Abstract
Objective
This study aimed to compare laparoscopic peritoneal vaginoplasty and laparoscopic sigmoid colon vaginoplasty in patients with congenital absence of vagina, aiming to provide more robust guidance for clinicians and patients with congenital absence of vagina in choosing the most appropriate surgical approach.
Methods
Patients with congenital absence of vagina who underwent laparoscopic vaginoplasty in our hospital from 2011 to 2023 were included in this study. Participants were divided into two groups: the laparoscopic peritoneal vaginoplasty group (peritoneal group, n = 20) and the laparoscopic sigmoid colon vaginoplasty group (sigmoid colon group, n = 30). Short-term outcomes (operative duration, intraoperative hemorrhage, postoperative ventilation time, time to resume oral intake, length of postoperative hospital stay,) and long-term outcomes (sexual satisfaction, vaginal discharge odor, complications, vaginal mold duration) were evaluated.
Results
Comparative analysis revealed that the peritoneal group demonstrated significantly reduced operative duration (p < 0.01), accelerated postoperative ventilation recovery (p < 0.01), and earlier resumption of oral intake (p < 0.01). No significant intergroup differences were observed in intraoperative blood loss (p = 0.10), length of postoperative hospital stay (p = 0.52), or vaginal discharge odor (p = 1). The peritoneal group had shorter vaginal mold use (p < 0.05) and higher sexual satisfaction (p < 0.01). While the peritoneal group showed a trend toward lower postoperative complication rates (3% vs. 8%), this difference did not reach statistical significance (p = 0.53).
Conclusions
Laparoscopic peritoneal vaginoplasty demonstrates superior perioperative outcomes, optimized intestinal function restoration, reduced requirement for vaginal mold application, and improved sexual satisfaction in patients with congenital absence of vagina. This procedure shows promise as a preferred surgical approach in clinical practice.
Keywords: Congenital absence of vagina, Laparoscopic peritoneal vaginoplasty, Laparoscopic sigmoid colon vaginoplasty
Introduction
Congenital absence of vagina, also known as Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, is a rare Müllerian duct anomaly resulting from either bilateral paramesonephric duct malformation or caudal regression during embryonic development [1]. It accounts for a significant proportion of genital tract malformations, although its overall prevalence remains low (1/4000–1/5000) [2]. This disorder presents a unique anatomical profile featuring normal external female genitalia contrasted with variable degrees of internal reproductive tract hypoplasia, including vaginal aplasia and Müllerian duct-derived structure abnormalities. The uterine architecture typically demonstrates complete agenesis or the presence of bilateral rudimentary horns, with fully developed uterine structures being exceptionally rare in this population. However, ovarian function remains typically unaffected, ensuring normal endocrine profiles and secondary sexual characteristics [3]. The hallmark clinical manifestations comprise primary amenorrhea in phenotypically normal adolescents and coital impossibility, which collectively represent the most frequent indications for gynecological evaluation in this patient population [4].
The primary therapeutic objective focuses on anatomical reconstruction of a functional neovagina to restore sexual capacity, thereby addressing both physical and psychological dimensions of patient well-being. Contemporary management strategies encompass a spectrum of interventions, ranging from conservative mechanical dilation of the vaginal vestibule to advanced surgical reconstruction utilizing various graft materials, including autologous tissue flaps or biocompatible substitutes [5]. Optimal treatment strategies emphasize minimally invasive approaches that balance procedural simplicity, clinical efficacy, and favorable patient outcomes, including low complication rates and high satisfaction. The preferred treatment approaches for congenital absence of vagina differ significantly between Asian countries, such as China, and Western countries, including those in Europe and the United States. In Western countries, early intervention is favored, with vaginal reconstruction often initiated during childhood or adolescence using the Frank dilation technique. This approach benefits from the wider pelvic structure of Western women, which facilitates the identification of a suitable vaginal tunnel between the bladder and rectum. In contrast, in China, sociocultural conservatism often delays treatment until adulthood, typically when sexual activity is anticipated. By this stage, the compliance and elasticity of the vestibular mucosa are reduced. Additionally, the narrower pelvic anatomy of Chinese women makes surgical intervention a more reliable method for identifying and creating the vaginal tunnel.
