Volume 3, Issue 1 (2018)                   SJMR 2018, 3(1): 79-84 | Back to browse issues page


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Saremi A, Bahrami H, Hamideh khoo T. A report of laparoscopic vaginoplasty surgery using Modified Vecchietti Method in vaginal agenesis. SJMR 2018; 3 (1) :79-84
URL: http://saremjrm.com/article-1-64-en.html
1- “Sarem Fertility & Infertility Research Center (SAFIR)” and “Sarem Cell Research Center (SCRC)”, Sarem Women’s Hospital, Tehran, Iran , saremiat@yahoo.com
2- Sarem Fertility & Infertility Research Center (SAFIR), Sarem Women’s Hospital, Tehran, Iran
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Introduction
In the developmental disorder of the Mullerian duct, during originating from these ducts, if the origin of the celiac epithelium occurs in the fifth embryonic week, vaginal anomalies occur by attaching the urogenital sinus in the eighth week. The most common examples of these abnormalities are lack of uterine and vaginal evolution, Maycer-Rokitainsky- Küster-Hauser syndrome. In Michigan between 1953 and 1957, the prevalence of this malformation was reported in one in 4,000 patients referring to Mayo Clinic and one in 10588 newborn girls [1].
Patients usually have normal karyotype, natural ovaries, and secondary sexual traits, including natural external genitalia. In these patients, there is a common association with other congenital skeletal, urologic and especially renal anomalies. Tubes and ovaries are usually normal, and despite the lack of uterus, evolutionary structures of the uterus may also be seen in different sizes and shapes [1].
In such a situation, since there is no uterus, menstruation does not occur, but ovulation occurs. Sometimes the ovaries are not completely normal and there are polycystic or dysgenic ovaries, along with congenital lack of the vagina. Hypergondaotropic hypogonadism occurs in some cases. In these patients, polygenic or multivariate inheritance, single mutated genes, contact with teratogenic substances on days 37 to 41 of pregnancy, rare inheritance of the dominant autosome and sometimes the mutated gene transmitted by male relatives can be the causes. Contact with teratogenic substances and mutated genes are the most likely causes [1].
One of the differential diagnosis of this disease is androgen insensitivity syndrome; it is characterized by male gonads, XY karyotype and short vagina. The disease is one in 13,000. Other differential diagnosis, is a small vagina or lack of vagina, due to radiotherapy or surgery [2].
Various vaginoplasty techniques have been devised to correct this abnormality and to create a vagina with proper appearance and normal sexual function. These vaginoplasty methods are divided into non-surgical and surgical procedures. In the first method, special molds of various sizes from small to large are pressed on a vaginal stop daily for two hours and each size for one month. For example, the template (the generator) is placed at the correct anatomical location and the patient cycles. In surgical procedures, there are several different techniques; the most common method is to open the blocked space between the bladder and the rectum by cutting the vagina. After complete hemostasis, a mold with the size equal to the length of the natural vagina covered with a thin layer of graft is placed in the space. After about a week, the mold is removed and the new vagina is produced with an epithelialized surface. Over the course of several years, in attempting to devise the best vaginoplasty technique, various grafts including the skin (Mcindoe method), amniotic membrane, buccal mucosa, sigmoid colon, peritoneum, a layer of fine muscles such as musculocutaneous and labia skin have been used.
Another technique is the formation of vagina with continuous pressure method, known as Vecchietti Method. In the Vecchietti method, the basis of the work is pulling on the peak of the primary vagina and creating a new vagina from an individual's vaginal epithelium. In this method, the vaginal peak is connected to the traction device embedded on the patient's abdominal cavity and the pressure is increased so that 1.5 of invagination is obtained daily. Eventually, a new vagina (Neovagina) is produced within 7 to 9 days. After that active dilatation is performed until sexual intercourse begins. For further explanation, it should be added that in the original Vecchietti method, the elasticity after the dissection of the oscillatory space was performed, but today, instead of using the Fibonacci dissection, this procedure is done in a laparoscopic manner and the vesicorectal space is not opened; this method is called Modified Vecchietti [1]. Since 1992, this technique has been used laparoscopically [3]. In Iran for the first time in 2009, this procedure was launched as a useful surgical technique for patients with vaginal agenesis in Sarem Hospital. Given the increasing importance of using the least complicated surgical procedures, a report from 9 patients undergoing surgery has been presented.
Surgical Technique: The method we are describing is a modified and improved technique for Vecchietti method that was first described by Gauwerky, Wallweiner, and Bastert [4]. In this method, the vaginal blockage is drawn with a controlled elongation on a mold. The desired mold is stretched with two threads number 4 (usually mersilene or trilen and sometimes silk), which is connected to the generator on one side and on the other side it is connected to a pulling device on the abdominal surface.
In this method, the vaginal blockage is perforated without creating a canal in the vesicorectal region (Figure 1) and the perforation process is controlled simultaneously by laparoscopy and cystoscopy.
 
