Vaginal substitution: Attempts to create the ideal replacement

Purpose: Vaginal substitution may be necessary for vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome), cloacal anomalies and certain intersex disorders or following pelvic exenterative surgery. The ideal method of vaginal replacement should provide a cosmetically acceptable, low maintenance vaginal substitute with minimal morbidity and excellent long-term function. We present the available literature on the various approaches to vaginal substitution, focusing on outcomes, complications and long-term durability in terms of sexual function. Materials and Methods: We performed an extensive search of the medical literature for nonoperative and operative alternatives for vaginal replacement. We focused on surgical indications, complications, long-term sexual function if available, and inherent advantages and disadvantages of the specified technique. Results: Popular methods of vaginal substitution include passive dilation, inlay skin grafts, rotational myocutaneous flaps and bowel substitute vaginoplasty. These methods have been modified to some extent, and carry inherent advantages and disadvantages. Reports in the literature show the inherent biases of the proponents of different methods. Conclusions: There are many options for vaginoplasty. The ideal method is not currently known and depends on numerous factors including patient preparedness, surgeon experience, and patient and surgeon preference. Despite these issues, patients must be provided with nonoperative and operative options that address individual patient expectations, potential complications, long-term durability and long-term sexual function.