Among available graft options for neovaginal reconstruction, peritoneal and intestinal tissues have emerged as the most clinically utilized materials. The artificial vagina constructed from peritoneal tissue offers a smooth surface, excellent elasticity, and ease of procurement. As an autologous graft, it eliminates the risk of immune rejection, leading to high patient acceptance. Postoperatively, lactobacilli gradually colonize the neovagina, establishing an acidic environment and a microecosystem that closely resembles that of a natural vagina [6, 7]. The sigmoid colon, with its robust vascular supply, provides an artificial vagina of adequate length and width. Its abundant glandular content ensures natural lubrication, which enhances postoperative sexual satisfaction [8]. Despite the widespread clinical adoption of both peritoneal and sigmoid colon vaginoplasty as established surgical interventions for congenital absence of vagina, the optimal surgical approach remains controversial. This investigation seeks to perform a comprehensive comparative evaluation of these techniques, examining both perioperative outcomes and long-term functional results, thereby contributing valuable evidence to inform clinical decision-making and optimize therapeutic strategies for patients with congenital absence of vagina.
Methods
Study population
This study included patients with congenital absence of vagina who underwent surgical treatment at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China, between 2011 and 2023. Among the cases, a greater number underwent transabdominal sigmoid colon vaginoplasty. However, open technique is associated with significant limitations, including increased surgical invasiveness and compromised cosmetic results. The evolution of minimally invasive techniques has led to growing preference for laparoscopic vaginoplasty, which is progressively supplanting conventional open procedures due to its technical advantages and superior patient outcomes. Considering significant inherent differences between open and laparoscopic procedures, we performed a comparative study focusing on laparoscopic sigmoid colon and peritoneal vaginoplasty.
Inclusion Criteria: 1. Patients with congenital absence of vagina who met diagnostic criteria; 2. Patients undergoing laparoscopic sigmoid colon or peritoneal vaginoplasty for the first time at our hospital. Exclusion Criteria: 1. Patients diagnosed with congenital absence of vagina who either did not undergo vaginoplasty or had prior surgeries not performed at our hospital; 2. Patients with comorbid gynecological conditions potentially impacting study outcomes; 3. Patients with severe dysfunction of other organs, including heart, liver, or lungs; 4. Patients with malignant tumors; 5. Cases where vaginoplasty was not performed laparoscopically; 6. Patients with incomplete clinical data or loss to follow-up.
Treatment and follow-up
Laparoscopic peritoneal vaginoplasty: The patient was positioned in standard lithotomy position. Under laparoscopic visualization, a systematic abdominal exploration was performed. A pneumoperitoneum needle was then inserted through the vaginal vestibule under finger guidance, advancing through the urethral bladder and rectal space until reaching the Douglas pouch peritoneum. Approximately 200–300 mL of sterile saline was injected under controlled pressure to create a hydrodissection effect, evidenced by peritoneal thinning, blanching, and spherical bulging into the pelvic cavity. The needle was subsequently withdrawn while maintaining continuous fluid infusion, ensuring complete expansion of the rectovesical space.
The vestibular mucosa was carefully punctured using a mid-curved forceps at the designated vestibular puncture site. A tunnel was then created through blunt dissection, achieving a diameter sufficient to accommodate two transverse fingers. This tunnel was extended cephalad until it reached the pelvic floor peritoneum. Under laparoscopic guidance, a suction-irrigator was utilized to identify and guide the tunnel opening through the pelvic floor peritoneum, ensuring its trajectory remained anterior to the fibrous cords and directed anteriorly. A #10 dilatation rod, wrapped in gauze, was advanced through the tunnel toward the pelvic floor peritoneum. The bladder was gently retracted upward using vascular forceps to expose the free peritoneum, which was then elevated into a spherical shape by the tip of the rod. The peritoneum at the tip of the dilator was incised, establishing communication between the vulvar vestibule and the pelvic cavity to form the vaginal tunnel. The tunnel was subsequently expanded bluntly and gradually to accommodate three fingers. Under laparoscopic guidance, the peritoneal edge of the pelvic floor was sutured at four cardinal points. These sutures were then exteriorized through the tunnel and secured to the corresponding mucosal edges of the vulvar vestibule, ensuring the peritoneum covered the tunnel surface to create an artificial vagina. A suitably sized vaginal mold was inserted into the neovagina and fixed to the labia majora to prevent prolapse. Laparoscopic purse-string sutures were placed, and the suture ends were tied extracorporeally to close the pelvic floor and form the apex of the artificial vagina.
