Case Report Opening the Anterior Vaginal Vault: A Novel Approach to Vaginoplasty with a Modified McIndoe Procedure Using an Artificial Dermis Yasuhiko Kamada MD, PhD 1,*, Ai Sakamoto MD 1,2, Kazuhiro Tabuchi MD 1,2, Miwa Matsuda MD 1,2, Keiko Shimizu MD 1,2, Mikiya Nakatsuka MD, PhD 1,3, Yuji Hiramatsu MD, PhD 1,2 1
Department of Obstetrics and Gynecology, Okayama University Hospital, Okayama, Japan Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan 3 Graduate School of Health Sciences, Okayama University, Okayama, Japan 2
a b s t r a c t Background: Although preparation of a potential vaginal space between the bladder and rectum is a pivotal step in various vaginal reconstructions for patients with vaginal agenesis, few papers have mentioned the importance of this procedure. € ster-Hauser syndrome using a Case: We report the successful creation of a neovagina in 3 Japanese patients with Mayer-Rokitansky-Ku novel modified McIndoe procedure that involved separation between the bladder and the rudimentary uterus in a laparoscopically assisted manner. Summary and Conclusion: Opening “the anterior vaginal vault” between the bladder and uterus is a novel concept of vaginal reconstruction; this approach has not been described hitherto in the literature. Based on the outcome of our cases, we conclude that this procedure is advantageous in creating a large and soft neovagina. Key Words: Anterior vaginal vault, Artificial dermis, Neovagina, Potential vaginal space, Vaginal agenesis, Vaginal canal, Vaginoplasty
Introduction
€ ster-Hauser (MRKH) syndrome is Mayer-Rokitansky-Ku characterized by the presence of congenital vaginal agenesis, a rudimentary uterus (although not in all MRKH cases), and normal fallopian tubes and ovaries.1 This syndrome is estimated to occur in 1:1500 to 1:4000 female births.2 The creation of a neovagina is a crucial requirement for these patients to have sexual intercourse. Many surgical and nonsurgical techniques for vaginal reconstruction have been described thus far. Although preparation of a potential vaginal space between the bladder and rectum is a pivotal step in various vaginoplasties, few papers have mentioned the importance of this procedure. The apex of the space, as has been reported previously, anatomically corresponds to the “posterior vaginal vault.” However, we experienced some functionally unsuccessful cases in which the neovagina undergoes shortening, shrinking, and tapering, despite daily selfdilation after surgery. Therefore, we conceived the idea of opening an “anterior vaginal vault” between the bladder and uterus to ensure a wider apex for the vesicorectal vaginal canal. We report the successful creation of a neovagina in 3 Japanese patients with MRKH syndrome by a novel modified McIndoe procedure that involved the opening of an “anterior vaginal vault” in a laparoscopically assisted manner. All The authors indicate no conflicts of interest. * Address correspondence to: Yasuhiko Kamada, MD, PhD, Department of Obstetrics and Gynecology, Okayama University Medical School, 2-5-1 Shikata, Kita-ku, Okayama-city, Okayama 700-8558, Japan; fax: þ81-86-225-9570 E-mail address: [email protected] (Y. Kamada).
the cases were retrospectively analyzed after institutional review board approval was obtained for this study. Cases Case 1
A 20-year-old Japanese woman with vaginal agenesis was referred to us for further examination and treatment (Table 1). She had initially visited a gynecologist with primary amenorrhea at 19 years of age. Upon presentation at our hospital, normal secondary sexual development and a vaginal dimple without a vaginal orifice were noted. The patient's hormonal profile was the same as that of normal reproductive women. Abdominal and rectal ultrasonography revealed normal ovaries on both sides and a small uterus without endometrium. A magnetic resonance imaging scan of the pelvis also showed normal ovaries on both sides, a rudimentary uterus, and absence of a vagina. Chromosomal analysis showed a normal karyotype of 46,XX. Therefore, the patient was diagnosed with MRKH syndrome. The woman and her parents requested vaginal reconstruction. The patient and her parents were presented with 3 treatment options, namely, structured use of vaginal dilators, our modified McIndoe procedure using an artificial dermis,1 or our novel modified McIndoe procedure involving the opening of an “anterior vaginal vault.” They were counseled about the objectives and possible complications of each procedure and provided written consent to undergo the newly developed procedure. The patient began to perform dilation daily for approximately
1083-3188/$ - see front matter Ó 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.02.016
2
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Table 1 Characteristics of the Patients Case
Age at Diagnosis*
Age at Operation*
Urinary Tract Anomaly
Length of the Vaginal Canal (cm)
Length of the Neovagina at Postoperative 3 Months (cm)
Length of the Neovagina at Postoperative 12 Months (cm)
Sexual Intercourse
19 13 16
20 20 17
() () ()
11 12 12
8 8 9
7 8 8
() (þ) (þ)
1 2 3 * In years.
