A retrospective study of eight patients who had undergone a posterior sagittal approach vaginoplasty without using bowel was presented by authors from London. This approach provides excellent exposure, and successful vaginoplasties can be achieved with total urogenital mobilization, despite long common channels.
To review our experience with revision vaginoplasty without using bowel, by the posterior sagittal approach.
PATIENTS AND METHODS
The notes of eight patients (median age 12.3 years, range 9.0–15.6) were retrospectively reviewed; all had had revision vaginoplasty using a posterior sagittal approach. Their original diagnosis was cloacal anomaly in three, urogenital sinus in two, cloacal exstrophy in two, and congenital adrenal hyperplasia in one patient.
Indications for re-operation included: haematocolpos in four patients, absent vaginal opening in two, hydrocolpos in one, and vesico-vaginal fistula in one. The vagina was reconstructed by total urogenital mobilization in seven patients and in one by anastomosing anterior and posterior aspects of a duplicated vagina. The vagina was mobilized by up to 6 cm in this manner. Bowel was not required for any of the vaginoplasties. The median (range) inpatient stay was 6 (4–17) days after surgery and the median follow-up was 35.3 (4.5–50) months. One patient developed a vesico-vaginal fistula and vaginal stenosis, and had further surgery. Two patients required subsequent use of vaginal dilators. The remainder have had a satisfactory outcome.
For revisional vaginal surgery the posterior approach provides excellent exposure, and can be useful in dealing with a variety of pathologies. Combined with total urogenital mobilization, vaginoplasty can be successful despite long common channels. However, there were still several complications.
Problems from primary vaginoplasty operations are common; revisional surgery may be required in 30–78% of patients after their original vaginoplasty [1,2]. Those who develop long-term complications from their original vaginoplasty are a challenging group to treat. The surgical options for them may be broadly categorized to include: ‘cut- back’ techniques, flap vaginoplasty, bowel interposition and pull-through methods [3–5]. Cut-back and flap techniques can be used only on if the length to be bridged is short. Bowel interposition requires a laparotomy and may be associated with stenosis, prolapse or excessive mucus production [6–8]. Pull-through procedures may appear challenging in the face of previous surgery, but confer the advantages of using the native vagina. We review our experience with revision vaginoplasty.
PATIENTS AND METHODS
We retrospectively reviewed the notes of all patients who had had revision vaginoplasty using the posterior sagittal approach between September 2000 and July 2003; eight patients were identified (median age at surgery 12.3 years, range 9.0–15.6). Their original diagnosis had been cloaca in three patients, urogenital sinus in two, cloacal exstrophy in two, and one patient who had congenital adrenal hyperplasia. The primary operative details were not available in three patients. Of the remainder, all had originally been operated at or before 2 years old. Four had had posterior sagittal approach pull-through procedures, and one had what was described as a vaginal pull-through.
A decision to use the posterior sagittal approach was made on the basis of anatomical considerations and specifically the length of the vaginal defect. The posterior sagittal approach was used in patients in whom it was thought that cut-back techniques would be inadequate to bridge an excessively long defect of the vagina. Patients did not routinely undergo bowel preparation, unless it was considered that a very long defect might require bowel interposition. During surgery, after an examination under anaesthesia and cysto-vaginoscopy, a urethral and suprapubic catheter was placed, and then the patient placed prone in the jack-knife position. The posterior sagittal approach was made through the midline. Good access to the vagina could be obtained by simply mobilizing the anus and rectum to one side, rather than splitting or dividing them. A total urogenital mobilization was used to bring the vagina to the perineum. No drain or pack was left in the vagina. In the first 2 days after the operation analgesia was either from an i.v. opioid infusion or an epidural. Feeding was commenced when it was evident that ileus had resolved with: a return of appetite, absence of abdominal distension and passage of flatus. The patient was started on a stool softener, e.g. lactulose. The urethral catheter was removed a week after surgery. The suprapubic catheter was clamped and released from ≈ 2 weeks after surgery. When efficient urethral voiding became established the suprapubic catheter was removed.