Laparoscopic sigmoid colon vaginoplasty: Patients underwent comprehensive preoperative bowel preparation. After establishing pneumoperitoneum using standard techniques, the laparoscope and surgical instruments were introduced into the abdominal cavity. A thorough exploration of the abdominal cavity was performed, and an intraoperative consultation with a gastrointestinal surgeon was obtained to mobilize the sigmoid colon. Approximately 10 cm of the distal sigmoid colon was freed at the sigmoid-rectal junction, corresponding to the level of the sacral promontory. The distribution and trajectory of the sigmoid mesenteric vessels were meticulously assessed. The peritoneum of the left and right mesenteric lobes was incised, starting from the distal sigmoid colon and extending toward the origin of the sigmoid artery, ensuring preservation of major vascular structures. Selective ligation of secondary vascular branches was performed at the root of the mesenteric vessels, followed by a combination of blunt and sharp dissection to fully mobilize the sigmoid colon up to the upper rectal segment.
The isolated segment of the sigmoid colon was transected at both ends using an intestinal stapler. Bowel continuity was restored by performing an end-to-end anastomosis between the proximal and distal colonic segments using an intestinal anastomosis staple. At the vaginal vestibule, a curved incision was made at the level of the hymenal ring. The vestibular mucosa was dissected cephalad to create a neovaginal space between the urethra, bladder, and rectum, ensuring a diameter sufficient to accommodate three fingers. The pelvic floor peritoneum was then incised transversely, posterior to the uterine remnants, to establish communication with the newly created neovaginal tunnel.
The free sigmoid colon segment was carefully pulled through the neovaginal tunnel, ensuring the mesentery remained untwisted and the vascular supply was preserved. Interrupted sutures were used to approximate the vaginal vestibule mucosa to the intestinal wall of the sigmoid colon, creating the neovaginal introitus. The implanted sigmoid colon was securely anchored to the pelvic floor peritoneum, with meticulous attention to maintaining the integrity of the mesenteric vasculature. A digital rectal examination was performed to assess the rectal mucosa, confirming its smooth contour and absence of abnormalities. The pelvic cavity was irrigated, and the neovagina was sterilized using povidone-iodine solution. A roll of iodoform gauze impregnated with petroleum jelly was inserted into the neovagina and secured in place to maintain patency and prevent prolapse.
Sexual quality of life assessment: Sexual quality of life was assessed using validated questionnaires at one year postoperatively and annually thereafter. The most recent available data for each patient were analyzed, with the longest follow-up duration in this study extending to 13 years. During each follow-up visit, patients were evaluated for the presence of vaginal discharge odor and any postoperative complications, including stenosis, prolapse, or graft-related issues. These findings were systematically documented to ensure comprehensive long-term outcome analysis.
Data collection
Data were systematically collected and analyzed to compare short-term clinical outcomes, including operative duration, intraoperative blood loss, time to postoperative flatus, time to resumption of oral intake, and length of postoperative hospital stay. Long-term postoperative outcomes were also evaluated, encompassing sexual life satisfaction, presence of vaginal discharge odor, and the incidence of complications such as vaginal adhesions, prolapse, stenosis, fistula formation, hemorrhage, abscess formation, and intestinal obstruction. Additionally, the duration of vaginal mold placement was documented. Postoperative sexual quality of life was assessed using the female sexual function index (FSFI) [9], which evaluates six domains: sexual desire, arousal, lubrication, orgasm, satisfaction, and pain during intercourse. Each domain is scored on a scale of up to 5 points, with a total score of 23 or higher indicating satisfactory sexual quality of life.
Statistical analysis
All data were analyzed using SPSS version 27.0 statistical software. Continuous variables following a normal distribution were expressed as mean ± standard deviation () and compared using the independent samples t-test. The variables that were not normally distributed can be analyzed via Mann–Whitney U test. Categorical data were analyzed using the chi-square (χ2) test and reported as frequencies and percentages [n (%)]. A p-value of < 0.05 was considered statistically significant.
Ethical approval
This retrospective study was approved by the Ethics Committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology (TJ-IRB202412003). All participants gave verbal consent to participate in the study. The study was conducted in accordance with the principles of the Declaration of Helsinki.
