Department of Plastic Surgery, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorder (BIRDEM), 122 Kazi Nazrul Islam Avenue, Dhaka, Bangladesh
Vaginoplasty is a procedure for the reconstruction of vaginal canal. Various
surgical techniques have been described for vaginal reconstruction with
variable success. The aim of this study was to assess the use of sigmoid colon
in vaginal reconstruction of patients with disorders of sex development.
Methods: Eleven patients
were included in this study from January 2009 to December 2016. All patients underwent karyotyping,
pelvi-abdominal ultrasonography, endocrine and psychiatric assessment.
Sigmoid neo-vaginoplasty was the procedure chosen for all the cases. Surgical
and functional outcomes were assessed post-operatively over a period of 6 month
to 6 years.
Results: The preoperative
diagnosis included 9 cases of aplasia of the Mullerian ducts or Mayer-Rokitansky-Küster-Hauser
syndrome (MRKH), 1 androgen insensitivity syndrome (AIS) and 1 pseudohermaphrodite
case. The mean age of the study population was 22.5 years (range 15-30 yrs). No
intra-operative or early postoperative complications occurred. The mean vaginal
length achieved was 13.0 cm (range 10.5 – 15 cm). Long term follow-up showed
introital stenosis in 2 cases (17%) which resolved well to vaginal dilatation.
One patient had pelvic abscess and treated by surgery. Sexual satisfaction was
achieved in 10 cases, as 1 case was unmarried.
Conclusion: For patients with
disorders of sex development of various etiologies, sigmoid vaginoplasty is the
preferred technique for vaginal reconstruction. It is a safe technique and
provides the patient with a cosmetic neovagina of adequate caliber with satisfactory
IMC J Med Sci 2018; 12(1): 27-31
Address for Correspondence: Dr. Mohammed Rashedul Islam, Assistant
Professor, Department of Plastic Surgery, BIRDEM General Hospital, Room No. 1119,
122 Kazi Nazrul Islam Avenue, Dhaka – 1000. Email: firstname.lastname@example.org
is a procedure for the reconstruction of vaginal
canal and the vulva that can be performed in various clinical situations. Though a rare procedure, the
commonest indication is the congenital absence of the vagina, which occurs as a
result of aplasia of the Mullerian ducts (46, XX) or Mayer-Rokitansky -Küster-Hauser
syndrome (MRKH). Second indication is disorders of sex development (DSD). A large
number of medical conditions involving the reproductive system fall under DSD,
which is used as an umbrella term for these anomalies. The most common DSD is
congenital adrenal hyperplasia (CAH) followed
by androgen insensitivity syndrome (AIS, 46, XY) . Genetic sexual
ambiguity and vaginal loss resulting from gynecologic cancer or post traumatic
injury are other two indications for neo-vaginoplasty . The ovaries, given their
separate embryologic source, are normal in structure and function. Reported
incidences of congenital absence of the vagina vary from 1 in 4,000 to 5,000
female births [2,3].
Several surgical techniques are
described for vaginal
reconstruction. These are chronic dilatation of the shallow vaginal introitus
(pressure tube technique), Frank’s or Vecchietti method of skin graft vaginoplasty
(Mclndoe procedure), Davydov’s method of reconstruction with peritoneum and use
of various skin flaps. None of these procedures are entirely satisfactory, as
they may lead to neovaginal stenosis, inadequate length, poor lubrication, or
all three. Baldwin was the first one to describe the use of intestinal segment
for vaginoplasty in 1904 . Based on this principle, Wallace was able to use
the sigmoid colon successfully in 1911 . Later on, this procedure was
discontinued due to its high morbidity rate . In the last few decades, the
use of bowel segment for vaginoplasty was
reviewed including laparoscopic approach after the reported high
complication rate of other methods of vaginal reconstruction .
The three basic tenets of vaginoplasty are: (a) creation of space
between urethra and urinary bladder anteriorly anus and rectum posteriorly, (b)
providing this space with a durable lining and (c) maintaining the dimensions
and integrity of the newly created vagina.
