particular, bowel vaginoplasty, for these patients.

Labial skin-flap vaginoplasty using tissue expanders

In severe vaginal malformations, when the distance between the upper vaginal pouch and perineum is too long (6 cm or more), reconstruction of the vagina can be performed by colonic interposition or by long cutaneous flaps obtained by the tissue expansion technique. Two female adolescents were treated using expanded labial skin flaps. Dissection and anastomosis between the vaginal remnant and cutaneous tube was performed by the transtrigonal approach. Results were satisfactory at 2.5-year follow-up. In our opinion, expanded labial skin-flap vaginoplasty has three main advantages: (1) it permits the construction of a large, soft, well-vascularized neovagina using non-hair-bearing labial skin; (2) it obviates postoperative dilations and prevents delayed strictures; and (3) a transtrigonal approach permits an easy vaginal dissection and a careful, tension-free anastomosis.

Vaginoplasty: combination therapy using labia minora flaps and lucite dilators--preliminary report

The treatment of vaginal agenesis is varied. The combination of creating a vaginal cavity with local skin flaps, then progressively dilating to a functional size has been successful in the past. We describe a technique using tubularized labia minora vascularized flaps to create a deep vaginal pouch that is widened and elongated with lucite dilators. The new vagina has an epithelial lining of nonhair-bearing skin. Three teenage girls, 2 with the Mayer-Rokitansky syndrome and 1 with mixed gonadal dysgenesis, underwent this procedure without any postoperative complications. Since neither abdominal surgery nor skin grafting was required there were no extra scars, excessive neovaginal secretions or need for long-term splinting during the 1-year followup period. The patients have almost normal-appearing genitalia postoperatively and neovaginas averaging 2 cm. wide and 6.3 cm. deep before dilation. We recommend this procedure as first line treatment for teenage girls with vaginal agenesis.

Vaginal replacement in children

Between 1980 and 1990, 17 patients underwent total vaginal replacement at our hospital. The majority of these patients presented with müllerian failure or gender reassignment for intersex. Colon vaginal replacement was done in 15 patients and small bowel was used in 2. Complications included prolapse in 2 patients and stenosis in 2. Of the 17 patients 4 are married, 10 are sexually active, only 1 reports dyspareunia and 1 requires home self-dilation.