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Study Objective To review the currently available methods for surgical and nonsurgical neovaginal creation with an additional focus on situations requiring vaginal stretching, replacement, or augmentation and the management of vaginal stenosis or stricture. Design Review of the existing literature Methods PUBMED search with key words vaginal agenesis, neovaginal creation, vaginoplasty, vaginal stretching, vaginal augmentation, vaginal stenosis, outcomes of vaginoplasty, Mullerian anomalies, vaginal anomalies Results The need to perform vaginal stretching, replacement, or augmentation will vary depending on the underlying reproductive tract condition. Conclusions A variety of techniques have been described to performed vaginal stretching, replacement, or augmentation. There are risks and benefits to each technique. Vaginal stricture and stenosis remain difficult problems given the high rates of these complications in patients undergoing these procedures. Although several techniques can alleviate this problem, they rely on the thickness of the stenosis and the location of the stenosis within the vagina.

Treatment for children born with vaginal agenesis remains difficult, without a clear gold standard for tissue replacement. An autologous-engineered vaginal replacement would significantly improve quality of life for people born with this condition. The aim of this study was to critically review literature on the current state of tissue engineering for vaginal reconstruction in a pediatric population. An electronic literature search was conducted using PubMed for articles describing pediatric vaginal tissue engineering from January 2003 to December 2020. Nine studies met inclusion criteria and were reviewed. The model, methods, cell type and source, scaffold type, and time of analysis and evaluation were compared. Three studies used

Although it has been clearly stated that vaginal dilation must be considered the first-line treatment for clinical conditions characterized by an absent or hypoplastic vagina, mainly Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, a great number of scientific papers on surgical vaginal reconstructions are reported every year. This wide variety of surgical techniques (more than 10) are recognized and performed worldwide, making it difficult to compare results and define an evidence-based approach. Standardized treatment should be considered even more important in the pediatric and adolescent population for the implications offered by the uterus transplantation scenario.

Study Objective To investigate the clinical appearance and morphologic and ultrastructural aspects of the mucosa of the peritoneal neovagina after laparoscopic Davydov neovaginoplasty in patients with Mayer-Rokitansky-Kuster-Hauser syndrome. Design The study group was a prospective, observational, experimental cohort of cases treated in the same institution between 2015 and 2019. Patients were followed up at 3, 6, and 12 months after surgery and then every 12 months. Setting Single-center academic institution and teaching hospital in Milan, Italy. Patients Fifty-one consecutive subjects with clinical and imaging diagnosis of Mayer-Rokitansky-Kuster-Hauser syndrome surgically treated by the same team and postoperatively followed. Interventions All the subjects underwent the same standardized surgical procedure and thereafter were followed up at 3, 6, and 12 months after surgery and then every 12 months; a minimum follow-up of 12 months was achieved in all cases. Vaginoscopy and Schiller test were performed at each follow-up visit, and a biopsy specimen of the neovagina was obtained in a limited number of patients (6 out of 51) for light microscopy (LM) and scanning electron microscopy (SEM) analysis of the tissue. Measurements and Main Results In vaginoscopy, the neovaginal mucosa appeared homogeneous, smooth, and pink all along the neovaginal tract; the Schiller test detected iodine positivity at different degrees of extension upward from the hymenal ring, starting at 3 months postoperatively with almost complete positivity between 6 to 12 months in all cases. LM demonstrated adequate thickness and differentiation of the new mucosa along with the presence of glycogen storage; SEM revealed an ultrastructural surface appearance very close to normality. The main difference compared with a normal vagina was the reduced presence of vaginal mucosal folds. Conclusion Under different techniques (vaginoscopy, Schiller test, LM, and SEM), a minimum of 6 months after surgery, the peritoneal neovagina epithelium showed aspects comparable to the natal mucosa of the vagina.

Increasing numbers of transgender patients are opting for gender-affirming care. Since pediatric and adolescent gynaecology (PAG) providers perform the majority of vaginoplasty procedures for developmental anomalies of the female reproductive tract (such as vaginal agenesis), this commentary supports the position that PAG providers should be involved in the pre- and postoperative care of trans women.

Background Creating a functional neovagina is a practical therapeutic intervention for women with congenital vaginal agenesis and sexual needs. Although the incidence of neovaginal prolapse (NP) is low, it is inconvenient for patients and is a challenging problem for gynecologists. Case A 32-year-old woman who had undergone transabdominal sigmoid vaginoplasty 10 years previously at another hospital visited our clinic for evaluation and treatment of NP. Gynecological examination showed exstrophy of the vaginal apex, 4 cm beyond the hymen. Laparoscopic sacrocolpopexy was performed using a mesh. The mesh was sutured at the anterior wall and apex of the neovagina and suspended in the anterior sacral region without blood vessels. Summary and Conclusion Laparoscopic sacrocolpopexy might be an effective and safe treatment for NP.

Background. There is still no standardized treatment for vaginal agenesis; surgical repair using a minimally invasive technique is a good option, as it offers rapid results along with a fast postoperative recovery. Objective. To describe a new modified Vecchietti procedure by a mini-laparoscopic approach with intraoperative use of indocyanine green fluorescence technology for the creation of a neovagina in the setting of congenital vaginal agenesis. Methods. Retrospective review of all cases of congenital vaginal agenesis submitted to a mini-laparoscopic modified Vecchietti procedure with intraoperative use of indocyanine green (ICG) fluorescence (between June and September 2019). Patient relevant medical history, surgical technique, postoperative care, outcomes, and complications are described. Results. Four patients with Mayer–Rokitansky–Küster–Hauser syndrome (mean age: 19 years; mean preoperative vaginal length: 1.5 cm) were included in the study. The procedure was completed successfully and uneventfully in all patients. External traction device was removed 5–7 days after surgery and replaced by external vaginal silicone dilators. This technique was able to create 10–11 cm neovaginas in 1 week; six weeks after surgery all patients had an epithelized 10.5–12 cm length and 2.5–3 cm diameter neovagina. Complications consisted of one case of isolated fever at the ninth postoperative day, solved with empiric antibiotic treatment. Conclusion. The mini-laparoscopic modified Vecchietti approach, associated with ICG fluorescence imaging, is feasible and effective in the treatment of congenital vaginal agenesis, as it is a simple and safe procedure with promising outcomes.