Results
Comparison of baseline data between groups
According to the predefined inclusion and exclusion criteria, 50 patients were enrolled in this study, including 20 who underwent laparoscopic peritoneal vaginoplasty (peritoneal group) and 30 who underwent laparoscopic sigmoid colon vaginoplasty (sigmoid colon group) (Fig. 1). In the peritoneal group, the age at diagnosis ranged from 12 to 23 years (17.00 ± 3.34 years), the age at surgery ranged from 12 to 33 years (23.70 ± 4.87 years), and the BMI range from 18.80 to 22.10 (20.11 ± 1.01 kg/m2). In the sigmoid colon group, the age at diagnosis ranged from 7 months to 23 years (15.89 ± 3.70 years), the age at surgery ranged from 12 to 37 years (24.17 ± 5.55 years), and the BMI range from 18.60 to 23.10 (20.04 ± 1.03 kg/m2). One patient in the peritoneal group and two in the sigmoid group had previously undergone abdominal surgery. Ten patients in the peritoneal group and seventeen patients in the sigmoid group had no uterus. However, the patients in both groups who had a uterus also had a basal uterus. No statistically significant differences were observed in the baseline data between the two groups (Table 1), confirming their comparability.
Fig. 1.
Flow chart of the study
Table 1.
Comparison of baseline data between two groups of patients with congenital absence of vagina
| Surgical procedures | Number of cases | Mean | Standard deviation | p | |
|---|---|---|---|---|---|
| Age at diagnosis (years) | Peritoneal group | 20 | 17 | 3.34 | 0.28 |
| Sigmoid colon group | 30 | 15.89 | 3.7 | ||
| Age at surgery (years) | Peritoneal group | 20 | 23.7 | 4.87 | 0.76 |
| Sigmoid colon group | 30 | 24.17 | 5.55 | ||
| BMI (kg/m2) | Peritoneal group | 20 | 20.11 | 1.01 | 0.85 |
| Sigmoid colon group | 30 | 20.04 | 1.03 | ||
| Prior abdominal surgeries | Peritoneal group | 20 | – | – | 1 |
| Sigmoid colon group | 30 | – | – | ||
| No uterus | Peritoneal group | 20 | – | – | 0.64 |
| Sigmoid colon group | 30 | – | – |
Comparison of short-term clinical outcomes between groups
The short-term clinical outcomes in patients with congenital absence of vagina primarily focused on surgical metrics and recovery of bowel function (Table 2). The operative duration was significantly shorter in the laparoscopic peritoneal vaginoplasty group (2.75 ± 1.06 h) compared to the laparoscopic sigmoid colon vaginoplasty group (3.96 ± 1.03 h; p < 0.05). Although intraoperative blood loss was lower in the peritoneal group (101.50 ± 94.94 mL) than in the sigmoid colon group (151.00 ± 112.17 mL), this difference did not reach statistical significance. Both the time to postoperative flatus and the time to resumption of oral intake were significantly shorter in the peritoneal group compared to the sigmoid colon group (p < 0.05), suggesting faster recovery of intestinal function in the former. No statistically significant difference was observed in the length of postoperative hospital stay between the two groups (p > 0.05).
Table 2.
Comparison of short-term clinical outcomes in two groups of patients with congenital absence of vagina
| Surgical procedures | Number of cases | Mean | Standard deviation | p | |
|---|---|---|---|---|---|
| Operative duration (hours) | Peritoneal group | 20 | 2.75 | 1.06 | < 0.001 |
| Sigmoid colon group | 30 | 3.96 | 1.03 | ||
| Intraoperative haemorrhage (mL) | Peritoneal group | 20 | 101.5 | 94.94 | 0.1 |
| Sigmoid colon group | 30 | 151 | 112.17 | ||
| Postoperative ventilation time (hours) | Peritoneal group | 20 | 43.2 | 9.85 | < 0.001 |
| Sigmoid colon group | 30 | 68.8 | 30.06 | ||
| Time to resume oral intake (hours) | Peritoneal group | 20 | 53.33 | 41.18 | < 0.001 |
| Sigmoid colon group | 30 | 122.67 | 29.55 | ||
| The length of postoperative hospital stay (days) | Peritoneal group | 20 | 11.15 | 3.79 | 0.52 |
| Sigmoid colon group | 30 | 10.53 | 2.19 |
Comparison of postoperative long-term indicators between groups
After surgery, the duration of vaginal mold placement was significantly shorter in the peritoneal group (3.0 ± 2.25 months) compared to the sigmoid colon group (4.7 ± 2.45 months; Table 3). Postoperative vaginal discharge odor was reported in 5 patients (25%) in the peritoneal group and 7 patients (23.3%) in the sigmoid colon group, with no statistically significant difference between the groups (p = 1.00).
Table 3.