 
Figure 1) Puncture of the vagina, without creating a canal in the vesicorectal region
 
The vaginal blockage is driven by the push of a finger in the direction of the navel towards the abdomen. At the same time, underneath the finger, a direct tool that contains two threads attached to the vaginal membrane enters, and all this must be done when the rectum is pushed with the middle finger of the left hand to the opposite. At this stage, it is recommended that the surgeon move the small and primary uterus upwards, ventrally and cranially. This step is to ensure that the bladder is not in place of the hole. Threads are removed from the thread guide and the guide rod is removed. The sickle-shaped rods are placed in the predetermined points in the abdominal wall in subperitoneal region (Figure 2).
 
 
Figure 2) Placing the sickle-shaped rods in the subperitoneal area
 
Any thread that is hooked up to the hood is subtracted to the abdominal wall surface. The Foley catheter is embedded in small size (some surgeons use a suprapubic catheter to avoid pressure on the urethra). After that, the surgeon ensure that the damage to the bladder and rectum is not done by cystoscopy and rectal examination. As far as possible, the stretching of the vaginal end is done in form of cranio-ventral (Fig. 3).
 
Figure 3) Application of stretching of the vaginal ending in form of cranio-ventral
 
The traction device attaches to the abdominal wall surface (Fig. 4), and then the surgeon must be sure of double stretching by both threads.
 
 
Figure 4) Attachment of the device to the abdominal wall surface
 
During the patient's admission for about 6 to 10 days, 1 to 1.5 centimeters a day, the screw for tension of threads is twisted, and after this time a new vagina is created.
On the basis of the amount that the mold has been pulled toward, the threads are cut off and the traction device is removed after the optimum vaginal ultimate length is reached.  6 months use of the mold is recommended after dismissing the patient. In addition to the use of dilator, estrogen cream is also prescribed to relieve estrogen deficiency and vaginal softness and 2 weeks later, the patient is allowed to have intercourse sexual relationship [5-7].
For the patients in this study, in the first 24 hours, intravenous antibiotics were given as cephazolin, one gram every 6 hours, and on the basis of surgical intervention, sometimes in addition to cephazolin, gentamicin and after 24 hours, cephalexin and metronidazole were administered orally for one week.
 