Objective To investigate the clinical characteristics and outcomes of pelvic abscess after cervicovaginal canalization for congenital cervical and vaginal agenesis. Cases Four patients who had pelvic abscess after cervicovaginal canalization for congenital cervical and vaginal agenesis are reported. The mean onset time of pelvic abscess after primary canalization was 67.7 months. Three patients presented with pelvic endometriosis. Three patients underwent cervical catheter or intrauterine device placement, with a mean time of 62 months. All patients underwent hysterectomy and pelvic abscess removal, and no recurrence of pelvic abscess or formation of pelvic pseudocysts was observed during the follow-up. Conclusion Pelvic abscess after cervicovaginal canalization was mainly due to re-obstruction of the neocanal, the risk of which may increase when surgery is combined with prolonged cervical stent placement and pelvic endometriosis. Hysterectomy should be suggested once pelvic abscess is diagnosed.

Cervicovaginal atresia with a functional uterus is rare. There are no established surgical methods to treat this condition, and only a few reports have been published on surgical techniques. Furthermore, postoperative complications, such as restenosis, often require reoperation. A 19-year-old woman was pointed out cervical hypoplasia and referred to our hospital for further examination and treatment. A pelvic examination revealed that the vagina had a slight recession with a blind end. Transrectal ultrasound and pelvic magnetic resonance imaging revealed congenital vaginal agenesis and cervical hypoplasia. Elective surgery was performed after reshaping the vagina. A radical surgery was performed 10 months later after sufficient self-dilation by using Frank's technique in an outpatient setting. At first, we approached by laparoscopically to correct autologous peritoneum and to bladder detach, then the cervical canal was identified. Next, a skin biopsy punch was used several times to hollow out the cervical tissue to shape and expand the cervical canal. A catheter was then placed in the uterus and autologous peritoneum was wrapped around it and fixed to the cervical canal. The catheter was removed 6 weeks postoperatively, and the patient continued dilating her vagina until she was able to have sexual intercourse, and then stopped the self-dilation. Eight months postoperatively, the patient did not report any menstrual irregularities. It is important to make corrections to prevent restenosis of the vagina and cervical canal and prevent the symptoms from recurring. Make use of autologous peritoneum as graft onto the cervical canal is effective method for the treatment of cervicovaginal atresia.

Our objective was to provide a minimally invasive neovaginoplasty technique to construct a nearly physiologic vagina to facilitate sexual functioning and appropriate vaginal length in patients with congenital vaginal agenesis. This retrospective study at a tertiary care hospital comprised 52 patients with congenital vaginal agenesis because of Mayer-Rokitansky-Kuster-Hauser syndrome or androgen insensitivity syndrome presented for vaginal reconstruction. Modified McIndoe vaginoplasty was done in all patients between 2010 and 2018 using a vaginal mold created with glove, nonadherent petroleum gauze, and Interceed absorbable adhesion barrier (Ethicon, Johnson & Johnson, Somerville, NJ) that was placed in the neovagina space created between the bladder and rectum for 7 days. Operative details, complications, length and width of the neovagina, and functional outcome were evaluated. The mean operation time was 35 minutes. The mean length of the constructed neovagina was 8.4 cm × 3.4 cm at 6 weeks follow-up. Epithelialization was completed by 4 to 6 months. All patients reported satisfactory sexual activity with no pain and good mucosal sensitivity. This modified neovaginoplasty technique is easy to perform, involves painless postoperative dilatations as the cornerstone of treatment, and results in adequate secretion, allowing lubrication and acceptable physiologic results.

The vagina is a membranous muscular tube that connects the vulva and uterus. Congenital or congenital abnormalities in the form of complete or partial absence of the vagina (vaginal agenesis). Patients who experience vaginal agenesis have less frequency, namely 1 in 4000 births, 1 in 4000 to 10,000 births (ACOG). Meanwhile in Dr. Cipto Mangunkusumo Jakarta from 1995 to 1999, an average of 10-12 cases per year. It has been reported the case of a female patient aged 14 years who entered the Gynecology Ward Dr. M. Djamil Padang on January 25, 2014 at 11.00 WIB with a delivery from the RSMJ gyn clinic with a diagnosis of transverse vaginal septum + hematometra + hematotrachelos + hematokolpos planned for a septal incision. After performing the operative action, ± 500 cc of blackish brown liquid was successfully removed.Keywords: Agenesis Vagina, TVS, Tranverse Septum Vagina, Case Report

