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Ileal J-pouch vaginoplasty
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Ileal J-pouch vaginoplasty Reconstruction of a physiologic vagina with an ileal J-pouch Wolfgang Schneider, MD, PhD; Phuong Nguyen-Thanh, MD, PhD; Henning Dralle, MD, PhD; Ursula Mirastschijski, MD, Dr.phil
Problem: multiple complications Congenital or acquired vaginal absence has been the object of reconstructive treatment for more than a century. Nonsurgical methods such as dilatation have been abandoned as ineffective, and surgical reconstruction has been accomplished with skin grafts, fasciocutaneous and muscle flaps, and omentum or bowel transfers.1 Split-thickness skin transplants were widely used at first, but complications such as extremely high shrinkage rates and vaginal obliteration in up to 41% of the patients led to other surgical approaches.2-4 Among the many local flaps that have been used are unilateral or bilateral gracilis flaps, rectus abdominis flaps, pedicled deep inferior epigastric flaps, and fasciocutaneous advancement flaps.1,5-8 Complications of these procedures include inadequate vaginal capacity; vaginal stenosis requiring dilatation; wound-healing problems, including infections; fistula formation; scarring; and pain with inability to perform sexual intercourse.5,6,9 The first neovaginas made from bowel were constructed with rectum by From the Department of Plastic, Aesthetic, and Hand Surgery, University Hospital, Otto-von-Guericke University Magdeburg, Germany (Dr Schneider); the Department of General, Visceral, and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle, Germany (Drs Nguyen-Thanh and Dralle); and the Department of Plastic, Hand and Reconstructive Surgery, University Hospital, Hannover Medical School, Hannover, Germany (Dr Mirastschijski). 0002-9378/$36.00 © 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.03.009
Click Supplementary Content under VIDEO the article title in the online Table of Contents
694.e1
Vaginal reconstruction has been performed for more than a century. Main complications are vaginal stenosis requiring dilatation, dyspareunia, excessive mucus secretion, and poor aesthetic and functional outcome. Here we report a new operation method modified after Baldwin for intestinal vaginoplasty in a patient with pelvic exenteration after spinal cell carcinoma of the vagina. Because of balanced liquid resorption and mucus secretion with sufficient vessel length in the terminal ileum, this intestinal segment was chosen. A J-pouch of distal ileum was constructed pedicled on the ileocolic artery and accompanying nervous plexus, transferred into the lower pelvis and sutured to the vaginal stump. One year follow-up showed a highly satisfied, sexually active patient, with adequate vaginal size, optimal lubrication and no molesting fecal odor. Terminal ileum J-pouch vaginoplasty is an optimal method for vaginal reconstruction providing a sufficient vaginal lumen and lubrication and thereby restoring patients’ sexual life and increasing life quality. Key words: ileal J-pouch vaginal reconstruction, vaginoplasty Cite this article as: Schneider W, Nguyen-Thanh P, Dralle H, et al. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009;200:694.e1-694.e4.
Sneguireff10 in 1892 and with ileum by Baldwin11 in 1904. In Baldwin’s 2-step procedure, distal ileum was transferred into the pelvis with the ileal limbs sutured together; the septum was removed 2 weeks later. A high mortality rate led to the abandonment of Baldwin’s technique. More recently, ileocecal segments, distal ileum, sigmoid colon, and cecum were each used for vaginal reconstruction.12-18 While the sigmoid colon and cecum offer low shrinkage tendency, good lubrication, and sufficient lumen size, major complications of colon use have included excessive mucus secretion with maceration, vaginal stenosis, and fecal odor. The occurrence of adenocarcinoma in neovagina constructed from bowel was also reported.19,20
Our solution We report a new surgical method for creation of a physiologic neovagina. The distal ileum was used to create a J-pouch that was pedicled on the ileocolic artery and accompanying nerve plexus. The Jpouch, which serves as the vaginal reservoir, was transferred into the lower pelvis and sutured to the vaginal stump.
