Vaginoplasty using amnion graft

Vaginoplasty ( Neovagina)
 Dr Aruku Naidu MD FRCOG CU

http://www.youtube.com/watch?v=F4UN4d0C5To

The vagina has many functions these includes to the release menstrual bleeding, for intercourse, for childbirth, for gynaecological examination and self esteem and feeling being a female. Unfortunately, there are various forms of vaginal defects develop as a result of failure to develop during the organogenesis: agenesis/hypogenesis, failure to fusion during the developmental stage: Unicornuate/ Bicornuate and failure to reabsorb during the final development stage in the fetus: septal defects

The common vaginal defects includes Complete vaginal agenesis, Incomplete vaginal agenesis,Transverse septum, Imperforated hymen, Longitudinal septum. The incidence are around 1: 4000 childbirth, Prof Yunisaf from University of Indonesia, Jakarta sees around 8-10/cases per year. In Malaysia there are 3-4 cases/ per year and they are referred from all over Malaysia.

There are various factors contributing to this defects which includes Autosomal recessive disorder, Transmitted sex-link autosomal dominan, Enzymatic, Agents eg. Thalidomide and most of the time the exact cause is unknown.

The indications for surgery are for adequate sexual function, wanting to have a baby, when patients present with haematocolpos and for personal preference, The timing for surgery is when there is presence of haematocolpos or haematometra and when the patients had engaged or just married.

There are many different surgeries for this condition, this includes Frank Technique: Incision & dilatation, Wharton technique : Creation of vaginal opening in between rectal wall & bladder, without any placement of grafts, Mc Indoe technique: Same as Wharton’s technique but with graft placement from skin, Use of other graft eg. Bowels or peritoneum has also been described, Wlliam’s technique: Use of labial graft and Prof Junisaf has been  using of amnion graft since 1990 and he has done nearly 30cases.

The technique to harvest the amnion graft and creation of neovagina involves the use of amnion, consent from both, the donor and recipient, testing for infectious diseases, preparation of graft. The timing of Caesaean Section is important to havest a fresh graft and this can be implamted immediately after adequate washing and preparation with normal saline and antiseptic solutions. The graft mold mounting of the graft onto the mole is done prior to the creation of neovagina. The mold is covered with sterile condom and the graft is mounted over it. The space in between the rectum and bladder is infiltrated with Marcaine/ Adrenalin 1:200, diluted into 40mls solution ( N/S). Dissection start at the vestibule of vagina and the space is created using sharp and blunt dissection (using fingers & retractors). There can be excessive bleeing from the inferior rectal vessels and adequate haemostasis is essential prior to the introduction of the graft mold into the newly created vaginal space.

After the insertion of the mold covered by amniotic graft into the created vagina space and the mold is fixation  by approximating the two labia’s with silk. The mold is kept in situ for 10 days. The Catheter ( CBD) is inserted and kept for 10 days.

Upon Discharge the patient are provided with adequate pain killers ( Cox-inhibitors & Tramal 50mg bd/tds). They were advice to take care of the perineum by performing perineal toilet tds/qid. They should also keep the perineum dry. Syp lactulose 15ml nocte is provided to prevent constipation adequate reassurance & counseling is very important.


Post operative review is usually around 10 days, during this visit the labial stitches were removed. Spontaneous expulsion of the mold is observed and the patients were taught and counseled regarding the need to do regular dilation of the neovagina. It is advisable to dilatation 3x/day for 1-2/52 than daily for 3 - indefinitely or under natural intercourse is resumed

URINARY INCONTINENCE: SUFFERING IN SILENCE

Urinary incontinence affects as many as one in four women in the developed countries¹. In Malaysia the true figure is hard to get, as there is no nation wide study on prevalence. It is estimated that there are more than 1 million suffers. Pelvic organ prolapse and urinary incontinence is the most common chronic condition in women, accounting to about 35% of all chronic medical condition, much more common than hypertension (25%), depression (20%) and diabetes (8%).  Many of them regard it as normal and as part of aging or as embarrassing complaint and did not seek any medical advice. Many of them suffer in silent. It contributes to tremendous physical and emotional trauma to the individual and the financial cost is enormous².