2 months before the surgery. After hospitalization, she received a low-fiber diet for 2 days before the operation. On the evening before the operation, she was administered a cleansing enema. Under general and epidural anesthesia, the patient was placed in the lithotomy position. Before the surgery, urologists performed cystoscopy, placed bilateral ureteral stents for the visualization of the ureter, and inserted a Foley catheter into the urinary bladder. A 5-mm optical trocar was directly inserted into the abdominal cavity through the center of the navel. A 5-mm wide laparoscope was introduced via the umbilical trocar after the establishment of an adequate pneumoperitoneum. Pelvic exploration revealed a cord connecting 2 rudimentary uterine horns. The ovaries and fallopian tubes on both sides appeared normal. The amount of peritoneal fluid pooled in the cul-de-sac was within the physiological limit. An H-shaped incision was made in the vestibular part of the vagina and a potential vaginal space was created. With a finger in the rectum, the bladder and rectal lumen were detached bluntly and sharply until the peritoneum was visualized (Fig. 1, A). The light of the laparoscope was identified through the peritoneum between the rectum and the cord of the rudimentary uterus. Then, the vesicorectal vaginal canal was extended by using a vaginal speculum. A peritoneal dome of diameter 4 cm was created on the apex of the vaginal canal. Next, the bladder was separated from the rudimentary uterus by sharp and blunt dissection (Fig. 1, B). Before creating the vesicouterine space (that is, the “anterior vaginal vault”), the position of the ureters of both sides around the uterine cord was confirmed by placing a finger under the laparoscope (Fig. 2, A). On reaching the
peritoneum, the space was extended laterally with special care to avoid injury to the ureters (Fig. 2, B). Then, the hard tissues on the peritoneum lining the uterine cord were removed carefully (Fig. 2, C). The removed tissues contained smooth muscles, connective fibers, vessels, and nerve fibers and were histologically similar to the normal uterus and parametrium (Fig. 2, D). Finally, a vaginal canal, at least 4 cm in diameter and 11 cm in length, was prepared. A large (4 cm 9 cm), bullet-shaped mold (Zoutituyoprothese, Atom Medical, Tokyo, Japan) made of acrylic resin was wrapped with the artificial dermis lined with silicone membrane (Terudermis, Terumo, Tokyo, Japan), and the edge of the artificial dermis was sutured with 2-0 polyglactin 910 (Coated Vicryl Rapide, Johnson and Johnson, Tokyo, Japan). The mold with the artificial dermis was then inserted into the newly created vaginal canal and the edge of the dermis was sutured to the vaginal orifice in an interrupted fashion using 2-0 polyglactin 910 circumferentially. After the ureteral stents were removed from both sides, the labia were sutured together over the mold to prevent prolapse. The operation time was 2 hours 24 minutes, and the blood loss was estimated to be 100 g. The patient wore an intermittent pneumatic compression device and was permitted minimal walking within her room. Antibiotics were administered for prophylaxis. A liquid diet or a low-fiber diet was recommended to avoid defecation. The urinary catheter was maintained in place for 1 week to avoid urinary retention and the external genitalia were washed with warm saline twice a day to prevent contamination. Epidural anesthesia was continued for 2 days after surgery, and appropriate painkillers were administered, as required. The intravaginal mold was removed on the 7th postoperative day, without
Fig. 1. Schematic diagram of the new procedure. Preparation of a potential vaginal space: (A) The bladder and rectal lumen were detached bluntly and sharply until the peritoneum was visualized. (B) To open the “anterior vaginal vault” (arrow), the bladder was separated carefully from the rudimentary uterus by sharp and blunt dissection toward the peritoneum under laparoscopic view.
