V9-02: Complete Vestibulectomy for Neuro-Proliferative Vestibulodynia (NPVD): Urologic Surgical Technique and Outcomes
The vestibule, derived from the endodermal urogenital sinus and homologue of the male penile urethra is defined as introital tissue between vulva and vagina and surrounds the female urethral meatus. Vestibular pathology is commonly associated with introital dyspareunia. Women often complain of lower urinary tract symptoms and bladder pain, secondary in part to high tone pelvic floor dysfunction, and are often misdiagnosed with interstitial cystitis. Vestibulodynia is diagnosed by vestibular examination and cotton swab testing. Patients with diffuse vestibular pain may have NPVD, a mast cell disease of endoderm resulting in an increased density of C afferent nociceptors in the vestibule. Successful urologic surgery may require complete excision of the vestibule, from hymen to Hart&[prime]s line, passing within a millimeter of the meatus. Vaginal flap reconstruction is required to cover the defect from excised vestibule. We review a single urologist&[prime]s technique and surgical outcomes over a 7-year period showing complete vestibulectomy to be a safe outpatient urological treatment for NPVD._x000D_
In lithotomy position, the labia minora are retracted laterally. The incision is outlined 1 mm right/left of the urethral meatus, extending superiorly for several centimeters, passing laterally to Hart&[prime]s line and inferiorly 2 cm below the posterior fourchette. Medially the incision passes inferiorly from meatus to hymenal tissue extending 2-3 mm below the hymenal ring. Liposomal bupivacaine is used to hydro-dissect vestibular epithelium off the subcutaneous tissue. The 3 mm deep specimen is sharply dissected en bloc. Reconstruction involves left/right anterior repair to close the dead-space bringing together urethral meatus to vulva. Posterior repair involves developing a vaginal tissue advancement flap with finger dissection of rectovaginal fascia. Anchoring sutures are placed from rectovaginal fascia though vaginal wall. Final repair brings together vagina to vulva. Additional liposomal bupivacaine is placed for post-op pain control. _x000D_
60 patients from 2009-2016 underwent complete vestibulectomy for NPVD with mean operative time 60 minutes, and mean intra-op blood loss 75 ml. There were no anesthesia complications, post-operative infections, flap complications, or acute re-explorations. No patient experienced worsened pain and 80% were pain free at 1 year.
A safe technique with wide resection for outpatient complete vestibulectomy has been reviewed.