Patients and methods
Patients with vaginal agenesis who referred to Sarem Hospital from 2009 to 2015 were studied. To detect urological malformations, karyotype and sonography were performed and the initial length of vaginal blockage was measured. After a definite diagnosis of Rokitansky syndrome, a total of 9 women aged 17-35 years were undergone laparoscopic vaginoplasty with Modified Vecchietti Method.
Out of 9 patients who undergone surgery, 4 cases had hirsutism and one case had hyperandrogenism. Ovarian problems in these patients (according to the referring time) were as follows:
Patient 1: had left ventricular dermoid cyst and Tubo ovarian Abcess in the left tube.
Patient 2: had a follicular cyst 5 cm in the left ovary.
Patient 3: had premature menopause and atrophic ovaries.
Patient 4: had monosomal mosaic, chromosome XX (46Xo-46X) and banded ovaries.
Patient 5: had polycystic ovaries.
Patient 6: had no right tube and ovary.
Patient 7: had no other complications.
Patient 8: had polycystic ovaries in ultrasound.
Patient 9: had no right ovaries and tubes.
Herni inguinal history was reported in patients 5 and 6. No significant surgical complications were observed. In the patient 4, who had a monosomal mosaic of chromosome X as well, the right pelvic kidney was observed. The mean hospitalization time was 7.3 days and the mean duration of surgery was 2 hours and 8 minutes. The average final length of the vagina was 6.5 cm (the minimum vaginal length was 3 cm and the maximum vagina length was 10 cm). Of the 9 patients, 7 patients were satisfied with vaginal length and intercourse. Two patients who were dissatisfied, not only had prevented regular sexual intercourse because of fear of intercourse, but also had not used the vaginal mold. The findings are summarized in Tables 1 and 2.
 
Table 1) Clinical information and results of laparoscopic vaginoplasty in 9 patients referred to Sarem Specialized Hospital
 
Table 2) Clinical information and results of laparoscopic vaginoplasty in 9 patients referred to Sarem Specialized Hospital

 
Discussion
In this study, the mean vaginal length obtained by using the modified laparoscopic vaginoplasty technique in 9 patients with vaginal agenesis was 6.5 cm. This figure is 1.37 centimeters less than the mean vaginal length obtained in study by Sara K. et al., Who reported laparoscopy with Vecchietti method and the mean vaginal length of 7.87 cm [2].
In a study by J. Kechstein et al., The above method was performed with opening the visicorectal space (instead of passing the needle carrying the yarn from the septum). Of the 9 patients, 7 had complete satisfaction with sexual intercourse. In this study, the mean duration of surgery was 88 minutes, the mean vaginal length after surgery was 9.6 cm, the mean vaginal length in the follow-up study was 11.5 cm and the duration of hospitalization was 13.8 days [6].
In a study, 101 vaginoplasty were done with the above method and patients were divided into 2 groups. In one group, the vesicorectal space was opened and in another group this space was not opened. Accordingly, in a group that the opening of this space had not been done (71 patients), and instead, the treatment was done using new tools, the mean vaginal length was 9.6 cm, and in the group that the space had been opened (12 patients) and the old tools had been used, the mean vaginal length was 8.9 cm. Also, in another group, who had undergone no opening of vesicorectal area and the use of old tools (18 patients), the mean vaginal length was 7.8 cm [3].
The mean duration of surgery in the Modified Vecchietti method was 45-44 minutes in 19 articles. In contrast, in open and intestine laparoscopic procedures, the mean duration of the operation was 181 minutes, and the duration of the procedure was different in the methods of using graft skins, oral mucosa and embryonic membrane were different from 20 minutes to 245 minutes. In Vecchietti method, urologic damage and peritoneal method, intestine injury were more common. The longest vaginal length was evaluated in the intestinal method with a mean length of 12.88 centimeters and the shortest vaginal length was due to a non-surgical dilatation method with a length of 6.65 centimeters.
The complication of this surgery in long-term follow-up is hair growth in the vagina, which is rarely caused by grafting of hairy areas or skin grafts of other areas of the body. Other late complications include vaginal prolapse, which can be seen in all methods, except for Vecchietti, Williams and Davydov. Among other complications is the use of graft, condyloma and vaginal cancer [2]. Urinary and ovarian disorders such as polycystic ovaries, banded ovaries and atrophic ovaries are consistent with previous studies [1].
Regarding the non-observance of the post-operative conditions, both in terms of regular sexual intercourse and regular use of the vaginal mold, it is advisable to explain the postoperative conditions or postoperative complications before surgery, and the pre-operative patients receive psychiatric counseling as well.
In general, in contrast to methods such as Mc Indoe, the lack of complications such as bleeding, lack of infection and graft removal, and lack of infection transfusion through graft are the benefits of the Modified Vecchietti method [1, 5].
Regarding a case of urinary retention due to spontaneous foliar catheter exit and the difficulty of reinserting Foley's cutter, it seems that using superapubic catheter to prevent such cases and preventing ultrasound necrosis seems to be a more appropriate method [5].
In our study, 7 patients out of 9 patients were satisfied with their post-surgical sexual intercourse. There was no major complication after surgery. Two other patients ignored the advice of using dilator and regular sexual intercourse. Regarding the lack of vaginal length, it seems that increasing the length of the traction days can increase the length of the vagina.
According to the US Congress of Women-Obstetrics and Gynecology recommends in 2013, it is better to treat the vaginal dilatation by the patient herself in the first line of treatment. The reason is that this method has been successful between 43% and 94.5% and has little or no cost.
Meanwhile, for individual dilatation, it is advisable to have a minimum depth of 2.5 cm in the vaginal blockage and, on the other hand, do it at least 6 months per day.
 