Women suffer incontinence more than women, with a third of suffers are in the childbearing age and the rest are postmenopausal women. Urinary incontinence is divided into four groups. The commonest being the stress and urge incontinence. The other groups are overflow and functional incontinence. Stress incontinence is basically means leakage of urine upon coughing, laughing or sneezing. It is contributed by childbirth, the menopause, previous surgery and chronic cough. Urge incontinence is leakage of urine before being able to reach the toilet. It is caused by detrusor instability (80 percent idiopathic and 20 percent due to infection, inflammation, stones, foreign bodies, tumors and others). The other two groups are rare and have it own factors contributing to the incontinence.

The impact of urinary stress incontinence on the quality of life includes social isolation, and depression. Many of them suffer in silent and will not seek help. In our country many had and would take this problem to grave without realizing that majority of urinary problems can be treated by simple conservative methods or surgically. Some doctors or medical carers are also partly to be blamed. A few would just pat them and say that this problem is basically as a result of childbirth and aging and nothing can be done. This is not true. In fact 70 percent of sufferers can be helped and taught to manage their incontinence better.

Patients seeking advice on urinary incontinence should be assessed with sensitivity and empathy. A detailed history, including details of fluid consumption, severity of incontinence, and other associated medical or surgical problems. If a patient has a bladder diary for three to seven days, this can be of help in assessing the pattern of incontinence and bladder function. A urine test should be carried out to rule out underlying urine infection. Clinical assessment includes measurement of height, weight and blood pressure. The abdominal examination may reveal a distended bladder or a pelvic mass. Vaginal examination may reveal stress incontinence, urogenital atrophy, genital prolapse, fistula and pelvic muscle strength.

Pelvic Health Concept

Ipoh hospital is the first public hospital to set up the Pelvic Health Unit (urogynaecology and pelvic reconstructive unit) under the department of obstetrics and gynaecology. The first line of management is to educate patients about good bladder habits, such as posture during micturation, avoidance of bladder irritants, pelvic floor exercises and maintenance of good general health. Our unit has started the “Beat the Bladder Blues” campaign to create awareness among public and how to seek advice with regards to their bladder or prolapse problem.

In terms of posture for urination, we advice patients to sit firmly on the seat and lean forward with their feet flat on the ground, in order to empty the bladder completely³. ‘Hovering’ or ‘hanging the feet’ would only partially empty the bladder. One could also do double voiding if the feel the bladder is not completely emptied by simply leaning back for 10 seconds and then lean forward again to empty any residual urine. It is also important to avoid bladder irritant if patients bladder is sensitive and if they have urgency and urge incontinence. They should avoid caffeine drinks or drink less than 2 cups of coffee/tea/coke/chocolate per day. Alcohol is also bladder irritant. Other bladder irritants are concentrated urine, infection, atrophy and constipation. Patients should avoid or treat the under lying cause as appropriately. Good bladder habits include drinking about 6-8 cups (2 liters) of fluids a day. Avoid drinking anything within 2 hours of going to bed. Avoid ‘just in case’ visits to the toilets. Topical vaginal estrogen creams are helpful in alleviating irritative lower urinary tract symptoms⁷. Treating underlying urine infection and constipation is also important to improve the bladder function. Pelvic floor exercises have been shown to improve incontinence in about 65 percent of patients⁴. These exercises can be learned by reading the brochures or can be explained in sessions by the physiotherapist.

Based on information, it is estimate that, about 55-60 percent of patient’s presents with stress incontinence, while 35-40 percent presents with urge-like symptoms. Evidence has shown that up to 60 percent of patients reported improvement or cure with the conservative management alone without any surgical intervention. For those who did not improve or requires surgical intervention, a special test called ‘urodynamics’ are carried⁶, This test would provide a more detailed diagnosis and assist management in most cases.

With the advent of minimally invasive surgery such as the suburethral sling procedures, the surgical management of stress incontinence has become more successful and less painful and with shorter hospital stay. Most of these surgeries can be done as daycases. Surgery should be performed by a surgeon who has been trained in the operation and who has a caseload to provide good long-term success rate. The primary surgery is the most important operation as subsequent operation for stress incontinence has been shown to provide poor outcome. Newer drugs, which are organ specific, and have fewer side effects and improved patient’s compliance, are currently available in the market⁸. Research continues to find new drugs for both stress and urge incontinence that are effective and have few side effects if any.

