Distal vaginal agenesis reconstruction with interval buccal graft vaginoplasty followed by anastomosis to the upper vagina: A case report

Pull-through vaginoplasty, commonly performed for management of distal vaginal agenesis, risks post-operative stenosis if the proximal vagina is > 3 cm from the introitus. An alternative may be staged reconstruction using buccal graft vaginoplasty followed by interval anastomosis to native vagina. A 12-year-old pubertal female with history of multiple laryngopharyngeal congenital anomalies presented with acute on chronic back pain. Spinal MRI incidentally identified hematometrocolpos measuring 7.3 × 8 × 15.6 cm with inflammation of atretic native upper vagina leading to a diagnosis of distal vaginal atresia. The distal aspect of the native upper vagina was found to be over 6 cm from the introitus. Given this distance, she was not deemed to be an ideal candidate for native pull-through vaginoplasty. IR-guided drainage of hematometrocolpos was performed for symptomatic relief. Hormonal suppression was used to allow sufficient time for resolution of vaginal wall inflammation bridging to staged surgical procedures. A buccal graft neovagina was created first, followed by routine postoperative dilation to allow for optimal development of the lower buccal graft. After 8 months, laparoscopic mobilization of Müllerian structures with transvaginal anastomosis to the interposition buccal graft neovagina was completed. 5 months postoperatively a stricture was identified that was injected with triamcinolone and bupivacaine. The final total vaginal length approached 9 cm without evidence of strictures or stenosis. This novel staged surgical approach allows graft maturity and optimizes time utilization and healing, and may be an alternative for patients at risk of complications from native pull-through vaginoplasty.