The main objective of treatment for patients with vaginal agenesis is to reconstruct a neovagina to facilitate satisfactory intercourse.1 The management of these patients consists of nonsurgical and surgical creation of a neovagina, and vaginal dilation therapy is recognized as the first-line approach.2 The surgical techniques rely on different types of tissues such as peritoneum, segments of the intestines, amnion, flaps, or skin grafts.3–10 Every technique has inherent advantages and limitations. At present, there is still no consensus regarding the best management for surgical treatment. Buccal mucosa has been applied as a material for vaginoplasty since 200311,12 with promising postoperative results. However, the systematic surgical data are limited and all of these studies include only small numbers of patients. As a result of the limited availability of buccal mucosa, it may take a long time to complete the epithelization of the neovagina.
In light of the success of using the microskin technique for repairing severe burn wounds, we attempted to use autologous buccal micromucosa as the lining material of the neovagina since 2006. According to our initial experiences, the outcomes of vaginoplasty with autologous buccal micromucosa were promising.13 In this article, we described the details of this technique and the long-term anatomical, functional, and sexual results of using autologous buccal micromucosa for the creation of a neovagina in a series of 38 women (33 with Mayer-Rokitansky-Kuster-Hauser syndrome and five with complete androgen insensitivity syndrome).
MATERIALS AND METHODS
From June 2006 to April 2012, 33 patients (including the nine patients reported in 2009)13 with Mayer-Rokitansky-Kuster-Hauser syndrome and five patients with complete androgen insensitivity syndrome underwent transvestibular vaginoplasty with autologous buccal micromucosa at Plastic Surgery Hospital, Chinese Academy of Medical Sciences, and Peking Union Medical School. The institutional review board of Plastic Surgery Hospital approved the study. Preoperative assessment of the patients included counseling, physical examination, genetic evaluation, vaginal ultrasonography, computed tomography, intravenous pyelography, and gonadal hormonal profile.
Informed consent forms were obtained from all of the patients. All the patients were provided counseling on the advantages and disadvantages of the nonsurgical technique (Frank's method) and surgical techniques (Vecchietti's method, McIndoe's method, intestinal transplantation, Davydov's technique, and our method), and all patients were encouraged to try Frank's method using a dilator, but transvestibular vaginoplasty with autologous buccal micromucosa was their final choice.
Preoperative preparation included a low-residue semifluid diet for 2 days and fasting for 1 day. A cleaning enema was added on the day before surgery.
All operations performed for these patients were primary procedures. Under general anesthesia, the patients were placed in the lithotomic position, A Foley's catheter was inserted to avoid urethral injury during dissection. Operations were performed by two operative teams: one for oral mucosa graft harvesting and the other for reconstruction of the neovaginal cavity.
Isotonic sodium chloride solution was injected into the space between the rectum and bladder. An X-shaped incision was made 1 cm below the posterior fourchette in the perineum (Fig. 1). A new vaginal cavity, at a depth of 9–12 cm and diameter of 3–4 cm, was made between the rectum and the bladder with blunt dissection. A finger was inserted into the rectum to aid identification of anatomical boundaries and to avoid rectal injury. Meticulous hemostasis of the neocavity was achieved using bipolar electrocoagulation to avoid the postoperative bleeding.
A mouth retractor was applied and the parotid duct was identified to avoid being injured. Then, a solution of epinephrine and lidocaine was injected submucosally at the donor sites for hemostasis with a concentration of 1:200,000 for epinephrine and 1% for lidocaine. The mucosa was hooked up by a round needle and then cut off by surgical scissors. Thirty to 40 full-thickness mucosal pieces (approximately 7×5 mm) were harvested from both cheeks (Fig. 2A). The donor sites were compressed with gauze for hemostasis without suturing. The mucosal pieces were rinsed three times using isotonic sodium chloride solution and then minced into particles approximately 0.7- to 1-mm diameter using surgical scissors (Fig. 3). Using a blade holder, the micromucosa grafts were spread on five to six strips of gelatin sponge (with a size of 2.5×6.0 cm2) (Fig. 4).
