Vaginal Reconstruction

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The problem of the woman with an absent or inadequate vagina is unresolved. Much of the reported work has been on patients with intersex conditions, but the same principles apply to the vaginal anomalies associated with ARM. A variety of techniques for reconstruction are available. None has been shown to produce an ideal substitute for the natural organ and it seems unlikely that any would have the same sexual sensation as the natural vagina. In an extensive review of the literature, it was found that follow-up assessment was usually confined to the observation that penetrative intercourse was possible, with no attempt to measure its quality [22]. There was little critical evaluation of female sexuality. In Pena's series there were 22 females over the age of 14 years. Only seven were considered to be gynaecologically normal. Six had a small or absent uterus and nine had an obstructed uterus at a variety of levels [7]. It is these patients who present a major surgical challenge. Although it is correct to evaluate as well as possible the quality of intercourse to decide which technique is the best, it must be remembered that surgery only enables penetrative intercourse to take place; it might be said that poor intercourse may be better than none at all.

If the vagina is normal and unscarred but narrow, every effort should be made to enlarge it by progressive self-dilatation. In motivated adults, it is possible over several months to lengthen a vagina from 5 mm to 10 cm with sufficient diameter for intercourse, with graded acrylic moulds (Fig. 36.3). The advantage of this technique is that the vagina maintains normal physiological function, including lubrication [23].

There is some conflict about the wisdom of routine dilatation of the vagina after genitoplasty in infancy. Krege et al. suggest that it should not be routine if only because of the psychological problems that it may cause (though they offer no evidence for this fear) [24]. Gearhart and, even more strongly, Hen-dren recommend dilatation to prevent postoperative stenosis [25]. In spite of this, all of the patients required further, albeit minor, surgery at puberty to allow intercourse.

In cases where the perineal tissues are scarred, dilatation therapy may not be an option. Occasionally, it may be possible to dilate the vagina under anaesthetic sufficiently that the woman can maintain its calibre

Vaginal Reconstruction
Fig. 36.3 Amielle dilators

with regular dilatation or intercourse. When dilatation is possible, the outcome for sexual intercourse appears satisfactory in the small number of cases that have been reported: in one series all of three women with congenital adrenal hyperplasia (CAH) were able to have satisfactory intercourse and two became pregnant. In contrast, 50% of patients (none of whom had CAH) who had various forms of reconstruction complained of bleeding with intercourse [23].

If reconstructive surgery is required, careful definition of the extent of the problem is required. The patients should be adequately assessed and long-term follow-up is essential (Table 36.2). The external genitalia and vagina are best defined by examination under anaesthetic by all of the surgeons likely to be involved in the reconstruction - gynaecologist, plastic surgeon and urologist. The cystoscope can be used to inspect the vagina above a narrow introitus, often finding that the upper part of the vagina is normal. The internal genitalia are best defined by magnetic resonance imaging. The results are much better if there is a natural introitus, with clitoris and labia.

A narrow vagina may be augmented with bowel or skin. Bowel augmentation may be achieved with any suitable part of the large or small intestine. A piece of ileum equal in length to the existing vagina and with a long enough pedicle to reach the introitus is selected. It is opened on its antimesenteric border. The vagina is opened longitudinally either anteriorly or posteriorly and sutured "face to face" with the ileum. Follow up has been confined to establishing that intercourse takes place without undue difficulty. Up to 70% of women who had an intestinal vagina formed in infancy report the ability to have intercourse, with a 10% incidence of dyspareunia [26].

Table 36.2 Vaginoplasty assessment considerations; adapted from Davies et al. [15]. MRI Magnetic resonance imaging, EUA examination under anaesthesia

Assessment

Recommendations

Imaging

All patients should have pelvic MRI to assess:

• Cervix - presence and patency

• Distance between proximal and distal vagina

• Presence of uterus +/- haematometra

• Bony pelvis

Chromosome studies

Normally performed in neonates, but diagnosis should be confirmed

Psychology

Required pre- and post-operatively to:

• Agree timing of surgery

• Ensure expectations of surgery are realistic

• Improve compliance with post-operative dilator therapy

• Help deal with post-operative complications

• Urethra, bladder and rectum

• Pliability of tissues

• Presence and extent of scarring

Post-operative assessment

Should be ongoing and long-term and include:

• Menstruation

• Sexual intercourse

Long-term follow-up

Possible long-term malignancy risk:

• Annual vaginal examination

• Early reporting of bleeding or discharge

Skin augmentation is usually performed by using skin from the medial aspect of the thigh. The technique was originally described by Sir Archibald Mc-Indoe in 1938. There have been several modifications, but the principle remains the same: a cavity is created in the position of the vagina and lined with meshed split skin on a mould. The initial complication rate is high as the skin fails to take in about 65% of patients. Most will require at least one revision procedure and final surgery is best left until after puberty. About 75% of patients are able to have intercourse (and some of the remainder may be unwilling rather than unable). Self-dilatation with a mould is usually needed in periods of sexual inactivity [27]. A variety of other tissues have been used as free grafts to line a vagina that has been split open longitudinally. Many of the series are small and the results unpredictable [28].

In the small number of girls with normal internal genitalia and no vagina (Fig. 36.4), the timing of surgery is critical; however, menstruation can be suppressed temporarily with luteinising hormone releasing hormone agonists. Bowel, skin, amnion and other materials have been used to make replacement vaginas in these situations, but again, none is satisfactory. Skin on a pedicled flap is rather bulky and split skin has a poor take. The vagina is dry and the squamous lining desquamates, producing a foul discharge. Amnion has shown quite promising results, but availability is limited, especially in the era of HIV infection. Ileum may be too narrow, colon too large and both may produce copious smelly mucus, thus condemning the girl to a lifetime of wearing sanitary protection, which is far from ideal. There is a general tendency to make intestinal vaginas too long, which compounds the problem (Fig. 36.5).

The timing of reconstruction is very important. If surgery is carried out in young girls, dilatation may be required throughout childhood for an organ that, it may be hoped, will not be used for 14 years or more. Perhaps the most compelling argument against surgery in infancy is the risk of neoplasia. In a review, Schober identified five cases of squamous cell carcinoma of skin vaginas and four cases of adenocarci-noma of intestinal vaginas between 1927 and 1994.

The cases occurred in women between 25 and 30 years old and between 8 and 25 years after reconstruction [22]. The average time from surgery to diagnosis is estimated to be 17 years [29]. They are admittedly very rare cancers and none of the relatively large series of vaginal reconstruction report any cases. Nonetheless, the risk remains and a good case can be made for de-

Urethra Site of vagina

Anal pull through

Fig. 36.4 Clinical photograph of an adult female born with anorectal and vaginal agenesis

Speculum

Ileal vagina Introitos

Fig. 36.5 Clinical photograph of a vagina constructed from the ileum in a woman born with anorectal agenesis. The appearance is good, but persistent coital haemorrhage has been a severe impediment to regular intercourse ferring elective surgery until a woman needs a vagina and can give her own consent.

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  • joann
    How long has vaginal reconstruction been available?
    8 years ago

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