Y. Kamada et al. / J Pediatr Adolesc Gynecol xxx (2014) 1e4
3
Fig. 2. (A) Before the surgery, ureteral stents were placed bilaterally. This helped confirm the position of the ureters (arrows) around the rudimentary uterus by palpation under laparoscopic visualization. (B) The bladder was separated from the rudimentary uterus by sharp and blunt dissection. After reaching the peritoneum, the vesicouterine space was also extended laterally. (C) Beneath the “anterior vaginal vault” (arrows), some hard tissue was present transversely on the peritoneum (arrowheads). (D) The tissue contained smooth muscles, connective fibers, vessels, and nerve fibers. Hematoxylin and eosin stain, 100 magnification.
any bleeding or infection. However, she wished to remain hospitalized rather than receive follow-up treatments at the outpatient clinic. During the next 7 days, the neovagina was irrigated with 0.01% benzalkonium chloride solution twice a day, before insertion and after removal of the mold, which was placed in the neovagina only when the patient slept. The silicone membrane was removed spontaneously from the neovagina. After the 14th postoperative day, she was instructed to wear an acrylic-resin mold (diameter, 4 cm) inserted by herself when she slept. She was discharged on the 17th postoperative day without any complications. She was examined weekly for 1 month. At each visit, the vaginal depth and epithelium were assessed to evaluate the function of the neovagina. Six weeks after the operation, epithelialization of the neovagina was complete and vaginal bleeding had diminished. Thereafter, the patient started to dilate the neovagina with a hand-made styrene-foam dilator (diameter 4 cm) by herself for 10-15 minutes a day, followed by the insertion of a hand-made styrene-foam mold (diameter 3.5 cm) at night. Approximately 12 months after the operation, the neovagina was at least 7 cm long and 4 cm wide since a largesized acrylic-resin mold could be inserted smoothly into it. We believe that her neovagina is sufficiently long and wide for sexual intercourse, but she is not currently in a sexual relationship, and therefore, we have been unable to verify this. Cases 2 and 3
The other 2 patients were 20- and 17-year-old Japanese women who were diagnosed with vaginal agenesis at 13
(patient 2) and 16 years (patient 3) of age, respectively (Table 1). Both had initially visited gynecologists with amenorrhea and were referred to us for further examination and treatment. The clinical profiles of these patients were similar to those of the previous patient. Neither of the patients had any anomaly of the urinary tracts. They wished to undergo the same operation performed in the first case. The operative time was 2 hours 57 minutes and 3 hours 42 minutes and the amount of blood loss was 100 g and 60 g, respectively, for patients 2 and 3. The vaginal length created was 12 cm in both cases. Both patients were discharged from our hospital on the 17th postoperative day. They were able to have sexual intercourse at 24 weeks after the operation and to maintain regular and satisfactory sexual activity thereafter. Summary and Conclusion
This paper reports a novel approach of preparing a potential vaginal space between the bladder and rectum for creating a neovagina laparoscopically; to our knowledge, this approach has not been described hitherto in the literature. There are many methods of vaginal reconstruction in patients with congenital vaginal agenesis, including MRKH syndrome. Among the surgical methods used for treatment, the epidermal skin graft or a vascularized intestinal substitution has been historically used for vaginoplasty. The McIndoe procedure originally involved the use of a split-thickness skin graft to cover a mold inserted into a surgically prepared vaginal space between the bladder and rectum.3 However, skin grafts can lead to significant
4
Y. Kamada et al. / J Pediatr Adolesc Gynecol xxx (2014) 1e4
