PEDIATRIC UROLOGY

Vaginal construction using sigmoid colon in children and young adults
Rajimwale A, Furness PD 3rd, Brant WO, Koyle MA
The Children’s Hospital, Denver, CO, USA
BJU Int. 2004; 94: 115-9

• Objective: To evaluate the age at which patients who required vaginal replacement (an uncommon procedure in children) were diagnosed, and the cause of their anomaly, and to relate these variables to the surgical outcome.
• Patients and Methods: Patients who had vaginal replacement at the author’s institution between 1990 and 2002 were reviewed retrospectively. Depending on the age at reconstructive surgery, patients were divided into pre- and post-pubertal groups. Results: A neovagina was constructed in 23 patients during the study period; sigmoid colon was used in 20 but not in two patients with cloacal exstrophy and in one with Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS). These cases were excluded from the analysis of outcomes and complications. Group 1 comprised patients diagnosed and treated before puberty and group 2 those diagnosed and/or treated afterward. In group 1 the presenting diagnoses included androgen insensitivity syndrome (AIS) in six patients, MRKHS in two, cloacal exstrophy in two, vaginal tumour in one, Mullerian duct renal aplasia cervicothoracic somite dysplasia, vertebral abnormalities, anal atresia, cardiac anomalies, tracheo-oesophageal fistula, and/or oesophageal atresia, renal abnormalities and limb defects syndromes in one each. In group 2 the presenting diagnoses included MRKHS in seven, AIS in two, and congenital adrenal hyperplasia in one. Complications included superficial wound infection (two patients), recurrent introital stenosis, and blind loop mucocele, complete stenosis of perineal neovaginal opening (one each) and dyspareunia in three. Neither age nor pelvic habitus (android vs gynaecoid) influenced the outcome, and the cosmetic results were excellent in all the patients.
• Conclusion: Isolated sigmoid neovaginal construction appears to be applicable to many diagnoses and in patients at any age. Although an android pelvis can present technical challenges, in this experience it was not associated with a greater complication rate. The long-term satisfaction with the sigmoid neovagina for intercourse, especially in those constructed before puberty, still requires long-term evaluation.
  
  
• Editorial Comment
  Vaginal reconstruction is an uncommon procedure, but carries special significance when done. It is, of course, most common in patients with some form of intersex and involves the genitalia, both of which raise the anxiety level of parents considerably. Moreover, the type of reconstruction varies considerably by specialty, with plastic surgeons and gynecologists generally recommending skin graft/dilation procedures and pediatric urologists recommending bowel vaginoplasty. Furthermore, the timing of the reconstruction remains highly controversial.
  This is an interesting review that helps the reader in several ways. First, I believe that it provides the reader with a realistic estimate of the potential complications of bowel vaginoplasty. Three patients out of 20 had introital stenosis (of course these were quite fixable) and all three who are sexually active suffered from dyspareunia. Fortunately this was not severe enough to prevent sexual activity, but nonetheless, this would be important to mention in preoperative counseling. Interestingly, in the authors hands, bowel vaginoplasty was no more risky in children who were pre-pubertal (mean age 4) than in those who were post-pubertal. This is likely because these patients did not require dilation postoperatively. When using techniques that require dilation postoperatively, the procedure should surely be postponed until after puberty.

Dr. Barry A. Kogan
Chief and Professor of Urology and Pediatrics
Albany Medical College
Albany, New York, USA