“Vaginoplasty is the art of plastic repair of herniations of the urethra, bladder and rectum into the vaginal sheath”; Robert Toll defined the term “vaginoplasty” in his manuscript titled “VAGINOPLASTY” in 1946Citation1 by these word, describing surgical procedures to decrease “a sense of things dropping out”.Citation2,Citation3
To date “vaginoplasty” means still correcting structural defects, but still also reconstruct vagina or a part of it after cancer surgery, after malformation, or for sex-change purposes.Citation4–7
Mayer-Rokitansky-Kűster-Hauser syndrome is one of the most important malformative diseases, which needs a surgery for vaginoplasty. This syndrome is diagnosed every year in 1/4,500 female and its etiology remains unknown. Phenotype is characterized by Mullerian duct structures agenesis and vaginal atresia is one of most common variant. Other abnormalities can involve uterus, kidneys. and skeleton.Citation8–11
The main reason for a surgeon to perform a vaginoplasty, however, remains the cancer, in particular the uterine cervix carcinoma. Its epidemiology has undergone radical change in the last 10 years: screenings with Papanicolaou test (Pap-test) allows more and more patients to develop precancerous or early cancer, with a significant reduction in mortality. Gold standard treatment for patients with uterine cervix carcinoma at stage Ia to IIb is radical resection including a part of the vagina plus radiotherapy.Citation12–14 Despite gold standard, surgery and radiotherapy often produce important reconstructive issues determining a narrowing of vagina with significant problems for patients.Citation15–17
So, what the surgeon must keep in mind approaching to vaginal reconstruction?
The reconstruction procedure must consider type of cancer, type of resection, and if radiotherapy is necessary because it makes dystrophic the surrounding tissues.
Type of cancer can involve vagina in different ways: for example, surgeon can expect to find anterior invasion from bladder carcinomas and posterior invasion from colon carcinomas and so.Citation18 In this way, surgeon can plan to remove a single portion (front, back, or lateral) or whole vagina with circular defect for oncological surgery.
On the basis of what has just been said, Andrea Pusic and Babak Mehrara of the Memorial Sloan-Kettering Cancer Center (New York) proposed in 2006 a defect classification and a reconstructive approach based on the type of defects.Citation19 The idea was to catalog two basic types of defects: partial (type 1) and circumferential (type 2). Type 1 is divided into type 1A (anterior or lateral wall) and 1B (posterior wall). Type 2 is divided into 2A (upper two-thirds) and 2B (total). Proposed reconstructive algorithms described use three pedicled flaps: Singapore flap for defect type 1A, Rectus and Rolled Rectus for defects 1B and 2A, respectively, and bilateral gracilis flap for defect type 2B.Citation20,Citation21 The author concludes that even when meticulous reconstruction is made, women have a significant decrease in sexual function.
This issue is very important, in fact many authors emphasize how sexual function is reduced after this kind of surgery.Citation5,Citation12,Citation22–24
Over the years, other reconstructive approaches were proposed. Some of this involves the use of skin graft kept in place by cylindrical vaginal stent. The idea of the cylindrical stents is conceptually simple to understand, and more options have been proposed to improve the results such as the use of negative pressure: Fussey et al. proposed a modern approach for vaginoplasty using skin graft and a dressing foam of KCI negative pressure therapy system as cylindrical stent; fibrin tissue sealant was sprayed before inserting skin graft. Success rate of graft was 100% (7 cases) with normal sexual function at 4 months from surgery.Citation25,Citation26
The development of biomaterials has undergone strong impetus in recent years, and one of the most used biomaterials in reconstructive surgery is dermic matrices without cellular components: the “acellular dermal matrix” or ADM. ADM is used in many reconstructive surgeriesCitation7,Citation27,Citation28 and a new group proposed it for vaginal repair after partial resection for cervix uterine carcinoma plus radiotherapy. The authors involved 16 patients submitted to surgery for cervix uterine carcinoma resection; reconstruction was obtained using acellular dermal matrix grafted with helping of sterilized condom filled by iodoform gauze. ADM was remover 2 weeks after surgery. Evaluation of sexual satisfaction was made at follow-up with questionnaire and good results were found.
