The power of peritoneum: lengthen the vagina with the davydov

In this video we demonstrate varying surgical techniques for the use of the Davydov procedure to augment vaginal length for an acquired shortened vagina. Vaginal elongation with the Davydov begins with mobilizing peritoneum overlying the bladder and the rectum. A vaginal probe assists with traction/counter-traction to delineate surgical planes. Both blunt and sharp dissection can be used for mobilization. In patients with significant pelvic adhesive disease, an endoanal sizer placed in the rectum can aid dissection posteriorly. Similarly, a bladder demarcator consisting of a rigid catheter guide placed within the Foley catheter can be used to delineate anterior surgical planes to avoid injury to the bladder. The bladder can also be mobilized if additional peritoneum is needed. Once adequate peritoneal mobilization is achieved, a colpotomy is made. The peritoneum is then attached to the vaginal epithelium with a series of interrupted delayed absorbable sutures. This can be done laparoscopically or vaginally. The use of interrupted sutures helps prevent stricture or narrowing at the cuff. The new vaginal apex is created by placing a purse string of delayed absorbable suture through the peritoneum at the desired site of the new apex, avoiding incorporation of the ureters or adjacent peritoneum. A second stitch placed in the same fashion reinforces the new apex. Cystoscopy is then performed to ensure ureteral patency. Postoperative vaginal mold use followed by regular dilation or intercourse is essential to maintaining a patent vagina. Although the Davydov procedure was originally described for neovagina creation in the setting of vaginal agenesis, this same technique can be used to augment vaginal length. Given the familiar surgical technique, high success rate for neovagina creation, and ease of recovery for patients, this procedure should be considered for surgical augmentation of an acquired shortened vagina.