(61) Guidewires and Amnion Tissue Grafts: A Novel Approach for Surgical Management of Distal Vaginal Agenesis

Background: Distal vaginal agenesis is a rare congenital anomaly that often requires surgical intervention and vaginoplasty. Depending on the individual, a graft may be necessary to augment the creation of the lower neo vagina. Amnion tissue grafts are being more widely used in surgical specialties, however, they are less commonly used in pediatric gynecological surgeries. This case documents the successful use of an amnion graft and guidewire during vaginal reconstructive surgery.

Case: A 12 year old female presented to the emergency department with severe abdominal pain. Pelvic imaging revealed hematocolpos and absent vagina. Due to her young age, the decision was made to defer surgery and suppress menses. The hematocolpos was drained laparoscopically, and menstrual suppression was initiated with oral norethindrone acetate and depo medroxyprogesterone. Within 2 months, the patient had a reaccumulation of hematocolpos. This was drained by interventional radiology (IR) and the patient was transitioned to leuprolide. Shortly thereafter, another accumulation occurred. In consultation with pediatric gynecology, urology, surgery and IR, a tailored surgical plan was offered, which the family elected.

The procedure began with IR using ultrasound (US) guidance to insert a guidewire into the closed upper vagina containing the hematocolpos. A catheter was then inserted and inflated; the wire was removed. An H incision was made into the planned vaginal space. The tissue was carefully pulled down and secured with sutures. Using US,, tension from the inflated catheter, and careful dissection, the upper vagina was mobilized to the newly created introitus and secured with tension relieving sutures. The hematocolpos was suctioned. A 3x2cm deficit was noted after using the mobilized upper vagina as lining in the neovagina. An amnion tissue graft (Clarix) was utilized to line this deficit. A vaginal dilator with estrogen cream was placed into the newly created vagina and sutured to the labia to ensure proper placement as a stent. After a 7 day hospital stay, the dilator was removed. The patient was discharged home after dilator teaching and instructions. Post operatively, the patient was examined at 2 weeks and 1 month following her surgery. The vaginal mucosa was well healed and approximated.

Comments: Amnion tissue grafts are a safe and useful scientific development for the future of complex pediatric gynecologic surgeries. This case also tested the use of a guidewire with IR guidance as a method for safely creating a neovagina in a patient with very small spaces in the pelvis.