Mayer-Rokitansky-Küster-Hauser syndrome (MRKH) is characterized by uterine aplasia and at least two-thirds vaginal aplasia due to Müllerian duct fusion defect. This condition affects 1 in 4,500-5,000 women. Patient's clinical history usually shows normal development of secondary sexual characteristics, associated with primary amenorrhea. Imaging with pelvic MRI or pelvic ultrasound confirms the diagnosis and enables a complete evaluation of the disease, looking for ovarian agenesis, rudimentary uterine horn, renal or upper urinary tract anomalies. 
In this video, a robot assisted modified Davydov neovaginoplasty is described through a single laparoscopic approach without requiring a vaginal access for suturing the distal peritoneal flap, as opposed to previous publications.

A 39-years-old woman was referred for vaginal agenesis in the context of Mayer-Küster-Hauser-Rokitansky syndrome. Given isolated sexual dissatisfaction during intercourse without any possibility of penetration, the patient was offered vaginal dilation. After several years of unsuccessful conservative management using these vaginal dilators, a surgical treatment was proposed  and accepted by the patient. Magnetic Resonance Imaging confirmed uterine agenesis, the presence of 2 ovaries and the absence of any urinary malformation.  Thus, a modified robot-assisted laparoscopic Davydov's neovaginoplasty was chosen. 


Under general anesthesia, the patient was placed in dorsal supine position with legs in slight abduction. The bladder was emptied with an indwelling Foley catheter. Peritoneal cavity was accessed after peri-umbilical peritoneal insufflation with CO2 at a pressure of 12 mm Hg using a Veress needle. The Intuitive® surgical Da Vinci Xi robot with four arms was then docked on the left side through four 8mm port sites and one supplementary port site of 10mm was placed for the assistant surgeon. First, Fallopian tubes were removed to eliminate any risk of ectopic pregnancy. Second, dissection of the vesico-vaginal and recto-vaginal spaces were performed revealing the underdeveloped vagina. Third, the vaginal stump was incised horizontally over 3 cm followed by suturing laparoscopically anterior and posterior vaginal edges to the adjacent peritoneum using polyglactin 1-0 sutures (This suturing step was realized through a vaginal route in previous publications). After complete vagino-peritoneal solidarization, a metallic Hegar’s dilator was inserted vaginally by the assistant to extend and calibrate the neovagina opening. At this point, a peritoneal flap was created by widely dissecting the pre-vesical peritoneum. This flap was then attached to the peritoneum laterally and to the pre-rectal peritoneum with a polypropylene 2/0 double purse-string suture. The neovagina thus created was kept open by the introduction of a vaginal probe made of gauzes wrapped in one finger of a glove.

The patient had a non-complicated postoperative course apart from isolated pelvic pain on day 1, which did not require analgesics.  Hospital discharge was on day 2 when the vaginal probe was removed and the patient was asked to continue daily vaginal dilations with Amielle®  dilators. She was treated with 15 days of preventive anticoagulation and venous compression stockings.
At 6 weeks follow-up after surgery, the patient was satisfied and did not have any complaint. Vaginal squamous cell metaplasia of the neovaginal peritoneum was observed. The total vaginal length measured was 10 cm. The patient continued her daily vaginal dilation sessions at home. Vaginal penetration during intercourse was permitted at 3 months post-operatively.

This video showed a modified Davydov neovaginoplasty which was performed entirely via the robot-assisted laparoscopic route and did not require vaginal suturing via the vaginal canal. This technique allowed a single approach without requiring any re-positioning of the patient in lithotomy or any scrubbing of the surgeon at the console. Postoperative anatomical and functional results are good.

Continence 12S (2024) 101532
DOI: 10.1016/j.cont.2024.101532