With the mucosal grafts facing the neovaginal walls, the five aspects including the anterior, posterior, bilateral, and apex of the canal were covered by the gelatin sponge. A soft polyporous silicone stent measuring 5 cm in diameter and 10 cm in length was meticulously inserted into the neovaginal cavity and fixed to the skin around the new vagina to maintain the stent in position. We stuffed sterile gauzes into the hollow stent to make the mucosal particles stick to the wound. Finally, a soft gauze compressive dressing was placed for additional support.
Antibiotic prophylaxis was used for 5 days postoperatively (cefuroxime sodium and metronidazole), and the patients were placed on bed rest for 5 days. The gauzes in the oral cavity were removed on postoperative day 1 and the patients were advised to rinse the oral cavity using 0.02% chlorhexidine acetate three times a day for 5–7 days until the donor site was healed. The first dressing change of the neovaginal cavity was on postoperative day 6. The gauzes inside the stent were removed and the neovaginal cavity was douched using normal saline and the epithelial growth was examined. Then new gauzes were reinserted to keep the pliable stent for cavity maintenance. This routine procedure was continued for 1 month. Patients were usually discharged on postoperative day 14 when the Foley catheter had been removed.
Follow-up of patients was carried out by visiting the hospital at 1, 3, 6, and 12 months after the surgery and every 6 months thereafter. In the follow-up, patients with any complaint at any time were encouraged to visit the hospital. The soft stent was replaced by a hard one at 1 month postoperatively (Fig. 5). All the patients were asked to keep the hard stent in situ at all times in the next 3 months. Sexual intercourse was interdicted in 4 months postoperatively. Thereafter, patients could start regular intercourse and gradually reduce the duration of stent wearing. At the 3-month follow-up visit, we obtained biopsy specimens of the neovagina from the vaginal apex and lateral vaginal wall in three patients under local anesthesia. The patients felt little pain and the wound healed after 10 days. After complete removal of the vaginal stent, a neovaginal mold was made using dental alginate impression materials. The circumference, length, and volume of the neovagina were measured and recorded (Fig. 6).
Functional results were assessed by using Rosen's Female Sexual Function Index questionnaire, which is a validated test for the evaluation of female sexual quality. Scoring is done with regard to six main domains that include desire, arousal, lubrication, pain, orgasm, and sexual and relationship satisfaction. The highest total Female Sexual Function Index score that may be obtained is 36. When the score is greater than 30, the functional result is considered to be “very good,” when the score is between 23 and 29, it is considered to be “good,” and when the score is less than 23, it is considered to be “poor.”14
Over the past 7 years, 38 patients (33 with Mayer-Rokitansky-Kuster-Hauser syndrome and five with complete androgen insensitivity syndrome) underwent transvestibular vaginoplasty with autologous buccal micromucosa. The mean age of the patients was 23 years (range 16–32 years). All the patients reported primary amenorrhea. Five (13.2%) patients were married and reported severe dyspareunia. All the female patients with Mayer-Rokitansky-Kuster-Hauser syndrome had normal karyotype (46, XX), ovarian function, normal secondary sexual characteristics, typically female hair distribution, and normal vulvar development. Two of them had concomitant unilateral renal agenesis and spinal deformities. The patients with complete androgen insensitivity syndrome had 46, XY karyotype. Their testicles were hypoplastic and had descended to the groin or labia majora.
The operation was performed successfully in all 38 patients. The mean operation time was 86.4 minutes (range 75–120 minutes) and the mean blood loss during operation was estimated 68.5 mL (range 40–80 mL). No rectal or bladder injury occurred. Vaginal bleeding occurred in one patient. We took the gauzes out of the stent, kept the stent in place, cleaned the blood clot, douched the cavity using normal saline, and then stuffed new gauzes firmly into the stent to exert higher pressure. The bleeding stopped and the wound healed well. There were no other postoperative complications. The mean postoperative hospital stay was 14 days (range 12–15 days). The duration of healing for oral mucosa donor site was 5–7 days. There was no visible scar and no change in the mouth opening (Fig. 2B). The mean time for mucosal epithelialization to cover the entire neovaginal cavity was 13 days (range 12–15 days).
