JBRA Assist. Reprod. 2026 2026;00(0):00-00
CASE REPORT
doi: 10.5935/1518-0557.20260085
Primary Amenorrhea due to Mayer-Rokitansky-Küster-Hauser Syndrome Managed with Laparoscopic Davydov Procedure: A Case Report
1Faculty of Medicine, Universitas Muhammadiyah Palembang, Palembang, Indonesia
2Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia
CONFLICT OF INTEREST
The authors declare no conflict of interest.
ABSTRACT
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital Müllerian anomaly characterized by uterovag-inal agenesis in phenotypic females with normal second-ary sexual characteristics and preserved ovarian function. Vaginal reconstruction may be required to allow satisfac-tory sexual function, particularly when nonsurgical dilation is declined, not tolerated, or not preferred. Laparoscopic Davydov vaginoplasty uses autologous peritoneum to line the neovaginal canal and may provide favorable anatomical outcomes when postoperative dilation is performed consis-tently. We report the case of an 18-year-old phenotypic female who presented with primary amenorrhea and nor-mal pubertal development. Examination showed normal external genitalia with a shallow vaginal dimple measuring approximately 3 cm. Pelvic ultrasonography demonstrated absence of the uterus with normal ovaries, and karyotype was 46,XX. Endocrine evaluation showed normal gonado-tropins, estradiol within the expected range, normal pro-lactin, and normal thyroid function tests. Renal evaluation revealed no abnormalities, supporting the diagnosis of MRKH type I. The patient underwent laparoscopic Davy-dov vaginoplasty, with detailed operative steps, trocar placement, injury-prevention strategies, and perioperative management described. A structured postoperative dila-tion protocol was implemented. At 2 months, the neovag-inal canal remained patent, with an approximate length of 8 cm; Hegar 30 was tolerated, and no early postoper-ative complications were observed. Laparoscopic Davydov vaginoplasty is a feasible surgical option for vaginal re-construction in MRKH syndrome, provided that diagnostic confirmation, reproducible operative and perioperative de-tails, and a structured postoperative dilation protocol are carefully established.
Keywords: MRKH syndrome, primary amenorrhea, lapa-roscopic Davydov, neovagina, vaginoplasty
INTRODUCTION
Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital disorder resulting from failure of Müllerian duct development and is characterized by agenesis or severe hypoplasia of the uterus and upper two-thirds of the vagina in otherwise phenotypic females with normal secondary sexual characteristics and functional ovaries (Morcel et al., 2007; Herlin et al., 2020). MRKH syndrome represents one of the most common causes of primary amenorrhea in adolescents (ACOG Committee Opinion, 2018).
Two clinical forms are recognized: type I (isolated uterovaginal agenesis) and type II, also referred to as MURCS association, which includes renal, skeletal, or other extragenital anomalies (Herlin et al., 2020; ACOG Committee Opinion, 2018). The primary goal of treatment is to create a functional vagina that allows satisfactory sexual activity while minimizing complications and psychological burden. First-line management is non-surgical progressive dilation; however, surgical reconstruction may be indicated when dilation fails, is not tolerated, or when patients prefer operative management (ACOG Committee Opinion, 2018).
Among surgical techniques, laparoscopic Davydov vaginoplasty employs autologous peritoneum to line a neovaginal canal and has demonstrated favorable anatomical outcomes, particularly when postoperative dilation is maintained (Park et al., 2012; Kisu et al., 2021; Martens et al., 2024). We report a case of MRKH syndrome type I managed with laparoscopic Davydov vaginoplasty and provide a reproducible description of operative and postoperative protocols.
CASE PRESENTATION
An 18-year-old nulligravid woman presented with primary amenorrhea. She reported normal breast development and pubic hair growth. She denied cyclic pelvic pain, urinary symptoms, bowel symptoms, or history of genital trauma. She had no prior chronic illness, no history of pelvic surgery, and was not taking regular medications.
On physical examination, vital signs were stable. Secondary sexual characteristics were Tanner stage B4 and P4. Abdominal examination was unremarkable. External genitalia were normal. A vaginal dimple measuring approximately 3 cm in depth was present. Speculum examination was not performed. Rectal examination revealed normal sphincter tone without palpable masses.
