The management of severe vaginal obstruction from genital chronic graft-versus-host disease: diagnosis, surgical technique and follow-up.
OBJECTIVE
Chronic graft-versus-host disease (GVHD) is one of the most important systemic late-onset complications of haematopoietic stem cell transplantation. Gynaecological manifestations are considered relatively rare, and involve lower genital tract skin and mucosa, causing vulvar scarring, vaginal stenosis, affecting the patients' sexual life, and leading to more serious complications as haematocolpos, haematometra and abscesses. Genital GVHD can be treated with topical therapy when mild to moderate disease is present. Surgery is indicated in advanced and complicated cases to restore normal anatomy. The aim of this study is to propose a standard approach for the management of such condition when medical therapy is not effective.


METHODS
From May 2000 to January 2002, 8 patients suffering from genital chronic GVHD were operated in our institution. We describe clinical and sonographic presurgical assessment, simple or ultrasonographic guided surgical technique, postsurgical treatment and follow-up.


RESULTS
Surgery was completely successful in restoring genital anatomy in all the cases. Mean follow-up was of 17 months (6 to 38 months). Two patients early discontinued the postsurgical treatment. At 1 month complete vaginal patency was found in 6 cases, weak partial adhesions in 1 case, while 1 patient refused follow-up. Eventually, complete vaginal patency was maintained in 2 cases, and partial adhesions were found in 5 cases.


CONCLUSIONS
The combined use of clinical examination and endosonography provides a precise assessment of the level of the obstruction. The surgical technique here described is feasible and successful in restoring normal anatomy, while long term results seem related to the compliance towards the postsurgical treatment.
Department of Gynaecology and Obstetrics, S. Martino Hospital, University of Genoa, Italy. costante@unige.it
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S
Costantini
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E
Di Capua
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S
Bosi
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S
Chiodi
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S
Spinelli
D000328:Adult; D002908:Chronic Disease; D005260:Female; D005500:Follow-Up Studies; D006086:Graft vs Host Disease / Q000150:complications* / Q000209:etiology; D013509:Gynecologic Surgical Procedures / Q000379:methods; D018380:Hematopoietic Stem Cell Transplantation / Q000009:adverse effects; D006801:Humans; D008875:Middle Aged; D012720:Severity of Illness Index; D014623:Vaginal Diseases / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*