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Vaginal Agenesia Treatment by a Readjustable Prothesis

Introduction

The neovagina formation by a continuous traction, was described by Vecchietti in 1965. In 1992 was modified by Gauwerky, who introduced the laparoscopy approach. We were using using the Remeex readjustable prosthesis for female urinary stress incontinence treatment, and in July 3, 2000 we adept the Remeex readjustable prosthesis to treat some vaginal agenesia types.
The purpose of this paper is to describe our technique and expose the first results. We are conscient that the short number of cases do not permit big conclusions, but if we take in consideration that the original Vecchietti technique, already demonstrated its efficacy, our technique is a variation of Vecchietti’s technique that simplifies the procedure, and do not need wide statistic justification. This paper pretends to be a preliminary communication.

Technique description

In a previous paper, we consider that the Vechietti’s technique was different to the McIndoe for its bigger physiologic substrate. The tissue that coated the neovagina was from the some embryologic origin. The difficulty in designing a similar traction mechanism to the one employed in the original technique, was a stopping step to its use.
The introduction of the readjustable Remeex prosthesis for the urinary stress incontinence with excellent results, drive us to use the Remeex System in the vaginal agenesia, modifiying the Vecchietti technique, not only simplifying it but also in the access way.
The Vecchietti’s technique is made by a laparoscopy (Pfannenestiel). The traction threads are passed from the interior of the abdomino-pelvic cavity to the exterior, to the pseudohimeneal membrane. In our technique, the traction threads are passed laparoscopically from the pseudohimeneal membrane, to the uterine bladder fold..
The Remeex prosthesis is made of titanium and high weight polyethylene . It consist of an abdominal support rectangular plate that can adapt to the abdominal surface of every patient by cutting its extremes. The plate stands over a latex cushion to minimize the pressure over the skin. By a manipulator, there is connected to the varitensor, we can apply traction to the traction threads that pull a vaginal button. This laparoscopy is performed as usually, but with the advise that the accessory accesses have to be as high as possible, at the anterior iliac spines. By doing so, the traction threads pull the vaginal membrane as horizontal as possible in relation to the varitensor. Any angulation’s close to 90º will press the urethra and will compromise the success of the technique because traction will have to be stopped.

The technique in conclusion will include the following steps:

1. Permanent bladder catheterisation.
2. Rectal (palpation) and analysis of the perineal space that substitutes the vagina.
3. Pressure with one or two fingers through the vulva pushing the pseudo hymeneal membrane like in a vaginal tact through the laparoscope we have to recognise the moment of the parietal peritoneum bulging by the manual pressure that we are applying from the vulva introit. Then with a needle we perforate the pseudo hymeneal membrane and the peritoneum entering into the abdominal cavity.
4. The previous manoeuvre is controlled laparoscopically to avoid bladder perforation with the needle.
5. The traction threads are passed through the needle and by a laparoscopic forceps are pulled into the abdominal cavity.
6. Through the laparoscopic accessory ports, we pass two needles moderately curved sub peritoneal.
7. Take the traction threads there are in the pelvic cavity and pull it to the exterior abdominal wall always extraperitoneally.
8. Withdraw the laparoscopic accessory ports.
9. Pass the traction threads through the rectangular abdominal base support and connect the traction threads to the varitensor. Initiate the traction. 
10. During the postoperatory, the urethra catheter will be maintained. Everyday the manipulator will be turned 10 complete turning that represents approx. 1 cm of traction applied to the vaginal button. Hospital discharge will be at day 4, if urine voiding is normal.
11. The prosthesis will be withdrawn after 10 days, checking the neovaginal canal that may be enough to initiate the use of vaginal moulds of 3-4 cm diameter to hold the neovagina space until patient initiate active sexual intercourse.

Results:

Of 5 cases performed with the Remeex readjustable prosthesis, 3 were successful, and in two patients the prostheses had to be withdrawn by compression over the urethra. It’s possible that the success in our fist patients, do not facilitate the analysis of the surgical manoeuvres and do not valorise properly the necessary anatomical conditions to apply the continuous traction technique.
The necessary condition is that the pseudo-hymeneal membrane have to be malleable when compressed by fingers, and that by pressure application a +/- 15 mm space has to be created between the introit and the membrane.
The vaginal button connected to the traction threads is placed below the mid-urethra, between the meatus and the bladder. The traction has to be as tangential as possible to avoid urethral compression.

Discussion:

Our previous experience in vaginal agenesia treatment using the McIndoe technique was successful. Over 25 cases, with age range of 27-36, we hadn’t important complications, except one rectal perforation that was sutured during the same intervention with no further postoperatory complication sexual relations were successful in 24 of the 25 patients.
If we look only at the results, it’s obvious that the McIndoe technique is of high safety and satisfaction for the patient; but technically it is complex. It requires the cooperation of two surgical teams: the plastic surgeon to repair the dermo-epidermic
graft and the gynaecologist to create the cavity where the graft will be located.
The hospitalisation is long, +/- 10 days, the systems area where we take the grafts, it shows a visible scar tissue and the neovagina hasn’t an original tissue characteristics. Even that the tissue do not affect the patient satisfaction, we can see it by a simply vaginoscopy, but in one case we a tricomone infection, as in a normal vaginal mucous.
The technique that we describe can’t be applied to all cases of vaginal agenesia. If the pseudo hymeneal membrane is rigid and can’t be depressed, the technique will not work.
The anatomical necessary condition to apply continuous traction without urethral compression risk, apart from the proper traction thread positioning, it’s the presence of a minimal tissue concavity as a minimal vaginal entrance, and that the vaginal button is almost covered by the labia minora. In our short experience the technique was due to not taking in consideration this anatomical principle.
It’s obvious that the quality of the obtained vaginal duct is anatomically and cosmetically superior to the dermo-epidermic graft. Probably the sexual satisfaction will be superior too. When we have a larger list of patients to make the comparative analysis.
Another advantage over the McIndoe technique is that hospitalisation is reduced by half.

Conclusion:

A new technique is presented for vaginal agenesia treatment by a readjustable prosthesis. It’s a preliminary communication with 5 cases from July 2000.
It’s compared to the McIndoe technique that was the election technique by the authors before the introduction of the described technique.
The principal advantages are the final vaginal tissue quality, same as a normal vagina, the surgical procedure simplification and the reduction of hospitalisation. We describe the necessary anatomical conditions to use the technique.

Words:

Vaginal agenesia, Rokitansky-Küster-Hauser Syndrome, Vaginal agenesia treatment, Remeex.

Bibliography

1. Vecchietti, G. “Creazione de neovagina secondo Vecchietti”. In Trattato di Técnica chirurgica. Vol. XVI/1: 249-253. Editorial Utet. Torino.1986
2. Gawerky JF, Wallwiener D, Bastert G., “An endocopically assisted technique for construction of a neovagina”. Arch Gynecol. Obstet. 1992; 252(2): 59-63
3. Sas A., Martínez de la Tejada B., Dexeus S., et al. “Reconstrucción Vaginal mediante Técnica de McIndoe”. Prog. ObstetGinecol. 2001; 44:17-22


S. Dexeus, D. Dexeus, J. Ruiz

Instituto Universitario Dexeus, Barcelona, Spain

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