The use of isolated caecal bowel segment in complicated vaginal reconstruction D. FILIPAS, P. BLACK and R. HOHENFELLNER Department of Urology, University of Mainz, School of Medicine, Mainz, Germany Objective To report a one-stage procedure, using a segment of caecum, both to overcome failed previous procedures and for primary vaginal replacement in patients with congenital vaginal aplasia, where primary reconstruction often results in vaginal obstruction and ®stula formation. Patients and methods The vagina was reconstructed using a 15-cm isolated caecal segment placed between the bladder and rectum and anastomosed to the introitus. Between 1985 and 1997 the technique was used in 17 patients (mean age 23 years). Indications included congenital malformations and vaginal loss through anterior exenteration or trauma. Seven of the 17 patients had undergone previous complex recon- structions; four of these had undergone previous ®stula formation. Fourteen patients were followed for a mean of 3.6 (1±9) years. The surgical outcome was evaluated using a questionnaire completed by the patients. Results The postoperative course was unremarkable in all patients. Four patients developed an introital stenosis requiring surgical intervention. Two patients were minors at the time of follow-up, while all the others had had sexual intercourse and reported that they were very satis®ed with the functional and cosmetic result. Conclusion In patients in whom previous vaginal reconstruction has failed, the caecal segment should be used to create a neovagina. By considering the patient's age, the surgeon can optimize the surgical result. Keywords Vaginal reconstruction, caecal segment, vaginal agenesis, satisfaction, cosmesis, function Introduction Patients with congenital absence of the vagina (Mayer von Rokitansky Ku È ster syndrome, MRK) usually present initially to a gynaecologist, who may then use different forms of vaginal reconstruction, including the use of split or full-thickness skin grafts (with or without tissue expanders) or amnion, peritoneum or bowel [1±9]. The urologist most commonly becomes involved later, during interdisciplinary co-operation when standard techniques have failed and complications, e.g. bladder and rectal ®stulae after the Vecchietti operation [10], or vaginal obstruction or inadequate vaginal length [11±13], demand complex reconstruction. To overcome urinary and faecal incontinence, we have used a caecal segment to cover the complex ®stulae and create a neovagina in a one-stage procedure. Furthermore, patients with a urogenital sinus, pseudo- hermaphroditism, traumatic or surgical loss of the vagina by extensive anterior exenteration for pelvic tumour require complex reconstruction, in both the gynaecolo- gical and urological domains. After promising initial results [3], we continued to use bowel, preferably the caecal segment, for vaginal reconstruction and report our further experience with this technique. Patients and methods Between 1985 and 1997, 17 patients (mean age at surgery 23 years, range 12±55) underwent vaginal reconstruction using a caecal segment. The indication for surgery was most commonly a congenital anomaly, followed by anterior exenteration and urinary diversion caused by malignancy; Table 1 list the patients' characteristics. The patients had undergone the previous surgery a mean (range) of 3.6 (1±9) years earlier. In four patients a previous vaginal reconstruction had failed; one (no. 3) had undergone previous replacement with lyodura, after which a rectovaginal ®stula developed. A vesicovaginal ®stula occurred one year after the Vecchietti procedure [10] in a second patient (no. 4) and was treated by a permanent transurethral catheter. One patient (no. 2) developed an obliteration of the proximal two-thirds of the neovagina one year after reconstruction with the Davydov technique [14,15] using a peritoneal ¯ap. Another patient (no. 1) developed a rectovaginal ®stula 3 years after the same procedure. The sigmoid colon was unsuitable for use in any of these patients. Accepted for publication 2 November 1999 BJU International (2000), 85, 715±719 # 2000 BJU International 715