TECHNIQUES AND INSTRUMENTATION

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1 TECHNIQUES AND INSTRUMENTATION FERTILITY AND STERILITY VOL. 80, NO. 3, SEPTEMBER 2003 Copyright 2003 American Society for Reproductive Medicine Published by Elsevier Inc. Printed on acid-free paper in U.S.A. Sexuality after sigmoid colpopoiesis in patients with Mayer Rokitansky Kuster Hauser syndrome Pierre-Henri Communal, M.D., a Marie Chevret-Measson, M.D., b Francois Golfier, M.D., a and Daniel Raudrant, M.D. a Centre Hospitalo-Universitaire Hôtel-Dieu, Lyon, France Objective: To assess the functional outcome and sexuality of patients after creation of a sigmoid neovagina. Design: Clinical study performed between 1992 and 2002, with a mean follow-up of 3.3 years (range, 6 months to 9 years). Setting: Tertiary care center. Patient(s): Sixteen consecutive patients with Rokitansky syndrome. Intervention(s): Creation of a neovagina with an antiperistaltic (n 13) or isoperistaltic (n 3) sigmoid graft and colovestibular anastomosis by interrupted suture (n 11) or PCEEA forceps (n 5). All patients had a neovaginal vault suspension (n 16). Main Outcome Measure(s): Functional results were evaluated in patients 6 or more months after the operation (n 12) by using the standardized Female Sexual Function Index (FSFI). This index assesses four domains of sexual dysfunction: desire disorder, arousal disorder, orgasm disorder, and sexual pain disorder. Lubrification and sexual quality of life was also evaluated. Normal patients had a mean full FSFI score of 30 5of36. Result(s): The mean full FSFI score was 28 5 (range: 22 34). Seventy-two percent of patients had vaginal intercourse at least once a week; in this subset, the mean full FSFI score was 30 3 (range: 25 34). Conclusion(s): Sigmoid neovagina allowed a normal sexual life in patients who had sexual relations. (Fertil Steril 2003;80: by American Society for Reproductive Medicine.) Key Words: Rokitansky syndrome, vaginal aplasia, sigmoid transplantation, sexuality Received October 14, 2002; revised and accepted February 14, Reprint requests: Daniel Raudrant, M.D., Centre Hospitalo-Universitaire de l Hôtel-Dieu, Place de l Hôpital, Lyon, France (FAX: ; daniel. raudrant@chu-lyon.fr). a Department of Obstetrics and Gynecology, Hôtel- Dieu. b Pavillon L, Hôpital Edouard Herriot, Lyon, France /03/$30.00 doi: /s (03) Paramesonephrotic duct (müllerian duct) agenesis causes an absence of the uterus and the vagina. This phenomenon, which is called Mayer von Rokitansky Kuster Hauser (MRKH) syndrome or müllerian aplasia, occurs in persons with a normal female karyotype (46,XX) and functional ovaries. Patients with a normal male karyotype (46,XY) and functional testes with a serum T level in the pubertal male range have androgen insensitivity syndrome. The MRKH syndrome is the second most common cause of primary amenorrhea, after gonadal dysgenesis (45,XO or 45,XO/46,XX) (1, 2). It is an uncommon but not rare disorder, with an incidence of 1 in 5,000 live female births (3). Severe concomitant congenital malformations occur with müllerian aplasia and are related to a genetic or chromosomal defect; these include limb hypoplasia, cardiac defect, growth and mental retardation, and bilateral multicystic kidney disease (1). More often, MRKH syndrome (whose etiology is unknown) is associated with milder abnormalities: unilateral renal agenesis (21% of patients) (4), cervicothoracic vertebrae abnormality (12%) (5), mild deafness (6), or Turner-like (head-neck) morphotype (Klippel Feil syndrome; müllerian, renal, and cervical spine abnormalities) (1). However, the abnormality that seems to most adversely affect quality of life is absence of the uterus and the vagina, resulting in infertility and lack of normal sexual intercourse. After learning about their disorder, patients often experience a distortion of body image, leading to a decrease in self-esteem; one third of patients develops moderate to severe depression (7). 600

