Vaginal Replacement Maneuvers During Posterior Sagittal Anorectovagino-Urethroplasty / PSARVUP
Colorectal surgeons at Cincinnati Children's Hospital Medical Center provides information about vaginal replacement maneuvers during Posterior Sagittal Anorectovagino-Urethroplasty / PSARVUP.
In those particular cases where the vagina does not reach the perineum, the surgeon may use one of the following maneuvers:
- Skin or labia flap, useful to fill a one to two centimeter gap
- Vaginal replacement with a piece of intestine, useful for long-gap or total vaginal replacement
- Vaginal dome flap, useful in those cases with a long common channel associated with a very large but high vagina (hydrocolpos)
Skin flaps can be developed from the perineal tissue on both sides of the future vaginal location or from the labia, which unfortunately, are usually small; they can be unfolded and represent very nice flaps to fill this gap.
These flaps can also be done with full-thickness skin preserving its subcutaneous tissue to give as much good blood supply as possible.
Both perineal defects left by the flaps are closed reapproximating the skin and suturing it in two layers.
In cases of large gaps as well as those with absent vagina, the replacement can be done with a piece of small bowel or sigmoid colon, preserving its mesentery.
For this, it is necessary to open the abdomen in addition to the posterior sagittal approach.
Once the urethra has been reconstructed and the rectum mobilized, and the decision has been made to use some form of vaginal replacement, the wound is temporarily packed with sterile gauze and covered with sterile plastic dressing. The patient is then turned and a total body prep is performed.
The abdomen is then entered and a piece of intenstine with its mesentery is selected. The intestine is isolated and the intestinal continuity is reestablished by an end-to-end anastomosis.
The intestine then can be anchored to the gauze used to pack the pelvis.
The perineal stage of the procedure is started by lifting the patient's legs up. The gauze is pulled through the perineum bringing down the isolated piece of intestine that will be sutured in its upper portion to the uterus or the lower edge of the vaginal stump, and the lower part of the intestine is sutured to the perineal or vulvar skin using one layer of long-term absorbable fine sutures.
The rest of the rectal reconstruction should be done the same as previously described.
The vaginal dome flap is done in cases of a large and high vagina which is rather difficult to mobilize. The flap must be created long enough to fill the gap between the lower vaginal end and the perineum, as shown in these figures.
The flaps must be manipulated to be sure that a normal, well-vascularized piece of vagina is left in front of the urethral suture line to prevent the formation of a urethrovaginal fistula. The rectal component of this defect is then repaired as previously described for the other defects.
For more information or to request an appointment, please contact the Colorectal Center at Cincinnati Children's.
