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Vaginoplasty: Combination Therapy Using Labia Minora Flaps and Lucite Dilators—Preliminary Report
0022-534 7/93/1502-0654$03.00/0 THE JOURNAL OF UROLOGY Copyright © 1993 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 150, 654-656, August 1993
Printed in U. S. A.
VAGINOPLASTY: COMBINATION THERAPY USING LABIA MINORA FLAPS AND LUCITE DILATORS-PRELIMINARY REPORT CHARLES E. FLACK, MARK A. BARRAZA AND PETER S. STEVENS From the University of Florida, Gainesville and the Division of Urology, Department of Surgery, Nemour's Children's Clinic, Jacksonville, Florida
ABSTRACT
The treatment of vaginal agenesis is varied. The combination of creating a vaginal cavity with local skin flaps, then progressively dilating to a functional size has been successful in the past. We describe a technique using tubularized labia minora vascularized flaps to create a deep vaginal pouch that is widened and elongated with lucite dilators. The new vagina has an epithelial lining of nonhair-bearing skin. Three teenage girls, 2 with the Mayer-Rokitansky syndrome and 1 with mixed gonadal dysgenesis, underwent this procedure without any postoperative complications. Since neither abdominal surgery nor skin grafting was required there were no extra scars, excessive neovaginal secretions or need for long-term splinting during the I-year followup period. The patients have almost normal-appearing genitalia postoperatively and neovaginas averaging 2 cm. wide and 6.3 cm. deep before dilation. We recommend this procedure as first line treatment for teenage girls with vaginal agenesis. KEY WORD S :
gonadal dysgenesis, mixed; vagina; surgery
An acceptable treatment for vaginal agenesis has been sought for many years, at least as early as the writings of Celsus in the first century AD and probably earlier. 1 Even today, however, there is still no consensus as to the best therapy. Treatments have varied considerably from the nonoperative approach of Frank, using intermittent pressure and dilation, 2 to the extreme of vaginal transplantation from mother to daughter.3 Other methods include free skin grafts, amnion grafts, peritoneal grafts, bladder mucosa! grafts, 4 local skin or musculocutaneous flaps and bowel interpositions.5 • Except for bowel interpositions, surgery usually requires postoperative dilation until a satisfactory vaginal size is reached or until intercourse is regularly engaged to prevent contraction. Although bowel does not require dilations or splinting, it does create an abdominal scar and the possibility of bowel obstruc tion. The Mcindoe technique of free skin graft over a mold leaves unsightly donor scars and has a tendency to contract. Local vascularized flaps or vulvovaginoplasty avoids these scars, severe contraction problems and problems associated with abdominal surgery. However, the Williams vulvovagino plasty technique and its modifications have the disadvantage of creating a vaginal pouch with an abnormal axis requiring dilation to correct. The nonoperative Frank technique is ar duous if the vaginal dimple is shallow but it is acceptable with vaginal dimples of 3 to 4 cm. 7 We describe a technique to create a neovaginal pouch lined with labia minora vascularized flaps. The resulting vagina is lined with smooth, nonhair-bearing, elastic skin and it is easily dilated with lucite dilators to provide a cosmetically excellent vagina. 6
MATERlALS AND METHODS
Three patients 16, 18 and 19 years old underwent vagino plasty during summer 1991. All patients were followed for 1 year and seen at least once postoperatively and once at 1 year. The first 2 girls presented with amenorrhea and the Mayer Rokitansky syndrome.8 • Both had normal secondary sex char acteristics, normal chromosomes, absent uterus and vagina, and vaginal dimples less than 1 cm. The third patient had mixed gonadal dysgenesis and XY karyotype. She had under gone gonadectomy and phallectomy during infancy, as well as unsuccessful local flap procedures to create a vagina. She was managed on estrogen and progesterone but still had vaginal introital stenosis and only a small proximal cavity. All patients underwent a similar procedure (fig. 1). With the 9
654
patient in the lithotomy position, an inc1s10n is begun just under the urethral meatus and extended transversely to the labia minora on both sides. The incision extends upward along the medial edges of the labia minora, then across them and downward along the junction of the labia majora and minora. The upper third of the labia minora is left intact. These flaps are then dissected and the labia are unfolded. With a finger in the rectum and a catheter in the bladder to facilitate dissection, a cavity is created posterior to the meatus extending to the level of the peritoneum. The medial edges of the labial flaps are sewn together, and the lateral edges and apex are approxi mated, creating a conical pocket that is then rotated into the cavity at an axis compatible with intercourse. The apex of the labial flap is secured in place with absorbable sutures to the apex of the cavity. The skin edges are brought together primarily. The final vaginal appearance is near normal with predominantly shiny pink skin now lining the neovagina. A finger cot packed with gauze impregnated with antibiotic cream is left in place for 5 days with the labia majora sewn over it to prevent dislodgement. A urinary catheter is also left indwelling for 5 days, and patients are maintained on a low residue diet. Dilations can begin as early as 3 weeks postoperatively. The lucite Ingraham* dilators are available in 3 sets to be used sequentially: set 1 is 1.5 cm. wide with 10 dilators 1.5 to 10 cm. long, set 2 is 2.5 cm. in diameter with 5 dilators 3 to 10 cm. long and set 3 is 3.5 cm. in diameter with 5 dilators 3 to 10 cm. long (fig. 2). 