In cases of congenital vaginal absence caused by vaginal agenesis or in cases of male to female sexual or gender reassignment surgery (GRS), where a vaginal cavity never existed, a significant surgical procedure known as vaginoplasty is carried out to establish an artificial vaginal cavity.

About 1 in 4000 to 5000 live-born girls have Mullerian dysgenesis. Females are susceptible to Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome, an autosomal-dominant disorder that primarily impacts the reproductive system. The uterus and vagina are absent or underdeveloped as a result of this disorder.

Due to the absence of the uterus, affected women typically do not have menstrual periods; this is how these patients typically appear as primary amenorrhea. Women with MRKH Syndrome have ovaries that function normally and a female chromosomal pattern (46 XX). Additionally, their pubic hair, axillary hair and breast development, as well as their external female genitalia, are normal. Assisted reproduction may allow women with this disorder to have children, even if they are typically unable to carry a pregnancy [1].

A solitary absence of the proximal two thirds of the vagina is the hallmark of type 1 MRKH Syndrome, while other abnormalities such as cardiac, urologic (upper tract), otologic, and vertebral abnormalities are characteristic of type 2. When the müllerian ducts completely fail to develop, the uterus, fallopian tubes, and the majority of the vagina are absent (Mayer-Rokitansky- Küster-Hauser [MRKH] syndrome). In these situations, the vulva is probably normal, although there might be a variable-depth depression that represents the vagina's bottom (urogenital sinus) portion. Such a depression with a normal hymen covering it is typical (table1 and fig.1).

The patients' karyotype is typical for females. Skeletal abnormalities, cardiac abnormalities, and renal ectopy and agenesis are linked. It has been suggested that inheritance is multiple. Reduced g alactose-1-phosphate uridyltransferase activity has been associated with MRKH syndrome, which increases intrauterine galactose exposure.

The treatment's purpose is to ensure that the patient have unscarred vagina that permits sexual activity. Even when the Mullerian agenesis anomaly in a certain patient is clearly understood, it may not be possible to determine the proper form of the defect until surgery is performed.

To ensure a successful surgery, it is crucial to have a solid understanding of the surgical anatomy of this area. It is crucial that the patient and her parents receive in-depth counseling about her changed marital prospects, including sexuality, marrying someone who isn't interested in having children outside of the marriage, social and financial independence, etc.

Table 1: Classification of mullerian anomalies [2]

Reprinted by permission from American Society for Reproductive Medicine (fertility and sterility 1988; Vol 49 (6): page 944-945).

Figure 1: The American Society for Reproductive Medicine classification of Mullerian anomalies.

Reprinted by permission from American Society for Reproductive Medicine (fertility and sterility 1988; Vol 49 (6): page 944-945)

Embryology:

The female reproductive system is made up of the gonads, internal duct system, and external genitalia. These elements come from many primordia and are closely related to the hindgut and urine system from an embryological perspective (Figure 2) [3]. While the Wolffian duct system regresses in the early stages of a female fetus, the Mullerian duct system is subsidized to develop instead. The Fallopian tubes, the uterine corpus and cervix, and a section of the vagina are formed by the Mullerian ducts, which continue to grow and reach full maturity. Mullerian ducts and the urogenital sinus combine to produce the vagina (Figure2) [3].

Figure 2: Development of female reproductive system [3]

Cell growth at the caudal terminus of the united Mullerian ducts produces a solid vaginal cord. From the urogenital sinus below, the cord eventually lengthens to meet the bilateral sinovaginal bulb. The whole development of the vagina is achieved by subsequent canalization and epithelialization with cells primarily derived from the urogenital sinus. The hymen, which is not derived from the Mullerian ducts, is the embryological septum that separates the urogenital sinus below and the sinovaginal bulbs above. The fundamental cause of various types of vaginal agenesis is a failure in the Mullerian duct's growth at any point between its genesis from the coelomic epithelium and its fusion with the urogenital sinus [4,5].

Synopsis of surgery:

Indications of surgery: The leading cause for vaginoplasty is Mayer- Rokitansky-Kuster-Hauser syndrome, which is a congenital absence of the uterus and vagina. Vaginoplasty is also necessary for an incomplete form with a transverse vaginal septum or a partially atretic vagina with an intact uterus. Male gonadal inhibition of Mullerian duct development may result in inadequate vaginal development in testicular feminization syndrome or Androgen insensitivity syndrome. To have a satisfactory sexual function in their female gender role, these genetically male individuals with female phenotypes who lack a fully developed   vagina   should   have surgery to fix it. Similarly, in   cases of male to female sexual or gender reassignment surgery (SRS or GRS) where a vaginal cavity did not exist, an ineffective suppression of mullerian ducts may result in ambiguous genitalia associated with a small rudimentary uterus or a partially developed vagina requiring vaginoplasty in congenital adrenal hyperplasia.