Where are we heading?

The concept of pelvic health needs expansion. Women spend lots of attention in taking care of hair, face and skin, since it promotes body image. However more than half the female population in developed and developing countries suffers from pelvic health problem such as incontinence, genital prolapse or lower bowel and sexual problems. Very little attention is made to promote good bladder habits from early age, regular pelvic exercises and bladder retraining. Little attention is made to improve the quality of life of such patients. Vast majority of women spend their life in the perimenopause and postmenopausal period, suffering in silence and feeling unwanted, isolated in their golden years¹⁰.

In conclusion, there is various strategy and treatment for most of the pelvic health problems, from simple conservative management to minimally invasive surgery for stress incontinence and drug therapy for urge incontinence. Challenges remain, in promoting the concept of pelvic health and make people and care providers to aware that help is available.

 References

1. Chiarelli P, Brown W. Leaking urine: prevalence and associated factors in Australian women. Neurourol Urodyn 1999; 18(6): 576-7.
2. Moore K. The cost of urinary incontinence. Med J Australia 2001; 174: 436-7.
3. Rane A, Corstiaans A. Does leaning forward improve micturation? J Obstet Gynaecol 2000; 20(6): 628-9.
4. Hay-Smith EJ, Bo K, Berhmans LC. Pelvic floor exercise training for urinary incontinence in women. Cochrane Database Syst Rev 2003; CD001407.
5. Bezerra CA, Bruschini H. Suburethral Sling operation for urinary stress incontinence in women.  Cochrane Database Syst Rev 2002; CD001754.
6. Glazener CMA, Lapitan MC. Urodynamic investigation for management of urinary incontinence in adults. Cochrane Database Syst Rev 2003; CD003195.
7. Moehrer B, Hextall A, Jackson S. Oestrogen for urinary incontinence in women. Cochrane Database Syst Rev 2003; CD001405
8. Abrams P, Rentzhog L, Stanton S, et al. Efficacy and tolerability of tolterodine vs oxybutinin and placebo in patients with detrusor instability. Br J Urol 1998;81(1):42-8
9. Royal College of Obstetricians and Gynaecologists Guideline No 35.
10. Ismail NN. A study on the menopause in Malaysia. Maturitas 1994; 19(3): 205-9

DESIGNER PERINEUM SURGERY – WHAT IS THE HIP ALL ABOUT?”

DESIGNER PERINEUM SURGERY – WHAT IS THE HIP ALL ABOUT?”

Dr Aruku Naidu MD(UKM), FRCOG(London). Consultant Urogynaecologist

Dr Zalina Nusee MD(UKM), MOG(UKM), Fellow in Urogynaecology

Plastic surgery for the face and body is well accepted by our society and gradually    becoming a trend among our young and old women. Our society’s penchant for perfection has finally migrated “below the belt” as well. These latest procedures include tightening and reshaping of the vulva and vagina. What is unique about this area is the patented and secretive nature of some of the most marketed technologies and the large financial gain driving this industry. This leads to a serious concern with regards to its safety and efficacy.

This surgery has brought to public attention two years ago by extensive media coverage especially in developed countries. Articles have appeared in the Wall Street Journal, New York Times, Canadian National Post, and numerous online journals. This publicity has led to an outcry by providers in women’s sexual health especially on an international website. Driving many of the objections are the slick advertisements and supported assertions that patented their methods are superior to conventional techniques without mentioning of its adverse effect. The impact was tremendously increased request for genitoplasty in British NHS which has double in one year period from 2004-05 (Liao LM 2007).

 A similar article regarding cosmetic procedures has also been published In Malaysia, by Health at Large, Sunday 15 April 2007 revealed opinion from few private gynaecologists. A month later following this article, the  Ministry of Health, had came out with a technology review paper regarding their stand pertaining to the procedures titled ‘Laser Vaginal Rejuvenation and Design Laser Vaginoplasty’.

                                                                                             

What is “designer perineum surgery” ?

