Restoration of a Total Vaginal Closure Following McIndoe Vaginoplasty — Suleyman Tas PubMed

CASE REPORT Restoration of a total vaginal closure following McIndoe vaginoplasty Süleyman Taş & Yeşim Bayo ğlu Tekin Received: 9 September 2014 / Accepted: 22 December 2014 / Published online: 18 January 2015 # Springer-V erlag Berlin Heidelberg 2015 Abstract Vaginal aplasia is a rare congenital anomaly, and McIndoe technique is the most preferred for this anomaly. Here, the authors present an unusual case with a total vaginal closure following McIndoe vaginoplasty, its management, and surgical tips and reviewed the related literature. Level of Evidence: Level V , therapeutic study. Keywords Closure . McIndoe . Restoration . Va gi n a Introduction V aginal aplasia is a rare congenital anomaly of the female genital tract, which occurs in 1/4000 female newborns [ 1]. This anomaly may be as complete absence of the vagina or partial which a shallow dimple can be demonstrated at the introitus area. In the pathophysiology of vaginal aplasia, one or more mechanism is involved during embryogenesis such as absence of the origin of the vagina due to non-development of the urogenital sinus, disruption of the vaginal epithelization in a primary stage or non-development of the Mullerian ducts [2]. Most of the vaginal aplasia cases are diagnosed as part of the Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH syndrome) [3]. The authors encountered an unusual case which underwent a McIndoe vaginoplasty 15 years ago and admitted to our clinic with a total vaginal closure; we presented here its management and surgical tips and reviewed the related literature. Case report A 50-year-old female patient with congenital vaginal agenesis of the distal two-thirds was referred to our department for vaginal reconstruction. It was learned from her history and documentation that she underwent a McIndoe vaginoplasty operation 15 years before she was married; after operation, she had sexual life for 1 year, and then she lost her husband; after this worrying event, she did not use any vaginal mold or had no sexual life. In the time of admitting to us, she wondered to marry again and she had a candidate for this. In the physical examination, external genitalia was normal except for the vaginal opening which was absent (Fig. 1). Ultrasound and magnetic resonance imaging (MRI) showed hypoplastic uterus measuring 4.9×2.8-cm size. Endometrial thickness was 3.6 mm. Bilateral ovaries were normal. V aginal agenesis was observed. Extensive scar tissue was identified in operation logy (Fig. 2). Karyotype analysis was 46 XX. Con- genital vaginal agenesis and total vaginal closure was diag- nosed. Under general anesthesia in the lithotomy position with urinary catheterization, a transabdominal approach was per- formed as cesarean, bladder, rectum, uterus, and douglas pouch were identified. Through cervix, a vacuum aspiration tip was inserted and the foot print of it was observed in the external vaginal area which the location was wondered to create a new vaginal pouch such as the anatomical axis of a normal vagina (Fig. 3a). Feeling the aspiration tip with palpa- tion, a horizontal incision was performed and a new vaginal pouch was created following blunt dissection with a care of protecting rectum and bladder by observation through transabdominal incision (Fig. 3b). One large piece of full- thickness graft was gained by performing a mini- S. Taş (*) Department of Plastic, Reconstructive and Aesthetic Surgery, R.T.E. University Training & Research Hospital, Rize 53100, Turkey e-mail: drsuleymantas@live.com Y . Bayoğlu Tekin Department of Obstetrics and Gynecology Surgery, R.T.E. University Training & Research Hospital, Rize 53100, Turkey Eur J Plast Surg (2015) 38:157–160 DOI 10.1007/s00238-014-1058-x

