Vaginectomy

INTRODUCTION — Partial and total vaginectomy refer to procedures in which the vaginal epithelium is excised without disruption of the adjacent tissues of the paracolpium. Radical vaginectomy involves resection of tissues lateral to the vagina, particularly the upper vagina. Partial radical vaginectomy (including removal of the upper vagina) is performed with radical parametrectomy.

The procedure of vaginectomy is reviewed here. Conditions for which vaginectomy is indicated (eg, vaginal intraepithelial neoplasia, vaginal carcinoma, gender-affirming surgery in transgender men) are discussed in detail separately. (See "Vaginal intraepithelial neoplasia" and "Vaginal cancer" and "Vulvar lichen planus" and "Gender-affirming surgery: Female to male".)

PARTIAL OR TOTAL VAGINECTOMY

Preoperative preparation — The procedure should be clearly explained to patients (and their partners), particularly with regard to complications. Vaginal reconstruction should also be discussed, depending on the amount of vagina to be removed and patient's wishes.

Bowel preparation, to minimize morbidity in the event of injury to the rectum or anus, is utilized when extensive vaginal surgery is planned. (See "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Bowel preparation'.)

Operative procedure — General, epidural, or spinal anesthesia is administered. Positioning of the patient is dependent on the surgical approach (ie, abdominal only, perineal only, combined abdominoperineal). For the abdominal (including laparoscopic) approach, the modified lithotomy position has the advantage of allowing easy access to the vagina from below during the procedure.

A total abdominal or vaginal hysterectomy is usually performed concurrently in patients with an intact uterus who require total vaginectomy or upper partial vaginectomy. If two surgeons are available, a combined abdominoperineal approach facilitates the surgery. For patients who have previously undergone hysterectomy, it is possible to perform total vaginectomy entirely from below but care must be taken to include all vaginal skin in the angles and vault of the vagina.

To determine whether a total or partial vaginectomy is to be performed, the vagina is initially inspected and the margins of resection identified. Placing one or more sutures to mark the extent of planned resection, or staining the vagina, may facilitate subsequent dissection, particularly if the procedure is being performed by the abdominal route. If a lesion is to be excised, then the placement of sutures at key points around it is particularly useful. When small lesions are excised, the mucosa of the vagina can be closed using 3/0 polyglactin sutures.

In a combined abdominovaginal procedure, the vaginal part of the procedure is usually quicker than the abdominal, so the vaginal operator may delay this dissection until the uterus has been mobilized. The lower incision is made with a scalpel circumferentially around the vagina. Forceps are applied to the upper edge; applying gentle traction allows the operator to dissect the vaginal skin off underlying structures with scissors. Care must be taken anteriorly over the urethra because the tough underlying connective tissue makes dissection difficult. "Buttonholes" and tears of the vagina should be avoided. Dissection is continued as far up the vagina as can be reached easily. Bleeding may be reduced by the prophylactic injection of a vasoconstricting agent such as epinephrine diluted to 1 to 100,000 in saline but, even then, bleeding from venous sinuses may require hemostatic suture.

The abdominal surgeon performs the first stages of a total abdominal or radical hysterectomy (see "Hysterectomy: Abdominal (open) route" and "Radical hysterectomy"). The broad ligaments are clamped and cut, the uterovesical fold of peritoneum is divided, and the bladder dissected off the adjacent upper vagina. The uterine arteries are divided and ligated. Further bladder dissection is aided by traction on the uterus, which stretches the vagina, together with gentle retraction of the previously dissected bladder (figure 1). Sharp dissection should be used to reduce bleeding and preserve tissue planes. The dissection should be continued laterally posterior to the distal ureter on each side. The peritoneum of the cul-de-sac (pouch of Douglas) is incised in the midline close to its attachment to the cervix and vagina, and the rectum is dissected gently away. This dissection can be completed readily with the assistance of the perineal surgeon.

Straight Zeppelin forceps are placed on the paravaginal tissues along the line of the vagina medial to the uterine artery pedicles. A scalpel is used to divide the tissues on the vaginal side, and the pedicles are transfixed and ligated. It is important to ensure that the ureters are not caught in the forceps or resulting pedicle. If the ureters cannot be clearly identified, they should be dissected off the parametrium after deroofing the ureteric tunnel, employing a technique similar to that used for radical hysterectomy (see "Radical hysterectomy"). Additional pedicles are clamped and cut until the lower limit of resection is reached. The vagina is opened anteriorly from above, with the perineal surgeon guiding the appropriate point of entry.

