Long-term outcome after laparoscopic creation of a neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome by a modified Vecchietti procedure
© Springer-Verlag 2007
Received: 3 May 2007
Accepted: 4 July 2007
Published: 6 September 2007
Several conservative and surgical methods have been proposed for patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. The technique described by Vecchietti is a combination of both dilatation and surgery. We describe a minimally invasive modification of this approach including dissection of the vesico-rectal septum and present long-term patient outcome. Eight patients who underwent surgery at our department between 1996 and 2005 for MRKH syndrome were included in the present analysis. Post-operative follow-up and a semi-structured telephone interview were performed to obtain information on neovaginal functionality, immediate and long-term post-operative outcome, sexual function and physiological and psychological well-being evaluated on a 10-point scale and by the Sintonen 15D questionnaire. After a median post-operative (median operation time: 88 min, range: 63–116 min) follow-up period of 40.3 months (range: 18–84 months) without major complications and a median post-operative stay of 13.8 days (range: 6–15 days), a functional neovagina was created in seven of eight patients. Median vaginal length at the time of discharge from the hospital ranged between 7 and 10 cm (median: 9.6 cm) and reached 11.5 cm (range: 5–15 cm) at the time of evaluation. Except for one patient who neither had regular sexual intercourse nor used the vaginal dilator, sexual intercourse was quoted as satisfactory in six cases (one patient still used the dilator only). Patients reported an improvement of quality of life (mean: 8.1, range: 5–10) and self-confidence (8.1, range: 5–10) and general well-being evaluated by the Sintonen 15D questionnaire (average score of 1.8, SD = 0.06). The laparoscopic-assisted Vecchietti procedure with dissection of the vesico-rectal septum is a safe and effective method for creation of a neovagina in MRKH patients.
Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is a rare congenital abnormality of the female genital tract (incidence 1:5000) based on agenesis of the paramesonephric duct (Müllerian duct) which is associated with a short or aplastic vagina, a rudimentary or absent uterus in the presence of a functioning ovary, normogonadotrophic sex steroid levels, normal secondary sexual characteristics and a normal female karyotype . As a consequence, patients experience primary amenorrhoea and are unable to practice normal sexual intercourse, which often leads to psychological problems based on a decreased self-esteem. In order to create a functioning neovagina in patients with MRKH, several methods have been described to date. Non-surgical approaches include dilatation of the vaginal groove with a hand-held dilator in a squatting position first described by Frank [13, 20] or by passive dilatation using the patient’s own weight according to the method of Ingram . In addition, various surgical methods have been described such as the creation of a split-thickness skin graft which covers a stent inserted into the space between bladder and rectum (McIndoe and Bannister) , the use of the patient’s own peritoneum for vaginal reconstruction (Davydov technique)  or creation of a neovagina with a sigmoid graft . Although there is no standardized method, the majority of surgically treated cases (up to 300) have been described by Vecchietti [18, 19] who proposed a combination of the surgical and conservative approaches by performing a laparotomy, dissection of the vesico-rectal septum followed by fixation of a vaginal “dilatation olive” with two sutures passing from the abdominal wall through the pseudohymenal septum. To date, several authors have described laparoscopic modifications of the Vecchietti method in which the vesico-rectal septum is protruded with a thread-bearing cutting needle laparoscopically down to the vaginal groove, followed by placement of a vaginal dilatation instrument which is attached to the abdominal wall with preperitoneal traction sutures. Although both laparotomic and laparoscopic procedures yield similar outcomes , intra-operative complications such as perforation of the bladder or the rectum with the thread-bearing needle have been described . We report the long-term outcome of a minimally invasive approach based on the original laparotomic variant described by Vecchietti which includes laparoscopic dissection of the vesico-rectal septum.
Materials and methods
Description of patients (n = 8) included in the study
21.9 years (range: 18–24)
Urinary tract anomalies
Localization of the ovaries
Complications and post-operative period
No intra- or post-operative complications were observed in any of the eight patients undergoing the surgical procedure. Post-operative recovery was rapid although post-operative need for analgetics was present in six of eight patients and ranged from 5 days to intermittent use of oral pain-relieving medication for up to 24 weeks (two of eight patients) with a median time of 11 weeks. Patients were discharged home between days 6 and 15 with a median post-operative stay of 13.8 days.
