Creation of a Neovagina by Laparoscopic Modified Vecchietti Technique: Anatomic and Functional Results

Abstract

Purpose To evaluate the anatomic and functional results of a laparoscopic modified Vecchietti technique for the creation of a neovagina in patients with congenital vaginal aplasia.

Methods Retrospective study of nine patients with congenital vaginal aplasia submitted to the laparoscopic Vecchietti procedure, in our department, between 2006 and 2013. The anatomical results were evaluated by assessing the length, width and epithelialization of the neovagina at the postoperative visits. The functional outcome was evaluated using the Rosen Female Sexual Function Index (FSFI) questionnaire and comparing the patients' results to those of a control group of 20 healthy women. The statistical analysis was performed using SPSS Statistics version 19.0 (IBM, Armonk, NY, USA), Student t-test, Mann-Whitney U test and Fisher exact test.

Results The condition underlying the vaginal aplasia was Mayer-Rokitansky-Küster-Hauser syndrome in eight cases, and androgen insensitivity syndrome in one case. The average preoperative vaginal length was 2.9 cm. At surgery, the mean age of the patients was 22.2 years. The surgery was performed successfully in all patients and no intra or postoperative complications were recorded. At the first postoperative visit (6 to 8 weeks after surgery), the mean vaginal length was 8.1 cm. In all cases, the neovagina was epithelialized and had an appropriate width. The mean FSFI total and single domain scores did not differ significantly from those of the control group: 27.5 vs. 30.6 (total); 4.0 vs. 4.2 (desire); 4.4 vs. 5.2 (arousal); 5.2 vs. 5.3 (lubrication); 4.2 vs. 5.0 (orgasm); 5.3 vs. 5.5 (satisfaction) and 4.4 vs. 5.4 (comfort).

Conclusions This modified laparoscopic Vecchietti technique is a simple, safe and effective procedure, which allows patients with congenital vaginal aplasia to have a satisfactory sexual activity, comparable to that of normal controls.

Resumo

Objetivo Avaliar os resultados anatômicos e funcionais da técnica laparoscópica modificada de Vecchietti para a criação de uma neovagina em pacientes com aplasia vaginal congênita.

Métodos Estudo retrospectivo de nove pacientes com aplasia vaginal congênita submetidas à técnica laparoscópica modificada de Vecchietti, no nosso departamento, entre 2006 e 2013. Os resultados anatômicos foram aferidos através da avaliação do comprimento, largura e reepitelização da neovagina nas consultas pós-operatórias. Os resultados funcionais foram avaliados com recurso à versão em português do questionário Female Sexual Function Index de Rosen, comparando os resultados das pacientes aos de um grupo de controle de 20 mulheres saudáveis. A análise estatística foi realizada utilizando o programa SPSS Statistics versão 19.0), o teste t de Student, teste U de Mann-Whitney e teste exato de Fisher.

Resultados A etiologia subjacente à aplasia vaginal foi a síndrome de Mayer-Rokitansky-Küster-Hauser em oito casos, e a síndrome de insensibilidade aos andrógenos em um caso. O comprimento vaginal médio pré-operatório era de 2,9 cm. À data da cirurgia, a média de idade das pacientes era de 22,2 anos. A cirurgia foi realizada com sucesso em todos os casos, sem registo de complicações intra ou pós-operatórias. Na primeira avaliação pós-operatória (6 a 8 semanas após a cirurgia), o comprimento vaginal médio foi de 8,1 cm. Em todos os casos, a neovagina estava reepitelizada e com amplitude adequada. As pontuações médias, total e de cada domínio, obtidas no questionário de avaliação da função sexual não diferiram significativamente das do grupo controle: 27,5 vs 30,6 (total); 4.0 vs 4.2 (desejo); 4,4 vs 5,2 (excitação); 5,2 vs 5,3 (lubrificação); 4,2 vs 5,0 (orgasmo); 5,3 vs 5,5 (satisfação) e 4,4 vs 5,4 (conforto).

Conclusões A técnica laparoscópica modificada de Vecchietti é um procedimento simples, seguro e eficaz, permitindo às pacientes com aplasia vaginal congênita uma atividade sexual satisfatória, comparável à dos controles normais.