Background Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, also referred to as Müllerian aplasia, is a congenital disorder characterized by aplasia of the uterus and upper part of the vagina in females with normal secondary sex characteristics and a normal female karyotype (46,XX). Main body The diagnosis is often made during adolescence following investigations for primary amenorrhea and has an estimated prevalence of 1 in 5000 live female births. MRKH syndrome is classified as type I (isolated uterovaginal aplasia) or type II (associated with extragenital manifestations). Extragenital anomalies typically include renal, skeletal, ear, or cardiac malformations. The etiology of MRKH syndrome still remains elusive, however increasing reports of familial clustering point towards genetic causes and the use of various genomic techniques has allowed the identification of promising recurrent genetic abnormalities in some patients. The psychosexual impact of having MRKH syndrome should not be underestimated and the clinical care foremost involves thorough counselling and support in careful dialogue with the patient. Vaginal agenesis therapy is available for mature patients following therapeutical counselling and education with non-invasive vaginal dilations recommended as first-line therapy or by surgery. MRKH syndrome involves absolute uterine factor infertility and until recently, the only option for the patients to achieve biological motherhood was through gestational surrogacy, which is prohibited in most countries. However, the successful clinical trial of uterus transplantation (UTx) by a Swedish team followed by the first live-birth in September, 2014 in Gothenburg, proofed the first available fertility treatment in MRKH syndrome and UTx is now being performed in other countries around the world allowing women with MRKH syndrome to carry their own child and achieve biological motherhood. Conclusion Several advances in research across multiple disciplines have been made in the recent years and this kaleidoscopic review provides a current status of various key aspects in MRKH syndrome and provides perspectives for future research and improved clinical care.

This video reviews technical considerations for performing a modified McIndoe vaginoplasty with skin graft. A 24-year-old female was referred for management of vaginal agenesis. She had unsuccessfully tried vaginal dilation and was interested in vaginal canal creation. A 10 × 20-cm split-thickness skin graft was harvested from the buttock and secured to a condom-covered rubber-sponge mold. The vaginal dissection was initially performed with electrocautery and sharp dissection to enter the plane between the bladder anteriorly and the rectum posteriorly. Then, blunt dissection using a finger, surgical sponges, and retractors was performed to open the space to the level of the peritoneal reflection. With the dissection completed, the graft-covered mold was inserted and secured with labial stay sutures. During the second stage of the procedure, roughly 14 days later, the mold was removed, the graft assessed, and the distal edges secured. A polyethylene mold was then used as the wound continued to heal. The patient had an uncomplicated perioperative course. She had excellent take of her skin graft, with 10 cm vaginal length and adequate vaginal caliber. Vaginoplasty with a split-thickness skin graft is an excellent surgical option for vaginal canal creation in patients with vaginal agenesis.

The purpose of this study was to explore the long-term follow-up of treatment of congenital partial vaginal agenesis using the Wharton-Sheares-George technique. The technique was performed on 52 patients with congenital partial vaginal atresia from January 2009 to December 2017. As a result, the mean operating time of the Wharton-Sheares-George technique procedure was 25.6 ± 2.2 min. The mean estimated blood loss was 16.7 ± 4.7 mL. The average length of stay in hospital for the patients was 2.3 ± 0.2 days. There were no intraoperative and postoperative complications. The median duration of follow-up was 58 months. All of the patients experienced a resumption of menses. The mean vaginal length at 3 months was 7.3 ± 0.8 cm. Vaginal stenosis and adhesion did not occur in any cases during the follow-up. Twenty patients had sexual activities and the mean value of the FSFI questionnaire was 31.2 ± 4.0. Six cases became pregnant. There were four cases who each delivered one child and two cases who both delivered two children.IMPACT STATEMENT

Vaginal dilator therapy is used to increase vaginal length for vaginal agenesis, to increase vaginal width for vaginal narrowing, and to prevent or treat stenosis after vaginal surgery. Although it is an effective therapy, many reproductive health providers have had little training on how to guide patients through this therapy. The purpose of this review is to educate providers on how to assess patient readiness and how to support patients through the process of vaginal dilation.

STUDY QUESTION Do sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome differ from a comparison group of women without the condition? SUMMARY ANSWER In comparison to controls, women with MRKH with a non-surgically or surgically created neovagina did not differ in psychological and relational functioning but reported lower sexual esteem and more negative genital self-image, intercourse-related pain, clinically relevant sexual distress and sexual dysfunction, with sexual esteem levels strongly associated with sexual distress and sexual dysfunction. WHAT IS KNOWN ALREADY Studies on sexual functioning measured with standardized questionnaires in women with MRKH syndrome compared with women without the condition have yielded contradictory results. Factors associated with sexual functioning in this patient population have rarely been investigated. STUDY DESIGN, SIZE, DURATION Between November 2015 and May 2017, 54 women with MRKH syndrome with a neovagina and 79 age-matched healthy women without the condition were enrolled in this case–control study. PARTICIPANTS/MATERIALS, SETTING, METHODS All participants had to be at least 18-years old and had to live in a steady heterosexual relationship. Women with MRKH syndrome were asked to participate by their (former) gynecologists at three university hospitals and by MRKH peer support group. Controls were recruited via advertisement in local newspapers and social media. Standardized questionnaires were administered to assess sexual functioning, sexual esteem, genital self-image and psychological and relational functioning. MAIN RESULTS AND THE ROLE OF CHANCE Women with MRKH syndrome with a surgically or non-surgically created neovagina reported significantly more pain during intercourse (P LIMITATIONS, REASONS FOR CAUTION Given the nature of the study focusing on sexual functioning, a potential selection bias cannot be excluded. It is possible that those women with the most severe sexual and/or psychological disturbances did or did not choose to participate in our study. WIDER IMPLICATIONS OF THE FINDINGS The study results add new data to the very limited knowledge about psychosexual functioning of women with MRKH syndrome and are of importance for more adequate counseling and treatment of these women. STUDY FUNDING/COMPETING INTEREST(S) The research was financially supported by the Dutch Scientific Society of Sexology (Nederlandse wetenschappelijke Vereniging Voor Seksuologie). The funding was unrestricted, and there was no involvement in the conduct of the research. There are no conflicts of interest to declare.

