Functional and anatomic results of amnion vaginoplasty in young women with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)

Literature Review Article

Functional and anatomic results of amnion vaginoplasty in young women with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH). C. Fotopoulou, J. Sehouli, N. Gehrmann, I. Schoenborn and W. Lichtenegger. Fertility and Sterility. 2010; 94:217-322 

Review
Obehi A. Asemota, M.D.
 

Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH) is the second most common cause of primary amenorrhea in young women and refers to a condition of mullerian agenesis where the mullerian ducts fail to develop, resulting in absence of abnormal uterus and vagina in the presence of a normal 46, XX karyotype.

There are numerous methods for creating a neovagina in MRKH patients, but there is no ideal standard. The objective of this study was to assess the surgical and functional outcome according to clinical records and validated questionnaires about sexuality (Female Sexual Function Index [FSFI]) of all consecutive MRKH patients surgically treated in a university hospital by the creation of an “amnion” neovagina.

From July 2005 to August 2008, the authors surgically treated seven MRKH patients with a mean age of 20.86 ± 3.56 years (range 17-26 years). All patients underwent a vaginoplasty, the McIndoe procedure modified by using chemically processed and sterilized freeze-dried human amniotic membranes. The human amnion was readily harvested from the amniotic sac of term infants delivered from healthy women. The mean operative time was 24.7 ± 2.09 minutes (range 20-33 minutes).  Median follow-up for the whole group of patients was 16.42 months (range 4-41 months).  Their results were:

  •  In all of the patients except one, a satisfactory neovaginal length of at least 9cm could be obtained (mean vaginal length 9.8 ± 1.7cm, range 9-12cm) and the neovaginal cavity was easily passable for two fingers.
     
  •  The follow-up examinations one, three and six months after surgery revealed a well epithelialzed neovaginal cavity, without stricture formation or shortening, because all of the patients successfully applied the vaginal phantom or had regular vaginal intercourse.
     
  •  None of the patients stated having dysparuenia or contact bleeding during intercourse.
     
  •  The mean full FSFI score of all five sexually active patients was 30.0 ± 6.9; corresponding to the equivalent of 30.2 ± 6.1 reached by healthy women.

Based on these results, the authors concluded that neovaginal reconstruction using freeze-dried amniotic membranes is a safe and easy technique, without induction of scar at the donor site, and should be the preferred surgical technique, as a modification of the McIndoe procedure, for patients with Rokitansky syndrome.

Comments
Steven R. Lindheim, M.D.
Meike L. Uhler, M.D.
 

This article addresses the management of congenital absence of the uterus and vagina.  The options for treatment include:
 

  • Modified Abbe-McIndoe technique:

    o Most commonly performed surgical technique which involves harvesting a meshed split-thickness skin graft from the patient's buttocks and placing it over a vaginal mold.
     
  •  Laparoscopic approaches:

    o Davydov vaginoplasty involves placing an approximately 10-cm segment of bowel that can be mobilized but retain an adequate vascular pedicle to reach the perineum without traction on the pedicle or graft.
     
    o Vecchietti procedure involves placement of an acrylic 2-cm olive-shaped bead onto the vaginal dimple, which is gradually pulled superiorly by threads laparoscopically placed that are then connected to the traction device placed on the patient's abdomen. The threads are then gradually tightened approximately 1.0 to 1.5 cm/day for a week.
     
  • Non-operative approaches:

    o Progressive dilation, which places enough pressure to invaginate the tissues.

    o  Ingram modification of dilation, which involves sitting on a bicycle seat stool.

Using the Modified Abbe-McIndoe technique, Keser et al. followed the patients’ long term results with few postoperative complications and excellent results in vaginal depth.  This group of patients can be reassured that available treatment options will result in satisfactory quality of life.

*See also the review of Treatment of vaginal agenesis with modified Abbe-McIndoe technique: long-term follow-up in 22 patients. A.Keser, N.Bozkurt, Ö.Taner, Ö.Şensöz. European Journal of Obstetrics & Gynecology and Reproductive Biology, Volume 121, Issue 1, Pages 110-116.

The above review and commentary on this article were written by SRS Members. Publication of these summaries does not reflect endorsement of any particular procedure or treatment. Views expressed in these summaries do not necessarily reflect the views of SRS or ASRM.

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