Wednesday, 15 June 2011

Vaginoplasty using amnion graft

Vaginoplasty ( Neovagina)
 Dr Aruku Naidu MD FRCOG CU

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

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