Methods and results
A 32-year-old woman came to our obstetrics and gynecology clinic for evaluation and treatment of NP. She underwent transabdominal sigmoid vaginoplasty 10 years previously in another hospital. Three months later, she had satisfying sexual intercourse with her husband, and did not perform vaginal dilation. Two years ago, she found a mass protruding from vaginal introitus, aggravating when she was standing for a long time or coughing and so on increased abdominal pressure. In addition, she was troubled by the increasing foul-smelling vaginal discharge, which seriously affected her daily life and sexual intercourse. The patient requested surgical repair. Gynecologic examination showed exstrophy of the vaginal apex 4 centimeters beyond the hymen (Figure S1). Gynecological sonography prompted no uterus was detected, and no obvious abnormality was found in urinary system examination. Pelvic magnetic resonance revealed malformation of reproductive system, and vaginal wall was slightly thickened.
After well informing the patients about the risks and benefits of using a mesh and laparoscopic operations, and obtaining the informed consent of the patient, we performed the laparoscopic sacro-colpopexy with a mesh. Under the general anesthesia, the patient was placed in the lithotomy position. During the operation, we recognized intestines were compact adherent to the parietal peritoneum. After blunt and sharp dissection, we observed the absence of uterus and right adnexa in pelvic cavity. Using the uterine manipulator to explore the sigmoid neovagina, and the original bowel was located on the left of artificial vagina. For the vascular pedicle locating on the posterior wall of vagina, we could only completely separate the anterior wall. After carefully exploring the anterior region of sacral vertebra, we opened the right retroperitoneum from the sacral promontory, as well as dissected and isolated the right ureter. The mesh was sutured at the anterior wall and apex of neovagina (Figure 1), and then was suspended in the anterior sacral region without blood vessels (Figure 2). Then peritoneum was closed with interrupted suture with absorbable thread to posit the mesh completely retroperitoneal (Figure 3). After surgery, we performed the gynecological examination again, and there was no prolapse of neovagina (Figure 4).
The operation lasted 195 minutes. The postoperative course was uneventful without any mesh related complications. The patient was discharged 6 days after surgery. One month after operation, the patient returned for reexamine. No neovagina prolapse was detectable (Figure S2), and the patient presented significant improvement of symptoms and satisfied with sexual intercourse.