scarring and stenosis with cosmetic and functional morbidity.4 To minimize surgical scarring, we have previously reported a modified McIndoe procedure using artificial dermis (an atelocollagen sponge) instead of skin grafts.1 Preparation of a vesicorectal vaginal canal is a crucial step in various vaginoplasties. The apex of this canal forms the “posterior vaginal vault” in the normal anatomy. However, until the epithelialization of the neovagina is complete, it can shrink and shorten to a certain degree. Indeed, we have encountered cases of patients who had difficulty in performing sexual intercourse because of the tapering of the neovagina despite daily self-dilation after surgery. A normal vaginal end forms a wide space, in other words, the anterior and posterior vaginal vaults. Therefore, we conceived the idea of establishing an “anterior vaginal vault” between the bladder and the rudimentary uterus to provide a wider apex for the neovagina. In preparing the anterior vaginal vault, the presence of the ureters on both sides may pose a problem. Under normal conditions, the ureters penetrate through the uterovesical ligament and enter the bladder; blind separation of the bladder and the uterus may lead to ureteral injuries. Moreover, uterovaginal agenesis can be associated in 30%40% of the cases of congenital anomalies of the upper urinary tract, of which the most common are unilateral renal agenesis and the pelvic kidney.5,6 Consequently, we inserted the ureteral stents and confirmed the localization of the ureters by palpation and visualization under a laparoscope; this made the procedure safe and easy. In all the 3 cases, the location of the urinary tracts was similar to that in normal women. After opening the “anterior vaginal vault” and removing the hard tissue around the rudimentary uterus, the apex of the vaginal canal became soft and could be stretched well. Furthermore, the vaginal canal was sufficiently large to accommodate a large (4 cm 9 cm) bulletshaped acrylic-resin mold with the artificial dermis. The Davydov method is another modified McIndoe procedure, wherein the patient's own pelvic peritoneum is used instead of skin grafts.7 After preparing the vaginal canal, the pelvic peritoneum is pulled through the canal and circumferentially sutured to the orifice. Based on our
experience, by using our novel “opening the anterior vaginal vault” method, the peritoneum could be easily pulled toward the vaginal orifice. However, we are not clear whether the use of our novel method in combination with the Davydov method would improve the length and width of the neovagina. Postoperative active self-dilation of the vagina is also important to maintain a functional neovagina. We prepared a hand-made styrene-foam dilator and mold for selfdilation, with some degree of vaginal epithelialization. Styrene foam is light, of appropriate hardness, and cheap. In addition, patients can adjust the size and shape by themselves. Thus, it is patient-friendly and suitable for use for daily self-dilation. In all cases, the apex of the neovagina was still sufficiently soft to allow sexual intercourse 12 months after the operation. However, the long-term prognosis is unknown because it depends on the patients' motivation for daily self-dilation and sexual activity. Although we have presented only 3 Japanese cases of MRKH syndrome, our procedure appears to offer an advantage by establishing a large and soft neovagina. Moreover, the bilateral placement of ureteral stents and management with laparoscopic assistance are useful for the prevention of urinary tract injury during vaginoplasty. Further evaluation is necessary to confirm the benefits of this procedure. References 1. Noguchi S, Nakatsuka M, Sugiyama Y, et al: Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a € ster-Hauser syndrome. Hum Reprod 2004; patient with Mayer-Rokitansky-Ku 19:1629 2. Aittomaki C, Eroila H, Kajanoja P: A population-based study of the incidence of € llerian aplasia in Finland. Fertil Steril 2001; 76:624 Mu 3. McIndoe AH, Bannister JB: An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Emp 1938; 45:490 4. Oakes MB, Beck S, Smith YR, et al: Augmentation vaginoplasty of colonic neovagina structure using oral mucosa graft. J Pediatr Adolesc Gynecol 2010; 23:e39 € bbe EH, Willemsen WN, Lemmens JA, et al: Mayer-Rokitansky-Ku € ster-Hauser 5. Stru syndrome: distinction between 2 forms based on excretory urographic, sonographic, and laparoscopic findings. AJR Am J Roentgenol 1993; 160:331 var F, Lo pez E, et al: Gonadal agenesis 46, XX associated with 6. Gorgojo JJ, Almodo the atypical form of Rokitansky syndrome. Fertil Steril 2002; 77:185 7. Davydov SN: Colpopoeisis from the peritoneum of the uterorectal space. [Article in Russian] Akush Gynekol (Mosk) 1969; 45:55
Department of Obstetrics and Gynecology, Okayama University Hospital, Okayama, Japan Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, Japan 3 Graduate School of Health Sciences, Okayama University, Okayama, Japan 2
