The use of free jejunal autograft for the treatment of vaginal agenesis: surgical methods and long-term results

Transcription

1 British Journal of Plastie Surgery (2000), 53, The British Association of Plastic Surgeons doi: /bjps BRITISH JOURNAL OF [ ~ J PLASTIC SURGERY The use of free jejunal autograft for the treatment of vaginal agenesis: surgical methods and long-term results H. Sakurai, M. Nozaki, K. Sasaki and H. Nakazawa Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan SUMMARY. Two young women with congenital vaginal agenesis were treated with free jejunal autograft. At follow-up of 5 and 2 years there was no significant constriction without long term use of stents and obturators. Mucosal secretion of the grafted tissue was reduced within a few months postoperatively but still remained high necessitating a cotton napkin. Nonetheless, it provided a suitable condition with appropriate lubrication for sexual intercourse. Our experience indicates that the free jejunal autograft may be the ideal operation for selected patients The British Association of Plastic Surgeons Keywords: vaginal agenesis, neovaginoplasty, free jejunal graft. Vaginal agenesis is rare, with an incidence of 1:5000 to births due to two causes: the Mayer- Rokitansky syndrome and intersex states. ~ Both syndromes are associated with normal female external genitalia, and the patients are raised as females. Absence of the vagina is usually discovered during adolescence because of amenorrhoea or failure to achieve intercourse. Satisfactory creation of a vagina has been accomplished through nonoperative and operative techniques, but the perfect procedure is a subject of continued debate. Among a number of methods to form the neovagina, Emiro~lu et al 2 used free jejunal graft. However, without follow-up assessment beyond 6 months, the adequacy of this method had not been well defined. We present two cases in which the free jejunal transfer was used for construction of a neovagina. This report evaluates this method with respect to sexual behaviour and morbidity of the donor site with long-term follow-up. Surgical technique A standard preoperative bowel preparation is utilised. After general anaesthesia is induced, the patient is placed in the lithotomy position with a catheter in the urethra. Two teams work simultaneously; one team prepares the vaginal cavity and recipient vessels, and the other prepares the jejunal segment. A superiorly based U-shaped incision is used to dissect a flap made of introital mucosa. This is later inserted into the new vaginal cavity and sutured to the incised jejunal graft in order to prevent a circular scar contracture at the introitus. A recto-vesical cavity is created by blunt dissection making a space that will accommodate the length of two fingers. The mid-line sagittal fibrous septurn may have to be divided with scissors at the top of the neovagina. Recipient vessels are prepared for the free tissue transfer with an incision in the right groin. This incision is extended to the femoral triangle where 319 the saphenous vein is exposed. A suprafascial undermining is performed superiorly, and the rectus sheath is incised to expose the deep inferior epigastric artery. Once sufficient vessel length has been obtained to avoid tension at the future anastomotic site (femoral triangle), the distal end of the deep inferior epigastric artery is clipped temporarily. The end of the severed vessel is turned down to the femoral triangle through the inguinal ligament. At the femoral triangle, the great saphenous vein is prepared as a recipient vein. The jejunal segment is followed to approximately 40 cm below the ligament of Treitz, where the vascular arcades are evaluated by transillumination. Although the length of jejunal segment used for the neovagina is merely 8 cm, approximately 25 cm of jejunum should be harvested to obtain the long pedicle. Following the transection of the bowel segment, intestinal continuity is restored by an end-to-end closure of the jejunum. For elongation of the vascular pedicle of jejunal segment, an additional procedure is performed. The proximal margin of the mesentry is dissected transversely preserving the most distal arcade, vasa recta, and at least one mesenteric artery and vein to which the distal side of the arcade is connected (Fig. 1A). Thereafter, the jejunal segment is discarded except 8 cm of the jejunal segment at the proximal end (Fig. 1B). With these procedures, more than 15 cm of vascular pedicle can be obtained. After vascular anastomoses under magnification (Fig. 1C), the vascularised jejunal segment is easily transferred to the perineum through the subcutaneous tunnel, and inserted to the vaginal pocket with the plastic mould (Fig. 1D). The plastic mould and the urethral catheter are maintained for 5 days after operation. Case reports Case 1 A 26-year-old woman presented with primary amenorrhoea. The patient had been already diagnosed as having

2 320 British Journal of Plastic Surgery 25cm Jejunum ) Inferiorepigastricartery ~ii~ I, ) ' ~ Ix, \1?"',o, 'l) Great sa... ~) j ~ ] Figure l--operative proceduresof freejejunal transfer for neovaginalconstruction.(a, B) A long vascularpedmeis obtainedwith a mesentericdissectionand discardedjejunal segment.((2) Vascularanastomosesare achievedat the femoraltriangle.

