Research www.AJOG.org

GENERAL GYNECOLOGY Creation of a neovagina by Davydov’s laparoscopic modified technique in patients with Rokitansky syndrome Luigi Fedele, MD; Giada Frontino, MD; Elisa Restelli, MD; Nevio Ciappina, MD; Francesca Motta, MD; Stefano Bianchi, MD

OBJECTIVE: The purpose of this study was to assess anatomic and RESULTS: No perioperative complications occurred. At 6 months, ana- functional results after the laparoscopic Davydov procedure for the cre- tomic success was achieved in 97% of the patients (n ϭ 29); functional ation of a neovagina in Rokitansky syndrome. success and optimal results for the Female Sexual Function Index ques- STUDY DESIGN: Thirty patients with Rokitansky syndrome underwent tionnaire were obtained in 96% of patients. Vaginoscopy and biopsy re- the laparoscopic Davydov technique from June 2005–August 2008. sults showed a normal iodine-positive vaginal epithelium. Mean follow-up time lasted 30 months (range, 6–44 months) and in- cluded clinical examinations and evaluation of the quality of sexual in- CONCLUSION: The Davydov technique seems to be a safe and effective tercourse; vaginoscopy, Schiller’s test, and neovaginal biopsies were treatment for vaginal agenesis in patients with Rokitansky syndrome. performed after 6 and 12 months. Functional results were assessed with the use of Rosen’s Female Sexual Function Index and were com- Key words: Davydov technique, , neovagina, Rokitansky pared with age-matched normal control subjects. syndrome, sexual function

Cite this article as: Fedele L, Frontino G, Restelli E, et al. Creation of a neovagina by Davydov’s laparoscopic modified technique in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010;202:33.e1-6.

he Mayer-Rokitansky-Kuster- dence of this syndrome is unknown, al- Before surgery, all patients underwent THauser syndrome is a malforma- though the only recent epidemiologic pelvic and abdominal ultrasonography, tion complex that is defined by the ab- study estimated it to be of 1:1500 to pelvic magnetic resonance imaging, and sence of the and . Such 1:4000 born female infants.3 Numerous karyotyping. Diagnostic criteria for Ro- condition is represented by primary surgical and nonsurgical procedures kitansky syndrome were primary amen- amenorrhea, with a normal ovarian have been described, all of which have orrhea, vaginal agenesis, absence of the function, normal female karyotype, and aimed at creating a neovagina of ade- uterus, normal external genitalia, and a secondary sexual characteristics. Anom- quate size and physiologic condition to normal female karyotype (46,XX). The 4 alies of the urinary tract and the skeletal permit normal sexual intercourse. presence of a pelvic kidney was consid- system are associated variably with the The purpose of this study was to assess ered a contraindication to Davydov’s Rokitansky syndrome.1,2 The exact inci- anatomic, functional, and sexual long- procedure. term outcomes after the creation of a neo- The modified laparoscopic Davydov vagina with Davydov’s laparoscopically technique involves a laparoscopic step, From the Department of and modified technique, in which the vesico- followed by a vaginal approach. During 5-10 Gynecology, Fondazione “Policlinico- rectal space is coated by peritoneum. the laparoscopic step, after exploration Mangiagalli-Regina Elena” (Drs Fedele, of the pelvis and abdominal cavity, the Frontino, Restelli, Ciappina, and Motta), MATERIALS AND METHODS strand that connects the 2 rudimental and the Department of Obstetrics and The subjects of the study were all patients uterine horns is lifted, and the perito- Gynecology, Ospedale San Giuseppe (Dr (n ϭ 30) with Rokitansky syndrome who neum immediately below is incised Bianchi), University of Milan, Milan, Italy. underwent surgery by the same operator transversely for a section of 4–5 cm (Fig- Received April 22, 2009; revised June 16, (L.F.), who used the laparoscopically ure 1). Guided by the middle finger, 2009; accepted Aug. 19, 2009. modified Davydov technique from June which is inserted in the patient’s , Reprints: Luigi Fedele, MD, Clinica Ostetrica e this incision is extended in a horseshoe- Ginecologica I, Università di Milano, Istituto 2005–August 2008 in a tertiary referral Luigi Mangiagalli, Via della Commenda 12, center for the Rokitansky syndrome at shaped fashion for approximately 1 cm 20122 Milan, Italy. [email protected]. the University of Milan, Italy. into the connective tissue beneath which Authorship and contribution to the article are The preliminary hypothesis of our separates the bladder from the rectum. limited to the 6 authors indicated. There was study was that the modified laparoscopi- In order to mobilize the peritoneum, no outside funding or technical assistance with cally directed version of the Davydov which will constitute the neovaginal the production of this article. procedure allows satisfactory anatomic walls and vault, the round ligaments are 0002-9378/$36.00 and functional results for the creation of identified by applying traction on the © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2009.08.035 a neovagina in patients with Rokitansky uterine remnants and then are cut bilat- syndrome. erally. The supravesical peritoneum is

