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Neovagina

Absence of the vagina is associated with intersex states in which there has been a female gender assignment, such as male pseudohermaphroditism and Mayer-Rokitansky syndrome. The techniques for vaginal replacement include the use of split-thickness skin, full-thickness skin and bowel neovagina, new vagina. The most popular tissue for vaginal replacement during the last three decades has been the split-thickness skin graft, as described by McIndoe. This procedure employs the use of several split-thickness skin grafts, usually harvested from the buttocks or upper thigh, which are then refashioned over a vaginal stent to form a neovagina.

There is also a significant incidence of inadequate vaginal length, vaginal stenosis, and dyspareunia. Consequently, attention was turned toward the use of isolated bowel segments for vaginal replacement.

A sleeve of distal sigmoid colon is now most commonly used for vaginal replacement. When the use of this segment is contraindicated, such as when there has been previous surgery.

An 8- to 10-cm sleeve of distal sigmoid colon, based on the left colic or superior hemorrhoidal vessels, is sufficient to provide a capacious neovagina. Keeping the segment short avoids the excess mucous production that can be associated.

The sigmoid segment is taken between noncrushing Allen-Kocher clamps, and bowel continuity is re-established with either standard stapled or hand-sewn colocolostomy. Removing and discarding another 6-cm segment just distal to the segment isolated for the neovagina will give added length and mobility for the mesentery of the neovagina. Depending on the length of mesentery, the isolated segment is brought to the perineum in either isoperistaltic fashion or rotated 180 degrees. The proximal portion of the neovagina is then closed in two layers, using absorbable suture. In patients who lack an adequate vaginal remnant because of gender reassignment, a direct anastomosis of the colonic neovagina can be performed to the perineum. The neovagina is drawn through the newly created circular perineal opening and fixed securely in place. It is mandatory that the perineal opening be made large enough to prevent postoperative contracture and vaginal stenosis. In patients with Mayer-Rokitansky syndrome or those with a hypoplastic vagina, a Hagar dilator can be used to extend this vaginal remnant into the cul-de-sac for it to be used in the vaginoplasty. With the hypoplastic vagina pushed into the cul-de-sac, it can be grasped and opened widely.

The neovagina is stented for 5 days postoperatively, using antibiotic-soaked gauze wrapped around the barrel of a 10- or 20-ml syringe . A Foley catheter drains the bladder during the period of vaginal stenting. Patients are examined at 3 weeks and 3 months.

In a study of 30 patients, long-term results were assessed by questionnaires. Ten of the women (71%) were sexually active. Four (29%) were married, and another three (21%) had been married but were divorced. Only one patient described dyspareunia; she had received an ileal vagina, which required home dilation because of some degree of stenosis. The other 13 patients required no home dilation. Wesley and Coran (1992) reported on six sigmoid vaginoplasties, four performed on adolescents and two on infants. Three of these patients are sexually active, and none require lubrication. In addition, Turner-Warwick and Kirby (1990) reported on 13 patients who underwent colocecal vaginoplasty. Three patients required minor revisions to adjust the introitus, and one patient had a protrusion of the neovagina, which required a simple circumferential resection of redundant intestine. Seven of the 13 patients in this series were sexually active. Consequently, the authors believe that bowel segments are an ideal tissue for replacement of the vagina. Unlike other methods of vaginoplasty, this procedure creates a normal, capacious vagina that is capable of providing natural lubrication during sexual activity. Furthermore, chronic dilation of the neovagina.

Vulvoplasty

It is generally accepted that neonates presenting with ambiguous genitalia consisting of a micropenis with a fused perineum and who are found to be genotypic males are best assigned to a female gender. The smallest size of a micropenis that can develop into a sexually adequate adult penis is not known with certainty, but the responsiveness to growth of the organ can be tested with testosterone administration. A phallus originally smaller than 2.5 cm in the full-term neonate is likely.

In the patient with micropenis, simple exteriorization of the penile and bulbar urethra will simulate the appearance of a vulva. Lateral preputial or shaft skin flaps can be advanced inferiorly on either side of the opened urethra to form labia minora. As in the flap vaginoplasty, a small flap can be turned into the deep bulbar urethra to avoid perineal contractures. When a short vaginal pouch from incomplete mullerian duct inhibition is also present, the flap can be turned into the vagina at the time of urethral exteriorization. Nearing puberty, construction of a neovagina may be considered if a functional vagina is not achieved.