Following removal of the specimen, hemostasis is secured using electrocauterization and suture ligatures. The procedure now depends upon the extent of the vaginectomy and the need for vaginal reconstruction.

Previous hysterectomy — If the patient has had a previous hysterectomy, total or partial vaginectomy can be performed separately, from above or below. There are proponents of both routes, but the abdominal approach has the advantage of allowing better visualization and dissection of the ureters, and facilitating a more complete excision of the vault and corners of the vaginal vault where intraepithelial neoplasia can remain hidden. Bowel adherent to the vault can also be more easily dissected free. A technique of vaginal resection performed from below for locally recurrent carcinoma of the cervix in patients who have previously undergone hysterectomy has been described [1].

In the abdominal approach, the vault of the vagina is identified with the aid of an instrument (eg, gauze roll on a sponge holder) placed in the vagina to stretch up the vault. After incising the peritoneum over the vault, the bladder is dissected off the vagina with dissecting scissors. The posterior cul-de-sac peritoneum is incised, and the rectum is separated from the vagina and uterosacral ligaments. The course of the ureters may have been distorted as a result of previous surgery, and care must be taken to identify them. They may have to be dissected off, and away from, the upper vagina, as with a radical hysterectomy. Once the bladder, ureters, and rectum are clear, the dissection continues as described above. When vaginectomy is performed from above, use of a laparoscopic approach may be feasible and has the advantage of avoiding a larger incision [2].

Closure — If no vaginal reconstruction is to be performed, the vaginal defect can be allowed to close off. A suction drain may be brought out through the abdomen or perineum. If there is persistent oozing, a povidone-iodine-soaked pack can be inserted for 24 to 48 hours with its tail brought out through the perineum.

If an upper vaginectomy has been undertaken and vaginal reconstruction is not planned, the edges of the residual vagina may be run from above with continuous 0 polyglactin suture for hemostasis and left open, or closed with interrupted sutures. If there is only residual vaginal skin at the lower end, no special closure is necessary, although it is sometimes possible to mobilize the residual skin and sew the anterior and posterior edges together to prevent sequestration of vaginal epithelium in which intraepithelial neoplasia may develop.

Following the extensive dissection, bladder integrity can be tested by distending it with saline, with or without dilute methylene blue.

RADICAL VAGINECTOMY

Operative procedure — When performed concurrently with radical hysterectomy or parametrectomy, but not as part of an exenteration procedure, the distal ureters and bladder are dissected from the upper vagina, paracolpium, and parametrium. The rectum is separated from the vagina and uterosacral ligaments, and the uterosacral ligaments are divided as part of the radical hysterectomy. (See "Radical hysterectomy".)

A nerve-sparing technique to preserve the autonomic nerves to the bladder should be used whenever possible at the time of upper vaginectomy performed with radical hysterectomy [3].

The parametrial tissues are clamped and ligated. Following this, the bladder and ureters are gently elevated by retractors and, while the uterus and vagina are stretched cephalad, the surgeon dissects the bladder distally off the vagina. The excisional part of the procedure is completed when the vagina is transected at the required level. If the whole vagina is to be removed, it is best for two surgeons to work together. While the abdominal surgeon dissects the ureters, bladder, and rectum away from the vagina, parametrium, and paracolpium, the perineal surgeon pushes the vagina medially and guides placement of the straight Zeppelin forceps onto these tissues by the abdominal surgeon (figure 2). The upper lateral tissues of the paracolpium are clamped, divided, and ligated until the vagina is freed on both sides. Hemostasis is then secured and vaginal reconstruction is performed, if planned.

A laparoscopic approach can be used for radical vaginectomy performed both at the time of radical hysterectomy [4] and at the time of total pelvic exenteration [5]. A robotic-assisted upper vaginectomy at the time of radical parametrectomy has been described [6] as has a laparoscopic approach to total vaginectomy for patients with primary vaginal carcinoma [7]. Although it is usually necessary to remove the upper 2 to 3 cm of the vagina at the time of radical hysterectomy for cervix cancer clinically confined to the cervix, preservation of bladder function can be facilitated by avoidance of injury to the autonomic nerves running in the dorsal and posterior part of the parametrium. Care should be taken to restrict resection to only the medial paracolpium tissues in the upper third of the vagina [8].