Preoperative evaluation: When the patient is between the ages of 17 and 19, when they are psychologically as well as cognitively mature enough to easily handle the vaginal mold that will be utilized to preserve the neovaginal space, the treatment should begin. As an alternative, a vaginaloplasty could be scheduled a few months before marriage to start regular intercourse and keep the vagina open.

Investigations: A missing uterus can be seen using abdominal ultrasound, which can also assist distinguish between pelvic kidney, endometrial and other ovarian cysts, hematocolpos, and hematometra. It is also necessary to perform a scan for further renal abnormalities an intravenous pyelogram to identify any abnormalities in the kidneys. MRI can be used to diagnose renal, vaginal, and uterine problems. Several methods for vaginal construction. Regarding the best way to address the issue of vaginal agenesis, there is no universal agreement. Both nonsurgical and surgical corrective techniques have advantages and disadvantages.

Nonsurgical methods:

Frank technique or perineal dilatation: The Frank technique, also known as perineal dilatation, is based on the gradual dilation of the vaginal dimple at the introitus. Firm pressure is applied to the dilators (Figure 3) [6] against the fourchette for 15 minutes twice a day, or more frequently, or using a bicycle seat stool. Slowly, the dilatation will continue until the vagina is full length. The self-administered technique necessitates patience and patient drive. Patients with vaginal dimples or those without vagina may not comply well since they may feel uncomfortable and stop using the dilator. It is necessary for the attendant overseeing the patient's case to support her enthusiasm [6-8].

Figure 3: Perineal dilators [6]

Surgical methods: Among the surgical techniques, we have performed the McIndoe surgery on all three of our patients. Other surgical techniques include William vulvovaginoplasty, Colon vaginoplasty, and Laparoscopic neovaginoplasty (Vecchietti procedure), McIndoe procedure. Abbe was the first to describe the McIndoe technique, which was subsequently revised by McIndoe and Banester as well as several other scholars. During this procedure, a 0.5 cm incision is made across the fourchette region, primarily using blunt dissection to create a gap between the bladder and rectum. After that, a blunt finger dissection is performed to get the ideal vaginal length of 10–12 cm. At freshly made amnion graft is used to line the area (Figure 4) [9]. After that, the graft is placed over an appropriate mold, its deep surface facing outward to make contact with the freshly formed vaginal wall. The molds can be pliable and constructed of rubber foam packed into rubber condoms, or they can be stiff over a dental stent. In order to prevent the new vagina from contracting, McIndoe first left the mold in place for three months [5, 8, 10].

Postoperative care: For the neovagina to retain its ideal size and shape, all vaginoplasty procedures require careful postoperative care and follow-up. Labial sutures are popped up one week following surgery, and the cavity is examined for healing and epithelialization progress. After cleaning the mold, the patient is shown how to re- insert it so that the neovaginal cavity can continue to dilate on its own. The patient is directed to continue neovaginal dilatation four to six times daily for a total of forty-five minutes each day. This dilatation seems painful and laborious at first, but it is eventually needed less frequently. If there is no frequent sexual activity or any artificial dilation of the neovagina, the neovagina has a strong tendency to constrict at any stage of life. Therefore, to maintain its benefits, a neovagina needs to be maintained throughout one's life.

Figure 4: McIndoe Procedure [12]

Complications: By far the most frequent and serious side effect after vaginoplasty is vaginal stenosis. It has been demonstrated that a prolonged time of non- dilation can cause the neovagina narrow in both length and diameter. It is normally possible to recover from this loss with cautious perseverance and a little discomfort. Fibrotic vaginal bands and infection are the usual outcomes of first surgical failure. Since it is more difficult to dissect stiff fibrous tissue than it is to dissect loose soft tissues during the initial procedure, repeat surgery in these patients entails the highest risk of fistula formation. The most dangerous complication is fistula creation; if it happens during surgery, the initial procedure should be stopped and the fistula closure treatment should be started first. Anticoagulant medication combined with intermittent leg compression can also prevent pulmonary embolism from deep vein thrombosis. Urine may occasionally squirt during micturition; this normally goes away when the vaginal swelling goes down. The patient should be reassured about the inevitable effects of the altered vaginal anatomy and their propensity to adjust with time [9, 11, 12].