2 Gestational surrogacy is a feasible option for patients with MRKH syndrome (8, 9). The risk of müllerian aplasia in the offspring is 1% to 2% (1). Late sexual development is evident and increases with delayed diagnosis and treatment. Numerous surgical and nonsurgical methods have been described to create a neovagina (10). The most commonly used procedure is the Abbe MacIndoe operation and the Ingram method for passive vaginal dilatation (11). Newer procedures are laparoscopic modifications of the Vecchietti (4, 12) and Bloch Davydov operations (13). According to Roberts et al. (11), conservative dilatation techniques require a long time to create a neovagina (mean, 11 months [range: 3 to 33 months]), and patients tend to prefer immediate surgical correction. However, functional outcome (sexuality) is difficult to assess, and in the absence of a prospective randomized trial, there is no consensus on the best option for surgical correction (14). The use of bowel graft to line the cavity was introduced by Baldwin 100 years ago (15). Because of associated morbidity, intestinal surgery has not historically been used as a first-line treatment. Nevertheless, this one-step treatment provides good anatomical results (16), and progress in colorectal anastomosis (17), mechanical intestinal preparation, and antibiotic prophylaxis (18) has recently permitted use of sigmoid graft as a first-line surgical therapy. We sought to assess the functional outcome (sexuality) of sigmoid neovagina by using a standardized questionnaire: the Female Sexual Function Index (FSFI), a multidimensional self-report instrument ( (19). We also report anatomical results and complications of 16 consecutive patients with MRKH syndrome who underwent operation by a single surgeon (DR). MATERIALS AND METHODS Sixteen patients with MRKH syndrome were referred to the University Hospital Hôtel-Dieu between 1992 and All underwent surgery to create a neovagina with a sigmoid loop. Fifteen patients had a mean age of 18 years (range, 17 to 22 years) at the time of surgery. One patient was 38 years of age. This last patient had been previously operated on at 21 years of age without success (Dupuytren Wharton operation [20]). Another patient had undergone surgery 18 months after failure of a laparoscopic Vecchietti operation. In the remaining 14 patients, sigmoid neovagina was proposed as a first-line surgical therapy (2 of whom had had previous unsuccessful coital dilatation [21]) after receiving information about surgical and nonsurgical methods of neocolpopoiesis. All the patients underwent surgery because they wished to be able to have sexual intercourse. Mechanical intestinal preparation (polyethylene glycol and rectal enema) was started 36 hours before surgery. Antibiotics (under various protocols) were administered during surgery and continued for 3 to 4 days after surgery. The surgical procedure was performed through a Pfannenstiel incision. After checking the anatomy of the internal genital organs and colon mobility and length, the rudimentary uterine horns and the upper part of the fibromuscular median septum were removed. Next, a channel was created between the bladder and the rectum, from the Douglas pouch to the perineum. For the first 10 patients, dissection was performed from the perineum to the peritoneal cavity after vestibular incision. One minor rectal laceration was recognized and repaired immediately without further complication. The next 6 patients had an exclusive abdominal dissection of the neovaginal cavity, because it appears to provide a larger space for the graft. Bladder and rectum injury were prevented by exposure of the vestibular dimple with a translucent dilator lighted from the perineum. The third step was preparation of the sigmoid graft as described by Champeau (22). After mobilization of the sigmoid colon, a 15- to 20-cm-long loop was selected above the rectosigmoidal junction. This segment was pedicled on a single artery (third inferior sigmoid artery) after examination of the vascular anatomy by transillumination of the mesosigmoid. The aboral border was closed by using a GIA 60-mm stapler (GastroIntestinal Anastomosis Auto Suture; U.S. Surgical Corp., Norwalk, CT). A clamp temporally closed the oral end of the graft. Immediate bowel continuity was restored by an end-to-end stapled anastomosis with a PCEEA 28- or 31-mm forceps (Premium Plus Circular End-to-End Anastomosis Auto Suture; U.S. Surgical Corp.) introduced rectally. During the fourth step, the isolated colonic segment was brought down to the perineum through the channel between bladder and rectum. No traction was obtained on the blood vessel using an antiperistaltic (n 13) or isoperistaltic (n 3) graft. The first 11 patients had a colovestibular anastomosis made with interrupted polyglactine 3/0 suture. The other 5 patients had an original colovestibular stapled