Actually, acellular dermal matrix is a biomaterial widely used also for other types of reconstructive surgery such as breast surgery, abdominal surgery, paravaginal patches, pelvic reconstruction surgery, oral surgery, and surgery of burns,Citation12,Citation29,Citation30 so what was interesting in this research?
One of the main problem the research group had to solve was the narrowing of the vagina. The surgeons performed a skin graft and covered it with ADM for 2 weeks. ADM was removed after 2 weeks and the re-epithelization of neovagina was complete.
This reduced-healing-time was probably due to the presence of ADM, a low-antigenic biomaterial that allowed a good three-dimensional stabilization of the skin graft.
What does it produces?
A short time of healing has allowed a sexual activity after only 2 months: this early sexual activity allowed to reduce the use of vaginal mould without determining vaginal narrowing. In this way, the final reconstructive result was very good: all patients had normal vaginal length and vaginal depth and 75% had satisfactory sexual activity.
The idea of using acellular dermal matrix has made possible to obtain good results both in preventing narrowing vagina and in the sexual satisfaction of these patients.
To date we are still far from perfect vaginal reconstruction, but research and progress in the field of biomaterials will probably bring significant improvements that will allow us to achieve more satisfying results.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. No commercial relationship or financial support or personal financial interest exists.
References
- Toll RM. Vaginoplasty. Am J Surg. 1946;72(5):742.
- D'Antonio A, Cuomo R, Angrisani B, Memoli D, Angrisani P. Desmoplastic cellular neurothekeoma mimicking a desmoplastic melanocytic tumor. J Am Acad Dermatol. 2011;65(2):e57–8.
- Cuomo R, Zerini I, Botteri G, Barberi L, Nisi G, D'Aniello C. Postsurgical pain related to breast implant: reduction with lipofilling procedure. In vivo. 2014;28(5):993–6.
- Ratliff CR, Gershenson DM, Morris M, Burke TW, Levenback C, Schover LR, et al. Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration. Cancer. 1996;78(10):2229–35.
- Del Carmen MG, Eisner B, Willet CG, Fuller AF. Intraoperative radiation therapy in the management of gynecologic and genitourinary malignancies. Surg Oncol Clin N Am. 2003;12(4):1031–42.
- D'Antonio A, Addesso M, Memoli D, Liguori P, Cuomo R, Boscaino A, et al. Lymph node-based disease and HHV-8/KSHV infection in HIV seronegative patients: report of three new cases of a heterogeneous group of diseases. International journal of hematology. 2011;93(6):795–801.
- Cuomo R, Nisi G, Grimaldi L, Brandi C, Sisti A, D'Aniello C. Immunosuppression and Abdominal Wall Defects: Use of Autologous Dermis. In vivo. 2015;29(6):753–5.
- Rampone B, Filippeschi M, Di Martino M, Marrelli D, Pedrazzani C, Grimaldi L, et al. Mayer-Rokitansky-Kuster-Hauser syndrome presenting as vaginal atresia: report of two cases. G Chir. 2008;29(4):165–7.
- Cuomo R, Russo F, Sisti A, Nisi G, Grimaldi L, Brandi C, et al. Abdominoplasty in Mildly Obese Patients (BMI 30-35 kg/m2): Metabolic, Biochemical and Complication Analysis at One Year. In vivo. 2015;29(6):757–61.
- Cuomo R, Sisti A, Grimaldi L, D'Aniello C. Modified Arrow Flap Technique for Nipple Reconstruction. The breast journal. 2016;22(6):710–1.
- D'Aniello C, Cuomo R, Grimaldi L, Brandi C, Sisti A, Tassinari J, et al. Superior Pedicle Mammaplasty without Parenchymal Incisions after Massive Weight Loss. Journal of investigative surgery. 2017;30(6):410–20.
- Unknown. Vaginoplasty with Acellular Dermal Matrix after Radical Resection for Carcinoma of the Uterine Cervix. Journal of Investigative Surgery IN PRESS. 2017; unknown(unknown):unknown.