 It is an aesthetic surgical procedure of the vulva structures, labia minora, labia majora, mons pubis, clitoris, perineum, introitus and hymen. This plastic surgery is to repair or reshape or reduce the vaginal muscles and/or the perineum, and interior/posterior repair, and also reshape the mons pubis. The vaginoplasty surgery tightens the vaginal walls, reinforces the vaginal support (muscles and connective tissue), and tightens the vaginal opening. The latest is Designer Laser Vaginoplasty (DLV). This technique was developed by Dr David Matlock from the United State.  It is basically just a modification of traditional perinealrrhaphy, where instead of using a scalpel, laser is used to open up a passage to vagina for a precise surgical incision. The pencil-like tip of laser equipment can take delicate design easily, bloodless, less adhesion, less painful and without scar formation. It has anti-bacterial properties, therefore reduces post operative wound infection and faster recovery. The procedure is done under general, epidural or local anaesthesia which last about 60 to 120 minutes (Matlock 2006) depending on the type of procedure, whether single or combination with Laser Vaginal Rejuvenation (VLR).

Designer Laser Vaginoplasty (DLV) can correct problems ranging from irregularly shaped and sized labia to skin discolouration to restoration of the hymen. Procedures are individually tailored to the patient to address her specific problems and concerns. These are the most commonly performed DLV procedures:

• Laser Reduction Labioplasty can sculpture the elongated or unequal labial minora according to ones specification. Most women they do not want the small inner lips to project beyond the large outer lips. Laser reduction labiaplasty techniques can also reconstruct conditions that are due to the aging process, childbirth trauma, or injury.
• Laser Perineoplasty is to rejuvenate the relaxed or aging perineum. It can also enhance the sagging labia majora and labia minora. Overall, this labia plastic surgery procedure can provide a youthful and aesthetically appealing vulva.
• Augmentation Labioplasty can provide aesthetically enhanced and youthful labia majora by autologous fat transplant (removal of the patient’s fat via liposculpturing and transplanting it into the labia majora).
• Vulvar Lipoplasty can remove unwanted fat of the Mons pubis and upper parts of the labia majora. Liposculpturing can alleviate the unsightly fatty bulges of this area and produce an aesthetically pleasing contour.
• Hymenoplasty (reconstruction of the hymen) can repair the hymen as if nothing ever occurred. 
• Combination of DLV with LVR: LVR and DLV can be performed in combination. They can also be performed with most other cosmetic surgery; the most popular of these are Liposculpturing, breast implants, breast reduction, tummy tuck, nose surgery, and eyelid surgery.

Laser Vaginal Rejuvenation (LVR) is a modification of a standard gynaecologic surgical procedure for the enhancement of the sexual gratification. According to Masters and Johnson, sexual gratification for female is directly related to the amount of frictional force generated. LVR can help restore optimum frictional during intercourse and also provide an aesthetic enhancement of external vaginal structures, resulting in a more youthful look. The vaginal muscles and connective tissues are tightened as well as reduction of redundant vaginal mucosa. The procedure enhances vaginal muscle, tone, strength and control, and effectively decreases the internal and external introitus. It can also build up the perineal body. 

WHY DO COSMETIC SURGERY?

Designer perineal surgeries definitely will benefits these groups of patients: pelvic organ prolapsed,  urinary incontinence, ambiguous genitalia ( hermaphrodites), wide, absent or stenosed vagina, painful episiotomy wound or  bad perineal scar following vaginal delivery, redundant or stenosed prepuce and enlarge clitoris.

Current practice shows that gynecological surgery isn't just for medical reasons anymore; some women say it enhances sexual pleasure. Other subjective indications include feeling of discomfort when wearing clothing, performing exercises or during sex. Some women claimed that abnormal appearance of vulva shape decreases their self-esteem and confidence. Weak perineal muscles reduces vaginal support and vagina is no longer at it optimum state causing diminish sexual gratification.

WHAT IS THE HIP ALL ABOUT?”

The aim of cosmetic surgery is to reach to ideal vulva and vagina! Scientifically there is an exact medical terminology for the anatomy of female genitalia. Unfortunately majority of women do not really know what is normal and what is abnormal. Their knowledge is mainly base on the observation of children genitalia or from the ‘Playboy’ magazine. The perception of normal perineum is also influenced by cultural taboo(Braun V 2001).  Therefore research into socio cultural representations of the vagina may be relevant to consideration of genital appearance. 

Variation in genital appearance is to be expected , and as women aged there will be changes in labia minora. Some women are born with wide vagina. Distinction should be made in women who seek labial reduction when there is no suggestion of disease.

