Surgical Approaches to Vaginal Agenesis: The Past, Present and Future.

Although the McIndoe, Vecchietti, and Davydov represent the most utilized surgical approaches, other techniques exist. The use of labia minora flaps has been described [ 16 , 17 ], which is appealing due to its relatively straightforward nature and the lack of graft site scars. Two different methods have been described: the use of two labia minora flaps sutured in the middle, versus a horseshoe flap which includes both the labia minora along with the prepucial skin of the clitoris, all as a single flap [ 16 ]. Notably, these methods require adequate baseline labial tissue to accomplish. The technique of intestinal neovagina creation has important historical value, as well as continued use internationally. The use of intestinal segments for creation of a neovagina was first described as early as the beginning of the twentieth century. This technique involves the harvest of bowel mucosa for transplantation into a newly created vaginal opening. Although differing segments of bowel have been described for this indication, sigmoid colon is the most commonly used in modern practice. Since its inception, several large case series have described adequate outcomes with this technique [ 18 – 21 ]. However, this technique has largely fallen out of favor owing to its complication profile and the availability of less invasive options. Use of an intestinal segment can result in high rates of bothersome vaginal mucous production, which can result in the need for long-term upkeep and douching. Introital atresia is also a commonly reported issue with this technique [ 22 , 23 ]. Finally, although rare, serious complications such as inflammatory bowel disease or neoplasia can develop within the transposed intestinal segment [ 24 ]. Given its relatively increased complication rate, this approach can most appropriately be reserved for unique situations where prior approaches have failed.

There is no current consensus on the need for routine screening following vaginoplasty. The native components of the neovagina remain susceptible to HPV, and vulvar and/or vaginal dysplasia or intraepithelial neoplasia are possible. In a case series of Vecchietti patients, 7 cases of HPV were noted with associated low- and high-grade abnormalities, and 1 case of vaginal intraepithelial neoplasia grade 2 [ 13 ]. Currently, the American College of Obstetricians and Gynecologists does not recommend routine pap screening of the neovagina [ 4 ]. With respect to other sexually transmitted infections, screening should be offered according to standard guidelines. At any point in a patient’s care – irrespective of their decision to pursue surgery – they should be offered comprehensive reproductive counseling, including options for assisted reproductive techniques with use of a gestational carrier. Lastly, navigating a diagnosis of vaginal agenesis can have a drastic psychosocial impact on affected patients. Support resources should be provided to patients throughout both the pre- and postoperative period.

The Davydov approach involves surgically mobilizing and inlaying peritoneum to line a newly created vaginal space. Like the Vecchietti approach, this is a graft-less procedure, and although initially described via laparotomy has now evolved into a minimally invasive procedure. Dissection is first undertaken from a perineal approach, developing a space between the rectum and bladder. After achieving abdominal access (again, most commonly laparoscopically) an incision is then made in the peritoneum and peritoneal flaps are developed overlying the vaginal dissection. These peritoneal flaps are passed through the newly created vaginal space and secured to the introitus. The apex of the vagina is closed by suturing the peritoneum in a purse-string fashion ( Fig. 6 ). Large case series of outcomes reported with the Davydov approach are summarized in Table 3 . The Davydov offers another graft-less and relatively short operative procedure. Unlike the McIndoe and Vecchietti, this procedure is not staged and can be accomplished in one surgical encounter. This procedure is not appropriate for patients with a history of multiple abdominal surgeries, intra-abdominal infections, or history of endometriosis, as pelvic adhesions or scar tissue hinders adequate mobilization of the peritoneum.

