Vaginal reconstruction/fistulae

Vaginal reconstruction is required in congenital absence of the vagina in the paediatric population and in patients with surgical (anterior exenteration) or traumatic loss of the vagina. Although vaginal agenesis is rare, its description and attempts at replacement vaginoplasty date back to antiquity. Different forms of vaginal reconstruction are described, including the use of split-thickness or full-thickness grafts, amnion, peritoneum or bowel. Experience with bowel segments for vaginoplasty, with few complications and high success rates, have expanded the indications for this technique, rendering it of great importance in the field of vaginal reconstruction, especially when large bowel segments are utilized. Most vaginal fistulae occur after gynaecological surgery. There is a multitude of established techniques for closure of vaginal fistulae with comparable success rates, and two different approaches (vaginal or abdominal) may be used. Preferable for complicated or recurrent fistulae is the abdominal approach because a well vascularized pedicled omentum majus flap can be interposed. Postirradiation fistulae, although rare, represent a challenge for the reconstructive surgeon. Fistula excision and closure fails in a high percentage of patients, and in cases of additional bladder and vaginal shrinkage urinary continence can only be achieved by urinary diversion.