to the Augs Urogynecology webinar series. I'm Dr. Eva Welch, member of the Augs Education Committee and the moderator for today's webinar. Today's webinar is titled Complex Vaginal Reconstruction. Our speaker today is Dr. Cassandra Kisby. Dr. Cassandra Kisby is an assistant professor in the Department of Obstetrics and Gynecology at Duke practicing urogynecology. She completed her undergraduate education at Duke University. She continued her training at Duke for both medical school and OBGYN residency. Dr. Kisby completed fellowship in female pelvic medicine and reconstructive surgery at Mayo Clinic Rochester in 2021. During fellowship, she also earned a master's in biomedical research and certificate in clinical and translational research. Clinically, Dr. Kisby treats women and gender diverse individuals for a variety of pelvic floor disorders, including urinary leakage, pelvic organ prolapse, pelvic fistulas, and defecatory dysfunction, offering both conservative treatment plans, as well as a variety of surgical approaches, including complex vaginal surgery and reconstruction. Her clinical expertise is in congenital urinary disorders. She is the director of the Genitourinary Congenital Anatomic Differences, GU CARES, program at Duke. Her research is preliminarily translational in nature, focusing on regenerative medicine, innovation in surgical practice, and congenital abnormalities. She is also involved in efforts to create a diverse and inclusive work and patient care environment, as well as equity for women in medicine. Outside of work, she enjoys cycling, good food, and spending time with her husband and two children. With regards to reminders, the presentation will run about 45 minutes, and the last 15 minutes of the webinar will be dedicated to Q&A. Before we begin, I'd like to review some housekeeping items. AUGS designates this live activity for a maximum of one AMA PRA Category 1 credit. To claim your CME credit, you must log into the AUGS eLearning Portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live-streamed. A recording of the webinar will be made available in the AUGS eLearning Portal. Please use the Q&A feature of the Zoom webinar to ask any of the speaker questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues, AUGS staff will be monitoring the chat and can assist. Dr. Kisby, you may begin. Thank you so much for that kind introduction, Dr. Welch, and thank you all for joining me this evening. Many of you who are on the East Coast here, it is 7 p.m. Those on the West Coast a little bit earlier, but I hope to make this interesting, educational, and maybe even a little entertaining. So these are my disclosures. As Dr. Welch mentioned, I'm an assistant professor at Duke. I lead the GU CARES program for our patients with congenital anatomic differences, and I'll try to intentionally use that sort of terminology as I talk about some congenital cases today as I try to refrain from the use of the word anomalies. I'm also the assistant program director for our fellowship, and I share my time between clinical and research duties. So our objectives today are threefold. So first, I want you to be able to describe the candidates and how you would work them up whenever you're considering a complex vaginal reconstructive procedure. And when I say complex vaginal reconstructive procedure, I'm implying sort of complex procedures on the vagina, not necessarily of the vaginal approach, because I am going to describe some minimally invasive laparoscopic and robotic approaches. So I also want you to be able to plan and execute some common flaps and graphs that we might use in our practice. We as pelvic surgeons are kind of experts in this area, and it oftentimes is very common for pelvic reconstructive surgeons to do their own flaps and graphs, or at least to be able to sort of work beside plastic surgeons or other people who might do these as a second panel. So I also want you to be able to describe some complex techniques for surgical management of congenital abnormalities and how you might engage in multidisciplinary management, because many of these cases do require that. So where do we start? It really depends on where the patient is arriving from, whether it's a known diagnosis, a suspected diagnosis, or undifferentiated. It also depends on what they've had done in the past, any imaging or other things, and also their psychological readiness to move forward and do something. So this is a common algorithm that I kind of think about whenever I'm taking an undifferentiated patient through trying to get at a diagnosis and then ultimately a plan. So a very detailed history, making sure to ask about any neonatal procedures, because some of these patients' operative history goes back to day of life one. You want to do a very detailed physical exam and document really, really well. Describe all of your findings or defer this to an exam under anesthesia if the patient is very young or otherwise doesn't tolerate an office exam. So the things that you're looking for are, you know, doing a detailed abdominal exam. Sometimes they have so many scars on their belly or different holes or things that you can't necessarily identify what's what. I just offer a very simple question. Where does urine come from? Where does stool come out? And oftentimes, they'll be able to instruct you as to what's going on. In the vagina, you're looking for one, is it present? If so, are there any strictures, septums, or other things that we need to attend to? And then in terms of the uterus, is there one present? How many horns? And this may be something that is less appreciated on the exam, maybe more obtained from imaging or other things. And in terms of imaging, I usually tend towards, for these complex patients, more of abdominal MRI, because I'm usually looking for other concomitant things that are going on, like renal anomalies or other things in the abdomen. For some of our patients who are disorders of sex development type patients, or you have a concern for such a condition, you may also consider a karyotype or an endocrine workup. And then if you're diagnosed really after all of that is unclear, do an exam under anesthesia and these other listed procedures. So if you're going down a congenital route and you suspect your patient has a congenital anatomic difference, this is a very helpful resource for you to use. So the ASRM re-establishes in 2021, and you can actually scan the QR code here on the screen or once you have the recording, and it helps you to differentiate different diagnoses from each other and suspected workup and treatment pathways. This is an example of one of the pages of the PDF. I actually have laminated forms of this in our exam rooms that I walk through with patients to kind of help them guide as to, you know, which bucket they fall into and how we can address their concerns. The main things that you want to distinguish are, in terms of uterine anatomy, how many are there, if there is one present. Most