Comparison of duration of vaginal mold application in two groups of patients with congenital absence of vagina
| Surgical procedures | Number of cases | Mean | Standard deviation | p | |
|---|---|---|---|---|---|
| Duration of vaginal mold application (months) | Peritoneal group | 20 | 3 | 2.25 | < 0.05 |
| Sigmoid colon group | 30 | 4.7 | 2.45 |
In the peritoneal group, three patients (15%) experienced postoperative complications, including vaginal hemorrhage in two patients and vaginal atresia in one patient. In the sigmoid colon group, eight patients (26.67%) developed complications, including vaginal adhesions in two patients, vaginal atresia in three patients, vaginal hemorrhage in one patient, vaginal stenosis in one patient, and partial intestinal obstruction in one patient (Table 4). Although the incidence of complications was higher in the sigmoid colon group, the difference between the two groups did not reach statistical significance (p > 0.05).
Table 4.
Comparison of vaginal discharge odor and postoperative complications between two groups of patients with congenital absence of vagina
| Surgical procedures | Total number of cases | Number of cases (percentage) | p | |
|---|---|---|---|---|
| Vaginal discharge odor | Peritoneal group | 20 | 5 (25%) | 1 |
| Sigmoid colon group | 30 | 7 (23.33%) | ||
| Postoperative complication | Peritoneal group | 20 | 3 (15%) | 0.53 |
| Sigmoid colon group | 30 | 8 (26.67%) | ||
| Vaginal adhesion | Peritoneal group | 20 | 0 | |
| Sigmoid colon group | 30 | 2 (6.67%) | ||
| Vaginal atresia | Peritoneal group | 20 | 1 (5%) | |
| Sigmoid colon group | 30 | 3 (10% | ||
| Vaginal hemorrhage | Peritoneal group | 20 | 2 (10%) | |
| Sigmoid colon group | 30 | 1 (3.33%) | ||
| Vaginal stenosis | Peritoneal group | 20 | 0 | |
| Sigmoid colon group | 30 | 1 (3.33%) | ||
| Intestinal obstruction | Peritoneal group | 20 | 0 | |
| Sigmoid colon group | 30 | 1 (3.33%) |
Comparison of postoperative sexual quality of life between groups
In the laparoscopic peritoneal vaginoplasty group, 20 patients were evaluated, of whom 19 were sexually active. In the sigmoid group, 30 patients were assessed, with 28 being sexually active (Table 5). According to the FSFI scoring criteria, no statistically significant differences were observed between the two groups in the domains of sexual desire and sexual arousal (p > 0.05). However, the peritoneal group demonstrated significantly higher scores in vaginal lubrication, orgasm, satisfaction with sexual intercourse, and pain during intercourse, as well as a higher overall FSFI score compared to the sigmoid colon group (p < 0.05).
Table 5.
Comparison of postoperative quality of sexual life in two groups of patients with congenital absence of vagina (scores)
| Surgical procedures | Number of cases | Mean | Standard deviation | p | |
|---|---|---|---|---|---|
| Sexual desire | Peritoneal group | 19 | 4.44 | 0.3 | 0.69 |
| Sigmoid colon group | 28 | 4.47 | 0.34 | ||
| Sexual arousal | Peritoneal group | 19 | 4.25 | 0.2 | 0.67 |
| Sigmoid colon group | 28 | 4.28 | 0.21 | ||
| Vaginal lubrication | Peritoneal group | 19 | 4.58 | 0.33 | < 0.001 |
| Sigmoid colon group | 28 | 3.64 | 0.79 | ||
| Orgasm | Peritoneal group | 19 | 4.76 | 0.29 | < 0.001 |
| Sigmoid colon group | 28 | 3.68 | 0.72 | ||
| Satisfaction with sexual intercourse | Peritoneal group | 19 | 4.78 | 0.29 | < 0.001 |
| Sigmoid colon group | 28 | 3.62 | 0.78 | ||
| Pain during sexual intercourse | Peritoneal group | 19 | 4.67 | 0.28 | < 0.001 |
| Sigmoid colon group | 28 | 3.64 | 0.83 | ||
| Totals | Peritoneal group | 19 | 27.47 | 1.06 | < 0.001 |
| Sigmoid colon group | 28 | 23.33 | 3.03 |
Discussion
Artificial vaginoplasty is the cornerstone of treatment for congenital absence of the vagina and can be categorized into non-surgical and surgical approaches [9, 10]. Among non-surgical methods, Frank’s technique—which involves the use of vaginal dilators to compress the vestibular mucosa—is a well-established option [11]. In 2002, the American College of Obstetricians and Gynecologists (ACOG) recommended non-surgical treatments as the first-line option for patients with congenital absence of the vagina, particularly for those with good adherence to therapy [12]. In China, surgical interventions are currently the preferred method for reconstructing vaginal anatomy in patients with congenital absence of the vagina. Surgical approaches can be broadly categorized into autologous tissue vaginoplasty and allogeneic biomaterial vaginoplasty. Autologous tissues, such as skin grafts, skin flaps, and oral mucosa, have notable limitations: skin flaps may contract, skin grafts can develop hair growth, and the harvestable area of oral mucosa is limited, all of which restrict their widespread use [13]. Among allogeneic biomaterials, amniotic membrane and fetal skin fragments were initially utilized, but ethical concerns and immune rejection reactions have limited their application, leading to their gradual replacement by alternative techniques. More recently, biopatches and tissue-engineered materials have emerged as innovative options for patients with congenital absence of the vagina. However, these materials are costly, and their clinical adoption requires further refinement. Despite these challenges, they represent promising future options for vaginoplasty. Currently, the peritoneum and sigmoid colon remain the most widely used and preferred materials for the surgical treatment of congenital absence of the vagina.
