Vaginoplasty For Congenital Vaginal Agenesis

PART ONECLINICAL STUDY OF IMPROVED LAPAROSCOPIC PERITONEAL VAGINOPLASTYABSTRACTObjective:To analysis the operative techniques and perioperative managements of improved laparoscopic peritoneal vaginolplasty and to investigate its clinical application value by assessing its feasibility, effectiveness and practicability.Methods:From Nov2007to Jun2014, improved laparoscopic peritoneal vaginolplasty was performed for470cases, incliding457cases of Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH),12cases of androgen insensitivity syndrome (AIS) and1case of congenital adrenal hyperplasia (CAH). The surgical situation (operative time, blood loss, anal exhaust time, the rate of complication and conversion to laparotomy) and postoperative results (morphology and histology, sexual function, sex psychology and microecology of artificial vagina) were retrospectively analysed and follow-up was performed from2month after operation.Results:1、Analysis of surgical conditions:The mean operation time was56.5±11.6minutes (range35-105min). Average blood loss was17.8±12.6milliliter (range5-90mL). Average anal exhaust time was14.6±7.9hours (range12-30h). The rate of perioperative complication was2.55%(12/470).2cases were converted to open vaginoplasty, with the rate of0.43% (2/470).2、Postoperative results:395cases were followed up after operation, the follow-up rate was84.04%(395/470), the dropout rate was15.96%(75/470). Duration of follow-up was2months to6years.(1) Morphology and histology of artificial vagina:Artificial vagina was gradually coverd by vestibular mucosa lines after vaginoplasty. Histological examination of mucosa of artificial vagina revealed signs of squamous epithelization, similar to normal vaginal mucos. The mean artificial vagina was8.4±0.8centimeters (range6-12cm) long,1-3cm wide. When anatomical success was defined as a length of>7cm and a width allowing the easy introduction of two fingers, the anatomical success rates was96.45%(381/395).(2) Evaluation of sex psychology:Psychosexual functioning was assessed with the female sexual function index (FSFI) and the female sexual distress scale-revised (FSDS-R). Functional success was defined as the FSFI score>24, while female sexual dysfunction (FSD) was defined as FSDS-R score>11. The total FSFI score of the patients was27.7±3.9, with no significant difference as compared with control group28.1±2.9(P>0.05). And the functional success rates was84.57%(274/324). The mean FSDS-R was18.7±11.9, significantly higher than that in control group6.7±3.3(P<0.05). The rate of FDS was36.42%(118/470), also significantly higher than that in control group24.00%(12/50)(P<0.05). FSFI score was negatively correlated with FSDS-R (rs=-0.32, P<0.05).(3) Microecological evaluation of artificial vagina:After vaginolplasty,58.73%(74/126) of advantage microflora in artificial vagina were lactobacillus bacteria; bacterial diversity in Ⅱ-Ⅲ, accounting for57.14%(72/126); pH≤4.5, accounting for65.08%(82/126), were all less than that in control group (P<0.05). Dysbiosis incidence accounted for43.65%(55/126) was higher than that in control group28.00%(14/50)(P<0.05), too.Conclusions: 1、 The improved laparoscopic peritoneal vaginoplasty is one of effective way to treat the congenital vagina agenesis.2、The rate of complication and convertion was low. So improved laparoscopic peritoneal vaginalplasty is safe and feasible.3、The operative time of improved laparoscopic peritoneal vaginalplasty was short,the blood loss was little and the recovery time was soon. And its indications in congenital vaginal agenesis were expanded. This vaginoplasty was well accepted by both patients and gynecologist because of easy operating and early sexual life without mold. So it is an ideal operation, worth to widly application.4、Improved laparoscopic peritoneal vaginoplasty performed satisfactory clinical effects, but there was still some sexual distress and vaginal