The advantages of using a bowel segment in contrast to other methods of
vaginoplasty are: 1) no graft failure or secondary contracture/stenosis because
a vascularized epithelial-lined tube is used,
2) patency and depth can be maintained without a mold and with minimal dilatation,
3) spontaneous mucus production matches that of the normal vagina and facilitates
sexual intercourse, 4) dyspareunia, frequently seen with skin grafts, is avoided
by the ability of the intestinal segment to withstand local trauma, 5) the use of
an intestinal segment offers the option of performing a bowel interposition vaginoplasty
during infancy at the time of surgical correction of more complex associated caudal
anomalies and 6) avoids the disadvantage of sweating, maceration, hair growth
and foul smell associated with skin flaps. The sigmoid colon is the best choice
for interposition vaginoplasty because of size, location, and ease of
preserving blood supply . In this series, we evaluated the use of sigmoid
colon for vaginal replacement among patients with MKRH and DSD.
population and baseline investigations: The current study included 11
patients from January 2009 to December 2016. All were reared as females.
Complete hormonal assessment was done. Sigmoid neo-vaginoplasty was the
procedure chosen for all the cases. Surgical and functional outcomes were assessed postoperatively. All
patients were subjected to history taking and physical examination. All
patients underwent karyotyping, pelvi-abdominal ultrasonography, endocrine and
psychiatric assessment. Informed written consent was obtained from all patients
or their guardians. None of the patients underwent mechanical and/or antibiotic
bowel preparation prior to surgery.
Surgical technique: Under general
anesthesia and in an extended lithotomy position, a Pfannestiel incision was
made to select, mobilize and isolate a segment of 12-15
cm of the distal sigmoid colon on its vascular pedicle, the superior
hemorrhoidal artery (Fig. 1a, 1b and 1c). The remaining portion of colon
was re-anastomosed (Fig. 1a). A space between rectum and bladder at the site of
vaginal dimple was created using progressively larger Hegar dilators. The
cul-de-sac was opened over a Hegar dilator pushed through the perineal route.
The isolated colonic segment was closed by 2 layers at its proximal end. The
distal end was pulled thorough the abdomino-perineal pouch to the perineum
where it was sutured to vulvar mucosa (Fig. 1d). The peritoneum was closed
above the transposed bowel and the neovagina. Post-operatively, all patients
underwent vaginal dilatation program in the form of self-dilatation until the
patient became sexually active. Follow-up was done for 6 months to 6 years.
Physical examination was performed to assess the vaginal length and width,
cosmetic appearance of the neovagina and occurrence of any complications. The
grade of satisfaction of the surgical outcome was estimated by a subjective
satisfaction score (range from 0 = very disappointed to 10 = satisfied) .
All cases were interviewed by the gynecologists to assess the functional
outcome among the sexually active patients.
patients were 11 with a mean age of 22.5 years (range 15 to 30 years). All were
reared as females. They sought medical attention due to primary amenorrhea. No
sexual ambiguity was found on physical examination, except in one patient who
was male pseudohermaphrodite.
evaluation revealed 9 cases of Mullerian aplasia (MKRH), one case of AIS and one case of male pseudohermaphrodite. In ten
cases karyotype was 46, XX and one case had 46, XY (Table-1). According
to the age and sex matched reference values, follicular stimulating hormone,
luteinizing hormone and estradiol were within the normal limits in all eleven
cases . On ultrasonography, rudimentary or absent uterus was found in 10
cases and a developed uterus was seen in the case with AIS (Table-1).
Table-1: Baseline clinical status of the study population (n=11)
cases underwent sigmoid vaginoplasty. The mean operative time was 3 hours. No
bowel preparation was done. No intra-operative complications occurred and the
post-operative period was uneventful. The patients were discharged from the
hospital within 6 – 8 days. The mean vaginal length was 13.0 cm (range 10.5 –
15 cm). Excessive vaginal discharge, although present, was not found to be a
major complain amongst patients of our series. However, it ceased markedly
within the next 1 – 3 months. One patient developed fungal infection of the
vagina that was treated with oral and topical antifungal drugs.One patient
presented with acute abdomen secondary to pelvic abscess which was managed surgically.
Long term follow-up showed introital stenosis in 2 cases (17%) but both
resolved well after vaginal dilatation. Sexual satisfaction was achieved in 10
cases as onepatient was unmarried. During follow up, the neovagina was found to
have an excellent cosmetic appearance (Fig. 1e and 1f).
Fig.1: Photograph showing steps
neovaginoplasty using sigmoid colon flap technique. 1a: Schematic
representation of reconstructed vagina isolating a 12-15 cm segment of the distal sigmoid colon
keeping the superior hemorrhoidal artery; 1b: Mobilized segment of distal
sigmoid colon on its vascular pedicle - superior hemorrhoidal artery; 1c:
Isolated segment of sigmoid colon; 1d: Suturing of sigmoid colon to vulvar
mucosa; 1e and 1f: Appearance of vagina before and after the neovaginoplasty.