At our institution, laparoscopic peritoneal vaginoplasty is performed using the LoHu technique, the advantages of which are well-documented in the literature [14]. However, the presence of prior pelvic adhesions represents a relative contraindication for laparoscopic peritoneal vaginoplasty, necessitating alternative surgical approaches in such cases. Although complications related to intestinal anastomosis were historically common in early intestinal substitution vaginoplasty, advancements in antibiotic therapy, surgical techniques, and anesthesia have significantly improved the safety and efficacy of the procedure. The sigmoid colon’s anatomical proximity to the vulva, combined with its well-vascularized tip that can be easily extended into the vaginal tunnel, has established it as a preferred material, alongside the peritoneum, for artificial vaginal reconstruction [15]. Furthermore, sigmoid colon vaginoplasty is often recommended for patients in whom other vaginoplasty techniques have failed. A case reported by Rui Hou et al. [16] described a rare instance of neovaginal adenocarcinoma in a patient who had undergone sigmoid colon vaginoplasty 20 years prior and tested positive for HPV types 39 and 68. The neovagina, being part of the intestinal tract, exhibits lower resistance to infection compared to a natural vagina, and HPV infection poses a significant risk for neovaginal adenocarcinoma. Therefore, regular postoperative HPV screening is strongly recommended for patients who undergo sigmoid colon vaginoplasty. Fortunately, none of the patients in this study developed new vaginal adenocarcinomas.
There remains a lack of standardized treatment protocols for congenital absence of the vagina, both domestically and internationally. Additionally, a comprehensive evaluation system for comparing the efficacy of various artificial vaginoplasty techniques has yet to be established. Currently, most assessments focus on surgical metrics and patient-reported sexual satisfaction, highlighting the need for more holistic evaluation frameworks that incorporate long-term functional and quality-of-life outcomes.
In this study, the operative duration for the laparoscopic peritoneal vaginoplasty group was significantly shorter than that of the sigmoid colon group (p < 0.05). This difference is likely attributable to the additional time required in the sigmoid colon group for selecting and mobilizing the appropriate intestinal segment, as well as performing anastomosis of the transected intestinal ends. Postoperative outcomes revealed that the time to first flatus and the resumption of oral intake were significantly shorter in the peritoneal group compared to the sigmoid colon group (p < 0.05). This can be explained by the absence of intestinal manipulation in the peritoneal group, which facilitates faster recovery of bowel function. Notably, the intraoperative blood loss and length of postoperative hospital stay was comparable between the two groups, with no statistically significant difference (p > 0.05). Patients in the peritoneal group required a significantly shorter duration of vaginal mold placement compared to those in the sigmoid colon group (p < 0.05). All patients in the sigmoid colon group used vaginal molds postoperatively, with a duration ranging from 3 to 12 months, whereas patients in the peritoneal group used molds for a maximum of 6 months. Notably, recent cases in the peritoneal group at our institution have demonstrated that the need for vaginal molds can be virtually eliminated. Regular vaginal dilation performed with the assistance of family members has been shown to achieve comparable outcomes to mold placement. The incidence of vaginal discharge odor was comparable between the two groups, occurring in 5 patients (25%) in the peritoneal group and 7 patients (23.3%) in the sigmoid colon group. The odor was partly attributed to postoperative vaginitis; however, in the sigmoid group, the odor may have been exacerbated by the natural glandular secretions of the sigmoid colon, a factor that is likely unavoidable. Although the incidence of postoperative complications was lower in the peritoneal group (15%; 3 of 20 patients) compared to the sigmoid colon group (26.67%; 8 of 30 patients), the difference was not statistically significant (p > 0.05).
