The segment of the ileum, once isolated, is opened along its anti-mesenteric border
(a) The intestinal segment is folded and reconfigured into a “U” shape and (b) anastomosed with the anti-mesenteric sides toward each other
The neovagina is constructed from an ileal U-pouch anastomosed to the vaginal stump
Another surgical option is the application of the Monti principle to ileal vaginoplasty: the isolated segment is detubularized and transversally retubularized in order to configure the roof of the neovagina. The proximal end of the conduit is closed with two layers of absorbable suture material (Fig. 19.4).
Detubularization-and-retubularization technique. (a) A 12-cm ileal segment is isolated, (b) detubularized through longitudinal incision halfway on the anterior side. (c) The flap is then rotated and (d) transversally retubularized with total running suture. (e) The vault of the neovagina is then configured and prepared for the anastomosis with the perineum or the distal
The ileal segment is then brought to the perineum with as little tension as possible in order to allow a tension-free anastomosis. Ileo-cutaneous anastomoses with interrupted absorbable sutures (Monocryl 3-0) are finally performed through the perineal approach.
An inflatable silicon vaginal tutor is introduced in the vaginal cavity and is maintained all day long for 7 days. The catheter is removed after 5 days.
126.96.36.199 Postoperative Management
It is important to avoid washing the neovagina with substances that can damage or irritate the ileum: utilization of sterile saline solution is recommended in the first postoperative month. After removal of the inflatable silicon vaginal tutor, patients are instructed to insert a lubrified dilator in the neovagina to prevent stenosis of the introitus and in order to achieve a correct modeling of the cavity. In our opinion, prolonged stenting of the neovagina is mandatory when neovagina creation is performed after failure of a previous surgical method.
Many techniques have been described for secondary vaginal reconstruction , but disadvantages are in all of them. The nonoperative techniques for vaginal dilation rely on repeated pressure against the vaginal dimple to create the vagina . Results of this technique have not been universally satisfactory : this procedure has the disadvantages of requiring long-term dilations, which may be not well accepted by all patients. Vecchietti developed a laparotomic surgical variant which has been widely used for many years . It consists of implantation of a device designed to increase the depth of the vaginal cupola. The technique does not require vesicorectal dissection and has a good success rate. However, a daily application of a vaginal probe is required for a long time, and the resulting depth of the neovagina is limited. A laparoscopic modification of this technique has been done successfully but still requires the use of dilators .
The most popular technique for vaginal replacement has been the split-thickness free graft or McIndoe procedure. Advantages of the technique are the ease of surgery, but it requires continuous and frequent home dilation and the wearing of a vaginal stent during the night. In addition, there is a high rate of incidence of inadequate vaginal length, vaginal stenosis, and dyspareunia .
Several series now have shown the utilities of intestinal vaginoplasty for reconstruction [23, 24]. Reconstruction with bowel can be done at any age, and the risk of flap necrosis or lack of graft take is minimal. Moreover, the reconstructed vagina has a natural axis for sexual intercourse. Other advantages of using bowel segments include the limited need for dilations in the postoperative period, the relatively stronger resistance of the mucosa to trauma, and the ability of the intestinal mucus to act as lubrifier.
In the last years, many authors have reported their successful experience in the use of the sigmoid colon for vaginal replacement in children and adults [12, 23]. The sigmoid colon has been popular because of its proximity and its easily mobilized vascular pedicle . Use of the ileum and cecum has been described too, but reports are more rare . As a matter of fact, when ileum is used, its smaller diameter and its mesentery’s origin make construction more challenging, and extra care must be taken to ensure the distal segment will reach the perineum tension free .
Formation of an ileo-neovagina by longitudinal detubularization and transverse retubularization has many advantages: small intestinal segments are necessary; the mesentery remains in the central portion of the tube leaving the two branches free; in this manner the conduit is highly mobile, with the opportunity to reach the perineum and provide a tension-free anastomosis: as a matter of fact, the ileum has a low vascular loops and short mesenterium; standard ileal vaginoplasty requires isolation of long segments (20–30 cm at least) to reach the perineum safely, without tension. Furthermore, the diameter of the conduit can be selected according to individual needs and allows sufficient drainage of mucus; the tube is cylindrical, regular, and of an adjustable length so as to achieve a correct modeling of the cavity .
Moreover, dehiscence, necrosis, and late complications such as stenosis and perforation of the tube have not been reported so far in the Monti channel .
Alternatively, a 12- to 15-cm segment of the ileum, once isolated, can be opened along its anti-mesenteric border, reconfigured into a “U” shape, and tabularized to create the vagina. This is commonly performed over a 20-F Hegar dilator to approximate an adequate caliber. Care is taken to create a tension-free anastomosis that is recessed at the introitus, similar to sigmoid repair .
More recently, a J-pouch of the 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 .
As far as we are concerned, there are several reasons to prefer the ileum instead of sigmoid colon for vaginal reconstruction. First of all, the ileum is technically the least demanding of the conduits to create, and this is why it has become the segment of choice in conduit diversion in urological practice . Secondly, the ileum has a lower mucus production as compared to the large bowel, and last but not least, the urologist has a general familiarity with the small bowel used for reconstructive surgery. In a recent review on intestinal vaginoplasty, Bouman analyzed surgical procedures performed by gynecologists, urologists, and plastic surgeons. Although no rationale was provided for choosing either the ileum or sigmoid as the graft donor site, he observed that ileal graft was mostly used by urologists, perhaps because of their experience with the use of ileal grafts in bladder reconstruction. Gynecologists and plastic surgeons tended to use sigmoid grafts .
Furthermore, the ileal segment has the advantages of satisfactory neovaginal function similar to a normal vagina with self-lubrication, which decreases the incidence of dyspareunia; less secondary deformity in the perineum ; and a natural axis for sexual intercourse .
Moreover, there are several potential chronic complications of the use of sigmoid segments that must be underlined. Sigmoid segment isolation may induce diversion colitis: this pathology may be more common than suspected and may take as long as 7 years to develop [32–34]. The mucous discharge commonly seen after colon vaginoplasty is possibly secondary to asymptomatic diversion colitis in most patients.
We have described a case in which mucus production within the neovaginal continued and the introital stenosis led to stasis of the mucus, which ultimately perforated the neovagina and caused acute peritonitis .
Moreover, patients may develop gastrointestinal disease such as ulcerative colitis or hereditary polyposis . Primary adenocarcinoma in sigmoid neovagina has been reported too [37, 38].
In accordance with Syed et al. , in patients who need an enterovaginoplasty, the use of small bowel should be assessed as an alternative to the sigmoid colon. If the colon is used, the risk of diversion colitis should be explained and long-term surveillance should be recommended because of the theoretical increased risk of malignant change.
Today, the use of bowel segments for vaginoplasty is becoming more frequent, as in some centers (e.g., Free University, Amsterdam), younger patients are being treated with hormonal treatment, which is arresting the puberty; consequently, less amount of penile skin is available for lining the neovagina and bowel vaginoplasty is primarily indicated .