For women with congenital vaginal agenesis and sexual needs, creating a functioning neovagina is a practical therapeutic schedule. Colpopoiesis using the sigmoid intestine were more reported in the literatures. Though the incidence of neovaginal prolapse (NP) is relatively low (3-8%), it does bring great inconvenience to patients, and expose gynecologists to tough challenges. Hereon, we report a case of NP 10 years after sigmoid colon vaginoplasty that was successfully repaired by laparoscopic sacro-colpopexy with a mesh, hoping to provide meaningful evidence for this rare situation.

An observational, retrospective study was completed to compare the results of the PACIENA clinical trial (using the modified McIndoe technique) with a historical control group of nine patients who were operated on at San Juan University Hospital (1992–2015) using the classic technique. The PACIENA clinical trial included seven patients with vaginal agenesis who were operated on at two reference sites (May 2017–May 2018) using a neovaginal polylactic acid (PLA) prosthesis (PACIENA® prosthesis) and avoiding the use of a skin graft. The results illustrate a reduction in the length of surgery, 86.43 ± 4.75 min in the group with no skin graft compared to 155.56 ± 28.44 in the control group (p < 0.05); and reduction in the length of hospitalization time. Differences were also registered in the length of the neovagina, the average being 8.93 ± 1.42 cm for cases and 6.56 ± 1.13 cm for controls, with no differences in neovaginal epithelialization times or in the satisfaction of sexual relations occurring between groups. The modification of the classical McIndoe technique using the neovaginal PACIENA® prosthesis appears to be successful, obtaining good clinical results with shorter surgery and hospitalization times.

Background Vaginal agenesis, a rare condition, is treated by various surgical techniques to achieve neovaginal reconstruction. The main difference between the approaches lies in the graft material used to cover the newly formed cavity. Objectives The purpose of this retrospective study was to describe the surgical procedure and outcomes of autologous buccal mucosal grafting in neovaginal reconstruction. Methods Sixteen patients with vaginal agenesis admitted to our department between January 2016 and January 2019 were included in our study. A reconstruction procedure, described in detail here, involving autologous buccal mucosa as graft material was successfully conducted in all of the patients. Long-term anatomic and functional outcomes were evaluated. Results The blood loss during operation was estimated to be 15 to 20 mL in all cases. No rectal or bladder injury occurred. The buccal mucosal wound completely healed 10 to 14 days after the operation. All patients had a well-formed neovagina 8 to 10 cm in length, with a mean diameter of >3 finger-breadths. Conclusions The application of autologous buccal mucosa in neovaginal construction is a simple procedure. Autologous buccal mucosa is an ideal material to achieve excellent cosmetic and functional results in patients with vaginal agenesis. Level of Evidence: 4

Mayer–Rokitansky–Küster–Hauser syndrome causes absence or underdevelopment of uterus and vagina, but women’s subjective experience remains understudied. This systematic review was conducted to examine the psychological and health-related quality-of-life outcomes of Mayer–Rokitansky–Küster–Hauser syndrome. In total, 22 articles identified through electronic search matched the inclusion criteria and were included in our review. Mayer–Rokitansky–Küster–Hauser syndrome may be associated with psychological symptoms and impaired quality of life, but especially with poor sexual esteem and genital image. Women may experience difficulties managing intimacy and disclosing to partners. Mothers may be perceived as overinvolved, with consequent negative emotions in women with the disease.

An observational, retrospective study was completed to compare the results of the PACIENA clinical trial (using the modified McIndoe technique) with a historical control group of nine patients who were operated on at San Juan University Hospital (1992-2015) using the classic technique. The PACIENA clinical trial included seven patients with vaginal agenesis who were operated on at two reference sites (May 2017-May 2018) using a neovaginal polylactic acid (PLA) prosthesis (PACIENA(R) prosthesis) and avoiding the use of a skin graft. The results illustrate a reduction in the length of surgery, 86.43 +/- 4.75 min in the group with no skin graft compared to 155.56 +/- 28.44 in the control group (p < 0.05); and reduction in the length of hospitalization time. Differences were also registered in the length of the neovagina, the average being 8.93 +/- 1.42 cm for cases and 6.56 +/- 1.13 cm for controls, with no differences in neovaginal epithelialization times or in the satisfaction of sexual relations occurring between groups. The modification of the classical McIndoe technique using the neovaginal PACIENA(R) prosthesis appears to be successful, obtaining good clinical results with shorter surgery and hospitalization times.

Neovagina surgery in patients with vaginal agenesis is rare. No consensus exists regarding the best surgical technique. The aims of the current study were to show a new Thiel-embalmed cadaveric model to teach the surgical steps for different techniques of neovagina surgery and to evaluate opinions of this surgical teaching procedure. Four techniques&mdash, modified McIndoe, Vecchietti, Davydov, and vulvoperineal pediculated flaps&mdash, were recorded using an external camera and/or laparoscopic vision during their execution in a dissection room on &ldquo, feminized&rdquo, male cadavers. To determine the opinion of this teaching model, we designed an anonymous online survey that was available to participants via a computer application. After watching the video, more than 92% of participants agreed that feminized male cadavers were an excellent procedure for teaching these surgical techniques. Before watching this video, the most employed techniques were the McIndoe and Vecchietti procedures. After watching the video, modified McIndoe and vulvoperineal flaps were preferred by participants because they were considered to be easier to perform. It was considered that this model was useful for training neovagina techniques and, moreover, it should be recommended before techniques were performed on a real patient. Further investigation is needed to validate this model.