Congenital absence of the vagina is most commonly caused by Muillerian
aplasia, and is frequently called by the eponym Mayer-Rokitansky-Küster-Hauser
syndrome (MRKH). Mullerian aplasia is usually accompanied by a rudimentary
uterus in the form of bilateral and non-canaliculated muscular buds, normal
tubes and ovaries, normal female secondary sex
characteristics, and otherwise normal endocrine and cytogenic features.
The differential diagnosis of absence of the vagina in an otherwise normal
appearing female includes partial absence of
the vagina (usually the lower third) and testicular feminization, or the AIS. The latter may be
diagnosed during infancy due to the
high incidence of bilateral inguinal hernias. The vagina in these
patients will be abnormally shallow or absent all together.
including our experiences have shown that the sigmoid colon serves as an
extraordinarily effective substitute for the vaginal canal. Obtaining adequate
length is no problem, and there is no tendency
toward contraction, narrowing, or stenosis provided that the bowel
segment has an adequate blood supply, and that the anastomosis to the hymenal
region is generous. Wearing a stent is unnecessary and dilatations, if needed
at all, are temporary, infrequent (we
recommend once weekly), and well tolerated. The thick wall of the colon
tolerates trauma with less reaction and bleeding than does small bowel or
split-thickness skin graft. Bleeding may be intermittent or bothersome during
the first month or two, but thereafter rarely occurs. Though mentioned in
various literatures, initial exuberant mucus production by the sigmoid
neovagina generally has not been observed and did not present as a problem in
our series. The mucosa atrophies to a mild degree in its new position.
Moreover, mucus production is sufficient to keep the neovagina moist and lubrication before intercourse is
The sigmoid colon is the best choice for interposition vaginoplasty because
of size, location, and ease of preserving blood supply. Minimal long-term care
is required, although surveillance must be maintained at regular intervals
(every 6 months) to monitor the development of adenocarcinoma in the
transplanted bowel segment.
study revealed that sigmoid neovaginoplasty can provide the patient with a self-lubricating,
aesthetically pleasing neovagina of adequate size without the need for daily
vaginal dilatation or vaginal stenting with vaginal molds. It has an excellent
functional outcome with low complication rate and a less incidence of introital
are very much grateful to the Department of Gynecology
Special Unit, BIREDM-2, for referring the study cases.
MRI was involved in diagnosis,
treatment, follow- up of patients, manuscript writing and overall supervision.
AKD, FBI were involved in patient selection, diagnosis and management. RA, MAI and MUA were involved in literature review and data analysis.
declare no conflict of interest.
1. Speiser PW, White PC. Congenital adrenal
hyperplasia. N Engl J Med. 2003; 349(8): 776-788.
Committee Opinion on Adolescent Health Care. ACOG Committee Opinion No.
355: Vaginal agenesis: diagnosis, management, and routine care. Obstet Gynecol. 2006; 108(6): 1605-1609.
3. Monstrey S, Van Landuyt K, Blondeel P, Hamdi M, Roche N. Chirurgische reconstructie
van de vagina bij congenital agenesie. Tijdschrift voor Geneeskunde. 2009; 65(16):
4. Baldwin JF. XIV: The formation of an
artificial vagina by intestinal transplantation. Ann Surg. 1904; 40(3):
5. Goligher JC. The use of pedicled transplants
of sigmoid or other parts of the intestinal tract for vaginal construction. Ann R Coll Surg Engl. 1983; 65(6): 353-5.
6. Fall FH. A simple method for making an
artificial vagina. AmJ Obstet Gynecol.
1940; 40: 906-917.
7. Li B, Wang J, Wu JX, Wang LY. Clinical
analysis of vaginoplasty with sigmoid colon
by laparoscopic surgery. Zhonghua Fu Chan
Ke Za Zhi. 2009; 44: 673-675.
8. Wesley J R. and Arnold G. C. Intestinal vaginoplasty
for congenital absence of the vagina. J Pediatric
Surg. 1992; 27(7): 885-889
9. Elmlinger MW, Kühnel W, Ranke MB. Reference
ranges for serum concentrations of lutropin (LH), follitropin (FSH), estradiol
(E2), prolactin, progesterone, sex hormone -binding globulin (SHBG), dehydro-epiandrosterone
sulfate (DHEAS), cortisol and ferritin in neonates, children and young adults. Clin Chem Lab Med. 2002; 40(11): 1151-1160.