abdominoplasty through the transabdominal incision. After the graft wrapped around an inflatable mold, it was inserted into the pouch and distal edge of the graft was sutured to the all-around of the vaginal incision with vicrly (Fig. 3c). The mold was kept in place by suturing the labia minors and majors each other. After 7 days, the mold was removed and full graft take was observed. The soft mold was replaced by a rigid hollow mold for 3 months regularly expect only short periods of time for vaginal irrigation. After the first 3 months, the patient was allowed to engage in sexual intercourse. For the following 3 months, mold use was incrementally decreased until the patient kept the mold in the new vaginal cavity for only 1 h per day. Six months after the surgery, due to the patient engaged in regular sexual intercourse, mold use was left. During 1 year follow-up, no complications, such as hemor- rhages, infections, hypertrophic scar on the donor site or fistulas, were observed. Patient reported that they were engag- i n gi ns a t i s f a c t o r ys e x u a la c t i v i t yw i t hn op a i n ,a n dw i t hg o o d mucosal sensitivity. At postoperative 1 year, the dimension of new vagina was 12×4 cm and the result was satisfactory for both of us and the patient (Fig. 4). Discussion There are so numerous techniques for correction of the vaginal aplasia such as auto-dilatation by continuous dilatation of the cavity with subsequent spontaneous reepithelialisation, interm ittent pressure (Frank tech- nique), vulvovaginoplasty, pedicle subcutaneous flaps, fasciocutaneous and musculocutaneous flap, pedicle/free intestinal grafts, peritoneal amnion or bladder mucosa grafts, tissue expansion vaginoplasty, and McIndoe tech- nique [ 4–6]. Despite so many techniques, McIndoe technique is the most commonly preferred procedure for correction of the vaginal aplasia because it is simple, applicable, and quick [ 4, 5]. However, there is no concern in this point; some authors consider that McIndoe is a quite complicated procedure with potentially serious complication [6]. Intra- and postoperative complications of McIndoe are well known and documented. Intraoperative complications includ- ed bleeding, perforation of the rectum and bladder. Early postoperative complications are infection, vaginal abscess, hematoma, failure of graft take, and rectovaginal and urovaginal fistula. Late postoperative complications are in- ability to retain the mold, rectocele, vaginal stricture, vaginal contracture, or loss of most of the length of the vagina, Fig. 1 Total V aginal closure was observed Fig. 2 In MRI, hypoplastic uterus, vaginal agenesis, extensive scar tissue in operation logy were identified 158 Eur J Plast Surg (2015) 38:157–160

incontinence, recurrent infections in the urinary system and areas of granulation tissue requiring treatment progressive contracture of the vagina. Contracture may occur in several years [4–7]. The perforation of rectum and bladder during the McIndoe are rare, undesired, serious and life-threatening complications. Especially for the seconder cases, these complications are more possible because of the scarring Fig. 3 a The foot print of the vacuum aspiration tip was observed in the external vaginal area. The black arrow shows the foot print of the aspiration tip. b Following the vaginal pouch was created. c After the graft wrapped around, inflatable mold was inserted Eur J Plast Surg (2015) 38:157–160 159

around of the logy of the operation. Therefore, to identify rectum and bladder in a clear tissue plane and to deter- mine the correct direction of the pouch will be created, we used a transabdominal approach with McIndoe outside of its original description, and we mentioned the surgical details and tips. McIndoe technique is an effective and simple procedure for the treatment of vaginal agenesis, but using mold regularly is very important [5]. In our case, we consider that the reason of the total closure of the vagina is that. To our best knowledge, total vaginal closure have not been reported until now, despite one total vaginal stricture [ 7] and many partial vaginal stric- tures [4–7]w e r er e p o r t e d . Conclusion Following the McIndoe surgery, proper mold usage after surgery remains the cornerstone of the treatment. Using a transabdominal approach for McIndoe would prevent the serious complication for hard and seconder case. Conflict of interest None. Ethical standards For this type of retrospective study formal consent from an ethics committee is not required. Patient consent Patients provided written consent for the use of their images. References 1. Capraro VJ, Gallego MB (1976) V aginal agenesis. Am J Obstet Gynecol 124:98–107 2. Rock JA, Breech LL (2008) Surgery foranomalies of the Mullerian ducts. In: Rock JA, Jones HW (eds) Te Linde’s operative gynecology, 10th edn. Lippincott Williams & Wilkins, Philadelphia (PA), pp 539–84 3. McIndoe A (1950) The treatment of congenital absence and oblitera- tive conditions of the vagina. Br J Plast Surg 2:254 –267 4. Højsgaard A, Villadsen I (1995) McIndoe procedure for congenital vaginal agenesis: complications and results. Br J Plast Surg 48:97–102 5. Bastu E, Akhan SE, Mutlu MF et al (2012) Treatment of vaginal agenesis using a modified McIndoe technique: long-term follow-up of 23 patients and a literature review. Can J Plast Surg 20:241 –244 6. Creatsas G, Deligeoroglou E (2007) Expert opinion: vaginal aplasia: creation of a neovagina following the Creatsas vaginoplasty. Eur J Obstet Gynecol Reprod Biol 131:248–252 7. Wiser WL, Bates GW (1984) Management of agenesis of the vagina. Surg Gynecol Obstet 159:108–112 Fig. 4 At postoperative 1 year, the dimension of new vagina was 12× 4 cm and the result was satisfactory for both of us and the patient 160 Eur J Plast Surg (2015) 38:157–160