10 Patients are instructed to use the dilators 2 times a day for 1 hour each time. The dilator selected should be large enough to give a sense of pressure or discomfort and should be kept in place with tight pants, a rolled towel or bicycle seat. 1 0
RESULTS
There were no postoperative complications, and all patients were discharged from the hospital by 7 days postoperatively. The table outlines the dimensions of the neovagina in the immediate postoperative period and again after dilations. The first patient was the most compliant with the dilators. She performed dilations 1 hour in the morning and 1 hour in the evening, at least 2 times a week, wearing tight underwear and pants to keep the dilator in place. She now has almost normal appearing genitalia and is starting on the third set of dilators. * Faulkner Plastics, Tampa, Florida.
655
VAGINOPLASTY
D.
E.
FIG. 1. A, labial minora flaps outlined in patient. B, medial edges of flaps sewn together. C, lateral edges of flaps sewn together. D, flaps rotated and secured into dissected cavity. E, skin closed primarily.
FIG. 2. Lucite dilators. First set has 10 dilators 1.5 cm. wide and 1.5 to 10 cm. long, second set has 5 dilators 2.5 cm. wide and 3 to 10 cm. long, and third set has 5 dilators 3.5 cm. wide and 3 to 10 cm. long. Vaginal dimensions preoperatively, postoperatively and at 1 - year followup Pt. No.
Immediate Postop. (cm.)
Preop. (cm.)
Width 1 2
3''
Less than 1 dimple Less than 1 dimple 2.5 dimple
* Patient 3 has not used dilators.
1.5 2.5 2
Length 7
5
7
After Dilations (cm.) Width 2.5 2.5
2
Length 10 9 7
The second patient who is obese had problems keeping the first set of dilators in place. Once she progressed to the larger set of dilators she had no further problems. The last patient has not used the dilators yet since shortly postoperatively she was imprisoned. However, vaginal dimensions at 1-year followup are the same as those immediately postoperatively. DISCUSSION
The combination of creating a vaginal cavity with local skin flaps and then progressively dilating it to a functional size has been successful in the past. 7 • 11·13 Using labia minora for the skin flaps is also not new, 1 2 • 14 and its rich neurovascular net work has been well described. 1 5 The tube thus created by these
flaps can be successfully rotated inward and provide an epithe lial lined cavity for subsequent dilations. The new vagina has an epithelial lining that is nonhair-bearing, poorly keratinized and predominantly smooth, shiny and pink, with subcutaneous tissue rich in elastic fibers and numerous sebaceous glands. The labia minora are also erectile, responsive to stimulation and influenced by estrogen, providing an ideal flap for lining the neovaginal canal anatomically and physiologically. The labia minora have the advantage of also being in an axis appropriate for intercourse, unlike the Williams technique or its modifications. 7 • 1 2 • 13 The operation is simple and easy to perform, and the risks appear mostly related to creating the vaginal cavity. The pa tients did not comply with the recommended dilation schedule but they still achieved widening and elongation of the neovagina with at least biweekly dilations. Cosmetically the vulva appears almost indistinguishable from normal. We do not know the functional result since none of our patients is sexually active yet. We have not experienced a prolapse as reported with bowel6 or with the Frank technique. 10• 16 Because skin grafts are not used we have avoided unnecessary scars and severe contraction problems. However, periodic splinting may be necessary with this technique once maximal size is reached if sexual inter course is not regularly practiced. By not using abdominal contents we have avoided additional scars and associated mor bidity, such as small bowel obstruction and excessive mucous secretions. Although we have limited our technique to patients with adequate labial skin, such as those with the Mayer Rokitansky syndrome and mixed gonadal dysgenesis with am ple labial scrotal skin, with the use of tissue expanders even patients with a paucity of skin may be able to benefit from this procedure. 1 7 This technique may also be applied to the poten tially fertile patient by connecting the neovagina before or after dilations to the vaginal remnant or directly to the uterus. 1 8• 19 However, before recommending expanding this technique to a large group of patients further followup is required to determine the long-term need for splinting or dilations as well as the ultimate functional success. REFERENCES
