Non-Congenital Vaginal Obliteration: Surgical Restoration of Vaginal Patency for Severe GVHD

Objectives: The objectives of this video are to provide a brief overview of non-congenital causes of vaginal obliteration and stenosis, discuss a unique case of vaginal agglutination in a patient who developed genital graft-versus-host-disease (GVHD) after receiving a bone marrow transplant, and present the steps of a laparoscopic total hysterectomy and lysis of vaginal adhesions that successfully led to restoration of vaginal patency without the need for additional grafting.

Methods: In this video, we give an overview of non-congenital causes of vaginal obliteration with a focus on genital GVHD. We review its incidence, causes, characteristics, clinical presentations, and treatment options with a focus on surgical management. We present the case of a 54-year-old female with a remote history of acute monocytic leukemia treated with chemotherapy and a bone marrow transplant. She subsequently developed genital GVHD leading to complete vaginal obliteration, precluding penetrative intercourse, and causing pain, discomfort, and decreased quality of life. We discuss her clinical course leading up to urogynecologic consultation for surgical management. We present a combined laparoscopic and vaginal surgical procedure that highlights the value of a multimodal approach to better assess our patient’s distorted anatomy. Ultimately, a neovagina was successfully created with a normal length and girth. While grafting is sometimes necessary due to marked tissue inflammation and scarring, we were able to avoid a graft by approaching adhesiolysis laparoscopically and vaginally, followed by restoration of continuity between the unaffected upper and lower vaginal tissues.

Clinical Relevance: Genital GVHD is a known possible complication of bone marrow transplantation. This condition can be quite debilitating for patients and can lead to complete vaginal obliteration, affecting sexual performance and quality of life. A combined laparoscopic and vaginal approach is a feasible option for patients with complex pathology not amenable to simple transvaginal adhesiolysis. Surgical restoration of the vagina in patients with vaginal obliteration does not necessarily require the use of a graft if the anatomy is reestablished to a normal vaginal length and caliber, and vaginal epithelium is preserved.