The Abbe-Wharton-McIndoe technique – often referred to as simply the McIndoe – is perhaps the most widely accepted surgical approach to neovagina creation. When first described by Wharton, this technique involved dissection of the vaginal space between the rectum and bladder, and placement of a form to maintain shape and patency. The addition of a split-thickness graft to the outside of the vaginal form was proposed in 1938 by Banister and McIndoe [ 6 ]; since this modification, additional graft materials have been posited, and will be described later in this review. In brief, the McIndoe procedure involves two, staged procedures. The first procedure involves (1) dissection of the space between the rectum and bladder and (2) insertion of a graft material and temporary mold ( Fig. 2 ). During the second procedure (typically performed two weeks later), the mold is removed and graft health is assessed. The graft edges are trimmed and sutured to the introitus circumferentially ( Fig. 3 ). The final step is the placement of a permanent mold for continuous use for a prolonged period postoperatively. Long-term, patency must be maintained with intercourse or dilators. Outcomes for this technique have been well-described; selected publications on this technique are highlighted in Table 1 . Advantages of the McIndoe technique include the use of a graft; the graft source and dimensions are modifiable, increasing flexibility for the surgeon to tailor the dimensions and biomechanical properties based on the patient’s anatomy and goals. Conversely, the use of a graft introduces the potential for graft failure, graft site infections, and suboptimal cosmesis of the graft donor site. Patients must be counseled on the staged nature of the McIndoe procedure and the need for two anesthesia encounters. Several materials have been described for use as the graft component of this procedure. The original procedure as described by McIndoe utilizes a split thickness graft, commonly harvested from the skin of the thigh or buttocks. This approach is still favored by many experts, as this allows for adequate surface area of the graft. However, buccal mucosal grafts are also in use, often for vaginoplasty in younger patients due to the limited surface area [ 7 , 8 ]. Some authors have utilized absorbable adhesion barriers – such as Interceed – in the place of skin grafts [ 9 , 10 ]. Although these barriers may theoretically result in a less physiologic neovaginal tissue quality, they also avoid graft donor site complications and cosmetic issues. Amniotic membrane allografts retrieved from recently parturient women have also been described, with reasonable anatomic outcomes [ 11 , 12 ]. However, appropriate precautions must be taken against disease transmission, and despite the low antigenic property of amnion there remains a risk of graft rejection. Finally, tissue engineering and regenerative medicine hold promise in this realm and will be discussed later in this review.

As mentioned previously, surgical innovation has moved several of the most common vaginoplasty techniques from open abdominal to minimally invasive procedures. Several authors are further advancing these techniques, including use of single port laparoscopy for Vecchietti [ 25 ] and a transumbilical technique for a modified Vecchietti using a sutureless balloon traction device [ 26 ]. Perhaps the most promising realm of innovation for neovaginal surgery is that of tissue engineering. Numerous studies have described methods for combining either autologous or allogenic cellular material, biomaterials, and signaling factors to optimize new materials or stimulate host regenerative efforts. Sueters et al. performed a large systematic review on tissue engineering for this indication [ 27 ]. Acknowledging the relative paucity of robust studies to date, this review does emphasize that a tissue engineering-supported modified McIndoe technique may represent a novel way to provide patients with functional neovaginas without the need for the morbidity and negative cosmesis associated with autologous buccal or split-thickness graft harvest. With any biomaterials used, the surgeon should be aware of the expected biomechanical properties and timeline of healing, so patients can be appropriately counseled. For example, decellularized basement membrane products are sometimes used to line neovaginal spaces and, experientially, these have more shrinkage and less distensibility than other grafting techniques.