are incomplete sort of uterine defects and the most common ones are arcuate or septate uterus. They can be as extreme as what's shown up here on the top right, which is a didelphic uterus. And then you also want to distinguish how many services that they have, because you can have many different variations. On the bottom right there, you see a patient who has what we call cervical bicollis or two cervixes. Just their risk factors and their management will be very different moving forward throughout their life, even after their surgical correction. And then the other things that you want to be aware of are if they have a functional uterus, thinking about menstrual flow or both sides flowing, or is there a concern for obstructed menstruation. So when you do your exam, you want to be very cautious about taking a pause and really taking in all the information that you can gain from their vulvar anatomy and vaginal anatomy. I've shown a couple of different sort of vulvas and vaginas here for you to kind of think about. I'm going to give you a little test here. I put some numbers on here. So which one of these is vaginal egenesis? It's not necessarily as simple as you might think, but it does give you a fair amount of information if you kind of take a moment. So number four was the vaginal egenesis and the other ones were kind of these lookalikes. Septate hymen and perforate hymen are this more complex sort of oblique septum that comes in a syndrome that we'll talk about later called ovirus syndrome. So imperfect hymen is honestly the easiest one. This is your slam dunk one. It's not a true malaria abnormality. It really presents with like this big, big blue bulge. It's blottable. You know, it's very easy. What you do, you go to the OR, you don't have to do any other workup. You resect that part and the patient does really well. A little bit more complex, there is a transverse vaginal septum. So these can sometimes be deceiving. Initially, it can look like vaginal egenesis, particularly if they're very distal. Transverse septums can happen at any level in the vagina. And the important thing is, is that you establish this as a transverse septum versus vaginal egenesis. Sometimes if there's some blood backed up behind them, you can sort of use that to your advantage. You can put a vascath or a needle through it to kind of guide your dissection and know where the blood is behind it. The key is to make sure that you kind of use a Goldilocks approach. You want to take enough, but not take too much because you need to be able to bridge that skin back together whenever you're doing your interrupted sutures to close afterwards. And then I talked about ovirus syndrome just briefly. So this is a syndrome, it's called obstructed heavy vagina and ipsilateral renal anomaly. It was previously a genesis. However, that we're finding that not everyone has a genesis. Sometimes they have some differences in anatomy of their kidney. So what it consists of is a didelphic uterus. One side can menstruate and is non-obstructed. The other side is obstructed by this oblique septum that is blocking one of the cervices and you get hematocopos and hematometra. And so you're seeing that bulge in the picture there in the middle. So oftentimes these patients are menstruating, but they present with progressive pain and the treatment is really to relieve that outflow obstruction. So this is an example of one of my patients. On the top left picture, you see they have normal external genitalia. When you take a closer look, this is kind of a smaller sort of obstructed menstruation. So there's a small bulge there on the patient's left side. And then when you open up that vaginal septum, there's kind of this hollow cavity on the inside with this older blood that's inside. Once you finish resecting that septum, then down on the bottom right, you see kind of that previously hidden cervix. Usually this is a smaller cervix than the other side because they usually tend to have a dominant side and a more diminutive side. All right. So as you're starting to warm up your brain and I'm showing you some of these cases, you're thinking about vaginal surgery or not. How are you going to approach some of these really tough cases? And it's a good warm up as you hear lots of people talk about the different things that they're doing, trying to figure out what is your approach going to be? What are the pros cons? So I've given some examples here. So on the left, yes, these are vaginal surgery cases. So the one in the middle shows urethral trauma, absolutely a vaginal case. The one to the left, it was a patient who had spina bifida, who had a uterine prolapse. We did a vaginal hysterectomy and then her TVL really was only four centimeters after that. So we did a uterus sacral ligament suspension and put a biologic graft on top of that in order to give her a normal vaginal length. These patients on the right, the one that you see the firefly and the ICG lighting up. So that patient had an ectopic ureter along with other congenital abnormalities. And so in order to take out that ectopic ureter, which was filling urine into the vagina, obviously needed a laparoscopic or robotic approach. And the patient on the right had menorrhagia with a didelphic uterus and wanted a hysterectomy. Okay. I'm going to give these little pauses that show a little bit of Duke's campus along the way, just to give our brains a little bit of a break. Okay. So thinking about a patient with vaginal agenesis and using your exam. So with this particular patient, you want to sort of take in what you're seeing and where are you starting from. For this patient, she has a normal urethra, normal labia, but she really doesn't have much in the way of a dimple for her to start with. I mean, it's always wise to try to start with dilation, but it can be challenging in these patients who don't necessarily have a dimple to seat the dilator into. So malarian agenesis, also known as Meyer-Rogatansy-Kusterhauser syndrome, is aplasia of the uterus. And then you get also get agenesis of that upper two-thirds of the vagina. Remember that's a different embryologic origin than the lower one-third of the vagina. They otherwise have normal secondary sexual characteristics, normal chromosomes. And so here's some other pictures of MRKH. This patient on the top right does have a little bit more of a dimple, will most likely have an easier time dilating just because they have some, you know, somewhere to start from. Whenever we're talking about the MRKH, I also really want to know if a patient has uterine remnants, meaning these little nubbins of uterine tissue that are on the inside, because some of them can be, can be active. They can have endometrium. And so oftentimes I'll ask about cyclic pelvic pain and or MRI to evaluate to see if there is endometrial tissue there. And I would consider a little hysterectomy if they did have endometrial tissue. The things you also need to be screening for are other concurrent