American Journal of Obstetrics & Gynecology JUNE 2009
Among the advantages of the distal ileum is its intrapelvic location. Furthermore, the segment is nourished by the relatively long ileocolic artery and innervated by the nerve plexus accompanying the vessel—an artery must be long enough to allow the construct to be transposed to the pelvic floor without causing tension on the blood vessels that supply the region and without jeopardizing tissue survival (Figure 1). In addition, equilibrium between liquid resorption and mucus secretion in the distal ileum provides optimal lubrication of the neovagina. Our patient was a 51-year-old woman who underwent pelvic exenteration for squamous cell carcinoma of the vagina in 1995. After this surgery, a vaginal stump measuring only 2-cm from the vaginal introitus remained. Sexual intercourse was impossible, and the patient desired reconstruction. Otherwise, she was healthy and had no history of cancer recurrence. After written consent, the operation was performed. First, the patient’s intestines were purged with a preoperative colonic prep-
Surgeon’s Corner
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FIGURE 1
Distal parts of the ileum and the cecum are nourished by the ileocolic artery, and vegetative innervation is provided by the nerve plexus of the superior mesenteric branch. Schneider. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009.
aration. Once this was accomplished, she was placed in a supine lithotomic position, which allowed simultaneous abdominal and perineal access. A median laparotomy was performed, and the terminal ileal segment needed for pouch formation was identified. After dissection of adhesions in the narrowing of the pelvic outlet, the ileocolic artery and accompanying veins were localized by cold light diaphanoscopy. Then the distal ileum was isolated. A 23-cm length of ileal segment was resected about 10 cm above the ileocecal valve, and the proximal and distal ends were closed with staples (Figure 2). The vessel arcade, including the intact vegetative nerve plexus in the mesentery of the dissected ileal segment, was isolated in a V-shaped fashion up to the central origin, the superior mesenteric artery. In the second phase of the operation, the vaginal stump was identified and prepared via intraabdominal and extra-
abdominal access. Circular incisions were made in the vaginal stump and mucosa in order to remove fibrotic adhesions and scars. Next, the J-pouch was formed. At the bottom of the loop, an incision was made for the linear cutter. This device was then inserted into the ileal loop, and an anastomosis of the antimesenteric wall of the ileum was produced in order to double the original volume of the ileal lumen. In doing so, the distal part of the pouch was kept 2 cm shorter than the proximal part. The incision was closed with staples. After that, the construct was carefully moved down to the pelvic floor without any tension on the associated blood vessels. A tension-free anastomosis was formed between the J-pouch and the vaginal stump by attaching the opened bottom of the J-pouch loop to the open end of the vaginal stump with singleknotted, 4-0 Vicryl sutures (Ethicon Endo-Surgery Inc, Cincinnati, OH).
Subsequently, the pouch was secured to the connective tissue of the bladder and to adjacent muscle fascia of the pelvic floor with Vicryl sutures. Intestinal continuity was restored with an ileoileostomy; this was achieved with inverted single-knot 3-0 PDS sutures. The mesentery was closed with a 4-0 Vicryl continuous suture. Finally, the intestines were repositioned intraabdominally, and the abdominal wall was closed in a standard way. Throughout surgery, excellent blood supply was demonstrated in the dissected ileum segment and in the anastomosed parts of the ileum. No major complications occurred during the postoperative course. An initial, mild, anastomotic stenosis occurred after the patient neglected a facet of postsurgical care, but the stenosis responded well to short-term dilation. At 1-year follow-up, the patient was sexually active and highly satisfied with the surgical results. She reported adequate lubrication without stenosis recurrence, excessive mucus discharge, or fecal odor. Interestingly, she reported an orgasm-like sensation in the supraumbilical area during sexual intercourse. This new sensation might be caused by nerve plexus stimulation following pouch dilation. Vaginal endoscopy verified intact peristaltic motion and a total vaginal length of 18 cm (video). Calculation of the total length included the 12-cm ileal J-pouch, the 2-cm vaginal stump, and the 4-cm vaginal introitus. Simultaneously, tissue samples were taken for histology. No malignancy or abnormal tissue structures were found. Ileoanal J-pouch anastomosis was first described by Utsunomiya et al21 in 1980. They reported excision of the rectum, formation of a loop-type ileal reservoir from distal parts of the ileum, transfer of the J-pouch to the pelvic floor, and its anastomosis to anal tissue. The technique is relatively uncomplicated, ensures sufficient blood supply to both parts of the loop, and yields a suitable reservoir size with reduced risk for stenosis.21,22 It has been widely used, mainly in patients with ulcerative colitis. In this group, ileoanal J-pouch anastomosis is considered a standard procedure because it is performed easily by
