1 Department of Obstetrics and Gynecology, Okayama University Medical School, 2-5-1 Shikata, Okayama-city, Okayama 700-8558, Japan
2 To whom correspondence should be addressed. e-mail: soichi{at}d2.dion.ne.jp
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Abstract |
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Key words: artificial dermis/bFGF/vaginoplasty/MayerRokitanskyKüsterHauser syndrome
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Introduction |
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We report successful creation of a neovagina in a patient with MayerRokitanskyKüsterHauser syndrome with a modified Wharton procedure using artificial dermis (atelocollagen sponge) and recombinant basic fibroblast growth factor (bFGF) spray to reduce the problem associated with the original procedure.
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Case report |
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An incision was made in the vestibular part of the vagina, and the bladder and the rectal lumen were detached bluntly, reaching the Douglas pouch. The mould, which is made of acrylic resin (Figure 1A, right), was wrapped with the artificial dermis (TerudermisR, Terumo Co. Ltd, Tokyo, Japan) (Figure 1A, left), and the edge of the artificial dermis was sutured with 2-0 polyglactin 910 (Coated Vicryl Rapid; Johnson and Johnson Medical Co., Tokyo, Japan) (Figure 1B). The mould was then inserted into the newly created cavity, the artificial dermis was fixed to the newly created vaginal space, and the edge was sutured to the vaginal entrance in an interrupted fashion using 2-0 polyglactin 910. The labia were sutured together over the mould. Operation time was 1 h. Estimated blood loss was <100 ml.
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Discussion |
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Whartons procedure simply involves placing a condom-covered mould in the neovagina to epithelialize vaginal granulation tissue. Although this is easy and is a less invasive procedure, there have been complaints of prolonged bloody vaginal discharge from the granulation tissue. Jackson and Rosenblatt (1994) have described four cases of vaginoplasty with the modified Whartons method using an Interceed absorbable adhesion barrier. This method is also useful and less invasive, but complete epithelialization of the new vaginal wall required 36 months.
The artificial dermis is a collagen sponge composed of fibrillar atelocollagen and heat-denatured atelocollagen cross-linked dehydrothermally (Hatoko et al., 2000). After being grafted onto a living subject, host cells such as endothelial cells and fibroblasts are introduced into the collagen matrix, which is gradually replaced by host tissue. Finally, dermis-like tissue is produced (Maruguchi et al., 1994
; Matsui et al., 1996
; Suzuki et al., 1999
). Artificial dermis is acknowledged to be useful for treating full-thickness skin defects and oral vestibular extension (Bessho et al., 1998
). The recombinant bFGF stimulates proliferation and differentiation of neuroectodermal and mesodermal tissues such as endothelial cells and fibroblasts, and plays a key part in the regeneration of granulation tissues (Bennett and Schultz, 1993
). Fu and co-workers reported that recombinant bFGF decreased wound healing time, accelerated epidermal regeneration and stimulated granulation tissue formation in patients with second-degree burns (Fu et al., 1998
). In addition, the combination of an atelocollagen sponge and bFGF accelerates tissue regeneration in vivo compared with atelocollagen sponge alone (Kawai et al., 2000
). Based on this knowledge, we used artificial dermis and recombinant bFGF for vaginoplasty to accelerate epithelialization of the neovagina, and to reduce complaints of prolonged bloody vaginal discharge from the granulation tissue.
A second patient received the same operation as this first case. At 2 months after the operation, the neovagina was epithelialized in exactly the same way as the first case. In both cases, the neovagina was covered by a very thin epithelium-like layer, with neovascularization around the twentieth post-operative day. The complete epitherialization like normal vaginal mucosa started from the entrance of the neovagina toward the cuff. We think that several host cells such as fibroblasts and endothelial cells invaded the atelocollagen sponge from the basement, then these cells proliferated, formed the new capillaries, and differentiated to epithelium as described by Kawai et al. (2000). In addition, the epithelial cells in the vaginal entrance that were the same as normal vaginal epithelium migrated onto the atelocollagen toward the cuff. Finally, the epithelialization of the neovagina was completed.
Although no definite conclusions can be made based on these limited cases, the result achieved with these patients is, nonetheless, encouraging. Further investigation of artificial dermis and bFGF spray for use in vaginoplasty is warranted.
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References |
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Submitted on July 14, 2003; accepted on March 12, 2004.