1. Goldwyn, R. M.: History of attempts to form a vagina. Plast. Reconstr. Surg., 59: 319, 1977.
656
VAGINOPLASTY
2. Frank, R. T.: The formation of an artificial vaginal without oper ation. Amer. J. Obst. Gynec., 35: 1053, 1938. 3. Papanicolaou, N.: Successful vaginal transplant, mother to daugh ter. Obst. Gynec. News, 8: 1, 1973. 4. Martinez-Mora, J., Isnard, R., Castellvi, A. and Lopez Ortiz, P.: Neovagina in vaginal agenesis: surgical methods and long-term results. J. Ped. Surg., 27: 10, 1992. 5. Tolhurst, D. E. and van der Helm, T. W.: The treatment of vaginal atresia. Surg., Gynec. & Obst., 1 72: 407, 1991. 6. Hensle, T. W. and Dean, G. E.: Vaginal replacement in children. J. Urol., 1 48: 677, 1992. 7. Capraro, V. J. and Gallego, M. B.: Vaginal agenesis. Amer. J. Obst. Gynec., 1 24: 98, 1976. 8. Stephens, F. D.: The Mayer-Rokitansky syndrome. J. Urol., 1 35: 106, 1986. 9. Tarry, W. F., Duckett, J. W. and Stephens, F. D.: The Mayer Rokitansky syndrome: pathogenesis, classification and manage ment. J. Urol., 136: 648, 1986. 10. Ingram, J. M.: The bicycle seat stool in the treatment of vaginal agenesis and stenosis: a preliminary report. Amer. J. Obst. Gy nec., 1 40: 867, 1981.
11. Fliegner, J. R.: A simple surgical cure for congenital absence of the vagina. Aust. New Zeal. J. Surg., 56: 505, 1986. 12. Williams, E. A.: Congenital absence of the vagina: a simple opera tion for its relief. J. Obst. Gynec., 7 1 : 511, 1964. 13. O'Brien, B. M., Mellow, C. G., Maclsaac, I. A., Maher, P. J. and Barbaro, C.: Treatment of vaginal agenesis with a new vulvova ginoplasty. Plast. Reconstr. Surg., 85: 942, 1990. 14. Brady, L.: Methods of constructing a vagina. Ann. Surg., 121: 518, 1945. 15. Hwang, W.-Y., Chang, T.-S., Sum, P. and Chung, T. H.: Vaginal reconstruction using labia minora flaps in congenital total ab sence. Ann. Plast. Surg., 1 5: 534, 1985. 16. Peters, W. A., III and Uhlir, J. K.: Prolapse of a neovagina created by self-dilatation. Obst. Gynec., 76: 904, 1990. 17. Lilford, R. J., Sharpe, D. T. and Thomas, D. F.: Use of tissue expansion techniques to create skin flaps for vaginoplasty. Case report. Brit. J. Obst. Gynaec., 95: 402, 1988. 18. Passerini-Glazel, G.: A new 1-stage procedure for clitorovagino plasty in severely masculinized female pseudohermaphrodites. J. Urol., part 2, 1 42: 565, 1989. 19. Broadbent, T. R., Woolf, R. M. and Hebertson, R.: Nonoperative construction of the vagina: two unusual cases. Plast. Reconstr. Surg., 73: 117, 1984.