Conclusion
In general, Modified Vecchietti technique is less complicated than other vaginoplasty methods. In addition, it has better efficacy and higher acceptability and higher satisfaction, as the patient's lack of graft and transplantation has no complications.
 
Acknowledgements: We acknowledge the co-workers in the operating room of Sarem Women’s Hospital and Mr Iraj Shasti.
Ethical permissions: The case was not found by the authors.
Conflict of interests: The case was not found by the authors.
Financial support: This study was supported by Sarem Fertility and Infertility Research Center.
Contribution of authors: Aboutaleb Saremi (First author), author of the article/methodology/main author/author of discussion (%50); Homa Bahrami (Second author), author of the article/methodology/helper author (%25); Tarlan Hamideh Khoo (Third author), author of the article/methodology/helper author/author of discussion (%25).
Article Type: Series Report | Subject: Reproduction
Received: 2017/01/10 | Accepted: 2017/05/19 | Published: 2018/05/22

References
1. Jones HW, Rock JA. Te Linde's operative gynecology. Philadelphia: Lippincott Williams & Wilkins; 2015. [Link]
2. McQuillan SK, Grover SR. Dilation and surgical management in vaginal agenesis: a systematic review. Int Urogynecol J. 2014;25(3):299-311 [Link] [DOI:10.1007/s00192-013-2221-9] [PMID]
3. Brucker SY, Gegusch M, Zubke W, Rall K, Gauwerky JF, Wallwiener D. Neovagina creation in vaginal agenesis: Development of a new laparoscopic Vecchietti-based procedure and optimized instruments in a prospective comparative interventional study in 101 patients. Fertil Steril. 2008 Nov;90(5):1940-52. [Link] [DOI:10.1016/j.fertnstert.2007.08.070] [PMID]
4. Gauwerky J, Wallwiener D, Bastert G. An endoscopically assisted technique for construction of a neovagina. Arch Gynecol Obstet. 1992;252(2):59-63. [Link] [DOI:10.1007/BF02389629]
5. Viola M, Van der Merwe J, Siebert T, Kruger T. Neovagina creation–laparoscopic Vecchietti-based approach with the new kit. South African J Obstet Gynaecol. 2013;19(1). [Link]
6. Keckstein J, Kandolf O, Rauter G, Hudelist G. Long-term outcome after laparoscopic creation of a neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome by a modified Vecchietti procedure. Gynecol Surg. 2008;5(1):21-5. [Link] [DOI:10.1007/s10397-007-0323-4]
7. Nezhat C, Nezhat F, Nezhat C. Nezhat's Video-Assisted and Robotic-Assisted Laparoscopy and Hysteroscopy with DVD. England: Cambridge University Press; 2013. [Link]

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