MRKH: COMPARISON TO OTHER SURGICAL PROCEDURES

SURGICAL NEOVAGINAL TECHNIQUES
There have been many different surgical techniques describe to create a neovagina and most have been very invasive large surgeries with variable success rates. According to the scientfific literature the most common surgery performed by gynecologists is the McIndoe procedure, the surgery with the highest success rates and least complications are the Davydov and Vecchietti and the most common surgery used for sexual reassignment is the colonic or segmental intestinal interposition surgery. Description of these surgeries are seen below:

LAPAROSCOPIC DAVYDOV PROCEDURE
Dr’s Moore and Miklos utilize a laparoscopic modification of the Davydov procedure. This makes it even more minimally invasive than the original procedure. In their hands the surgery is performed through two ¾ inch incisions and two 1/3 inch incisions—-truly minimally invasive.Dr Miklos Moore travelled to Russia where they learned the laparoscopic technique developed by Dr L.V. Adamyan. They have used their laparoscopic expertise and suturing skills to modify the procedure even more and to do more of it laparoscopically (it is a combined laparoscopic and vaginal procedure) as they do most of the suturing required through the mini-incisions in the belly button and abdomen while working off High-Definition large screen TV’s. In a recent study the procedure had a 97% functional success rate with sexual function scores in the good to very good range. Typically, patients can have normal sexual function including arousal, lubrication, orgasm and satisfaction. The procedure itself is much less invasive than most of the alternative surgical options and achieves better length with less risk of scarring down.The procedure usually takes between 1 and 2 hours and is completed in an outpatient surgical setting (or a 23 hour stay facility). Recovery is rapid and intercourse can be achieved in as little as 2 weeks post-operatively. A vaginal pack is typically left in for just 36-48 hours (in some other procedures that may require skin grafting of the vagina, the pack must be left in for up to 1-2 months), however in some cases it may need to be changed and left in for approximately a week. Pain is usually minimal and return to normal activities such as school is usually very rapid.Drs. Miklos and Moore have utilized this laparoscopic technique on women with MRKH and Androgen Insensitivity Syndrome (AIS) throughout the world including patients from China, Mexico, Australia, U.K., Dominican Republic, Canada, South America, and of course the U.S. They have also performed this operation on many patients who have failed Neovagina surgery by other surgeons and other techniques including: gracilis flaps, MeIndoe and skin grafts. They are still able to utilize their laparoscopic skills even in this more complicated subset of patients to create a neovagina with the pelvic peritoneum and still operate through mini-incisions and give the patient the benefit of very minimally invasive surgery. Patients that have had previous surgery cannot believe how much easier the approach was with Dr Moore and Miklos and the results they achieved after the procedure resulting in a normal, full length, functioning vagina!Drs. Moore and Miklos are considered world leaders in the laparoscopic approach to create a neovagina and are asked from experts throughout the world to come and lecture and teach on the subject. They have taught and lectured on their technique in Australia, South America, Africa, Europe and in the U.S.

COMPARATIVE TRIALS VECCHIETTI VS DAVYDOV PROCEDURE
1) In Milan Italy (2011) Bianchi et al performed a comparative trial between patients receiving the Vecchietti and the Davydov procedure was performed and revealed: no major complications in either group and at 12 months the functional and anatomic outcomes were similar between the two groups; and there was a significant greater vaginal length obtained by the Davydov approach.

2) In China (2015) Dong et al concluded: Both Vecchietti’s and Davydov’s laparoscopic techniques are simple, safe and effective surgical methods for vaginal reconstruction. In contrast, the Vecchietti’s procedure is more time efficient and minimally invasive, while the Davydov’s procedure can get less pain, longer vagina and higher sexual satisfaction.

MCINDOE VAGINOPLASTY
This surgery was invented by Dr Abbe in 1889 and made popular by Dr McIndoe in the 1930’s. The McIndoe operation is the most commonly preferred neovagina technique utilized by gynecologists but it certainly does not mean it is the best nor the most successful Neovagina surgery. Why do surgeons do a procedure which are take longer, have a higher complication rate and is less successful? The answer is simple they were not taught other techniques and are ignorant to their advantages.The McIndoe procedure involves the creation of a space between bladder and rectum, insertion of a mold covered with split-thickness skin graft into that neovaginal space and usually the patient is kept in the hospital for upwards of 14 days. After which time vaginal dilation is performed to avoid stenosis.The skin graft (donor site) is usually removed from the buttocks, thigh, lower back or from the inguinal region (see below). The donor site is often an obvious area of surgery and is often left discolored, a potential site of infection and poor aesthetic results.The Mayo Clinic in Rochester Minnesota reported (2003) their McIndoe experience of 225 patients over 65 years (1920-1985). That is an average of 2.88 patients per year. In this collection, 10% of patients suffered complications including: fistula, strictures, bleeding, prolapse, graft failure, or infection. 85% of patient were reported to have vaginal function as “satisfactory”.The main drawbacks of the procedure are a) the need for prolonged use of a vaginal stent for up to 6 months postoperatively or until regular intercourse commences, b) the postoperative immobilization for up to 14 days to get the skin graft to take and c) lack of lubrication with the Neovagina constructed of abdominal / buttocks skin.
Conclusion: Based upon Mayo Clinic 65-year result: The complication rate if 10% and the vaginal success rate is 85% while averaging less than 3 patients per year.

VECCHIETTI PROCEDURE (CONTINUOUS PRESSURE PROCEDURE)
The Vecchietti procedure was first described by Guissepi Vecchietti in 1965. This utilizes an acrylic olive shape apparatus that is applied under tension (via threads that are brought up through the abdominal wall via incision in the abdomen) against the vaginal dimple. A traction device is then used on the threads on the abdominal wall and tightened over time that draws the olive upward and stretches the skin, thus creating a neovagina.It has been suggested that the patient should have a vaginal pocket of at least 2 cm so the acrylic olive can be cradled (and doesn’t slip out) while tension is applied to the olive to lengthen the vagina. Though it has been reported that a complete functional vagina can be accomplished in 7-9 days, this can take up to 3 months to accomplish and then requires dilators after.Many studies show the laparoscopic Vecchietti procedure takes approximately 1 hour to perform, with minimal complications and a success rates greater than 95%. However, the wearing of the tensioning device can be cumbersome and inconvenient during the 2 weeks of tensioning.

COMPARATIVE TRIALS VECCHIETTI VS DAVYDOV PROCEDURE
1) In Milan Italy (2011) Bianchi et al performed a comparative trial between patients receiving the Vecchietti and the Davydov procedure was performed and revealed: no major complications in either group and at 12 months the functional and anatomic outcomes were similar between the two groups; and there was a significant greater vaginal length obtained by the Davydov approach.

2) In China (2015) Dong et al concluded: Both Vecchietti’s and Davydov’s laparoscopic techniques are simple, safe and effective surgical methods for vaginal reconstruction. In contrast, the Vecchietti’s procedure is more time efficient and minimally invasive, while the Davydov’s procedure can get less pain, longer vagina and higher sexual satisfaction.

Fertil Steril. 2011 Mar 1;95(3):1098-100.e1-3. doi: 10.1016/j.fertnstert.2010.11.032. Epub 2010 Dec 17.

Zhonghua Fu Chan Ke Za Zhi. 2015 Apr;50(4):278-82.