This document provides an overview of vaginal and genitourinary reconstruction techniques. It discusses the embryology and anatomy of the genital tract. It then covers various congenital defects including vaginal agenesis, ambiguous genitalia, and bladder exstrophy. Surgical techniques for vaginal reconstruction include serial dilation, bowel flaps, local flaps, and the McIndoe technique using a skin graft. Acquired defects from cancer or trauma can be addressed with skin grafts or flaps from the vulva, vaginal vault, penis, or scrotum. Goals of reconstruction include wound coverage and restoration of function.

1. Vaginal & Genitourinary Reconstruction Sanjay Sharma, M.D. Jeffrey Friedman, M.D. Rahul Nath, M.D. Tue Dinh, M.D.

3. Anatomy/Embryology

10. Ambiguous Genitalia

21. McIndoe Procedure

24. STSG Donor Sites Tumescence for uniform Surface skin graft

29. Graft Fixation , dermal side out

32. Avoid straight line incisions at introitus

34. Rectovesical Space Peritoneal reflection (15 cm)

35. Meticulous hemostasis is essential

38. Suture labia together, prevents extrusion

41. Check graft at POD #7 Regraft if >2 cm necrosis

43. Acquired Defects of GU System

76. Vaginal Vault Posterior Thigh Flap

77. Vaginal Vault Reconstuction

78. Vaginal Vault Reconstuction

79. Vaginal Vault Reconstuction

80. Vaginal Vault Reconstuction

81. Vaginal Vault Reconstuction

83. Penis and Scrotum

89. Scrotal Defects

90. Scrotal Defects

91. Scrotal Defect Gracilis myocutaneous flap

92. Scrotal Defect

93. Coverage with Gracilis

98. Penis Replantation

99. Penis Replantation

100. Penis Replantation

103. Penis Replantation

104. Penis Reconstruction

108. Radial Forearm Flap

118. Unilateral Cavernous Nerve resection with Sural Nerve graft

119. Nerve graft Silastic tubing Metal clip microsuture Melted end of suture Cavernous nerve repair with Sural nerve grafts Nerve graft

120. Results 0% 60% Bilateral nerve grafts 21% 75% Unilateral nerve grafts Percentage of successful inter-course WITHOUT nerve grafting Percentage of successful inter-course WITH nerve grafting 200 cases to date

123. Vascular Graft Coverage

124. Gracilis Rotation Coverage

125. Gracilis Rotation Flap

126. Sartorius Flap

127. Exposed Vascular Graft

128. Sartorius Rotation Coverage

134. Pelvic/Perineum Defect

135. VRAM Reconstruction

136. VRAM to Pelvic Defect

138. Pelvic/Perineal Defects

140. Pelvic/Perineal Defects

141. Final Result

145. THANKS TO: Jeff Friedman, M.D. Rahul Nath, M.D Tue Dinh, M.D.