- Cuomo R, Grimaldi L, Nisi G, Brandi C, D'Aniello C. Tendon Transfer Surgery: Focus on. Journal of investigative surgery. 2017; Nov 2:1–3.
- Sisti A, Tassinari J, Cuomo R, Milonia L, Nisi G, Brandi C, D'Aniello, Grimaldi L. A case of extramammary inguinal Paget disease in a male patient: surgical treatment with an abdominal advancement cutaneous flap. Acta bio-medica: Atenei Parmensis. 2017;88(1):79–81.
- Abitbol MM, Davenport JH. Sexual dysfunction after therapy for cervical carcinoma. Am J Obstet Gynecol. 1974;119(2):181–9.
- Bruner DW, Lanciano R, Keegan M, Corn B, Martin E, Hanks GE. Vaginal stenosis and sexual function following intracavitary radiation for the treatment of cervical and endometrial carcinoma. Int J Radiat Oncol Biol Phys. 1993;27(4):825–30.
- Krumm S, Lamberti J. Changes in sexual behavior following radiation therapy for cervical cancer. J Psychosom Obstet Gynaecol. 1993;14(1):51–63.
- Fleischmann NB, Nitti VW. Pelvic floor reconstruction: state-of-the-art and beyond. Urol Clin North Am. 2004;31(4):757–67.
- Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol. 2006;94(6):515–21.
- Grimaldi L, Cuomo R, Brandi C, Botteri G, Nisi G, D'Aniello C. Octyl-2-cyanoacrylate adhesive for skin closure: eight years experience. In vivo. 2015;29(1):145–8.
- Nisi G, Barberi L, Ceccaccio L, Cuomo R, Sisti A, Castagna A, et al. Effect of repeated subcutaneous injections of carbon dioxide (CO2) on inflammation linked to hypoxia in adipose tissue graft. European review for medical and pharmacological sciences. 2015;19(23):4501–6.
- Foley OW, Rauh-Hain JA, Clark RM, Goodman A, Growdon WB, Boruta DM, et al. Intraoperative Radiation Therapy in the Management of Gynecologic Malignancies. Am J Clin Oncol. 2016;39(4):329–34.
- Zerini I, Sisti A, Cuomo R, Ciappi S, Russo F, Brandi C, et al. Cellulite treatment: a comprehensive literature review. Journal of cosmetic dermatology. 2015;14(3):224–40.
- Nisi G, Cuomo R, Brandi C, Grimaldi L, Sisti A, D'Aniello C. Carbon dioxide therapy and hyaluronic acid for cosmetic correction of the nasolabial folds. Journal of cosmetic dermatology. 2016;15(2):169–75.
- Fussey JM, Luesley DM, Sterne GD. Vaginoplasty: a modern approach: a report of 2 cases. J Reprod Med. 2013;58(9-10):441–4.
- Campana M, Lazzeri D, Rosato L, Perello R, Vaccaro M, Ciappi S, Campa A, Brafa A, Nisi G, Brandi C, Grimaldi L, D'Aniello C. Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid in a HIV-positive patient. Journal of plastic, reconstructive & aesthetic surgery: JPRAS. 2010;63(9):e709–10.
- Sinha UK, Saadat D, Doherty CM, Rice DH. Use of AlloDerm implant to prevent frey syndrome after parotidectomy. Arch Facial Plast Surg. 2003;5(1):109–12.
- Zhou Y, Li Q, Ll S, Zhou C, Li F, Cao Y, et al. [Effectiveness of Vaginoplasty with Acellular Dermal Matrix and Mixed Particles Graft]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2015;29(6):761–5.
- Brafa A, Campana M, Grimaldi L, Nisi G, Brandi C, Lazzeri D, et al. Management of gynecomastia: an outcome analysis in a multicentric study. Minerva Chir. 2011;66(5):375–84.
- Rosato L, Lazzeri D, Campana M, Vaccaro M, Campa A, Ciappi S, Nisi G, Brandi C, Grimaldi L, D'Aniello C et al. Mesotherapy should not replace the surgical approach in the treatment of benign symmetric lipomatosis. Aesthetic plastic surgery. 2011;35(2):278–80.