Search

Objective: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare congenital disorder that results in vaginal agenesis. Lee's neovaginoplasty is a novel surgery for reconstructing the vagina. Transneovaginal oocyte retrieval completely changes the scope of fertility for patients with MRKH syndrome who have undergone neovaginal reconstruction., Case Report: A 22-year-old female with type 1 MRKH syndrome underwent Lee's neovaginoplasty successfully. Four years later, she sought embryo cryopreservation consultation and underwent controlled ovarian hyperstimulation. Upon examination, her anti-Müllerian hormone level was 1.97 ng/ml and she had only eight antral follicles. The neovaginal length was 8 cm with elasticity and extensibility. Transneovaginal oocyte retrieval was performed under ultrasound guidance, and seven oocytes were retrieved. The follicle-to-oocyte index was 87.5%., Conclusion: Lee's neovaginoplasty is a promising surgery for reconstructing the vagina in MRKH syndrome, and this case shows that transneovaginal oocyte retrieval can be successfully performed after vaginal reconstruction. This technique provides a minimally invasive option for retrieving oocytes in patients of MRKH syndrome., Competing Interests: Conflict of interest statement The authors have no conflicts of interest relevant to this article., (Copyright © 2024. Published by Elsevier B.V.)

Objective: To analyze the features of the epithelia coating neovaginas after vaginoplasty in women affected by Mayer-Rokitansky-Küster-Hauser syndrome STUDY DESIGN: We conducted a retrospective analysis of prospectively collected data. Women affected by Rokitansky syndrome who underwent neovaginal biopsy after vaginoplasty (McIndoe surgery, intestinal vaginoplasty, Vecchietti surgery, and Davydov surgery) were included. Macroscopic mucosal features were assessed through clinical examination and the Schilling test. Each biopsy specimen was prepared for examination by light microscopy and in some cases by scanning electron microscopy (SEM)., Results: Thirty-six patients (4 McIndoe, 2 intestinal vaginoplasty, 14 Vecchietti, and 16 Davydov) were included. All biopsies were performed without complications. In McIndoe's neovaginas, the mucosal microscopic features were similar to normal skin, with large areas of preserved epithelium, heterogeneous presence of dermal papillae, and superficial keratinization. The characteristics of the intestinal neovagina's surface were similar to those of a sigmoid colon, with well-shaped glands, cylindrical cells, and a secreting mucosa. In Vecchietti neovaginas, the surface the epithelium was flat and multilayered, highly similar to that of a normal vagina, with the presence of glycogen and superficial desquamation. On medium SEM magnification evaluation, the epithelium presented flattened polygonal cells. Finally, in Davydov neovaginas, none of the specimens had persistent mesothelial elements. The squamous neo-epithelium had regular aspects of differentiation with the presence of glycogen. At greater SEM magnification, microridges were evident, with a regular distribution., Conclusion: Each different technique of vaginoplasty leads to unique histological and structural features of the neovagina's mucosa. Knowledge of these elements must be the basis for the choice of the most appropriate intervention., Competing Interests: Conflicts of Interest None, (Copyright © 2024. Published by Elsevier Inc.)

Purpose: This systematic review aims to provide a data synthesis about the risk of neovaginal cancer in women with Müllerian anomalies and to investigate the association between the adopted reconstructive technique and the cancer histotype., Methods: PubMed, MEDLINE, Embase, Scopus, ClinicalTrials.gov and Web of Science databases were searched from inception to March 1st, 2023. Studies were included if: (1) only women affected by Müllerian malformations were included, (2) the congenital defect and the vaginoplasty technique were clearly reported, (3) the type of malignancy was specified., Results: Literature search yielded 18 cases of squamous cell carcinoma and two cases of vaginal intraepithelial neoplasia 3 (VAIN 3). Of these, 3 had been operated on according to the Wharton technique, 8 according to the McIndoe technique, 3 with a split-skin graft vaginoplasty, 2 according to the Davydov technique, 2 with a simple cleavage technique, 1 according to the Vecchietti technique and 1 with a bladder flap vaginoplasty. A total of 17 cases of adenocarcinoma and 1 case of high-grade polypoid dysplasia were also described. Of these, 15 had undergone intestinal vaginoplasty, 1 had been operated on according to the McIndoe technique and 1 had undergone non-surgical vaginoplasty. Finally, 1 case of verrucous carcinoma in a woman who had undergone a split-skin graft vaginoplasty, was reported., Conclusion: Although rare, neovaginal carcinoma is a definite risk after vaginal reconstruction, regardless of the adopted technique. Gynaecologic visits including the speculum examination, the HPV DNA and/or the Pap smear tests should be scheduled on an annual basis., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Vaginal agenesis is a rare condition worldwide. Most reported cases were accompanied by the absence of uterus or uterine hypoplasia; for patients with functional endometrium, hysterectomy was most likely to be conducted to lower postoperative complications., Objective: Based on our successful experience in vaginoplasty with autologous buccal mucosal, the purpose of this article is to discuss the surgical strategies in the reconstruction of neovaginal for vaginal agenesis patients with functional uterus and cervical hypoplasia., Methods: The uterus was preserved in our procedure, and the cervicoplasty was performed to connect the uterine cavity with the neovagina. After the vaginal cavity was formed, the cervix was confirmed and fixed. With the assistance of laparoscope, the direction and angle of the cervix and the uterine body were observed and confirmed. An incision was made in cervix to connect the uterine cavity, and a Foley's catheter was inserted. The newly formed opening of cervix and neovagina was covered by autologous buccal mucosal., Results: The connection between neovagina and cervix uteri was successfully conducted in patient with functional uterus. Unimpeded and regular menstrual was achieved, and the cyclic abdominal pain was disappeared. No complications were observed., Conclusion: For patients without functional uterus, vaginoplasty with autologous buccal mucosal can be conducted. However, fertility-preserving surgery should be the primary choice in patients with functional endometrium. It can be concluded from our experience that the utero-vaginal connection with the assistance of laparoscope and the use of autologous buccal mucosa is a promising way to achieve ideal outcomes., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

We describe a successful surgical technique of abdominal trachelectomy and re-vaginoplasty for cervico-vaginal stenosis following unsuccessful uterovaginal anastomosis and vaginoplasty in a patient with congenital cervical and vaginal aplasia. After the surgical procedure, cervico-vaginal stenosis was resolved and periodic menstruation without dysmenorrhoea resumed. While long-term follow-up is essential to ensure successful pregnancy and delivery, we conclude that this novel surgical procedure is a promising alternative for improvement of the quality of life and normal sexual function, and for preservation of fertility in patients with cervical and vaginal aplasia., (© 2021 John Wiley & Sons Ltd.)