For patients with congenital absence of the vagina, postoperative sexual quality of life is a critical outcome measure. Sexual quality of life was assessed using the FSFI, which revealed no significant differences between the groups in the domains of sexual desire and arousal (p > 0.05). However, the peritoneal group demonstrated significantly higher scores in vaginal lubrication, orgasm, satisfaction with sexual intercourse, pain during intercourse, and total FSFI score (p < 0.05). The mean total FSFI score exceeded 23 in both groups, indicating generally satisfactory postoperative sexual function. Nevertheless, some patients in the sigmoid colon group had total FSFI scores below 23, primarily due to reduced vaginal elasticity, inadequate lubrication, and pain during intercourse. These findings suggest that laparoscopic peritoneal vaginoplasty offers superior outcomes in the treatment of congenital absence of the vagina. This aligns with the results of a randomized controlled study conducted by Cao et al. [17] in 2013, which reported better functional outcomes and higher patient satisfaction in the peritoneal group. In contrast to the aforementioned randomized controlled trial, the current investigation enrolled a considerably greater cohort of patients, increasing the concern for recovery of digestive function and long-term postoperative complications.
The primary limitation of this study is its small sample size. Although 208 patients with congenital absence of the vagina underwent surgical treatment at our institution between 2011 and 2023, only 30 patients who underwent laparoscopic sigmoid colon vaginoplasty and 20 patients who underwent laparoscopic peritoneal vaginoplasty met the inclusion criteria after excluding those who had transabdominal surgery or were otherwise ineligible. Additionally, this study was conducted at a single center, which may limit the generalizability of the findings. However, a notable strength of this study is the extended follow-up period, with the earliest patient having been followed for 13 years—a duration rarely reported in similar studies. This long-term follow-up enables a comprehensive evaluation of the outcomes associated with both surgical techniques, particularly postoperative sexual quality of life, which is a critical consideration in the treatment of congenital absence of the vagina and a central focus of this study.
Conclusion
Compared to laparoscopic sigmoid colon vaginoplasty, laparoscopic peritoneal vaginoplasty is associated with a shorter operative duration, faster recovery of postoperative intestinal function, reduced need for vaginal mold use, and higher sexual quality of life. In conclusion, laparoscopic peritoneal vaginoplasty is a less invasive procedure that facilitates quicker recovery and provides superior sexual outcomes, making it a promising option for clinical application. However, a comprehensive clinical evaluation of the patient is essential. The optimal individualized treatment plan should be determined based on the patient’s physical condition, personal preferences, and specific clinical context.
Acknowledgements
We would like to thank our colleagues for their help in the completion of this manuscript.
Funding
This work was supported by the National Key R&D Program of China (Nos. 2023YFC2706003 and 2023YFC2706004).
Disclosures
Conflicts of interest
Authors Li Yinuo, Li Zihan, Lin Xiaorui, Li Yuting, Huang Yibao, Liu Rong, and Wu Mingfu have no conflicts of interest or financial ties to disclose.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Liu Rong and Wu Mingfu have contributed equally to this work.
Contributor Information
Liu Rong, Email: liurongdoctor@tjh.tjmu.edu.cn.
Wu Mingfu, Email: wu_mingfu@tjh.tjmu.edu.cn.