Vecchietti’s vaginoplasty technique involves placement of a dilation object (“olive”) at the perineum, and placement of continuous, progressive upward traction using a surgically affixed spring traction device. Initially described via laparotomy, minimally invasive approaches have now been described, allowing for faster recovery [ 13 – 15 ]. The Vecchietti procedure involves two procedures in a staged fashion, with the patient remaining admitted to the hospital in between. In the first procedure, abdominal access is gained (commonly via a minimally invasive approach). Under direct visualization, a sharp ligature carrier is passed vaginally by an assistant between the bladder and rectum to deliver sutures attached to a vaginal “olive” or dilation device. These sutures are brought up through the peritoneal cavity, tunneled along the anterior abdominal wall, pre-peritoneally, and eventually exit through the skin. The sutures are then attached to a specialized traction device ( Fig. 4 ) Postoperatively, increasing amounts of tension are applied to the perineal olive using the traction device; our usual practice is to increase tension twice daily. On average, patients are admitted 7–10 days, with approximately 1 cm of vaginal length gained daily. In a second procedure, the vaginal olive is then removed under sedation and a vaginal mold may be placed ( Fig. 5 ). As with the McIndoe approach, patency may be maintained long-term with intercourse or dilators. Several large case series involving Vecchietti’s technique have been published from high-volume centers ( Table 2 ). The Vecchietti is an attractive surgical option due to the relatively rapid achievement of vaginal length over the span of the immediate postoperative period. The procedure also obviates the need for a graft, eliminating graft-related complications. However, this technique requires the equipment and surgical expertise to successfully complete the procedure. This procedure also involves a postoperative hospital stay, which can be costly and during which patients can experience discomfort from increasing traction on the spring traction device. As with the McIndoe, this procedure is staged and requires two anesthesia events, though some providers remove the Vecchietti equipment at the beside and avoid the second anesthesia event. Modifications to this technique over time have included optimization of the traction device, various different objects for the vaginal “olive”, and a minimally invasive approach as described above.

Throughout history, there have been numerous approaches to the clinical conundrum of vaginal agenesis. The three most common techniques in practice today – the McIndoe, the Vecchietti, and the Davydov – each provide unique advantages, but also present the surgeon with specific technical considerations. Regardless of the approach taken, surgical treatment of vaginal agenesis requires thoughtful, patient-centered and comprehensive counseling. Proper anatomic evaluation and expectation-setting prior to surgery is crucial to guaranteeing a well-informed patient and a satisfactory surgical outcome. The role of dilation therapy in the perioperative management of this condition cannot be overstated, and patients must receive proper coaching in this technique. Lastly, while the aforementioned surgical techniques are a crucial tools in the armamentarium of a reconstructive vaginal surgeon, ongoing innovations in the realm of tissue engineering hold promise in further advancing the care of this patient population.

Vaginal agenesis can result from numerous causes, with many cases being of unknown etiology. Congenital causes commonly include formation or migration errors involving Müllerian tissues (such as Mayer-Rokitansky-Küster-Hauser syndrome (MRKH)) and genetic disorders such as Androgen Insensitivity Syndrome (AIS), among others. Secondary loss of vaginal patency can result from prior radiation, vulvovaginal dermatoses, or genitourinary surgery. While this review will focus on vaginal agenesis, it is important to emphasize that both congenital and secondary loss of vaginal patency can be addressed with similar vaginoplasty techniques. With congenital vaginal agenesis, substantial variability in patient anatomy can exist, from agenesis of all Müllerian structures, to isolated vaginal agenesis, to shortened vaginal length. For this reason, a comprehensive workup and understanding of an individual patient’s anatomy is crucial. This is also an important step for understanding any other associated anatomic differences that can be associated with vaginal agenesis (e.g. concurrent duplication or absence of the renal collecting system). The approach to workup and diagnosis of vaginal agenesis has been previously well-described and will not be detailed here. Although this review will focus on surgical approaches, the role of dilation in management of vaginal agenesis cannot be overstated. The use of dilators can be used alone as a primary nonsurgical approach to vaginal agenesis, and may achieve a goal vaginal length in upwards of 96% of patients [ 1 , 2 ]. Dilation is a recommended first-line approach due to its low-risk safety profile, cost-effectiveness, and relatively high success rates [ 3 , 4 ]. Dilator therapy also has an important role in the pre- and post-operative care of surgical neovaginas; considerations for postoperative dilation will be discussed later in this review. Surgery should be offered to well-counseled patients who desire additional intervention, or those who have failed nonsurgical management. Patient readiness to actively participate in the care of a neovagina must be ensured prior to surgery, including willingness to engage in chronic dilation or intercourse for maintaining neovaginal patency. Patients should be referred to surgical specialists comfortable with neovaginal approaches, including postoperative care, complications, and follow-up [ 4 ]. Numerous approaches to the surgical creation of neovaginas have been described. Although interventions for vaginal agenesis have been documented as early as 400 B.C., more modern techniques have largely developed over the past two centuries [ 5 ]. Figure 1 depicts a timeline of the seminal events leading to our currently available surgical techniques for neovaginal creation. In this review, we will describe the three most commonly utilized techniques for neovagina creation: the McIndoe, the Vecchietti, and the Davydov. Thereafter, we will outline surgical complication profiles, postoperative considerations, and emerging novel techniques.