anatomic differences, the most common of which are urologic abnormalities. So single or duplicated kidneys or ureters. Other common things would be spinal abnormalities and GI abnormalities. And a little bit more rare would be cardiac abnormalities. Taking a good sexual history is extremely important. You want to know whether it's a congenital or an acquired condition of a genesis or agglutination of the vagina. Are they sexually active or attempting to be sexually active? Do they have a partner? Is it a hope for them in the future? And what is their comfort with self-touch as dilation really requires this and you need to make sure that you're setting the patient up for success. And then the readiness to And then the readiness to intervene versus just education about where they are. So another reason why sexual history is important is I have several congenital patients who have shown up who have attempted sexual activity and unknowingly have had urethral intercourse. So these are two different patients who have had urethral trauma. One it kind of splayed open, the other dilated. So you just literally want to be aware of as we're counseling these patients as to kind of what we need to do to restore their anatomy. All right. So patient counseling. So something that you really want to start with is education about where they are with your anatomy. So I use that little ASRM and some other sort of handouts. And the biggest thing you can do for that patient is tell them that they're not alone. You're going to be with them. It may be a tough, rocky road, depending on what sort of route you decide to go down. But you're going to keep their goals of care in mind as you're moving along and making their plan. Vaginal dilation may be an option that you start with for most patients. I highly recommend it actually because it gets them used to using the dilators and self-touch. In the literature for congenital cases, it quotes a success about 80% in sort of real life use. I haven't necessarily seen that quite high of a success rate. Always be thinking about the uterus, whether they're uterine horns or a functional uterus that you need to be aware of. And then you always have sort of surgeries and reconstructive options available to you, but you want to de-emphasize that quick fix sort of component of it. All right. With vaginal dilation, we used to have these very archaic ways of dilating. However, we've become more modernized and have different options available that are more acceptable to our patients. On the left here are a set of graduated sit-on dilators. I really like this particular brand that patients can even buy from Amazon. And on the right side here are a set of handheld dilators, kind of the same sort of concept. I usually have patients dilate for 20 minutes twice a day. And I check in with them early on very frequently and kind of space those out as we go along. All right. So now we're going to talk about surgical management, some different complex vaginal pathologies. We're going to start with neovaginas. And in that, I'm going to use that topic to talk about grafts. When I'm sort of talking about this from a congenital spin, a lot of these concepts can actually be applied to patients who are non congenital. So patients who have vaginal agglutination for a variety of different reasons or loss of the vaginal space, shortened total vaginal length, et cetera. And then we're going to talk about some complex reconstruction with flaps, and then a couple of zebra cases at the end. So our first technique we're gonna talk about is McIndoe. So it's creating a neo vagina by doing a dissection and then laying in a graft. And this has been around for a while now. The McIndoe has three basic steps and it occurs in two stages. So the three steps are just dissecting between the urethra and the rectum in laying a graft. And then after that, the maintenance phase of dilating and intercourse in order to maintain the neo vagina. So with the first stage, this is the first procedures, first time they go to the OR, you're doing a majority of your work there. So you're creating that space both bluntly and sharply trying to maintain really excellent hemostasis, getting a total vaginal length that is usually around 10 to 11 centimeters, kind of dissecting up until approximately the peritoneal reflection. You obtain your graft, and we'll talk about the different means to do that, put it over a temporary mold, put that into the vaginal space that you've created. This is a sort of closer up picture of your dissection and what it could look like. And after this, this is sort of deeper on the inside that you've achieved hemostasis. And then this second sort of check in after you put in the graft, this is kind of looking to see like whenever someone who has a burn gets a skin graft, you wanna make sure that the skin graft took. Same idea here in the vagina. So afterwards you are sort of just cleaning out the space, assessing for any granulation tissue, cleaning up the edges and securing them. And then after this, the patient can then take out their mold and put it in themselves. So now I'm gonna take a quick aside and talk about grafts. And so with grafts, they're actually very simple to learn how to do the different techniques. It's just really important to know all the risks and benefits of your graft options. You wanna have some nuances about talking about what the risks are specific to a buccal graft or a split thickness. And also what are the things that you need to ask the patient when sort of planning where you're gonna obtain the graft from. For example, do they have tattoos in different areas of their body or is there areas that grow more hair or not? Cause that'll be important for things like split thickness skin grafts. So with biologic grafts, so really know the brands and the processing. Open up that big chunk of paperwork that comes in the box and read it. Be mindful of some of the biologic grafts. They do are processed from pork. And so be mindful of certain patients' pork restrictions. Also know the sightedness of your graft. This is really important. You can do some like mental gymnastics trying to figure out everybody who's used this particular type of graft with a notch on it knows. If you look at the instructions for use, you can do mental gymnastics about where that little cutout goes. I try to make it very simple for myself. I get a little dot of blood and I put it on there, whichever side it absorbs into, that's the side that goes toward the patient. Again, the dot of blood, if it absorbs towards the patient. And then think about shrinkage. It's gonna shrink about 15 to 20%. So just be aware of that. Okay, use of a biologic graft for increasing vaginal length. I showed this picture previously. You can use it to kind of make a cap, if you will, at the top of the vagina. The important thing you need to counsel about is that structure risk, because you have an interface of sort of need of vaginal tissue in a graft, there