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Surgeon’s Corner surgeons and provides efficient evacuation for patients.22,23 The location and versatility of the distal ileum also allows its use in urinary bladder reconstruction in the anterior pelvis.14 In an effort to avoid complications such as shrinkage requiring continuous self-dilatation, dyspareunia, and tissue fragility, various surgical techniques have evolved for vaginal reconstruction.3,5,24,25 Vaginoplasties relying on portions of the bowel, an old concept, have become increasingly common in recent years.10,11,16,26 We chose to modify the J-pouch procedure for vaginal reconstruction by forming an anastomosis between the looped end of the pouch and the vaginal stump. Use of the terminal ileum offered a good blood supply from the ileocolic artery, a sufficient lumen size, and adequate lubrication. Hanna27 used proximal parts of the ileum in 1987 to construct a vagina in children with a female phenotype and a 46 XY genotype. A drawback is the very short length of the ileal arteries that nourish the proximal two-thirds of the ileum—these derive directly from the superior mesenteric artery. A distinct advantage of our method is that extensive mobilization of the colon is unnecessary, thus reducing the risk of bleeding or bowel rotation and strangulation. For example, the use of ileocecal segments requires the mobilization of the right colonic flexure, and this poses a risk of tension on the blood vessels that supply it.13 However, the ileocolic artery branch that feeds the terminal ileum is long enough to permit tension-free transfer of the ileum to the pelvic floor. Our work contrasts with other reports stating that the small bowel mesentery is too short for vaginal reconstruction.16,17 However, Bürger et al13 advised the use of the terminal ileum if the cecal mesentery could not be extended sufficiently. In addition, no problems with the arterial length were identified when the Monti principle was applied to ileal vaginoplasties performed with laparoscopic procedures.15,28 The previous use of other ileum parts for vaginal reconstruction was limited by inadequate lumen size and excessive mu694.e3
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FIGURE 2
Illustrations and photographs of the surgical method. A, A 23 cm long segment of the distal ileum pedicled on the ileocolic artery and nerves is excised. B, Intestinal continuity is restored with an ileoileostomy. C, The excised ileal segment is curved to create a J-pouch. D, For J-pouch formation, a linear cutter device is used. E, The neovagina is constructed from an ileal J-pouch anastomosed to the vaginal stump. F, Pouch formation is shown at the intraoperative site. G, The J-pouch is pulled toward the vaginal stump and anastomosed. Schneider. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009.
cus discharge. By creating a J-pouch from a 23-cm length of distal ileum, we were able to significantly increase the lumen size, making continuous self-dilation unnecessary. Experience (alternative: a dummy for 14 days following sexual intercourse) indicates that postoperative stenosis at the vaginal-ileal anastomosis responds well to initial dilatation without need for ongoing treatment.1 No shrinkage of the neovagina or bleeding has occurred with this method, a benefit when compared with other techniques.6,15,16,29 Unlike nonintestinal reconstruction methods, patients with bowel-based vaginal reconstructions do
American Journal of Obstetrics & Gynecology JUNE 2009
not require lubrication, a finding also noted in our patient.12,25 Furthermore, the previously noted equilibrium of liquid resorption and mucus secretion that occurs in terminal parts of the ileum avoids— or at least diminishes— the likelihood of excessive mucus discharge, as well as the fecal odor often noted in reconstructions employing the sigmoid colon or rectum.16,17,30-32 Diversion colitis, ulcerative colitis, hereditary polyposis, and adenocarcinoma have been noted in vaginal reconstructions using the colon—these observations further support use of the small intestine.19,20,33-35
Surgeon’s Corner
www.AJOG.org The sexual function of vaginal reconstructions, including the patient’s satisfaction with sexual activity, is as important in neovagina formation as are the appearance of anatomic features and the occurrence of postoperative complications.18 Once the patient’s wounds had healed, she was able to resume sexual activity. She noticed a new, very pleasant, periumbilical sensation during sexual intercourse that was probably attributable to the intact nerve supply by branches of the supramesenteric plexus accompanying the ileocolic artery; this phenomenon was also reported by Pratt.26 Peristaltic movements within the neovagina were reported by the patient’s husband and verified by endoscopy. Although our method proved successful for this patient, we recognize that anatomical variations of vessel length and course could hamper this technique in other patients. Further procedures are planned to validate our surgical f method. ACKNOWLEDGMENTS Peter Malfertheiner, MD, Department of Gastroenterology, Otto-von-Guericke University, Magdeburg, Germany, performed the vaginal endoscopy.
