(095) Initial Case Series of Updated Assessment of Patients with Neuroproliferative Vestibulodynia and Buccal Mucosal Graft Performed Simultaneously with Complete Vestibulectomy and Vaginal Advancement Flap Reconstruction

Introduction Buccal mucosal grafts (BMG) are easy to harvest, have a favorable healing profile, and are highly effective for urethral stricture reconstruction where primary anastomosis is not feasible. BMG have been used as a second stage salvage procedure in patients with neuroproliferative vestibulodynia (NPV) and severe anterior vestibular pain after having complete posterior vestibulectomy with vaginal advancement flap (VAF) reconstruction. Advancements in pain assessment tools allow for a better understanding pre-operatively as to the extent of vestibular tissue excision required to potentially eliminate pain. As vagina cannot be advanced above the urethral meatus to provide anterior vestibule tissue coverage, BMG are needed. Objective We report on the initial 6 cases of patients with pain throughout the anterior an posterior vestibule who underwent simultaneous BMG and anterior vestibulectomy with VAF and posterior vestibulectomy. Methods Pre-operative assessment involves cotton-tip swab testing at 1:00,.3:00. 5:00. 6:00, 7;00, 9:00 and 11:00 of the vestibule just lateral of the hymen, as is standard. The modification to standard testing is the addition of the region just under the clitoris in a horizontal plain, left lateral, mid and right lateral, advancing inferiorly 1 cm at a time for a total of 12 assessment points, the most inferior location being just above the urethral meatus. If testing is positive all the way to the region directly under the clitoris, a BMG is considered. In the OR, two teams are utilized: one performs an anterior and posterior vestibulectomy with VAF reconstruction in standard fashion, the other harvests a BMG to a dimension predetermined by measuring between Hart’s lines for the horizontal length and from just below the frenulum to the urethral meatus for the vertical length of the anterior vestibule, typically 2.5 x 2.5 cm. The BMG is secured to the anterior vestibule with 5-0 PDS suture on a taper needle performed in an interrupted fashion. A small relaxing incision is made at the inferior midline of the graft to allow the BMG to surround the urethral meatus. The graft is secured to the edge of the anterior aspect of the urethral meatus and vulva at Hart’s line. Multiple stab incisions to the graft and underlying graft bed are performed with an 11-blade. Quilting sutures are then placed with 5-0 chromic. Results Mean age was 31 ± 9 years. Post-operative photos taken daily for 2 weeks show that the mouth, BMG, and VAF reconstruction heal well (Figure 1), with integration of the graft around day 6. Vulvoscopy reveals negative allodynia testing of both anterior and posterior regions, resolution of umbilical hypersensitivity, and significant improvement in pain scores elicited by cotton-tipped swab testing 6 weeks postoperatively. Patients asked to perform self-exam with digital insertion have substantial improvement in entry pain. Conclusions Patients with NPV with extensive anterior and posterior vestibule pain may be considered for BMG concomitant with anterior and posterior vestibulectomy with VAF reconstruction. Accurately assessing degree of pain involvement of the anterior region preoperatively is critical to selecting proper surgical approach and reducing failure and risk of or need for salvage procedures. Disclosure No