Functional and anatomic results after creation of a neovagina ...

MATERIALS AND METHODS
Between June 2001 and September 2009, 17 consecutive young women with
MRKH syndrome were surgically treated with neovaginoplasty according to
the Wharton-Sheares-George technique at the Department of Obstetrics and
Gynecology, Medical University of Vienna, Austria. All operations were
performed by the same gynecologist (R.W.).
All women underwent an extensive preoperative diagnostic workup, including
an intravenous pyelography to detect anomalies of the urinary tract.
The surgical procedure is described in detail by Sch€atz et al. (36). After local
pretreatment with estriol cream for 3 weeks, a diagnostic laparoscopy was
performed under general anesthesia for orientation and confirmation of the
abdominal organs. Afterward, the rudimentary M€ullerian ducts (which could
be identified in all patients, 2 cm dorsal to the external urethral ostium and 1
cm paramedially) were dilated incrementally by gently pushing Hegar dilatators
(2.5–14) in the direction of the pelvic axis (Fig. 1). The median raphe
was intersected with diathermy, and subsequently, a vaginal mold, coated
with estriol, was inserted into the newly created cavity. On the seventh
day, the vaginal mold was exchanged for a larger one. Based on our experience
as well as recommendations in the literature (16, 19, 30), patients were
advised to continue using the plastic mold for the first 3 postoperative
months, day and night, to prevent stenosis and shrinking of the neovagina.
After this period, normal sexual intercourse was possible.
All patients with MRKH syndrome who had been treated surgically according
to the Wharton-Sheares-George technique at the Department of Obstetrics
and Gynecology, Medical University of Vienna, Austria (n ¼ 17),
were invited for a follow-up evaluation, conducted from September 2009
to February 2010. Three women were excluded from the study because of
a follow-up time of less than 3 months. Three patients were lost to followup
because of changes in their addresses and cell phone numbers, and 1
woman refused to return because of a new job a greater distance away. Therefore,
10 patients could be included in this open study evaluating the longterm
functional and anatomic success of the operation.
Institutional Review Board approval was obtained for the study, and
women gave their verbal and written informed consent before inclusion.
All procedures were performed in accordance with the standards of the responsible
ethics committee.
At the follow-up visit, participants underwent a gynecologic examination,
including palpation, pelvic ultrasound, vaginal swab, bacterial culture, Papanicolaou
(PAP) smear, hybrid capture test for human papillomavirus (HPV)
typing, and biopsy. Afterward, women were asked to grade the severity of
pain during the examination on a 100-mm visual analogue scale (VAS). Individual
quality of psychosexual life and overall subjective degree of satisfaction
with the operation were assessed by 2 specific questionnaires.
The Rosen Female Sexual Function Index (FSFI) questionnaire, validated
for the German-speaking population, contains 19 standardized questions for
the evaluation of female sexual quality of function (i.e., desire, arousal, orgasmic
and sexual pain disorder, quality of vaginal lubrication, and global
sexual and relationship satisfaction) (37). Women were also asked to fill
out a second questionnaire created by our group containing 23 specific questions
to elucidate the individual medical history and current situation of the
patients (e.g., influence of the diagnosis and surgical treatment on selfesteem,
sexual life, and relationships). Well-being scores before surgery
compared with the present time were recorded at the follow-up examination.
The main outcome measure of the present study was the functional (satisfaction
with sexual parameters and quality of life), long-term result of the
surgical procedure. In addition, we evaluated the anatomic (length and width
of the neovagina, structure of the vaginal epithelium, and type of bacterial
colonization) outcome.
RESULTS
At the time of the neovaginoplasty according to Wharton-Sheares-
George, the mean age of the patients was 20.0 5.8 years (range,
15–34 years). Mean follow-up since the operation was 33.5
22.4 months (range, 3–77 months).
All operations had been performed without major complications.
In 6 patients, minor old blood secretions were found during the
Fertility and Sterility â
FIGURE 1
Vaginal dimple—rudimentary M€ullerian ducts. Hegar is pointing to
the left M€ullerian duct.
Walch. Long-term outcomes after Wharton-Sheares-George surgery. Fertil Steril 2011.
exchange of the vaginal mold on the seventh postoperative day. In
1 patient, elevated body temperature occurred postoperatively concomitant
with fluid retention in the neovaginal region but was
treated effectively with antibiotics; no surgical intervention was
needed. Eight patients reported mild abdominal pain during the first
postoperative days; analgesic medication was administered. Mean
operation time, including diagnostic laparoscopy (additional adhesiolysis
in 1 patient and tubectomy in another), was 46 9 minutes
(range, 30–65 minutes). The mean time for Wharton-Sheares-
George dilation was 21.5 2 minutes (range, 20–25 minutes).
Four of the 10 patients (40%) presented with congenital inguinal
hernia in their medical history. In all of these patients, surgical treatment
had been performed successfully in the past. In one of the patients,
multiple skeletal anomalies (Morbus Sprengel) and a throat
fistula had also been found. Another patient demonstrated a pelvic
kidney on the left side.
At the follow-up investigation, the external genitals were regular
in all patients, and no prolapse of the neovagina had occurred postoperatively
in any of the patients. A gynecologic examination with 2
standard specula (Breisky anterior speculum, 100 25; Matzenauer
posterior speculum, 100 25 mm; KLS Martin Group) could be
performed in every patient. The mean score for severity of pain during
the examination was 12 11 (range, 0–30; no pain at all, 0 and
maximum, 100).
In 9 of 10 patients, the neovagina appeared macroscopically
regular; in 1 patient, the process of epithelialization was not yet
complete because the time since the operation was relatively short
(