is a high risk of structure there. So they just need to be aware of that and dilate very often. You can also do this via a laparoscopic or robotic approach. This particular patient also needed an endometriosis resection. She had a very short TVL from a history of a gender urinary sinus. So we then wanted to give her a longer vaginal length and did this via a biologic approach or use of a biologic graft. Okay, so this is another application. You can use it for urethroplasty. So I showed that previous patient who had the urethral trauma due to unknowingly having intercourse in the urethra. She unfortunately kind of split up right up through the trigone between her four ureteral orifices. And we reconstructed and then did a urethroplasty and for the anterior vaginal wall had to use a biologic graft because that tissue had been obliterated. And stay tuned. One of our fantastic residents who's going to be a fellow at UCSD next year after next is going to be giving a video on Wednesday at Augs to show this concept. Okay, so buccal grafts. With buccal graft harvest, it's a pretty straightforward thing. We're not used to operating in the mouth but it's actually a pretty easy to translate some very basic concepts there. You really wanna counsel the patient appropriately about what she'll expect with the sort of something inside of her mouth. But luckily inside of the mouth heals extremely quickly. The important part is to counsel them about the risk of dry mouth. Stenson's duct is right in front of the second molar on the top. So you just wanna make sure and mark that and avoid that such that you decrease the risk of dry mouth after obtaining the graft. Be cautious with the airway. This particular patient has a nasal airway actually in place. You can use an oral airway. You just need to lateralize it. Make sure not to use electrocautery near that airway. Okay, this is an example of a buccal graft in the mouth, the harvest site, and then the obtained graft. I like to close that graft harvest site afterwards just because it can be strange for the patient to feel that raw surface there. All right, so split thickness grafts. You obtain these via dermatome. This is just one brand, a pageant. There's also Escolap and several other types of dermatomes that you can use. You'll just wanna know the settings, the type of blades and things that you have available. And it's a little bit more complicated than what you're used to, but it's a little bit more manageable. And then set yourself up with using mineral oil to kind of make the surface slippery, have an assistant to help you to obtain the graft so it doesn't get all wrapped up. Okay, this is an example of a graft from the buttocks and a graft from the thigh. After I harvest the graft, I then put epinephrine-soaked sponges onto it because these things can bleed like stink. So you really wanna take that prophylactic measure. You wanna put the graft on a side table, come back to it later, redress it, put a pressure dressing on. You wanna set yourself up for success because you'd hate for this to be the area the patient hemorrhages from. Okay, so shaping the graft over the mold. So this is the picture of one of my fellows doing exactly that. So you wanna take that graft. And again, we talked about sidedness, get it correct. So the shiny side goes outward. This outside skin part goes towards the lumen. You shape it kind of around a soft mold in order to place in the vagina. This is, again, a picture of that kind of putting the shiny side outward, if you will, to make sure that you get the sidedness correct. And then the mold is extremely important. So you wanna make sure, I'm very aggressive with dilating. So I usually tell my patients to do it for nine months. And so you'll have them do a long-term mold for that period of time. There are certain patients who'd have kind of differences in their anatomy and a typical mold might not work. And in those situations, different people have fashioned different things. I've used 3D printing in order to help in those particular situations. Okay, so cosmesis. Another thing to counsel the patient about. You will always see this graft harvest site. Some people more than others. This is a six-week and six-month example in one patient. Here is another at six-week, a little bit more purply pronounced. And this is some pictures from one of my mentors. I don't yet have 20-year outcomes to be able to show, but you can see some skin difference there inside the vagina too. So it's something else just to make sure that they're aware of. Okay, so what about agglutination or shortened vaginal length in non-congenital type patients? And so when you think about short TVL and think surgery, surgery, surgery, when you're thinking about causes, you think about many of the things that we do, things like hysterectomy, particularly radical hysterectomy, prolapse repairs and multiple prolapse repairs, leaps and things like that. And then you add in radiation therapy and we have several women who do have these unfortunate instances of shortened vaginal length. There are some other medical causes. Remember things to be aware of, postmenopausal state, ear lichens, more rare things like graft versus host disease. Whenever you're approaching these, go simple first. Attempt license of adhesions, try a vaginal route. Sometimes you get in the right plane and it just kind of gives after you get through that scar. You may wanna consider imaging for some patients who have a uterus and who are still menstruating if it's obstructed to kind of know what you're dealing with. And then if you are having some medical issues that are contributing to the picture like your lichens, make sure and get control of that. The last thing you wanna do is operate and operate and operate, and then their disease just keeps coming back and causing it to re-agglutinate. Be very cautious with radiation. Radiation is the gift that keeps skipping. You can approach a scar and you think, you're in the right trajectory and you might have the rectum kind of pulled up into that area. So just be very cautious there. And those situations I would actually recommend laparoscopic or robotic assistance. And then consider other things like stents depending on multi-operated or other things where you're concerned that the ureters might be pulled in. So this is an example of a patient with graft versus host disease. In this middle picture here, you can kind of see there's a line there where she's had some agglutination and the upper vagina has just become inaccessible. And her TVL was about a centimeter and a half. So for this patient, we actually ended up going combined vaginal laparoscopic because she failed an initial attempt at just vaginal lysis of adhesions. And there's a video here. We don't have time given that we had our little snafu with the earlier to go through this whole video, but if you wanted to take a look at it, it is published in J-MIG. Okay. All right, so moving on to the Vecchietti. So this