Feasibility of Acellular Matrix for reconstruction of vaginal anomalies and acquired stenosis
Steven Papastefan, MD1, Sarah Collins, MD2, Margaret Mueller, MD2, Julia Geynisman-Tan, MD2, Marleta Reynolds, MD1, Earl Cheng, MD1, Elizabeth Yerkes, MD1, Julia Grabowski, MD1.
1Lurie Children's Hospital of Chicago, Chicago, IL, USA, 2Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
BACKGROUND: Many approaches to creation of neovagina have been described: progressive dilations, intestinal interposition, free graft with skin or oral mucosa. There are advantages and disadvantages of each and the preferred approach is often surgeon-specific. Porcine small intestinal submucosa (SIS) extracellular matrix grafts, familiar to urologists from hypospadias and continence procedures, have been cited an alternative substrate. The aim of this work is to examine feasibility of SIS (OASIS, Cook Biotech/Smith +Nephew) in the creation of neovagina and for other congenital or acquired stenoses or deficiency.
Methods: Thirteen patients underwent vaginoplasty with our multispecialty team between 2018-2022, using 3-ply meshed acellular porcine SIS grafts in combination with a vaginal mold. Operative and clinical data, postoperative mold management, vaginal length as measured by dilator, and complications were reviewed.
Results: Patient age at time of repair was 13-30 years (median 19 years). Patient diagnosis included Mayer-Rokitansky-Küster-Hauser syndrome (n = 4), isolated vaginal atresia with or without a transverse vaginal septum (n=4), cloacal anomalies (n=5), and vaginal rhabdomyosarcoma requiring partial vaginectomy (n=1). After dissection for neovagina or obstruction was complete, a compressible implant-grade silicone mold wrapped with SIS graft and coated with estrogen cream was inserted and the labia sutured closed. Early ambulation was permitted. The vaginal mold and Foley catheter are removed in the office on postoperative day 7 and daily dilation are taught. Across all indications, median (IQR) operative time was 171 (118-192) minutes, estimated blood loss was 10 (5-20) mL, and length of stay was 2 (1-3) days. Follow-up after vaginoplasty ranged from 3 to 47 months (median 9 months). Two patients developed postoperative vaginal stenosis that resolved with dilation under anesthesia and re-engagement in dilations. All thirteen patients had successful graft take and performed routine self-dilations or progressed to intercourse to maintain patency. There was no graft rejection or graft site complication.
Conclusions: Meshed porcine small intestinal submucosa (SIS) grafts are a safe and feasible option for coverage of the vaginal mold for various forms of vaginoplasty. Our experience demonstrates minimal perioperative morbidity, early ambulation, early mold removal, and progression to successful dilation with maintenance of a functional vaginal length. Patient reported outcomes for sexual function will add further insights into this technique.
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