The patient was counselled regarding available treatment options, including progressive vaginal dilation as the recommended first-line approach. However, she declined non-surgical dilation because she preferred a definitive anatomical reconstruction and had concerns about the need for prolonged daily dilation therapy. After discussion of the risks, benefits, and alternatives, laparoscopic Davydov vaginoplasty was selected as the preferred management option.
Timeline
• Initial presentation: primary amenorrhea
• Diagnostic workup: endocrine testing, pelvic ultrasonography, renal evaluation
• Genetic confirmation: karyotype 46,XX
• Counselling: diagnosis and treatment options discussed
• Surgery: laparoscopic Davydov vaginoplasty
• Postoperative course: inpatient recovery with mould and Foley catheter
• Follow-up: 1-2 weeks and 6-8 weeks
• Outcome at 2 months: neovaginal length ~8 cm, Hegar 30 tolerated, no early postoperative complications
Investigations
Imaging
Pelvic ultrasonography (Figure 1) demonstrated absence of the uterus with normal bilateral ovaries (right ovary: 3.10 × 2.42 cm; left ovary: 2.90 × 2.23 cm). No pelvic mass or free fluid was identified. Renal ultrasonography showed kidneys and urinary bladder within normal limits, with no hydronephrosis.
Figure 1. Pelvic ultrasonography findingsPelvic ultrasonography demonstrating absence of the uterus with normal bilateral ovaries, consistent with uterovaginal agen-esis in Mayer-Rokitansky-Küster-Hauser syndrome.
Endocrine assessment
A complete endocrine evaluation was performed as part of the diagnostic framework for primary amenorrhea. Gonadotropins (FSH and LH) were within normal limits, estradiol was consistent with preserved ovarian function, and prolactin and thyroid function tests were normal (Table 1) (ACOG Committee Opinion, 2018).
Table 1. Hormonal profile of the patient with primary amenorrheaHormone Result Reference Range FSH 8 mIU/mL 3-10 mIU/mL LH 10 mIU/mL 2-12 mIU/mL Estradiol 42 pg/mL 30-120 pg/mL Progesterone 3.6 ng/mL <1 ng/mL (follicular) Prolactin 12.63 ng/mL 4-23 ng/mL TSH 1.57 µIU/mL 0.4-4.0 µIU/mL FT3 2.90 pg/mL 2.3-4.2 pg/mL Total T4 7.71 µg/dL 5.1-14.1 µg/dL
Androgen evaluation
Androgen testing was not clinically indicated because the patient had no signs of virilization (hirsutism, acne, clitoromegaly) and demonstrated normal female secondary sexual characteristics (ACOG Committee Opinion, 2018).
Genetics
Karyotype analysis revealed a normal female chromosomal pattern (46,XX), supporting the diagnosis of MRKH syndrome and excluding androgen insensitivity syndrome.
Classification and associated malformations
Based on uterovaginal agenesis with normal ovaries and absence of renal anomalies, the diagnosis was consistent with MRKH type I (isolated uterovaginal agenesis). Skeletal anomalies were assessed by clinical musculoskeletal examination and were unremarkable.
Surgical Technique (Laparoscopic Davydov Vaginoplasty)
Laparoscopic Davydov vaginoplasty was performed under general anesthesia. The patient was initially placed in the supine position and subsequently repositioned to the lithotomy position with Trendelenburg. Standard aseptic and antiseptic preparation was performed and the operative field was draped. A Foley catheter (16 Fr) was inserted for bladder decompression.
Trocar size and placement
Pneumoperitoneum was established through the umbilical entry. Four laparoscopic ports were inserted in a standard configuration: a 10-mm umbilical camera port, a 5-mm suprapubic port, and two 5-mm working ports in the right and left lower quadrants (Park et al., 2012; Kisu et al., 2021).
Laparoscopic exploration
Exploration demonstrated normal adnexal anatomy with both ovaries appearing normal in size and morphology, and both fallopian tubes appearing normal. The uterus was absent, consistent with Müllerian agenesis. These laparoscopic findings are shown in Figure 2.
Figure 2. Diagnostic laparoscopyLaparoscopic view showing uterine remnants as a thin fibrous band with normal bilateral ovaries and fallopian tubes, confirming uterovaginal agenesis.