is an accelerated blunt dissection technique. It does require specialized equipment. You get a functional vaginal length in about a week. So this is the special equipment. It looks a little intimidating when you first look at it. On the bottom left, there are the plastic olives that you kind of have a main one. You snap the others onto it. Bottom right is a spring traction device that goes on the patient's abdomen. There's a suture that connects these two together and you kind of crank it. And then a variety of other introducer instruments in the tray. Okay, so suture type. I have liked borrowing a suture actually from orthopedics that they use on joints. It's called fiber wire. After I had another permanent suture snap, I converted to this and I've had no issues with that. So that's what I use to attach to my olive. And that's what it looks like once you run the suture through the olive. And then in terms of port placement, go with the umbilicus. And then I put one port on each side of the spring traction device. And so this is kind of just a pictorial representation of the procedure. So you gain laparoscopic access. You thread your suture that's on your olive from the perineum to the abdomen, laparoscopically grasp that. And then you're actually gonna tunnel. Use some of those tumbling instruments that I showed initially to tunnel pre-peritoneally then go into the abdomen, grab your sutures and bring them back out. So then you're gonna attach those sutures to the spring traction device and you're applying tension usually twice a day. And the patient is admitted during this time. You go back whenever you've reached an adequate vaginal length. I like to do it in the OR. I take off all the instruments and just do an exam under anesthesia. So the nice thing for Rebecca Yeti is it's a sort of more natural vaginal tissue, if you will, cause you're kind of just stretching what's there. It also gives the potential for a uterine transplant in the future. And there are various other benefits as well. So one of my fellows also has a video for this at AUGS this year. So she's presenting this on Friday. So if you'd like to learn more about this, she gives lots of tips and tricks in order to make the Becky Yeti more approachable. All right, this lovely picture of the Duke Gardens. All right, so the last procedure I'm just gonna quickly go through is a dabby dab. And just the caveat is I don't typically perform this procedure. I'll explain a little bit about why that is, but it's basically a peritoneal flat mobilization procedure. And so what you're doing, this is all done laparoscopically as well. So you're doing a vaginal dissection like you typically would for the McIndoe. You're usually introducing like an EEA or some other thing per the vagina. And then laparoscopically, what you do is you identify and mobilize that peritoneum, you make a hole in it, and then you'll bring it back down to the peritoneum. Once it's brought to the peritoneum, you affix it kind of circumferentially. And then your next task is to create an apex. So the apex is created via usually two purse string sutures at the top. And my sort of personal surgeon bias, two purse string sutures for a lifetime of intercourse just seems a little risky. So for me, this isn't my go-to procedure just for that reason. However, I know some people have a lot of success with this procedure as well. Okay. Now we're gonna move on to flaps. These are kind of the exciting part because you can get really creative with what you can do, the amount of space you can fill. So flaps can be musculocutaneous or fasciocutaneous, and they can be sort of islands or paddles that we use for reconstruction in the pelvis. So they can be pedicled or non-pedicled. So what do I mean by that? So pedicled, you can think of like the old kitchens in the nineties where they have those peninsulas in the kitchen, and you can kind of move the peninsula from side to side. That's a pedicled flap. So it's still attached. Whereas as a non-pedicled, you can think of, still using that kitchen analogy, is like a kitchen island. So the kitchen island isn't attached to anything. If you move it around, it's just an island, okay? So most commonly used things in pelvic reconstruction are rectus abdominis flaps, gracilis flaps. Singapore is sometimes called groin flaps. And then martius, this is kind of a space filling, a little bit of a misnomer when it's labeled a flap, but it's more space filling. So starting with the martius, this is an example of a martius. What you're basically doing is harvesting the fat pad from one of the labia. Counseling is very important here. You want the patient to know what to expect. And you'll, I mean, the cosmetic outcome is they will have a scar, but they'll also have sort of flattening of one of their labia that looks different than the other side. You sacrifice one of the, either the upper or lower vascular pedicles, and then sort of swing it inward towards whatever you're trying to cover, whether it's for fistula or for urethral reconstruction, these are very helpful sort of space filling flaps. This is an example of a Singapore flap. This is one of the patients who had congenital adrenal hyperplasia. So she was one, she did not want grafting from other places, didn't like the idea of something in her mouth being done, didn't like the idea of a scar on her leg or other places for a split thickness graft. So she wanted to do a Singapore flap as sort of her grafting, if you will. And so we did this on her left sort of groin surface and then closed it. And universally these patients, it's a pretty painful procedure and they're usually in the hospital for a couple of days afterwards. They universally need pelvic floor PT afterwards. This is one that I'm very aggressive with PT with just because they have a lot of pelvic floor spasm given all the rearranging you're kind of doing in their groin. This is an example of doing bilateral Singapore flaps. So you see it harvested on both sides. In the left picture, they've laid first the left one and then the right picture, they've laid both of the flaps. I like to use drains in these because there is a, they do weep a lot. And just like any other groin incision, I counsel patients of the high risk of these winds breaking down or getting infected. All right, gracilis is another common flap that we're used to working with. Very helpful in things like fistulas, radiated pelvises, really nice to give you bulk in an area where you need some bulk. I'm gonna scroll forward in this video. All right, so I just want to show how you lay this gracilis flap. So they've harvested already and then they're bringing it, they have a sort of delivering tunnel that they're delivering it through. And then after that, they're gonna place a drain in the leg and then start to apply the flap in the vaginal space that they're reconstructing. Now, I will tell you gracilis is one of the ones that I have plastic surgery harvest for me. I'm less inclined to