Historically, neovaginal creation procedures have been performed in patients with congenital anomalies such as vaginal agenesis. This video demonstrates our neovaginal creation technique in two women with iatrogenically foreshortened vaginas. It is a modification of the McIndoe procedure used in patients with congenital vaginal agenesis which uses a split thickness skin graft to create a neovagina. The objectives of this video are to discuss the clinical considerations for neovaginal creation in the setting of the foreshortened vagina, to demonstrate the procurement and modeling of the split thickness skin graft for use in the vagina, to demonstrate various techniques of neovaginal creation, and to describe limited clinical outcomes. The foreshortened vagina can be attributed to multiple iatrogenic causes including vaginectomy for the treatment of vaginal or cervical cancers, radiation effects, mesh or graft complications after pelvic reconstructive surgery, and multiple vaginal surgeries, typically in the face of recurrent pelvic organ prolapse. Prior to vaginal reconstructive surgery in a patient with a foreshortened vagina, it is vital to review the patient's medical and surgical histories in order to anticipate surgical findings. An MRI may be obtained in select situations. For example, if one is concerned for retained mesh or graft, this imaging may be helpful. Vaginal estrogen should be applied preoperatively to optimize tissue quality. Patients must be counseled on the postoperative course including stent use and a five to seven day hospital stay. Furthermore, they must understand that they will likely need to use dilators postoperatively and that this may be a lifelong commitment. Situations for graft revascularization include adjacent organs, omental J-flaps, and bladder peritoneum. The patient is placed in a low lithotomy position using yellow fin stirrups in order to have access to the abdomen, vagina, and rectum, and a three-way Foley catheter is placed. End-to-end anastomotic sizers are available. This first case demonstrates these techniques in a patient with a foreshortened vagina resulting from a vaginectomy and radiation. A thorough examination under anesthesia is completed. As seen here, it reveals a foreshortened vagina with normal epithelium. Next, laparoscopy is performed. We have found this step invaluable in our experience, even in cases where intra-abdominal graft is not ultimately placed. Palpation of the vagina and bladder can help delineate organs, as can rectal placement of the EEA sizer. In this case, the laparoscopy reveals normal anatomy with the exception of a foreshortened vagina. Given these findings, an intraperitoneal repair will be performed. The abdomen is carefully examined for recipient sites. While we had considered an omental flap, this patient's omentum is surgically absent. We elect to use the bladder peritoneum instead. Laparoscopically, the bladder is retrograde-filled to facilitate visualization of its margins. The peritoneum is grasped at the superior edge of the bladder and opened. The peritoneum is then bluntly dissected from the bladder muscularis. As we near the bladder base, the dissection becomes more difficult, likely due to tissue radiation effect. The tissue is infiltrated with normal saline to facilitate dissection. In order to further mobilize the peritoneum, we perform a retropubic dissection to release the bladder from the pubic symphysis, which brings the dissected peritoneum closer to the graft implant site. A plastic surgery consultant then assists with the split thickness skin graft procurement. Mineral oil is applied to the leg. The graft is collected and passed off the table for further processing. The donor site is covered with gauze soaked in dilute epinephrine. Immediately after procurement, it is plated and passed through the skin mesher. The skin mesher perforates the tissue, expanding the surface area of the graft. The perforations also permit egress of blood and fluid from the surgical site postoperatively. Next, the graft is placed around the mold, which in this case is a mentor stent. It is important to place the dermal, or shiny side, on the outside to facilitate neovascularization and adherence to the implant site. In this case, we also apply a sheet of small intestine subucosa, or SIS. This non-immunogenic material acts as a scaffold, which is later replaced by well-organized host tissues. Typically, we use SIS in cases when we are attempting to bridge a gap in native tissue. Once the stent is molded with the graft, a copotomy is performed and the stent is placed in the vagina. The peritoneum is then used to cover the stent. In areas where gaps exist, bowel epicloaca are used to provide extra coverage. Vaginally, the graft is sewn to the vaginal epithelium. The labia are sutured closed over the stent. This next example demonstrates a patient whose vagina was foreshortened after multiple vaginal reconstructive procedures, which were complicated by biologic graft rejection. The exam under anesthesia reveals significant granulation tissue on the anterior vagina. At the time of laparoscopy, the patient initially appears to have normal anatomy. However, on closer examination using cystoscopy and vaginal palpation, it is clear that the bladder and rectum abut without separation by vaginal tissue. Given these findings, the decision was made to proceed vaginally. Electrocautery is used to remove the granulation tissue to optimize graft adherence. A split-thickness skin graft is then procured, molded, and inserted into the vagina. Postoperatively, our patients are admitted to the hospital for 5 to 7 days, during which time they are kept on bed rest and a clear liquid diet. A Foley catheter remains in place. Thromboprophylaxis is administered. After 5 to 7 days, the patient returns to the operating room and the stent is removed. The vagina is irrigated and excess graft is removed. The patient is discharged from the hospital and instructed to continue stent use with estrogen cream for the majority of the day. The patient is seen 4 weeks later and transitioned to silastic dilators, which are used for 30 minutes, 2 to 3 times per day. Our patients have done well postoperatively, with graft acceptance ranging from 80 to 95%. Thus far, we have encountered minimal morbidity. Those with pelvic organ prolapse and mesh-related complications have required staged prolapse procedures. We are encouraged by our outcomes with neovaginal creation using split thickness skin graft in women with an iatrogenically foreshortened vagina. While vaginal dilators should remain a first-line therapy for women with a foreshortened vagina, our technique offers a viable option for women who fail dilator therapy. The procedure both restores normal anatomy and sexual function in women with inadequate vaginal length. For more information visit www.FEMA.gov

neovaginal creation technique

iatrogenically foreshortened vaginas

McIndoe procedure

split thickness skin graft

clinical considerations