A successful surgical approach for anatomic causes of dyspareunia

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Surgery on a shortened or scarred vaginal canal can be an effective treatment for dyspareunia. That is particularly true of a relatively new laparoscopic technique called the Davydov procedure, which entails use of the pelvic peritoneum to increase vaginal length.

“In the past, decreased vaginal length caused by scar tissue from prior surgery such as hysterectomy, vaginal mesh complications or reconstructive vaginal surgery has not had good surgical options,” said Robert D. Moore, DO, director of advanced pelvic surgery at Miklos and Moore Urogynecology in Atlanta, Beverly Hills and Dubai. “All of these conditions can cause either narrowing or shortening of the vaginal canal, leading to painful intercourse.”

The Laparoscopic Davydov procedure, on the other hand, successfully adds significantly lengthens the vaginal canal so that it is fully functional.

“This is a procedure we have been using for the past 20 years to create vaginas in young women that suffer from vaginal agenesis (Mayer-Rokitansky-Küster-Hauser [MRKH] syndrome) and have only 1 to 2 cm of a vaginal dimple,” said Dr. Moore, in a presentation on surgical approaches for anatomic causes of dyspareunia at the 2018 global conference of the American Association of Gynecologic Laparoscopists (AAGL) in Las Vegas.

Using skin grafts to create vaginas in these patients has a high potential of scarring back down to a length of less than 6 cm to 7 cm, which is not adequate for sexual function, according to Dr. Moore. “We have been able to successfully use the Davydov procedure, not only in patients as a primary surgery for MRKH to create a full-length vagina, but also in women who have had a failed McIndoe procedure for their initial treatment for vaginal agenesis,” he said.

However, a clinician needs to have extensive knowledge and experience with the Davydov procedure and the pelvic anatomy, as well as possessing expert laparoscopic skills, to be able to perform the procedure safely and effectively, according to Dr. Moore.

No matter the reason for dyspareunia caused by decreased vaginal length, before committing to surgery, patients should try conservative therapies such as pelvic floor physical therapy and vaginal dilators to attempt to lengthen the vagina beyond 7 cm and soften the apical scar tissue. 

For the Davydov procedure, the surgeon starts vaginally by making an incision at the top of the vagina and dissecting between the bladder and the rectum to reach the pelvic peritoneum. Afterward, using a laparoscopic approach, a probe is placed in the vagina and elevated up against the peritoneum.

“The bladder and rectum must be identified prior to making an incision in the peritoneum on top of the vaginal probe,” Dr. Moore said. “The probe should be able to be seen between the bladder and rectum; in other words, the probe should be visualized through the peritoneum, so that the surgeon does not injure the bladder or the rectum.”

The peritoneum is then incised and actually sutured to the vaginal epithelium, circumferentially, all the way around. “This creates the space for the vaginal canal,” Dr. Moore said. “However, the width of the vagina at the vaginal apex where you make the incision needs to be wide enough so that it is not narrowed at that point. You do not want to create an apple-core type of effect in the mid-portion of the new vaginal canal.”

Next, the peritoneum at the top of the pelvis is brought together with a purse-string suture, which creates the top of the new vagina.

“The peritoneum over the bladder also needs to be released to allow the peritoneum at the top of the pelvis to be drawn together in a purse-string fashion to create the apex of the new vagina,” Dr. Moore said. Care needs to be taken to not obstruct the rectum at this point as well. 

The procedure is performed under general anesthesia and patients are in the hospital for 23 hours. They typically resume daily activities within 1 to 2 weeks.

“The nice thing about the Davydovprocedure is that patients no longer have to be fitted with a vaginal implant in the vagina for a period of 4 to 6 weeks, as needed with procedures such as the McIndoe,” Dr. Moore said. Instead, a vaginal pack is placed for 48 hours, followed by simple passing of vaginal dilators 2 to 3 times a day. 

Patients can be sexually active in as little as 6 weeks following the surgery. 

Disclosures:

Dr. Moore reports no relevant financial disclosures.