Chapter 99 VAGINOPLASTY—CONSTRUCTION OF NEOVAGINA

Reconstruction of the female perineum is indicated for congenital absence of the vagina, lymphedema, vaginal defects, previous ablative surgery for various perineal malignancies, relief of pain after radiation therapy, and repair of labial hypertrophy. Vaginal reconstruction has become a standard procedure performed by plastic surgeons, gynecologists, and urologists. The most common indication for vaginal reconstruction is congenital absence of the vagina.

In general, the results of vaginal reconstruction are satisfactory. However, problems may include inadequate genital wound coverage because of foreshortened graft or flap harvest, fecal contamination if preoperative bowel preparation has not been adequate, adjacent urethral injuries during dissection of the new vaginal pocket, and difficult immobilization of the patient in the postoperative period.

Counseller ¹ reported that congenital absence of the vagina occurs in approximately 1 of every 4000 births and that these abnormalities usually coexist with uterus and urinary tract abnormalities. Usually, the ovaries are not affected, and the secondary sex characteristics develop normally. Embryologically, because the cervix and vagina initially form a solid unit, the lack of cavitation and cell death needed to form a vagina is the reason for vaginal agenesis.¹ However, the hormonal factors that stimulate cavitation are unknown.

Patients with labial hypertrophy undergo labioplasty for functional, aesthetic, and social reasons. Hypertrophy of the labia minor or labia majora may be congenital or acquired. Patients with this condition may experience inflammation, poor hygiene, and self-consciousness during sexual activity and when wearing tight pants. Reduction of the labia minora or labia majora is a relatively minor outpatient procedure that yields satisfactory results for many patients.

VAGINAL RECONSTRUCTION

History

In 1573, a student of Vesalius, Realdus Colombus, first reported vaginal agenesis, and it was not until 1872 that Heppner described vaginal reconstruction using the labia.² However, the landmark report for vaginal reconstruction is credited to Abbe in 1898.³ In one patient, Abbe described dissecting a canal and lining it with split-thickness skin grafts.

These skin grafts were placed over a rubber stent packed with gauze. After 10 days, the stent was removed, and the skin grafts were completely vascularized. The patient was asked to wear a vaginal conformer postoperatively, and evidently, intercourse was possible. However, Abbe’s report was lost for almost 40 years, until McIndoe ⁴ popularized the Abbe technique by lining the new vaginal canal with partial-thickness skin grafts. McIndoe reported an impressive array of 63 repairs,⁵ and in 1948, Counseller reported 70.¹ Other methods of vaginal reconstruction have been attempted, but most have had undesirable effects, especially when segments of the gastrointestinal tract have been used for lining the new vaginal canal. In 1953, Conway and Stark⁶ described use of the rectum; earlier, Sneguireff,⁷ Popow,⁸ and Schubert⁹ had described the same thing. In 1904, Baldwin¹⁰ even described using a loop of ileum. However, obvious difficulties with bowel transposition such as necrosis, infection, and abscess formation occurred. If the procedure was successful, the secretions arising from the bowel lining were mostly inappropriate and unwanted. The added morbidity of an intra-abdominal procedure, various bowel anastomoses, the possibility of vascular compromise, and undesired mucosal secretions account for the lack of popularity of these procedures.

The Frank procedure, a nonoperative technique, has been successful in some instances of incomplete vaginal atresia. In 1927, Frank and Geist ¹¹ demonstrated the use of intermittent pressure at the perineal dimple between the anus and the urethra in the normal location of the vagina. This pressure is applied until the patient feels mild discomfort by a series of graduated obturators in the form of increasing sizes of test tubes. The pressure is relieved and then reapplied. The skin is inwardly stretched in the same way that a skin expander works with an outward force. This process continues for weeks until the largest dilator can be introduced within the neovagina and worn comfortably. This procedure requires a very compliant and persistent patient and an anatomy that is consistent with incomplete vaginal agenesis. The skin lining the new vagina is cutaneous squamous epithelium, and it must be lubricated externally to allow intercourse.

Surgical Techniques

Abbe-McIndoe Procedure

Over the years, the Abbe-McIndoe procedure evolved to become the easiest and most successful method of vaginal reconstruction, avoiding the risks and disadvantages of laparotomy (Figs. 99-1 and 99-2). The procedure must be performed under general or spinal anesthesia. A Y-shaped incision is made along the median raphe between the urethra and the anus. A catheter is placed in the urethra, and dissection is carried cephaloposteriorly. This dissection can be done relatively bluntly, and safety is ensured by keeping a gloved finger in the rectum for tactile ease of dissection. The Y incision allows three cutaneous flaps to be enfolded into the vaginal canal so that circumferential scar contraction can be avoided. The depth of dissection should be somewhat exaggerated and is in the range of 10 to 14 cm in the adult. The surgeon must overcorrect somewhat because of the expected subsequent contraction (Fig. 99-3).

Figure 99-1 Congenital vaginal aplasia with an enlarged urethral meatus below the clitoris.

(From Lesavoy MA, Carter EJ: Vaginal reconstruction. In Raz S [ed]: Female Urology, 2nd ed. Philadelphia, WB Saunders, 1996, pp 605-616.)

Figure 99-2 Sutures holding the labia majora.

(From Lesavoy MA, Carter EJ: Vaginal reconstruction. In Raz S [ed]: Female Urology, 2nd ed. Philadelphia, WB Saunders, 1996, pp 605-616.)

Figure 99-3 Catheter in the urethra and dissection of the neovaginal canal.

(From Lesavoy MA, Carter EJ: Vaginal reconstruction. In Raz S [ed]: Female Urology, 2nd ed. Philadelphia, WB Saunders, 1996, pp 605-616.)

After the vaginal canal has been bluntly dissected, a partial-thickness skin graft is harvested from the buttock-hip area. The surgeon must keep in mind the subsequent scar that will ensue from this partial-thickness skin graft and therefore should avoid harvesting the graft from an area low on the thigh. The skin graft can be taken with any type of dermatome, and two or three sheets of skin may be needed to achieve a total dimension of approximately 14 × 7 cm.

Several techniques have been developed to apply the skin graft to the vaginal canal. Historically, candle wax, carved balsa wood, gauze packing, syringe casing, dental wax, and hard plastic conformers have been used. The Heyer-Schulte Company has produced a soft, pliable, and expandable vaginal conformer that works very well. This stent has a central semirigid foam core and a surrounding silicone envelope that can be expanded with air or saline (Fig. 99-4). There is a central drain site through the core of the stent. After the graft has been harvested, the vaginal stent should be inflated with air and lubricated with mineral oil.

Figure 99-4 Heyer-Schulte inflatable vaginal stent.

(From Lesavoy MA, Carter EJ: Vaginal reconstruction. In Raz S [ed]: Female Urology, 2nd ed. Philadelphia, WB Saunders, 1996, pp 605-616.)

The skin graft sheets are sutured to each other and placed over the stent with the raw dermal sides out (Fig. 99-5). The epidermal side of the skin is adjacent to the stent. Subsequently, hemostasis is checked in the neovaginal canal, and the stent and overlying skin grafts are eased into the canal (Fig. 99-6). It may be necessary to deflate the vaginal stent while slowly rotating and pushing the stent and skin graft into the vaginal canal, but after the stent is seated to the depth of the dissection, it should again be inflated to spread out the skin graft, ensure direct apposition to the raw walls, and provide an excellent bolster for the ensuing neovascularization of the skin graft.