Treatment Options for Patients with Vaginal Agenesis / MRKH

Patients with vaginal agenesis will need treatment to become sexually active and, therefore, will need creation of a neovagina. Timing of this will depend on the patient and her family and the surgeon feel she is emotionally and physically matured enough to undergo the procedure or surgery. Ideally, in the past it was felt that the patient should be ready to be sexually active shortly after any surgical procedure to create a vagina, however, many patients and families opt for treatment prior to this as the young woman desires a vaginal canal at a younger age as she wants to feel “normal” and doesn’t want to wait until she is ready to be active. This is certainly understandable and why many young women undergo the procedure in their late teens. In this case, if the young woman is not planning on sexual activity for a period of time (and this could be years) after the surgery, then she will need to be prepared to use dilators to maintain the vaginal canal until she is having intercourse on a regular basis.

There are excellent treatment options available to create a functioning vagina. Some older techniques are much more invasive than others and require large abdominal incisions with major surgery, extensive recovery and very large abdominal wall scars while others require skin grafts, muscle flaps taken from the legs or other areas which are also very invasive with extensive recovery time.  Drs. Miklos and Moore utilize a modification of an abdominal technique that utilizes the patients own peritoneum, requires no grafts or implants and has excellent success rates, however they utilize a laparoscopic approach with mini-incisions that enables the procedure to be completed on an outpatient basis with a very rapid recovery.

NON-SURGICAL NEOVAGINAL TREATMENT

►SELF-DILATION

This treatment is sometimes used as a first attempt to create or lengthen the very short or non-existent vagina. In this treatment, the patient presses (or eventually sits on) a small rod (dilator) against the skin or the small vagina for 15-20 minutes a day. Progressively larger dilators are used to expand and lengthen the vagina. Several months may be required to obtain the needed length. It is recommended that the vagina be at least 2.5 cm in length to start (i.e. prior to dilating) otherwise the success rates are not adequate.

SURGICAL NEOVAGINAL TECHNIQUES

There have been many different surgical techniques describe to create a neovagina and most have been very invasive large surgeries with variable success rates. Some of the most common ones described are below:

►MCINDOE VAGINOPLASTY

A complicated procedure that requires skin grafts and/or muscle grafts from the thigh or leg and requires and implant in the vagina for up to 3 months after surgery and then dilator use following this.

►VECCHIETTI PROCEDURE:

This utilizes an acrylic olive shape apparatus that is applied under tension (via threads that are brought up through the abdominal wall via incision in the abdomen) against the vaginal dimple. A traction device is then used on the threads on the abdominal wall and tightened over time that draws the olive upward and stretches the skin, thus creating a neovagina. This can take up to 3 months to accomplish and then requires dilators after.

►BOWEL VAGINOPLASTY:

The sigmoid colon or other loop of intestinal bowel can be transposed down into the pelvis and utilized as a new vagina. This is a major abdominal surgery that requires bowel resection and carries major risks and complications.

►DAVYDOV PROCEDURE:

A complicated procedure that requires skin grafts and/or muscle grafts from the thigh or leg and requires an implant in the vagina for up to 3 months after surgery and then dilator use following this.

LAPAROSCOPIC CREATION OF A NEOVAGINA

Drs Moore and Miklos utilize a laparoscopic modification of the Davydov procedure. This makes it even more minimally invasive than the original procedure. The doctors travelled to Russia and were trained by Dr L.V. Adamyan, who developed this original technique. They have used their laparoscopic expertise and suturing skills to modify the procedure even more and to do more of it laparoscopically (it is a combined laparoscopic and vaginal procedure) as they do most of the suturing required through the mini-incisions in the belly button and abdomen while working off of High-Definition large screen TV’s. In a recent study the procedure had a 96% functional success rate with sexual function scores in the good to very good rate. Typically, patients are able to have normal sexual function including arousal, lubrication, orgasm and satisfaction. The procedure itself is much less invasive than most of the alternative surgical options and achieves better length with less risk of scarring down.

The procedure usually takes between 1 and 2 hours and is completed in an outpatient surgical setting (or a 23 hour stay facility). Recovery is rapid and intercourse is able to be achieved in as little as 2 weeks post-operatively. A vaginal pack is typically left in for just 36-48 hours (in some other procedures that may require skin grafting of the vagina, the pack has to be left in for up to 1-2 months), however in some cases it may need to be changed and left in for approximately a week. Pain is usually minimal and return to normal activities such as school is usually very rapid.

Drs. Miklos and Moore have utilized this laparoscopic technique on women throughout the US, including many young women that have had attempts of neovagina by other techniques and other surgeons and have failed. They are still able to utilize their laparoscopic skills even in this more complicated subset of patients to create a neovagina with the pelvic peritoneum and still operate through mini-incisions and give the patient the benefit of very minimally invasive surgery. Patients that have had previous surgery cannot believe how much easier the approach was with Dr Moore and Miklos and the results they achieved after the procedure resulting in a normal, full length, functioning vagina!

Drs. Moore and Miklos are considered world leaders in the laparoscopic approach to create a neovagina and are asked from experts throughout the world to come and lecture and teach on the subject.  They recently arrived from Dubai where they taught surgeons from throughout Europe and the Middle East their laparoscopic techniques.