REFERENCES 1. Magrina JF, Masterson BJ. Vaginal reconstruction in gynecological oncology: a review of techniques. Obstet Gynecol Surv 1981;36:1-10. 2. Kirschner M, Wagner GA. Ein neues verfahren der künstlichen scheidenbildung. Zentralbl Gynakol 1930;54:2690. 3. McIndoe AH, Banister JB. An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Commonw 1938;45: 490-4. 4. Cali RW, Pratt JH. Congenital absence of the vagina: long-term results of vaginal reconstruction 175 cases. Am J Obstet Gynecol 1968; 100:752-63. 5. Hendren SK, Swallow CJ, Smith A, et al. Complications and sexual function after vaginectomy for anorectal tumors. Dis Colon Rectum 2007;50:810-6.
6. Soper JT, Havrilesky LJ, Secord AA, Berchuck A, Clarke-Pearson DL. Rectus abdominis myocutaneous flaps for neovaginal reconstruction after radical pelvic surgery. Int J Gynecol Cancer 2005;15:542-8. 7. Wang X, Qiao Q, Burd A, et al. A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Plast Reconstr Surg 2007;119:1785-90. 8. Lee PK, Choi MS, Ahn ST, Oh DY, Rhie JW, Han KT. Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap. Plast Reconstr Surg 2006;118:401-6. 9. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center experience (1987 to 2003). Gynecol Oncol 2006;101:261-8. 10. Sneguireff FW. Un cas d’établissement d’un vagin artificiel au moyen d’une nouvelle méthod opératoire. Arch de Tocnologie et de Gynaecologie 1892;19:568-77. 11. Baldwin JF. The formation of an artificial vagina by intestinal transplantation. Ann Surg 1904;40:398-403. 12. El-Aziz S. Vaginal reconstruction using the ileocecal segment after resection of pelvic malignancy. J Egypt Natl Cancer Inst 2006; 18:1-7. 13. Bürger RA, Riedmiller H, Knapstein PG, Friedberg V, Hohenfellner R. Ileocecal vaginal construction. Am J Obstet Gynecol 1989;161: 162-7. 14. Hendry WF, Christmas TJ, Shepherd JH. Anterior pelvic reconstruction with ileum after cancer treatment. J R Soc Med 1991;84: 709-13. 15. Liguori G, Trombetta C, Bucci S, et al. Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals. Urology 2005;66:293-8. 16. Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol 1998; 159:1035-8. 17. Karateke A, Gurbuz A, Haliloglu B, Kabaca C, Koksal N. Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study. Surgical method of sigmoid colon vaginoplasty in vaginal agenesis. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:40-5. 18. Hensle TW, Shabsigh A, Shabsigh R, Reiley EA, Meyer-Bahlburg HF. Sexual function following bowel vaginoplasty. J Urol 2006;175: 2283-6. 19. Hiroi H, Yasugi T, Matsumoto K, et al. Mucinous adenocarcinoma arising in a neovagina using the sigmoid colon thirty years after operation: a case report. J Surg Oncol 2001;77:61-4.