References
- 1.Herlin MK, Petersen MB, Brannstrom M (2020) Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome: a comprehensive update. Orphanet J Rare Dis. 10.1186/s13023-020-01491-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Committee on Adolescent Health (2018) ACOG committee opinion No. 728: Mullerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 10.1097/AOG.0000000000002458 [DOI] [PubMed] [Google Scholar]
- 3.Londra L, Chuong FS, Kolp L (2015) Mayer-Rokitansky-Kuster-Hauser syndrome: a review. Int J Womens Health. 10.2147/IJWH.S75637 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Chen N, Song S, Bao X, Zhu L (2022) Update on Mayer-Rokitansky-Kuster-Hauser syndrome. Front Med. 10.1007/s11684-022-0969-3 [DOI] [PubMed] [Google Scholar]
- 5.Wee A, Bagchi T, Kimble R (2022) Creation and maintenance of neo-vagina with the use of vaginal dilators as first line treatment: results from a quaternary paediatric and adolescent gynaecology service in Australia. Aust N Z J Obstet Gynaecol. 10.1111/ajo.13487 [DOI] [PubMed] [Google Scholar]
- 6.Chen N, Hao L, Zhang Z, Qin C, Jie Z, Pan H, Duan J, Huang X, Zhang Y, Gao H, Lu R, Sun T, Yang H, Shi J, Liang M, Guo J, Gao Q, Zhao X, Dou Z, Xiao L, Zhang S, Jin X, Xu X, Yang H, Wang J, Jia H, Zhang T, Kristiansen K, Chen C, Zhu L (2024) Insights into the assembly of the neovaginal microbiota in Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome patients. Nat Commun. 10.1038/s41467-024-52102-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Qin C, Luo G, Luo X, Lifschutz BN, Zhu Z, Fang Y (2019) Analysis of the artificial vaginal microecology in patients after laparoscopic peritoneal vaginoplasty. Sci Rep. 10.1038/s41598-019-44511-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bhaskar V, Sinha RJ, Mehrotra S, Mehrotra CN, Singh V (2018) Long-term outcomes of sigmoid vaginoplasty in patients with disorder of sexual development—our experience. Urol Ann. 10.4103/UA.UA_88_17 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Callens N, De Cuypere G, De Sutter P, Monstrey S, Weyers S, Hoebeke P, Cools M (2014) An update on surgical and non-surgical treatments for vaginal hypoplasia. Hum Reprod Update. 10.1093/humupd/dmu024 [DOI] [PubMed] [Google Scholar]
- 10.Michala L, Cutner A, Creighton SM (2007) Surgical approaches to treating vaginal agenesis. BJOG. 10.1111/j.1471-0528.2007.01547.x [DOI] [PubMed] [Google Scholar]
- 11.Willemsen WN, Kluivers KB (2015) Long-term results of vaginal construction with the use of Frank dilation and a peritoneal graft (Davydov procedure) in patients with Mayer-Rokitansky-Kuster syndrome. Fertil Steril. 10.1016/j.fertnstert.2014.10.014 [DOI] [PubMed] [Google Scholar]
- 12.American College of Obstetrics and Gynecology (2002) ACOG committee opinion. Nonsurgical diagnosis and management of vaginal agenesis. Number 274, July 2002. Committee on adolescent health care. American College of Obstetrics and Gynecology. Int J Gynaecol Obstet. 10.1016/s0020-7292(02)00326-0 [DOI] [PubMed] [Google Scholar]
- 13.Wu M, Wang Y, Xu J, Dai H, Zhong X, Sun M, Lv C, Xue C (2020) Vaginoplasty with mesh autologous buccal mucosa in vaginal agenesis: a multidisciplinary approach and literature review. Aesthet Surg J. 10.1093/asj/sjaa147 [DOI] [PubMed] [Google Scholar]
- 14.Qin C, Luo G, Du M, Liao S, Wang C, Xu K, Tang J, Li B, Zhang J, Pan H, Ball TW, Fang Y (2016) The clinical application of laparoscope-assisted peritoneal vaginoplasty for the treatment of congenital absence of vagina. Int J Gynaecol Obstet. 10.1016/j.ijgo.2015.11.015 [DOI] [PubMed] [Google Scholar]
- 15.Delshad S, Delshad B, Mogheimi P (2022) Postoperative outcomes of sigmoid colon vaginoplasty for vaginal agenesis: a randomized controlled trial. Ann Med Surg. 10.1016/j.amsu.2022.103833 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Hou R, Liu HX, Feng YL (2024) Adenocarcinoma arising in sigmoid colon neovagina 20 years after construction: a case report. Asian J Surg. 10.1016/j.asjsur.2024.05.308 [DOI] [PubMed] [Google Scholar]
- 17.Cao L, Wang Y, Li Y, Xu H (2013) Prospective randomized comparison of laparoscopic peritoneal vaginoplasty with laparoscopic sigmoid vaginoplasty for treating congenital vaginal agenesis. Int Urogynecol J. 10.1007/s00192-012-1991-9 [DOI] [PubMed] [Google Scholar]