(66) Long Term Outcomes in Patients with Bowel Neovaginas

Background: The primary goals of constructing a neovagina are creating a vagina of adequate size to accommodate intercourse and/or providing an outflow tract for menstrual blood. No surgical technique has been established as the gold standard. Complications of bowel neovaginas include stenosis, mucosal prolapse, mucous production, diversion colitis, and inflammatory bowel disease. Long term data are lacking, however, particularly in patients for whose surgery was performed pre- or peri-pubertally. This study seeks to assess clinical outcomes of patients who underwent neovaginal reconstruction with bowel grafts.

Methods: A retrospective review of patients with a bowel neovagina who were seen at a single institution utilizing available electronic medical records from January 1, 2004 to August 1, 2024 (IRB#2023-0746) was performed. Patients with fewer than 1 month of post-surgical follow up data were excluded from this study.

Results: A total of 83 patients who underwent creation of a bowel neovagina between the age of 3 months and 26 years old (median age 3 years old) were identified, followed for a total of 531 person-years. The most common indication was cloaca (60, 72%), followed by anorectal malformation (9, 11%). The most common tissue type used was rectum (44, 53%), followed by sigmoid colon (31, 37%), and small bowel (8, 9%). The most common intraoperative complication was bladder/ureteral injury (2, 2%). Interval evaluations most commonly occurred in the operating room (183 exams, 81% of those performed). Significant mucous production was identified on 39 exams (21%). While postoperative regimens including dilation and irrigation were planned for 35 patients, only 3 reported adherence. The most common postoperative complications were stricture/stenosis (29, 35%), need for reoperation (26, 32%), prolapse (21, 25%), fistula (5, 6%), bowel obstruction (5, 6%), infection (4, 5%), and development of IBD (3, 4%). 9 patients developed hydrosalpinx (11%). 6 developed obstruction of menstrual fluid (7%). 12 patients became sexually active within the study period (16%). 2 of these patients reported being unable to engage in penetrative neovaginal intercourse. 7 patients reported dyspareunia (58% of those who became sexually active). 4 patients reported sexual satisfaction (33%). 1 patient achieved a spontaneous pregnancy.

Conclusions: Given that neovaginas are created to allow an outflow tract for menses and to accommodate intercourse, the high rates of complications of bowel neovaginas including stenosis pose significant challenges. It is important to consider treatment indications, patients’ postoperative expectations, and expected outcomes with various techniques for vaginal reconstruction.