Laparoscopic Upper Colpectomy for VAIN III after Previous Total Hysterectomy

To demonstrate the feasibility of laparoscopic upper colpectomy for the treatment of vaginal intraepithelial neoplasia (VAIN) after previous total hysterectomy.

Stepwise demonstration of the technique with narrated video footage.

In 2014, our patient aged 60 years underwent a routine smear that reported severe dyskaryosis. This was treated with large loop excision of the transformation zone. Histopathology confirmed cervical intraepithelial neoplasia II, with positive ectocervical margins. The patient was counseled for both repeat large loop excision of the transformation zone and hysterectomy, opting for definitive surgery. A total abdominal hysterectomy with bilateral salpingo-oophorectomy was performed in January 2015, completely excising the residual cervical intraepithelial neoplasiaII. A vault smear was performed in October 2015, reporting further severe dyskaryosis. The patient subsequently underwent examination under anesthesia and multiple upper vaginal mapping biopsies-identifying extensive VAIN III. The case was successfully managed by a laparoscopic upper colpectomy. When determining the area of VAIN to be excised, it can be useful to place a vaginal marker stitch; however, we chose to perform a colposcopy and apply acetic acid to help delineate the extent of the VAIN, immediately before laparoscopy. The right-sided pelvic sidewall dissection proved more extensive owing to the disease burden on that side. No intra- or postoperative complications occurred. The final histopathology confirmed a 65 × 35 × 8-mm upper colpectomy specimen with VAIN III and clear surgical margins. The patient has since had a normal vault smear and no recurrence to date.

We highlight the importance of gaining early retroperitoneal access and developing the lateral pelvic spaces to identify the ureters and gain vascular control of the pelvis. We demonstrate an approach to safely developing the posthysterectomy vesicovaginal plane, with the aid of bladder filling. We used a McCartney tube (Kebomed UK, Cullompton, Devon) to facilitate colpotomy and closed the vagina using a laparoscopic suturing technique.

We believe laparoscopic upper colpectomy offers definitive management of VAIN-a condition that otherwise has a propensity for recurrence and is hence often associated with multiple vaginal excisional procedures.