1 Department of Obstetrics and Gynecology, 2 Department of Reproductive Medicine, Hopital E.Herriot, 69437 Lyon, cedex 03, France and 3 Department of Obstetrics and Gynecology, Ospedale San Martino, 16132 Genova, Italy
4 To whom correspondence should be addressed at: Department of Obstetrics and Gynecology, Pavillon L, Hopital E.Herriot, 69437 Lyon, cedex 03, France. E-mail: patrice.mathevet{at}chu-lyon.fr
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Abstract |
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Key words: laparoscopic Davydov/peritoneum/Rokitansky syndrome/sexuality/vaginal agenesis
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Introduction |
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The diagnosis of vaginal aplasia is emotionally traumatic for these young women. The physicians approach is very important for their psychological well-being and future medical management. At present there is no consensus regarding the best management option. As stated by the American College of Obstetrics and Gynecology (ACOG Committee Opinion, 2002), non-surgical treatment is the first choice. In patients who refuse or fail to achieve a functional vagina with passive dilatation, a surgical approach may be required. But the surgical reconstruction has to be postponed until such time as the patient is emotionally mature and motivated to maintain a neovagina once it has been created.
The surgical techniques are designed to create a canal of adequate size oriented in the correct axis by developing the space situated between the bladder and rectum. The newly created space may be covered by different materials: skin graft taken from the buttock (McIndoe, 1995; Klingele et al., 2003
), peritoneum (Davydov, 1969
; Davydov and Zhvitiascvili, 1974
; Friedberg, 1974)
, amnion (Nisolle and Donnez, 1992
) and artificial dermis (Noguchi et al., 2004
). An alternative is to use intestine: ileum, caecum, sigmoid colon (Novak et al., 1978
; Parsons et al., 2002
; Crouch and Creighton, 2003
). An alternative approach is exploited by the Vecchiettis procedure, which achieves the dilation by passive traction on an ovoid device placed in contact with the vestibule and attached to the abdominal wall by traction wires (Borruto, 1992
). Whatever the technique used, its success or failure depends largely on the cooperation of the patient.
The aim of this paper is to assess the anatomical and functional outcomes after creation of a neovagina using Davydovs technique. The anatomical result has been assessed clinically and the sexual result by a standardized questionnaire: the Female Sexual Function Index (Rosen et al., 2000). A control group with characteristics similar to those of the study group was recruited.
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Materials and methods |
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First laparoscopic step
The aim of the first laparoscopic step is to separate the urinary bladder and rectum. The pelvic peritoneum is opened transversely at the bottom of the pouch of Douglas. The incision can be performed either in front of the transverse bundle joining the two ovaries and tubes or behind it. A 2728 Hegar dilator is placed in contact with the vestibulum and pushed upwards. A cold light cable is connected to this dilator to form a trans-illuminating device, and once the tip of the dilator becomes visible this indicates that vestibulotomy has been achieved.
Perineal step
Once the position of the patient has been slightly changed (flexion of the thighs) the two borders of the peritoneal incision are drawn downwards and stitched to the lips of the vestibulotomy. In those cases where the tissues interposed between the vestibulum and the peritoneal cul-de-sac are thick and the tip of the luminous guide cannot easily be identified during the first laparoscopic step, the vestibulotomy is performed during this perineal step by making a classical H-shaped incision. If the labia minora are hypertrophic and if the vestibulum is reduced, the skin of the labia can be used for the anastomosis with the peritoneum and making the inferior third of the neovagina (nymphoplasty) by partially dividing them over a short length.
Second laparoscopic step
The vault of the neovagina is created during the second laparoscopic step. A so-called purse-string stitch is performed by taking peritoneum of the bladder, the right-sided round ligament, the right-sided utero-ovarian ligament, the pelvic peritoneum between the right ovary and rectum (beware of the ureter) and then the right-side surface of the rectum before going to its ventral surface to do the same thing in reverse order on the patients left side.
Two solutions are suggested to avoid the neovaginal cavity collapsing spontaneously. The first involves inserting a double envelope mould which is removed, cleaned, and reinserted every time the patient micturates and/or defaecates. This stays in situ until complete epithelialization of the neovagina has occurred. The second solution does not involve inserting anything but the patient is asked to perform dilation herself at least three times a day using the Hegar dilator. The patient is discharged as soon as she is able to take care of her neovagina. A clinical assessment by a member of the team or by the referring gynaecologist is arranged. Sexual intercourse is recommended as soon as epithelialization of the neovagina allows this to occur.