Three vaginal agenesis patients who were hospitalized to the obstetrics and gynecology ward of Nootan General Hospital in Visnagar in 2023–2024 were the subjects of this study. Every patient who arrived at the gynecological outpatient department had primary amenorrhea, which is defined as not having a period by the age of sixteen while exhibiting secondary sexual characteristics. The patients were between the ages of 18 and 21.

The examination was conducted methodically in accordance with the protocol followed while assessing a patient who had primary amenorrhea. Each patient exhibited well-developed secondary sexual features, such as pubic, axillary, and breast hairs, and was of a standard stature. Upon local examination, the vagina was blind, but the external genitalia were normal. A thorough pelvic and renal ultrasound was performed, and the results showed that the ovaries were present but the uterus was lacking in every case. There were no renal abnormalities or associated urine complaints in any of the patients.

Although vaginal septum, secondary vaginal atresia, and androgen insensitivity syndrome are among the various causes for which our hospital performs vaginoplasty, only cases of MRKH Syndrome were chosen for amnion vaginoplasty due to its lack of homogeneity. IVP was not performed because none of the patients exhibited any renal abnormalities. Hemogram, blood group, serum urea, creatinine, blood sugar, sr. bilirubin, urine routine and microscope inspection, ECG, and chest X-ray were among the other pertinent preoperative tests that were performed.

Patients and their parents underwent in-depth psychological counseling. A thorough explanation of the entire process, potential side effects, and the necessity of a strict follow-up was given. We obtained written and verbal permit for utilization of another individual's foreign tissue since we lined the neo-vaginal area with amnion. All of their concerns about the spread of hepatitis and HIV were addressed. The patients politely waited despite being fit for surgery because their procedure was scheduled for the day of the elective cesarean section, which required fresh amnion. The night before surgery, bowel preparation was completed and the injection of an antibiotic was initiated.

Preparation of amniotic membrane: After elective cesarean delivery, the amniotic membrane was collected sterilely from a seronegative donor; alternatively, it could be preserved in regular saline for 48–72 hours at 4 degrees Celsius. Grafting should not be performed on amniotic membranes that have meconium stains, probable chorio-amnionitis, or premature rupture. All amnion donor were examined for syphilis, HIV, hepatitis B, and hepatitis C. An antibiotic-containing balanced saline solution is used to wash the placenta clear of blood clots.

Blunt dissection has been utilized to separate the inner amniotic membrane from the remainder of the chorion (via the potential voids between these two tissues). With the exception of where the umbilical cord inserts, the amnion can separate from the placenta's fetal surface. The amnion's exterior surface contrasts with the chorion's interior appearance, which allows it to be peeled off (Figure 5).membrane over the mold, skin grafting is not necessary [5, 13].

Figure 5: Preparation of amniotic membrane

Surgical technique: The McIndoe vaginoplasty with Sheares modification was the surgical procedure was performed in all three patients. The procedures were carried out by two distinct gynecologists with over ten years of expertise. The patient was put in a lithotomy posture with their legs in stirrup following regional anesthesia. Part shave been cleaned and draped. Foley's catheter was used to catheterize the bladder. In order to diagnose accidental harm due to improper dissection or in the incorrect plane as soon as possible, a small amount of methylene blue was injected into the bladder via catheter. We created two apertures that admit small fingers, each about 4-5 cm long, by using Hegar dilators to stretch up the paramesonephric duct region on either side of a midline septum between them (Figure 4).

After that, scissors were used to split the midline septum into a single cavity that could easily accommodate two fingers width-wise. Because dissection beyond this point raises the risk of damaging the bladder anteriorly and the rectum posteriorly, further dissection was done cephalad with utmost tenderness and caution. An assistant's gloved finger in the rectum will serve as a guide to avoid perforation and excessive dissection and posterior burrowing. Likewise, the Foley catheter could be used anteriorly as an orienting aid. An empty syringe with a needle can be used to aspirate through the anterior vaginal wall when it's unclear if it's in the proper plane. Aspirating blue-colored fluid indicates that the plane is incorrect and that we are closer to the bladder.