3 Treatment of vaginal agenesis with free jejunal autograft 321,0, Figure 1--(D) Vascularisedjejunal segment is inserted to vaginal pocket with the plastic mould. Mayer-Rokitansky syndrome at her local hospital. On examination, her body habitus was normal female, except for absence of the vagina. There was a small vaginal dimple where the introitus should be (Fig. 2A). On rectal examination, a rudimentary uterus was palpable. Endocrine tests and chromosome studies were normal. After detailed discussion it was agreed that we applied our technique described above. The postoperative course was uneventful, and the patient was discharged on the 1lth day after surgery. Mild stenosis at the mucocutaneous anastomosis was noticed at the first visit to the outpatient clinic, however, this complication was readily amenable to daily dilatation until the patient became sexually active. She was married 2 months after surgery. After 5 years, the examination showed normal-appearing external genitalia with a sufficient vaginal depth (Fig. 2B). Questionnaire on sexual behaviour revealed no dyspareunia, presence of lubrication and overall satisfaction. She reported that she had been able to experience orgasms related to vaginal intercourse. B Figure 2--Case I. (A) Preoperativeview with vaginal agenesis. (B) Five years after operation with freejejunal graft. Case 2 A 22-year-old woman was already diagnosed by the Department of Urology as having testicular feminisation. After bilateral orchidectomy, the patient was referred to our department to create a neovagina. With hormonal therapy, her body habitus was normal female, except for absence of the vagina and mild clitoral hypertrophy (Fig. 3A). The patient and her family were informed of the reconstructive procedures using free jejunal graft. Postoperative healing was uneventful and the patient was discharged on the 15th day after surgery. Now, 2 years after surgery, the vaginal cavity is well preserved, allowing the introduction of two fingers in width and length (Fig. 3B). Although she has not had sexual partners, there was no sign of pain or tenderness during the physical examination. Discussion The history of attempts to form a vagina is a fascinating and colourful chapter in the history of medicine that begins in ancient times. 3 Despite the number of current approaches to create a neovagina, recent extensive review 4,5 revealed that the technique described by McIndoe and Banister 6 is deservedly the most popular because of the simplicity and relatively high success rate. However, arguments against this method have been the donor site morbidity and constriction of the neovagina, subsequently necessitating long-term use of a stent and obturator. To avoid this cumbersome procedure, several methods using perineal fasciocutaneous flaps have been developed. 7~8 Although these methods can provide excellent distensibility and a long-lasting vaginal cavity without the need for stenting and dilatation, the lining skin remains dry and requires lubrication before coitus. Further more, hair growth in the neovagina can be troublesome in some cases. The area of skin required sufficient to line a vaginal cavity is large and since the ultimate purpose of this surgery is