Perineal approach and creation of rectovesical space
On the vaginal side, inspection and palpation revealed a vaginal introitus with a blind pouch measuring approximately 3 cm in depth. Horizontal incisions were made laterally on both sides of the vaginal dimple and blunt dissection was performed to deepen the rectovesical space. A Penser clamp was inserted through the vaginal introitus and advanced cranially as a guide.Careful blunt dissection was performed strictly within the midline rectovesical plane to minimize the risk of rectal injury. The Foley catheter balloon served as an anatomical landmark for bladder identification during dissection. Laparoscopic visualization was used to confirm the correct plane and to assess rectal integrity before the peritoneal incision was made.
Peritoneal incision and peritoneal pull-down
Under laparoscopic guidance, a transverse peritoneal incision was made at the point of protrusion of the Penser clamp. A sterile vaginal mould covered with a condom was inserted transvaginally. Once the mould bulge was clearly visualized laparoscopically as a marker, the incision was extended laterally until the mould entered the abdominal cavity. The mould was then gradually pulled down into the vaginal canal.The anterior and posterior peritoneal layers were mobilized and pulled into the vaginal cavity. The anterior peritoneal layer was grasped using ovum forceps and sutured to the vaginal mucosa with interrupted absorbable sutures (PGA 2-0). The posterior peritoneal layer was similarly pulled down and sutured with interrupted PGA 2-0 to create a peritoneal-lined neovagina (Park et al., 2012; Samantray et al., 2021). The key steps of peritoneal mobilization are illustrated in Figure 3.
Figure 3. Laparoscopic Davydov vaginoplasty - peritoneal mobilization.(A) Peritoneal incision during the abdominal phase of the Davydov procedure.(B) Mobilization of the anterior and posterior peritoneal layers prior to pull-down into the neovaginal canal.
A sterile cork-shaped mould covered with a condom was placed to maintain the neovaginal cavity.
Neovaginal cuff formation
From the abdominal side, the anterior and posterior peritoneal layers were sutured circumferentially in a transverse circular manner using PGA 2-0 to form the neovaginal cuff. From the vaginal side, the vaginal wall was sutured in an interrupted fashion to secure the mould. Formation of the neovaginal canal and cuff is shown in Figure 4.
Figure 4. Formation of the neovaginal canal.(A) Pull-down of the anterior and posterior peritoneal layers into the neovaginal canal.(B) Formation of the neovaginal cuff using interrupted sutures during laparoscopic Davydov vaginoplasty.
Hemostasis and completion
Hemostasis was performed as required. The trocars were removed, and the abdominal wall incisions were closed using absorbable sutures (PGA 3-0). The operation started at 09:00 AM and was completed at 10:30 AM. No intraoperative complications were noted.
Perioperative management
Postoperatively, the patient received prophylactic antibiotics according to institutional protocol. A Foley catheter was maintained and removed on postoperative day 1. The vaginal mould was planned to remain in situ for 14 days. The patient was discharged in stable condition with written postoperative instructions.
Postoperative Care and Outcome (Table 2)
Immediate postoperative management
Postoperatively, the patient was monitored in the ward with routine vital sign surveillance and assessment of vaginal bleeding. Analgesia and supportive care were provided according to institutional protocol. Prophylactic antibiotics were administered postoperatively. A Foley catheter was maintained overnight and removed on postoperative day 1. The patient was encouraged to mobilize early and tolerated oral intake.
Table 2. Postoperative protocol and outcomes after laparoscopic Davydov vaginoplastyTime point Management / protocol Findings Complications POD 0-1 Monitoring, analgesia, antibiotics, Foley catheter Stable, minimal bleeding None POD 1 Foley catheter removal Normal voiding None Post-op week 2 Vaginal mould removal and assessment Canal patent, no infection None Week 2 onward Dilation twice daily, 15-20 min/session Progressive size increase None 6-8 weeks (2 months) Continued dilation Length ~8 cm, Hegar 30 tolerated None ≥6-12 months Not available Not available Not available (limitation)
Vaginal mould care and removal
The patient was instructed regarding perineal hygiene and avoidance of excessive physical activity. The vaginal mould was maintained continuously during the first 14 postoperative days. Mould removal was scheduled at 2 weeks postoperatively under outpatient follow-up. After mould removal, inspection was performed to evaluate the introitus and neovaginal canal patency and to exclude infection, bleeding, or early stenosis.