sort of muck around, around the knee and harvest it myself. However, I do lay it myself. Okay, another common one that you may be familiar with often used in breast surgery is a vertical rectus abdominal muscle flap. Again, you're taking the rectus muscle attached to its blood supply, which would be the inferior epigastric in this situation, taking the overlying vertical skin, as opposed to the transverse abdominal muscle flap, which are doing the transverse sort of left to right type of skin. I like this one because it works really well for sort of folding into a lumen, but it is a very morbid sort of flap to harvest and then recover from. All right, so we have a little time here, I just want to keep track here. To talk about some complex cases. So these are the ones that kind of keep you up at night that you're thinking about trying to figure out how am I going to approach that case? They're the cases that break all the rules and that you oftentimes have to tap into other brains who are really smart around you who can help you come up with a plan. In our program, we oftentimes take these to a case conference where we put all of our heads together and kind of shout out different things to figure out what we're going to do next. My best advice is never go down alone. Always have multiple heads in sort of in the game making suggestions because you want to approach these cases with a really good first attempt because especially if the patient has a very complex surgical history, you oftentimes don't get multiple attempts at trying to repair things. Okay, so our first case. So this is a patient who presented to me who had vaginal agenesis, but uniquely also had a fully formed uterus and was menstruating. For a while, she had been suppressed, so I'm going to show this video. This was a really great video that my fellow who graduated last year made. Dr. Catesby, the video does not have audio at the moment. Oh, I apologize. The video doesn't have audio. Okay, so I will narrate this then. I'm hearing it, but you're not. Okay. So he's describing the MRKH syndrome that we talked about before. So I'm going to go forward here to get to the surgical portion of things here. So this patient had... Sorry about the technical difficulties here. Let's see here. Okay, we'll start here. So this patient had some cyclical pain due to her retained uterus. So we obtained an MRI. And so there's a uterus that's distended with blood, a cervix, and then a little piece of upper vagina that has blood distended in there as well. We ended up taking her for an exam under anesthesia. So she had duplicated systems bilaterally whenever we did cystoscopy. And then we ended up evacuating her uterus because she had a lot of hematometra. We placed a drain from the uterus down to her perineum, basically, such that we could finish off draining a lot of that hematometra and then come back another day in order to do her neovaginal surgery. So we started stenting the ureter since she had two on each side. So this is her external exam. She had normal external genitalia. This is the drain that was previously put into the uterus. So we then used a combination of blunt and sharp dissection to develop that neovaginal space. So once we reached the peritoneal reflection, we then decided to sort of tag around the malicot drain. Then we could then attach it to the graft that we inlaid. So we packed in some sponges to maintain the space, and then we put the patient in decubitus position to then harvest the graft. This is the Dermatome that I typically use in my practice. This is where we're dressing it with epinephrine sponges and then we apply the graft onto the mold. So we put Xeriform on the graft herbicide. We bring that malicot drain that's draining the uterus through the graft. And we attach the previous sutures that we had tagged onto the graft to kind of bring them together. And we inserted this into the canal. Okay. All right. Sorry, you all didn't get to hear that sound. Okay, so say the patient has a uterus, but they are not ready for a new vaginal procedure yet. Another option would be to place some drains and allow for a little bit of epithelialization of the tract such that they can still have menstrual egress, but they don't have to necessarily undergo the bigger reconstructive procedure. So in this picture here, that blue drain that's going in is a malicot drain, which is inside the uterus. And the red rubber is just a really large red rubber that we put around it to kind of create a sort of wide track and I usually suture those in place, try to leave it in for six weeks. And then when you take them out, that tract is matured. You're basically creating sort of an intentional fistula, if you will, in that area. Okay, so case number two. So this is a very complex patient. So this patient has a history of bladder exstrophy. She has a metrophin off, so a catheterizable stoma at her umbilicus. She has a colostomy, which is what you see on her right side. And then unfortunately, she'd had two prior neovaginal surgery, which failed, unfortunately, because that provider didn't have her dilate past six weeks post-op. And it just demonstrates the big importance of continuing to dilate after the neovaginal surgery is performed. So as you can imagine, this patient had distorted anatomy. So whenever you have an exstrophy patient, oftentimes their anterior-posterior sort of diameter of their pelvis is very contracted. And so the usual trajectory that you would take during the dissection, unfortunately, ran into her coccyx. So we had to consult orthopedics intraoperatively, who then performed a partial resection of her coccyx. We were able to perform the neovaginal surgery successfully, and she didn't have any repercussions from the removal of the coccyx. But it goes to show that you should always think about what could go wrong and who you can involve when the anatomy isn't necessarily textbook. This is the patient for which we kind of got the 3D-printed vaginal mold idea from because she had a very different shaped pelvis. So these worked really nicely for her post-operatively. So again, this case demonstrates the need for a multidisciplinary team. So we had a lot of consultative discussions beforehand in terms of all the what-ifs that could happen. We didn't know that running into the coccyx was one of them, but we still talked to orthopedics intraop in order to get a good plan for this patient. And her goal was, because she was getting married, she wanted a successful neovaginal surgery. Okay, so a couple of reflections as we wrap up here. So many of these patients, whether particularly the congenital patients are young, they're often scared, or they've had multiple encounters with the healthcare system, good and bad experiences. So just keep that in mind as you're talking to the patients. They may or may not know the correct anatomical terms, so you really have to break it down for them. Using pictures is very helpful. You want to involve all the people