anastomosis (Fig. 1) with a PCEEA 28- or 31-mm forceps (PREMIUM CEEA; U.S. Surgical Corp.). In all patients, the far end of the neovagina was anchored to the promontory fascia with two polyester stitches. The procedure ended with closure of the mesosigmoid the abdominal cavity in a conventional manner. The mean duration of the surgical procedure was minutes. The first 12 patients had drainage of the graft bed, whereas the last 4 patients did not undergo drainage. A Foley catheter remained in the bladder for 3 days. Immediate postoperative course was uncomplicated in all cases. Discharge from the hospital was authorized an average of the 7th day after surgery (range: 6 to 11 days). All patients had two assessments of the anatomical result. The first examination was performed under general anesthe- FERTILITY & STERILITY 601

3 FIGURE 1 Abdominal view of a colovestibular stapled anastomosis. B bladder; G sigmoid graft; P perineum; R rectum. Communal. Sexuality after sigmoid colpopoiesis. Fertil Steril sia 1 month after the initial procedure, and the second examination was a regular ambulatory examination during routine follow-up. The first examination verified the vitality of the graft, perineal wound healing, and vaginal patency by using a number 31 to 32 Hegar dilator. Patients were encouraged to become sexually active. In the absence of sexual intercourse, they were counseled to practice dilatation every 2 or 3 days with a number 26 or 27 Hegar dilator. The mean duration of ambulatory follow up was 2 years (range: 1 month to 8 years). A digital examination verified the permeability of the cavity. The anatomical result was considered good if no stenosis occurred, intermediate if shrinkage occurred at the upper part of the graft, and poor when orificial stenosis of the neovagina occurred. Functional results were assessed by using a questionnaire designed in collaboration with a sexologist consultant (M.C- M). The questionnaire was explained to the patients during an interview with the surgeon or with their general practitioner, and patients were asked to answer the 32 questions quickly (within 15 minutes) while alone in the waiting room. The first 19 questions were those of Rosen s FSFI (19). This short quiz was validated for assessment of female quality of life and detects sexual dysfunction in adults. It is simple to administer and score and is unbiased with respect to age, ethnicity, education, and economic status. The 19 items were assigned to six separate domains of female sexual function. The first four domains were related to the four major categories of sexual dysfunction as described in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition: desire disorder, arousal disorder, orgasmic disorder, and sexual pain disorder. The fifth domain was the quality of vaginal lubrification. The sixth domain, which was the most important, was related to global sexual and relationship satisfaction. It was viewed as the quality of life domain of the scale. An arousal, lubrification, or orgasm domain score other than zero indicated that at least one form of sexual activity (vaginal intercourse, foreplay, caressing, or masturbation) was reported during the past month. A comfort domain (sexual pain disorder) score of zero indicated that there was no vaginal intercourse. The full FSFI scale score, which could be 36 at the highest, was obtained by adding the six domain scores. The normal women in Rosen et al. s study (19) had an average full FSFI score of 30. Thus, we considered the functional result to be good when the FSFI score was 30 to 36, intermediate between 23 and 29, and poor below 23. We added 13 items to the questionnaire that asked for details on sexual intercourse, vaginal discharge, self-esteem, and anxiety. Functional outcome was assessed in patients who had been operated more than 6 months previously; thus, the last 4 patients were excluded. Therefore, 12 patients were investigated for their functional results. Because the author (D.R.) was in personal contact with these patients during ongoing follow-up, institutional review board approval was not obtained for the study. RESULTS Complications No severe complications (abdominal wound abscess, graft necrosis, or intestinal anastomosis dehiscence) occurred. One patient had febrile urinary infection and, 2 years later, a left tubal abscess. In this patient, rectosigmoidscopy was normal; the abscess was drained by laparoscopy