Postoperative dilation protocol (structured and reproducible)
A structured dilation program was initiated after mould removal. The patient received written and verbal instructions and was counselled regarding the importance of adherence to prevent neovaginal stenosis (ACOG Committee Opinion, 2018).The dilation protocol was as follows:
• Start time: immediately after vaginal mould removal (postoperative week 2)
• Frequency: twice daily
• Duration: 15-20 minutes per session
• Method: insertion of a vaginal dilator or Hegar dilator with water-based lubricant, advanced gently until mild resistance was felt, avoiding pain or bleeding
• Progression: gradual increase in dilator size every 3-7 days as tolerated until reaching Hegar size 30
• Maintenance phase: once Hegar 30 was tolerated, dilation was continued daily for at least 6-8 weeks, followed by maintenance dilation 3-4 times per week until regular sexual activity begins
• Adherence support: counselling was reinforced at each follow-up visit, and the patient was advised to report pain, bleeding, fever, or abnormal discharge
Follow-up schedule and outcome assessment
Follow-up evaluations were scheduled at 1-2 weeks after discharge, at mould removal (2 weeks), and at 6-8 weeks postoperatively. Outcomes assessed included neovaginal patency, vaginal length, tolerance of dilator size, and postoperative complications; epithelialization was reviewed when clinically assessable.At the 2-month follow-up, the neovaginal canal remained patent with an approximate length of 8 cm, and the patient tolerated Hegar dilator size 30. Epithelialization status was not formally assessed at that visit. No postoperative complications such as infection, stenosis, bleeding, or prolapse were reported during the available follow-up period. Longer-term follow-up (6-12 months) was not yet available at the time of manuscript submission and is acknowledged as a limitation.
DISCUSSION
MRKH syndrome is a congenital Müllerian anomaly presenting most commonly as primary amenorrhea in adolescents with normal secondary sexual characteristics (Morcel et al., 2007; Herlin et al., 2020). Accurate diagnosis requires confirmation of a normal female karyotype, preserved ovarian function, and exclusion of endocrine etiologies. Standard evaluation also includes assessment of associated malformations to classify type I versus type II/MURCS, as renal and skeletal anomalies may coexist (ACOG Committee Opinion, 2018; Herlin et al., 2020).
In this case, the diagnosis was supported by uterine absence on pelvic ultrasonography, normal ovarian morphology, a normal female karyotype (46,XX), and an endocrine profile consistent with preserved ovarian function, including normal gonadotropins and estradiol. Prolactin and thyroid function tests were also within normal limits. Renal evaluation revealed no abnormalities, and skeletal anomalies were not identified on clinical musculoskeletal examination, supporting MRKH type I.
Management of vaginal agenesis should be individualized based on patient preference, psychosocial readiness, and clinical suitability. Although progressive vaginal dilation is recommended as first-line therapy, surgical reconstruction is indicated when dilation is not tolerated, fails, or is not preferred (ACOG Committee Opinion, 2018). In the present case, the patient preferred definitive surgical reconstruction over non-surgical dilation after counselling regarding the available management options. Among surgical approaches, laparoscopic Davydov vaginoplasty is a minimally invasive technique utilizing peritoneal pull-down to create a neovaginal lining. This technique offers advantages including favorable neovaginal axis, avoidance of graft material, and relatively rapid postoperative recovery (Park et al., 2012; Samantray et al., 2021; Kisu et al., 2021). Recent evidence suggests that Davydov vaginoplasty may provide comparable anatomical outcomes to other laparoscopic techniques, although long-term functional outcomes remain dependent on follow-up duration and postoperative adherence (Martens et al., 2024).
Postoperative management is a critical determinant of long-term success after Davydov vaginoplasty. Although the peritoneal lining provides a favorable biological surface for neovaginal epithelialization, early postoperative contraction and progressive stenosis may occur if adequate mechanical dilation is not maintained. Therefore, a structured dilation protocol, patient education, and adherence monitoring are essential components of care (ACOG Committee Opinion, 2018; Martens et al., 2024). Several studies and case reports have emphasized that anatomical and functional outcomes after peritoneal vaginoplasty are strongly influenced by consistent postoperative mould placement and regular dilator use, particularly during the first 6-12 weeks when tissue remodeling is most active (Park et al., 2012; Samantray et al., 2021; Kisu et al., 2021). In our case, a standardized protocol was implemented starting after mould removal at postoperative week 2, with twice-daily dilation and gradual progression in dilator size, resulting in a satisfactory early anatomical outcome at 2 months (neovaginal length approximately 8 cm with tolerance of Hegar 30). Nevertheless, longer follow-up is required to confirm durable patency, complete epithelialization, and sexual function outcomes, and this limitation should be considered when interpreting the early success of this case (Martens et al., 2024; Herlin et al., 2020).