Vol. 150, 654-656, August 1993
Printed in U. S. A.
VAGINOPLASTY: COMBINATION THERAPY USING LABIA MINORA FLAPS AND LUCITE DILATORS-PRELIMINARY REPORT CHARLES E. FLACK, MARK A. BARRAZA AND PETER S. STEVENS From the University of Florida, Gainesville and the Division of Urology, Department of Surgery, Nemour's Children's Clinic, Jacksonville, Florida
ABSTRACT
The treatment of vaginal agenesis is varied. The combination of creating a vaginal cavity with local skin flaps, then progressively dilating to a functional size has been successful in the past. We describe a technique using tubularized labia minora vascularized flaps to create a deep vaginal pouch that is widened and elongated with lucite dilators. The new vagina has an epithelial lining of nonhair-bearing skin. Three teenage girls, 2 with the Mayer-Rokitansky syndrome and 1 with mixed gonadal dysgenesis, underwent this procedure without any postoperative complications. Since neither abdominal surgery nor skin grafting was required there were no extra scars, excessive neovaginal secretions or need for long-term splinting during the I-year followup period. The patients have almost normal-appearing genitalia postoperatively and neovaginas averaging 2 cm. wide and 6.3 cm. deep before dilation. We recommend this procedure as first line treatment for teenage girls with vaginal agenesis. KEY WORD S :
gonadal dysgenesis, mixed; vagina; surgery
An acceptable treatment for vaginal agenesis has been sought for many years, at least as early as the writings of Celsus in the first century AD and probably earlier. 1 Even today, however, there is still no consensus as to the best therapy. Treatments have varied considerably from the nonoperative approach of Frank, using intermittent pressure and dilation, 2 to the extreme of vaginal transplantation from mother to daughter.3 Other methods include free skin grafts, amnion grafts, peritoneal grafts, bladder mucosa! grafts, 4 local skin or musculocutaneous flaps and bowel interpositions.5 • Except for bowel interpositions, surgery usually requires postoperative dilation until a satisfactory vaginal size is reached or until intercourse is regularly engaged to prevent contraction. Although bowel does not require dilations or splinting, it does create an abdominal scar and the possibility of bowel obstruc tion. The Mcindoe technique of free skin graft over a mold leaves unsightly donor scars and has a tendency to contract. Local vascularized flaps or vulvovaginoplasty avoids these scars, severe contraction problems and problems associated with abdominal surgery. However, the Williams vulvovagino plasty technique and its modifications have the disadvantage of creating a vaginal pouch with an abnormal axis requiring dilation to correct. The nonoperative Frank technique is ar duous if the vaginal dimple is shallow but it is acceptable with vaginal dimples of 3 to 4 cm. 7 We describe a technique to create a neovaginal pouch lined with labia minora vascularized flaps. The resulting vagina is lined with smooth, nonhair-bearing, elastic skin and it is easily dilated with lucite dilators to provide a cosmetically excellent vagina. 6
MATERlALS AND METHODS
Three patients 16, 18 and 19 years old underwent vagino plasty during summer 1991. All patients were followed for 1 year and seen at least once postoperatively and once at 1 year. The first 2 girls presented with amenorrhea and the Mayer Rokitansky syndrome.8 • Both had normal secondary sex char acteristics, normal chromosomes, absent uterus and vagina, and vaginal dimples less than 1 cm. The third patient had mixed gonadal dysgenesis and XY karyotype. She had under gone gonadectomy and phallectomy during infancy, as well as unsuccessful local flap procedures to create a vagina. She was managed on estrogen and progesterone but still had vaginal introital stenosis and only a small proximal cavity. All patients underwent a similar procedure (fig. 1). With the 9
654
patient in the lithotomy position, an inc1s10n is begun just under the urethral meatus and extended transversely to the labia minora on both sides. The incision extends upward along the medial edges of the labia minora, then across them and downward along the junction of the labia majora and minora. The upper third of the labia minora is left intact. These flaps are then dissected and the labia are unfolded. With a finger in the rectum and a catheter in the bladder to facilitate dissection, a cavity is created posterior to the meatus extending to the level of the peritoneum. The medial edges of the labial flaps are sewn together, and the lateral edges and apex are approxi mated, creating a conical pocket that is then rotated into the cavity at an axis compatible with intercourse. The apex of the labial flap is secured in place with absorbable sutures to the apex of the cavity. The skin edges are brought together primarily. The final vaginal appearance is near normal with predominantly shiny pink skin now lining the neovagina. A finger cot packed with gauze impregnated with antibiotic cream is left in place for 5 days with the labia majora sewn over it to prevent dislodgement. A urinary catheter is also left indwelling for 5 days, and patients are maintained on a low residue diet. Dilations can begin as early as 3 weeks postoperatively. The lucite Ingraham* dilators are available in 3 sets to be used sequentially: set 1 is 1.5 cm. wide with 10 dilators 1.5 to 10 cm. long, set 2 is 2.5 cm. in diameter with 5 dilators 3 to 10 cm. long and set 3 is 3.5 cm. in diameter with 5 dilators 3 to 10 cm. long (fig. 2). 10 Patients are instructed to use the dilators 2 times a day for 1 hour each time. The dilator selected should be large enough to give a sense of pressure or discomfort and should be kept in place with tight pants, a rolled towel or bicycle seat. 1 0