and the left tube was removed, leading to a quick recovery. Another patient developed an abscess of the right labia major 1 month after the first postoperative examination. Surgical drainage led to a rapid improvement. One patient had a mechanical bowel obstruction 1.5 years after the initial surgery. It resolved without surgery after treatment by nasogastric aspiration and rectal enema, and it did not recur. Anatomical Results Table 1 shows anatomical results of surgery. Two patients had stenosis of the colovestibular anastomosis. One of these patients (No. 5) had poor compliance in that she would not perform dilatation until she was having sexual intercourse. She had a transversal vestibular incision during the initial perineal surgery. Despite vestibular plasty, the neovagina remained stenotic. Her first sexual experience was unsuccessful. The second patient (No. 1), who had irregular sexual 602 Communal et al. Sexuality after sigmoid colpopoiesis Vol. 80, No. 3, September 2003

4 TABLE 1 Functional, anatomical, and intercourse results as determined by the Female Sexual Function Index. Patient Desire Arousability Lubrification Orgasm Satisfaction Comfort Full score Anatomical result Sexual intercourse Stenotic at depth of 10 cm Y Stenotic at depth of 7 cm Y G Y G Y Orificial stenosis b N Stenotic at depth of 6 cm Y a 25.3 Stenotic at depth of 10 cm Y G N G Y G N 11 NA NA NA NA NA NA NA G NA G Y 13 NE NE NE NE NE NE NE G NE 14 NE NE NE NE NE NE NE G NE 15 NE NE NE NE NE NE NE G NE 16 NE NE NE NE NE NE NE G NE mean ( SD) c Normal women d Note: G good anatomical result, no orificial stenosis, no graft contraction; N no; NA not available (patient lost to follow-up); NE not evaluated (patients operated on 6 months earlier); Y yes. a Mean of the two answers given by the patient. b Orifice 18 mm in width; patient declined monthly examination. c 11 patients with MRKH syndrome (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 12). d 131 normal patients. Communal. Sexuality after sigmoid colpopoiesis. Fertil Steril intercourse and had had a previous neocolpopoieisis 17 years earlier, had a successful perineal Z-plasty 2 years after the sigmoid neovagina. Four patients (1, 2, 6, and 7) had a moderate shrinkage of the graft 6 to 10 cm above the neovaginal orifice. Patient 6, whose shrinkage was 6 cm above the orifice, was counseled to practice self-dilatation but did not do so. Functional Results Eleven patients answered the questionnaire (91%). One patient was lost to follow-up. At the time of investigation, the average age of 10 patients was 22 years, and 1 patient was 47 years of age. A mean of 3.3 years (range: 6 months to 9 years) had elapsed between the initial procedure and administration of the questionnaire. Eight patients (72%) had regular vaginal intercourse. Seven (63%) had intercourse at least two or three times weekly. The mean time before the first sexual relations after surgery was 3 months (range: 1 to 9 months) for 7 patients. One patient (No. 2) had a first sexual intercourse 3 years after initial surgery. Three patients had no sexual relations; two were operated on less than 1 year earlier (patients 8 and 10). Table 1 shows FSFI scores. The mean full FSFI score was 28. The three lowest scores, in patients 5, 8, and 10, were observed in those who did not attempt vaginal intercourse (comfort domain of zero). Patients with MRKH syndrome differed little from normal patients for each domain of sexual function. After creation of a sigmoid neovagina, patients with MRKH syndrome can be considered normal in terms of global sexual satisfaction, desire, arousability, pleasure, and lubrification. Scores differed among patients for the comfort domain; however, the three patients who did not attempt vaginal intercourse lowered the mean value. The mean score among the 8 patients who had intercourse was higher for this domain (4.8 of 6), as was their full FSFI score (30 3). Three of these patients had an intermediate score of 3. These patients also had an intermediate anatomical result, with moderate shrinkage of the upper part of the neocavity. The remaining 5 patients had a mean score of 5 of 6. One of these patients (No. 6) had moderate contraction of the graft (6 cm above the vestibular orifice) and a very good comfort score, which may explain why she did not perform the prescribed dilatations. Although the 8 patients who had sexual intercourse had a good comfort score on the FSFI, they experienced some pain (Table 2). Six had deep dyspareunia (mean pain score, 2.4 of 5 [range: 1 to 4]); in patients 1, 6, and 7, this phenomenon FERTILITY & STERILITY 603