Keywords

laparoscopy - gynecologic surgery - minimally invasive surgery - mayer-rokitansky-küster-hauser syndrome - androgen insensitivity syndrome - sexuality

Palavras-chave

laparoscopia - cirurgia ginecológica - cirurgia minimamente invasiva - síndrome de mayer-rokitansky-kuster-hauser - síndrome de insensibilidade aos andrógenos - sexualidade

• References

• 1 Capraro VJ, Gallego MB. Vaginal agenesis. Am J Obstet Gynecol 1976; 124 (1) 98-107
• 2 Mayer CAJ. Über Verdoppelungen des Uterus und ihre Arten, nebst Bemerkungen über Hasenscharte und Wolfsrachen. J Chir Augenheilkd. 1829; 13: 525-565
• 3 Committee on Adolescent Health Care. Committee opinion: no. 562: müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol 2013; 121 (5) 1134-1137
• 4 Oppelt P, Renner SP, Kellermann A , et al. Clinical aspects of Mayer-Rokitansky-Kuester-Hauser syndrome: recommendations for clinical diagnosis and staging. Hum Reprod 2006; 21 (3) 792-797
• 5 Frank RT. The formation of an artificial vagina without operation. Am J Obstet Gynecol 1938; 35 (6) 1053-1055
• 6 Amussat JZ. Observation sur une opération de vagin artificiel pratiquée avec succèss par un nouveau procédé, suivie de quelques refléxions sur les vices de conformation du vagin. Gaz Med Paris. 1835; 50: 785-817
• 7 Brindeau A. Créeation d'un vagin artificiel à l'aide des membranes ovulaires d'un oeuf à terme. Gynecol Obstet. 1934; 29: 385-392
• 8 Confalonieri C. Neovagina con trapianto di dura-madre omologata liofilizzata. Gazz Sanit 1972; 43 (9) 407-420
• 9 Hwang WY, Chang TS, Sun P, Chung TH. Vaginal reconstruction using labia minora flaps in congenital total absence. Ann Plast Surg 1985; 15 (6) 534-537
• 10 McIndoe AH, Bannister JB. An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Emp 1938; 45 (3) 490-494
• 11 Davydov SN. [Colpopoeisis from the peritoneum of the uterorectal space]. Akush Ginekol (Mosk) 1969; 45 (12) 55-57
• 12 Noguchi S, Nakatsuka M, Sugiyama Y, Chekir C, Kamada Y, Hiramatsu Y. Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome. Hum Reprod 2004; 19 (7) 1629-1632
• 13 Lin WC, Chang CY, Shen YY, Tsai HD. Use of autologous buccal mucosa for vaginoplasty: a study of eight cases. Hum Reprod 2003; 18 (3) 604-607
• 14 Panici PB, Bellati F, Boni T, Francescangeli F, Frati L, Marchese C. Vaginoplasty using autologous in vitro cultured vaginal tissue in a patient with Mayer-von-Rokitansky-Kuster-Hauser syndrome. Hum Reprod 2007; 22 (7) 2025-2028
• 15 Vecchietti G. Creation of an artificial vagina in Rokitansky-Küster-Hauser syndrome. Attual Ostet Ginecol 1965; 11 (2) 131-147
• 16 Gauwerky JF, Wallwiener D, Bastert G. An endoscopically assisted technique for construction of a neovagina. Arch Gynecol Obstet 1992; 252 (2) 59-63
• 17 Brucker SY, Gegusch M, Zubke W, Rall K, Gauwerky JF, Wallwiener D. Neovagina creation in vaginal agenesis: development of a new laparoscopic Vecchietti-based procedure and optimized instruments in a prospective comparative interventional study in 101 patients. Fertil Steril 2008; 90 (5) 1940-1952
• 18 Rosen R, Brown C, Heiman J , et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26 (2) 191-208
• 19 Fedele L, Bianchi S, Berlanda N, Fontana E, Bulfoni A, Borruto F. Laparoscopic creation of a neovagina with the laparoscopic Vecchietti operation: comparison of two instrument sets. Fertil Steril 2006; 86 (2) 429-432
• 20 Fedele L, Bianchi S, Frontino G, Fontana E, Restelli E, Bruni V. The laparoscopic Vecchietti's modified technique in Rokitansky syndrome: anatomic, functional, and sexual long-term results. Am J Obstet Gynecol 2008; 198 (4) 377.e1-377.e6
• 21 Folgueira G, Perez-Medina T, Martinez-Cortes L , et al. Laparoscopic creation of a neovagina in Mayer-Rokitansky-Küster-Hauser syndrome by modified Vecchietti's procedure. Eur J Obstet Gynecol Reprod Biol 2006; 127 (2) 240-243
• 22 Busacca M, Perino A, Venezia R. Laparoscopic-ultrasonographic combined technique for the creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. Fertil Steril 1996; 66 (6) 1039-1041
