Ontogenetic anatomy of the distal vagina: Relevance for local tumor spread and implications for cancer surgery

ObjectiveWe have suggested to base cancer surgery on ontogenetic anatomy and the compartment theory of tumor permeation in order to improve local tumor control and to lower treatment-related morbidity. Following the validation of this concept for the uterine cervix, proximal vagina and vulva, this study explores its applicability for the distal vagina.MethodsSerial transverse sections of female embryos and fetuses aged 8–17 weeks were assessed for the morphological changes in the region defined by the deep urogenital sinus–vaginal plate complex. Histopathological pattern analysis of local tumor spread was performed with carcinomas of the lower genital tract involving the distal vagina to test the compartment theory.ResultsOntogenetically, the female urethra, urethrovaginal septum, distal vagina and rectovaginal septum represent a morphogenetic unit derived from the deep urogenital sinus–vaginal plate complex. Herein, the posterior urethra, the urethrovaginal septum and the distal vagina form a distinct subcompartment differentiated from the dorsal wall of the urogenital sinus. From 150 consecutive patients with distal vaginectomy as part of their surgical treatment 26 carcinomas of the lower genital tract had infiltrated the distal vagina. All 22 tumors involving the ventral wall invaded the urethra/periurethral tissue. Of the five carcinomas involving the dorsal wall none invaded the rectum/mesorectum.ConclusionThe pattern of local tumor permeation of lower genital tract cancer in the distal vagina can be consistently explained with ontogenetic anatomy and the compartment theory.

Research highlights
► The distal vagina and female urethra are directly derived from a common precursor tissue.
► (Peri-)urethral infiltration has to be expected in gynecologic cancers involving the distal anterior vagina.