who are involved in their lives, whether it's caregivers or parents, collateral information givers. And be aware that if this is something that you kind of want to take on as your own, as your complex vaginal surgery practice, outside ERs won't necessarily know what to do with your patients. It's really important to counsel your patients, always come back to home base. And the best chance for a great outcome is your first attempt. That's really important. And then multidisciplinary outcomes really are superior to any one surgeon working alone. Okay, so at Duke, we do this in our program. We have the GU Cares program, which we mentioned earlier. We kind of had our soft launch in 2023. We've been growing and growing into a multidisciplinary program. We have people from PAGS and Urogyne and Pediatrology, REI, et cetera. And it's been a really great experience to put our minds together and figure out how to best care for these patients. We have a kind of specialized system that we've developed to kind of keep our patients organized. And we have a way that we have a referral type and we see patients in person, we see patients virtually. We kind of label our patients a little bit differently in our schedules such that everybody can identify and ask appropriate questions of them so the patients don't feel stigmatized. So this is something that you're trying to recreate. I share this just to kind of give you food for thought. And our program is meant to be lifespan care. So once you do this really complex procedure on this patient, you can't necessarily just let them go out. You have to really follow them over time because you're going to know their anatomy best in exactly what you did in that scenario. And so the expectation is really that patient becomes your patient for life. And my last reflection, as I sort of wrap up here and then we move on to question is that no two pieces are exactly alike. You always want to keep those wheels turning. The biggest thing that I encourage you to do is put your heads together with your group if you have a difficult case or you're wondering how to approach it because I've always found that having multiple people think about something is much better than the singular idea that I came up with. So with that, I'm going to sort of close here. I put my email address here. If you have any questions, concerns, thoughts that we don't get to address today in the Q&A, I encourage you to reach out and it's been a pleasure. And I thank Oggs for inviting me to give this webinar. Thank you so much, Dr. Kisbe. Now it's time for questions. As a reminder, please use the Q&A feature on the Zoom webinar to ask questions. I have a couple coming in. The first one is, how do you choose which type of graft to use during reconstruction? It's a really great question. I try to offer the menu to the patients and counsel them a little about individual risk factors. For example, a patient who has a history of PCOS and has a lot of hair growth in certain places, it wouldn't do them justice in order to do a split thickness graft unless they were willing to first do hair removal first. Such that we don't graft and then have a problem with hair inside the neovaginal space. Same thing with buccal grafts. You wanna make sure the patient is comfortable with the care, the maintenance, the risk of dry mouth. Buccal grafts can be sometimes challenging when we're talking about adult vaginal surgery in order to get enough sort of real estate to construct a large surface area. So sometimes you have to harvest from both sides. And sometimes you need to do a lot of work and sometimes you need to, with the buccal graft, I showed it previously with the sort of fat on the bottom side of it. You have to defat it and sometimes even run it through this little machine that creates little stippling or holes in it in order to make it a bigger graft. So there are little ways that you can help set yourself up for success. But there are nuances as you're practicing and figuring out how to do this. Understood, thank you. And then how do you decide between say, for example, like a buccal graft versus a biograft? I assume that there's sometimes like sizing as well as kind of the patient characteristics. What are your kind of algorithm for that? Yeah, so I tend to reserve buccal graft. I really like it in urethral reconstruction. It works really well there. And then I keep in mind the size things that we talked about earlier. The other thing to think about with the biologic graft is there is a fair amount of shrinkage that occurs with it. And just from personal experience in discussing with patients, there tends to be a little bit less sort of biological give. From a mechanical perspective. And then the other thing to think about is cost. Biologic grafts can cost up to $10,000 per graft. So just being cost-conscious in terms of thinking about the total cost of all these procedures and things that we're offering. Thank you. One question is how would you propose your gynecologist get involved in performing all of these surgeries? Watch videos you and others provide and collaborate with plastic surgery and urology. Would you recommend any simulation training or cadaver training that would help? Yes, that's a really great question. I would love to see a cadaver training, perhaps something, you know, if Oggs sought value in that, would love to sort of participate in. Because I do think we are reconstructive pelvic surgeon experts, and this is really sort of our field. And, you know, we participated a lot in laying the grass. I do think we could also sort of practice harvesting them more. I personally, in fellowship, shadowed a lot of plastic surgeons who got involved in cases there, watched videos, and then also just had some plastic surgeons on standby as I was doing my initial pieces in order to give tips and tricks and things. The important thing to know is that when you're going across institutions, if you are going from a training institution to your sort of working institution, the equipment will be very different. That was just sort of a learning curve for myself in terms of going from fellowship into attending job is that the equipment was different. You do have to kind of get somebody to show you how to use it in a different way. I have a question from Dr. Becky Rogers from Albany Med. This was a great talk. Thank you. Can dilation in older patients be successful? Dilation can be successful in older patients. I think one of the hardest thing for some older patients, depending on their dexterity, and whether they have arthritis or severe issues with their hands, just like in our pessary patients, it can be hard for them to hold pressure for 20 minutes twice a day. It just takes a certain set of endurance and ability to manipulate. However, in some of our patients who use the sit-on dilators, you can get the very smallest sizes and start small and work your way up. Sometimes that can be more successful. I've found that giving vaginal