a b s t r a c t Background: Although preparation of a potential vaginal space between the bladder and rectum is a pivotal step in various vaginal reconstructions for patients with vaginal agenesis, few papers have mentioned the importance of this procedure. € ster-Hauser syndrome using a Case: We report the successful creation of a neovagina in 3 Japanese patients with Mayer-Rokitansky-Ku novel modified McIndoe procedure that involved separation between the bladder and the rudimentary uterus in a laparoscopically assisted manner. Summary and Conclusion: Opening “the anterior vaginal vault” between the bladder and uterus is a novel concept of vaginal reconstruction; this approach has not been described hitherto in the literature. Based on the outcome of our cases, we conclude that this procedure is advantageous in creating a large and soft neovagina. Key Words: Anterior vaginal vault, Artificial dermis, Neovagina, Potential vaginal space, Vaginal agenesis, Vaginal canal, Vaginoplasty
Introduction
€ ster-Hauser (MRKH) syndrome is Mayer-Rokitansky-Ku characterized by the presence of congenital vaginal agenesis, a rudimentary uterus (although not in all MRKH cases), and normal fallopian tubes and ovaries.1 This syndrome is estimated to occur in 1:1500 to 1:4000 female births.2 The creation of a neovagina is a crucial requirement for these patients to have sexual intercourse. Many surgical and nonsurgical techniques for vaginal reconstruction have been described thus far. Although preparation of a potential vaginal space between the bladder and rectum is a pivotal step in various vaginoplasties, few papers have mentioned the importance of this procedure. The apex of the space, as has been reported previously, anatomically corresponds to the “posterior vaginal vault.” However, we experienced some functionally unsuccessful cases in which the neovagina undergoes shortening, shrinking, and tapering, despite daily selfdilation after surgery. Therefore, we conceived the idea of opening an “anterior vaginal vault” between the bladder and uterus to ensure a wider apex for the vesicorectal vaginal canal. We report the successful creation of a neovagina in 3 Japanese patients with MRKH syndrome by a novel modified McIndoe procedure that involved the opening of an “anterior vaginal vault” in a laparoscopically assisted manner. All The authors indicate no conflicts of interest. * Address correspondence to: Yasuhiko Kamada, MD, PhD, Department of Obstetrics and Gynecology, Okayama University Medical School, 2-5-1 Shikata, Kita-ku, Okayama-city, Okayama 700-8558, Japan; fax: þ81-86-225-9570 E-mail address: [email protected] (Y. Kamada).
the cases were retrospectively analyzed after institutional review board approval was obtained for this study. Cases Case 1
A 20-year-old Japanese woman with vaginal agenesis was referred to us for further examination and treatment (Table 1). She had initially visited a gynecologist with primary amenorrhea at 19 years of age. Upon presentation at our hospital, normal secondary sexual development and a vaginal dimple without a vaginal orifice were noted. The patient's hormonal profile was the same as that of normal reproductive women. Abdominal and rectal ultrasonography revealed normal ovaries on both sides and a small uterus without endometrium. A magnetic resonance imaging scan of the pelvis also showed normal ovaries on both sides, a rudimentary uterus, and absence of a vagina. Chromosomal analysis showed a normal karyotype of 46,XX. Therefore, the patient was diagnosed with MRKH syndrome. The woman and her parents requested vaginal reconstruction. The patient and her parents were presented with 3 treatment options, namely, structured use of vaginal dilators, our modified McIndoe procedure using an artificial dermis,1 or our novel modified McIndoe procedure involving the opening of an “anterior vaginal vault.” They were counseled about the objectives and possible complications of each procedure and provided written consent to undergo the newly developed procedure. The patient began to perform dilation daily for approximately
1083-3188/$ - see front matter Ó 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.jpag.2014.02.016
2
Y. Kamada et al. / J Pediatr Adolesc Gynecol xxx (2014) 1e4
Table 1 Characteristics of the Patients Case
Age at Diagnosis*
Age at Operation*
Urinary Tract Anomaly
Length of the Vaginal Canal (cm)
Length of the Neovagina at Postoperative 3 Months (cm)
Length of the Neovagina at Postoperative 12 Months (cm)
Sexual Intercourse
19 13 16
20 20 17
() () ()
11 12 12
8 8 9
7 8 8
() (þ) (þ)
1 2 3 * In years.