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Patients |
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Separation of the bladder and rectum was done in front of the transverse centro-pelvic bundle in the first 15 patients (first group: February 1996 to July 2001) and behind it in the other 13 (second group: August 2001 to March 2003). The vestibulotomy was performed laparoscopically in 23 cases and via the perineum in the other five cases. The perineal vestibulotomy was completed by a nymphoplasty in these five cases to which one more case should be added: six cases of nymphoplasty equally distributed in the two groups.
The mean age of the patients was 17.8 ± 3.2 years at diagnosis and 21.6 ± 6.2 years at surgery (Table I). Four patients had had previous unsuccessful surgery. Fourteen patients had associated malformations, 11 of them affecting the urinary system including one case of urinary incontinence due to spina bifida. Three patients presented with multiple malformations (cardiac and skeletal abnormalities). Two women suffered from epilepsy.
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We assessed functional outcome by a brief and valid self-report questionnaire evaluating female sexual life (Female Sexual Function Index, FSFI). FSFI assesses six domains: desire, arousal, lubrication, orgasm, satisfaction and pain. FSFI full score is between 2 and 36. According to previous reports we considered the functional result to be very good when the FSFI score was >30, good 2329 and poor <23. We compared the functional outcome of our population with a control group consisting of 28 age-matched (± 2 years) women who came with patients to our outpatient clinic. These volunteers were aged less than 45 years and they didnt have any gynaeclogical problem. The two groups were comparable with respect to race, education and social status. Data from subjects who had no sexual activity within the past month were excluded from final analysis.
Statistical analysis
The associations between the discrete variables were assessed using 2 test with Yatess correction when appropriate. Fishers exact test was used when necessary. Continuous variables were compared by Students t-test. P < 0.05 was considered statistically significant. The follow-up period was measured from the date of the surgery to October 2004. Statistical analysis was performed using the SPSS software (SPSS Inc., Chicago, IL, USA).
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Results |
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The anatomical result was judged to be unsatisfactory (vaginal length < 7 cm) at the first assessment in five cases, including four in the first group and one in the second. In these five cases, dilation was performed under general anaesthesia after incision of the vault of the neovagina. This complementary surgery was done 220 months after the initial surgery. Ambulatory monopolar cauterization and/or laser vaporization were carried out for two additional patients in the first group because of granuloma of the vaginal vault.
The anatomical results, considered to have stabilized, were assessed after a mean of 43.8 months (range 15100). No patient was lost to follow-up. Length, diameter, softness and smoothness (no granuloma) of the neovagina were assessed. All patients had a soft and smooth vagina whose length, at bidigital assessment, was 7.2 ± 1.5 cm: 7.3 ± 1.7 cm in the first group and 7.0 ± 0.7 cm in the second (not significant). The associated nymphoplasty which made the surgery and the hospital stay longer (147 ± 45 versus 112 ± 35 min and 9.2 ± 2.7 versus 7.9 ± 1.7 days, not significant) did not increase the rate of complications and allowed a certain benefit with regards to length (7.6 ± 1.3 versus 7.0 ± 1.4 cm, not significant).
The sexual result, as stated previously, was assessed using the FSFI. All patients were contacted. All of them had attempted to have sexual intercourse. The average delay between surgery and the attempt was 7.0 (range 148) months: 9.6 (148) months in the first group and 4.1 (19) months in the second (not significant). At the time of the inquiry, one patient was not sexually active and two patients refused to answer. The full FSFI score, for the 25 assessed patients, was on average 26.54 ± 5.6 with no difference between the two groups and no difference either between the patients submitted and not submitted to nymphoplasty.
The stories of the two women who refused to answer Rosens questionnaire are perhaps the more informative in our inquiry. The first was the 45 year old patient who had re-operation 20 years after a first fruitless attempt. She had, after the second surgery, normal sexual intercourse and family life but she told us that it was too late for her to answer to such a question. The second patient was 23 years old. She was fully satisfied with her sexuality and relationship but shocked by the questions concerning sexuality which never was her main problem (fertility was the issue from the very beginning and still is).