Objective: To describe how to create an inflatable vaginal stent for use in McIndoe vaginoplasty that can be constructed using standard operating room supplies., Design: Step-by-step video instructions that demonstrate how to construct and use an inflatable vaginal stent. (This video article was exempt from institutional review board approval.) SETTING: Academic hospital., Patient(s): A woman presenting with vaginal agenesis requiring a McIndoe vaginoplasty for the creation of a neovagina., Intervention(s): A novel inflatable vaginal stent compliant with operating room procedures that is radio-opaque, functional, and can be used for patients with or without a functional uterus. The device is modeled after the effective inflatable vaginal stent that was previously commercially available but is no longer produced. Although a vaginal stent may be created in the operating room by placing surgical sponges inside a sterilized condom, many operating rooms have restrictions on equipment that can be brought into the operating room and special criteria for how to sterilize this equipment, and there are also restrictions against leaving non-radio-opaque objects "inside" the patient. The novel inflatable vaginal stent we have developed has multiple advantages compared with a rigid dilator: it is deflatable, so it does not cause trauma or interrupt the delicate tissue graft during insertion, removal, or repositioning; it is firm enough to conform and circumferentially press the tissue graft against the dissected vaginal space but is soft enough to decrease the risk of pressure necrosis or damage to the urethra; and it has a drainage port to prevent the buildup of a fluid pocket that could interfere with graft adherence. Our stent incorporates all these unique properties and can be easily constructed using sterile operating room supplies. The construction of this device requires a silicone Foley catheter, sterile foam sponges from a vaginal prep kit, a sterile radio-opaque sponge, a sterile vaginal ultrasound probe cover, a long Kelly, a 60-cc catheter tip syringe, a ruler, scissors, 0-vicryl suture, and sterile gloves., Main Outcome Measure(s): Effectiveness of a self-made inflatable vaginal stent using standard operating room supplies that meets operating room protocol standards., Result(s): A standard dose of prophylactic antibiotics should be administered preoperatively to prevent surgical site infection. After placement of the tissue graft in the dissected neovagina cavity, the vaginal stent is placed and slowly inflated to circumferentially apply the tissue graft against the dissected vaginal space. The stent remains in place for 7 days and then should be removed in the operating room to allow for an examination under anesthesia, which provides the ideal setting to best evaluate the initial graft adherence. After careful inspection of the neovagina and tissue graft, a standard silicone vaginal mold is placed to maintain vaginal patency and prevent stricture of the tissue graft. The silicone mold should remain in place continuously until complete graft adherence occurs (approximately 4 to 6 weeks), and then it can be worn nightly until the patient is regularly sexually active. If at any point the patient discontinues nightly use of the silicone mold before regular sexual activity, vaginal stricture and a decrease in vaginal caliber will occur., Conclusion(s): Our novel inflatable vaginal stent is useful to surgeons performing a McIndoe vaginoplasty for vaginal agenesis with or without a uterus. It is compliant with operating room protocols and restrictions, as it is constructed from operating room supplies and is radio-opaque. Moreover, it is adjustable in size and effective in applying circumferential pressure for graft adherence. When used for segmental vaginal agenesis, the Foley catheter may be advanced through the cervix, then the balloon can be inflated, to stabilize the position of the stent during the first week postoperatively. The main limitation of this device is that it must be constructed by the surgeon, but the advantage of self-constructing the stent is that the size and shape can be tailored to conform to each individual patient. We prefer this inflatable vaginal stent to a rigid vaginal dilator in the first week of tissue healing to allow for easy insertion and removal of the stent without disrupting the tissue graft, to help prevent tissue necrosis, and to provide a fluid drainage port during graft adherence. We recommend this device as an ideal option for surgeons to consider when performing a McIndoe vaginoplasty., (Copyright © 2020 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction and Objectives: Anorectal malformations (ARMs) represent a complex spectrum of anorectal and genitourinary anomalies and a paucity of evidence is available on long-term urologic outcomes in all ARM subtypes. It was our subjective bias from being a referral center for ARM patients that the subtype of rectovestibular fistula and absent vagina had higher risk of renal and bladder abnormalities than typical rectovestibular fistula patients. Therefore, to confirm or refute our clinical suspicions, the purpose of this study was to review this specific cohort of ARM patients and describe both the clinical urological and urodynamic outcomes., Methods: A retrospective cohort study was performed for 120 patients who were treated for ARM and vaginal replacement at our institution between 1991 and 2017. Fifteen patients with rectovestibular fistula and absent vagina were included in our review. Demographic and clinical data were abstracted from their medical records, including urodynamic findings, need for clean intermittent catheterization (CIC), urinary continence, and renal function., Results: Vaginal replacement surgery was undertaken concomitantly with ARM repair in 10 of the 15 patients (67%). One patient was lost to follow up, and mean follow up postoperatively was 39 months. In all but one patient, rectum or colon was used as the substrate for vaginal replacement. Of the 15 patients, 13 had continence data available. A total of 10 patients (77%) were able to achieve social continence. Overall six patients used CIC to manage their bladder and 40% of continent patients used CIC. Urinary continence outcomes in patients who had partial vaginal replacement compared to those with total vaginal replacement did not reveal a clinically significant difference. Continence was achieved in 3/4 patients (75%) with a history of tethered cord compared to 7/9 patients (78%) without a history of tethered cord release. Urodynamics were performed postoperatively in 7 of the 157 patients (47%). Uninhibited detrusor contractions (UDCs) were present in 3 out of 7 patients, and a cystometric capacity greater than expected was noted in 4 patients. Additionally, 2 patients had end filling detrusor pressure greater than 40 cm H2O. GFR data were available for 13 of the 15 patients and (85%) were classified as chronic kidney disease (CKD) stage I or not having any significant loss of renal function., Conclusions: In this cohort of rectovestibular fistula and absent vagina, 77% reported achieving urinary continence. However CIC was employed in 40% of the patients which is higher than prior published noncloaca female ARM patient population. Urodynamic abnormalities were noted when performed and led to change in bladder management. Renal function measured with GFR was normal in 85%. Patients with rectovestibular fistula and absent vagina benefit from urologic screening given higher rates of lower urinary tract dysfunction that can require CIC to protect the upper urinary tract and achieve urinary continence., Type of Study: Case series., Level of Evidence: Level IV., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Mayer-Rokitansky-Küster-Hauser syndrome is the second most common cause of primary amenorrhea, trailing only to gonadal dysgenesis. Neovaginoplasty is an appropriate treatment option for patients who have failed dilation therapy. Several biomaterials have been used in this procedure, including peritoneum, amnion, skin grafts, and myocutaneous flaps. Nile Tilapia Fish Skin has noninfectious microbiota, morphologic structure comparable to human skin, and high in vivo bioresorption. In addition, it showed good outcomes when used as a xenograft for burn treatment. Thus, we suggest it as a new biologic graft for vaginal agenesis management. In this descriptive study, neovaginoplasty using Nile Tilapia Fish Skin offered 3 patients an anatomic and functional neovagina via a simple method with potential long-term effectiveness. When postsurgical dilation was performed correctly, a vaginal length greater than 6 cm was maintained at 180 days follow-up. Histologic and immunohistochemical analyses revealed the presence of stratified squamous epithelium with high expression of cytokeratins and fibroblast growth factor, matching the characteristics of normal adult vaginal tissue. We believe that further studies will show Nile Tilapia Fish Skin to be a relevant option in the therapeutic arsenal of Mayer-Rokitansky-Küster-Hauser syndrome., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

