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Apligraf Shows Promise in Building Vaginal Wall in Rokitansky Syndrome


 

NEW ORLEANS — Apligraf has been used successfully to line a new vagina in a patient with Mayer-Rokitansky-Küster-Hauser syndrome.

The human skin equivalent derived from human infant foreskin has been used widely for wound repair, but this is the first reported successful use for this purpose, Albert Altchek, M.D., reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

The 19-year-old patient with congenital absence of the uterus and vagina refused the split-thickness skin graft typically used for treating the condition and instead underwent the Apligraf procedure. Perineal biopsy and dissection were used to create a vaginal space, and 20 Apligraf patches—sewn together and wrapped around a soft, inflatable vaginal stent—were applied to the space, said Dr. Altchek of Mount Sinai School of Medicine, New York.

After the patient remained on bed rest for 1 week, the stent was removed and a second Apligraf application was placed. A week later, the Apligraf lining was found to be degenerating as a result of graft rejection; however, a small patch of vaginal mucosal cells that had been present proliferated to cover the entire neovagina. Soft vaginal stents were used to prevent strictures.

The result was a soft, pliable, moist, normal-looking vaginal mucosal wall, which has maintained patency for 61/2 years without a stent, Dr. Altchek said.

Apligraf was previously thought to stimulate only skin growth, but based on this case, it appears that it “actually preferentially stimulates another tissue—mucosa,” he said.

In the case of the 19-year-old patient, she had an excellent result. At 6-month follow-up she had normal cytology, and at 4 years she reported frequent sexual activity with orgasm. At last contact she was being referred for a surrogate gestational carrier.

This new method for correcting the defects associated with Mayer-Rokitansky-Küster-Hauser syndrome is investigational but shows great promise, he said, noting that it has several advantages over the split-thickness skin graft approach. Aside from scarring at the donor site, the split-thickness graft approach—unlike the Apligraf approach—results in atypical appearance and function; it also tends to cause malodor because the vagina is created using skin.

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