Early anatomic, functional, and histopathologic outcomes after da Vinci SP-assisted Davydov vaginoplasty for Mayer–Rokitansky–Küster–Hauser syndrome: a three-patient retrospective pilot series

Technical Summary: da Vinci SP-Assisted Davydov Vaginoplasty for MRKH Syndrome

Problem Statement
Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome is a congenital condition characterized by uterovaginal agenesis, significantly impacting gynecologic and sexual health. While progressive vaginal dilation is the first-line treatment, some patients fail conservative management or prefer immediate surgical correction. The Davydov vaginoplasty, which utilizes pelvic peritoneum to construct a neovagina, is a standard surgical option that avoids bowel resection and skin graft donor-site morbidity. However, this procedure requires deep pelvic dissection and precise intracorporeal suturing in a narrow field. While robotic surgery offers advantages for such tasks, published experience specifically utilizing the da Vinci Single-Port (SP) system for Davydov vaginoplasty in MRKH patients remains extremely limited. Furthermore, the histopathologic timeline of epithelial transformation in peritoneum-lined neovaginas requires further clinical validation.

Methodology
This study presents a retrospective, observational pilot series of three consecutive women with Type I MRKH syndrome (isolated uterovaginal agenesis) who underwent da Vinci SP-assisted Davydov vaginoplasty at a single tertiary center between January 2021 and September 2024.

• Surgical Technique: All procedures were performed by a single surgeon experienced in laparoscopic and multiport robotic Davydov vaginoplasty. The surgery utilized a single 2-cm vertical trans-umbilical incision with a flexible 4-bore multichannel trocar to accommodate the da Vinci SP metal cannula.
• Procedure Details: The technique involved mobilizing the pelvic peritoneum, creating a neovaginal canal between the bladder and rectum via hydro-dissection, and suturing the peritoneal flaps to the vaginal vestibulum. The neovaginal apex was closed with a purse-string suture incorporating bladder and rectal serosa while excluding ureters and ovaries. Opportunistic salpingectomy was performed where clinically appropriate.
• Postoperative Care: Patients utilized a soft vaginal mold initially, transitioning to a rigid mold. Follow-up included assessment of neovaginal length, Schiller testing, and evaluation for complications such as stenosis or granulation tissue.
• Histopathology: In two patients who underwent trimming of hypertrophic apical tissue during follow-up, specimens were analyzed using Hematoxylin and Eosin (H&E) staining and cytokeratin immunostaining to assess epithelial differentiation.

Key Results

• Feasibility and Safety: All three procedures were completed successfully through the single umbilical port without the need for additional ports, blood transfusion, or conversion to another surgical approach. There were no major intraoperative complications, including bladder or bowel injury.
• Operative Metrics: Total operative time ranged from 171 to 188 minutes, with console times between 159 and 171 minutes. Estimated blood loss was minimal (85–115 mL). Hospital stays ranged from 5 to 6 days.
• Anatomic Outcomes: Neovaginal length was 9–10 cm on postoperative day 3 and maintained at 8–9 cm at the 12-month follow-up. No cases of vaginal stenosis occurred. All patients tested positive on the Schiller test at 12 months.
• Functional Outcomes: Two patients achieved satisfactory penetrative intercourse at 6 and 7 months post-surgery. The third patient maintained neovaginal patency through regular mold use.
• Complications: Two patients developed granulation tissue or tissue hypertrophy at the neovaginal apex approximately 3 months post-surgery, presenting as spotting. These were successfully managed with laser vaporization or limited debridement.
• Histopathologic Findings: In the two patients with available tissue specimens, H&E staining revealed surface squamoid cells, and cytokeratin immunostaining confirmed their epithelial nature. These findings support the occurrence of early epithelial transformation of the peritoneal lining within three months of surgery.

Significance and Claims
The authors claim that this study provides preliminary evidence that da Vinci SP-assisted Davydov vaginoplasty is a feasible and safe reconstructive option for selected women with Type I MRKH syndrome. The significance of the work lies in three main areas:

1. Technical Application: It describes a rare application of the da Vinci SP platform in MRKH reconstruction, demonstrating that the system's ergonomic advantages (improved triangulation and reduced instrument collision in the deep pelvis) facilitate complex intracorporeal suturing through a single concealed incision.
2. Clinical Outcomes: The series reports favorable early anatomic and functional outcomes, including preserved neovaginal length, absence of stenosis, and successful sexual function in sexually active patients, comparable to existing literature on laparoscopic Davydov vaginoplasty.
3. Pathologic Evidence: The study offers direct clinicopathologic evidence of early epithelial transformation (squamoid differentiation) in the neovaginal lining as early as three months post-operation, reinforcing the biological rationale for using peritoneum in this reconstruction.

The authors maintain a modest tone, acknowledging the study's limitations as a small, single-center, retrospective pilot series without a control group. They conclude that while the early results are promising, larger comparative studies with longer follow-up and standardized patient-reported outcome measures are necessary to definitively establish the procedure's comparative effectiveness.