Dear Editor, We read with great interest the recent article published by Putri et al.1 on the laparoscopic approach using a modified technique of autologous peritoneal graft, commonly known as Davydov's vaginoplasty. It is a safe and effective technique that provides adequate postoperative vaginal length and sexual satisfaction.1 However, surgical steps are not described in detail. This report aims to demonstrate the steps of laparoscopic Davydov's vaginoplasty. A 20-year-old unmarried female presented with primary amenorrhea and lower abdominal pain for 5 days. She had normal stature, well-developed breasts, and axillary and pubic hairs (Tanner Stage 4). Local examination revealed a blind vagina, normal external genitalia, and no inguinal swelling. Hormone levels (follicule stimulating hormone (FSH) and testosterone) were within normal range and karyotype was 46, XX. Magnetic resonance imaging of the pelvis suggested an oblong tubular uterine horn toward the left side (~3.1 cm × 3.1 cm × 3.2 cm) with an endometrial thickness of ~10 mm. The cervix and vagina appeared hypoplastic. The diagnosis of mayer-rokitansky-küster-hauser (MRKH) syndrome was made, and she was planned for laparoscopic removal of the rudimentary uterine horn and Davydov's vaginoplasty. Initially, a vaginal approach was used to create neovagina. The rectovesical space was dissected till the peritoneum with caution to avoid injury to the bladder and rectum. Following this, a laparoscopy was performed. On laparoscopy Figure 1, a unicornuate rudimentary horn (3.5 cm × 3 cm) was seen on the left side and a uterine remnant on the right side. The left ovary was normal, and the right ovary had a simple cyst ~3 cm × 3 cm. The left rudimentary horn excision, bilateral salpingectomy, and right ovarian cystectomy were performed.Figure 1: Laparoscopic view of the patient's pelvic anatomyFigure 2 demonstrates the steps of laparoscopic Davydov's vaginoplasty. A sponge in a holder was kept in neovagina and pushed from the vaginal end. The anterior peritoneal flap was raised by dissecting the peritoneum in between the uterine strand and bladder. The posterior peritoneal flap was raised by dissecting the pouch of Douglas' peritoneum in between the uterine strand and rectum. The peritoneum was mobilized adequately till bilateral infundibulopelvic ligament to facilitate tension-free closure. The uterine strand was dissected by a longitudinal incision. A transverse incision was made over the most prominent part of the vault and extended laterally. Rudimentary horn, fallopian tubes, and right ovarian cyst specimens were retrieved vaginally. Following this, an allies forceps was introduced vaginally to grasp the edges of the anterior and posterior peritoneal flap. The peritoneal edges were pulled down to the vaginal introitus to line the newly created vaginal space and sutured to the introitus with 2-0 Vicryl in an interrupted fashion. The apex of neovagina was created by putting a purse string suture with 1-0 Vicryl suture from supravesical peritoneum, right round ligament, right uterine remnant, suprarectal peritoneum, left uterine remnant, and left round ligament. A neovagina of 8 cm × 3 cm, lined by the patient's own peritoneum (autologous graft), was created. A foam mold covered with a condom was kept in neovagina to prevent restenosis for 1 week. At 1-year follow-up, she is asymptomatic, neovagina is patent (~8 cm), and well-epithelialized.Figure 2: Steps of laparoscopic Davydov's vaginoplasty. (a) The anterior peritoneal flap was raised by dissecting the peritoneum in between the uterine strand (US) and bladder; (b) Posterior peritoneal flap was raised by dissecting the pouch of Douglas' peritoneum in between US and rectum; (c) Uterine strand was dissected by a longitudinal incision; (d) A transverse incision was made over the most prominent part of vault and extended laterally; (e) The peritoneal edges were pulled down to vaginal introitus to line the newly created vaginal space; (f) The apex of neovagina was created by putting a purse string suture with 1-0 Vicryl suture from supravesical peritoneum, right round ligament, right uterine remnant, suprarectal peritoneum, left uterine remnant, and left round ligament. APF: Anterior peritoneal flap, PPF: Posterior peritoneal flap, US: Uterine strandThe incidence of MRKH syndrome is 1 in 5000 females.2 Usually presents with primary amenorrhea, dyspareunia, or infertility. The ideal management option in these patients is neovagina creation with minimal morbidity and fast recovery. Various procedures are described in literature such as Frank and Ingram dilatation method (nonsurgical), McIndoe's vaginoplasty, Williams vaginoplasty, myocutaneous flap, full-thickness skin graft, Vecchietti traction procedure, Baldwin, and Davydov colpocleisis.3 Laparoscopic Davydov's vaginoplasty is a minimally invasive alternative for young women with MRKH syndrome.2 There is rarely any complication with Davydov's techniques as patient's own peritoneum lines the neovagina.4 It obviates the issues associated with skin grafts (donor site scarring and graft stenosis) and bowel grafts, and prolonged postprocedure use of vaginal mold.5 In our practice, the most commonly performed surgical technique is McIndoe's vaginoplasty, a vaginal procedure with a high success rate. However, patients need to use a vaginal mold for at least 6 months to 1 year postprocedure or till their marriage/initiation of sexual intercourse. This is associated with the risk of infections and vaginal restenosis. Therefore, it is preferred to do McIndoe's vaginoplasty 6 months before marriage/initiation of sexual intercourse, whereas in laparoscopic Davydov's vaginoplasty, the patient's own peritoneum is used to line neovagina. Therefore, there is no risk of vaginal restenosis, and there is no need to use vaginal mold postprocedure with a successful creation of adequate length of neovagina. Ethics statement This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki and its amendments. The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Author contributions Concept: K.K., Design: K.K., Data Collection or Processing: K.C.D., P.G., and K.Y., Analysis or Interpretation: K.K. and J.C., Literature Search: K.K., K.C.D., P.G., and K.Y., Writing: K.K. and K.C.D. All authors have read and agreed to the final version of the manuscript. Data availability statement Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Khoiwal et al. (Wed,) studied this question.
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