Although surgical vaginoplasty can provide a successful outcome, patients must be transparently counseled regarding the potential complications. Intraoperative complications often center around difficulty with dissection of the neovaginal space, and largely center around viscous perforation such as cystotomy or proctotomy. The sites of split thickness graft or flap harvest can come with short-term graft site infections and risk of hemorrhage and long-term cosmetic issues. Buccal grafting has the added risk of xerostomia, should Stensen’s duct be inadvertently injured during graft harvest. Complication rates from selected large studies of the three primary vaginoplasty techniques are summarized in Tables 1 , 2 and 3 . Long-term complications most commonly include vaginal stenosis or agglutination, loss of vaginal length, fistula, granulation tissue, and prolapse. Ultimate reoperation rates after vaginoplasty – for anatomic failure or complication – have been reported as high as 40% [ 31 ], though in experienced hands this is likely an overestimate. Prolapse has been described in cases of neovaginas created with both dilation and surgical approaches. Intestinal neovaginas appear to be at relatively high risk compared to other approaches [ 27 ], though no robust comparison studies have been done. Patients with neovaginas have options for prolapse repair, though their specific anatomy, vaginal length and prior vaginoplasty approach must be considered. Successful repair of neovaginal prolapse has been described via mesh sacrocolpopexy [ 32 – 34 ] and sacrospinous ligament suspensions [ 35 , 36 ], among other approaches.

Close follow-up is crucial during both the short- and long-term postoperative period after neovagina creation. Surgeons undertaking neovaginal cases should have the clinic infrastructure and resources to continue following patients postoperatively, and should provide staff education on the care of these patients. Surgeons should also devote adequate time preoperatively to counsel patients about the postoperative timeline and realistic expectations. Dilator therapy is universally recommended after surgery to optimize results. Therefore, a crucial preoperative step is ensuring patient readiness to adhere to a dilator schedule [ 28 ]. There is no consensus regarding ideal timing or duration of postoperative dilation. One study evaluated intermittent dilation versus continuous mold use for 6 months postoperatively and found no significant difference in anatomic outcomes [ 29 ]. Our general practice for patients maintaining patency with a dilator is to initiate dilation once cleared by their surgeon (immediate after Vecchietti, delayed after indwelling mold removal for Davydov and McIndoe) and to dilate 1–3 times per day for 10–30 min each session for the first 3 months, then space out to 3 times per week thereafter. Increasing frequency of dilation (when dilation is used as the primary method of neovagina creation) does not appear to impact functional success [ 1 , 28 ]. If at any point the patient experiences new difficulties with dilation, they should be evaluated comprehensively for adhesions, stenosis, or levator spasm causing vaginismus. Conversely, a misplaced dilator or surgical mold should always prompt evaluation for possible perforation. Coitus can generally be resumed or initiated immediately after non-grafting neovaginal procedures and 8–12 weeks after grafting neovaginal procedures. Patients may elect to utilize coitus instead of or in addition to dilation therapy for maintaining vaginal length and patency long-term. No data exist comparing these two methods in the postoperative setting; however, when dilation is used as the method of primary neovagina creation, coital dilation appears to result in longer average vaginal length than self-dilation [ 30 ].