Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with Mayer–Rokitansky–Küster–Hauser syndrome

Soichi Noguchi1,2, Mikiya Nakatsuka1, Yuka Sugiyama1, Chebib Chekir1, Yasuhiko Kamada1 and Yuji Hiramatsu1

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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 Case report
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Vaginal agenesis is an uncommon, but not rare, condition. Although there are many methods for creating a neovagina, the optimal treatment is unknown. An 18-year-old woman with Mayer–Rokitansky–Küster–Hauser syndrome received vaginoplasty with a modified Wharton procedure using an artificial dermis (atelocollagen sponge). From 10 days after the operation, the patient was administered human recombinant basic fibroblast growth factor (bFGF) spray to accelerate epithelialization on the neovagina. At 50 days after the operation, we confirmed histological squamous epithelialization of the vaginal epithelium. At 12 months after the operation, the neovagina was at least 3.5 cm in width and ~8 cm in length. In this case, use of artificial dermis and recombinant bFGF to create a neovagina was an easy, less invasive and useful method.

Key words: artificial dermis/bFGF/vaginoplasty/Mayer–Rokitansky–Küster–Hauser syndrome


    Introduction
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
Mayer–Rokitansky–Küster–Hauser syndrome is characterized by congenital agenesis of the vagina, a rudimentary uterus, and normal fallopian tubes and ovaries. It occurs in ~1 out of every 4000–10 000 female births (Rock and Azziz, 1987Go). Although numerous methods for creating a neovagina have been proposed, there is no unanimity of opinion concerning which procedure should be chosen. The difference between procedures lies in the substance covering the newly created vaginal space. Wharton recommended simply placing a condom-covered mould in the neovagina to allow the vaginal granulation tissue to epithelialize (Wharton, 1938Go). However, this method fell out of favour because of complaints of prolonged bloody vaginal discharge from the granulation tissue.

We report successful creation of a neovagina in a patient with Mayer–Rokitansky–Küster–Hauser 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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 Abstract
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 Case report
 Discussion
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An 18-year-old Japanese woman was referred to us complaining of primary amenorrhoea. Upon presentation at our hospital, normal secondary sexual development and a vaginal dimple without vaginal orifice were noted. Magnetic resonance imaging demonstrated normal bilateral ovaries, a rudimentary uterus and an absence of the vagina. Chromosomal analysis showed a normal karyotype of 46,XX, and Mayer–Rokitansky–Küster–Hauser syndrome was diagnosed. The woman and her parents requested vaginal reconstruction. They were counselled before the operation about the methods, as well as possible complications associated with the procedures. It was decided to carry out the modified Wharton’s method using artificial dermis and bFGF. Before the operation, we obtained Institutional Review Board approval for this procedure. The patient had a low-fibre diet for 2 days before the operation. The night before the operation, she was administered a cleansing enema.

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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Figure 1. (A) A 10 cm x 10 cm artificial dermis with silicone membrane (left), and a mould made of acrylic resin (right). (B) The mould was covered with the artificial dermis and the edge of the artificial dermis was sutured with 2-0 polyglactin 910.

 
The patient took antibiotics for prophylaxis. A liquid diet or a low-fibre diet was given for 5 days to avoid defaecation and contamination of the external genitalia by stools. A Foley catheter was maintained for 1 week to avoid post-operative urine retention and contamination of the external genitalia by urine. The intra-vaginal mould was removed on the seventh day without bleeding or foul discharge. The neovagina was irrigated with 0.01% benzalkonium chloride solution once every day. The silicone membrane was removed spontaneously from the neovagina on the ninth day. From 10 days after the operation, the patient was administered human recombinant bFGF spray (FiblastR spray; Kaken Pharmaceutical Co. Ltd, Tokyo, Japan) to accelerate epithelialization on the neovagina. She was discharged on the nineteenth post-operative day. At that time, the neovagina was covered by a very thin epithelium-like layer with neovascularization; a quarter of the neovagina (~2 cm from the entrance) was epitherialized completely like normal vaginal mucosa. She was advised to dilate the neovagina with a Hegar’s cervical dilator (2.5 cm in diameter) by herself for 5–10 min each day and night during the initial 1 month post-operative period. She was examined weekly for a month. At each visit, vaginal depth and epithelium were noted to assess the functional length of the neovagina. Squamous epithelialization of the vaginal epithelium was confirmed by histological examination at 50 days after the operation, and no stenosis was observed (Figure 2A and B). Because she had no sexual intercourse at the time, she wore the mould while sleeping to prevent stenosis and shrinking. About 12 months after the operation, the neovagina was at least 3.5 cm in width and ~8 cm in length, because the mould could be inserted smoothly into the neovagina.