20. Ursic-Vrscaj M, Lindtner J, Lamovec J, Novak J. Adenocarcinoma in a sigmoid neovagina 22 years after Wertheim-Meigs operation: case report. Eur J Gynaecol Oncol 1994;15:24-8. 21. Utsunomiya J, Iwama T, Imajo M, et al. Total colectomy, mucosal proctectomy, and ileoanal anastomosis. Dis Colon Rectum 1980;23: 459-66. 22. McGuire BB, Brannigan AE, O’Connell PR. Ileal pouch-anal anastomosis. Br J Surg 2007; 94:812-23. 23. Bruch HP, Schwandner O, Farke S, Nolde J. Pouch reconstruction in the pelvis. Langenbecks Arch Surg 2003;388:60-75. 24. Frank R, Geist S. Formation of an artificial vagina by a new plastic technique. Am J Obstet Gynecol 1927;14:712-8. 25. McIndoe A. The treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg 1950;2:254-67. 26. Pratt JH. Vaginal atresia corrected by use of small and large bowel. Clin Obstet Gynecol 1972;15:639-49. 27. Hanna MK. Vaginal construction. Urology 1987;29:272-5. 28. Trombetta C, Liguori G, Siracusano S, Bortul M, Belgrano E. Transverse retubularized ileal vaginoplasty: a new application of the Monti principle—preliminary report. Eur Urol 2005;48: 1018-23. 29. Peña A, Levitt Ma, Hong A, Midulla P. Surgical management of cloacal malformations: a review of 339 patients. J Pediatr Surg 2004; 39:470-9. 30. Hautmann RE, de Petriconi R, Gottfried HW, Kleinschmidt K, Mattes R, Paiss T. The ileal neobladder: complications and functional results in 363 patients after 11 years of follow-up. J Urol 1999;161:422-7. 31. Jurado M, Bazán A, Elejabeitia J, Paloma V, Martínez-Monge R, Alcázar JL. Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity. Gynecol Oncol 2000;77:293-7. 32. Verbaeys C, Hoebeke P, Oosterlinck W. Complicated postirradiation vesicovaginal fistula in young women: keep off or try reconstruction? Eur Urol 2007;51:243-6. 33. Abbasakoor F, Mahon C, Boulos PB. Diversion colitis in sigmoid neovagina. Colorectal Dis 2004;6:290-1. 34. Toolenaar TA, Freundt I, Huikeshoven FJ, Drogendijk AC, Jeekel H, Chadha-Ajwani S. The occurrence of diversion colitis in patients with a sigmoid neovagina. Hum Pathol 1993; 24:846-9. 35. Malka D, Anquetil C, Ruszniewski P. Ulcerative colitis in a sigmoid neovagina. N Engl J Med 2000;343:369.
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Ileal J-pouch vaginoplasty Reconstruction of a physiologic vagina with an ileal J-pouch Wolfgang Schneider, MD, PhD; Phuong Nguyen-Thanh, MD, PhD; Henning Dralle, MD, PhD; Ursula Mirastschijski, MD, Dr.phil
Problem: multiple complications Congenital or acquired vaginal absence has been the object of reconstructive treatment for more than a century. Nonsurgical methods such as dilatation have been abandoned as ineffective, and surgical reconstruction has been accomplished with skin grafts, fasciocutaneous and muscle flaps, and omentum or bowel transfers.1 Split-thickness skin transplants were widely used at first, but complications such as extremely high shrinkage rates and vaginal obliteration in up to 41% of the patients led to other surgical approaches.2-4 Among the many local flaps that have been used are unilateral or bilateral gracilis flaps, rectus abdominis flaps, pedicled deep inferior epigastric flaps, and fasciocutaneous advancement flaps.1,5-8 Complications of these procedures include inadequate vaginal capacity; vaginal stenosis requiring dilatation; wound-healing problems, including infections; fistula formation; scarring; and pain with inability to perform sexual intercourse.5,6,9 The first neovaginas made from bowel were constructed with rectum by From the Department of Plastic, Aesthetic, and Hand Surgery, University Hospital, Otto-von-Guericke University Magdeburg, Germany (Dr Schneider); the Department of General, Visceral, and Vascular Surgery, University Hospital, Martin Luther University Halle-Wittenberg, Halle, Germany (Drs Nguyen-Thanh and Dralle); and the Department of Plastic, Hand and Reconstructive Surgery, University Hospital, Hannover Medical School, Hannover, Germany (Dr Mirastschijski). 0002-9378/$36.00 © 2009 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.03.009
