Distension versus traction in laparoscopically assisted balloon vaginoplasty for management of vaginal aplasia

Abstract

Creation of a neovagina in women with vaginal aplasia using laparoscopically assisted balloon vaginoplasty (LAB-V) has been described previously [1]. The creation of the neovagina depends on the traction and distension of the Foley catheter balloon. Alternative procedures such as sigmoid neovaginoplasty, McIndoe procedure, and peritoneoplasty are more technically demanding and have higher complication rates [1]. Preliminary results attest to the safety and effectiveness of LAB-V [1], [2]. It is possible that traction contributes length to the neovagina, while distension contributes width. The most important contributing factor to satisfactory sexual intercourse is unknown. The aim of the present prospective study was to compare the effects of postoperative predominant traction and predominant distension on penetration and sexual satisfaction among women undergoing LAB-V and their partners. Eighteen women with vaginal aplasia were included in the study. Sexual satisfaction was measured using a visual analogue scale from zero to 100 and divided into 10 compartments, with 100 representing maximum satisfaction and 0 representing no satisfaction. Each woman's partner was assessed using a similar scale to measure depth of penetration and sexual satisfaction. After counseling about the procedure and the alternatives, the patients were randomly allocated to either the predominant distension group (PD) or the predominant traction group (PT) after informed consent was obtained. Ethical approval was granted by the Department of Obstetrics and Gynecology. The operative procedure was the same for both groups [1] and was performed by one of the authors [AME]. Postoperative care consisted of preventing infection [1], and controlled traction and distension in each group but at different levels. In the PD group, the balloon was distended at 5 mL/day to a maximum of 40 mL reached on the seventh postoperative day. The catheter was then removed the following day. Traction was performed at a rate of 1 cm per day. In the PT group, traction was done daily using the catheter to the level of patient tolerance (maximum 3 cm) and controlled distension at a rate of 3 mL every other day. Counter traction was applied in both groups every 20–30 minutes during the first 6 hours after the daily increase in traction force. Upward massage of the upper thigh and inward massage of perineal skin were also done to relieve the pressure exerted by the distension and traction. The length and width of the vagina were measured by a specially designed measurement piece, graded in centimeters (0–20) with two ball ends, the smaller being 2 cm and the larger being 4 cm. Continuous data were summarized using the mean or range. Nonparametric tests were used because of the small sample size. The differences between the 2 groups were assessed using the Mann-Whitney test (continuous variables) or test (number of women who reported dyspareunia). The age of the patients at the time of the operation ranged from 16–23 years. Poor sexual penetration and satisfaction were reported by all of the women preoperatively. Mean operative time was 20 ±4 minutes. The balloon ruptured in 2 women in the PD group. A new catheter was inserted using the previous catheter stem as a guide in 1 patient and 1 patient deferred reinserting another catheter and so it was removed. Postoperative penetration and satisfaction scores are shown in Table 1. The lower pain scores in the PD group may be due to the even increase in the neovagina in all directions by the distended balloon. In the PT group, however, the traction on the balloon was applied to the apex of the neovagina, which possibly caused more pain. The women in the PD group had higher satisfaction scores than the women in the PT group (P = 0.0001). The higher penetration and satisfaction scores reported by the husbands of women in PT group may be due to the deeper and narrower neovagina. Caution is needed in interpreting these results because sexual satisfaction may be affected by factors other than the length of the neovagina [3]. The earlier resumption of sexual activities and fewer cases of dyspareunia in women in the PD group may be explained by the wider vagina, which may be more comfortable for the woman during intercourse. In addition, the lower postoperative pain scores may have encouraged the women in the PD group to recommence sexual intercourse earlier than the women in the PT group. In conclusion, increasing traction or distension is effective and safe, although increasing distension can lead to rupture of the Foley catheter balloon. Women in the PD group experienced less postoperative pain and less dyspareunia than women in the PT group.