RESULTS
There were no postoperative complications, and all patients were discharged from the hospital by 7 days postoperatively. The table outlines the dimensions of the neovagina in the immediate postoperative period and again after dilations. The first patient was the most compliant with the dilators. She performed dilations 1 hour in the morning and 1 hour in the evening, at least 2 times a week, wearing tight underwear and pants to keep the dilator in place. She now has almost normal appearing genitalia and is starting on the third set of dilators. * Faulkner Plastics, Tampa, Florida.
655
VAGINOPLASTY
D.
E.
FIG. 1. A, labial minora flaps outlined in patient. B, medial edges of flaps sewn together. C, lateral edges of flaps sewn together. D, flaps rotated and secured into dissected cavity. E, skin closed primarily.
FIG. 2. Lucite dilators. First set has 10 dilators 1.5 cm. wide and 1.5 to 10 cm. long, second set has 5 dilators 2.5 cm. wide and 3 to 10 cm. long, and third set has 5 dilators 3.5 cm. wide and 3 to 10 cm. long. Vaginal dimensions preoperatively, postoperatively and at 1 - year followup Pt. No.
Immediate Postop. (cm.)
Preop. (cm.)
Width 1 2
3''
Less than 1 dimple Less than 1 dimple 2.5 dimple
* Patient 3 has not used dilators.
1.5 2.5 2
Length 7
5
7
After Dilations (cm.) Width 2.5 2.5
2
Length 10 9 7
The second patient who is obese had problems keeping the first set of dilators in place. Once she progressed to the larger set of dilators she had no further problems. The last patient has not used the dilators yet since shortly postoperatively she was imprisoned. However, vaginal dimensions at 1-year followup are the same as those immediately postoperatively. DISCUSSION
The combination of creating a vaginal cavity with local skin flaps and then progressively dilating it to a functional size has been successful in the past. 7 • 11·13 Using labia minora for the skin flaps is also not new, 1 2 • 14 and its rich neurovascular net work has been well described. 1 5 The tube thus created by these
flaps can be successfully rotated inward and provide an epithe lial lined cavity for subsequent dilations. The new vagina has an epithelial lining that is nonhair-bearing, poorly keratinized and predominantly smooth, shiny and pink, with subcutaneous tissue rich in elastic fibers and numerous sebaceous glands. The labia minora are also erectile, responsive to stimulation and influenced by estrogen, providing an ideal flap for lining the neovaginal canal anatomically and physiologically. The labia minora have the advantage of also being in an axis appropriate for intercourse, unlike the Williams technique or its modifications. 7 • 1 2 • 13 The operation is simple and easy to perform, and the risks appear mostly related to creating the vaginal cavity. The pa tients did not comply with the recommended dilation schedule but they still achieved widening and elongation of the neovagina with at least biweekly dilations. Cosmetically the vulva appears almost indistinguishable from normal. We do not know the functional result since none of our patients is sexually active yet. We have not experienced a prolapse as reported with bowel6 or with the Frank technique. 10• 16 Because skin grafts are not used we have avoided unnecessary scars and severe contraction problems. However, periodic splinting may be necessary with this technique once maximal size is reached if sexual inter course is not regularly practiced. By not using abdominal contents we have avoided additional scars and associated mor bidity, such as small bowel obstruction and excessive mucous secretions. Although we have limited our technique to patients with adequate labial skin, such as those with the Mayer Rokitansky syndrome and mixed gonadal dysgenesis with am ple labial scrotal skin, with the use of tissue expanders even patients with a paucity of skin may be able to benefit from this procedure. 1 7 This technique may also be applied to the poten tially fertile patient by connecting the neovagina before or after dilations to the vaginal remnant or directly to the uterus. 1 8• 19 However, before recommending expanding this technique to a large group of patients further followup is required to determine the long-term need for splinting or dilations as well as the ultimate functional success. REFERENCES