High above Sunset Boulevard, in Matlock's plush, 5,000-square-foot office, vaginas are being redesigned, labia modified, vulvae reconfigured. The women spreading their legs, exposing their personal secrets to the antiseptic trimmings and surgical prunings of a trusty laser are ad hoc pioneers in a rapidly growing industry. The Laser Vaginal Rejuvenation ad featured a bikini-clad woman writhing in orgasmic delight. The headline read: "You Won't Believe How Good Sex Can Be!" But is LVR truly a way of enhancing sexual gratification or simply a way of selling gynecological surgery while pushing the perfect vagina? With the reasons for LVR and DLV as diverse as the vaginas themselves, the answers are not so cut-and-dried.

According to Matlock, Gynecology is a super surgical subspecialty, we dedicate our entire professional careers to the reproductive tract. But do we ever go back and look at the things that result from labor, delivery and childbirth? There can be relaxation of that structure and thus a diminishment or a decrease in sexual gratification. Do we concern ourselves with that?  We only concern ourselves with obstetrics. Research is needed in this area, because women do enjoy sex and want to enjoy sex. Women want to be able to enhance their sexuality if they can.

It's a personal preference. For women who are severely damaged, sex should still be intense and passionate." And herein lies the crux of the problem. No one would disagree that "severely damaged" women are entitled to great sex. While a staggering 30 percent of women will develop some form of pelvic floor disorder resulting in incontinence or compromise of vaginal integrity after birth, only 5 to 10 percent will be so damaged that they can easily fit a household appliance in their vaginas. This is why these 40-, 50-, 60-year-old men are running after younger women?

There are over 25 medications for male impotence, and it takes $500 to $600 million to bring one drug into research and development. Those are facts. There is nothing remotely similar there for women.  There are over 200 prosthetic devices for men on the market but nothing similar for women. If men had babies, and certain body parts stretched out as a result, they would have been looked at, researched and solved a long time ago.

Virginity is restored by a technique called hymenoplasty. Essentially the reconstruction of the hymen, has brought the gynaecologist’s office a steady clientele of Middle Eastern women. Believe it or not how hysterical some of these women. They claimed that they're going to get killed unless they get this done. If the families get to know that they are no more virgin, they will kill them. The majority of these Middle Eastern women are coming in to have hymenoplasty because they're getting ready to get married in their home country.  The groom's side of the family can pick whatever doctor they want to determine whether or not she's a virgin, to determine whether she's worth it or not to be married to their son. So there are religious implications, there are social implications.

Serious perhaps, but not always a question of life or death, make hymenoplasty at one point became a regular thing. These cited the occasional flurry Japanese women who come to the States, do a little school, go on vacation, then come here, have hymenalplasty and go home.  As for Americans, women is seeking the "virgin experience" to share with their husbands and some do it just before celebrating their wedding anniversary.

As cosmetic surgery becomes more widespread, designer vaginas may become as common as the silicon breast -- a sinister prospect that has many women's advocates up in arms. "Women's genitals are fascinating, unique and beautiful," says pioneering sex therapist Betty Dodson, who for decades has helped women discover their genitals, and particularly their clitoris, which she describes as women's "little phallic symbol that terrifies the status quo". She considers LVR and DVR as truly odious procedures except for very extreme cases.

"Now we want little doll-like genitals and vaginal orgasms and Viagra for women!" she laments, reemphasizing the need for women to assert their "clit power" as the only true road to enhanced sexual gratification. "If men can get close enough to lick and diddle, they don't give a rat's ass about the size of your genitals or the shape of your labias," she says. Dismissing the link between vaginal tightness and sexual gratification as a way for men to cash in on women's insecurities and for women to appease the male ego.

"I think this is a way of preying on vulnerable women," says Dr. Linda Brubaker, fellowship director of Female Pelvic Medicine & Reconstructive Surgery at Loyola University Medical Center. "I reconstruct vaginas all the time. I agree that the field of women's sexual functioning is a poorly studied area. But I don't buy any of what Matlock is saying. There are standard pre- and post-operative intervention tests and tools that could be applied here to substantiate his claims. Curious that Matlock has not applied any of them to his own work, nor published any scientific material relating to his work, nor subjected anything to peer review. The longer this is untested, the better for him."