2 months before the surgery. After hospitalization, she received a low-fiber diet for 2 days before the operation. On the evening before the operation, she was administered a cleansing enema. Under general and epidural anesthesia, the patient was placed in the lithotomy position. Before the surgery, urologists performed cystoscopy, placed bilateral ureteral stents for the visualization of the ureter, and inserted a Foley catheter into the urinary bladder. A 5-mm optical trocar was directly inserted into the abdominal cavity through the center of the navel. A 5-mm wide laparoscope was introduced via the umbilical trocar after the establishment of an adequate pneumoperitoneum. Pelvic exploration revealed a cord connecting 2 rudimentary uterine horns. The ovaries and fallopian tubes on both sides appeared normal. The amount of peritoneal fluid pooled in the cul-de-sac was within the physiological limit. An H-shaped incision was made in the vestibular part of the vagina and a potential vaginal space was created. With a finger in the rectum, the bladder and rectal lumen were detached bluntly and sharply until the peritoneum was visualized (Fig. 1, A). The light of the laparoscope was identified through the peritoneum between the rectum and the cord of the rudimentary uterus. Then, the vesicorectal vaginal canal was extended by using a vaginal speculum. A peritoneal dome of diameter 4 cm was created on the apex of the vaginal canal. Next, the bladder was separated from the rudimentary uterus by sharp and blunt dissection (Fig. 1, B). Before creating the vesicouterine space (that is, the “anterior vaginal vault”), the position of the ureters of both sides around the uterine cord was confirmed by placing a finger under the laparoscope (Fig. 2, A). On reaching the
peritoneum, the space was extended laterally with special care to avoid injury to the ureters (Fig. 2, B). Then, the hard tissues on the peritoneum lining the uterine cord were removed carefully (Fig. 2, C). The removed tissues contained smooth muscles, connective fibers, vessels, and nerve fibers and were histologically similar to the normal uterus and parametrium (Fig. 2, D). Finally, a vaginal canal, at least 4 cm in diameter and 11 cm in length, was prepared. A large (4 cm 9 cm), bullet-shaped mold (Zoutituyoprothese, Atom Medical, Tokyo, Japan) made of acrylic resin was wrapped with the artificial dermis lined with silicone membrane (Terudermis, Terumo, Tokyo, Japan), and the edge of the artificial dermis was sutured with 2-0 polyglactin 910 (Coated Vicryl Rapide, Johnson and Johnson, Tokyo, Japan). The mold with the artificial dermis was then inserted into the newly created vaginal canal and the edge of the dermis was sutured to the vaginal orifice in an interrupted fashion using 2-0 polyglactin 910 circumferentially. After the ureteral stents were removed from both sides, the labia were sutured together over the mold to prevent prolapse. The operation time was 2 hours 24 minutes, and the blood loss was estimated to be 100 g. The patient wore an intermittent pneumatic compression device and was permitted minimal walking within her room. Antibiotics were administered for prophylaxis. A liquid diet or a low-fiber diet was recommended to avoid defecation. The urinary catheter was maintained in place for 1 week to avoid urinary retention and the external genitalia were washed with warm saline twice a day to prevent contamination. Epidural anesthesia was continued for 2 days after surgery, and appropriate painkillers were administered, as required. The intravaginal mold was removed on the 7th postoperative day, without
Fig. 1. Schematic diagram of the new procedure. Preparation of a potential vaginal space: (A) The bladder and rectal lumen were detached bluntly and sharply until the peritoneum was visualized. (B) To open the “anterior vaginal vault” (arrow), the bladder was separated carefully from the rudimentary uterus by sharp and blunt dissection toward the peritoneum under laparoscopic view.