1. Goldwyn, R. M.: History of attempts to form a vagina. Plast. Reconstr. Surg., 59: 319, 1977.
656
VAGINOPLASTY
2. Frank, R. T.: The formation of an artificial vaginal without oper ation. Amer. J. Obst. Gynec., 35: 1053, 1938. 3. Papanicolaou, N.: Successful vaginal transplant, mother to daugh ter. Obst. Gynec. News, 8: 1, 1973. 4. Martinez-Mora, J., Isnard, R., Castellvi, A. and Lopez Ortiz, P.: Neovagina in vaginal agenesis: surgical methods and long-term results. J. Ped. Surg., 27: 10, 1992. 5. Tolhurst, D. E. and van der Helm, T. W.: The treatment of vaginal atresia. Surg., Gynec. & Obst., 1 72: 407, 1991. 6. Hensle, T. W. and Dean, G. E.: Vaginal replacement in children. J. Urol., 1 48: 677, 1992. 7. Capraro, V. J. and Gallego, M. B.: Vaginal agenesis. Amer. J. Obst. Gynec., 1 24: 98, 1976. 8. Stephens, F. D.: The Mayer-Rokitansky syndrome. J. Urol., 1 35: 106, 1986. 9. Tarry, W. F., Duckett, J. W. and Stephens, F. D.: The Mayer Rokitansky syndrome: pathogenesis, classification and manage ment. J. Urol., 136: 648, 1986. 10. Ingram, J. M.: The bicycle seat stool in the treatment of vaginal agenesis and stenosis: a preliminary report. Amer. J. Obst. Gy nec., 1 40: 867, 1981.
11. Fliegner, J. R.: A simple surgical cure for congenital absence of the vagina. Aust. New Zeal. J. Surg., 56: 505, 1986. 12. Williams, E. A.: Congenital absence of the vagina: a simple opera tion for its relief. J. Obst. Gynec., 7 1 : 511, 1964. 13. O'Brien, B. M., Mellow, C. G., Maclsaac, I. A., Maher, P. J. and Barbaro, C.: Treatment of vaginal agenesis with a new vulvova ginoplasty. Plast. Reconstr. Surg., 85: 942, 1990. 14. Brady, L.: Methods of constructing a vagina. Ann. Surg., 121: 518, 1945. 15. Hwang, W.-Y., Chang, T.-S., Sum, P. and Chung, T. H.: Vaginal reconstruction using labia minora flaps in congenital total ab sence. Ann. Plast. Surg., 1 5: 534, 1985. 16. Peters, W. A., III and Uhlir, J. K.: Prolapse of a neovagina created by self-dilatation. Obst. Gynec., 76: 904, 1990. 17. Lilford, R. J., Sharpe, D. T. and Thomas, D. F.: Use of tissue expansion techniques to create skin flaps for vaginoplasty. Case report. Brit. J. Obst. Gynaec., 95: 402, 1988. 18. Passerini-Glazel, G.: A new 1-stage procedure for clitorovagino plasty in severely masculinized female pseudohermaphrodites. J. Urol., part 2, 1 42: 565, 1989. 19. Broadbent, T. R., Woolf, R. M. and Hebertson, R.: Nonoperative construction of the vagina: two unusual cases. Plast. Reconstr. Surg., 73: 117, 1984.