Background To evaluate the feasibility and clinical outcomes of vaginoplasties using a neovaginal polylactic acid prosthesis made with 3-dimensional (3D) printing technology as an intraneovaginal mould. Methods This was an interventionist, prospective, and multicentre clinical pilot investigation of a sanitary product (PACIENA prosthesis®) aiming to recruit and operate on 8 patients over 6 months with a follow-up period of 6 months. Only six patients with Rokitansky syndrome and one patient with Morris syndrome (7 patients in total) were operated on in two university hospitals: “La Fe”, Valencia (H1) and “Arrixaca”, Murcia (H2). Interventions: Extensive surgical dissection of a defined space between the urethra and bladder in the front and of the rectum in the back as well as insertion of the PACIENA prosthesis® covered with Interceed® were performed. After 12 days, the prosthesis was changed to the silicone-covered version for daily application. Results In the 6 patients with Rokitansky syndrome (86%), the primary endpoint (satisfactory vaginal outcome in terms of appearance, function, and sensation without relevant additional morbidity) was achieved, although only 2 patients (28%) were sexually active at the end of 6 months of follow-up. The patient with Morris syndrome withdrew from the study after 1 month. Patients without bacterial colonization showed positive Schiller tests at 1 month, and subsequent biopsies showed adequate keratinization and epidermization. Epithelization and iodopositivity were delayed in the patients who developed inflammatory granulomas. Conclusions Good anatomical and functional results can be achieved with the PACIENA prosthesis® for vaginoplasties without skin grafts. However, adequate patient selection and education, good surgical techniques and haemostasis, postoperative support, and prevention of bacterial colonization are important. Trial registration This clinical study was approved by the Ethical Clinical Investigation Committee of San Juan University Hospital on September 27, 2016, to be conducted in the participating centres; it was authorized by the Spanish Agency of Medicines and Health Products (AEMPS) on April 24, 2017 (exp. no. 585/16/EC), to be carried out in that hospitals.

Congenital pouch colon is a rare anorectal malformation of unknown embryogenesis in which all or part of the large intestine is replaced by a pouch-like dilatation that usually communicates with the urogenital tract via a fistula. This condition is more common among males in North Indian population and is associated with various anomalies such as uterovaginal malformations. It has been classified into five types that are showing a shift over the years towards less severe types such as type 4. We report a case of type 4 congenital pouch colon with anal agenesis without fistula and lower vaginal agenesis in a 29-week-old female fetus diagnosed during autopsy. The absence of a fistula and association with vaginal agenesis in a female fetus, which gets overlooked even in live births, makes it a unique case. Early prenatal diagnosis and awareness about this condition are essential for appropriate management and favorable surgical outcome.

Transgender reassignment surgeries have become a major topic of interest within the last decade. Although there are numerous surgical techniques for male-to-female reassignment, a physician must assess each patient's anatomy and past medical history to determine the most suitable technique. Additionally, patient preference is important. The neovaginal constructive technique most commonly used in male-to-female reassignment surgery is penile skin inversion, but various other techniques and tissues can also be used including pelvic peritoneum, buccal mucosa, and bowel. Surgical text descriptions were enhanced by creating new anatomical illustrations. Donor and recipient site anatomies, and the surgical technique leading to creation of the neovagina, are demonstrated in detail with relevant illustrations. A review of the literature concerning the anatomy, procedure development, and outcomes is presented. The pelvic peritoneum was originally used in neovaginal construction for females with vaginal agenesis as a result of MRKH syndrome. The use of this technique to create a neovagina in male-to-female transgender reassignment surgery has become appealing owing to the relative ease of the procedure, low complication rates, and overall high patient satisfaction. This technique offers a potential new choice for transgender male-to-female neovaginal construction, but further studies are needed to confirm its successful use in transgender surgery. Clin. Anat. 31:175-180, 2018. © 2017 Wiley Periodicals, Inc.

Objective To describe the different steps of the Davydov surgical technique for creating a neovagina, emphasizing visualization of the rectovesical cleavage and peritoneal-vaginal anastomosis by laparoscopic and vaginal approaches. Design Production of a step-by-step surgical video tutorial with narrative video footage. Setting Uterovaginal agenesis is a rare congenital defect, observed in 1 case per 4000 to 5000 newborn female infants [1] . Vaginal agenesis treatment can be performed by different nonsurgical and surgical techniques that are based on neocavity creation. The Davydov intervention uses the pelvic peritoneum as “covering” tissue for a neocavity and avoids the use of allogenic or autologous transplants, traction devices, or specialized surgical equipment. It is a minimally invasive technique that provides long-term functionality and anatomically satisfying results [2] . Interventions We treated an 18-year-old patient with Mayer-Rokitansky-Kuster-Hauser syndrome who underwent the Davydov procedure after dissatisfaction with the Franck self-expansion method. We created a neovagina using peritoneal flaps that were obtained after rectovesical cleavage by laparoscopic approach and were then fastened to the introitus by vaginal approach. Finally, the vaginal vault was reconstructed laparoscopically, and an intravaginal dilator was left in place. The result after 1 year showed the transition from a narrow vaginal dimple 2 cm in length to a neovagina 10 cm in length, permeable, well epithelialized, and correctly healed without associated stenosis. Sexual intercourse is satisfying for both partners. Conclusion The Davydov technique is less invasive than other surgical techniques and allows good outcomes [ 3 , 4 ] without the invasive use of sigmoidal grafts, cutaneous flaps, or prostheses. It should be proposed to patients experiencing failure with the Franck nonsurgical method.