The effectiveness of the procedures is still unclear. Matlock (2006) claimed that he is currently numerous studies on the effectiveness of his procedures. The cost for DLV and VLV is estimated to range between USD$3000.00 and USD$20,000 depending on the type of procedure and anaesthesia (Laube 2006).

Those procedures are not permanent, aging process and delivery will destroy the integrity of the vagina. Augmentation labioplasty using outologous fat will only last for few weeks. Like face lift, vaginal cosmetic surgery need to re do. There was no retrieval evidence regarding the effectiveness of the procedures and the safety aspect of this technology, only anecdotal claims from customers were found from the web site. To those considering LVR or DLV two procedures that are not without their risks, among them hemorrhage, infection, loss of sensitivity, lingering pain from nerve damage and sexual dysfunction. To date no related legal action being reported pertaining to these procedures.

There was no literature found mentioning about legal aspect of the procedure. It could level DLV as a form of female genital mutilation. Following the WHO definition, all procedures involving partial or total removal of female external genitalia or other injury to the female genital organs whether for cultural, religious or other non-therapeutic reasons is consider genital mutilation.(Convoy 2006).  In Arabs countries, hymenoplasty is an illegal procedure.  Therefore Matlock could become the Salman Rushdie of the Islamic vagina. On the contrary. He claimed that "If I can help a woman in this unfair world, then I'm going to go ahead and do it. I have no problems about doing it whatsoever. The man, he gets to do whatever he wants to do. Is he held accountable for anything? Absolutely not”.

  There were women who claimed no changes in her sexual life after the procedure (R Bramwell 2007). Some of them still not satisfied with the look of her vagina following the procedure because of the lack of understanding of how is the normal vagina look like. By obscuring the lines between the severely damaged and the naturally relaxed vagina, Matlock has leveled the playing fields among all women and widened the market potential for his genital landscaping. His tight-vagina hype also flagrantly misses the point. With sexual ground zero located in the clitoris, one can only wonder for whom the tight vagina truly tolls -- men or women?

Women have to be clear that the procedure would not improve the sexual libido. Sexual gratification is individualized it could be affected by not only physical problems but also psychosocial. Before offering a women the procedure their sexual life need to be explored, preferably by psychosexual counselor. Unfortunately women who see the problem as physical may resist referral to psychosexual or other psychological services. Furthermore such services are currently rare and have long waiting lists (R Bramwell 2007). 

Conclusion

Till now there is no retrievable evidence on safety, efficacy or cost effectiveness and legality of DLV and VLV. Patient who wish to undergo the procedure need a detail counseling regarding the indication, the long term and short term implication especially the safety aspects.

The use of this technology in our society should be made with extreme caution to avoid unethical practice by gynaecologist as this procedure may be used for wrong purposes.   

Figure 1: Training on use of laser for vaginal Rejuvenation

References

1. Liao LM, Creighton SM. Requests for cosmetic genitoplasty: how should health providers respond? BMJ 2007;334:1090-2.

2. Braun V, Kitzinger C. Telling it straight? Dictionary definitions of women’s genitals. J Socioling 2001;5:214-32.

3.  Braun V, Wilkinson S. Socio-cultural representations of the vagina. J Reprod  Infant Psycol 2001;19:17-32.

 

4. Braun V, Kitzinger C. The perfectible vagina: size matters. Cult health sex 2001;3:263-77.

5. Debra Ollivier.Designer vaginas, Nov.14,2000

6. Conroy R.M. (2006). Female genital mutilation: whose problem, whose solution? BMJ,333(7559):106-107.

7. Matlock D(2006). The Laser Vaginal Rejuvenation Institute of Los angeles. Cited 14” May 2007 and 21^st May 2007. Available from http://www.drmatlock.com

8. Laube D.W. Clinical Obstetrics&Gynaecology,.49(2):335-336

9. Bramwell R, Morland C, Garden AS. Expectations and experience of labial reduction: a qualitative study. BJOG 2007;114: 1493-1499

10. Kong Howe Leng. Reviving the passage of birth. After birth april 2007.

11. Junainah S, Norzakiah M.T, Rugayah B. Laser Vaginal Rejuvenation, Designer Laser Vaginoplasty. Health Technology assessment Unit, Medical Development Division Ministry of Health Malaysia. Mei 2007