Y. Kamada et al. / J Pediatr Adolesc Gynecol xxx (2014) 1e4
3
Fig. 2. (A) Before the surgery, ureteral stents were placed bilaterally. This helped confirm the position of the ureters (arrows) around the rudimentary uterus by palpation under laparoscopic visualization. (B) The bladder was separated from the rudimentary uterus by sharp and blunt dissection. After reaching the peritoneum, the vesicouterine space was also extended laterally. (C) Beneath the “anterior vaginal vault” (arrows), some hard tissue was present transversely on the peritoneum (arrowheads). (D) The tissue contained smooth muscles, connective fibers, vessels, and nerve fibers. Hematoxylin and eosin stain, 100 magnification.
any bleeding or infection. However, she wished to remain hospitalized rather than receive follow-up treatments at the outpatient clinic. During the next 7 days, the neovagina was irrigated with 0.01% benzalkonium chloride solution twice a day, before insertion and after removal of the mold, which was placed in the neovagina only when the patient slept. The silicone membrane was removed spontaneously from the neovagina. After the 14th postoperative day, she was instructed to wear an acrylic-resin mold (diameter, 4 cm) inserted by herself when she slept. She was discharged on the 17th postoperative day without any complications. She was examined weekly for 1 month. At each visit, the vaginal depth and epithelium were assessed to evaluate the function of the neovagina. Six weeks after the operation, epithelialization of the neovagina was complete and vaginal bleeding had diminished. Thereafter, the patient started to dilate the neovagina with a hand-made styrene-foam dilator (diameter 4 cm) by herself for 10-15 minutes a day, followed by the insertion of a hand-made styrene-foam mold (diameter 3.5 cm) at night. Approximately 12 months after the operation, the neovagina was at least 7 cm long and 4 cm wide since a largesized acrylic-resin mold could be inserted smoothly into it. We believe that her neovagina is sufficiently long and wide for sexual intercourse, but she is not currently in a sexual relationship, and therefore, we have been unable to verify this. Cases 2 and 3
The other 2 patients were 20- and 17-year-old Japanese women who were diagnosed with vaginal agenesis at 13
(patient 2) and 16 years (patient 3) of age, respectively (Table 1). Both had initially visited gynecologists with amenorrhea and were referred to us for further examination and treatment. The clinical profiles of these patients were similar to those of the previous patient. Neither of the patients had any anomaly of the urinary tracts. They wished to undergo the same operation performed in the first case. The operative time was 2 hours 57 minutes and 3 hours 42 minutes and the amount of blood loss was 100 g and 60 g, respectively, for patients 2 and 3. The vaginal length created was 12 cm in both cases. Both patients were discharged from our hospital on the 17th postoperative day. They were able to have sexual intercourse at 24 weeks after the operation and to maintain regular and satisfactory sexual activity thereafter. Summary and Conclusion
This paper reports a novel approach of preparing a potential vaginal space between the bladder and rectum for creating a neovagina laparoscopically; to our knowledge, this approach has not been described hitherto in the literature. There are many methods of vaginal reconstruction in patients with congenital vaginal agenesis, including MRKH syndrome. Among the surgical methods used for treatment, the epidermal skin graft or a vascularized intestinal substitution has been historically used for vaginoplasty. The McIndoe procedure originally involved the use of a split-thickness skin graft to cover a mold inserted into a surgically prepared vaginal space between the bladder and rectum.3 However, skin grafts can lead to significant
4
Y. Kamada et al. / J Pediatr Adolesc Gynecol xxx (2014) 1e4
