Results
The patients' mean age was 22.5 years (range 16–32 years). Most (27) of the patients had Müllerian agenesis; one patient needed a reconstruction because of previous oncologic surgery.
One patient had testicular feminization syndrome and had previously received a skin flap but developed postoperative stenosis. Only two patients had a normal uterus; their neovaginas were connected to the cervix, and they now experience a normal menstrual cycle with vaginal bleeding.
Three patients required reoperation because of venous compromise in the flap that occurred on postoperative days 2, 3, and 9. All flaps were salvaged. There was one mucosal prolapse, which was treated surgically. One patient developed hematomas in the abdominal and inguinal incision, which resolved with drainage. There were no surgical, urinary, or gastrointestinal infections or complications.
Follow-up ranged from 3 to 50 months. The patients were allowed to engage in sexual intercourse 1 month after surgery. Although two reported mild bleeding during intercourse early on, this did not continue. One patient developed an introital stricture that was treated with temporary dilation.
While mucosal secretion is one of the big benefits of an intestinal reconstruction—eliminating the need for artificial lubrication during sex—hypersecretion can be a problem as well, Dr. Akar said. Dr. Silverman agreed. “It's thicker than normal vaginal mucus, and sometimes, this can get to be so much of a problem that the women need to wear a pad,” he said.
Three of Dr. Akar's patients complained of this problem, but the severity lessened with time, she said. The incidence seems to be lower than what is observed after a pedicle bowel transfer, possibly because of the ischemia induced during the transfer period. In fact, Dr. Akar said, she and her colleagues are preparing to report on some adjustments they have made to cope with discharge, observing that the ischemia period seems to decrease the amount of mucus the graft secretes after transfer.
Most of the patients (29) are now able to have satisfactory sexual intercourse. Two patients are single and haven't engaged in intercourse yet. Although the investigators did not report any specific sexual outcomes data, Dr. Akar said “there were no complaints in that regard” conveyed by patients.
Follow-up will continue, and one question that remains is the possibility of conception in those patients with a normal uterus. “If there is endometrium and now a connection to the cervix, there is a chance to get pregnant, although we don't know how that will go in the future,” Dr. Akar said. Of course, any term pregnancies would have to be delivered by cesarean section, she said, since the grafted intestine would not expand enough to permit a vaginal birth.
The large abdominal incision for the reconstruction procedure is a drawback, she admitted, but the improvements may be made in the future. The team has performed one similar procedure with laparoscopic assist—a pedicled jejunal flap transfer on a woman who had most of her reproductive organs removed due to cancer when she was 3 years old.
The team used three cannula ports. The jejunal segment and vascular pedicle were divided laparoscopically. Insertion into the neovaginal pouch was completed through a Pfannenstiel incision (Microsurgery 2008;28:671-5).
Because of the length of transfer needed to reconstruct an entire vagina, the pedicle technique is a better alternative for women who have some vaginal length and need a distal extension, Dr. Akar said.
Otherwise, the transfer might put too much pressure on the vascular pedicle and endanger the graft.
Disclosures: None was reported.
Although the procedure and recovery period are long, the end result is worthwhile.
Source DR. AKAR
This image provides an immediate postoperative view of the neovaginal introitus and the jejunum flap. Results were promising for vaginal reconstruction in 31 patients.
Source Courtesy Dr. Münire E. Akar