In most cases of MRKH and CAIS vaginal dilation is all that will be required to create a vagina. Vaginal dilation, first described by Frank [13], is a virtually risk free method with reported success rates ranging between 40 and 90 % (see Chap. 16) [6, 26]. It entails the insertion of moulds of increasing sizes within the vaginal dimple and applying pressure. Depending on the motivation and psychological support available, treatment could be completed in weeks, but will usually take as long as few months [18]; the median reported time to achieve a sufficient vaginal length varies between 6 and 18 months. This may be one of the drawbacks of the method, as it often requires a long commitment that may be psychologically taxing for some patients. For the small percentage of women where dilation will not be successful, being familiar with dilators will prove useful following a surgical vaginoplasty, when the patient will be asked to use them postoperatively, to prevent constrictions and stenosis.

Being non-invasive and risk-free, vaginal dilation could be recommended as a first line treatment option for patients having a vaginal dimple present. For those cases that will fail, or where anatomically there is no vaginal dimple on the perineum or where a complex anomaly exists, a surgical procedure will be required.

The Vecchietti method was first described as an open procedure in the 1960s [32] and has since been modified into a minimal access one [5, 11]. The anatomical success rates, defined as the achievement of a post-operative vaginal length >6 cm, are reported to be as high as ~99 %, associated with functional success rates of ~95 % [6]; the mean post-operative neovagina length has been measured ~7.9 cm [22]. This technique involves the insertion of an acrylic bead in the vaginal dimple that is attached via the peritoneal cavity onto a traction device positioned on the abdominal wall that will gradually pull the vaginal vault upwards. The patient usually remains an inpatient for a week, at the end of which the traction device, bead and threads are removed. Postoperatively, the patient will have to maintain vaginal length with dilation or through coitus.

Risks of the procedure relate to the laparoscopic procedure itself and the possible injury to the bladder during insertion of the threads into the peritoneal cavity [10]. A variation of the Vecchietti technique involves the introduction in the introitus of an inflated Foley’s balloon, instead of an acrylic bead, the advantage being that a better vaginal width can be achieved as compared to the one obtained through the Vecchietti method [9].