Women who need vaginal reconstruction now have another surgical option—a vascularized free jejunal graft that provides a durable, lubricated neovagina without the scarring that skin grafts can leave.
Dr. Münire E. Akar and her colleagues have reported the largest series of these operations yet—31 patients since 2005. During the mean follow-up of 19 months, the team has had a 100% graft survival rate and a 10% rate of anastomosis revision.
Dr. Akar reported on 14 of these patients at the Global Congress of Minimally Invasive Gynecology, held last November. In December, she and her colleagues published a series of 22 such cases (Microsurgery 2009 [doi:10.1002/micr.20713]), but since the article was accepted, the team has performed 9 more operations, for a total of 31. All procedures were performed at Akdeniz (Turkey) University, Antalya; Dr. Akar is currently performing research at Wake Forest University, Winston-Salem, N.C.
Although the procedure takes about 5 hours and the recovery period is long, the end result is worthwhile, Dr. Akar said in an interview. “It can be very hard for patients to go through, but usually they are fed up with their condition and so they are ready to do whatever is necessary,” she said.
The ideal vaginal reconstruction should provide a long-lasting, functional passage for sexual intercourse that does not need maintenance with dilators or lubrication for sexual activity. The jejunal flap offers these advantages over grafted skin and is less likely to cause gastrointestinal problems, compared with the more widely performed colon transfer, she said. Although she and her team have not had any graft failures, if one did occur there would be plenty of replacement material, which is not the case with a bowel transfer, she added.
The surgery is a significant contributor, but not a perfect answer, for women with vaginal agenesis or those who require reconstruction as a result of trauma or gynecologic surgery, said Dr. Ronald Silverman, chief of plastic surgery at the University of Maryland, Baltimore.
“It's definitely an excellent technique, but there are some negatives,” he said in an interview. “It's very high demand in terms of the length of operation and the technical demand on the surgeons. And since it's done through the abdomen, there is an additional scar.”
Harvesting the intestine is much more invasive than taking skin. “This would not be my first choice of technique,” said Dr. Silverman, who prefers the Singapore, or pudendal, thigh, flap. “One of the nice things about [the thigh flap] is that the medial thigh does have erogenous sensation, while the jejunal transfer is insensate,” because of the severing of its neural connections. “The whole reason for doing a vaginal reconstruction is to have a normal sex life,” so having vaginal sensation is a logical goal for such surgery, he said.
A skin-grafted neovagina, however, requires a lot of postoperative care to maintain its integrity. Unless the woman engages in frequent penetrative sex, she must make regular use of a dilator or stent to maintain vaginal depth and avoid introital constriction. In Turkey, this is an almost unthinkable task for women, Dr. Akar said.
“Women in our society are not conditioned to do this kind of thing. Our culture is very conservative, so until they are married, girls don't ever touch their genitals or even talk to their mothers about such things. It's very hard to ask them to do this—it's not really a choice for our women.”
This societal inhibition also precludes what is often the first-line treatment for vaginal agenesis: the use of graduated dilators or internal traction to create a functional vagina.
After making a 10-cm incision beside the umbilicus, the surgeon isolates a jejunal segment of about 30 cm, distal to Treitz's ligament.
The segment is removed, along with its vascular pedicle, and the ends of the remaining jejunum approximated and anastomosed.
The surgeon creates a pouch for the neovagina from the blind vaginal introitus into the abdominal cavity. The jejunal segment is transferred into this pouch vaginally, and the proximal end closed with sutures and anchored to the retropubic periosteum.
A second tunnel from the periosteum to the inguinal region accommodates the vascular pedicle. Arterial and venous anastomoses between the flap and the recipient vessels are performed through a 6- to 7-cm inguinal incision. Finally, the surgeon attaches the distal opening of the jejunal segment to the vaginal introitus, creating a vagina of about 15–17 cm in length.
The mean surgical time in the series was 5 hours, with patients discharged about 2 weeks later. They were allowed to engage in sexual intercourse after 1 month.