JANUARY 2010 American Journal of Obstetrics & Gynecology 33.e1 Research General Gynecology www.AJOG.org

tified. The peritoneal margins are then year thereafter. At each follow-up visit, FIGURE 1 hooked by interrupted sutures in PDS vaginal and rectal examinations and The modified laparoscopic evaluation of symptoms and of the qual- Davydov technique involves 3-0 to the vestibulum’s mucosa, which ity of sexual intercourse were performed. a laparoscopic step start from the median line where mobi- lization of the margins is easiest (Figures Vaginoscopy was performed at 6 months 4 and 5). At this point, a paraffin gauze and 1 year after surgery, along with a bi- dressing tampon can be inserted in the opsy and Schiller’s test to evaluate epi- peritoneum-coated neovagina. thelization of the neovagina. Removal of the catheter and gauze At the first follow-up visit, the fre- dressing and the use of vaginal obtura- quency in use of obturators was reas- tors were scheduled 48 hours after sur- sessed, and the possibility to start sexual gery. The obturators are made of soft la- activity was evaluated based on the ana- tex and are 10 cm in length and 2.5 cm in tomic results. Primary outcomes were width. Before use, the obturators are the achievement of anatomic and func- washed and sterilized with an antiseptic tional success. Anatomic success was de- solution or otherwise simply washed and fined, as previously reported,11 as a neo- The strand that connects the 2 rudimental uter- covered with a condom. An estrogen- vagina of Ն6 cm in length that allows the ine horns is lifted, and the peritoneum immedi- based vaginal cream is applied to the ob- easy introduction of 2 fingers within 6 ately below is incised transversely for a section of turators before use to promote neovagi- months after surgery. Achievement of 4–5cm(dotted line). nal epithelization. All patients have to functional success was considered when Fedele. Creation of neovagina in patients with Rokitansky use the obturators for approximately syndrome. Am J Obstet Gynecol 2010. the patient reported satisfactory sexual 6–8 hours each day and perform neo- intercourse that started from 6 months vaginal irrigations with sterile saline so- after surgery. Functional results were incised along the apparent line that con- lution daily. also assessed by the use of a standardized nects the rudiments. A monofilament Clinical follow-up was planned at 1, 3, questionnaire, the Female Sexual Func- (polydioxanone synthetic absorbable su- 6, and 12 months after surgery and every tion Index (FSFI),12 which is an interna- ture [PDS] 2-0) is used to create 2 purse- string sutures for each hemi pelvis. Each suture is begun from the mobilized peri- FIGURE 2 toneum above the bladder dome by Creation of 2 purse-string sutures for each hemi pelvis transfixing consecutively the round liga- ment, the tubal isthmus, the uteroovar- ian ligament, and the lateral peritoneal leaf, prior identification of the ureters. The 2 sutures then include the lateral as- pect of the mesorectum and the end in- cluding the anterior aspect of the rectal serosa immediately below the rectosig- moid junction (Figure 2). The perineal step allows the creation of an anastomo- sis between the previously incised pelvic peritoneum and the mucosa of the vagi- nal vestibulum. An H-shaped incision is made on the vaginal vestibulum, with a transverse cut from the base of 1 minor labia to the contralateral and 2 vertical cuts that run adjacent to the extremities of the transverse incision (Figure 3). The dissection between the bladder and rec- tum is started along the vertical inci- sions, which creates 2 paramedian tun- nels, while the median raphe is cut A, Transfixion of the round ligament; B, creation of the left purse-string suture by transfixing consec- subsequently. The surgeon works by utively the round ligament, the tubal isthmus, the uteroovarian ligament, the lateral peritoneal leaf, blunt and sharp dissection until the peri- and the rectal serosa; C, closure of the right purse-string; D, final laparoscopic vision. toneal margins of the laparoscopically Fedele. Creation of neovagina in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010. performed transverse incision are iden-