estrogen can also help them be more successful, and sometimes a topical lidocaine as well to help with pain control. However, there are a certain number of patients who just have these really fibrous bands that they can't dilate past. So I think that's our job whenever we're doing a detailed pelvic exam to kind of gauge that sort of chance of success with the patient. Thank you. Dr. Kawasaki asks, for recurrent rectovaginal fistula, what is your approach for flaps and graft choice? Yeah, so for recurrent rectovaginal fistula, typically I'm looking more towards harvesting either a local flap, a pedicled flap versus a gracilis. I really like the gracilis because it gives you sort of an extra oomph in bulk, particularly if in the recurrent setting. And it's usually outside of a field if the patient has had pelvic radiation, which is sometimes the cause of rectovaginal fistulas. It's outside of the field of radiation such that it's kind of fresh tissue that's coming in. The downside to that is it does bring in bulk. So you just have to set those expectations with the patient. And then it's pretty painful in the first couple of weeks to months afterwards. I previously had got a tip from a plastic surgeon who actually did Botox in the muscle after they laid it in order to kind of not let it spasm such that it was more tolerable for the patient as they're getting used to it. Another question is, what kind of psychological care do these patients need? Great talk. Yeah, so the probably initial thing that I do whenever I have a patient come in is I validate where they are. I ask them what their goals are. And it's really one of those, we talk for the first 10 to 15 minutes of our consultation about what has happened, what has went well, what hasn't gone well, what are their goals of care? And then we talk about, okay, so this is your goal. This is how we're gonna achieve your expectations. This is the best case scenario and this is the worst case scenario. So my initial visits are honestly a lot of talking, a lot of counseling, because the best thing you want to do is make sure that the patient feels understood, they feel supported and they feel like they have options. Sometimes the options are very limited or not what they expected they were going to be. And sometimes it's, I'm sorry, I don't have many options for you. And that's a hard thing to say, but in the end they walk out feeling understood and that you explored all the things that could potentially have been options had they been in a different situation. Great talk, thank you. One of the participants is asking exactly when do you remove the vaginal mold after surgery? And does that differ based on what type? Of course. So I, like I mentioned, am pretty aggressive with my dilation regimen. So the first week after a vaginoplasty surgery, I actually suture the labia over top of the mold such that the patient can't take it out and there's no risk of it coming out. And that is very important, particularly for the skin graft based procedures, because you don't want the graft to shear and move a lot if the graft has a lot of mobility. And then after that, I have the patient take it out once a day. And then I usually do a three, six, nine kind of timeline for the patient as long as things are going well. So they need to wear it most of the time for three months, only at night from three to six months, and then three times a week for six to nine months. And then from nine to 12, as long as they're having intercourse, they don't necessarily need to intentionally dilate. If they feel like they're ever losing any sort of, I have the mark on their dilator where kind of their neovaginal length is. If they feel like they're losing any depth there, then they need to go backwards to three times a week again. And just as a follow-up question for that, how often and what's kind of your interval for following up these patients? So I follow them pretty closely. So I see them after their surgery, I see them a week, and then I see them at two weeks, six weeks, and then three months, six months, nine months. And they can call me or come see me anytime in between those. Oftentimes we're doing telehealth or other things, discussion about self-cares or how things are going. A question is, is there any hope for a patient who undergoes failed initial surgery for reconstructive surgery that gets rectovaginal fistula? And this is for vaginal agenesis. Yeah, so I'm assuming they had an attempted procedure and fortunately had a rectovaginal fistula. Yes, so that's when you kind of have the patient cool off and take a sort of recovery period to let that tissue recuperate. That may be a patient that I suggest we do some sort of inlay sort of on the posterior vaginal wall, whether it's a Martius or some other inlay to give a little bit more sort of oomph to that rectovaginal septum, for lack of better words, before you put in any other graft that you're using. You just have to take really extreme caution depending on how far that provider got in their dissection, whether it's they had a rectotomy that may have been unrecognized and didn't finish, or if it was just an unrecognized something that happened or was just unknown cause, so. And one last question. Can you talk a little bit more about the process of the 3D printing? Like how is it done? What is the material and how long does it last for the patient? Of course. So this is something that we published in the Green Journal and we're continuing to pursue as sort of a hopeful clinical translation at some point. And so it's 3D printed like any other medical sort of 3D printed devices. Orthopedics uses 3D printing a lot. They, for ankle screws and plates and other things. And so I think gynecology is just starting to tap into that resource. That particular one that I showed is made out of a dental resin. The easy thing was is that it was accessible already because sort of the 3D printers in that facility were medical 3D printers and they made dentures. And so it was something that is very hard to break, gives a good sort of smooth surface. So don't get a lot of bacteria buildup and other things on the surface of it. We're exploring other biomaterials to kind of optimize that. It can last honestly forever. So once it's made, as long as it's not lost or broken in some way, the patient can continue to use it. Awesome. Well, on behalf of Oggs, I'd like to thank all of our faculty, Dr. Cusby for this excellent webinar. Be sure to register for upcoming webinars on September 18th. Join Dr. Benjamin Barron as he presents the webinar title, Don't Get Burned, Electrosurgery in the OR. Follow Oggs on Twitter and Instagram and check our website for information on all upcoming webinars. Thank you all for joining and have a wonderful evening. Thank you all, everyone. Have a great night.

vaginal reconstruction procedures

flaps and grafts

collaboration

patient counseling

graft types

3D printing molds

follow-up care

psychological care

neovaginal surgery