Creation of a Neovagina: A Modified Davydov Approach

Video Description

This video presents a stepwise approach to the creation of a neovagina through a modified laparoscopic Davydov approach. This is most commonly performed for vaginal agenesis.

First line treatment is self-dilation with multidisciplinary support. When first line treatment fails, a surgical approach to neovaginal creation is the Davydov procedure.

It is comprised of five steps: 1) define the anatomy (+ salpingectomy), 2) create the neovaginal space, 3) line the neovagina with peritoneum, 4) dissect the pelvic sidewall, and 5) suture the neovagina over the stent.

The modified laparoscopic approach involves round ligament preservation (instead of transection) for added vaginal support. It also involves transection of the utero-ovarian ligaments (instead of preservation) to keep ovaries in their anatomical location. More extensive pelvic sidewall dissection helps avoid tension on sidewall structures.The Davydov procedure has high rates of sexual satisfaction and should be considered for the surgical creation of a neovagina.

Presented By

Affiliations

University of Toronto

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Video Transcript: Creation of a Neovagina: A Modified Davydov Approach

This video presents the creation of a neovagina through a modified Davydov approach.

The primary indication for the Davydov procedure is vaginal agenesis. It may also be indicated for augmentation of vaginal length after prior vaginoplasty or radiotherapy.

First-line treatment for vaginal agenesis is self-dilation with multidisciplinary support, including pelvic physiotherapy and psychologic care.

When 1st line treatment fails, surgery is often indicated. Surgical options include split or full thickness flaps, buccal or intestinal vaginoplasty, the Davydov procedure, or the Vecchieti procedure. This video will focus on the Davydov procedure for creating a neovagina.

The Davydov procedure was first described in 1969 and involved lining a neovaginal space with peritoneum. A laparoscopic approach was then described in 1993. This video presents a modification to the laparoscopic Davydov procedure.

Contraindications include pelvic kidney, inability to mobilize peritoneum from prior surgery or adhesions, and inability to stent or dilate postoperatively.

Surgical steps include first defining the anatomy. If fallopian tubes are present, salpingectomy is recommended for ovarian cancer risk reduction. Second, create the neovaginal space. Third, line the neovagina with peritoneum. Fourth, dissect the pelvic sidewall structures off the peritoneum. Finally, suture the neovagina over the stent.

Step One: Define the Anatomy

The left hemipelvis contains a normal ovary and fallopian tube connected to a uterine remnant. There are no midline gynecologic organs. 

Anatomic variations are more prevalent in patients with Mullerian anomalies. On the right, the common iliac artery runs deep into the pelvis before bifurcating into the internal and external branches. The ureter is underneath the common iliac artery.

For ovarian cancer risk reduction, a bilateral salpingectomy is then performed.

Step Two: Create the Neovaginal Space

Here you can see a blind-ended vagina. The vaginal vestibulum is divided in the midline using electrosurgery. The neovaginal space is created primarily through blunt dissection, first with a suction tip and then digitally. Laparoscopic guidance is used to ensure blunt dissection creates a space between the rectum and bladder. Blunt dissection is continued with right angle retractors and then a large diameter Hegar dilator. Laparoscopic guidance is used throughout. A rectal probe can be used to deflect the rectum posteriorly to help avoid injury. 

Step Three: Line the Neovagina With Peritoneum

A sponge forceps is introduced into the neovaginal space and used to grasp the pelvic peritoneum. The peritoneum is then pulled down towards the vaginal introitus. The peritoneum is divided with scissors allowing access to the peritoneal cavity. It is then stretched to accommodate the width of two fingers. The peritoneum is then sutured to the mucosa of the vaginal vestibulum using 2-0 polysorb or vicryl sutures. This is performed circumferentially in a simple interrupted fashion. Sutures are held with snaps and only tied down once all stitches have been placed. In the absence of commercially available vaginal stents, a vaginal stent two finger-breadths wide is created using sterile gauze covered by two latex-free condoms. It should measure around 10cm in length and 3cm in width. It is then inserted into the neovaginal space.

Step Four: Dissect the Pelvic Sidewall

The retroperitoneal space is opened, first on the left in this case, and the pelvic sidewall structures are lateralized off the peritoneum. This helps to avoid tension on the pelvic sidewall during the formation of the neovaginal apex and maximizes the peritoneum available to create the upper vaginal vault.

The utero-ovarian ligament is divided to preserve the anatomical location of the ovaries. This prevents them from being pulled medially when suturing the apex of the neovagina, unlike in the traditional laparoscopic approach. 

The same is then performed on the right side. The traditional Davydov procedure involved round ligament transection to prevent tension on pelvic sidewall structures. The modified approach presented here utilizes a more extensive sidewall dissection while preserving the round ligaments for additional neovaginal vault support. On the right, the ureter can be seen coursing deep to the common iliac artery variant. 

Step Five: Suture the Neovagina Over the Stent

Using a 1 biosyn or monocryl suture, a purse-string stitch is run through the left uterine remnant, the connective tissue band connecting the two uterine remnants in the midline, and the right uterine remnant, and then the peri-rectal fascia on either side of the rectum. It is then tied down with a Roeder knot to create the neovaginal apex.

To review the surgical steps, step one is to define the anatomy. Step two is to create the neovaginal space. Step three is to line the neovagina with the peritoneum. Step four is to dissect the pelvic sidewall. And step five is to suture the neovagina over the stent.

The stent is left in place for six to twelve weeks postoperatively. Ongoing care involves the periodic use of dilators and/or intercourse to prevent vaginal stenosis. Vaginal estrogen can be considered during the postoperative period.

A systematic review and meta-analysis in 2014 concluded that no surgical technique was superior over another.

A meta-analysis of 500 patients who underwent the Davydov procedure found that the average neovaginal length was 8.86cm. 81.5% of patients engaged in penetrative sexual intercourse, sexual satisfaction was 96.7%, and only 2 patients suffered from vaginal stenosis.

In conclusion, 1st line treatment for vaginal agenesis is self-dilation. Although no single technique is superior, the Davydov procedure results in high rates of sexual satisfaction. The modified laparoscopic approach presented here preserves the round ligaments for added support, avoids tension on pelvic sidewall structures, and preserves the anatomical location of the ovaries.