33.e2 American Journal of Obstetrics & Gynecology JANUARY 2010 www.AJOG.org General Gynecology Research

FIGURE 3 FIGURE 4 Perineal step

A, The pelvic peritoneum is identified before the creation of an anastomosis with the vaginal vestib- An H-shaped incision is made on the vaginal ves- ulum; B, final vision of the neovagina, which is covered by peritoneum. tibulum (dashed line). Fedele. Creation of neovagina in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010. Fedele. Creation of neovagina in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010. sent; uterine remnants were present in all nary retention were observed after cath- patients, which were unilateral in 4 cases eter removal, which resolved after the tionally validated test for the evaluation (13%) and bilateral in 26 cases (87%). catheter was repositioned for 4 days and of female quality of sexual function. FSFI The mean diameter of the remnants was antibiotic treatment. In 1 case at ultra- assesses 6 domains: desire, arousal, lu- 22 mm. Only 1 patient had a single ; sound examination, a hematoma of 4 cm brication, orgasm, satisfaction, and pain. in 6 patients (20.7%), the were diameter that eventually resolved spon- The functional result is considered to be extrapelvic. taneously was observed on the rectum’s “very good” when the FSFI score is Ͼ30, The surgical procedure was completed anterior wall. The patients were dis- “good” when the score is between 23–29, successfully in all patients. The operating missed from the hospital at a mean of 3.9 and “poor” when the score is Ͻ23. The time was 125 Ϯ 23 minutes, and the in- Ϯ 1.4 days after surgery. highest total FSFI score that may be ob- traoperative bleeding was 178 Ϯ 139 mL. At the end of the surgical procedure, tained is 36. Patients who had started No perioperative complications oc- the neovagina that was obtained was ap- sexual activity completed the question- curred. The catheter was removed 2.45 proximately 7–8 cm in depth and 3 cm in naire 6 months after surgery. The results Ϯ 1.1 days after surgery. Five cases of uri- width. At hospital dismissal, the mean that were obtained were compared with age-matched normal control subjects. FIGURE 5 The results of the FSFI questionnaire were analyzed with STATA software (Stata Corp, College Station, TX). The mean score (Ϯ SD) and 95% confidence interval for each item were calculated, and the comparison between cases and normal age-matched control subjects was done with the t test. A probability value of Ͻ .05 was considered statisti- cally significant.

RESULTS The mean age of patients at surgery was 20 Ϯ 4.3 years (range, 15–34 years). None of the patients had had previous pelvic surgeries. The procedure was also performed in 2 patients with a single kid- ney; we excluded from our study 2 pa- tients with pelvic kidney who underwent the Vecchietti technique.13,14 The mean Final view after creation of the vaginal vault and the anastomosis between the peritoneum and length of the vaginal fovea before surgery vestibulum. was 9.4 mm (range, 5–25 mm). In all Fedele. Creation of neovagina in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010. cases, a median uterine structure was ab-