Retractors can be stretched outward and positioned along the lateral walls of the developing canals to increase the area. Additionally, further width can be added by cutting the puborectalis muscles' medial fibers. These muscles are sliced at a level midway along the anteroposterior length of the canals and along the lateral face of each canal. The canal extends to within 2 cm of Douglas's cul-de-sac on the cephalad. A layer of connective tissue remains attached to the peritoneum as a result. Compared to a smooth peritoneal surface, the skin graft will adhere to this connective tissue more successfully. The last solitary channel is about three fingerbreadths wide and 10 to 12 cm deep. Hemostasis is necessary before the mold is inserted because blood clots can detach the skin graft from the canal beds. In order to prevent leaking, a saline-soaked vaginal pack is placed inside the neovaginal cavity once the proper mold has been made. Because it promotes capillary vasoconstriction and hinders the subsequent graft uptake, adrenaline should not be administered [1, 5, 13].

Figure 6: Preop blind vagina

Vaginal mould preparation: A stent is required to adhere and secure the graft to the vaginal walls after graft harvesting and neovagina development. Both hard and soft shapes have been employed. Balsa wood, Pyrex, plastic, and synthetic silicone-based materials have all been used as rigid mold materials. Graft loss, fibrosis, contracture, and pressure-related bladder or rectal fistulas can all result from rigid stents. The frequency of these issues has dropped with the use of soft stents.

Figure 7: Creating neovagina

As a vaginal mold, we utilize condoms packed with foam rubber. The neovagina-corresponding size is chosen. A condom that is attached to its open end is then applied (Figure 8). An alternative is to use a 20 ml foam-covered syringe. Amnion graft has now been applied to the vaginal mold. The graft is taken out of the salt water. The graft's long axis is positioned parallel to the mold's long axis. After that, the graft is stretched over the tip of the mold. Next, using interrupted stitches of 3-0 catgut, the lateral margins of the amnion graft are roughly drawn on either side of the mold. It is crucial to adjust the mold to the size of the newly formed neovaginal canal. Tissue necrosis may ensue from pressure necrosis or insufficient drainage caused by an excessively wide mold. The mold is inserted when it has been properly sized and built. In order to keep the mold in place for the first seven postoperative days, the labia's edges are then stitched together along the midline using interrupted 2-0 silk sutures. The perineum is covered with a sterile compression bandage (Figure 9).

Figure 8: Vaginal mould

Figure 9: Post-Operative

Either vaginal dilatations, which are non-surgical techniques, or vaginoplasty, which is a surgical technique, can create a new vagina. In some instances of primary vaginal atresia, the non-surgical approach could be beneficial. Nonetheless, vaginal reconstruction is necessary for the majority of individuals. When it comes to vaginoplasty, the patient's cooperation is crucial. Maintaining the vaginal space during the contraction phase of wound healing is the most crucial step, and this is made possible by efficient molds and stents.

Congenital vaginal absence (Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome), gynecological tumor excision, male to female sex surgery, and secondary vaginal atresia are the main reasons for vaginal reconstruction.

With differing degrees of success, attempts to create an artificial vagina surgically have been made for decades. In 1559, Columbus may have been the first to mention congenital vaginal absence. The use of tampons to preserve patency after vaginoplasty was initially documented by Dupuytrens. Abbes were the first to use split-thickness skin graft to cover the mold. Nonetheless, McIndoe and Bannister were the ones that highlighted the necessity of creating a sufficient amount of space, covering the molds with split-thickness skin grafts, and—above all— continuous and extended dilatation throughout the contractile phase of healing. Sigmoid colon, ileum, caecum, pudental thigh flaps, fasciocutaneous flaps, gracilis myocutaneous flaps, labia minora flaps, flaps elevated after tissue expansion of the labial pocket, peritoneum, bladder mucosa, amnion, and other surgical techniques involve creating neovaginas. Patients may develop scars from free skin transplants, peritoneal grafts, local skin flaps, and bladder mucosal grafts. The drawbacks of bowel segments include the potential for intestinal blockage, secretions, unpleasant odor, mucosal ulcers, and abdominal scarring

One common reason of primary amenorrhea, the inability to resume menstruation, and the inability to conceive is mullerian development (MRKH syndrome). For sexual purposes, the vagina can be created. Although it has many advantages, vagina can be formed surgically as a primary corrective procedure called vaginoplasty or nonsurgically by gradual dilatation (Frank's approach).

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