Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 15  |  Issue : 1  |  Page : 24-26

Use of amnion graft and surgicel in vaginoplasty for secondary vaginal atresia: A case report


Department of Obstetrics and Gynecology, SMS Medical College, Jaipur, Rajasthan, India

Date of Web Publication26-Aug-2019

Correspondence Address:
Dr. Rajlaxmi Pardeshi
A-1 Navsundar Cooperative Housing Society, Near MSEB Colony, Aundh, Pune 411007, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_21_16

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  Abstract 


Vaginal atresia can be congenital or acquired. The tissue is virgin in primary vaginal atresia or agenesis, so various methods have been used with successful outcomes. On the other hand, one can expect a lot of fibrosed tissue in secondary atresia. There is no elaborate literature on secondary vaginal atresia. There is also no standard treatment for both the types of vaginal atresia. The use of amnion graft and surgicel in vaginoplasty for secondary atresia is one of our experiences with best results. We report a case of a 22-year-old primipara who presented with dyspareunia and cyclical lower abdominal pain for the past 4 months. She had a history of traumatic vaginal delivery 3 months prior to presentation. On examination, she was diagnosed with secondary vaginal atresia. We managed her by vaginoplasty with amnion grafting and surgicel, followed by regular dilatation with soft vaginal mould for the next 6 weeks. Our patient is doing well with normal coital function on follow-up.

Keywords: Amnion, secondary vaginal atresia, vaginoplasty


How to cite this article:
Pardeshi R, Meena K, Gurjar K. Use of amnion graft and surgicel in vaginoplasty for secondary vaginal atresia: A case report. Nigerian J Plast Surg 2019;15:24-6

How to cite this URL:
Pardeshi R, Meena K, Gurjar K. Use of amnion graft and surgicel in vaginoplasty for secondary vaginal atresia: A case report. Nigerian J Plast Surg [serial online] 2019 [cited 2019 Sep 16];15:24-6. Available from: http://www.njps.org/text.asp?2019/15/1/24/265407




  Introduction Top


Vaginal atresia can be congenital or acquired resulting in uterovaginal outflow obstruction.[1] Though there is no elaborate literature on secondary vaginal atresia, the only management for both types is creating functional neovagina either by a surgical or a nonsurgical method.[2] We are reporting a case of secondary vaginal atresia. We did vaginoplasty by using amnion graft and oxidized cellulose.


  Case Report Top


A 22-year-old primipara presented to us in outpatient department (OPD) with the complaints of dyspareunia and lower abdominal pain. She belonged to a nearby village and had a history of traumatic vaginal delivery 4 months prior to presentation. Prior to presentation, she delivered a full-term baby of 3000 g, whom she breastfed exclusively. Her postpartum period was uneventful. She also got her menses twice after 6 weeks but they were scanty of 1 to 2 days flow. She had no urinary or bowel complaints.

Her systemic and general examination was found normal. Speculum examination showed that her upper vaginal wall was completely fused, appearing like a pinhole, hardly allowing the examining finger to reach a depth of 1 to 2 cm. The cervix was not visualized at all. Lower part of vaginal canal was intact and the urethral orifice, mons pubis, labia majora, and anus were found normal. Her blood investigations were normal. Ultrasound (USG) pelvis revealed normal uterus and ovaries with endometrial thickness of 9 mm. A provisional diagnosis of secondary vaginal atresia following traumatic vaginal delivery was made and the patient was planned for vaginoplasty using human amnion graft and surgicel. The donor newborn’s mother was seronegative.

During surgery we found that anterior part of cervix was completely adherent to the posterior wall of bladder. Adhesions were separated by blunt dissection and cauterization. On the seventh postoperative day, the mould was removed. The graft was well taken up all over except over anterior lip of cervix. Surgicel was then placed over this raw area. A new mould was prepared and inserted to keep for 24 hours for the next 6 weeks and then only at night for the next 6 weeks, except at time of urination and defecation ([Figure 1]).
Figure 1 Photo showing mould after vaginoplasty.

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Follow-up period was uneventful ([Figure 2]). The couple was advised regular intercourse after 6 weeks and counseled for contraception to refrain from pregnancy till the next 1 year.
Figure 2 Follow-up image after vaginoplasty.