JANUARY 2010 American Journal of Obstetrics & Gynecology 33.e3 Research General Gynecology www.AJOG.org

tansky syndrome. The laparoscopic ap- TABLE proach allows minimal invasiveness, an Case vs control FSFI scores adequate visualization, optimal esthetic Variable Cases Control subjects results, and minimal scarring in these Total Female Sexual Function 28 Ϯ 4.6 (26.9–30.0)b 31 Ϯ 2.25 (30.0–32.0) young patients. Despite the relatively Index scorea ϭ ...... small sample size (n 30), Rokitansky Ն30, n 8 17 syndrome represents a rare entity...... 17 24–29, n 15 7 Adamyan et al, in 1994, first re- ...... ported a case series of 324 Davydov col- Յ23, n 1 0 ...... popoiesis, 27 of which were performed Desirea 4.3 Ϯ 0.9 (3.9–4.6)c 4.8 Ϯ 0.7 (4.5–5.1) ...... laparoscopically, showing the major ad- Arousala 4.8 Ϯ 1.1 (4.3–5.2) 5.1 Ϯ 0.7 (4.8–5.4) vantages of the endoscopic approach, ...... Lubrificationa 4.7 Ϯ 1.0 (4.3–5.1)d 5.6 Ϯ 0.4 (5.5–5.8) compared with the traditional lapa- ...... rotomic procedure. The mean duration Orgasma 4.4 Ϯ 1.0 (4.0–4.9)e 5.0 Ϯ 0.6 (4.8–5.3) ...... of surgery in the study was 98 and 52 Satisfactiona 5.1 Ϯ 1.3 (4.5–5.7) 5.0 Ϯ 1.1 (4.5–5.4) ...... minutes, respectively, for the lapa- Comforta 4.5 Ϯ 1.3 (4.0–5.1)f 5.6 Ϯ 0.6 (5.3–5.8) rotomic and laparoscopic approaches. In ...... FSFI, Female Sexual Function Index. the laparotomic and laparoscopic group, a Data are given as mean Ϯ SD (95% confidence interval); b P Ͻ .01; c P Ͻ .05; d P Ͻ .001; e P Ͻ .05; f P Ͻ .001. hospitalization lasted, respectively, a Fedele. Creation of neovagina in patients with Rokitansky syndrome. Am J Obstet Gynecol 2010. mean of 11 and 2 days; in the first group, 2 inadvertent enterotomies and 1 cystot- omy occurred, while no complications length and diameter of the neovagina At 6 months after surgery, functional occurred in the laparoscopic subgroup. were 7.4 Ϯ 2.3 cm and 2 Ϯ 0.6 cm, re- success was obtained in 23 of the 24 The anatomic results that were assessed spectively. Mean follow-up examinations sexually active patients (96%). Besides at a medium-term follow-up examina- lasted 30 months (range, 6–44 months). the only patient who did not experi- tion showed adequate results that were Anatomic success was achieved in 97% ence an adequate anatomic result, only comparable in both subgroups. of the operated patients (n ϭ 29). In 1 1 patient reported unsatisfactory sex- Compared with the first laparoscopi- case, the surgery did not succeed because ual intercourse; 4 patients had not cally assisted approach of Soong et 10,18 of the early formation of a severe fibrotic started sexual intercourse 6 months af- al, in our case series, the procedure stenosis at the neovaginal introitus after ter surgery. The Table shows single do- was modified to a first laparoscopic step 3 months from surgery. Mechanical di- main and total scores in the 24 sexually during which both mobilization and 2 lation of the neovaginal introitus in this active operated patients, compared purse-string sutures were obtained; a ϭ case was performed without success. The with normal control subjects (n 24). second final vaginal step included vesi- mean length of the neovagina 6 months The total score of the FSFI shows opti- corectal dissection and anastomosis of mal functional results in 23 of the 24 after surgery in the other 29 patients was the peritoneum to the vaginal vestibu- patients. In particular, the score was 8.1 Ϯ 2 cm, and the mean diameter was lum. The Müllerian rudiments were not very good in 8 patients (total FSFI removed, because there have been no re- 2.8 Ϯ 0.7 cm. score, Ն30) and good in 15 patients ports of neoplastic degeneration of the Vaginoscopy with Schiller’s test was (total FSFI score, 24–29); only in 1 case rudiments and because their excision performed in all 29 patients at 6 months was the total score Ͻ23. There were no could even temporarily affect the ovar- and 1 year after surgery to evaluate the significant differences in the domains ian vascularization; their precise vascular epithelization of the neovagina.15,16 This of arousal and satisfaction, although connections with the uterine rudiments was performed with a laparoscopic 0° slightly lower scores with significant are not clear and most likely might be optic, with an assistant retracting the differences were found in the domain extremely variable. As suggested in the neovagina using 2 small lateral retrac- of lubrication, desire, orgasm, and report by Soong et al,10 to obtain a longer tors. The neovaginal walls appeared to be pain for patients with Rokitansky syn- neovagina, peritoneal mobilization was coated completely with an iodine-posi- drome. Seven patients experienced performed prior sectioning of the round tive epithelium in the 29 patients with mild dyspareunia, which was, at times, ligaments and posterolateral incisions of anatomic success. superficial or deep. the peritoneal leaf along the infundibu- Biopsies were performed of the neo- lopelvic ligaments, after which the final vaginal mucosa, which at light micros- COMMENT mean neovaginal length was increased copy appeared very similar compared Based on our experience, the laparo- from 6–8.5 cm after their modified pro- with the normal vagina (ie, with normal scopic Davydov technique may be con- cedure. Moreover, in our case series, the thickness, normal squamous stratifica- sidered a safe and effective option for the addition of the laparoscopic supravesical tion, and a glycogen-rich epithelium). surgical treatment of women with Roki- peritoneal transverse incision facilitates