Highlights • Our article lists all cases in the neovaginal cancer literature since 1929. • We propose an explanation of the pathophysiology of the development of neovaginal cancer. • We propose a classification of neovaginal cancers., We report a case of mucinous adenocarcinoma developed on sigmoid colpoplasty, performed for a congenital agenesis vaginal. The cancer development of neovagina remains exceptional. Its management consists, in the majority of cases, in surgery for a complete excision. Adjuvant treatments are associated according to the pathological results and the neovagina reconstruction technique performed.

The objective of this case series is to describe the procedure and outcomes of a multidisciplinary approach to vaginoplasty using autologous buccal mucosa fenestrated grafts in two patients with vaginal agenesis. This procedure resulted in anatomic success with a functional neovagina with good vaginal length and caliber and satisfactory sexual function capacity and well healed buccal mucosa. There were no complications and patients were satisfied with surgical results. We conclude that the use of a single fenestrated graft of autologous buccal mucosa is a simple, effective procedure for the treatment of vaginal agenesis that results in an optimally functioning neovagina with respect to vaginal length, caliber, and sexual capacity.

Purpose of review Primary vaginal dilation is patient controlled, safe, less painful, and much lower cost compared with operative vaginoplasty and is considered first-line treatment for vaginal agenesis for women with Mayer-Rokitansky-Kuster-Hauser syndrome and androgen insensitivity syndrome. Recent findings This review will highlight studies that assess the optimal methods of primary vaginal dilation and clarify ideal counseling, frequency of dilation, management of side-effects, and long-term physical and psychological outcomes. Summary Providers who care for women with vaginal agenesis should be prepared to not only teach the technical skill of dilation, but also to assess readiness and troubleshoot symptoms associated with dilation.

INTRODUCTION AND OBJECTIVES:Vaginal agenesis is a rare congenital disorder of female genital tract, with patient usually presenting to us in late adolescence. Vaginal reconstruction using bowel seg...

BackgroundTo evaluate the feasibility and clinical outcomes of vaginoplasties using a neovaginal polylactic acid prosthesis made with 3-dimensional (3D) printing technology as an intraneovaginal mould.MethodsThis was an interventionist, prospective, and multicentre clinical pilot investigation of a sanitary product (PACIENA prosthesis (R)) aiming to recruit and operate on 8 patients over 6months with a follow-up period of 6months. Only six patients with Rokitansky syndrome and one patient with Morris syndrome (7 patients in total) were operated on in two university hospitals: "La Fe", Valencia (H1) and "Arrixaca", Murcia (H2). Interventions: Extensive surgical dissection of a defined space between the urethra and bladder in the front and of the rectum in the back as well as insertion of the PACIENA prosthesis (R) covered with Interceed (R) were performed. After 12days, the prosthesis was changed to the silicone-covered version for daily application.ResultsIn the 6 patients with Rokitansky syndrome (86%), the primary endpoint (satisfactory vaginal outcome in terms of appearance, function, and sensation without relevant additional morbidity) was achieved, although only 2 patients (28%) were sexually active at the end of 6months of follow-up. The patient with Morris syndrome withdrew from the study after 1month. Patients without bacterial colonization showed positive Schiller tests at 1month, and subsequent biopsies showed adequate keratinization and epidermization. Epithelization and iodopositivity were delayed in the patients who developed inflammatory granulomas.ConclusionsGood anatomical and functional results can be achieved with the PACIENA prosthesis (R) for vaginoplasties without skin grafts. However, adequate patient selection and education, good surgical techniques and haemostasis, postoperative support, and prevention of bacterial colonization are important.Trial registrationThis clinical study was approved by the Ethical Clinical Investigation Committee of San Juan University Hospital on September 27, 2016, to be conducted in the participating centres; it was authorized by the Spanish Agency of Medicines and Health Products (AEMPS) on April 24, 2017 (exp. no. 585/16/EC), to be carried out in that hospitals.

BACKGROUND: To evaluate the feasibility and clinical outcomes of vaginoplasties using a neovaginal polylactic acid prosthesis made with 3-dimensional (3D) printing technology as an intraneovaginal mould. METHODS: This was an interventionist, prospective, and multicentre clinical pilot investigation of a sanitary product (PACIENA prosthesis®) aiming to recruit and operate on 8 patients over 6 months with a follow-up period of 6 months. Only six patients with Rokitansky syndrome and one patient with Morris syndrome (7 patients in total) were operated on in two university hospitals: "La Fe", Valencia (H1) and "Arrixaca", Murcia (H2). INTERVENTIONS: Extensive surgical dissection of a defined space between the urethra and bladder in the front and of the rectum in the back as well as insertion of the PACIENA prosthesis® covered with Interceed® were performed. After 12 days, the prosthesis was changed to the silicone-covered version for daily application. RESULTS: In the 6 patients with Rokitansky syndrome (86%), the primary endpoint (satisfactory vaginal outcome in terms of appearance, function, and sensation without relevant additional morbidity) was achieved, although only 2 patients (28%) were sexually active at the end of 6 months of follow-up. The patient with Morris syndrome withdrew from the study after 1 month. Patients without bacterial colonization showed positive Schiller tests at 1 month, and subsequent biopsies showed adequate keratinization and epidermization. Epithelization and iodopositivity were delayed in the patients who developed inflammatory granulomas. CONCLUSIONS: Good anatomical and functional results can be achieved with the PACIENA prosthesis® for vaginoplasties without skin grafts. However, adequate patient selection and education, good surgical techniques and haemostasis, postoperative support, and prevention of bacterial colonization are important. TRIAL REGISTRATION: This clinical study was approved by the Ethical Clinical Investigation Committee of San Juan University Hospital on September 27, 2016, to be conducted in the participating centres; it was authorized by the Spanish Agency of Medicines and Health Products (AEMPS) on April 24, 2017 (exp. no. 585/16/EC), to be carried out in that hospitals.

