Laparoscopic proximal neovaginoplasty using autologous peritoneal graft to correct short vagina

Abstract

Introduction and importance

Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome is a rare condition characterized by congenital aplasia of the uterus and upper two-third vagina with normal secondary characteristics. Treatment of this condition consists of non-surgical and surgical management. After nonsurgical Frank method, neovaginal canal may be formed but sometimes the vaginal length may not be adequate to facilitate normal sexual intercourse.

Presentation of case

A 27-year-old woman, sexually active, complained about the difficulty of sexual intercouse. The patient was diagnosed with vaginal agenesis and uterine dysgenesis with normal secondary sexual characteristics and chromosome (46, XX). The patient has had nonsurgical treatment by Frank method for 6 years and as a result we found a 5 cm-vaginal indentation but she still complaint of pain and discomfort during intercourse. Laparoscopy proximal neovaginoplasty using autologous peritoneal graft was performed to add the proximal vaginal length.

Discussion

In our case, the patient may have a short vagina as the result from inadequate Frank method dilatation. This may cause dyspareunia and discomfort to her sexual partner. Therefore, laparoscopic proximal neovaginaplasty and uterine band excision were carried out to correct the anatomical restriction and improve her sexual function.

Conclusion

Laparoscopic proximal neovaginoplasty is a surgical method to increase proximal vaginal length by using autologous peritoneal graft which shows excellent result. This procedure should be considered in MRKH syndrome patients with unsatisactory nonsurgical treatment result.

Highlights

• •Davydov's procedure for Correction the Short Vagina after Frank Method in MRKH Syndrome Patient: a rare case
• •Davydov procedure should be considered in MRKH Syndrome patients with failed dilator treatment.
• •Davydov procedure in this case has a high success rate, fast, and safe compared to another method.

1. Introduction and importance

Mayer-Rokitansky-Kuster-Hauser (MRKH) is characterized by congenital aplasia of the uterus and upper two-third vagina with normal secondary characteristics (46 XX Karyotype). Vaginal agenesis can be treated by surgically or non-surgically based on the individual needs, motivation and patient’s preferences. The non-surgical treatment by Frank method can be done by inserting vaginal dilator regularly to increase the diameter and length of the vagina [1]. The surgical options are Vecchietti, McIndoe and Davydov procedure. The Davydov procedure using autologous peritoneal graft has a high success rate for correcting vaginal agenesis. However, there are limited studies about this method to correct short vagina resulted from inadequate Frank method dilatation [2]. In this article, we report the laparoscopic modified Davydov technique to manage short vagina after inadequate Frank method dilatation. This case report has been reported in line with the SCARE criteria [3].

2. Patient information

A 27-year old, sexually active woman complained about the difficulty of sexual intercourse since 6 years before admission. The breast and pubic hair started to grow at 9 years old. The patient has never had menstrual blood flow during her life. There is no disturbance of micturition or defecation The patient was diagnosed vaginal agenesis and uterus dysgenesis like a band. The husband reported that he could penetrated about 5 cm. After four years, the patient and husband felt pain doing sexual intercouse. The patient already had molding therapy twice a week for 20 min with wooden mold. The patient felt bored and pain after molding. The patient was referred to dr. Ciptomangunkusumo Hospital for the futher management. The similar condition in family was denied. Patient is a dentist. She has no history of drug consumption.

3. Clinical finding

From the physical examination, the patient had grade 1 obesity and Tanner stage M3P3. The smallest graves vaginal specula could be inserted to the neovaginal canal about 5 cm. The vaginal mucosa was smooth, but the portio was not visible. From the rectovaginal toucher bimanual, there was thick band-like structure between the rectum and bladder. (Fig. 1).

Fig. 1.

(A) Genitalia externa identification (B) Indentation vagina suitable to Frank method about 5 cm (C) Inserted smallest graves specula, portio was not visible

4. Diagnostic assessment

From the ultrasound, there was uterine hypoplasia and normal ovary and fallopian tube normal. MRI shows no abnormality in urinary tract system. The chromosomal analysis test was 46 XX. Therefore, the patient was diagnosed with vaginal agenesis and uterine dysgenesis of MRKH syndrome.