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-Küster-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., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: To describe a McIndoe procedure technique for surgical management of Mayer-Rokitansky-Kuster-Hauser syndrome with the use of Nile tilapia skin as a scaffold for the proliferation of new vaginal epithelium., Design: Surgical video article. Local Institutional Review Board approval and written permission from the patient were obtained. There were no conflicts of interest., Setting: University hospital., Patient(s): A 17-year-old woman who presented at our gynecology department with the complaint of primary amenorrhea. At physical examination, she had a phenotypically normal vulva with no vaginal canal. Magnetic resonance imaging of the abdomen and pelvis revealed normal ovaries and absence of uterus and vaginal canal. No other congenital malformations were found. Karyotype was 46,XX., Intervention(s): The McIndoe procedure involved only a vaginal approach. Labia minora were separated, and a transverse midline incision of 3 cm was made. The vesicorectal space was progressively dissected. Blunt dissection was performed initially with digital separation of tissues. The neovagina was then inspected with the introduction of a vaginal speculum, allowing for review of hemostasis. Blunt dissection was continued with the aid of the speculum, to reach the appropriate vaginal dimensions. Subsequently, a vaginal acrylic mold covered with two pieces of processed and sterilized tilapia fish skin was inserted and accommodated into the newly created cavity. The external side of the tilapia skin, which maintained its grayish coloration after the removal of the scales, stayed in contact with the acrylic mold, while the white internal side of the tilapia skin, which was previously attached to the fish's muscle, stayed in contact with the walls of the neocavity. The mold was held in position by four multifilament polyglactin 1.0 sutures in the labia majora, thus preventing expulsion., Main Outcome Measure(s): Anatomic data, such as measurement of the final canal length, and histomorphologic analysis, 180 days after surgery., Result(s): The patient remained on bed rest for 9 days, after which the tilapia fish skin had been partially reabsorbed. After this time, the acrylic mold was removed. A larger plastic mold was then inserted and the patient was advised to wear it day and night for the first postoperative month. The vaginal mold had to be worn each night until normal sexual intercourse was possible. The final canal length 180 days after surgery was between 8 and 9 cm. For the histopathologic analysis, fragments of the lateral vaginal wall were removed 180 days after surgery and showed the presence of stratified squamous epithelium with five cell layers, ectasic blood vessels, and occasional desquamated epithelial cells., Conclusion(s): The procedure described offered this patient an anatomic and functional neovagina by means of a simple, safe, easy, effective, quick, and minimally invasive procedure. Limitations include the experimental nature of this study, based on a single case report with no long-term outcome results. The tilapia fish skin is a low-cost and widely available biomaterial., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To summarize the self-reported sexual experiences of women with vaginal agenesis before treatment and discuss the clinical implications., Design: A retrospective review of pretreatment baseline sexuality data and medical records of women with vaginal agenesis seeking vaginal construction., Setting: A specialist multidisciplinary center for women with genital differences associated with diverse sex development., Participants: One hundred thirty-seven women with untreated vaginal agenesis associated with Mayer-Rokitansky-Küster-Hauser Syndrome and complete androgen insensitivity syndrome aged 15 to 41 years (mean age, 20 years)., Interventions: Gynecological examination and completion of questionnaires., Main Outcome Measures: (1) Sexual Experiences Questionnaire; (2) Multidimensional Sexuality Questionnaire; (3) Vaginal Self-Perceptions; and (4) vaginal length., Results: A sizable proportion of women reported having had sexually intimate experiences before any medical intervention on the vagina. Vaginal length, which ranged from dimple to 7 cm and averaged 2.7 cm for the cohort, was unrelated to the range of sexual experiences. Most women perceived their vagina as being too small, but less than half believed that a sexual partner would notice this. Two-thirds of the cohort subsequently completed the dilation program, which was not predicted by pretreatment vaginal length or sexual experience., Conclusion: Contrary to the assumption that a vagina of certain dimensions is a prerequisite for women to "have sex," many women with Mayer-Rokitansky-Küster-Hauser syndrome and complete androgen insensitivity syndrome reported having experienced genital and nongenital sexual activities with no medical interventions. It is recommended that treatment providers affirm women's capacity for sexual intimacy, relationships, and enjoyment before they introduce the topic of vaginal construction as a non-urgent choice., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: To study the outcome of a novel method of laparoscopic neovaginal reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft., Design: Canadian Task Force classification II-1., Setting: A university hospital., Patients: A retrospective study of 14 patients from 2000 to 2014 of patients with vaginal agenesis who underwent laparoscopic neovagina reconstruction using rudimentary uterine horn serosa and the pelvic peritoneum as a graft., Intervention: Patients with vaginal agenesis associated with müllerian agenesis who requested surgery. Tertiary referral center and laparoscopic unit. The creation of a neovagina using rudimentary uterine horn serosa and the pelvic peritoneum as a graft via a combined laparoscopic and vaginal route., Measurements and Main Results: Data were collected retrospectively including postoperative vaginal length and width, complications, stenosis or reoperations, dyspareunia, and sexual satisfaction. There were no major complications from the surgery with no rectal perforation or bladder or ureteric injury. The postoperative mean (±SD) vaginal length was 6.0±0.7 cm and a width of 2 fingerbreadths. The mean operation time was 142.7±45.9 min. Median blood loss was 100 ml (range: 10 to 300 mL). The mean duration of the hospital stay was 6.6±1.6 days. The follow-up period ranged from 3 to 84 months with a median follow-up of 11 months., Conclusion: Lee's method of neovaginoplasty using rudimentary uterine horn serosa and the pelvic peritoneum as a graft is a good method for neovagina creation with minimal morbidity, fast recovery, and minimal complications. This method results in good anatomic and functional outcome and can be a method that is widely used., (Copyright © 2018 AAGL. Published by Elsevier Inc. All rights reserved.)

Aim: The aims of this study were to present the results of using infragluteal folds as a skin graft donor site in cases of Mullerian agenesis undergoing full-thickness skin graft vaginoplasty and to evaluate the outcomes of the surgical technique., Methods: Demographics and clinical parameters of 24 consecutive Mullerian agenesis patients refusing any dilatational procedure and undergoing neovaginal construction using infragluteal folds skin grafts from May 2004 to July 2015 were analyzed., Results: The mean age of the patients was 21.5 ± 5.7 years. Five patients had nonfunctional rudimentary uterus, one patient had unilateral ovarian agenesis, one patient had unilateral renal agenesis, and one had undergone a previous vaginoplasty. There were no serious complications needing surgical or medical intervention. The depth of the neovagina in patients with a follow-up period of more than 6 months (n = 17) varied from 7 to 12 cm. Of these patients, the sexually active ones (n = 8) did not complain of dyspareunia or vaginal dryness during sexual intercourse. The resulting scars were satisfactory and acceptable for all patients., Conclusion: It has been our practice to use infragluteal folds as a skin graft donor site for full-thickness skin graft vaginoplasty. We believe that the results of this study demonstrate that this area is versatile and an excellent alternative to the groins and lower abdomen. Further clinical and histomorphological investigations are necessary for strong statements and results., (© 2018 Japan Society of Obstetrics and Gynecology.)

Objective: To compare the long-term anatomical outcome and complications in treatments of vaginal agenesis in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome., Design: A historical comparative follow-up study using medical chart reviews., Setting: Public hospitals., Patient(s): A nationwide cohort of patients diagnosed with MRKH syndrome (n = 168)., Intervention(s): McIndoe vaginoplasty (n = 54), self-dilation (n = 60), coital dilation (n = 20), Baldwin vaginoplasty (n = 4), Williams vaginoplasty (n = 3), Davydov vaginoplasty (n = 2), or no treatment (n = 29)., Main Outcome Measures(s): Mean vaginal depth at follow-up, anatomical treatment success rates at levels of ≥6 cm, ≥7 cm, and ≥8 cm, complications, and resurgery., Result(s): Mean vaginal depths were 7.4 cm (95% confidence interval [CI] 6.8-8.1 cm), 7.3 cm (95% CI 6.7-7.9 cm), and 8.7 cm (95% CI 7.9-9.5 cm) at follow-up in patients treated by McIndoe vaginoplasty, self-dilation, and coital dilation, respectively. Overall complication rates in the three groups were 35/54 (65%), 21/52 (35%), and 1/20 (5%), respectively. Eighteen (33%) of the patients who underwent McIndoe vaginoplasty needed resurgery., Conclusion(s): Our findings support the current recommendations of dilation therapy as the first-line treatment of vaginal agenesis and emphasize the relevance of coital dilation in patients able to regularly engage in coital activity. However, further studies of functional outcome and patient satisfaction are needed., (Copyright © 2018 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Although vaginal reconstructions with intestinal segments require particularly complex surgical procedures, this technique has become popular with respect to fairly good functional and esthetic outcomes. This study describes cases of vaginal reconstruction performed using a modified rectosigmoid colon held in an ischemic state in order to reduce secretion and denervated in order to prevent defecation problems. Vaginal reconstructions with rectosigmoid colon were performed on 43 patients. In this retrospective study, 34 patients had Müllerian agenesis, while nine had undergone male to female sex reassignment surgery in which adequate vaginal depth had not been achieved. A rectosigmoid colon with its vascular pedicle was used and left in an ischemic state. All nerve structures within the pedicle were excised intraoperatively. Follow-up period was between 12 and 60 months. Partial necrosis occurred in one patient which was reconstructed with local flap. Hematoma developed beneath the skin incision in two cases, but resolved with conservative treatment. A good esthetic outcome was achieved in all cases. Sexual function was assessed using the Female Sexual Function Index (FSFI) in 15 patients. Fourteen out of 15 patients scored above 26.5 on this scale and were determined as having no sexual dysfunction (FSFI score ≥26.5). In conclusion, vaginal reconstruction with denervated rectosigmoid held in an ischemic state appears to be a reasonable option among several available reconstruction techniques.