• 23 Csermely T, Halvax L, Sárkány A , et al. Sexual function after modified laparoscopic Vecchietti's vaginoplasty. J Pediatr Adolesc Gynecol 2011; 24 (3) 147-152
• 24 Giacalone PL, Laffargue F, Faure JM, Deschamps F. Ultrasound-assisted laparoscopic creation of a neovagina by modification of Vecchietti's operation. Obstet Gynecol 1999; 93 (3) 446-448
• 25 Fedele L, Bianchi S, Tozzi L, Borruto F, Vignali M. A new laparoscopic procedure for creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome. Fertil Steril 1996; 66 (5) 854-857
• 26 Pelzer V, Graf M. [The segmented phantom insert for the formation of a neovagina according to Vecchietti]. Geburtshilfe Frauenheilkd 1989; 49 (11) 977-980 German.
• 27 Abramowicz S, Oden S, Joutel N, Roman H, Gromez A, Marpeau L. Laparoscopic creation of a neovagina by Vecchietti's technique: anatomic and functional results. Gynecol Obstet Fertil 2013; 41 (1) 4-9
• 28 Keckstein J, Kandolf O, Rauter G, Hudelist G. Long-term outcome after laparoscopic creation of a neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome by a modified Vecchietti procedure. Gynecol Surg 2008; 5 (1) 21-25
• 29 Fedele L, Bianchi S, Zanconato G, Raffaelli R. Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases. Fertil Steril 2000; 74 (2) 384-389
• 30 Rall K, Schickner MC, Barresi G , et al. Laparoscopically assisted neovaginoplasty in vaginal agenesis: a long-term outcome study in 240 patients. J Pediatr Adolesc Gynecol 2014; 27 (6) 379-385
• 31 Ismail-Pratt IS, Bikoo M, Liao LM, Conway GS, Creighton SM. Normalization of the vagina by dilator treatment alone in Complete Androgen Insensitivity Syndrome and Mayer-Rokitansky-Küster-Hauser syndrome. Hum Reprod 2007; 22 (7) 2020-2024
• 32 Jasonni VM, La Marca A, Naldi S, Matonti G, D'Anna R. The management of vaginal agenesis: report of 104 cases. Fertil Steril 2007; 88 (6) 1653-1656
• 33 Keser A, Bozkurt N, Taner OF, Sensöz O. Treatment of vaginal agenesis with modified Abbé-McIndoe technique: long-term follow-up in 22 patients. Eur J Obstet Gynecol Reprod Biol 2005; 121 (1) 110-116
• 34 Cai B, Zhang JR, Xi XW, Yan Q, Wan XP. Laparoscopically assisted sigmoid colon vaginoplasty in women with Mayer-Rokitansky-Kuster-Hauser syndrome: feasibility and short-term results. BJOG 2007; 114 (12) 1486-1492
• 35 Communal PH, Chevret-Measson M, Golfier F, Raudrant D. Sexuality after sigmoid colpopoiesis in patients with Mayer-Rokitansky-Kuster-Hauser Syndrome. Fertil Steril 2003; 80 (3) 600-606
• 36 Darai E, Toullalan O, Besse O, Potiron L, Delga P. Anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty in women with Rokitansky's syndrome. Hum Reprod 2003; 18 (11) 2454-2459
• 37 Karateke A, Haliloglu B, Parlak O, Cam C, Coksuer H. Intestinal vaginoplasty: seven years' experience of a tertiary center. Fertil Steril 2010; 94 (6) 2312-2315
• 38 Khen-Dunlop N, Lortat-Jacob S, Thibaud E, Clément-Ziza M, Lyonnet S, Nihoul-Fekete C. Rokitansky syndrome: clinical experience and results of sigmoid vaginoplasty in 23 young girls. J Urol 2007; 177 (3) 1107-1111
• 39 Lima M, Ruggeri G, Randi B , et al. Vaginal replacement in the pediatric age group: a 34-year experience of intestinal vaginoplasty in children and young girls. J Pediatr Surg 2010; 45 (10) 2087-2091
• 40 Fedele L, Frontino G, Restelli E, Ciappina N, Motta F, Bianchi S. Creation of a neovagina by Davydov's laparoscopic modified technique in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010; 202 (1) 33.e1-33.e6
• 41 Belleannée G, Brun JL, Trouette H , et al. Cytologic findings in a neovagina created with Vecchietti's technique for treating vaginal aplasia. Acta Cytol 1998; 42 (4) 945-948
• 42 Fedele L, Bianchi S, Berlanda N , et al. Neovaginal mucosa after Vecchietti's laparoscopic operation for Rokitansky syndrome: structural and ultrastructural study. Am J Obstet Gynecol 2006; 195 (1) 56-61