Click Supplementary Content under VIDEO the article title in the online Table of Contents
694.e1
Vaginal reconstruction has been performed for more than a century. Main complications are vaginal stenosis requiring dilatation, dyspareunia, excessive mucus secretion, and poor aesthetic and functional outcome. Here we report a new operation method modified after Baldwin for intestinal vaginoplasty in a patient with pelvic exenteration after spinal cell carcinoma of the vagina. Because of balanced liquid resorption and mucus secretion with sufficient vessel length in the terminal ileum, this intestinal segment was chosen. A J-pouch of distal ileum was constructed pedicled on the ileocolic artery and accompanying nervous plexus, transferred into the lower pelvis and sutured to the vaginal stump. One year follow-up showed a highly satisfied, sexually active patient, with adequate vaginal size, optimal lubrication and no molesting fecal odor. Terminal ileum J-pouch vaginoplasty is an optimal method for vaginal reconstruction providing a sufficient vaginal lumen and lubrication and thereby restoring patients’ sexual life and increasing life quality. Key words: ileal J-pouch vaginal reconstruction, vaginoplasty Cite this article as: Schneider W, Nguyen-Thanh P, Dralle H, et al. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009;200:694.e1-694.e4.
Sneguireff10 in 1892 and with ileum by Baldwin11 in 1904. In Baldwin’s 2-step procedure, distal ileum was transferred into the pelvis with the ileal limbs sutured together; the septum was removed 2 weeks later. A high mortality rate led to the abandonment of Baldwin’s technique. More recently, ileocecal segments, distal ileum, sigmoid colon, and cecum were each used for vaginal reconstruction.12-18 While the sigmoid colon and cecum offer low shrinkage tendency, good lubrication, and sufficient lumen size, major complications of colon use have included excessive mucus secretion with maceration, vaginal stenosis, and fecal odor. The occurrence of adenocarcinoma in neovagina constructed from bowel was also reported.19,20
Our solution We report a new surgical method for creation of a physiologic neovagina. The distal ileum was used to create a J-pouch that was pedicled on the ileocolic artery and accompanying nerve plexus. The Jpouch, which serves as the vaginal reservoir, was transferred into the lower pelvis and sutured to the vaginal stump.
American Journal of Obstetrics & Gynecology JUNE 2009
Among the advantages of the distal ileum is its intrapelvic location. Furthermore, the segment is nourished by the relatively long ileocolic artery and innervated by the nerve plexus accompanying the vessel—an artery must be long enough to allow the construct to be transposed to the pelvic floor without causing tension on the blood vessels that supply the region and without jeopardizing tissue survival (Figure 1). In addition, equilibrium between liquid resorption and mucus secretion in the distal ileum provides optimal lubrication of the neovagina. Our patient was a 51-year-old woman who underwent pelvic exenteration for squamous cell carcinoma of the vagina in 1995. After this surgery, a vaginal stump measuring only 2-cm from the vaginal introitus remained. Sexual intercourse was impossible, and the patient desired reconstruction. Otherwise, she was healthy and had no history of cancer recurrence. After written consent, the operation was performed. First, the patient’s intestines were purged with a preoperative colonic prep-
Surgeon’s Corner
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FIGURE 1
Distal parts of the ileum and the cecum are nourished by the ileocolic artery, and vegetative innervation is provided by the nerve plexus of the superior mesenteric branch. Schneider. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009.
