Inverted balloon vaginoplasty technique was performed for a case with segmental vaginal aplasia and upper hematocolpos within 50 min operative time without any complications. The neovagina was naturally covered, 11 cm in depth and communicated with dimple at hymen’s site. Regular painless menstruations were reported.
Problem: vaginal aplasia with functioning uterus
Over 7 months, an 11-year-old girl experienced abdominal pain that recurred monthly and was progressively increasing. An abdominal examination revealed a centrally located lower abdominal mass equivalent in size to a uterus at 14 weeks. Inspection of the vulva and perineum revealed normal external genitals and a blind vaginal pouch. Sonography and magnetic resonance imaging were performed. A cystic upper vagina and distended uterus were identified; the lower two-thirds of the patient’s vagina were absent because of congenital vaginal aplasia.
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Our solution
Class I Müllerian anomalies range from absence of all Müllerian derivatives to various degrees of vaginal agenesis combined with a functioning uterus. Balloon vaginoplasty (BV) is a real advance in the management of vaginal aplasia, regardless of its cause. The original BV techniques were introduced for treatment of isolated complete vaginal aplasia. A blend of canalization and BV procedures was successful in treatment of vaginal aplasia coupled with a functioning uterus.
After comprehensive counseling and discussion of treatment options, our patient and her family signed an informed consent for inverted BV. This was conducted at the Woman’s Health Hospital, Assiut University, Assiut, Egypt, after obtaining institutional review board approval.
First, the surgical area was sterilized, and the patient was draped in the dorsal lithotomy position. A local examination revealed a normal vestibule and a blind vaginal dimple with complete obstruction above it. Next, a digital rectal examination was performed under anesthesia, and this disclosed a tense cystic distention of the upper vagina. Laparoscopy demonstrated that the pelvis was clear with a distended uterus and a noticeable swelling that protruded into the pouch of Douglas; this prominence was the distended vagina ( Figure 1 ) .
We used a customized long inserter to penetrate the bulge extending into the pouch of Douglas ( Figure 2 ) . This was accomplished with laparoscopic monitoring from above and bidigital guidance from below; the index finger of the left hand was inserted into the rectum to palpate the lower pole of the distended upper vagina, and the thumb of the left hand was placed at the vaginal dimple during the insertion process. The surgeon rotated and pushed the inserter along with his right hand, thus maintaining perfect control during the entire insertion process.
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