Postoperative management — If the bladder has been left in situ, a 16 French Foley catheter is inserted suprapubically at the time of surgery. This allows bladder function to be assessed postoperatively before catheter removal. If a perineal pack has been placed, it is removed after 24 to 48 hours. The patient is encouraged to resume a normal diet postoperatively.

COMPLICATIONS — The major postoperative complications are urinary and rectal fistula and chronic bladder and rectal dysfunction. These problems are more common after radical vaginectomy than total or partial procedures. Bladder dysfunction is markedly reduced using a nerve-sparing technique when upper vaginectomy is performed at the time of radical hysterectomy. Radical vaginal surgery may also alter body image perception and cause severe psychosexual problems.

VAGINAL RECONSTRUCTION — The goals of vaginal reconstruction are to promote rapid wound healing, decrease pelvic dead space, restore the pelvic floor, and reestablish good sexual function and body image [9].

Vaginal reconstruction may be indicated in patients who have vaginal defects from treatment of benign disease, gynecologic cancer, or nongynecologic cancer invading, or in close proximity to, the vagina.

Vaginal reconstruction is best performed at primary surgery because the cavity is "ready" and does not require further dissection. Delayed procedures are more difficult because of scarring and soft tissue contracture. In older patients with severe uterovaginal prolapse, the vagina may be resected and the cavity obliterated [10].

If only vaginectomy has been performed, without removal of the bladder or rectum, a number of techniques are available. A split-thickness skin graft may be applied to the residual tissues, if sufficient, or to an omental tube. A full-thickness skin graft, a transposition skin flap (eg, pudendal thigh flap [11]), or a sigmoid colon or cecal neovagina are alternatives. Myocutaneous flaps are too bulky after nonradical surgery (see "Congenital anomalies of the hymen and vagina", section on 'Vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)'). The use of an acellular dermal graft has been reported [12].

Following vaginectomy in combination with exenteration, reconstruction of a neovagina with skin flaps is inadequate due to poor vascularity, dead space, and lack of pelvic support. Myocutaneous flaps bring bulky vascularized tissue into the pelvis, which reduces the chance of the empty pelvis syndrome developing. Possibilities include gracilis [13] and rectus abdominis flaps [14], with the latter being more reliable [15].

Early complications include infection, delayed wound healing, loss of the flap due to necrosis, fistula formation, and small bowel herniation [9]. After the reconstructed vagina has healed, sexual function may be painful or otherwise unsatisfactory due a vagina that is too short, too narrow or wide, too dry or wet, or insensitive. Pre- and postoperative psychosexual counseling may help patients with these issues.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Vulvar cancer and vaginal cancer".)

SUMMARY AND RECOMMENDATIONS

●Partial and total vaginectomy refer to procedures in which the vaginal epithelium is removed without disruption of tissues of the paracolpium. The most common indication for partial vaginectomy is vaginal intraepithelial neoplasia. Radical vaginectomy refers to resection with part or all of the paravaginal tissues (paracolpium). (See 'Partial or total vaginectomy' above.)

●Total abdominal or vaginal hysterectomy may be performed concurrently in patients with an intact uterus who require total vaginectomy or upper partial vaginectomy. (See 'Operative procedure' above.)

●Abdominal and laparoscopic approaches (as opposed to perineal) provide better visualization for dissection of the ureters, and a more complete excision of the vaginal vault and, particularly, the corners of the vaginal vault where intraepithelial neoplasia can be hidden. Bowel adherent to the vault can also be dissected free more safely. (See 'Operative procedure' above.)

●If no vaginal reconstruction is to be performed, the vaginal defect can be allowed to close off. If vaginal reconstruction is desired, it can be performed at the time of vaginectomy. (See 'Closure' above.)

●The major postoperative complications are urinary and rectal fistula and chronic bladder and rectal dysfunction. (See 'Complications' above.)

●A nerve-sparing technique to preserve the autonomic nerves to the bladder should be used whenever possible at the time of upper vaginectomy performed with radical hysterectomy. (See 'Radical vaginectomy' above.)