Creation of Buccal Graft Neovagina for Distal Vaginal Agenesis
Alyssa K. Greiman, MD, Andrew Stec, MD.
Medical University of South Carolina, Charleston, SC, USA.
BACKGROUND: We present a video reviewing the creation of a buccal graft neovagina for distal vaginal agenesis in a female neonate who was referred for antenatal bilateral SFU grade 4 hydroureteronephrosis and a large pelvic fluid collection of mixed echogenicity pressing upon the posterior aspect of the bladder, obstructing the ureters. A diagnosis of distal vaginal agenesis was made and the child underwent temporizing cutaneous vaginostomy with subsequent peritoneal flap vaginoplasty at 12 months of age. She represented 5 months post-operatively with recurrent abdominal distension and stenosis of her vaginal introitus on exam. Repeat ultrasound was obtained showing recurrent SFU grade 4 hydroureteronephrosis with reaccumulation of hydrometrocolpos.The child underwent repeat temporizing cutaneous vaginostomy and was subsequently taken to the operating room for creation of a buccal graft neovagina.
METHODS: After cystoscopy and vaginoscopy, an inverted U incision was made at the perineum and was dissected down until the vaginal cavity was in close proximity; revealing approximately 2-3 cm of distal vaginal stenosis. The distal vagina was then opened widely to 24 french and silk holding sutures were placed to hold the distal vagina. The vaginal mucosa was then mobilized circumferentially with care to avoid injury to the rectum or urethra. The neovagina was then measured and a graft size of 3x7 cm was determined to be required to the buccal mucosa harvest. At this point, our pediatric ENT colleagues proceeded to harvest the buccal mucosa graft in three separate pieces. The grafts were defatted and sewn together with 5-0 PDS on the back bench to make one continuous graft. They were then fenestrated. The graft was then sewn up to the vaginal mucosa using 4-0 PDS sutures circumferentially. The graft was then sewn to the posterior aspect of the inverted U flap. The distal vagina was widely patent and accommodated a 30 Fr foley catheter that was cut in half to aid in apposition of the graft to the vaginal wall. This was secured with nylon sutures.
RESULTS: At 6 months post-operative, she is doing well with vaginal calibration using a 14 french catheter coated in triamcinolone cream daily.
CONCLUSIONS: We demonstrate successful creation of a buccal graft neovagina for distal vaginal agenesis after failed peritoneal flap vaginoplasty.
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