Study Objective: To investigate specialist clinicians' experiences of treating vaginal agenesis., Design: Semi-structured interviews., Setting: Twelve hospitals in Britain and Sweden., Participants: Thirty-two health professionals connected to multidisciplinary teams (MDTs) including medical specialists and psychologists., Interventions and Main Outcome Measures: Theoretical thematic analysis of recorded verbatim data., Results: The gynecologist and psychologist interviewees share certain observations including the importance of psychological readiness for and appropriate timing of treatment. Three overlapping themes are identified in our theoretical analysis of the MDT clinicians' talk: (1) the stigma of vaginal agenesis and the pressure to be "normal" can lead patients to minimize the time, effort, physical discomfort, and emotional cost inherent in treatment. (2) Under pressure, treatment might be presented to patients with insufficient attention to the potential psychological effect of the language used. Furthermore, the opportunity to question what is "normal" in sex is generally not taken up. It can be challenging to help the women to transcend their medicalized experiences to come to experiencing their bodies as sexual and enjoyable. (3) The reality of treatment demands, which are not always adequately processed before treatment, can lead to discontinuation and even disengagement with services., Conclusion: The MDT clinicians in this study emphasized the importance of psychological input in vaginal construction. However, such input should proactively question social norms about how women's genitalia should appear and function. Furthermore, rather than steering patients (back) to treatment, the entire MDT could more explicitly question social norms and help the women to do the same. By shifting the definition of success from anatomy to personal agency, the clinical focus is transformed from treatment to women., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: In view of the rarity of vaginal agenesis, malignancy arising in the neovagina is extremely rare., Case Presentation: Here, we report a 76-year-old female with an adenocarcinoma arising in the sigmoid colon neovagina which was constructed 53 years ago for congenital vaginal agenesis. Vaginal endoscopy to examine vaginal bleeding revealed a protruding lesion occupying three quarters of the lumen in the vicinity of anastomosis of the residual vagina and sigmoid colon. Transvaginal ultrasonography revealed the muscularis propria layer (hypoechoic fourth layer) to be interrupted. CT revealed no distant metastasis. Total pelvic exenteration was performed based on the diagnosis of neovaginal cancer at the anastomosis site. The 45-mm tumor showed well-differentiated adenocarcinoma with a mucinous adenocarcinoma component. Immunohistochemistry showed no p16-overexpressing tumor cells, suggesting the lack of human papilloma virus infection., Conclusions: Although rare, clinicians should be aware of cancer that arises in the ectopic intestine when anastomosed with other organs.

Aims: To evaluate the effect of adjuvants during intensive vaginal dilator therapy for functional and anatomical neovagina creation in women with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)., Methods: This retrospective cohort study included 75 women with MRKH undergoing intensive vaginal dilator treatment between 2000 and 2014. One specialist nurse performed non-surgical vaginal dilation aided by adjuvants, during inpatient admissions for several dilation sessions per day. Following discharge, women continued dilation at home and were advised to attend fortnightly follow-up appointments., Results: Outcomes from 68 women were analysed. The median age of starting treatment was 18 years (range: 13-36). There was a mean of 3 days per admission (range 1-5) with a median of 10 dilation sessions per admission. Adjuvant treatment was used by 48/68 (71%) women: oestriol cream 29/68 (43%), 50:50 nitrous oxide and oxygen 44/68 (65%), diazepam 8/68 (12%), lidocaine ointment 26/68 (39%), paracetamol 35/68 (51%) and naproxen 2/68 (3%). There were no statistically significant differences for changes in vaginal parameters. Women receiving adjuvants had a median increase of 4.5 cm (0.5-7 cm) in neovaginal length compared with women not receiving adjuvants who had a median increase of 3.25 cm (0-7 cm) during intensive treatment. Women who received adjuvants tolerated more dilation sessions per day (10 vs 6.5 median sessions respectively) than those who did not (P < 0.001). Of those with documented length at discharge, 42/56 (75%) women had an anatomical neovagina of 7 cm or greater length., Conclusions: Vaginal dilation delivered by intensive treatment and supplemented by adjuvant treatments in a multi-disciplinary centre is a rapid and effective method for creation of a neovagina in women with MRKH., (© 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Study Objective: To examine providers' experiences with vaginal dilator training for patients with vaginal agenesis., Design and Setting: Anonymous electronic survey., Participants: Members of the North American Society for Pediatric and Adolescent Gynecology., Interventions and Main Outcome Measures: How providers learn about vaginal dilator training, common techniques, and methods used for patient training, assessment of patient readiness, common patient complaints, issues leading to early discontinuation., Results: There were a total of 55 completed survey responses of which 31 respondents (56%) had been in practice for more than 10 years. Forty-nine were gynecologists (89%), 20 had completed a fellowship in pediatric and adolescent gynecology (36%), and 6 were reproductive endocrinologists (11%). Thirty-one respondents had first learned about vaginal dilator training through lectures (56%) whereas only 9 through mentorship and fellowship (16%). According to respondents, the most common issue leading to early discontinuation was lack of patient motivation and readiness (n = 42; 76%). The most common complication was pain or discomfort (n = 45; 82%). More than half of respondents determined dilator therapy was successful when patients reported comfortable sexual intercourse (n = 30; 55%) and 65% (n = 35) did not delineate any restrictions to initiation of sexual intercourse. Most respondents (87%) requested further vaginal dilator training at either a clinical meeting (n = 26; 47%) or with a training video (n = 22; 40%)., Conclusion: Our study in an experienced cohort of pediatric gynecology providers highlights the need for further research and training on vaginal dilation education., (Copyright © 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Introduction: Appropriate postoperative care and prolonged use of the mold are prerequisites for achieving successful results in McIndoe-style vaginoplasty., Objective: We introduce a specially designed pored polyacetal mold to maintain the reconstructed vagina, with favorable long-term results allowing drainage of the serous and bloody discharge without removal of the mold, and reduction of infection rate and the chance of skin graft shearing in McIndoe vaginoplasty., Methods: We retrospectively reviewed data of 10 consecutive patients with Mayer-Rokitansky-Kuster-Hauser syndrome who underwent McIndoe vaginoplasty between March 2010 and January 2014. We used a specially designed pored polyacetal mold (Figure) in all reconstructed vaginal wounds. The anatomical surgical success was evaluated by physical examination and functional success, which was defined as satisfaction with sex evaluated by patient self-assessed questionnaire., Results: The follow-up period ranged from 1 to 3.5 years. The postoperative mean vaginal length was 9.5 cm in nine patients who used the mold regularly. In all cases in which a pored polyacetal mold was used, skin engraftment was successfully maintained without partial skin graft loss or infection. The subjective patient self-assessed satisfaction evaluation reported a high satisfaction rate., Discussion: The multi-holed polyacetal vaginal mold was designed to perform vaginal irrigation without removal of the mold, allowing drainage of the serous and bloody discharge. This makes it possible to reduce infection rate and maintain successful skin engraftment by reducing the chance of skin graft shearing. The characteristics of polyacetal make it useful as a vaginal mold material as it is lightweight to use, easy to manufacture in accordance with the dimensions of the neovaginal space, and cost-effective. Although a constant follow-up evaluation is required, the pored polyacetal mold is an attractive vaginal mold dressing material to maximize the initial graft uptake, and it can be individually tailored in patients undergoing McIndoe-style vaginoplasty., Conclusions: The specially designed vaginal mold made up of pored polyacetal is a proper vaginal mold, which could maximize the initial graft uptake, decrease the risk of wound infection, and, therefore, decrease contracture of the neovagina in patients undergoing McIndoe vaginoplasty., (Copyright © 2017 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Although vaginal agenesis as may occur in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a rare condition, it is associated with not only anatomical problems but also serious psychological and social problems like painful sexual intercourse, primary amenorrhea and infertility. Surgery, which is aimed at reconstruction of a vagina of adequate length and width to serve the function, is the main method of treatment. Many methods for vaginal reconstruction have been described but each has its complications and limitations. The most commonly preferred procedure for treating this condition is the McIndoe vaginoplasty which involves dissection into the recto-vesical space, inserting two split thickness skin grafts folded over a mold in this newly created space and regular dilatation of the neovagina postoperatively to avoid stenosis. However surgeons with this expertise in this part of the world are rare to find and where they are available, the special molds on which to fold the skin grafts into the neovaginal space are not readily available., Case Presentation: A 21-year-old female with vaginal agenesis was operated on using a modification of the McIndoe procedure using a cylinder of a 60cm 3 syringe as a vaginal mold/form and kept in place. We left a Foley in place for 10 days and we did a dye test after removing the syringe to ensure that there was no leakage resulting from fistula formation., Conclusion: The operation was successful and on subsequent monthly reviews of the patient, she has a patent functional vagina of about 9 cm in length at 8 months after the operation with resumption of sexual intercourse.