5 TABLE 2 Pain during vaginal intercourse. Patient Neovaginal orifice Deep pain Abdominal pain (score range: 4 to 5). Patients who had sexual relations felt themselves as a relatively good lover (score range: 3 to 5). The two patients (3 and 9) who felt poorly as a woman (score 3) had a very good full FSFI score, but their anxiety regarding their infertility was strong (score 3). This anxious feeling may explain their poor self-esteem. 1 0 Intensity NA NI NI NI NI NI NI NI NI NI 11 a NA NA NA Note: Score ranges from 0 (no pain) to 5 (painful). NA not available; NI no intercourse. a Patient lost to follow-up. Communal. Sexuality after sigmoid colpopoiesis. Fertil Steril could be explained by moderate shrinkage of the deep end of the neovagina. Patients 2, 7, and 11 experienced superficial dyspareunia (mean pain score, 3.6 of 5 [range: 2 to 5]). Pain was severe ( 4) in two of these patients, of whom one (No. 2) was the only patient to experience vaginal dryness. Patients 6, 7, and 9 had abdominal pain associated with vaginal penetration. Nevertheless, patients reached orgasm most of the time (more than half time) when they had sexual stimulation (foreplay, self-stimulation, or sexual fantasy) or intercourse (FSFI item 11). Global sexuality quality of life was good (satisfaction) (Table 1). Six of the 8 patients (75%) who had vaginal intercourse were very satisfied with their sexual relationship (FSFI item 15). Lubrification was generally good (FSFI score domain of 5 of 6). However, vaginal swelling caused important or very important daily discomfort in 3 patients (27%), who used two to four pads daily. Two patients (18%) did not have vaginal swelling. The remaining 6 patients (55%) had rare or moderate daily discomfort. Overall, the women in the series used a mean of 1 to 2 pads daily. Two patients had vaginal discharge after vaginal intercourse. Usually, vaginal discharge during sexual relations was rare or absent (45%). Daily discomfort was unchanged regardless of the time from initial surgery. Psychological Effects Psychological effects were scored from 0 to 5. Infertility caused anxiety (mean score, 3.4 [range: 0 to 5]). Self-esteem as a woman and as a lover was good (mean scores, 3.7 and 3.4, respectively [range: 1 to 5 and 0 to 5]). Patients who did not attempt sexual intercourse felt less experienced as a lover (score range: 0 to 3) but felt strongly as a woman DISCUSSION From 1992 to 2002, several studies have been done on various causes of vaginal aplasia (MRKH syndrome, androgen insensitivity syndrome, gonadal dysgenesis, and transexualism) or post-surgical vaginal shortness (radical hysterectomy or vulvovaginal resection) (16, 23 26). Hensle and Reiley (27) described 20 cases of MRKH syndrome that were treated with a sigmoid graft; however, the functional outcome was not clearly evaluated, as it was mainly based on the presence or absence of sexual activity. Our report represents a broad study describing long-term results with a standardized questionnaire of patients with MRKH syndrome and a sigmoid neovagina. The aim of creating a neovagina is to restore normal sexual function and improve the body image. Determination of the functional outcome is difficult during a simple interview because it requires explicit frankness from the patient and objectivity from the surgeon. The gain must exceed the discomfort (dyspareunia and vaginal discharge) induced by the treatment. The psychological stress caused by infertility should be evaluated, as gestational surrogacy is the only treatment option. Our questionnaire allowed a relatively broad assessment because it took into consideration the above factors. Functional results of sigmoid neocolpopoiesis are good compared with normal women. Normal women in the study by Rosen et al. (19) differed slightly from our sample: Their mean age was 40 years (range: 21 to 68 years), and 59% had had children. In our study, desire and orgasm domain scores on the FSFI were better among patients with MRKH syndrome than in normal patients. The FSFI questionnaire is unbiased with regard to age, ethnicity, and social circumstances. However, satisfaction is subjective, and the sexual satisfaction of anatomically normal women may differ from that in women