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  Discussion Top


Primary vaginal atresia occurs when caudal portion of vagina, contributed by urogenital sinus, fails to form.[1] This is replaced by fibrous tissue. Its occurrence is 1 in 5000 to 10,000 female live births.[3] Congenital atresia occurs most commonly in association with a complex of anomalies rather than in isolation. The most common presentation in primary vaginal atresia is primary amenorrhoea. Secondary atresia may occur due to traumatic vaginal birth, manipulation during aseptic means of abortion, postradiotherapy ablative procedures, or trauma due to foreign body in vagina. Nonsurgical method of treatment includes the use of Frank dilators. These are of increasing diameter and length with spandex underwear as the patient sits on a stationary bicycle seat for every 30 to 120 minutes per day[1]

Surgical management was described first by Baldwin using intestinal graft in 1990s. The primary goal of surgery must be to relieve obstruction, pain, restore normal sex life, and to preserve reproductive potential. Various procedures are in practice and Abbe-McIndoe operation is frequently done. It uses split thickness skin graft so has less postoperative morbidity and mortality. Vaginal stenosis, lack of lubrication, and fistula formation are a few complications.

Reconstruction using musulocutaneous flaps though reliable are bulky, for example, rectus gracilis. It may also lead to scarring. Bilateral flaps are reserved for reconstruction after ablative procedures.[4],[5]

Reconstruction using intestinal tissues like sigmoid colon, sections of ileum, caecum, and rectosigmoid colon are also in practice.[6] Recently, laparoscopic-assisted biometric grafts are in use. Vecchietti procedure has gained acceptance. In this procedure, the surgeon places an olive-shaped device on the blind vaginal dimple. With the help of a laparoscope, a separate traction device is placed on the lower abdomen, to which the olive is attached with two threads. Every day the patient tightens the tration to pull the olive inward so that slowly a neovagina is created after a week. Later manual dilatation of this neovagina is also required.

Use of amnion as homograft was selected over skin grafting because of its easy availability. Amniotic membranes do not express HLA-A, B, and DR antigens—hence no chance of immunological rejection is seen.[7] Epithelialization is good due to antifibroblastic activity. Antimicrobial activity reduces the chances of infection and the operation is simple and less time-consuming.[2]

The use of surgicel in vaginoplasty for secondary atresia is one of our experiences with best results. Domelas et al. used oxidized cellulose in primary vaginal atresia for vaginoplasty in his study.[8] The use of oxidized cellulose does not require a separate operative procedure. The material is readily available and inexpensive. It is an absorbable plant-based product that provides a matrix for platelet aggregation by melting into bleeding tissue. Oxidized cellulose has bactericidal properties against a wide range of microorganisms.[9]


  Conclusion Top


The ideal method for vaginoplasty is yet to be defined as every method has got some advantages and some drawbacks. Although laparoscopic approach has evolved over last few years using biometric grafts, in developing countries with limited resources, vaginoplasty using amnion graft is still safe, simple, economically feasible, and effective with good outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schorge JO, Schaffer JI, Halvorson LM, Hoffman BL, Bradshaw KD, Cunningham FG. Williams Gynaecology. New York: McGraw Hill Medical; 2008;1(18):415-16.  Back to cited text no. 1
    
2.
Lin WC, Chang CYY, Shen YY, Tsai HD. Use of autologous buccal mucosa for vaginoplasty: A study of eight cases. Hum Reprod 2003;18:604-7.  Back to cited text no. 2
    
3.
Zafar M, Saeed S, Kant B, Murtaza B, Dar MF, Khan NA. Use of amnion in vaginoplasty for vaginal atresia. J Coll Physicians Surg Pak 2007;17:107-9.  Back to cited text no. 3
    
4.
Ganatra MA, Ansari N. Pudendal thigh flap for congenital absence of vagina. J Pak Med Assoc 2005;55:143-5.  Back to cited text no. 4
    
5.
Nisolle M, Donnez J. Vaginoplasty using amniotic membranes in cases of vaginal agenesis or after vaginectomy. J Gynecol Surg 1992;8:25-30.  Back to cited text no. 5
    
6.
Hensle TW, Reiley EA. Vaginal replacement in children and young adults. J Urol 1998;159:1035-8.  Back to cited text no. 6
    
7.
Simman R, Jackson I, Andrus L. Pre-fabricated buccal mucosa-lined flap in an animal model that could be used for vaginal reconstruction. Plast Reconstr Surg 2002;109:1044.  Back to cited text no. 7
    
8.
Domelas J, Jármy-Di Bella ZI, Heinke T, Kajikawa MM, Takano CC, Zucchi EV et al. Vaginoplasty with oxidised cellulose: Anatomical, functional and histological evaluation. Eur J Obstet Gynecol Reprod Biol 2012;163:204-9.  Back to cited text no. 8
    
9.
Spangler D, Rothenberg S, Nguyen K. In vitro antimicrobial activity of oxidized regenerated cellulose against antibiotic-resistant microorganisms. Surg Infect 2003;4:255-62.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2]



 

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