Study Objective: To assess the experience of dilator use for neovagina creation in women diagnosed with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome and identify barriers affecting patient compliance with dilator use., Design and Setting: This was a qualitative study using a structured questionnaire to investigate perception and identify barriers regarding vaginal dilator use. A questionnaire was administered after participants viewed a 2-minute patient educational video to additionally examine the usefulness of a patient education video tool as an adjunct to counseling in clinic on vaginal dilator use., Participants, Interventions, and Main Outcome Measures: We enrolled 13 adolescent girls and women diagnosed with MRKH, aged 14-48 years, recruited from clinic and during a conference geared toward women affected by MRKH., Results: The mean age of participants was 26 (±11.4) years with most diagnosed between the ages of 12 and 18 years. Of all participants, 69% (9/13) reported ever being sexually active with a mean age of coitarche of 16 (±2.6) years. Seventy-seven percent (10/13) reported current or past use of vaginal dilators, and most had some previous education on dilator use. Only 15% (2/13) reported no previous exposure to an educational tool. After viewing the 2-minute educational video, all participants rated it very helpful using a Likert scale (strongly agree to strongly disagree). Major themes that emerged as perceived barriers to dilator use included viewing dilation as a negative experience, uncertainty about success, and lack of motivation., Conclusion: Education is an integral part of improving compliance with vaginal dilator use among adolescent girls and women affected by MRKH. Technology can be used to reinforce face-to-face counseling in the clinic. To our knowledge, this is the first study to specifically investigate patient experience with dilator use and opinion regarding the use of video technology to demonstrate self-directed neovagina creation in an MRKH population. The barriers identified in this study provide new insights to inform future research and clinical management of dilator use., (Copyright © 2017 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the outcome of amnion vaginoplasty in cases of vaginal agenesis due to Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome managed at the authors' institution., Design: Retrospective study., Setting: Tertiary care hospital., Patient(s): Fifty women with MRKH who underwent neovaginoplasty., Intervention(s): Modified McIndoe's vaginoplasty was done in all the patients, using human amnion graft., Main Outcome Measure(s): Functional status assessed by Female Sexual Function Index, anatomic status (length and width of neovagina), and epithelialization of vagina., Result(s): Mean (±SD) vaginal length after surgery was 8.2 ± 1 cm. Mean vaginal length at 6-month follow-up in sexually active patients was significantly longer as compared with the patients who were not sexually active after surgery (8.4 ± 1.04 cm vs. 6.6 ± 2.4 cm). Mean Female Sexual Function Index score was 30.8 ± 2.1. Vaginal biopsy showed complete epithelialization of vaginal mucosa., Conclusion(s): In a developing nation like India, McIndoe's method with amnion graft seems to be a promising option owing to its low cost, easy availability, and safety, ease of the procedure not requiring any special instrument, physiologic outcome with respect to epithelialization of the vagina without hair growth, and satisfying functional outcome., (Copyright © 2017 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: The association of rectovestibular fistula (RVF) and vaginal agenesis (VA) presents a diagnostic and management challenge. The vaginal replacement is usually performed with rectum or sigmoid, which are the natural fecal reservoirs; thus, the fecal control could be affected. We present our experience utilizing ileum to preserve the rectum and sigmoid., Methods: We performed a retrospective study of eight patients with RVF and VA treated from May 2011 to June 2015 at two colorectal centers, at Pittsburgh and Mexico. We recorded the age at diagnosis of VA, treatment, presence of other associated malformations and outcome., Results: Eight of forty-nine girls with RVF had an associated VA (16.3%). Three patients had a timely diagnosis and five a delayed diagnosis. Six patients were submitted to a vaginal replacement with ileum and achieved fecal control. Two are waiting for surgery., Conclusions: A high index of suspicion of vaginal agenesis helps in a timely diagnosis in girls with RVF. The use of ileum allows for preservation of the fecal reservoirs, thus optimizing the chance for fecal control in patients with anorectal malformations., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome includes vaginal agenesis with varied uterine development. The objective of this video is to illustrate our surgical technique to create a cervical and vaginal canal to relieve menstrual obstruction for a teenager with a functional uterus and vaginal agenesis., Methods: Using vaginal dissection and a mini laparotomy, a sound placed through the fundus of the uterus created an endocervical and vaginal channel to relieve her menstrual obstruction. A Foley catheter stented the cervical canal and a red rubber chest tube catheter stented the vagina until epithelization was achieved., Results: No complications were encountered. The patient was examined with intermittent hysteroscopy with gentle dilation of the cervix. She had the red rubber catheter removed at 3 months, and she started using a small dilator. Her menses were suppressed with a gonadotropin releasing-hormone agonist allowing for complete healing. She is now 17. Her vaginal canal is well-epithelialized. Hysteroscopy confirmed a patent endocervical canal and uterine cavity., Conclusion: MRKH is rare. A small percentage of affected women has a functional endometrium requiring intervention for menstrual obstruction. Full vaginal reconstruction may be considered, but creation of a small canal to provide menstrual relief can be a temporary solution in those not desiring sexual function.