Objective: Retrospective analysis of cases that have undergone neovagina operation because of congenital vaginal agenesis was objected.Material and Methods: Seven cases applying with the complaints of primary amenorrhea or inability to have sexual intercourse were in the study. The cases were diagnosed with congenital vaginal agenesis and operated at Mustafa Kemal University Training and Research Hospital between 2011 and 2014. Vaginoplasty by the modified McIndoe method was performed in all cases. The main complaint, chromosomal analysis, duration of operation, preoperative and postoperative vaginal length, complications, postoperative treatment, and satisfaction from the sexual intercourse were all evaluated.Results: Average age of our patients was 28.14±8.61 (19-39) years. One patient was 46XX-45X0 mosaic Turner syndrome), 1 patient was 46XY (testicular feminization), and other 5 patients were 46XX. The average duration of operation was 2.7±0.56 (2–3.5 h). Postoperative infection was observed in 1 patient. In this infected patient, graft failure occurred and debridement was performed in reoperation. No early complications were seen in the others. Preoperative and postoperative average vaginal lengths were 1.85±0.62 (1–3 cm) and 8.71±1.11 (7–10 cm), respectively. Dyspareunia occurred in 2 cases that were not able to use dilatator regularly: 1 because of cancelation of marriage and the other because of postoperative infection; regular sexual life was achieved in remaining 5 (71%) cases.Conclusion: Although there is no consensus about the ideal method of making a functioning vagina among different specialties. The modified McIndoe technique is the most applied method by gynecologists and simple, minimally invasive and with low morbidity.

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. Case We report the successful creation of a neovagina in 3 Japanese patients with Mayer-Rokitansky-Kuster-Hauser syndrome using a 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.

Urethral coitus is a rare type of sexual practice, usually due to vaginal agenesis or hymeneal anomalies. We report a case of urethral coitus in a healthy couple who were evaluated for infertility. The female partner had cribriform hymen and dilated urethral orifice but did not report any problems except infertility and her genital anatomy was normal. The male partner reported concerns over his penile size but was otherwise healthy. After incision of hymen, they were able to have vaginal coitus and successfully conceived. While urethral coitus is rare, it should be suspected in women presenting with infertility and a dilated urethral orifice.

Background: Women with congenital uterovaginal agenesis have normal development of all secondary sexual characteristics. They face the cruel fact of being unable to bear children and enjoy sexual satisfaction. Good neo vaginal reconstruction is important in improving functional and psycho social impacts to womanhood. The aim of the study was to compare the three commonly done surgical procedures for vaginal reconstruction.Methods: All the vaginal agenesis patients who attended Department of plastic surgery Madras Medical College, Chennai during the period from August 2004 to April 2007 were included in our study.Results: In Abbe McIndoe procedure, graft take was full in all 7 cases with good cosmetic appearance. Flaps survived in all 10 patients underwent pudendal thigh flap surgery. 2 patients underwent horse shoe shaped labia minora flaps. The cosmetic appearance was fair because of the distortion of the labia. The mean vaginal depth obtained was 8 cm and width was 2 cm.Conclusions: Cosmetic appearance was good in patients who underwent McIndoe procedure as the genitalia were not distorted. Contracture rate was more in patients who underwent McIndoe procedure especially who were irregular in using stents. Flap procedure especially pudendal thigh flaps which has the least contraction rate is the preferable treatment option for such patients.

Mullerian duct anomalies are rare and can present with abnormalities in upper vagina, cervix, uterus, and fallopian tubes. The exact incidence of cervicovaginal agenesis is unknown and there are very few cases recorded in the literature. Authors report a 12-year-old girl referred from gynaecologist with chronic cyclical abdominal pain with underdeveloped, geniatilia and developed secondary sexual characters. Radiological investigations showed hypoplastic cervix with hematometra and left hemato salpinx. A definitive repair with creation of a neovagina using a sigmoid colon segment was performed in a single stage. Many techniques are described for reconstruction of cervicovaginal canal. Use of colon in creation of a neovagina is described by authors. Here we report a case of complete vaginal agenesis presenting with Hematometra-Hematosalpinx where a neovagina was created using a segment of sigmoid colon. Single staged surgery for neovagina creation using segment of sigmoid colon offers a promising and safe alternative for cervicovaginal agenesis.

Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is a congenital malformation resulting in the absent or small uterus and variable degrees of vaginal hypoplasia of its upper portion. One of the treatment goals for these patients is the creation of an artificial vagina either conservatively or surgically. Use of long-term prosthetic vaginal stents prevents the possible contraction of the reconstructed vagina, maintain vaginal width and depth and avoid vaginal stenosis. Prefabricated stents of standard sizes have widely been utilized to assist surgical creation of a neovagina. However, a customized stent has the evident advantage of the possibility of adjusting the size as per individual patient requirements. In the present clinical report, an early adolescent female patient with MRKH syndrome was surgically managed with insertion of a customized vaginal stent that offers the versatility of design configuration to suit the various clinical situations.

Background: The aim of this study is to determine the effectiveness of McIndoe Vaginoplasty in the creation of a neovagina for patients with vaginal agenesis.Methods: this is a retrospective study of 50 cases of vaginal agenesis, who underwent McIndoe Vaginoplasty over a period of 8 years (2004-2012) by using skin graft in 25 cases and amnion as graft in the remaining.Results: McIndoe Vaginoplasty was performed successfully in all 50 patients and post-surgical result was acceptable to the patient psychologically, sexually and aesthetically.Conclusions: McIndoe Vaginoplasty is a safe and effective procedure for providing a satisfactory and functional vagina in patients with MRKH syndrome.

