Intestinal vaginoplasty for congenital absence of the vagina

Abstract

Congenital absence of the vagina is rare and occurs as a result of aplasia of the Mullerian ducts (46,XX) or complete androgen insensitivity syndrome (AIS--46,XY). Both syndromes are associated with normal female external genitalia and these patients are raised as females. These children are usually treated during adolescence with chronic dilatation of the shallow vaginal introitus (pressure tube technique) or by skin graft vaginoplasty (Mcindoe procedure). Neither of these procedures is entirely satisfactory, as both may lead to neovaginal stenosis, inadequate length, poor lubrication, or all three. We have recently modified the operation first described by Baldwin in which a loop of sigmoid colon or small bowel is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and anastomosed to the hymenal ring. We have performed this operation on four adolescents (mean age, 15 years) and two infants (aged 4 days and 14 months) with excellent results (mean follow-up, 7.5 years for the adolescents and 1.8 years for the infants). The advantages of a bowel segment in contrast to a skin graft are: (1) minimal likelihood of "poor take" or later contraction 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) dysparenunia frequently seen with skin grafts is avoided by the ability of the intestinal segment to withstand local trauma; and (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. The sigmoid colon is the best choice for interposition vaginoplasty because of size, location, and ease of preserving blood supply.