Neovagina creation is essential for patients with the Mayer-Rokitansky-Kuster-Hauser syndrome. We compared a technique involved the pushing down of the peritoneum with the technique of separating the peritoneum for laparoscopy-assisted peritoneal vaginoplasty. We collected patients with congenital absence of vagina who underwent laparoscopy-assisted peritoneal vaginoplasty of the First Affiliated Hospital of Zhengzhou University between January 2011 and May 2013. The 2 surgical groups (pushing group and separating group) were compared for various parameters. The values of the following parameters were significantly lower for the pushing group compared with the separating group: mean operating time (78 ± 13 minutes vs 135 ± 28 minutes), mean duration of hospitalization (12.9 ± 2.7 days vs 18.0 ± 3.8 days), mean cost of hospitalization (14 016 ± 1640 RMB vs 18 783 ± 2143 RMB), requirement for a drainage tube (4% vs 27%; χ(2) = 8.864), requirement for analgesic drugs (20% vs 40%; χ(2) = 3.977), and postoperative rehospitalization (3.3% vs 10.0% at 2 months and 6.7% vs 26.7% at 6 months; χ(2) = 4.268 and 5.196). Mean values for blood loss (57 ± 19 mL vs 66 ± 20 mL), time to pass gas (21 ± 4 hours vs 23 ± 7 hours), and length of the reconstructed vagina (9.0 ± 0.4 cm vs 8.9 ± 0.5 cm) were not significantly different between the 2 groups. In addition, mean postoperative Female Sexual Function Index score did not differ significantly between the 2 groups or among the 2 groups and a control group (27.0 ± 4.8 vs 26.7 ± 5.2 vs 27.9 ± 4.5; p > .05). The technique involving pushing down of the peritoneum offers advantages of reduced cost, complications, hospitalization, operative time, and pain over the traditional technique. Sexuality approaches so-called "normal" sexuality., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

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-Küster-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., (Copyright © 2015 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Vaginal agenesis is rare and generally presents with primary amenorrhea and cyclic abdominal pain. We describe a case in which the diagnosis was delayed due to lack of initial pelvic examination and atypical findings on imaging., Case: A 13-year-old girl with a known renal anomaly presented to the emergency department with primary amenorrhea and cyclic abdominal pain. She declined a pelvic examination and had normal laboratory testing and pelvic magnetic resonance imaging results. At 16 months later, she presented again and was diagnosed with vaginal agenesis and a large endometrioma., Summary and Conclusion: This case illustrates the importance of the physical examination in the evaluation of primary amenorrhea. Further, it demonstrates that hematometra may not be present on imaging. Here, an endometrioma was the only abnormality noted on magnetic resonance imaging after 18 months of retrograde menstruation., (Published by Elsevier Inc.)

Objective: To compare two methods of neovagina construction, the Frank and McIndoe techniques, in terms of structural and biological aspects., Study Design: A total of 55 subjects were included in this retrospective study: 43 underwent the Frank technique (FT) and 12 underwent the McIndoe technique (MT). A clinical evaluation and a comparison of the structural (color, shine, presence of hair, and histology) and biological (bacteriological, pH, and hormonal determinations) features were performed. Statistical analysis was performed using the Fisher and Mann-Whitney tests., Results: The time to achieve a functional neovagina using the FT was longer than when using the MT (9.8±5.3 versus 5.8±2.9 months) (p=0.01). The neovaginal wall of the MT skin grafts was more rigid and drier, and it did not exhibit a shine in the way that the FT skin grafts did. The lining of the cavity formed by the FT in all subjects was similar to that of vaginal mucosa, whereas the lining formed by the MT persisted as a skin graft in 83.3% of the cases. The pH was lower for the FT (p<0.01), and Döderlein bacilli were present in 90% of the FT neovaginas but absent from the MT neovaginas. In the latter, flora with anaerobic bacteria was present. Hormonal cytology showed estrogen activity in 100% of the FT neovaginas, but there was no such activity in the MT neovaginas., Conclusions: Our data suggest that the FT may be clinically, structurally, and biologically superior to the MT for the creation of neovaginas and is also less costly., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Study Objective: To present the procedure and the results of a technique in which in vitro autologous cell cultures were used for the canal lining in patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) subjected to vaginoplasty with a modified Abbè-McIndoe technique. MRKHS is a rare anomaly characterized by vaginal agenesis with variable müllerian duct abnormalities. The Abbè-McIndoe procedure is 1 of the most frequent surgical treatments adopted in these women. In the last decades, several modifications have been introduced by different authors, mostly changing the lining material, but no consensus has been reached on what material should be used for the neovagina canal wall lining., Design: A pilot study (Canadian Task Force classification II-1)., Setting: Policlinico Umberto I, "Sapienza" University of Rome., Patients: A consecutive series of 23 women with MRKHS underwent neovaginoplasty with autologous vaginal tissue as the graft material between 2006 and 2013., Interventions: Each patient with MRKHS was subjected to a full-thickness mucosal biopsy from the vaginal vestibule. After enzymatic dissociation, cells were inoculated onto collagen IV-coated plates and cultured for 2 to 3 weeks. The patients were subjected to vaginoplasty with a modified Abbè-McIndoe technique with autologous in vitro cultured vaginal tissue. Patients underwent clinical follow-up visits at 1, 3, 6, and 12 months after surgery and every year thereafter. Anatomic, functional, and sexual results were assessed., Measurements and Main Results: In all cases, the vagina appeared normal in length and depth. A vaginal cytology and a vaginal biopsy obtained at the 3-month follow-up visit revealed physiological vaginal tissue. All 23 patients completed the Female Sexual Function Index questionnaire at 12 months after surgery. The results showed a total score of 27.2. These results indicate a satisfactory quality of sexual life., Conclusion: The modified Abbè-McIndoe technique with autologous vaginal tissue appears to be safe and feasible. This technique allows normal and satisfying sexual intercourse. Larger series with longer follow-ups will be necessary to confirm if this technique represents the ideal procedure for vaginal agenesis., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the management and long-term outcomes of transverse vaginal septae., Design: Observational study with cross-sectional and retrospective arms., Setting: Tertiary referral centre specialising in Müllerian anomalies., Population: Forty-six girls and women with a transverse vaginal septum., Methods: Data from medical records of all cases (1998-2013) of transverse vaginal septae were collected and reviewed. Patients over 16 years of age also completed a questionnaire., Main Outcome Measures: Presentation, examination findings, investigations, surgery, and long-term reproductive outcomes., Results: The septae in the study were described as follows: 61% (95% CI 0.46-0.74) were imperforate, and presented with obstructed menstruation; 39% (95% CI 0.26-0.54) were perforate, and presented with a variety of concerns; 72% (95% CI 0.57-0.83) were low, 22% (95% CI 0.12-0.36) were mid-vaginal, and 6% (95% CI 0.02-0.18) were high; 33% were managed via an abdominoperineal approach, 59% were managed via a vaginal approach, and 6% had laparoscopic resection (one patient did not have surgery); 11% (95% CI 0.05-0.23) of patients presented with reobstruction, all following abdominoperineal vaginoplasty; 7% presented with vaginal stenosis, two following vaginal resection and one following the abdominoperineal approach; 61% of questionnaires were returned. These results showed that 22/23 patients were menstruating and one had a hysterectomy, 74% had been sexually active, 35% had dyspareunia, and 36% complained of dysmenorrhoea. There were seven pregnancies, with one termination and six live births, all following the vaginal excision of a transverse vaginal septum., Conclusions: Transverse vaginal septae resected vaginally or laparoscopically have low complication rates and good long-term outcomes. Complex septae require more extensive surgery, with an increased risk of complications., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Objectives: The use of bowel for vaginal construction is a well-established procedure. In this paper, the lessons learned from 36 vaginoplasties over a 34-year period are discussed., Methods: Between 1980 and 2013, 36 patients between 1 and 21 years of age underwent vaginal construction. In 27 of the 36 patients, an inverted V-shaped perineal skin flap was incorporated into the posterior wall of the neovagina, and, when required, a detubularized pouch was used to avoid traction on the vascular pedicle. In nine patients, the sigmoid colon was anastomosed, in a circumferential manner, to the short blind-ending vaginal dimple., Results: Two of the nine sigmoid vaginas, where the perineal skin flap was omitted, developed introital stenosis. None of the sigmoid neovaginas that included the perineal flap developed stenosis. One patient with ileal segment vagina, at the onset of puberty, developed introital stenosis after 10 years; this was successfully corrected. Nineteen out of 28 patients available for long-term follow up were sexually active and reported no dyspareunia., Conclusions: Detubularization and reconfiguration to form a pouch reduces the traction on the mesentery of the bowel segment, which ensures adequate blood supply to the distal entero-cutaneous junction. The inverted V-shaped perineal skin flap should be incorporated in the anastomosis to avoid circumferential suture line and introital stenosis., (Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Rupture of the hymen before marriage is a significant problem for a woman and her family. The purpose of this article is to present a case report where hymen membrane perforation was required for vaginal agenesis in a 13-year-old adolescent, identify psychosocial issues related to the torn hymen in the Turkish culture, discuss gender inequality affecting health care of women with a torn hymen, identify the impact of a torn hymen on a Turkish woman's social status, and discuss health care implications for the woman and her family. The girl could not understand the situation and experienced feelings of guilt. The parents displayed an intense reaction of shock and denial after being informed about the disorder and treatment process and felt a sense of hopelessness about the future of their daughter. Nurses are expected to fulfill their training, counseling, and advocacy roles about this issue., (© The Author(s) 2014.)

