Mayer-Rokitansky-Kuster-Hauser Syndrome (MRKH) is characterized by the absence of a vagina and variable uterine growth in women with a normal phenotype and 46 XX karyotype due to the defect in the development of the Müllerian duct.                                                               The incidence of this syndrome is estimated to be 1 in 4000 to 5000 females.                     Patients typically present with primary amenorrhea in adolescence with normal growth and development. Sexual intercourse and infertility are also problematic.                       Transabdominal ultrasonography is a simple and noninvasive method, and must be the first investigation in evaluating patients with suspected Mullerian aplasia. Ultrasonography examination confirms kidneys, presence of the ovaries, and absence of uterus. MRI is a non-invasive technique that provides a more sensitive and more specific means of diagnosis when   Ultrasonography is not complete.                                                                                               The management of vaginal agenesis associated with MRKH syndrome is extremely difficult because the women's physical and psychological well-being are affected. Several approaches have been reported in order to improve the results of creating an artificial vagina, including non-operative ones like progressive dilatation and surgical ones like skin transplants, myocutaneous transplants, intestine graft and epithelialization from the outer layer of the skin). Yet there isn't a typical treatment available right now.  There is currently no proper treatment for patients with MRKH condition, despite the fact that a number of surgical procedures have been documented for establishing a neovagina. The purpose of this study was to evaluate the anatomical and functional results following the use of peritoneal graft for constructing a neovagina.

We conducted a retrospective study on 26 patients with vaginal agenesis Between February 2012 and March 2022, who had surgery in the urogynecology department of a tertiary hospital.
Due to the patient's unwillingness or lack of success in using dilation, it was decided to perform surgery for the patients. Patients' informed consent and local ethics agreement were obtained (IR.TBZMED.REC.1401.968). The surgeon identified vaginal agenesis as a symptom of the Mayer-Rokitansky-Küster-Hauser syndrome in all patients with amenorrhea. pelvic ultrasound were performed on all cases. 
Technique of Operetion:
The surgeon made a 2-cm transverse incision in the vaginal vestibulum to make a vaginal space between the bladder and the rectum. Then moved up to the pouch of Douglas with sharp and blunt dissection between the bladder and rectum. At the same time laparotomy was performed by second surgeon. The strand connecting the bilateral rudimental uterine horns was lifted forward and the peritoneum of posterior cul de sac was incised transversely. 4 locations were sutured with 2-0 Vicryl, and the peritoneal margins were pulled down and attached to the edge of the incised vaginal vestibulum. The apical portion of the neovagina closed using purse-string suture and a dilator (±mold) was inserted into neovagina for one week then several tlmes a day for 3 to 6 monthes.
 Postoperative assessment:
Following surgery, all patients were evaluated at 1, 3, and 12 months. The neovagina's width, length, granulation tissue, and stenosis were all measured and reported at each follow-up appointment. The achievement of anatomical and functional success was the main result. A neovagina that was anatomically successful within six months of surgery was one in which two fingers could be inserted with ease and that was longer than six centimeters. Functional success was deemed to have occurred when the patient was content with their sexual performance six months after surgery. The Female Sexual Function Index was used to evaluate functional outcomes (FSFI). At one year following surgery, patients who had started engaging in sexual activity completed the FSFI questionnaire.

26 patients with complete vaginal agenesis between February 2012 and march 2022, who had surgery in the urogynecology department of a tertiary hospital were evaluated. The mean age of the patients was 28.11± 7.71 years at surgery (minimum 19 years and maximum 45 years).The total average neo-vaginal length of the women was 7.76 ± 1.55 cm (minimum 3 cm and maximum 10 cm) with at least two finger in width, after 3 months post-surgery. No bladder injury occurred. In one woman, a rectovaginal fistula occurred because of wrong insertion of dilator in the vagina by patient. One case had granulation tissue at the second follow-up with massive hemorrhage. In addition, two stenosis due to the disruption using the mold, and unmarriage  status were happened. In terms of FSFI scoring, the results of this questionnaire domain showed that the mean (SD) desire score was 4.39 ± 1.13, arousal score was 4.66 ± 1.17, lubrication was 3.58 ± 0.31, orgasm score was 3.95 ± 0.49, satisfaction was 4.86 ± 1.33, and pain score 1.95 ± 0.60. The results emphasized that that 65.5 % of women had acceptable sexual function according to the FSFI scores.

We did 26 vaginoplasty using peritoneal graft. A mini laparatomy was done to access posterior cul de sac for peritoneal graft. Neovagina was created and covered by the cul de sac peritoneum.
We didn’t have any significant complication regarding to surgery. One rectovaginal fistula generated because of dilator pressure after 2 months that closed spontaneously. One vaginal hemorrhage accrued during dilator exchange and controlled by packing in second month after surgery. All patients had a vagina longer than 6 cm except one case (3 cm) and all patients that had partner, was sexual active. 65.5 % of women had acceptable sexual function and could be improved if psychological aspects of these women considered and managed in the right way.

MRKH syndrome has a devastating impact on a young woman’s emotional well-being and QoL, not only at the time of diagnosis but also during the miserable treatment process.
The goal of any method is to create a vaginal canal to accommodate sexual intercourse. Hence, both sexual function and QoL outcomes should be given full consideration to evaluate whether a certain treatment is ideal .
The vaginal dilation should be the first therapy advised for these patients, because all other therapies have a higher risk of complications.
If the non-surgical method is not possible or does not lead to a functional vagina, the surgical method according to Peritoneal graft is a safe , effective and minimally invasive technique to create a physiologically normal functioning vagina comparing to other surgical methods.
For example vaginoplasty using intestine, creating a neovagina with sufficient length, but  it is associated with complications such as colitis and adenocarcinoma, as well as intestinal mucous secretions.

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