Vaginal stenosis treatment using computed tomography and fluoroscopy guidance

Abstract

Introduction: Vaginal stenosis is a common complication following construction of a neovagina with vascularized myocutaneous flaps. This is primarily because of inconsistent or inappropriate vaginal dilator use. Image-guided recanalization, especially for obstructed genitourinary tracts, is an emerging idea in interventional radiology. Although multiple surgical techniques have been reported to treat vaginal agenesis or obstruction, the idea of image-guided recanalization of vaginal stenosis is a relatively new management strategy for vaginal stenosis.

Case: We present a challenging case of a patient who initially presented with the complaint of increasing pelvic pressure after the creation of a neovagina via vaginoplasty. She had a distal neovagina created after extensive surgical resection for a large infiltrating pelvic rectal adenocarcinoma. A computed tomography scan revealed a fluid-filled neovaginal abscess. Examination under anesthesia revealed complete stenosis of the neovagina with no identifiable tract for dilation.

Intervention: A computed tomography scan and fluoroscopy-guided sharp recanalization of the stenosed neovagina was performed, followed by serial fluoroscopic balloon angioplasty to dilate the stenosed neovagina. Finally, the patient underwent a gynecologic surgery for the excision of remaining granulation tissue to produce a more permanent patent neovagina, followed by regular and proper use of vaginal dilators to ensure patency.

Conclusion: This case report demonstrates that image-guided techniques can be used to aid in vaginal recanalization in the postoperative setting.

Keywords: CT-scan; fluoroscopy; image-guided; vaginal recanalization; vaginal stenosis; vaginoplasty.

Figure 1

Excluded vagina with wire access Transabdominal access (left). Transvaginal sharp recanalization (right) on computed tomography scans.

Figure 2

Wire access into excluded vagina from above and below A loop snare using the transabdominal approach to grab the transvaginal wire (left), followed by (right) through and through access. Contrast injection shows the newly created tract in the neovagina on the computed tomography scan.

Figure 3

Locking loop drain left to drain the infected neovagina

Figure 4

Excluded neovagina before and after drainage Computed tomography (CT) scan of the dilated neovagina before the procedure (left). Follow-up CT scan 9 months after recanalization showing the decompressed neovagina (right).

Figure 5

Balloon dilatation of new neovagina tract A 12 mm balloon dilation of the neovaginal tract followed by upsizing to a 26F Foley style catheter.