dysbiosis in several patients after vaginoplasty. So it is necessary for multi-disciplinary comprehensive treatment to get better postoperative results of anatomy, function and psychology. PART TWOCLINICAL APPLICATION AND EVALUSTION OFVAGINOPLASTY FOR CONGENITAL VAGINAL AGENESISABSTRACTObjective:To evaluate the clinical situation and application value of different vaginolplasty for congenital vaginal agenesis and to provide rational reference for gynecologist in choosing the appropriate vaginal reconstruction for the patients.Methods:1、Retrospective review was carried out to analyze the classification and constituent ratio of747patients with congenital vaginal agenesis from Jan2001to Jun2014.2、661patients were subjected to vaginal reconstruction. Different vaginolplasty, including Vecchitti vaginoplasty, peritoneal vaginalplasty and intestinal vaginoplasty were chosed to treat the patients. The surgical conditions (operative time, blood loss, anal exhaust time, complications and conversion to laparotomy) and surgical results (anatomy and sexual function of artificial vagina) were summarized.A vaginal tunnel was created between the urethra, bladder and rectum in vaginoplasty except Vecchitti technique. In improved laparoscopic peritoneal vaginoplasty Ⅰ, we used the peritoneal pushing rod to push down peritoneum to the external aperture of artificial vagina. In improved laparoscopic peritoneal vaginoplasty Ⅱ, the homemade colpectasis rods was applied, the pelvic peritoneum edge was stitched with the corresponding vestibular mucosa to cover the tunnel surface. In intestinal vaginoplasty, the16-18cm ileal segment and20cm sigmoid with vascular pedicle were taken as graft, respectively. Vaginoplasty with tissue engineered patch was done by implanting patch into the artificial vagina.Results:1、Clinical data:In747patients with congenital vaginal agenesis, there were93.44%(698/747), patients with MRKH, which occupied the majority. Among them,7.74%(54/698) were associated with urinary system and skeletal system malformation. There were20(2.68%) cases with AIS,14(1.87%) cases with vaginal atresia, and11(1.47%) cases with vaginal septum. CAH and chromosome abnormality were scarce, only4(0.54%) patients.2、Operation classification:661cases of vaginoplasty had been performed:141(21.33%) cases of improved laparoscopic peritoneal vaginoplasty I;470(71.10%) cases of improved laparoscopic peritoneal vaginoplasty Ⅱ;16(2.42%) cases of laparoscopic Vecchitti vaginoplasty;18(2.72%) cases of gasless laparoscopic ileal vaginoplasty;13(1.97%) cases of laparotomic sigmoid vaginoplasty;2(0.30%) cases of laparotomic ileal vaginoplasty, only1(0.15%) case of vaginoplasty with tissue-engineered biomaterial mesh. Among them,646(97.73%) patients were treated with laparoscopic technique and611(92.43%) patients were treated with laparoscopic peritoneal vaginoplasty.3、Surgical conditions of different vaginoplasty:Improved laparoscopic peritoneal vaginoplasty I (141cases):The mean operative time was82.8±15.6minutes (range55-135min). Average blood loss was19.2±13.1milliliters (range10-85mL). Average anal exhaust time was14.6±7.9hours (range12-30h). The rate of perioperative complication was4.26%(6/141).3cases were converted to open vaginoplasty, with the rate of2.13%(3/141).Improved laparoscopic peritoneal vaginoplasty II (470cases):The mean operative time was56.5±11.6min (range35-105min). Average blood loss was17.8±12.6mL (range5-90mL). Average anal exhaust time was14.6±7.9hours (range12-30h). The rate of perioperative complication was2.55%(12/470).2cases were converted to open vaginoplasty, with the rate of0.43%(2/470). Laparoscopic Vecchitti vaginoplasty (16cases):The mean operative time was32.1±7.3min (range25-70min). Average blood loss was7.1±4.2mL (range5-15mL). Average anal exhaust time was13.6±5.1hours (range14-28h). The rate of postoperative complication was12.5%(2/16). No cases were converted to open vaginoplasty.Gasless laparoscopic