Neovaginoplasty options and concerns
In situations where there is total absence of the vagina (figure 1), a variety of techniques have been described for the creation of a total neovagina, all with inherent advantages and disadvantages. The following is a short, selected list provided for illustrative purposes. For a more exhaustive review, see Human Reproduction Update (2014; 20:775-801) and others.
The Frank method. A nonoperative procedure first described in 1938 (Am J Obstet Gynecol 1938; 35:1053–5), the patient utilizes increasing sized sequential dilators to intermittently manually apply pressure on the perineal vaginal dimple where the vagina should have formed. Although clearly the least invasive and most cost-effective procedure, it requires substantial patient motivation, patient effort, and a significant time investment. Unfortunately, younger patients often show limited success, especially in cases with only a minimal skin dimple with which to start.
The Vecchietti procedure or traction vaginoplasty. Originally described in 1965 (Attual Ostet Ginecol 1965; 11:131–47) and later improved with a minimally invasive laparoscopic approach, the Vecchietti procedure establishes traction on a perineally positioned bead with sutures passing through the prevesical space to the traction tension device on the ventral abdominal wall. Continuous upward pressure is applied by the traction bead to the vaginal agenesis dimple, which in turn stretches, dissects, and elongates a mucosal cavity. There are some disadvantages, including pain with continued tightening of the traction device, potential abdominal or pelvic complications with traction thread placement, and discomfort and inconvenience of wearing an indwelling vaginal form at night for months after the vaginoplasty to prevent vaginal contraction and stenosis.