33.e4 American Journal of Obstetrics & Gynecology JANUARY 2010 www.AJOG.org General Gynecology Research the identification of the peritoneal mar- inal vascularization and thus represents gent et al.5 In our experience, the Davy- gin during the perineal step. an easy substrate for epithelization. dov technique permitted a good Although the duration of surgery was The vaginal step makes this procedure functional outcome in 90% of patients comparable with the case series by Soong particularly indicated for patients with who had started sexual intercourse. et al,10 the 2-step modification of the abnormalities of the external genitalia The FSFI results show that, in terms of Davydov’s laparoscopic technique can (such as female hypospadia) for which global satisfaction, there are no differ- potentially shorten the procedure; the the creation of a neovagina by vaginal ences between the patients and the age- laparoscopic assistance does aid in the pressure (such as in the laparoscopic matched control group. However, com- transvaginal identification of the perito- Vecchietti technique and Frank method) pared with the case series of Soong et al,10 neal margins. Again, in a study of 28 pa- is not indicated. Patients with a pelvic patients with Rokitansky syndrome gen- tients, Dargent et al5 reported a mean kidney were excluded from our study be- erally are referred more frequently for an duration of surgery of 119 minutes, with cause of the risk of damaging the kidney insufficient lubrication and sometimes a mean hospitalization of 8 days, and 4 or ureter during the laparoscopic mobi- mild superficial or deep dyspareunia. cases of perioperative complications and lization of the peritoneum. Similarly, The slight differences we have found may 4 medium-term neovaginal stenoses. previous pelvic surgery might be a rela- be due to the relatively short time spent Similarly to case series of Dargent et al,5 tive contraindication to Davydov’s tech- from vaginal surgery and the early as- the operating times in the present study nique. The presence of postoperative ad- sessment of the degree of lubrication and diminished after the initial cases. Al- hesions could complicate the surgical pain, which probably should be reas- though the surgical duration of this tech- procedure and increase the risk of in- sessed later. Slight differences were also nique is longer than the laparoscopic traoperative complications (such as found in desire. There is certainly no Vecchietti procedure,19 it is shorter than bleeding). unique interpretation of these results, al- other procedures, such as sigmoid col- Although in the present case series though it could be due to an objective poplasty.20-22 Compared with other there were no severe intraoperative or difficulty in lubrication and pain or techniques, intraoperative blood loss postoperative complications, as in all could also be related to a subjective hy- and vaginal bleeding after surgery are combined laparoscopic and vaginal pro- perreactivity in this particular subset of very scant. Postoperative vaginal bleed- cedures, complications of the Davydov patients, with frequently late diagnoses ing may be intermittent during the first 2 technique may involve intraoperative and protracted clinical histories. Al- months but is generally scant and rarely damage to the bladder, ureters, or rec- though most