High Insertion of the Vagina

Patients who are severely masculinized with a high insertion of the vagina, which is very rare, may require a complex clitorovaginoplasty. Historically, Hendren described a perineal pull-through vaginoplasty, as shown in Fig. 35.3 [6-8]. This involves separation of the vagina from the urogenital sinus and creation of two U-shaped flaps on the perineum above and below the area of the intended vaginal opening. The perineal flaps are required due to the inadequate length of the vagina, which enters the urogenital sinus high, close to the external sphincter of the urethra. In addition, the vagina itself is often diminutive. The final closure is an H-shaped configuration. Drawbacks to this procedure include an abnormal appearance to the perineum. We prefer the Passerini technique for this form of the ad-renogenital syndrome because it results in a normal-appearing introitus [13]. Figure 35.4 illustrates the preoperative and postoperative appearance. Cystos-copy is performed and a Fogarty balloon catheter is placed in the vagina. An inverted Y incision is made starting at the base of the phallus, which is completely

Fig. 35.2 Vaginoplasty for low urogenital sinus abnormalities

Fig. 35.2 Vaginoplasty for low urogenital sinus abnormalities

Images Vaginoplasty And Clitoroplasty

Fig. 35.3 Hendren flap vaginoplasty. cath. Catheter degloved in the plane between Buck's fascia and the Dartos layer, mobilizing the urogenital sinus down to where the urethral meatus is to be located. This leaves flaps, which will be used to construct the distal vagina. The midline attachments of the perineal and pelvic floor musculature are divided posteriorly between the urogenital sinus and the rectum until the balloon is reached and the vagina exposed. The vagina is separated from the urethra and the opening is closed with interrupted absorbable sutures. Traction sutures are placed in the vagina. A reduction clitoroplasty is performed as described above except in cases where the phallus is too large, and then a resection of the corporal bodies and clitoral reduction is performed, taking care to preserve the dorsal neurovascular bundle. The urogenital sinus is split dorsally up to the point where it approaches the recessed clitoris, where a Y-flap is left and tacked down to form the urethral opening. The flaps that were created from the degloving are sutured to the open urogenital sinus and this is tabular-ized and anastomosed to the exposed vaginal open-

Gonadal Dysgenesis Vaginal
Fig. 35.4 Passerini genitovaginoplasty. A Preoperative anatomy. B Immediate postoperative result. C One month postoperative result

ing. The skin edges are then closed and the vaginal opening is probed with a dilator.

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  • bildad
    How do we open the vagina?
    8 years ago

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