Introduction: Sexual adjustment and long-term results following vaginal reconstruction with free vascular jejunal flap are not well known., Aims: The study aims to investigate sexual adjustment and long-term results among patients who underwent vaginal reconstruction with free vascular jejunal flap., Methods: A total of 34 women, aged 16-31 years (mean 23.5), who underwent vaginal reconstruction with a vascular jejunal flap between 2005 and 2011 were evaluated. Indications for reconstruction included the following: Mayer Rokitansky Kuster Hauser syndrome (29 patients), isolated vaginal agenesis (2 patients), androgen insensitivity syndrome (2 patients), and (1) history of gynecologic-oncologic surgery., Main Outcome Measures: The study evaluates the perioperative results, complications, satisfaction with sexual function, length and width of the neovagina., Results: All of the surgeries were completed without any intraoperative complications. Three patients required reoperation because of postoperative venous compromise in the grafts. The flap success rate was 100%, and no infection was observed for any case. The mean follow-up was 50 months (between 20 and 87 months). The mean vaginal depth and diameter were satisfactory for all cases. Postoperatively, six patients complained of jejunal hypersecretion, one patient complained of mucosal prolapse, and one patient complained of vaginal constriction. The neovaginal prolapse was repaired via minor surgery. Twenty-seven were married and sexually active. Twenty patients completed the questionnaire on sexual function. Sexual function was assessed using the Female Sexual Function Index (FSFI). Eleven patients were satisfied with their sexual lives after surgery (FSFI scores≥25)., Conclusion: Based on our results, satisfactory sexual function was achieved using the free jejunal vascular flap., (© 2013 International Society for Sexual Medicine.)

Aim: The aim of this study is to describe a technique for and data from vaginoplasty surgeries performed using a pudendal thigh flap (PTF) thinned with liposuction., Method: A total of six patients diagnosed with Müllerian agenesis underwent vaginoplasty procedures using this technique between January 2009 and April 2012. The age range of the patients was 19-24 years. In the first stage, the subcutaneous fat tissue under the planned skin flap islands was thinned with liposuction. After 3 months, the second stage of the procedure was carried out and the PTFs were elevated., Results: Complications such as infection, dehiscence of the suture line and haematoma were not observed in any of the patients. Although a partial flap loss was observed at the distal aspect of a flap in one patient, total healing was achieved through debridement and local wound care. Mean tissue flap thickness was found to be thinner, and adequate vaginal depth was achieved in all patients on average 13 months following surgery., Conclusion: We are of the opinion that PTFs thinned with liposuction enable both a thinner tissue flap and a vaginal reconstruction that more closely resembles natural anatomy., (Copyright © 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Mullerian duct abnormalities are congenital malformations that are easily missed and can lead to incorrect diagnosis and unnecessary operative procedures. In this case, a young female presented with cyclic pelvic pain that continued after previous surgical resection of an ovarian cyst. Further investigation with clinical examinations and multimodality imaging demonstrated ipsilateral renal agenesis and a Class III Mullerian duct anomaly (MDA) requiring a second operative procedure. It is believed that this case is a variant of the described obstructed hemi-vagina with ipsilateral renal agenesis (OVIRA) anomaly as pathologically there was ipsilateral renal agenesis and complete vaginal agenesis in our case. It is imperative to have a high clinical suspicion of mullerian duct abnormalities when encountering a patient with other urogenital anomalies. This will decrease the amount of misdiagnoses, guide appropriate surgical intervention, and decrease the risk of future reproductive complications.

Objective Design Setting Population Methods Main Outcome Measures Results Conclusions To explore how women with Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome experience dilation or surgical vaginal lengthening treatment, and their current sexual well‐being.A qualitative interview study.Denmark.Women aged ≥25 years diagnosed with MRKH syndrome.Semi‐structured video interviews were conducted with 18 women. Interviews lasted a median of 92 min and were digitally recorded, transcribed and anonymised. Data were analysed using thematic analysis.A qualitative analysis of women's experiences.The analysis identified three themes. Firstly, Experiences with dilation treatment revealed dilation as an awkward routine, especially for adolescents living with parents and yet to sexually debut. While some experienced successful vaginal lengthening, others faced treatment failure leading to frustration and self‐blame. Secondly, Experiences with neovaginal surgery described the procedure as extremely painful but resulting in a ‘normal size’ vagina. Some women felt that the procedure had negatively impacted their self‐confidence, and all underscored the importance of maturity before opting for surgery. Lastly, Current sex life and sexual well‐being indicated a well‐functioning sex life for many women, but with reported low sexual confidence and genital self‐image due to the perceived ‘deviance’ of their genitalia.For women with MRKH syndrome, vaginal lengthening treatment, whether through dilation or surgery, may result in a ‘normal size’ vagina. However, according to the women's experiences, vaginal lengthening treatment does not adequately foster positive sexual esteem and genital self‐image. [ABSTRACT FROM AUTHOR]

Vaginal agenesis (VA) is frequently associated with mullerian agenesis. VA treatments include mechanical dilation and surgical vaginoplasty. We created a vaginal expansion sleeve (VES) as a novel device to progressively lengthen the vaginal canal. This study evaluated the histologic effects of the VES on rat vaginal tissue. The VES is a spring-like device made of proprietary woven cylindrical material and flat resin caps. The VESs were constructed as 25–30 mm, pre-contracted springs, which were secured into the vaginas of six Sprague Dawley rats and allowed to re-expand post-surgically. After one week, the VESs were removed, and the vaginas were harvested and measured in length. Test (n = 6) and control (n = 4) formalin-fixed paraffin-embedded tissues were stained with hematoxylin and eosin (H&E), Masson's trichrome, and anti-Desmin antibodies. The VESs achieved significant vaginal lengthening. The mean vaginal canal length increased from 20.0 ± 2.4 mm to 23.8 ± 1.2 mm after removal of the VESs (n = 6, p < 0.001), a 19% increase. There was a positive correlation between the expander/tension generated in the vagina and the amount of acute and chronic inflammation. H&E staining revealed increased submucosal eosinophilia in five of the six test tissues. One VES sample that was lengthened to 30 mm long showed evidence of lymphocytic and neutrophilic inflammation. Desmin immunostaining and Masson's trichrome stain revealed a thinner muscularis with more infiltrative fibrous tissue between muscle fibers in the test tissue compared to the control tissue. Although effective, the VES may provoke at least a transient increase in eosinophils consistent with a localized immune reaction during muscularis remodeling. [ABSTRACT FROM AUTHOR]