patients were satisfied with occurs. Unlike the techniques of McIn- tum, with a subsequent risk of fistula for- the surgery, it is also important to con- doe23 and Vecchietti and sigmoid vagi- mation. A rectovaginal fistula at 18 sider that success largely depends on noplasty, the Davydov laparoscopic months follow-up examination in 1 op- their cooperation in maintaining the re- technique does not require any particu- erated patient was reported in the case sults that are obtained with the surgery. lar surgical instrumentation and is per- series of Soong et al.10 In patients with Rokitansky syn- formed by a gynecologic team alone that A hyatrogenic septic peritonitis could drome, the laparoscopic Davydov tech- has to be experienced in laparoscopy and occur during the first 10 postoperative nique seems to represent a safe and effec- vaginal surgery. days because of the communication be- tive solution for the treatment of vaginal The catheter and neovaginal gauze tween the dome of the neovagina and the agenesis. f dressing can be removed 48 hours after peritoneal cavity. Such surgery; therefore, the risk of bladder probably can be prevented through ster- REFERENCES and neovaginal infections is minimized. ilization of the vaginal obturator before 1. Willemsen WN. Renal-skeletal-ear-and fa- Despite the mean hospitalization of 3.9 use and cautious insertion of the obtura- cial-anomalies in combination with the Mayer- days due to 5 cases of transient urinary tor to avoid bringing the neovaginal dis- Rokitansky-Küster (MRK) syndrome. Eur J Ob- retention, the hospital stay is relatively charge upward into the peritoneal cavity. stet Gynecol Reprod Biol 1982;14:121-30. 2. Strubbe EH, Thijn CJ, Willemsen WN, Lap- short, because patients can be discharged Sexual intercourse should be avoided pohn R. Evaluation of radiographic abnormali- 2–3 days after surgery (ie, after catheter until the first postoperative month fol- ties of the hand in patients with the Mayer-Ro- removal and when the patients are capa- low-up visit. No cases of peritonitis were kitansky-Kuster-Hauser syndrome. Skeletal ble of using the vaginal obturator). observed in this case series. Radiol 1987;16:227-31. As previously reported by Adamyan et The advantages with respect to an- 3. Aittomaki C, Eroila H, Kajanoja P. A popula- 17 24 tion-based study of the incidence of Mullerian al and Templeman et al, the Davydov other vaginal approach (such as the aplasia in Finland. Fertil Steril 2001;76:624-5. procedure is demonstrated to allow McIndoe technique) are undoubtedly 4. Edmonds DK. Congenital malformations of spontaneous squamous epithelization of the absence of major scarring from skin the genital tract. Obstet Gynecol Clin North Am the neovagina within 6 postoperative grafting in these frequently young pa- 2000;27:49-62. months. The reason for this rapid trans- tients. Despite the fact that sexuality after 5. Dargent D, Marchiolè P, Giannesi A, Ben- chaib M, Chevret-Mèasson M, Mathevet P. formation is not clear, although we laparoscopic Davydov procedure is Laparoscopic Davydov or laparoscopic trans- might hypothesize that, despite the dis- poorly documented, our results are sim- position of the peritoneal colpopoiesis de- located peritoneum, it preserves its orig- ilar to those of Giannesi et al25 and Dar- scribed by Davydov for the treatment of con-

