To the Editor:
In a recent article in Fertility and Sterility, Fedele et al. discuss the efficacy of the Williams vaginoplasty as a method of treatment for the colpopoiesis in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome patients with a pelvic kidney, and compare the safety and efficacy of this method with those of the Vecchietti’s laparoscopic modification. (1)
According to authors’ opinion, expressed in the Discussion section of the above mentioned article: “The extraperitoneal approach implied in the Williams techniques certainly minimizes the risks associated with the presence of a pelvic kidney. This vaginoplasty technique also has the advantage of having an extraperitoneal approach and being a relatively simple procedure.”
It is true that, due to the nature of the procedure, Williams vaginoplasty is indeed the safest method to perform, for the creation of a neovagina, especially in this subgroup of MRKH patients, as no dissection of the vesicorectal space is required.
Unfortunately, we are not in position to agree with authors’ further statement that “the presence of perineal hair and the nonphysiologic external angle of the neovagina that results from this technique do not allow optimal anatomical results.”
According to our experience, published several times in the past (2-4), after the performance of the Williams vaginoplasty, the functional axis of the neovagina tends to be very similar to the anatomical deviation of a normal vagina.
Furthermore, we would like to assure you that despite the fact that initially we were also surprised, during the long-term follow up of 200 cases treated by the Creatsas modification of the Williams vaginoplasty, in a course of more than 20 years, we find no perineal hair present at the inner segment of the neovagina.
In conclusion, we strongly believe that for the creation of a neovagina, especially in case of contemporaneous existence of a pelvic kidney, the simplest, quickest, most effective, but beyond all safest method, is the Creatsas modification of Williams vaginoplasty.
George Creatsas, MD, PhD, FACS, FRCOG, FACOG
Panagiotis Christopoulos, MD, MSc, PhD
Division of Pediatric-Adolescent Gynecology and Reconstructive Surgery
2nd Department of Obstetrics and Gynecology
University of Athens Medical School
1. Fedele L, Frontino G, Motta F, Restelli E, Candiani M. Creation of a neovagina in Rokitansky patients with a pelvic kidney: comparison of long-term results of the modified Vecchietti and McIndoe techniques. Fertil Steril. 2009 Jan 24. [Epub ahead of print]
2. Creatsas G, Deligeoroglou E. Expert opinion: vaginal aplasia: creation of a neovagina following the Creatsas vaginoplasty. Eur J Obstet Gynecol Reprod Biol. 2007 Apr;131(2):248-52.
3. Botsis D, Deligeoroglou E, Christopoulos P, Aravantinos L, Papagianni V, Creatsas G. Ultrasound imaging to evaluate Creatsas vaginoplasty. Int J Gynaecol Obstet. 2005 Apr;89(1):31-4.
4.Creatsas G, Deligeoroglou E, Makrakis E, Kontoravdis A, Papadimitriou L. Creation of a neovagina following Williams vaginoplasty and the Creatsas modification in 111 patients with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril. 2001 Nov;76(5):1036-40.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.08.047
The Authors Respond:
We apologize to Drs. Creatsas and Christopoulos for not having specified more in detail the characteristics of the Williams vulvovaginoplasty in the Discussion section of our paper entitled “Creation of a neovagina in Rokitansky patients with a pelvic kidney: comparison of long-term results of the modified Vecchietti and McIndoe techniques.” (1)
As we personally do not have experience in the Williams surgical procedure, the comments we have reported in our study had been obtained from previous studies regarding this technique (2-5). Undoubtedly, one of the primary factors of success is the surgeon’s experience in the surgical technique and in the postoperative management, both of which may have yielded the optimal results described in the publications of Creatsas and co-workers.
Luigi Fedele, MD
Giada Frontino, MD
Francesca Motta, MD
Elisa Restelli, MD
Massimo Candiani, MD
Clinica Ostetrica e Ginecologica I
Universita di Milan Fondazione Policlinico
Mangiagalli e Regina Elena
1. Fedele L, Frontino G, Motta F, Restelli E, Candiani M. Creation of a neovagina in Rokitansky patients with a pelvic kidney: comparison of long-term results of the modified Vecchietti and McIndoe techniques. Fertil Steril. 2009, in press.
2. Miller RJ and Breech LL. Surgical correction of vaginal anomalies. Clinical Obstetrics and Gynecology 2008;51(2):223-6.
3. Edmonds KD. Congenital malformations of the genital tract and their management. Best Pract Res Clin Obstet Gynecol 2003;17(1):19-40.
4. Noguchi S, Nakatsuka M, Sugiyama Y, Chekir C, Kamada Y, Hiramatsu Y. Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with Mayer-Rokitansky-Kuster-Hauser syndrome. Hum Reprod. 2004;19(7):1629-32.
5. Dewhurst’s Textbook of Obstetrics and Gynaecology, 7th Ed., Wiley-Blackwell Publishers, 2007.
Published online in Fertility and Sterility doi:10.1016/j.fertnstert.2009.08.048