A Novel Technology for Vaginal Reconstruction Using Porcine Small Intestinal Submucosa

Sir:

Up to 76% of women experience decreased genital sensation,¹ which is most commonly exemplified by the feeling of a widened vagina. In this communication, we report a novel surgery using biological grafts for vaginal reconstruction.

A widened vagina is a type of pelvic floor dysfunction. Relaxation is mainly caused by childbirth; violence and frequent use may increase postoperative recurrence. The vagina bears the pressure of the bladder, rectum, and the entire abdomen; therefore, it is often difficult for traditional surgical approaches to completely restore its anatomy. Because of critical issues such as erosion, exposure, and pain, synthetic mesh is not appropriate for vaginal surgery.²

Eighteen patients with severe pelvic organ prolapse underwent vaginal reconstruction using porcine small intestinal submucosa grafts (SIS)(Biodesign; Cook Medical, Inc., Indianapolis, Ind.). No recurrence was reported after 33 months of follow-up. In addition, fewer side effects, such as erosion, exposure, and pain, caused by the biological graft were reported. Our results revealed that vaginas reconstructed with biological grafts featured smooth walls, few scars, increased rigidity, and robust tensile strength. We placed the biological graft onto the vaginal front and rear walls in young patients with vaginal relaxation and discharge. To date, we have performed 4 operations, and the patients and their partners have been satisfied with their new vaginas.

Starting 1 cm from the urethra, a 5-cm space was introduced between the bladder and vagina, with one side connected to the arcus tendineus fasciae pelvis (ATFP). The bladder fascia was then subjected to transverse tightening and reinforced suturing (Kelly’s plication). Subsequently, a biological graft was placed between the vagina and bladder before 2 nonabsorbable sutures (ETHIBOND EXCEL X519; Ethicon, Diegem, Belgium) were used to suture the ATFP, lateral ligament of the bladder, and SIS graft, such that 3 stitches were introduced to facilitate consolidation. Starting from the hymen, a 5-cm space was introduced between the rectum and vagina, with one side connected to the ATFP. The rectal site defect was first repaired, and the rectal fascia was subsequently tightened and consolidated before 2 nonabsorbable sutures were used to suture the ATFP, lateral ligament of the rectum, SIS graft, and vaginal submucosa. Nonabsorbable sutures were also used to suture the fractured levator ani muscle, external sphincter muscle of the anus, superficial transverse perineal muscles, and bulbospongiosus muscle, thereby forming a new perineal body (Fig. 1).

Fig. 1.

A, anterior biological graft of the vagina and P, posterior biological graft of the vagina.

The Biodesign SIS graft is a heterogeneous acellular collagen scaffold that can release signals to induce surrounding tissues to grow into the scaffold, facilitating self-repair and the regeneration of healthy tissue.³ In this study, the biological graft repaired the vaginal mucosa; the muscle and fascia tissue exhibited high similarity to normal tissues, and physiological function was restored. In addition, the biological graft caused relatively minor side effects, such as erosion and pain.⁴

Tightening and consolidation of the bladder and rectal fascia connects the vagina, the lateral ligament of the bladder, and the lateral ligament of the rectum to the ATFP, therefore alleviating the feeling of a widened vagina within 2 months. After 2 months, the biological graft will produce a tightened vagina.

Nevertheless, the biological graft also has some drawbacks, such as considerable early swelling, exudation, and lack of strength.⁵ In addition, nascent tissue retains the defects of the original tissue. We anticipate positive results in further follow-up visits with our patients.