Vaginal stenosis treatment using computed tomography and fluoroscopy guidance

Abstract

INTRODUCTION

Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis.

CASE

We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation.

INTERVENTION

A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency.

CONCLUSION

This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.

Introduction

A vaginoplasty is the gynecologic procedure used to create or recreate the vagina. Indications for a vaginoplasty include gender affirmation surgery,¹ congenital anomalies,² and as part of reconstruction following radical oncologic surgeries in the pelvis.² Donor sites for vaginoplasty can be genital skin,¹ abdominal skin,² bowel, or peritoneum.³ If there is a question of adequate blood, myocutaneous flaps have some advantages, such as a rectus abdominis myocutaneous flap that only requires a single incision and has a lesser chance of necrosis when compared with a thigh muscle flap, for example, the gracilis.⁴

Important surgical outcomes for vaginoplasty are patency of the neocavity, long-term sexual satisfaction, and patient body image.² A common adverse outcome after vaginoplasty is neovaginal stricture or stenosis (19% as reported in a systemic review).^5,6 Inconsistent and/or inappropriate use of the vaginal dilator is a common reported cause of vaginal stenosis after vaginal surgeries.⁷ Preoperative patient counseling and thorough instructions regarding the correct dilator application protocol is an effective preventive strategy for vaginal stenosis after vaginoplasty.⁵

Besides multiple surgical vaginal canalization and recanalization procedures, image-guided recanalization for occluded genitourinary tracts⁸ is an emerging idea owing to the advancements in imaging and interventional imaging technologies. Male genitourinary tract dilatation under image guidance has been reported,⁹ particularly using ultrasound via a transrectal or transurethral route.10, 11, 12, 13 In terms of female genitourinary tract reconstruction, combined surgical and radiologic techniques have also been applied to create a neoendocervical canal in the setting of congenital vaginal atresia.¹⁴ However, most literature for vaginal recanalization procedures focuses on congenital anatomic defects in vaginal canal patency, whereas our case is unique in presenting with acquired postoperative vaginal stenosis.

Because of a paucity in the data supporting image-guided vaginal recanalization procedures, we present a successful case of computed tomography (CT) scan and fluoroscopy-guided recanalization and subsequent balloon dilation of a stenosed neovagina, followed by a gynecologic surgery to excise the remaining granulation tissue surrounding the stricture.

Narrative

Patient information

A 56-year-old woman with a cancer-related rectovaginal fistula had undergone preoperative radiation and extensive pelvic reconstructive surgery to resect a large rectal adenocarcinoma. Her surgery included a lower anterior resection with diverting ileostomy, bilateral salpingo-oophorectomy, and an upper vaginectomy. Plastic surgeons then created a new upper vagina using a myocutaneous flap from the rectus abdominis muscle. This patient had no relevant family and psychosocial history.

Clinical findings

After 4 years of no sexual intercourse and inconsistent dilation, the patient presented with increasing pelvic pressure and an inability to pass dilators at the time of presentation. Under anesthesia, an examination revealed a complete stricture at the junction of the neo- and native vagina where the rectal staple anastomosis existed. Speculum examination could not be performed past 4 cm.

Diagnostic assessment

A CT scan demonstrated fluid collection in the mid- to upper vagina. A dense hourglass stricture at the junction of neo- and native vagina was seen on the CT scan.

Therapeutic intervention

Owing to the extensive surgical history, an endoscopy and surgical dilation was abandoned because of the risk for perforation of her rectum. Hence, the Department of Interventional Radiology was consulted to develop a plan for recanalization of the obstructed lower neovagina. Under CT-fluoroscopic guidance, a 22-gauge 15 cm Chiba needle was advanced into the dilated neovagina using a transabdominal approach, followed by placement of a transitional 4F sheath. Subsequently, a 22-gauge 60 cm Chiba needle was used to gain access into the neovagina using a transvaginal approach under fluoroscopic guidance, followed by placement of a 0.018" wire within the neovaginal lumen. A CT scan was used to confirm the position within the neovagina and that the tract did not traverse the bladder or the rectum (Figure 1). A loop snare was used to grab the wire using the transabdominal access and to pull through the 4F transitional sheath for through and through transabdominal access through the neovagina and out the vagina (Figure 2). A 4F catheter was then advanced over the wire and exchanged for a 0.035" guide wire. The occluded vaginal segment was then dilated. Using the transvaginal approach, a 10F locking loop catheter was advanced into the lumen of the neovagina. Purulent fluid was aspirated and sent for culture.

Figure 1.

Excluded vagina with wire access

Transabdominal access (left). Transvaginal sharp recanalization (right) on computed tomography scans.

Mushtaq. Image-guided vaginal recanalization. Am J Obstet Gynecol Glob Rep 2023.

Figure 2.

Wire access into excluded vagina from above and below

A loop snare using the transabdominal approach to grab the transvaginal wire (left), followed by (right) through and through access. Contrast injection shows the newly created tract in the neovagina on the computed tomography scan.

Mushtaq. Image-guided vaginal recanalization. Am J Obstet Gynecol Glob Rep 2023.