Anatomical and functional outcome
The average operation time was 88 min and ranged between 63 and 116 min. Median time of post-operative follow-up was 40.3 months (range: 18–84 months). An adequate vaginal length, defined as ≥ 7 cm could be achieved in all except one patient who neither started regular sexual activity nor regularly used vaginal dilators and ranged between 7 and 10 cm at the time of discharge from the hospital (median: 9.6 cm) and reached 11.5 cm (range: 5–15 cm) at the time of evaluation. Except for two patients, six of eight patients started sexual intercourse 2–24 months after surgery (median: 6.8 months). In a case of irregular sexual contact, dilator use was performed without complications by one patient. Persistent use of vaginal lubricants before sexual intercourse or dilator use was noted in four cases. Although sexual intercourse was quoted as satisfactory in six of six cases, four of six patients sometimes experienced minor pain during sexual activity. Quantification of satisfactory sexual activity on a 10-point scale revealed a mean value of 7.8 (range: 2–10). Patients reported an improvement of quality of life (mean: 8.1, range: 5–10) and self-confidence (8.1, range: 5–10) after completion of the surgical procedure. In addition, general well-being and sexual health were quantified by the Sintonen 15D questionnaire and revealed an average score of 1.8 (SD = 0.06) compared to the corresponding average value of the normal female population reported by Sintonen et al.  of 0.96 (SD = 0.05). When patients were asked if they would undergo the operation again knowing all advantages and possible disadvantages, all except one patient agreed they would have the procedure performed again. The one patient who would refuse to undergo the operation a second time reported neither sexual intercourse nor the regular use of vaginal dilators as advised, which might have contributed to the unsatisfactory post-operative result.
Based on the variety and modifications of surgical techniques for vaginal reconstruction, there is a constant debate on the efficacy of either technique proposed by certain authors. In general, several lines of evidence indicate that the procedure described by Davydov is suitable for creation of a neovagina in patients with previous unsuccessful vaginal surgery [9, 12]. On the other hand, conservative approaches according to Frank [13, 20] or Ingram  have been shown to be successful in patients with a pre-existent vaginal groove who do not wish to undergo surgery . The use of an isolated segment of the sigmoid colon for vaginal construction has also been reported to yield satisfying post-operative outcomes [3, 4]. However, some reports point at major intra- and post-operative complications such as necrosis of the sigmoid graft, intestinal anastomosis dehiscence, prolapse of the neovagina or persistent vaginal outflow [2, 7, 17]. The present technique based on the method by Vecchietti  in its laparoscopic modification has been shown to be a safe and quick procedure with minor intra- and post-operative complications [6, 10]. In contrast to other authors, we perform dissection of the vesico-rectal space instead of protruding a thread-bearing needle through the septum. The advantage of this technique is preparation and visualization of the anatomical structures, i.e. bladder and rectum, which can be injured during protrusion of the needle. In addition, creation of a preformed space between bladder and rectum might facilitate the post-operative dilatation process. In our series of eight patients, no intra- or post-operative complications occurred. Although four of six patients with regular sexual intercourse sometimes experienced minor pain during sexual activity, the procedure was clearly beneficial in improving quality of life and self-esteem, even in patients who still used vaginal dilators and did not take up sexual activity yet. Only one patient did not appear to profit from the procedure with a post-operative reduction of vaginal length and unsatisfying intercourse. However, the patient neither took up regular sexual activity nor intermittent use of the dilator, which is a precondition for preservation of neovaginal functionality.
Taken together, the laparoscopic variant of the Vecchietti operation is a safe and effective method for creation of a neovagina in patients with MRKH. However, regular post-operative dilation of the reconstructed organ either by sexual intercourse or by use of dilators is necessary for satisfying long-term results of the procedure.
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