4 322 British Journal of Plastic Surgery A Figure4~Donor scar of case 1 after harvestingjejunal segment. B Figure3--Case 2. (A) Preoperativeviewwith vaginalagenesis. (B) Two years after operationwith freejejunal graft. for a female to be sexually active, a large scar after closure of the donor site is undesirable. Our method using a free jejunal segment leaves only approximately 5 cm of linear paraumbilical scar (Fig. 4). Intestinal segments have been used in the creation of a vagina with varying degrees of success; portions used have included the small intestine, ascending colon, sigmoid colon, and sigmoid and lower rectum. 9,1~ Theoretically, a vascularised intestinal transplant should be superior in providing a tube of adequate length with a negligible tendency to stricture, lined with mucous membrane. However, previous vaginoplasty using an intestinal segment has been performed as a pedicled transfer, necessitating an extensive intraabdominal procedure. Failure of these intra-abdominal procedures has led to a high mortality rate of 1-2% described in an early report. 9 On the other hand, the use of isolated jejunum as a free tissue transfer requires minimal intra-abdominal dissection and has gained wide acceptance as a safe and reliable method especially in head and neck reconstruction. 12 Mucus production is a common drawback of methods using intestinal segments. Tolhurst and van der Helm reviewed several methods for vaginal reconstruction, and mentioned more voluminous secretions with small intestine. In the two cases presented here, mucosal secretion of the grafted tissue was reduced within a few months postoperatively but still remained fairly high with occasional spotting of underwear. A cotton napkin changed once a day easily resolved this problem. Moreover, mucus production is sufficient to keep the neovagina moist, and lubrication before intercourse is unnecessary. The method of vaginal reconstruction using free jejunal graft was first described by Emiro~lu et al. 2 However, without any description about postoperative assessment beyond 6 months, the adequacy of this method had not been well-defined. Our experience has been that the free jejunal autograft serves as an extraordinarily effective substitute for the vaginal canal. Adequate length is readily obtained and there is no tendency toward contraction, narrowing or stenosis provided that the bowel segment has an adequate blood supply, and that the anastomosis to the hymenal region is generous. Wearing a stent is unnecessary and dilatations, if needed at all, are temporary, infrequent and well tolerated. Initially exuberant mucus production by the intestinal mucosa gradually tapers off over 3 months and generally has not been a problem. Moreover, mucus production is sufficient to keep the neovagina moist, and lubrication before intercourse is unnecessary. While many patients will be satisfied with a lesser procedure, the construction of a neovagina with a free jejunal graft may be the ideal operation for selected patients.

5 Treatment of vaginal agenesis with free jejunal autograft 323 References 1. Evans TN, Poland ML, Boving RL. Vaginal malformations. Am J Obstet Gynecol 1981; 141: Emiro~lu M, Giiltan SM, Adanali G, Apaydin I, Yormuk E. Vaginal reconstruction with free jejunal flap. Ann Plast Surg 1996; 36: Goldwyn RM. History of attempts to form a vagina. Plast Reconstr Surg 1977; 59: Alessandrescu D, Peltecu GC, Buhimschi CS, Buhimschi IA. Neocolpopoiesis with split-thickness skin graft as a surgical treatment of vaginal agenesis: retrospective review of 201 cases. Am J Obstet Gynecol 1996; 175: Tolhurst DE, van der Helm TWJS. The treatment of vaginal atresia. Surg Gynecol Obstet 1991; 172: McIndoe AH, Banister JB. An operation for the cure of congenital absence of the vagina. J Obstet Gynaecol Br Common 1938; 45: Giraldo F, Gaspar D, Gonzalez C, Bengoechea M, Ferr6n M. Treatment of vaginal agenesis with vulvoperineal fasciocutaneous flaps. Plast Reconstr Surg 1994; 93: Wee JTK, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg 1989; 83: Novak F, Kos L, Plegko E The advantages of the artificial vagina derived from sigmoid colon. Acta Obstet Gynecol Scand 1978; 57: Radhakrishnan J. Colon interposition vaginoplasty: a modification of the Wagne~Baldwin technique. J Pediatr Surg 1987; 22: l Turner-Warwick R, Kirby RS. The construction and reconstruction of the vagina with the colocecum. Surg Gynecol Obstet 1990; 170: Nozaki M, Huang TT, Hayashi M, Endo M, Hirayama T. Reconstruction of the pharyngoesophagus following pharyngoesophagectomy and irradiation therapy. Plast Reconstr Surg 1985; 76: The Authors Hiroynki Sakurai MD, PhD, Specialist in Plastic and Reconstructive Surgery Motohiro Nozaki MD, PhD, Professor, Head and Director Kenji Sasaki MD, PhD, Associate Professor Hiroakl Nakazawa MD, PhD, Assistant Professor Department of Plastic and Reconstructive Surgery, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjyuku-ku, Tokyo , Japan. Correspondence to Hiroyuki Sakurai. Paper received 2 July Accepted 23 February 2000, after revision.