who undergo treatment of a severe disorder. Ideally, women should be investigated about their sexual function before and after surgery to demonstrate improvement or lack thereof. Seventy-two percent of our patients had vaginal intercourse at least once weekly. The same frequency was found among Rosen et al. s normal women (19). Our patients who had regular intercourse had a good comfort domain score on the FSFI (4.8 of 6); however, the additional items on the questionnaire revealed that patients 2 and 7 (18%) had severe dyspareunia (score 3 of5). Pain during penile penetration is commonly related to neocolpopoiesis, regardless of the procedure used. After the 604 Communal et al. Sexuality after sigmoid colpopoiesis Vol. 80, No. 3, September 2003

6 neocavity was lined with both perineal cutaneous flap and peritoneum, severe dyspareunia still occurred in 50% of patients in one study (28). Using surgical stretching of the perineum (Vecchietti s procedure), Fedele et al. (4) reported that patients had constant early dyspareunia. This event was not solely due to lack of lubrification before the development of a vaginal mucosa (29). Penile penetration probably acted as a dilator in patients with an insufficient length of the neovagina and caused pain during intercourse. Using an inlay split-thickness skin graft (Abbe McIndoe procedure) De Souza reported a dyspareunia rate of 20% when the neovagina was more than 10 cm deep (30). A depth of 6 cm was the cut-off point below which all patients experienced dyspareunia (30). Review of the literature reveals that the length of a satisfactory neovagina is often short. For example, a satisfactory anatomical neovagina was 6 cm in length in Fedele et al. s study (4) and 5 cm in Alessandrescu et al. s study (31). Sigmoid colpoplasty creates a wide neovagina, as demonstrated by acceptance of the whole length of a number 34 Hegar dilator (16, 25). The Abbe McIndoe (32), Bloch Davydov (28, 33), and Vecchietti (12, 34, 35) procedures resulted in a mean neovagina length of 8 to 9 cm, which is not sufficient for painless vaginal intercourse. In our study, patients who experienced severe dyspareunia had shrinkage of the upper part of the neovagina 7 to 10 cm above entry, thereby reducing vaginal length. A good functional result of sigmoid neovagina does not depend only on a good anatomical result. Sigmoid mucosa provided good lubrification. Vaginal discharge was almost constant, but the score for daily discomfort was moderate. Patients with MRKH syndrome, who used to be dry, had to wear one or two pads daily, a result similar to findings in normal women. To evaluate long-term functional results after neovagina creation in patients with MRKH syndrome, all the domains of sexual function (desire, arousability, pleasure, and pain) must be considered. In addition, the global satisfaction or sexual quality of life of the patients must be evaluated. As previously suggested (20, 23), we showed that sigmoid neovagina provides normal sexual function in patients with regular intercourse. Recently developed procedures (colovestibular stapled anastomosis and laparoscopy-assisted sigmoid colpoplasty [36, 37]) should be evaluated by using a standardized questionnaire, such as the FSFI. Patients with MRKH syndrome should not be compared with normal women but act as their own control by completing the same questionnaire before and after surgery. Acknowledgment: The authors thank Saw-See Hong for reading the manuscript. References 1. Simpson JL. Genetics of the female reproductive ducts. Am J Med Genet 1999;89: Reinhold C, Hricak H, Forstner R, Ascher SM, Bret PM, Meyer WR, et al. Primary amenorrhea: evaluation with MR imaging. Radiology 1997; 203: Buttram VC Jr. Mullerian anomalies and their management. Fertil Steril 1983;40: Fedele L, Bianchi S, Zanconato G, Raffaelli R. Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases. Fertil Steril 2000;74: Lindenman E, Shepard MK, Pescovitz OH. Mullerian agenesis: an update. Obstet Gynecol 1997;90: Willemsen WN. Renal-skeletal-ear and facial-anomalies in combination with the Mayer-Rokitansky-Kuster (MRK) syndrome. Eur J Obstet Gynecol Reprod Biol 1982;14: Langer M, Grunberger W, Ringler M. Vaginal agenesis and congenital adrenal hyperplasia. Psychosocial sequelae of diagnosis and neovagina formation. Acta Obstet Gynecol Scand 1990;69: Wood EG, Batzer FR, Corson SL. Ovarian response to gonadotrophins, optimal method for oocyte retrieval and pregnancy outcome in patients with vaginal agenesis. Hum Reprod 1999;14: Beski S, Gorgy A, Venkat G, Craft IL, Edmonds K. Gestational surrogacy: a feasible option for patients with Rokitansky syndrome. Hum Reprod 2000;15: Karim RB, Hage JJ, Dekker JJ, Schoot CM. Evolution of the methods of neovaginoplasty for vaginal aplasia. Eur J Obstet Gynecol Reprod Biol 1995;58: Roberts CP, Haber MJ, Rock JA. Vaginal creation for mullerian agenesis. Am J Obstet Gynecol 2001;185: Fedele L, Bianchi S, Tozzi L, Borruto F, Vignali M. A new laparoscopic procedure for creation of a neovagina in Mayer-Rokitansky- Kuster-Hauser syndrome. Fertil Steril 1996;66: Templeman CL, Hertweck SP, Levine RL, Reich H. Use of laparoscopically mobilized peritoneum in the creation of a neovagina. Fertil Steril 2000;74: ACOG Committee Opinion. Number 274, July Nonsurgical diagnosis and management of vaginal agenesis. Obstet Gynecol 2002; 100: Pratt JH, Smith GR. Vaginal reconstruction with a sigmoid loop. Am J Obstet Gynecol 1966;96: Freundt I, Toolenaar TA, Huikeshoven FJ, Drogendijk AC, Jeekel H. A modified technique to create a neovagina with an isolated segment of sigmoid colon. Surg Gynecol Obstet 1992;174: Hansen O, Schwenk W, Hucke HP, Stock W. Colorectal stapled anastomoses. Experiences and results. Dis Colon Rectum 1996;39: Gainant A. [Prevention of anastomotic dehiscence in colorectal surgery]. J Chir (Paris) 2000;137: Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional selfreport instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26: Rochet Y, Rudigoz RC, Tian Y. [The treatment of vaginal aplasia. A report of 109 cases and 85 operations (author s transl)]. Chirurgie 1980;106: Lappohn RE. Congenital absence of the vagina results of conservative treatment. Eur J Obstet Gynecol Reprod Biol 1995;59: [Maurice Champeau ( )]. Arch Fr Mal App Dig 1968;57: Freundt I, Toolenaar TA, Huikeshoven FJ, Jeekel H, Drogendijk AC. Long-term psychosexual and psychosocial performance of patients with a sigmoid neovagina. Am J Obstet Gynecol 1993;169: Ghosh TS, Kwawukume EY. Construction of an artificial vagina with sigmoid colon in vaginal agenesis. Int J Gynaecol Obstet 1994;45: Louis-Sylvestre C, Haddad B, Paniel BJ. Creation of a sigmoid neovagina: technique and results in 16 cases. Eur J Obstet Gynecol Reprod Biol 1997;75: Tillem SM, Stock JA, Hanna MK. Vaginal construction in children. J Urol 1998;160: Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol 1998;159: Mobus VJ, Kortenhorn K, Kreienberg R, Friedberg V. Long-term results after operative correction of vaginal aplasia. Am J Obstet Gynecol 1996;175(3 Pt 1): Belleannee G, Brun JL, Trouette H, Mompart JP, Goussot JF, Brun G, et al. Cytologic findings in a neovagina created with Vecchietti s technique for treating vaginal aplasia. Acta Cytol 1998;42: de Souza AZ, Maluf M, Perin PM, Maluf Filho F, Perin LF. Surgical treatment of congenital uterovaginal agenesis: Mayer-Rokitansky- Kuster-Hauser syndrome. Int Surg 1987;72: Alessandrescu D, Peltecu GC, Buhimschi CS, Buhimschi IA. Neocolpopoiesis with split-thickness skin graft as a surgical treatment of FERTILITY & STERILITY 605

7 vaginal agenesis: retrospective review of 201 cases. Am J Obstet Gynecol 1996;175: Sabino Neto M, Baracat EC, Ferreira LM. Vaginal reconstruction by McIndoe technique with a vaginal expander mold. Int J Gynaecol Obstet 2001;73: Soong YK, Chang FH, Lai YM, Lee CL, Chou HH. Results of modified laparoscopically assisted neovaginoplasty in 18 patients with congenital absence of vagina. Hum Reprod 1996;11: Borruto F, Chasen ST, Chervenak FA, Fedele L. The Vecchietti procedure for surgical treatment of vaginal agenesis: comparison of laparoscopy and laparotomy. Int J Gynaecol Obstet 1999;64: Brun JL, Belleannee G, Grafeille N, Aslan AF, Brun GH. Long-term results after neovagina creation in Mayer-Rokitanski-Kuster-Hauser syndrome by Vecchietti s operation. Eur J Obstet Gynecol Reprod Biol 2002;103: Delga P, Potiron L. Sigmoid colpoplasty by laparoscopic and perineal surgery: a first case relative to Rokitansky-Kuster-Hauser syndrome. J Laparoendosc Adv Surg Tech A 1997;7: Ota H, Tanaka J, Murakami M, Murata M, Fukuda J, Tanaka T, et al. Laparoscopy-assisted Ruge procedure for the creation of a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome. Fertil Steril 2000;73: Communal et al. Sexuality after sigmoid colpopoiesis Vol. 80, No. 3, September 2003