Among the 25 assessed patients. Six had a poor FSFI score (Table II). One of them had a very complex personal story. She was born with spina bifida and underwent various surgeries in spite of which she still needed to self-catheterize and experienced recurrent urinary infections. She was sexually abused by her father-in-law as an adolescent. One year after the laparoscopic Davydov the vaginal length was 8 cm. No sexual intercourse had been attempted and autodilation was regularly performed. When sexual intercourse started the autodilations became painful and the length of the vagina collapsed to 5 cm. The FSFI was 11.4. For the other five poor results the scores were between 19 and 22. In all of these patients the factors lubrication and pain pulled the global score downwards but the other factors were at the highest or close to it, including the factor orgasm, with the exception of one patient who could obtain orgasm by clitoridian masturbation onlyas before surgery.
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Concerning the patients with a good or very good result (FSFI >24), the individual variations had the same origin as the complaints expressed by the patients with a poor result, i.e. low scores in the fields of lubrication and pain, but this deficit did not pull the global score to <23. On the other hand no significant difference was found between the patients and the controls, at least if the French controls are taken in consideration (Table II).
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Discussion |
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All our patients are satisfied with their surgery. They finally feel normal, they get more assurance and their quality of life has improved. Many of these women are obsessed by the idea that regular sexual activity is necessary to keep their vagina open. For this reason they are afraid whenever they do not have a partner. Besides, when they meet a new partner they may be afraid that he will notice their genital malformation.
Listening and providing information are the cornerstones of good comprehensive management of vaginal agenesis. Irrespective of the resistance the therapist meets from individuals (starting with him or herself) or groups, all questions concerning sexuality and fertility must also be considered including questions about IVF and surrogate mothers (Esfandiari et al., 2004). Forums offered by internet websites dedicated to this topic can be of great help. When the question of surgery arises, a standardized questionnaire such as Rosens can provide a snapshot and be very helpful as an Ariadnes thread for post-operative management. This is just as important as the pre-operative care.
In this context where surgery is only a part (and not the major part) of management, the key word must be simplicity. Apart from the McIndoe operation and its unattractive associated scarring, four procedures are vying for first place. One is carried out vaginally:peritoneal vaginoplasty (Tamaya and Fujimoto, 1997); and the other three are perfomed with the use of the laparoscope, i.e. without leaving visible scars: the laparoscopic Vecchietti (Borruto et al., 1999
; Fedele et al., 2000
; Brun et al., 2002
), the laparoscopic sigmoid colpoplasty (Communal et al., 2003
; Darai et al., 2003
; Urbanowicz et al., 2004
) and the laparoscopic Davydov. Tamaya et al. reported a limited series of five cases of peritoneal colpoplasty performed through the vagina. The authors reported that the described technique is easy to perform and that there were no complications in the five cases. But the authors did not clearly evaluate the sexual results of this technique.
Sexuality after the laparoscopic Vecchietti is poorly documented. In his last survey, Fedele et al. (2000) reported on
52 cases. Assessment of the vagina after stabilization of the result revealed it to be >7 cm in 50 (96%) cases. All patients succeeded in having sexual intercourse, 43 (82.6 %) of them had a stable sexual relationship and 49 (94.2%) were globally satisfied with their sexual life. Three per-operative complications occurred (three accidental bladder perforations). The surgery undoubtedly deserves the label of simplicity. The problem of post-operative pain, however, remains significant as traction on the wires is increased on a daily basis.
By using the laparoscopic bowel vaginoplasty, post-operative pain is more easily managed but this surgery, because it involves the intestine, will never be without danger. There are no data currently available regarding the sexual results but one can anticipate, if one considers the results of the laparotomy approach to this operation, that these results will be excellent. In the series of Communal et al. (2003), a sigmoid neovagina was created in 16 patients with Rokitansky syndrome. Functional results were determined in the 12 patients operated on >6 months earlier. Eleven patients (91%) answered the FSFI questionnaire: eight had regular vaginal intercourse; three had no sexual relationship. All the patients who had sexual intercourse, presenting good full FSFI scores, experienced some pain: either superficial or deep dyspareunia or abdominal pain associated with vaginal penetration. However, comparing our surgical patient group with women with a sigmoid neovagina, the sexual results seem identical.
In conclusion, sexuality overall after surgery for complete congenital agenesis of the vagina approaches so-called normal sexuality. Minimal access surgery facilitates integration of surgery into the management of those young women affected by this syndrome without jeopardizing the chances of success. Among the various laparoscopic operations, our preference is the laparoscopic Davydov because of its easiness, its good sexual results and its relatively low rate of complications.
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Submitted on January 31, 2005; resubmitted on May 11, 2005; accepted on May 19, 2005.
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