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35 Vaginal Constructions: Lessons learned
Christopher Wright, MD1, Moneer K. Hanna, MD, FRCS2.
1UMDNJ, Newark, NJ, USA, 2New York Presbyterian-Cornell, Great Neck, NY, USA.

BACKGROUND: The use of bowel for vaginal construction is a well established procedure. The purpose of this presentation is to review the outcome of vaginoplasty using either a segment of small bowel or the sigmoid colon, in the form of a pedicled tube or in a detubularized recofigurated fashion. We will discuss the lessons learned from 35 vaginoplasties over a 32 year period.
METHODS: Between 1980 and 2012 thirty five children and young adults between 1-21 years of age underwent vaginal construction. The diagnoses were Meyer-Rokitansky Syndrome (19), micropenis (5), complete androgen insensitivity (3), 46XY cloacal exstrophy (3), aphallia (3), 46XY bladder exstrophy (1) and true hermaphrodite (1). The sigmoid colon was used in (22), small bowel (12) and urothelium (1). In 12 patients (5 ileum and 7 sigmoid) the bowel segments were detubularized and reconfigured resulting in a pouch formation. Detubularization/pouch technique was advocated in cases where the mesentery seemed short and did not allow the distal end of the bowel to reach the perineum without tension. This surgical method was helpful in avoiding traction on the vascular mesenteric pedicle, but added some operative time. An inverted V-shaped perineal skin flap was incorporated into the posterior wall of the neo-vagina in 26/35patients. In 9 patients the sigmoid colon was anastomosed in a circumferential manner to the short blind ending vaginal dimple.
RESULTS: 28 patients were followed up for a minimum of one year, 10 for 5 years, 7 for 17 years and 1 for 30 years. 7 patients from overseas were followed by their local surgeon for at least 1 year. 2/9 sigmoid vaginas where the perineal skin flap was omitted developed introital stenosis. Both underwent Y-V plasty, one restenosed and a second revision followed by daily dilation was performed, both had patent introitus when last seen. One patient with ileal pouch vagina developed introital stenosis after 10 years at the onset of puberty and was successfully corrected. One child developed mucosal prolapse and is awaiting revision. 19/28 are sexually active and report no dysparunia.
CONCLUSIONS: Intestinal segments can be used to provide a cosmetic self-lubricating neovagina. 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-cutanous junction. The inverted V-shaped perineal skin flap should be incorporated in the anastomosis to avoid circumferential suture line and introital stenosis.


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