aration. Once this was accomplished, she was placed in a supine lithotomic position, which allowed simultaneous abdominal and perineal access. A median laparotomy was performed, and the terminal ileal segment needed for pouch formation was identified. After dissection of adhesions in the narrowing of the pelvic outlet, the ileocolic artery and accompanying veins were localized by cold light diaphanoscopy. Then the distal ileum was isolated. A 23-cm length of ileal segment was resected about 10 cm above the ileocecal valve, and the proximal and distal ends were closed with staples (Figure 2). The vessel arcade, including the intact vegetative nerve plexus in the mesentery of the dissected ileal segment, was isolated in a V-shaped fashion up to the central origin, the superior mesenteric artery. In the second phase of the operation, the vaginal stump was identified and prepared via intraabdominal and extra-
abdominal access. Circular incisions were made in the vaginal stump and mucosa in order to remove fibrotic adhesions and scars. Next, the J-pouch was formed. At the bottom of the loop, an incision was made for the linear cutter. This device was then inserted into the ileal loop, and an anastomosis of the antimesenteric wall of the ileum was produced in order to double the original volume of the ileal lumen. In doing so, the distal part of the pouch was kept 2 cm shorter than the proximal part. The incision was closed with staples. After that, the construct was carefully moved down to the pelvic floor without any tension on the associated blood vessels. A tension-free anastomosis was formed between the J-pouch and the vaginal stump by attaching the opened bottom of the J-pouch loop to the open end of the vaginal stump with singleknotted, 4-0 Vicryl sutures (Ethicon Endo-Surgery Inc, Cincinnati, OH).
Subsequently, the pouch was secured to the connective tissue of the bladder and to adjacent muscle fascia of the pelvic floor with Vicryl sutures. Intestinal continuity was restored with an ileoileostomy; this was achieved with inverted single-knot 3-0 PDS sutures. The mesentery was closed with a 4-0 Vicryl continuous suture. Finally, the intestines were repositioned intraabdominally, and the abdominal wall was closed in a standard way. Throughout surgery, excellent blood supply was demonstrated in the dissected ileum segment and in the anastomosed parts of the ileum. No major complications occurred during the postoperative course. An initial, mild, anastomotic stenosis occurred after the patient neglected a facet of postsurgical care, but the stenosis responded well to short-term dilation. At 1-year follow-up, the patient was sexually active and highly satisfied with the surgical results. She reported adequate lubrication without stenosis recurrence, excessive mucus discharge, or fecal odor. Interestingly, she reported an orgasm-like sensation in the supraumbilical area during sexual intercourse. This new sensation might be caused by nerve plexus stimulation following pouch dilation. Vaginal endoscopy verified intact peristaltic motion and a total vaginal length of 18 cm (video). Calculation of the total length included the 12-cm ileal J-pouch, the 2-cm vaginal stump, and the 4-cm vaginal introitus. Simultaneously, tissue samples were taken for histology. No malignancy or abnormal tissue structures were found. Ileoanal J-pouch anastomosis was first described by Utsunomiya et al21 in 1980. They reported excision of the rectum, formation of a loop-type ileal reservoir from distal parts of the ileum, transfer of the J-pouch to the pelvic floor, and its anastomosis to anal tissue. The technique is relatively uncomplicated, ensures sufficient blood supply to both parts of the loop, and yields a suitable reservoir size with reduced risk for stenosis.21,22 It has been widely used, mainly in patients with ulcerative colitis. In this group, ileoanal J-pouch anastomosis is considered a standard procedure because it is performed easily by
JUNE 2009 American Journal of Obstetrics & Gynecology
