New neovagina-creating technique based on fasciocutaneous flap for Müllerian agenesis

Background Müllerian agenesis, known as Mayer-Rokitansky-Küster-Hauser syndrome, is characterized by an absent uterus, cervix, and two-thirds proximal vagina (1). To allow sexual intercourse, dilatators-based conservative approaches and Vecchietti vaginoplasty generate progressive traction on the vaginal stump until adequate vaginal size is achieved. Other approaches create the neovagina using mucous/cutaneous, peritoneal, or ileal/sigmoid grafts or cutaneous flaps from the genitalia to fulfill a newly developed space between the bladder and rectum. The drawback of the first approach is the long time required, whereas stenosis, dehiscence, poor aesthetic results, or absence of vaginal sensitivity limit the latter (2) (3) (4). Objective To present a new surgical technique based on an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of external genitalia. Design Video demonstration of surgical steps. Setting University of Verona. Patient An 18-year-old girl with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counselling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve external genitalia with the chance to have a sensitive vagina guided the choice. Intervention The Cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm length canal bounded anteriorly by bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying vascular - from pudendal artery - and nervous pedicles. A tunnel between flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. Inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. In postoperative period no special positioning or ambulation restrictions were used. Main outcome measure Compliance and sensitivity of neovagina. Aesthetic result. Perioperative and long-term complications. Result The postoperative course was uneventful, with early mobilization. The hospital stay was 16 days to allow proper vaginal dilators use; initial daily followed by intermittent use was planned. At a two-year follow-up, neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and aesthetic result. Conclusions The new surgical technique was feasible and effective, preserving external genitalia and avoiding graft healing and bowel secretion drawbacks without an intraabdominal surgical step and related risks. However, more cases - two cases performed so far with similar results - and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.