Despite its minimally invasive approach and favorable anatomical results, laparoscopic Davydov vaginoplasty is not free from complications. Intraoperative risks include bladder injury, rectal injury, bleeding, and ureteric trauma, particularly during creation of the rectovesical space and peritoneal incision (Park et al., 2012; Kisu et al., 2021). Postoperative complications may include infection, hematoma, vaginal stenosis, shortening of the neovagina, prolapse of the neovaginal apex, granulation tissue formation, dyspareunia, and persistent discomfort requiring prolonged dilation support (Samantray et al., 2021; Martens et al., 2024; Vitols & Lidaka, 2024). Therefore, careful dissection within the correct midline rectovesical plane, use of anatomical landmarks such as a Foley catheter balloon, laparoscopic visualization before peritoneal opening, and intraoperative rectal integrity assessment are recommended to minimize injury and ensure procedural safety (Park et al., 2012; ACOG Committee Opinion, 2018). In addition, structured postoperative follow-up is necessary to detect early stenosis or infection and to reinforce adherence to dilation therapy (ACOG Committee Opinion, 2018; Martens et al., 2024). In the present case, no intraoperative complications were encountered, and no early postoperative complications were observed during the available 2-month follow-up; however, longer surveillance remains essential to evaluate late complications and long-term functional outcomes.
CONCLUSION
Laparoscopic Davydov vaginoplasty is a feasible surgical option for vaginal reconstruction in Mayer-Rokitansky-Küster-Hauser syndrome when non-surgical dilation is unsuccessful or not preferred. Thorough diagnostic evaluation-including complete endocrine testing and explicit assessment for associated malformations-along with reproducible operative/perioperative details and a structured postoperative dilation protocol, is essential for outcome appraisal. Longer-term follow-up is required to evaluate long-term patency, epithelialization, and functional sexual outcomes.
Ethical Approval and Consent:
Written informed consent for surgery and for publication of clinical data and images was obtained from the patient.
REFERENCES
Committee on Adolescent Health Care. ACOG Committee Opinion No. 728: Müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2018;131:e35-e42. PMID: 29266078 DOI: 10.1097/ AOG.0000000000002458
Medline
Herlin MK, Petersen MB, Brännström M. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome: a comprehensive update. Orphanet J Rare Dis. 2020;15:214. PMID: 32819397 DOI: 10.1186/s13023-020-01491-9
Medline
Kisu I, Iida M, Nakamura K, Banno K, Shiraishi T, Tokuoka A, Yamaguchi K, Tanaka K, Iijima M, Senba H, Matsuda K, Hirao N. Laparoscopic vaginoplasty procedure using a modified peritoneal pull-down technique with uterine strand incision in patients with Mayer-Rokitansky-Küster-Hauser syndrome: Kisu modification. J Clin Med. 2021;10:5510. PMID: 34884214 DOI: 10.3390/jcm10235510
Medline
Martens L, Tannenbaum L, Van Kuijk SMJ, Notten KJB, Kluivers KB. Laparoscopic Davydov vs. laparoscopic Vecchietti neovaginoplasty in women with Mayer-Rokitansky-Küster-Hauser syndrome; a systematic review and meta-analysis. Fertil Steril. 2024;121:679-92. PMID: 38104886 DOI: 10.1016/j.fertnstert.2023.12.015
Medline
Morcel K, Camborieux L, Guerrier D; Programme de Recherches sur les Aplasies Müllériennes. Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome. Orphanet J Rare Dis. 2007;2:13. PMID: 17359527 DOI: 10.1186/1750-1172-2-13
Medline
Samantray SR, Mohapatra I, Harshini N. Laparoscopic Davydov’s colpopoiesis for a case of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. Cureus. 2021;13:e13974. PMID: 33884233 DOI: 10.7759/cureus.13974
Medline
Vitols J, Lidaka L. Davydov vaginoplasty in Mayer-Rokitansky-Küster-Hauser syndrome patient presenting with urethral dilatation. Case Rep Obstet Gynecol. 2024;2024:9498667. PMID: 38962289 DOI: 10.1155/2024/9498667
Medline