Video Objective This video presents a stepwise approach to the creation of a neovagina through a modified laparoscopic Davydov approach. Setting This procedure is most commonly performed for vaginal agenesis. First line treatment is self-dilation with multidisciplinary support. When first line treatment fails, a surgical approach to neovaginal creation is the Davydov procedure. This video illustrates the steps of a modified laparoscopic Davydov procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser Syndrome. Interventions The modified laparoscopic Davydov procedure is comprised of five steps: 1) define the anatomy (± salpingectomy), 2) create the neovaginal space, 3) line the neovagina with peritoneum, 4) dissect the pelvic sidewall, and 5) suture the neovagina over the stent. The modified laparoscopic approach involves round ligament preservation (instead of transection) for added vaginal support. It also involves transection of the utero-ovarian ligaments (instead of preservation) to keep ovaries in their anatomical location. More extensive pelvic sidewall dissection helps avoid tension on sidewall structures. Conclusion The Davydov procedure has high rates of sexual satisfaction and should be considered for the surgical creation of a neovagina.

Video Objective To describe the surgical steps and postoperative care utilized when performing a laparoscopic Vecchietti procedure for the treatment of complete vaginal agenesis. Setting 21 year old female with complete vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome) who desires surgical management and creation of a neovagina. Interventions The laparoscopic Vecchietti procedure is a simple, minimally-invasive technique for the creation of a neovagina in patients with complete vaginal agenesis. Unlike other vaginoplasty techniques, this method does not rely on the use of grafts or surgical flaps. Instead, this procedure creates a neovagina through continuous invagination of the vaginal dimple by an olive-shaped vaginal dilator. The vaginal “olive” is connected to a spring-loaded tensioning device on the patient's abdomen via laparoscopically placed sub-peritoneal sutures. Following placement of the system in the operating room, the sutures are tensioned by 1 to 2 cm each day and a 10 cm neovagina is created over the course of 7 to 10 days. The vaginal olive and sutures are removed in the office, and the patient is instructed to perform daily vaginal dilation using handheld dilators to prevent shortening and stenosis of the neovagina. Conclusion The laparoscopic Vecchietti is a simple and effective procedure to treat complete vaginal agenesis using a minimally-invasive approach.

Video Objective To show the step by step procedure of a neovagina creation in Mayer-Rokitansky-Kuster-Hauser Syndrome. Setting 22-year-old patient with primary amenorrhea, normal feminine phenotype development and vaginal agenesis on clinical examination. Pelvic ultrasound noted uterine agenesis. Mayer-Rokitansky-Kuster-Hauser Syndrome was diagnosed. Interventions A Neovagina was created with simultaneous laparoscopic and perineal approach. Surgery lasted 1 hour. Patient uses dilators to maintain a functional neovagina. Conclusion We believe this technique is simple, requires no special instruments and is fully reproductible with basic laparoscopic and vaginal surgical training. A correct understanding of surgical anatomy in each individual case warrants excellent results.

Introduction: Vaginal agenesis is a rare congenital malformation of female genital tract. It is often associated with other organ anomalies. The patient generally presents with primary amenorrhoea in late puberty or early adolescent age. Various surgical and non-surgical methods have been used to create a functional neovagina. McIndoe’s vaginoplasty with its various modifications has been mentioned in the literature. Putting a graft and usage of a mould in the neovagina are essential for the success of this surgery. Various graft materials as well as various types of moulds have been used by various workers. We have used a different type of mould for this surgery. Aim: To evaluate the success of vaginoplasty in vaginal agenesis and to assess the acceptability and final outcome by the use of the soft mould in the postoperative period. Materials and Methods: In a prospective study, nine patients aged between 14 to 29 years underwent vaginoplasty in our institution from January 2013 to June 2016. A team of gynaecologists, reconstructive and plastic surgeons were involved in management of all the cases. McIndoe technique was adopted for creating the neovaginal space and a split thickness skin graft was used on a specially made mould. The subsequent moulds on removal of the first one with skin graft, we used a soft mould instead of the hard acrylic mould which is generally uncomfortable to the patients. Results: All the nine cases presented were with primary amenorrhoea. Four of them had associated anomalies of kidney besides having hypoplastic uterus. Surgical procedures remained uneventful in immediate and late postoperative period. Skin grafts were well taken in all the cases. Two cases developed vaginal stenosis due to failure to use dilator regularly. However, they improved following resumption of regular use of dilator. Satisfactory intercourse is experienced by the married couple and those who got married subsequently. Conclusion: McIndoe technique of vaginoplasty is simple, minimally invasive and without any significant complications and gives satisfactory coital function. Use of soft mould in the immediate postoperative period is a useful option.

Cervical agenesis or dysgenesis is the defect of vertical fusion of the mullerian duct and the urogenital sinus. The reported incidence is 0.01% in general population. Up to 53% of patients with mullerian agenesis have concomitant congenital malformations and hence these patients should be thoroughly evaluated for the same. We report a case of cervical dysgenesis with ectopically located right ureter in the uterus. This patient had cervical obstruction with absent vagina. Conservative surgical approach was adopted. Cervical reconstruction with cervicovaginal anastomosis with the neovagina was done. The ectopically located ureter was cut and reimplanted into the bladder. Hence in patients with cervical agenesis or dysgenesis radicle approach like hysterectomy should be adopted only in case of failure of conservative surgery. Thus giving the patient a chance for healthy reproductive life and prevent premature ovarian failure.