A Systematic Review of Primary Vaginoplasty Techniques and Outcomes in the Male-to-Female Transgender Population: A Call to Action

Abstract

PURPOSE: Primary vaginoplasty is an integral aspect of male-to-female (MtF) transgender surgery. Surgical techniques vary and outcomes, such as vaginal depth, complications, and patient-reported outcome measures (PROMs) are reported inconsistently. We aim to provide a synopsis of vaginoplasty technique variations and evaluation of outcomes. METHODS: A multi-database (EMBASE, Ovid, PubMed, and Web of Science) search (2008–2019) was performed using a search strategy executed with MeSH terms and keywords such as neovagina, vaginoplasty, and transgender. Studies describing primary MtF vaginoplasty that sufficiently detailed surgical technique and reported surgical outcomes and/or PROMs were selected. RESULTS: Twenty-three studies were included; 16 described unique populations representing 2021 MtF patients. Inversion vaginoplasty was performed in 96.6% of patients (n = 1952). Sixty-nine patients underwent intestinal vaginoplasty. Average length of admission was 8.5 days (range, 5.7–12.5 days). Average follow-up was 49.8 months (range, 6–92 months). Average vaginal depth achieved was 11.7 cm (range, 9.8–15 cm) with inversion vaginoplasty (n = 513) and 15.3 cm (range 12–16.3 cm) with intestinal vaginoplasty (n = 54). Neovagina was constructed with inversion flap only (69.8%), or augmented with full thickness skin graft (18.6%), spatulated urethra (9.5%), or both (2.0%). For intestinal vaginoplasty, either sigmoid (78.3%) or transverse (21.7%) colon was utilized. The most common complications were wound dehiscence after inversion vaginoplasty (19.2%) and introitus stricture after intestinal vaginoplasty (13.0%). Sixteen studies included PROMs. The most commonly utilized validated PROMs for sexual function were the Female Genital Self-Image Scale and Female Sexual Function Index. Patient satisfaction was high (88.7% inversion, 77.6% intestinal) while regret was low (1.0%). Rates of penetrative intercourse were similar (62.5% inversion, 51.2% intestinal). The majority of patients were able to achieve orgasm (74.5% inversion, 84.0% intestinal). CONCLUSIONS: Inversion vaginoplasty remains the most common method for neovagina creation. Utilization of adjunct tissue to augment neovaginal depth is more common, which correlates with increasing use of early hormonal therapy. Despite high satisfaction after primary vaginoplasty, standardized reporting of surgical complications and PROMs remains poor. Standardization of the way surgeons evaluate outcomes is critical to establish evidence-based guidelines for this surgical procedure.