scarring and stenosis with cosmetic and functional morbidity.4 To minimize surgical scarring, we have previously reported a modified McIndoe procedure using artificial dermis (an atelocollagen sponge) instead of skin grafts.1 Preparation of a vesicorectal vaginal canal is a crucial step in various vaginoplasties. The apex of this canal forms the “posterior vaginal vault” in the normal anatomy. However, until the epithelialization of the neovagina is complete, it can shrink and shorten to a certain degree. Indeed, we have encountered cases of patients who had difficulty in performing sexual intercourse because of the tapering of the neovagina despite daily self-dilation after surgery. A normal vaginal end forms a wide space, in other words, the anterior and posterior vaginal vaults. Therefore, we conceived the idea of establishing an “anterior vaginal vault” between the bladder and the rudimentary uterus to provide a wider apex for the neovagina. In preparing the anterior vaginal vault, the presence of the ureters on both sides may pose a problem. Under normal conditions, the ureters penetrate through the uterovesical ligament and enter the bladder; blind separation of the bladder and the uterus may lead to ureteral injuries. Moreover, uterovaginal agenesis can be associated in 30%40% of the cases of congenital anomalies of the upper urinary tract, of which the most common are unilateral renal agenesis and the pelvic kidney.5,6 Consequently, we inserted the ureteral stents and confirmed the localization of the ureters by palpation and visualization under a laparoscope; this made the procedure safe and easy. In all the 3 cases, the location of the urinary tracts was similar to that in normal women. After opening the “anterior vaginal vault” and removing the hard tissue around the rudimentary uterus, the apex of the vaginal canal became soft and could be stretched well. Furthermore, the vaginal canal was sufficiently large to accommodate a large (4 cm 9 cm) bulletshaped acrylic-resin mold with the artificial dermis. The Davydov method is another modified McIndoe procedure, wherein the patient's own pelvic peritoneum is used instead of skin grafts.7 After preparing the vaginal canal, the pelvic peritoneum is pulled through the canal and circumferentially sutured to the orifice. Based on our
experience, by using our novel “opening the anterior vaginal vault” method, the peritoneum could be easily pulled toward the vaginal orifice. However, we are not clear whether the use of our novel method in combination with the Davydov method would improve the length and width of the neovagina. Postoperative active self-dilation of the vagina is also important to maintain a functional neovagina. We prepared a hand-made styrene-foam dilator and mold for selfdilation, with some degree of vaginal epithelialization. Styrene foam is light, of appropriate hardness, and cheap. In addition, patients can adjust the size and shape by themselves. Thus, it is patient-friendly and suitable for use for daily self-dilation. In all cases, the apex of the neovagina was still sufficiently soft to allow sexual intercourse 12 months after the operation. However, the long-term prognosis is unknown because it depends on the patients' motivation for daily self-dilation and sexual activity. Although we have presented only 3 Japanese cases of MRKH syndrome, our procedure appears to offer an advantage by establishing a large and soft neovagina. Moreover, the bilateral placement of ureteral stents and management with laparoscopic assistance are useful for the prevention of urinary tract injury during vaginoplasty. Further evaluation is necessary to confirm the benefits of this procedure. References 1. Noguchi S, Nakatsuka M, Sugiyama Y, et al: Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a € ster-Hauser syndrome. Hum Reprod 2004; patient with Mayer-Rokitansky-Ku 19:1629 2. Aittomaki C, Eroila H, Kajanoja P: A population-based study of the incidence of € llerian aplasia in Finland. Fertil Steril 2001; 76:624 Mu 3. McIndoe AH, Bannister JB: An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Emp 1938; 45:490 4. Oakes MB, Beck S, Smith YR, et al: Augmentation vaginoplasty of colonic neovagina structure using oral mucosa graft. J Pediatr Adolesc Gynecol 2010; 23:e39 € bbe EH, Willemsen WN, Lemmens JA, et al: Mayer-Rokitansky-Ku € ster-Hauser 5. Stru syndrome: distinction between 2 forms based on excretory urographic, sonographic, and laparoscopic findings. AJR Am J Roentgenol 1993; 160:331 var F, Lo pez E, et al: Gonadal agenesis 46, XX associated with 6. Gorgojo JJ, Almodo the atypical form of Rokitansky syndrome. Fertil Steril 2002; 77:185 7. Davydov SN: Colpopoeisis from the peritoneum of the uterorectal space. [Article in Russian] Akush Gynekol (Mosk) 1969; 45:55
