Comments
Prolapse of the sigmoid neovagina is scarcely reported in the
literature, one study reviewed that the incidence of prolapse of
postoperative sigmoid neovagina was 2.3%[6].
However, its pathogenesis and treatment are still unclear. The
pathogenesis might be related to the lack of supporting structure and
the length of sigmoid neovagina[7]. Normally, the
vagina is divided into two parts according to the origin. The upper
two-thirds originate from the mesoderm (Mullerian’s duct), but others
originate from endoderm (urogenital sinus)[8]. The
upper part is anchored by the endopelvic connective tissue to the pelvic
wall or sacrum, and the middle and lower part is fused to the arcus
tendineus fascia pelvis and perineum. For women with congenital vaginal
agenesis or Mayer-Rokitansky-Küster Hauser Syndrome, no matter which
vaginoplasty was performed, it is impossible to perfect reconstruction
these support structures [9]. Another related
reason for the prolapse is neovaginal length. Though using sigmoid colon
creating a neovagina could achieve good neovaginal depth, people after
vaginoplasty also occurred NP, including mucosal prolapse and vaginal
vault prolapse[10]. Vaginal vault prolapse might
be closely related to short neovaginal[7], as well
as elongation and loosening of supporting tissues, but a large number of
epidemiological studies are needed to prove evidence.
The current recommended treatment for mild mucosal prolapse is surgical
removal or fulgerize the redundant tissue [11].
Nevertheless, there are no guidelines for vault prolapse or severe
mucosal prolapse, because few literature reported this kind of cases,
and the risk of recurrence is still uncertain. Matsui reported the first
case of prolapse of a sigmoid neovagina that was required with
retroperitoneal sacropexy in 1999, and the results are
satisfactory[12]. Rei Yokomizo reported two
patients developed severe mucosal prolapse repairing by resecting the
redundant sigmoid or replacement therapy by a connected skin graft, but
the former has recurred[10]. Some cases reported
that suspending the prolapsed neovagina with transabdominal sacral
colpopexy with or without paravaginal repair was an effective
treatment[13]. In addition, suspending the
neovagina to the sacrospinous ligament with or without a mesh has been
reported in literatures and successfully repaired the
prolapse[14]. In recent years, for the advantages
of light surgical trauma and faster postoperative recovery, laparoscopic
surgery has been successfully applied in the disposal of
NP[15]. Sacrospinous ligament fixation and
sacro-colpopexy
turn into be valid surgical options of treatment, and using mesh
repairing could enhance the support of the upper
neovagina[16]. However, the long-term efficacy and
safety of the mesh have not been clear. Overall, the choice of exact
treatment of patients with NP requires to be combined with the anatomy,
the length and width of the neovagina, as well as demands of patients
for daily life and sexual intercourse. Well-designed studies and more
case reports are needed to access the outcome and safety of various
treatment.
In conclusion, we reported a case of NP10 years after sigmoid
vaginoplasty that was successfully repaired by laparoscopic
sacro-colpopexy with a mesh. After adequately preoperative evaluation
and careful operation, the patient recovered well without any
complications. Laparoscopic sacro-colpopexy might be an effective and
safe treatment for NP. We will continue to follow up the outcome of this
patient, as well as the complications of the surgery and mesh.