Laparoscopic sigmoid vaginoplasty: a salvage option for genitourinary fistula after failed McIndoe's repair

Abstract

A 30-year-old woman presented with vesicovaginal fistula after a forceful intercourse. She was diagnosed as a case of Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome 14 years ago and had underwent McIndoe's vaginoplasty using amniotic membrane. Similarly, another 14-year-old girl presented with an iatrogenic urethral and bladder neck injury during an attempt at McIndoe's vaginoplasty 4 months ago at another centre leading to urinary fistula with absent vagina. A laparoscopic salvage was done for both the cases along with repair of genitourinary fistula using sigmoid colon. There was no further requirement of vaginal dilation. Both patients remain fully continent at 1 year follow-up. Laparoscopic sigmoid vaginoplasty is a worthy minimally invasive salvage method for the patients of MRKH who develop fistulous complication after a previous attempt at neovagina creation. The bowel wall provides a structurally strong layer to withstand the repeated sexual trauma of the vagina.

Keywords: obstetrics, gynaecology and fertility; plastic and reconstructive surgery; urinary and genital tract disorders; urological surgery.

Figure 1

(A) Vaginoscopic view of vesicovaginal fistula in the first case with McIndoe’s vaginoplasty done 14 years ago. (B) Operative image showing large bladder neck/urethrovaginal fistula in the second case after a failed attempt at McIndoe’s vaginoplasty 4 months ago. Space has been created between the bladder and rectum to subsequently accommodate the sigmoid segment as neovagina, as shown with full depth insertion of a Sim’s speculum.

Figure 2

(A) Port placement for sigmoid vaginoplasty. Additional 3 cm Pfannenstiel incision is required to pull out the sigmoid segment for placing anvil of circular stapling device. (B) Complete mobilisation of sigmoid mesentery saving the ureters on either side. (C) Endolinear cutter stapler device used to transect the rectum.

Figure 3

(A) Isolated sigmoid segment taken out via Pfannenstiel incision and insertion of anvil in the end of descending colon for use of circular stapler for colorectal anastomosis. (B) Creation of space in pelvis with finger inserted in vagina. (C) Final picture showing neovaginal introitus.