Vaginoplasty refers to the creation of a vagina of adequate depth and size, or restoring previous vaginal tightness for a more youthful look and feel. However, vaginoplasty in children is always aimed at creating a normal-appearing vagina as part of normal-appearing female external genitalia. This is intended to allow satisfactory sexual intercourse and normal menstrual flow later in life if the uterus and ovaries are normal, as well as facilitate normal fertility, if possible.
Vaginal agenesis or hypoplasia may result from several causes, and always requires a neovagina to be formed for future intercourse. This may happen in conditions such as congenital adrenal hypoplasia, androgen insensitivity syndrome, and Rokitansky syndrome. In some of these conditions, the uterus is also absent, while in others the vagina is absent but the ovaries are normal. Another cause for the absence of a vagina is severe and complex defects such as cloacal anomalies, or as a result of the severe trauma and scarring produced by corrective surgery for these defects.
Vaginoplasty for Disorders of Sex Development
This type of vaginoplasty is performed as part of the recreation of the female genitalia. Various techniques are used, depending on whether the lower vagina is open and the junction between the normal and abnormal tissue. This requires preoperative evaluation using endoscopy in addition to genitography.
Flap vaginoplaty involves creation of a perineal inverted U-shaped flap, which is inlaid into the posterior vaginal wall to increase its size. This is appropriate when the confluence point is low.
The first successful vaginoplasty for high-confluence patients used the tissue of the urogenital sinus to create the lining of the neovagina. A total urogenital mobilization approach, which avoids urethral dissection and mobilizes the posterior vaginal wall to allow the confluence to become more superficial and easier to connect to the perineum, is more commonly used today. Various modifications have been made to prevent vaginal introital stenosis. More research is needed to avoid urinary incontinence in later life following these procedures.
It is often recommended for vaginoplasty to be done later rather than earlier when possible because of the expected vaginal growth with puberty and descent towards the perineum, both of which facilitate vaginal repair. An additional factor in patients with a functioning uterus and ovaries is the availability of the stretched tissue over the hematocolpos.
Procedures in Vaginal Hypoplasia/Agenesis
Vaginal hypoplasia or agenesis procedures may be operative, non-operative, or a combination of both.
Frank’s method: Progressive dilation with a graduated series of dilators called Frank’s dilators apply pressure to what ought to have been the vaginal area to gradually expand the rectovesical space and enable it to be lined naturally in the same way. The main disadvantages of this method are the time it takes, and the need for the patient to be old enough and motivated enough to carry it out over several months, and to maintain it by regular weekly dilator use. Modifications have been worked out, such as Ingram’s bicycle seat with dilators. Psychological support is essential to ensure adequate compliance.
Vecchietti method: Another means of progressive dilation is the Vecchietti method using an acrylic olive placed so as to press against the region where the vagina should be, and pulling it up by threads attached laparoscopically to the abdomen via the peritoneal cavity. The rate of traction is about 1 cm/day, which results in the creation of a satisfactory neovagina lined with its own tissue within about 7-10 days. It is painful and requires constant analgesia during the period of traction and regular dilation to maintain vaginal caliber before sexual activity begins.
Balloon vaginoplasty: A third method originating in Egypt involves the use of a Foley catheter introduced into the rectovesical space with the bulb dilated against the region intended to be the vagina. The hollow distended balloon is as effective as the Vecchietti olive method but far less painful, accomplishing up to 12 cm expansion within 7 days to create an adequate neovagina.
Rectovesical Space Expansion Procedures
Each of the rectovesical space expansion procedure is based upon expanding the potential rectovesical space and then lining it with various tissues to ensure that it heals as a cavity destined to be the new vagina.
McIndoe vaginoplasty: This method uses a split-thickness skin graft from the buttocks to line a mold placed inside the expanded space. The healed neovagina must be kept open by regular dilation until sexual activity begins. The vagina is often found to be stenosed unless frequent intercourse happens, requiring dilation to be carried out often.
Davydov procedure: This is a laparoscopic or open procedure, which uses peritoneal flaps dissected from the pelvis to line the vagina around a mold. It is most useful when the perineum is already scarred from previous surgical correction, leaving it inelastic.
Williams’ technique and Creatsas modification: the original procedure creates a pouch by suturing the labia minora in the midline, but is now improved by the use of perineal tissue as well to form a stronger and deeper pouch, which allows for comfortable intercourse.
Intestinal vaginoplasty: This procedure uses a pedicled segment of colon or ileum as the neovagina. It is lubricated and comfortable, but is the most invasive and risky of all surgical vaginoplasties as bowel resection and anastomosis are involved. Excessive mucus production, malignancies in the colonic mucosa, and diversion colitis are some of the serious complications. As a result of these risks and complication, it is best reserved for creating a vagina in cases of complex cloacal anomalies.