Vaginal creation for müllerian agenesis
Roberts, C.P.; Haber, M.J.; Rock, J.A.
American Journal of Obstetrics and Gynecology 185(6): 1349-52; Discussion 1352-3
OBJECTIVE: The purpose of this study was to determine the effectiveness of passive vaginal dilation and McIndoe vaginoplasty in the creation of a neovagina for patients with mullerian agenesis. STUDY DESIGN: Fifty-one patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated for vaginal agenesis at either Johns Hopkins Hospital or Emory University. These historic prospective data were obtained by a review of medical records and a current office or telephone consultation. Initial office visits dated from November 18, 1983, through June 6, 1998. Their progress towards both anatomic and functional success was followed through August 1, 2000, which was a range of 2 to 16.8 years. One-way analysis of variance, Student t test, and logistic regression analysis were performed when appropriate. RESULTS: Four patients were lost to follow-up in various stages of the treatment. Ten patients refused vaginal dilation and proceeded to a successful modified McIndoe vaginoplasty. Of the 37 remaining patients, 91.9% anatomic and functional success was achieved from the Ingram method for vaginal dilation. Passive dilation failed in 8.1% of patients, who underwent a modified McIndoe vaginoplasty; all neovaginal creations Were successful. All patients who underwent McIndoe vaginoplasty were compliant with postoperative vaginal form use. None of our patients lost vaginal space through contractions or loss of skin graft. Of those patients for whom dilation failed, only 1 patient discontinued the study because of bleeding and discomfort. In addition, only 1 patient from the 3 cases of failure had undergone a previous hymenotomy. Interestingly, 6 patients for whom dilation was successful (6/34 patients; 17.6%) had also undergone a previous hymenotomy. The mean follow-up time for all patients in this study was 111.1+-7.2 months, with a range of 25 to 188 months. The mean follow-up time for those patients for whom dilation failed or who refused dilation was significantly lower at 64.5+-9.5 and 65.3+-18.5 months, respectively (P<.005). The mean time to successful dilation was 11.8+-1.6 months with a range of 3 to 33 months. Although longer, no statistically significant difference was observed for dilation time in those patients for whom there was a failure to achieve anatomic or functional success (20.5+-12.5 months; range, 8-33 months). CONCLUSION: These data reveal that passive dilation with the Ingram method is capable of creating an adequate vaginal canal in patients with vaginal agenesis, with respect to both function and anatomy even in those patients with a previous hymenotomy and resultant scar formation. Our modified McIndoe procedure has proved to be an excellent option for patients for whom conservative dilation techniques failed and who refuse to attempt any dilation. Interestingly, our data indicate that patients may now be trending toward immediate surgical correction rather than diligently using dilation techniques to create a vaginal space.