ileal vaginoplasty (18cases):The mean operative time was181.3±20.1min (range125-220min). Average blood loss was55.6±20.0mL (range25-80mL). Average anal exhaust time was30.5±18.1h (range24-42h). No complication and convertion occurred.Laparotomic ileal vaginoplasty (2cases):The operative time of two cases were160min and185min, respectively. Blood loss were90mL and100mL, respectively. And anal exhaust time were35h and30h, respectively.Laparotomic sigmoid vaginoplasty(13cases):The mean operative time was193.1±27.3min (range150-235min). Average blood loss was85.2±37.6mL (range50-145mL). Average anal exhaust time was38.5±12.1h (range22-48h). The rate of postoperative complication was7.69%(1/13).Vaginoplasty with tissue-engineered biomaterial mesh (1cases):The operation time, blood loss and anal exhaust time were95min,45mL and18h respectively.4、Postoperative results of different vaginoplasty:557cases were followed up after operation, the follow-up rate was84.27%(557/661),the dropout rate was15.73%(104/661). Duration of follow-up was2months to11years.Improved laparoscopic peritoneal vaginoplasty Ⅰ(118cases):The mean artificial vagina was8.1±1.6centimeters (range6-10cm) long,1-3cm wide, and the anatomical success rates was88.98%(105/118). The total FSFI score of the patients after surgery was26.5±2.1, and the functional success rates was83.67%(82/98).Improved laparoscopic peritoneal vaginoplasty Ⅱ (395cases):The mean artificial vagina was8.4±0.8centimeters (range6-12cm) long,1-3cm wide, and the anatomical success rates was96.45%(381/395). The total FSFI score of the patients after surgery was27.7±3.9, and the functional success rates was84.57%(274/324). Laparoscopic Vecchitti vaginoplasty (15cases):The mean artificial vagina was7.9±0.6centimeters (range6-12cm) long,2-3cm wide, and the anatomical success rates was93.33%(14/15). The total FSFI score of the patients after surgery was27.2±1.8, and the functional success rates was92.86%(13/14).Gasless laparoscopic ileal vaginoplasty (14cases):The mean artificial vagina was8.9±0.7centimeters (range7-12cm) long,1-3cm wide, and the anatomical success rates was78.57%(11/14). The total FSFI score of the patients after surgery was25.9±2.8, and the functional success rates was83.33%(10/12).Laparotomic ileal vaginoplasty (2cases):The artificial vagina of2cases were6cm and8cm in depth, respectively. One patient had satisfactory sexual life with the FSFI score of26.6.Laparotomic sigmoid vaginoplasty (12cases):The mean artificial vagina was9.1±1.2centimeters (range7-13cm) long,2-3cm wide, and the anatomical success rates was91.67%(11/12). The total FSFI score of the patients after surgery was26.0±2.6, and the functional success rates was81.82%(9/11).Vaginoplasty with tissue-engineered biomaterial mesh (1case):The patient was12years old. During postoperative follow-up, the artificial vagina was8cm long and menstruation was normal after vaginoplasty.Conclusions:1、In the patients with congenital vaginal agenesis, MRKH is the most, followed by AIS.2、Laparoscopic vaginoplasty becomes the main approach for congenital vaginal agenesis.3、Laparoscopic peritoneal vaginoplasty II expanded its surgical indications. The effect of operation meets the requirement of sexual activity. This procedure is safe and effective with good clinical application value, worth to widly application.4、The poor compliance and high selectivity of genital anatomy restrict the widely application of laparoscopic Vecchitti vaginoplasty.5、Intestinal vaginoplasty had not been recommended as first-line treatment. Gasless laparoscopic ileal vaginoplasty could be a good choice when other vaginoplasty was not apporiate or failure for the patients.6、Different vaginoplasty got satisfactory clinical effects according to approprate indications. The treatment should be individualized and comprehensive considering the patient’s anatomical characteristics and other factors, such as psychosexual, medical and reconstructive concerns.