The details of the patients are shown in Table 1; seven patients had a total urogenital mobilization via a posterior sagittal approach, to bring the vaginal opening to the perineum. In one patient with a duplicated vagina, a posterior sagittal approach was used to allow the anastomosis of a blind anterior vagina to a stenotic posterior vagina. In two patients, up to 6 cm of mobilization was achieved. No additional abdominal incision was required in any patient. The median inpatient stay after surgery was 6 (4–17) days; only one patient stayed for > 6 days, because she developed an abscess requiring further treatment (see below).
|Underlying disease||Age at 1ry surgery||Original operation||Indication for revision||Age at revision, years||Details of revision||Inpatient stay postop, days||Follow up, months||Details of last follow up|
|UG sinus||NDA||NDA||Massive haematocolpos||15.6||PS vaginoplasty, 1 left hydrocolpos||4||44.6||No problems|
|Cloaca||1.75 years||Peña correction of cloaca||Hydrocolpos||13.6||5–6 cm of distal atresia Vagina mobilized down via PS approach||6||45.3||Using vaginal dilators to prevent recurrent stenosis (no urological problems)|
|UG sinus||1||Vaginal PT||VVF and pyometria||9.0||Vagina fully mobilized, and detached to identify VVF via PS approach||5||26||No problems|
|Cloaca||2 weeks||NDA||Haematocolpos||10.5||PS PT + vesicostomy closure, excision of hemi- uterus and Mitrofanoff. Complicated by wound infection requiring I&D||17||49.4||Complicated by VVF and vaginal stenosis|
|Cloacal exstrophy||PS PT –||Haematocolpos||13.3||Vagino-vaginoplasty: blind anterior vagina anastomosed to posterior vagina||6||50.0||Good vagina|
|Cloacal exstrophy||2 years||PSARP and vaginoplasty||No vaginal orifice||14.2||Vagina mobilized via PS approach||6||8.7||Good result, using vaginal dilators|
|CAH||6 months||NDA||No vaginal orifice||10.6||5–6 cm common channel, TUM||6||4.5||Cosmetically good|
|Cloaca||1.8 years||PSARVUP||Haematocolpos||11.9||2 cm atretic portion distally excised. Vagina mobilized down with TUM||4||8.7||Dry day and night, faecal continence menstruating and vagina accepts 20 F|
At the outpatient follow-up, five of the eight patients were considered to have had good results, with a satisfactory vagina, continence, and requiring no further vaginal surgery. Two patients continue to use vaginal dilators although in one this is to prevent rather than treat a recurrence of the vaginal stenosis. One patient developed a late vesico-vaginal fistula; her underlying diagnosis was cloaca, and her original vaginoplasty was done elsewhere. She had a 4-cm long common channel at the time of her revision, a vesicostomy that required closure, and a left hemi-uterus that preoperative investigation showed to be blind-ending and not connected to the vagina or common channel. She had a vaginoplasty through the posterior sagittal approach, with excision of the hemi-uterus, closure of the vesicostomy and creation of a Mitrofanoff channel through an abdominal approach. After surgery she developed a local infection of her abdominal wound which required incision and drainage. A cysto-vaginoscopy at 3 months showed that the vagina was patent, but at 1 year after revision vaginoplasty she had become symptomatic with a hydrocolpos, associated with a tight vaginal stenosis and a vesico-vaginal fistula. She subsequently had a further revision vaginoplasty, again through the posterior sagittal approach.
Primary vaginoplasty carries a significant complication rate. Patients who develop significant problems after their original surgery are a challenging group to treat; we show that the posterior sagittal approach with total urogenital mobilization is a useful technique in this group. Pull-through techniques in vaginoplasty are not new . The technique of total urogenital mobilization was developed by Peña  to avoid dissecting the urethra from the vagina, a step that may be difficult and predispose to devitalization. The technique was originally described in patients with persistent cloaca, but it may be more widely applied to those requiring vaginoplasty for conditions such as congenital adrenal hyperplasia, urogenital sinus and selected exstrophy . Previous vaginal mobilization does not preclude a reattempt at vaginal mobilization. The posterior sagittal approach has been useful in the difficult setting of vaginal reconstruction after trauma , and for treating patients with cloaca who have developed complications from their original surgery, e.g. persistent or acquired urogenital sinus or vaginal atresia, with good results .
This particular technique has several benefits; the major advantage is the use of the patient's native vagina instead of a graft. Other advantages are that an abdominal incision is avoided, as the use of bowel in vaginoplasty may be associated with problems such as prolapse, stenosis, excessive mucus production, or even diversion colitis [6–8].
The timing of the surgery is relevant; a benefit of operating after the onset of menarche allows the subsequent haematocolpos or hydrocolpos to act as a natural tissue expander, improving the available quantity of vaginal tissue. If the haematocolpos is painful, then further periods can be hormonally prevented until surgery.
Vaginoplasty is expected to have a significant complication rate even when it is the primary procedure; in the setting of revisional surgery an even lower success rate is expected. In this series only one of the eight patients developed a serious complication requiring re-operation. Even including the two patients requiring continued use of vaginal dilators, nearly two-thirds of the group have had good results. This series shows that the posterior sagittal approach with total urogenital mobilization for revision vaginoplasty can produce good results. Even relatively long defects of up to 6 cm may be bridged using this technique.
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