Vaginal Agenesis

Treatment Options of vaginal agenesis

Is doing MRI compulsory?

In most of the situations in India a basic routine abdomen + pelvic ultrasound is performed on the girl. Should there be a clear suspicion of having a hypoplastic uterus, an absent uterus, and a partially formed or an absent vagina, further imaging in the form of an MRI is routinely warranted.

Further evaluation also needs to be done for the kidney, as associated anomalies of the kidney are common to co-exist with this condition. Routine abdomen + pelvic MRI would cost approximately 6000 rupees in India. Though this is on the slightly expensive side, Dr Jay Mehta and team routinely recommend an MRI for a patient who is suspected to have vaginal agenesis.

Can we women have normal menses?

Majority of these young girls present with a small uterus or hypoplastic uterus or an absent uterus. Despite having fully functional normal ovaries since there is a hypoplastic uterus there is no development of endometrium despite adequate hormonal parameters.

As a result of this even if the surgery is done to create a new vagina which is called as a vaginoplasty these girls do not experience any menses.

Menses can be assured or will resume only after a uterine transparent is done.

Do these women have normal hormones?

As mentioned because the ovary is normal and the ovarian parameters are absolutely normal these girls have all hormonal parameters which are normal. In certain situations an absent vagina is also found in something called androgen insensitivity syndrome.

Androgen insensitivity syndrome can present with abnormal hormonal parameters however the karyotyping in that situation is 46 XY, which is a male karyotype. Routinely girls who present with vaginal agenesis have a type 46XX, which is a female karyotype.

What is the surgical approach of choice?

Dr Jay Mehta and team have performed the maximum number of neo vaginal reconstruction surgeries in India. The team prefers to do a combined approach of vaginal + laparoscopic surgery.

A combination of these techniques along with proper placement of the graft in the form of INTERCEED, which is an OXIDIZED hemi cellulose graft, allows the patient to achieve a vaginal length of approximately 9 cm, allows to maintain excellent patency of the vagina and is excellent for the long term health of the vagina.

Using this technique also ensures adequate length to perform uterine transplant should it be required and the patient be willing for it in the future.

Can a non surgical option like mold be attempted?

In modern day medicine such types of techniques which are very time consuming, have no guarantee of results and are extremely difficult to perform and painful for the patient are no longer performed. After the surgery for creation of a new vagina is done using a combination of vaginal + laparoscopic approach a mold is temporarily placed in this newly created vagina to allow it to stay patent.

What is to be done if the surgery has failed?

Patients who have normally had a failed surgery would then seek the opinion of Dr Jay Mehta. Based on the type and manner in which the previous surgery has been done a repeat surgery is to be attempted. This repeat surgery is typically done laparoscopically.

Most of these patients also require radical vaginectomy. These patients would then benefit from a sigmoid vaginoplasty. Dr Jay Mehta has performed the highest number of sigmoid vaginoplasty in India. A beautiful video of the same is available as a masterclass on YouTube.

What are the complications of this surgery when done by an untrained surgeon?

As depicted in the diagram, organs like rectum and the bladder are extremely close to an absent vagina. As a result of this if there is a surgical trauma, chances of forming a fistula are extremely high in these patients. Repairing the fistula would then require a complex repeat surgery, with adequate diversion and a temporary need to create a stoma.

What is the graft used by Dr Jay Mehta and team?

Since the last 7 years our team has been using INTERCEDE, which is a synthetic oxidized hemicellulose graft, this is used extensively in gynecology as well as in other surgery as an adhesion barrier. The product is extremely safe, marketed and available internationally.

Can a Sigmoid Vaginoplasty achieve a good vagina?

In cases where a repeat surgery is required sigmoid vaginoplasty is the treatment of choice. A sigmoid vaginoplasty is also a commonly done procedure when patients require gender reassignment surgery (GRS). The great thing about the sigmoid is its ability to allow for adequate distension as well as have minimal secretions.

In the long term for patients who require a repeat surgery outcomes with having a vagina from the sigmoid are excellent. We also perform sigmoid vaginoplasty for patients who are post Radiation therapy and desire to have sexual intercourse.

What is the ideal age for getting this surgery done?

The surgery should be performed as soon as the condition is diagnosed. There does not exist any form of alternative medical management to this condition as this is an anatomical defect.

How much bed rest is needed after this surgery?

This is a surgery which is done with a combined approach of laparoscopic surgery + vaginal surgery. Patients are usually discharged within 48 hours of this procedure. There is no recommended bed rest after this surgery.

When can one plan for a Uterine Transplant after this procedure?

After an adequate length of approximately 8 to 10 cm of vagina has been established and has been kept patent for two years. Patients are usually considered for a uterine transplant. We have discussed the entire procedure for uterine transplant in a separate section. Dr Jay Mehta heads the department for Uterine transplant at Global Hospital in Mumbai.