At a mean follow-up of 33.5 months (range 15–76 months), vaginal stenosis was not detected in any patients. The mean time for the complete removal of the vaginal stent was 15±2.1 months (range 9–20 months). Neovaginal mucosa had a healthy red color and was smooth and elastic with little yellowish mucosal discharge without an unpleasant odor (Fig. 7). The perineum of each patient was comparable with that of normal healthy females. Histologically, the neovaginal lining was confirmed as nonkeratinized squamous stratified mucosa, which was similar to normal vaginal mucosa. After complete removal of the stent, it was found that all patients had a well-formed neovagina with 8.5±0.66 cm (range 7–10 cm) mean length, 12.3±1.24 cm (range 10–15 cm) mean circumference, and 100±8 mL (range 85–120 mL) mean volume. Patients were allowed to resume sexual activities 4 months after surgery and asked to complete the Female Sexual Function Index questionnaire 12 months after surgery. The mean Female Sexual Function Index score of the 32 sexually active patients was 28.8±2.1 (Table 1). No spouse reported discomfort during intercourse.
Based on our experience with the 38 patients, we are able to conclude that transvestibular vaginoplasty with autologous buccal micromucosa is simple and effective without the need of laparoscope. The neovagina is very similar in its macroscopic appearance and its microscopic structure to the normal vagina. This technique also permits the avoidance of visible scars that may remind the patient or her partner of the corrective surgery.
Oral mucosa was first reported as a material for repairing hypospadias in 1941.15 With the advantages of high survival and low contracture rate, it has been widely used by ophthalmologists and orthodontic and maxillofacial surgeons for reconstruction of the conjunctiva, tongue, cheek, larynx, and trachea. In 2003, Yeşim Ozgenel11 and Lin12 first used autologous buccal mucosa to line the neovaginal cavity. Differing from autologous skin grafts, there were no visible body scars. The vaginal cavity was covered with a pink smooth lining. The patients stated that they were able to have satisfactory vaginal intercourse with lubrication of the neovagina. The neovaginal lining was confirmed as mucosa on histologic examination, and the fluid found in the neovaginal cavity was confirmed as mucus.11 Although the surgical outcomes were promising, there were only small numbers of patients included and no long-term anatomical and functional outcomes were evaluated in their studies. During their surgical procedures, the buccal mucosal grafts approximately 2.5×7 cm2 in size were harvested from the oral surface of both cheeks and the donor sites were closed primarily with interrupted sutures. Then they made multiple stab incisions on the grafts or divided the mucosa into several smaller pieces to increase the size of the grafts and shorten the time of epithelization.
In light of the success of using the microskin technique for repairing the severe burn wounds, which can resurface a wound that is 10 times larger than its donor site,16 we modified the technique of vaginoplasty with buccal micromucosal grafts.13 We harvested multiple mucosal pieces approximately 7×5 mm2 in size from bilateral cheeks, and suturing was not necessary for the donor sites. Then the mucosal pieces were minced into particles approximately 1 mm2 and spread on the surface of the neovaginal canal. Each micrograft became a seed for epithelial regeneration as growing sites. The time period of epithelialization to cover the entire vaginal cavity was only 2 weeks in our study, which was much shorter than that reported by Yeşim Ozgenel.11
In our study, the neovaginal mucosa consisted of stratified squamous epithelium and a lamina propria on histologic evaluation, which was similar to the normal vaginal mucosa. We observed that the grafted buccal micromucosa had secretory function. The yellowish viscous fluid found in the neovaginal cavity was confirmed as mucus, which can play a role of lubrication during sexual intercourse. Thus, no patient in our series experienced dyspareunia and pain during sexual intercourse.
Our study put particular emphasis on the quality of sexual life, the main objective of the operation. In follow-up, we observed the postoperative perineal morphology of the patients was comparable with that of normal healthy females, which significantly reduced the psychological burden of the patients. Although the length of the neovagina was shorter than the transferred sigmoid flap (15–20 cm), as reported by Fotopoulou et al,17 it did not affect sexual satisfaction. The Female Sexual Function Index questionnaire was applied to patients to evaluate the satisfaction of sexual intercourse. The results demonstrated that the postoperatively restored quality of sexual life was good in most of the patients who had active sexual intercourse.
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© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.
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