Follow-up

The drainage catheter was left in place for 6 weeks with twice daily flushing (Figure 3) and 2 weeks of antibiotics. The indwelling drain was removed over a guide wire and a sheath was placed. Pullback sheath injection of the wire demonstrated a patent but markedly narrowed neovaginal opening (Figure 4). Dilation was performed using a 12 mm balloon, followed by placement of a 26F balloon style Foley catheter (Figure 5).

Figure 3.

Locking loop drain left to drain the infected neovagina

Mushtaq. Image-guided vaginal recanalization. Am J Obstet Gynecol Glob Rep 2023.

Figure 4.

Excluded neovagina before and after drainage

Computed tomography (CT) scan of the dilated neovagina before the procedure (left). Follow-up CT scan 9 months after recanalization showing the decompressed neovagina (right).

Mushtaq. Image-guided vaginal recanalization. Am J Obstet Gynecol Glob Rep 2023.

Figure 5.

Balloon dilatation of new neovagina tract

A 12 mm balloon dilation of the neovaginal tract followed by upsizing to a 26F Foley style catheter.

Mushtaq. Image-guided vaginal recanalization. Am J Obstet Gynecol Glob Rep 2023.

Outcome

The balloon style Foley catheter was removed after 2 months via gynecologic surgery. On removal, the smallest dilator was found to fit into the recanalized neovaginal tract easily. A vaginoscopy demonstrated a healthy vaginal flap and a decompressed neovagina of 13 cm long. Any remaining fluid was washed out via a vaginoscopy. In addition, granulation tissue at the site of the stricture was resected surgically to make the neovagina more permanently patent. The patient and her husband were trained on the appropriate dilation methods and educated on the importance of this as a preventive strategy to avoid re-stenosis. The patient has been keeping up with the dilation and has even upsized the dilator. There were no reported complications during follow-up.

Discussion

This case report describes the ability of a combination CT-fluoroscopy room to enable quick and easy switching between modalities for the formation of a neotract through a complete vaginal stenosis. Technological advancements in interventional radiology have allowed the development of minimally invasive transcervical tubal catheterization procedures for the treatment of proximal tubal obstruction¹⁵ with reduced risks, costs, and morbidity when compared with surgical procedures.¹⁶ Another example of this is the fluoroscopic recanalization of the fallopian tube in the workup of infertility.¹⁷ However, the use of these techniques for vaginal stenosis after a vaginoplasty is unusual currently. Several surgical techniques,¹⁸ including use of a new graft, robotic-assisted repeat vaginoplasty,¹⁹ intestinal vaginoplasty,⁵ and interdigitating vaginal flap surgery,¹⁹ have been proposed. This article presents a novel idea of image-guided reconstruction for this unique case, which is the primary strength of this study.

A common cause of repeat stricture after operation is reported to be the irregular or inappropriate use of vaginal dilators.⁷ An aggressive dilator regimen for the first 3 months postoperation is recommended.⁵ For a scarred neovagina, soft silicone dilators are suggested instead of the regular rigid dilators.⁵ Application of a lubricant can also help to provide stretch and softness to the neovagina.⁵ This technique of vaginal stretching has shown a 90% success rate.²

Recent literature suggests that pelvic recanalization surgery should be delayed until the patient shows a willingness to regularly use a dilator.²⁰ Some patients find it hard to comply with regular dilator use and resort to the easier and more comfortable way of using tampons instead of dilators.²¹ Unfortunately, without regular dilation, the reconstruction is prone to repeat strictures and the need for repeat recanalization. This scenario was true for our patient who originally did not realize the importance of this activity. Besides bringing to light a novel image-guided recanalization technique, this case also highlights the importance of regular and appropriate dilator use as a preventive strategy to avoid stenosis after vaginal reconstructive procedures. This adds further to the strength of the study.

In this innovative procedure, no major postprocedural complication was found. This successful attempt at image-guided tract formation and dilation of a completely stenosed neovagina established a patent vaginal tract in a novel way such that a stable tract could be formed and ultimately maintained by the patient through regular dilator use. The patient reported normal voiding and bowel movements without any pain or fever.

Because this new technique was performed in only 1 patient, we need a larger set of patient data to support the efficacy of this technique. Another limitation is that this procedure requires a specialized interventional radiology suite, which allows the use of both imaging modalities—CT and fluoroscopy—to guide the procedure. Performing this procedure also demands thorough understanding of genitourinary radiologic anatomy. Any postsurgical or postradiation alteration in anatomy needs to be taken into consideration before intervention.

For patients with an extensive surgical and radiation history, these image-guided reconstructive techniques need further exploration to expand minimally invasive treatment options. These effective techniques should save time and allow access with minimal pain to the patient and leaving minimal body scars.

Conclusions

Patient counseling regarding regular dilator use and sexual intercourse is helpful to prevent stenosis after a vaginoplasty. Current imaging modalities combined with technological advancements in image-guided procedures are creating novel diagnostic and therapeutic techniques for the access, imaging, and recanalization of diseased genitourinary tracts. With presentation of this case, it is hoped that interventional methodologies may be used for vaginal stenosis recanalization and/or maintenance in the future.