Definitive management for distal vaginal atresia is surgical, most commonly with pull-through vaginoplasty. If the proximal vagina is > 3cm from the introitus, the risk of stenosis with this procedure is high. However, current alternatives to pull-through vaginoplasty are limited and have included the use of graft tissue with less desirable properties (including bowel neovagina) to overcome the challenges of an atretic native vagina. Here, we describe a staged vaginal reconstruction using buccal graft vaginoplasty followed by interval anastomosis to native upper vagina performed for a 12-year-old with distal vaginal atresia.

A 12-year-old pubertal female with history of multiple laryngopharyngeal congenital anomalies presented with acute on chronic back pain. Spinal MRI incidentally identified hematometrocolpos measuring 7.3 × 8 × 15.6 cm with inflammation of an atretic native upper vagina leading to a diagnosis of distal vaginal atresia. The most distal aspect of the native upper vagina was found to be over 6 cm from the introitus. Given this distance, she was not deemed to be an ideal candidate for native pull-through vaginoplasty. IR-guided drainage of hematometrocolpos was performed for symptomatic relief. Hormonal suppression was used to allow sufficient time for resolution of vaginal wall inflammation bridging to staged surgical procedures. A buccal graft neovagina was created first, followed by routine postoperative dilation to allow for optimal development of the lower buccal graft. After 8 months, laparoscopic mobilization of Müllerian structures with transvaginal anastomosis to the interposition buccal graft neovagina was completed. The final total vaginal length approached 9 cm without evidence of strictures or stenosis.

In individuals with distal vaginal atresia, a staged surgical approach with initial creation of a lower buccal graft neovagina followed by anastomosis to native upper vagina allows graft maturity, optimizes time utilization and healing, and avoids less desirable properties of alternative tissue types. Routine postoperative neovaginal dilation serves as a readiness assessment for further postoperative dilation required at the time of anastomosis to native vagina. This novel approach may be a viable alternative for patients at high risk of complications from native pull-through vaginoplasty, including those with distance >3cm between proximal vagina and introitus, a short native vagina, and evidence of inflammation of the native vaginal tissue.