Case Report
Sigmoid vaginoplasty for treatment of vaginal agensis Uma Gupta, Narendra Kumar Gupta, Ayesha Arif Mayo Medical Centre, Lucknow. (UP) 226010 India ABSTRACT The Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is a rare cause of primary amenorrhea due to uterovaginal agenesis. Vaginoplasty using sigmoid graft for neovagina is an option, which offers adequate length and natural lubrication.
Neovagina of 8 cm could be obtained with no shrinkage during follow-up. (Rawal Med J 2013;38:449-450). Key-words: Neovagina, Rokitansky's syndrome, sigmoid graft.
INTRODUCTION Mayer Rokitansky Kuster Hauser Syndrome is the congenital absence or atresia of the uterus and vagina in a phenotypic and genotypic female and most common cause of primary amenorrhea. The incidence of MRKH Syndrome varies between 1 to 1000 to 1 in 5000.1-3
Diagnostic laparoscopy revealed a transverse band at the site of uterus, distal half of both tubes were present and both ovaries were normal showing signs of ovulation. Diagnosis of MRKH Syndrome type 1 was made. She was counseled on her future fertility options and advised vaginoplasty keeping in mind her complain of dyspareunia.
CASE PRESENTATION Mrs. RP 19 year old married woman one month back presented with primary amenorrhea and dyspareunia. On examination, she was phenotypically female with secondary sex characters. On local examination, at the site of vagina a depression of 1.5 cms was present (Fig 1); a vertical band was palpable in the centre of depression. On rectal examination, uterus was not felt and the fornices were normal. All routine examination including intravenous pyelography was within normal limits. Buccal smear was XX chromosomal pattern.
Fig 2. Hegar dilator in situ, position of sigmoid segment in neovagina.
Fig 1. External view of dimple on vagina.
Thorough bowel preparation was done. Patient was put in a semilithotomy position, which allowed simultaneous abdominoperineal approach. The space between the bladder and the rectum through perineum was dissected freely as high as possible. The vertical band in the centre was cut. Rectovesical fascia was dissected and space developed large enough to avoid compromise of intestinal blood supply. Gradually increasing size of Hegar's dilators were introduced into the rectovesical space to pierce the pouch of Douglas (Fig 2). Abdomen was opened and an appropriate length of sigmoid with blood supply that would comfortably reach the site of
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Sigmoid vaginoplasty for treatment of vaginal agensis
neovagina was identified. Segment of sigmoid along with mesentery was transposed down in to the pelvis to line the new vagina (Fig 3). Fig 3. Line Diagram showing lining the neovagina with sigmoid graft. A – Introitus, B- Proximal of graft, C- Distal end of graft, mucosa sutured to introitus, E- colocolic anastomosis, F- rectum, G- Bladder
DISCUSSION Baldwin first described use of bowel for creation of vagina in 1904. A segment of either ileum, cecum or sigmoid have been used together with its mesentry, to form neovagina.4-6 Improvement in technique7 and postoperative care has resulted in renewed enthusiasm for these techniques. In our patient, acceptance of graft was excellent, as reported by others.4-6 Author contributions: Conception and design: Uma Gupta Collection and assembly of data: Uma Gupta Drafting of the article: Ayesha Arif Critical revision of the article for important intellectual content: Narendra K. Gupta Final approval and guarantor of the article: Uma Gupta Corresponding author email:
[email protected] Conflict of Interest: None declared Rec. Date: Mar 28, 2013 Accept Date: Aug 16, 2013
REFERENCES 1. 2.
The distal mucosa was sutured to the introitus and proximal end of neovagina closed and fixed to posterior peritoneum to prevent prolapse. A 10 ml plastic syringe with its tip cut and wound with sofratullae was inserted and kept in neovagina. Perineal hygiene was maintained; total immobilization, intravenous fluids and antibiotics were given for seven days. Dressing changed on third day. From 7th day onwards sterile sponge in condom was inserted in neovagina daily with local Neosporin ointment. The vagina was admitting two fingers easily. Patient was taught to make and insert vaginal mould and discharged. On follow up after three weeks, the graft acceptance could be visualized and mucus secretion seen.
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3. 4. 5. 6. 7.
Bhatia P, Manchanda R, Chaudhry S. Mayer-Rokintasky Syndrome: A study of four cases. Asian J Obs Gynae Pract 2000;4:49-51. Patankar SP, Kalarao SP, Patankar SS. MayerRokitansky syndrome and anorectal malformation. Indian J Pediatr 2004;71:1133-5. Folch M, Pigem I, Konje JC. Mullerian agenesis: etiology, diagnosis, and management. Obstet Gynecol Surv 2000;55:644-9. Ghosh TS, Kwawukume EY. Construction of an artificial vagina with sigmoid colon in vaginal agenesis. Int J Gynaecol Obstet 1994;45:41-5. Benchekroun A, el Alj HA, Essayegh H, Zannoud M, Nouin Y, Marzouk M, et al. Vaginoplasty with sigmoid graft: report of 3 cases. Ann Urol (Paris) 2003;37:296-8. Rajimwale A, Furness PD 3rd, Brant WO, Koyle MA. Vaginal construction using sigmoid colon in children and young adults. BJU Int 2004;94:1143-4. Johnson N, Lilford RJ. The surgical treatment of gynecological congenital malformation. In Progress in Obstetrics and Gynecology Vol 8, Edi. Studd J. Churchill Livingstone, New York, 1990: 351-369.
Rawal Medical Journal: Vol. 38. No. 4, October-December 2013
