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.