To describe surgical correction of vaginal agenesis via a modified laparoscopic Vecchietti procedure with the goal of disseminating knowledge and improving surgical technique An 18-year-old female presented with primary amenorrhea, age-appropriate secondary sex characteristics, a shallow vagina, and 46,XX karyotype. Imaging showed rudimentary uterine horns and normal ovaries, kidneys, and spine. Diagnosis of Mayer-Rokitansky-Küster-Hauser syndrome type I was made. After an unsuccessful attempt at vaginal dilation and extensive counseling, the patient chose to have a laparoscopic Vecchietti procedure. Vecchietti vaginoplasty eliminates the need for grafts and creates a neovagina with accelerated vaginal dilation by stretching the introital mucosa with a spring mechanism. A modified laparoscopic Vecchietti procedure was performed. Postoperatively, daily suture adjustments were made. When the device was removed after 7 days, the examination revealed a 9-cm vaginal canal, which was maintained with self-dilation. [ABSTRACT FROM AUTHOR]

The demand for sexual life makes vaginoplasty a crucial need for patients who had complete vagina agenesis. We present our experience on vaginoplasty by using a maximum amount of meshing oral mucosal grafts in a case series study on 43 patients. The patients were followed up for an average of 19 months, ranging from 6 months to 4 years. No serious complications were reported. The patients gained good results also at neovagina and donor sites. These results were proved on clinical, endoscopy images, and biopsies. We recommend seven tips in the techniques to be used to achieve these significant results. [ABSTRACT FROM AUTHOR]

Background: Around 1 in 400-5000 live births of females result in vaginal agenesis, a malformation of the female genital tracts. Using an amnion graft to treat vaginal agenesis is a straightforward, widely accessible, economically advantageous, and physiological surgery that leaves no additional scars on the body. This study sought to ascertain whether individuals with vaginal agenesis may successfully undergo laparoscopic-assisted vaginoplasty utilising amnion as a transplant to create a neovagina. Methods: Ten cases of vaginal agenesis linked to Mayor- Rokitansky-Kuster-Hauser (MRKH) Syndrome were included in this case series and were hospitalised within a year. The ladies with MRKH condition were either previously married or unable to consummate their marriage due to a blind vagina when they were brought for surgical intervention. To maintain the patency of the neo-vagina, a laparoscopically guided vaginoplasty was carried out as part of the care. Results: In all but one of the patients, laparoscopy-guided vaginoplasty with an amnion graft was effective. The procedure was stopped when the rectum was hurt, and the harm to the rectum was repaired. Except for one example, the functional outcomes of the neovagina were quite good. None experienced any major postoperative problems. The patients were happy with the postoperative results. Also, the neovagina was psychologically acceptable and sufficiently patent for sexual function. Conclusion: Over the past few years, the new vaginoplasty technique has developed. The most common practice, however, is a laparoscopic approach using several graft materials. A safe and efficient method for treating MRKH syndrome patients with vaginal agenesis is vaginoplasty with amnion grafts. [ABSTRACT FROM AUTHOR]

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. Review of the existing literature PUBMED search with key words vaginal agenesis, neovaginal creation, vaginoplasty, vaginal stretching, vaginal augmentation, vaginal stenosis, outcomes of vaginoplasty, Mullerian anomalies, vaginal anomalies The need to perform vaginal stretching, replacement, or augmentation will vary depending on the underlying reproductive tract condition. 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. [ABSTRACT FROM AUTHOR]

The prevalence of congenital cervical agenesis or dysgenesis ranges from 1/80,000 to 1/100,000, and in about 50% of these cases it coexists with congenital vaginal agenesis. This narrative review summarizes the contemporary knowledge in the field of conservative surgical restoration of the reproductive tract. The management of congenital cervical malformations aims to [1] provide relief from the obstructive symptoms, [2] establish normal sexual function, and [3] preserve the uterus for future fertility. In cases of cervical agenesis and vaginal aplasia, the surgical approach involves the creation of neovagina, the creation of neocervix, and then subsequent restoration of the continuity of the genital tract. In cases where vagina is not congenitally absent, the surgical approach involves either a direct uterovaginal anastomosis or initial creation of neocervix and then subsequent restoration of the continuity of the genital tract. The neocervix can be surgically created with small intestinal submucosa, split-thickness skin graft, full-thickness skin graft, peritoneal flap, or vaginal mucosa lined with a polytetrafluoroethylene graft. Most of the published cases report long-term menstruation and sporadic pregnancies. Conservative surgery of cervical congenital malformations could serve as a first-line treatment. Sexual function and menstruation are established in the majority of patients. Extirpatory surgery may be preserved for surgical failures after initial restoration of the continuity of uterus-cervix-vagina or in cases with more complex anatomy. [ABSTRACT FROM AUTHOR]

Mayer-Rokitansky-Küster-Hauser syndrome is a rare congenital malformation that affects one in five thousand women. It is characterized by the lack (agenesis) of the vagina and uterus, but without alteration of the ovaries, external genitalia, secondary sexual characteristics and karyotype. This article aims to investigate, through literature analysis, the impact that the diagnosis of Mayer-Rokitansky- Küster-Hauser syndrome has on the patient's life and psychosexual aspects with the aim of validating the need for bio-psycho-social intervention. The diagnosis is almost always made very late, often during adolescence due to the lack of menarche. Besides the problems in the psychic and sexual sphere, the most debilitating aspect of the syndrome is infertility due to the absence of the uterine canal. From the diagnosis the self image that is reformulated is extremely negative, the girl feels defective, imperfect, and this consideration of herself is strongly linked to the symbolic representation of the uterus as a sign of femininity. Her gender identity, as the unitary and persistent perception of oneself as belonging to the male or female gender, is also questioned. The Rokitansky syndrome also has repercussions on the quality of romantic and sexual relationships. Women with vaginal agenesis tend to avoid being involved in romantic and sexual relationships, as their clinical situation may become a problem due to the fear of having to inform their partner of the diagnosis, the resulting infertility and the fear of not being able to satisfy him sexually. The issue of infertility is often linked to a loss of physical attraction and trust between partners. The inability to conceive a child can lead to a distortion of the psychological balance of both the individual and the couple and is compared to grief. Studies of infertile women reveal an increase in suspicion and hostility that can affect the relationship with the partner. There are different medical and surgical solutions to deal with this condition. However, medical intervention alone does not seem to be sufficient to pursue the well-being of the patient. Rokitansky syndrome has an enormous impact on the sexual life of patients even after treatment because often the coital relationship is painful (dyspareunia) and difficult both because of the small size of the vaginal canal and the poor lubrication that women complain about. The studies also report the importance of the affective dimension in the sexual satisfaction of the couple. In addition, the reactions of the family and the environment are an additional emotional issue that in- creases the adolescent's distress. It is therefore advisable to also take care of the emotional needs of the parents and respond to their information needs because the family provides the context that shapes the way patients experience the disease and communicate their experiences. It is therefore essential to use an integrated approach that provides both medical intervention and psychosexual counselling at the same time. As various research shows, patients express a desire to talk about their feelings and sexuality in a respectful and welcoming atmosphere. For this reason, they should always be at the centre of treatment and therapy and should be able to play an active role in the decision- making process. However, in clinical practice there is still a lack of communication between doctor and patient about sexuality, due to a lack of training of doctors on couple and sexual health problems in relation to physical and mental health problems. As a result, doctors tend to discard the psychosexual aspects of health, considering them less important than the diagnosis and treatment of the disease. In addition, many doctors lack comfort, competence and willingness to discuss intimate aspects of patients' lives. Therefore, it is necessary that clinicians are also adequately trained on psychological and sexual health problems in order to develop a greater sensitivity to these issues and, above all, to recognize the importance of the bio-psycho-social model and, therefore, to show a greater spirit of collaboration in teamwork. [ABSTRACT FROM AUTHOR]