V7-05: Immediate laparoscopic reconstruction of an acute iatrogenic vesico-vaginal fistula by a neo-vaginal dilator in a patient with Mayer-Rokitansky-Küster-Hauser-Syndrome

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Introductions and Objectives
Mayer-Rokitansky-Küster-Hauser-syndrome (MRKH) is a rare genital-aplasia syndrome. Patients need reconstruction of a neo-vagina before their first intercourse. They usually dilate their neo-vagina with vaginal-dilators regularly.

Methods
A 23 year old MRKH-syndrome patient came to our department complaining of a lost vaginal-dilator since inserted 2 days before. She suffered no bleeding or abdominal pain however, some occasional urinary-loss. She reported having abdominal-exploration for acute abdomen (3years ago) and the creation of a neo-vagina at the age of 16years. Clinical and radiological examinations revealed a vesico-neo-vaginal connection with urine leakage at 350ml bladder volume. A preoperative abdominal-CT showed that the missed dilator is located intra-vesically. After interdisciplinary discussions, a laparoscopic operation was prefered owing to the size of dilator and the narrow vagina. A diagnostic laparoscopy was followed by extraction of the dilator through the vesico-neo-vaginal perforation. After adequate preparation of pelvic organs, the vagina was closed separately with 2/0 Vicryl sutures, and then covered by a pedicled peritoneal-flap. This was followed by closure of urinary-bladder in two layers. An omentum-J-flap was then fixed in-between. the patient was followed up at 3 months interval afterwards

Results
The operative time was 185 minutes with negligible blood-loss, no injuries or need for conversion/revision. The urethral catheter was removed 7 days after cystographic documentation, postoperatively. The patient began normal micturition with adequate bladder capacity immediately. Postoperative recovery was uneventful. The patient resumed vaginal dilation as well as sexual activity after one month postoperatively. Follow up was uneventful and she expressed that she would advise the procedure. Evaluation using a Female-Sexual-Function-Index-questionnaire revealed a normal total score (27.50).

Conclusions
Laparoscopic removal of missed vaginal-dilator with immediate repair of the vesico-neo-vagina connection(s) in a single setting directly after acute trauma in patients with MRKH-syndrome could be a management option. It is a feasible, reproducible and safe procedure, adding all minimal invasive advantages to both patients and surgeon, in the hands of experienced laparoscopists.

Funding: none