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Surgeon’s Corner surgeons and provides efficient evacuation for patients.22,23 The location and versatility of the distal ileum also allows its use in urinary bladder reconstruction in the anterior pelvis.14 In an effort to avoid complications such as shrinkage requiring continuous self-dilatation, dyspareunia, and tissue fragility, various surgical techniques have evolved for vaginal reconstruction.3,5,24,25 Vaginoplasties relying on portions of the bowel, an old concept, have become increasingly common in recent years.10,11,16,26 We chose to modify the J-pouch procedure for vaginal reconstruction by forming an anastomosis between the looped end of the pouch and the vaginal stump. Use of the terminal ileum offered a good blood supply from the ileocolic artery, a sufficient lumen size, and adequate lubrication. Hanna27 used proximal parts of the ileum in 1987 to construct a vagina in children with a female phenotype and a 46 XY genotype. A drawback is the very short length of the ileal arteries that nourish the proximal two-thirds of the ileum—these derive directly from the superior mesenteric artery. A distinct advantage of our method is that extensive mobilization of the colon is unnecessary, thus reducing the risk of bleeding or bowel rotation and strangulation. For example, the use of ileocecal segments requires the mobilization of the right colonic flexure, and this poses a risk of tension on the blood vessels that supply it.13 However, the ileocolic artery branch that feeds the terminal ileum is long enough to permit tension-free transfer of the ileum to the pelvic floor. Our work contrasts with other reports stating that the small bowel mesentery is too short for vaginal reconstruction.16,17 However, Bürger et al13 advised the use of the terminal ileum if the cecal mesentery could not be extended sufficiently. In addition, no problems with the arterial length were identified when the Monti principle was applied to ileal vaginoplasties performed with laparoscopic procedures.15,28 The previous use of other ileum parts for vaginal reconstruction was limited by inadequate lumen size and excessive mu694.e3
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FIGURE 2
Illustrations and photographs of the surgical method. A, A 23 cm long segment of the distal ileum pedicled on the ileocolic artery and nerves is excised. B, Intestinal continuity is restored with an ileoileostomy. C, The excised ileal segment is curved to create a J-pouch. D, For J-pouch formation, a linear cutter device is used. E, The neovagina is constructed from an ileal J-pouch anastomosed to the vaginal stump. F, Pouch formation is shown at the intraoperative site. G, The J-pouch is pulled toward the vaginal stump and anastomosed. Schneider. Ileal J-pouch vaginoplasty. Am J Obstet Gynecol 2009.
cus discharge. By creating a J-pouch from a 23-cm length of distal ileum, we were able to significantly increase the lumen size, making continuous self-dilation unnecessary. Experience (alternative: a dummy for 14 days following sexual intercourse) indicates that postoperative stenosis at the vaginal-ileal anastomosis responds well to initial dilatation without need for ongoing treatment.1 No shrinkage of the neovagina or bleeding has occurred with this method, a benefit when compared with other techniques.6,15,16,29 Unlike nonintestinal reconstruction methods, patients with bowel-based vaginal reconstructions do
American Journal of Obstetrics & Gynecology JUNE 2009
not require lubrication, a finding also noted in our patient.12,25 Furthermore, the previously noted equilibrium of liquid resorption and mucus secretion that occurs in terminal parts of the ileum avoids— or at least diminishes— the likelihood of excessive mucus discharge, as well as the fecal odor often noted in reconstructions employing the sigmoid colon or rectum.16,17,30-32 Diversion colitis, ulcerative colitis, hereditary polyposis, and adenocarcinoma have been noted in vaginal reconstructions using the colon—these observations further support use of the small intestine.19,20,33-35
Surgeon’s Corner
www.AJOG.org The sexual function of vaginal reconstructions, including the patient’s satisfaction with sexual activity, is as important in neovagina formation as are the appearance of anatomic features and the occurrence of postoperative complications.18 Once the patient’s wounds had healed, she was able to resume sexual activity. She noticed a new, very pleasant, periumbilical sensation during sexual intercourse that was probably attributable to the intact nerve supply by branches of the supramesenteric plexus accompanying the ileocolic artery; this phenomenon was also reported by Pratt.26 Peristaltic movements within the neovagina were reported by the patient’s husband and verified by endoscopy. Although our method proved successful for this patient, we recognize that anatomical variations of vessel length and course could hamper this technique in other patients. Further procedures are planned to validate our surgical f method. ACKNOWLEDGMENTS Peter Malfertheiner, MD, Department of Gastroenterology, Otto-von-Guericke University, Magdeburg, Germany, performed the vaginal endoscopy.
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