5. Therapeutic intervention

Laparoscopic proximal neovaginoplasty and uterine band excision was done to correct the anatomical restriction and relieve symptoms. On laparoscopic view, a uterine dysgenesis and underdeveloped right and left cornu were identified. The uterine band was excised and posterior pelvic peritoneum was dissected and mobilized to cover the proximal neovaginal canal. The surgeon then used vaginal approach to reach the vaginal apex and released it using sharp dissction. The free peritoneum and the end of the initial vaginal apex were sutured at 3, 6, 9 clockwise with 2.0 PGA (Polyglycolic acid). Then, peritoneum was sutured to the vaginal top at 12,1,2 clockwise laparoscopically. The vaginal mold was inserted according the desired size (diameter 3 cm, length 8 cm). The mold was inserted up to the junction of the vaginal and peritoneum. The newly created vaginal top was sutured using tobacco string fashion with 2.0 PGA. Both ends of proximal cornu were sutured up to the vaginal top. Intraoperative bleeding was minimal (Fig. 2).

Fig. 2.

(A) Dysgenesis uterus with uterine band, normal right and left ovarium.(B) and (C) Peritoneum was inserted into vagina (D) 3 cm from the peritoneum was sutured to the vaginal top (E) Final view after surgery.

6. Follow up and outcome

Patient routinely use a vaginal mold. Three month after surgery, both the patient and her partner have no pain during sexual intercourse even without lubricants. She felt satisfactory intercourse proven by the increase FSFI score pre and postoperatively. (16 vs 24; FSFI score < 19 indicates female sexual dysfunction). Vaginal length was 8 cm on 3 month evaluation

7. Discussion

MRKH syndrome is characterized by vaginal agenesis and rudimentary or absent uterus. Patients with MRKH syndrome have symptoms like primary amenorrhea or sexual intercouse [4]^, [5]. For the management of MRKH Syndrome, the neovaginal is created using surgical or non-surgical methods. The dilatation method by Frank is the first-line therapy due to the high success rate and non-invasive. The patient may insert the dilator in the vagina for 15 minutes, two times or more [1]^, [5]. Similar to our case, the patients may have a short vagina as one of the complications from inadequate Frank method dilatation. This may cause dyspareunia. In severe conditions, the sexual partner may not be able to do sexual intercouse. Therefore, surgical treatment can be considered as an alternative treatment for such condition [2].

The surgical treatment for MRKH syndrome is better done when patients at 17-20 age and emotionally mature [5]. Laparoscopy Davydov procedure is one of the procedures to create neovagina in MRKH syndrome. This procedure uses the patient's peritoneum to create a canal vaginal and create apex vagina from approximation fibromuscular streaks [4]. It is based on the finding of stratified squamous epithelium in peritoneum tissue that similar to the introitus vagina [2]. Davydov's procedure is simple and safe procedure compared to other techniques. This procedure makes better lubrication because of the epithelium of neovagina can react to hormonal changes and sexual excitation like normal vagina tissue thus patients felt comfortable doing sexual intercouse [4]. However, the patient still has to use vaginal dilator postoperatively until she is able to do regular sexual intercourse. Considering the risk and benefit, Davydov procedure must be considered as an option in cases in which dilatation therapy fails to achieve the desired vaginal length. The complications that should be avoided are bowel perforation and creating a fistula [4]^, [6].

8. Conclusion

Laparoscopic proximal neovaginoplasty is a surgical method to increase proximal vaginal length by using autologous peritoneal graft which shows excellent result. This procedure should be considered in MRKH syndrome patients with unsatisactory nonsurgical treatment result.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Not required

Funding

No funding sources.

Author contribution

Alfa Putri Meutia: concept, surgeon who performed the Davydov procedure, data analysis, revising, final approval

Anggrainy Dwifitriana Kouwagam : data collection, data analysis, drafting, writing the paper

Suskhan Djusad: concept, drafting, revising, final approval

Surahman Hakim: surgeon who’s involved as member team surgeon who performed the neovagina

Tyas Priyatini: concept, drafting, revising, final approval

Achmad Kemal Harzif: surgeon who performed the Davydov procedure

Guarantor

Alfa Putri Meutia MD

Anggrainy Dwiftriana Kouwagam MD

Suskhan Djusad MD

Surahman Hakim MD

Tyas Priyatini MD

Achmad Kemal Harzif MD

Research registration number

None.

Conflict of interest statement

None declared