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Figure 2. (A) At 50 days after the operation, complete epithelialization occurred. (B) Biopsy of the neovagina showed stratified squamous epithelium. Haematoxylin and eosin stain, x200 magnification.

 

    Discussion
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 Abstract
 Introduction
 Case report
 Discussion
 References
 
This is the first published report of the creation of a neovagina with artificial dermis and bFGF. There are many methods to create a neovagina in patients with Mayer–Rokitansky–Küster–Hauser syndrome. The most commonly used methods to create a neovagina are the non-surgical Frank technique (Frank, 1938Go) and a variation of the surgical Frank technique, the Vecchietti procedure (Vecchietti, 1965Go; Fedele et al., 2000Go), which rely on serial dilatation of the vaginal pouch, and the McIndoe procedure (McIndoe and Bannister, 1938Go), in which a split-thickness skin graft is used to cover a stent inserted into a surgically created canal between the bladder and the rectum. Several modifications of the McIndoe procedure have been reported, including methods that use human amnion (Ashworth et al., 1986Go; Nisolle and Donnez, 1992Go), peritoneum (Davydov, 1969Go; Rothman, 1972Go) or buccal mucosa (Lin et al., 2003Go) instead of skin grafts to line the neovagina. In addition, bowel vaginoplasty, using a segment of the distal sigmoid colon (Franz, 1996Go) to line the newly formed vaginal canal, has gained popularity in some centres including our hospital. Although the Frank procedure is non-surgical, its success has been variable and unpredictable (Ashworth et al., 1986Go). The Vecchetti procedure and its modified method with laparoscopy require frequent follow-up to adjust the tension and a long time for self-dilation. Modified McIndoe procedures including free skin grafts, peritoneal grafts and buccal mucosal grafts may scar the patient. Use of human amnion grafts is scheduled for concomitant elective Caesarean deliveries and need time for preparation. From 1992 to 2001, we performed vaginoplasty on 10 patients with Mayer–Rokitansky–Küster–Hauser syndrome using sigmoid colon with laparotomy or laparoscopy. The patients received a functional neovagina without severe complications, but they complained of uncomfortable discharge for a long time (at least 6 months). Williams vaginoplasty (Williams, 1964Go) is easy and less invasive, but the neovagina is in the perineal space that is different from the normal vagina anatomically.

Wharton’s 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 (1994Go) have described four cases of vaginoplasty with the modified Wharton’s method using an Interceed absorbable adhesion barrier. This method is also useful and less invasive, but complete epithelialization of the new vaginal wall required 3–6 months.

The artificial dermis is a collagen sponge composed of fibrillar atelocollagen and heat-denatured atelocollagen cross-linked dehydrothermally (Hatoko et al., 2000Go). 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., 1994Go; Matsui et al., 1996Go; Suzuki et al., 1999Go). Artificial dermis is acknowledged to be useful for treating full-thickness skin defects and oral vestibular extension (Bessho et al., 1998Go). 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, 1993Go). 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., 1998Go). In addition, the combination of an atelocollagen sponge and bFGF accelerates tissue regeneration in vivo compared with atelocollagen sponge alone (Kawai et al., 2000Go). 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. (2000Go). 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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Submitted on July 14, 2003; accepted on March 12, 2004.