JANUARY 2010 American Journal of Obstetrics & Gynecology 33.e5 Research General Gynecology www.AJOG.org genital vaginal genesi: the technique and its ment of female sexual function. J Sex Marital tients with Rokitanky syndrome: analysis of 52 evolution. Gynecol Obstet Fertil 2004;32: Ther 2000;26:191-208. cases. Fertil Steril 2000;74:384-9. 1023-30. 13. Fedele L, Bianchi S, Dorta M, Zanconato G, 20. Louis-Sylvestre C, Haddad B, Paniel BJ. 6. Ismail IS, Cutner AS, Creighton SM. Laparo- Raffaelli R. Laparoscopic creation of a neova- Creation of a sigmoid neovagina: technique and scopic vaginoplasty: alternative techniques in gina in women with pelvic kideny. J Am Assoc results in 16 cases. Eur J Obst Gynec Repr Biol vaginal reconstruction. BJOG 2006;113:340-3. Gynecol Laparosc 1999;6:327-9. 1997;75:225-9. 7. Davydov SN. Colpopoiesis from the perito- 14. Fedele L, Frontino G, Motta F, Restelli E, 21. Delga P, Potiron L. Sigmoid colpoplasty by neum of the uterorectal space. Akush Ginekol Candiani M. Creation of a neovagina in Rokitan- laparoscopic and perineal surgery: a first case (Mosk) 1969;45:60-2. sky patients with a pelvic kidney: comparison of relative to Rokitansky-Kuster-Hauser syn- 8. Davydov SN, Zhvitiascvili OD. Formation of long-term results of the modified Vecchietti and drome. J Laparoendosc Adv Surg Tech vagina (colpopoiesis) from peritoneum of Doug- McIndoe techniques. Fertil Steril 2009. Epub 1997;7:195-9. ahead of print. 22. Darai E, Toullalan O, Besse O, Potiron L, las pouch. Acta Chir Plast 1974;16:35-41. 15. Fedele L, Bianchi S, Berlanda N, et al. Neo- Delga P. Anatomic and functional results of 9. Friedberg V. [Die bildung einter Kunstilchen vaginal mucosa after Vecchietti’s laparoscopic laparoscopic-perineal neovagina construction Sheide mittels peritoneum]. Geburtsh Frauen- operation for Rokitansky syndome: structural by sigmoid colpoplasty in women with Rokitan- heilkd 1974;34:719-23. and ultrastructural study. Am J Obstet Gynecol sky’s syndrome. Hum Reprod 2003;18: 10. Soong YK, Chang FH, Lai YM, Lee CL, 2006;195:56-61. 2454-9. Chou HH. Results of modified laparoscopically 16. Herman CJ, Willesman WN, Mastboom JL, 23. McIndoe AH. The treatment of congenital assisted neovaginoplasty in 18 patients with Vooijs GP. Artificial : possible sources of absence and obliterative conditions of the va- congenital absence of vagina. Hum Reprod epithelialization. Hum Pathol 1982;13:1100-5. gina. Br J Plast Surg 1950;2:254-67. 1996;11:200-3. 17. Adamyan LV, Kulakov VI, Murvatov KD, 24. Templeman CL, Hertweck SP, Levine RL, 11. Fedele L, Bianchi S, Frontino G, Fontana E, Zurabiani Z. Application of endoscopy in sur- Reich H. Use of laparoscopically mobilized peri- Restelli E, Bruni V. The laparoscopic Vecchiet- gery for malformations of genitalia. J Am Assoc toneum in the creation of a neovagina. Fertil ti’s modified technique in Rokitansky syndrome: Gynecol Laparosc 1994;1:S1. Steril 2000;74:589-92. anatomic, functional, and sexual long term re- 18. Soong YK, Chang FH, Lee CL, Lai YM. Vag- 25. Giannesi A, Marchiole P, Benchaib M, sults. Am J Obstet Gynecol 2008;198: inal agenesis treated by laparoscopically as- Chevret-Measson M, Mathevet P, Dargent D. 377.e1-6. sisted neovaginoplasty. Gynecol Endosc Sexuality after laparoscopic Davydov in patients 12. Rosen R, Brown C, Heiman J, et al. The 1994;3:217-20. affected by congenital complete vaginal agen- Female Sexual Function Index (FSFI): a multidi- 19. Fedele L, Bianchi S, Zanconato G, Raffaelli esis associated with uterine agenesis or hy- mensional self-report instrument for the assess- R. Laparoscopic creation of neovagina in pa- poplasia. Hum Reprod 2005;20:2954-7.

33.e6 American Journal of Obstetrics & Gynecology JANUARY 2010