Neovaginal Depth Research Articles

The use of peritoneum in female genital gender-affirming surgery: A systematic review

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen.Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty.Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8 cm and width of 3.5 cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty.This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.

(016) SALVAGE VAGINOPLASTY WITH SINGLE-PORT ROBOT ASSISTED TUBULARIZED URACHUS PERITONEAL HINGE FLAP: TECHNIQUE HIGHLIGHTS, OUTCOMES, AND AN EVIDENCE-BASED PROPOSAL FOR HOW AND WHEN TO USE (AND NOT USE!) PERITONEUM WITH VAGINOPLASTY

Abstract Introduction Vaginoplasty is a commonly performed genital gender affirming surgery. Currently there are two published techniques that describe using peritoneal tissue to contribute to the necessary tissue to line the neovaginal canal: The modified Davydov technique, first described in 2019 by Zhao et al, and the Tubularized Urachus-Peritoneal Hinge Flap, described by Garcia et al in 2022. Today many providers use the Davydov technique at time of primary vaginoplasty, while other providers argue that use of peritoneum is not necessary at the time of primary vaginoplasty. We use the urachus flap only for salvage surgery. Objective Herein, we report our technical innovations related to the urachus hinge flap, and our clinical outcomes at 1.5 years post-op. We also review the literature to determine whether there is evidence to support using peritoneum at time of primary vaginoplasty. Methods We review our single-port robot assisted urachus hinge flap technique to augment neovaginal depth after primary vaginoplasty complicated by loss of vaginal depth. We also review technical innovations to maximize neovaginal depth with primary vaginoplasty using only penile and scrotal skin. We present our literature review, and posit a theory that explains why, regardless of PV technique, mean neovaginal depth is 11-13 cm in all series. Results Our mean neovaginal depth after our salvage urachus hinge flap technique is 12.5 cm (range 11-14.2) at 409 days post-op. This is comparable to the Davydov PV technique. With primary vaginoplasty using only penile and scrotal skin, our mean depth is 12.5 cm, which is > other series using only penile/scrotal skn, and comparable to series that also use peritoneum. We use video to show how, with the Davydov technique, rectum and bowel are pulled deep into the pelvis post-op, which increases risk of bowel injury at time of salvage surgery with intestine. Conclusions By the techniques described herein, in our hands, with primary vaginoplasty using only penile and scrotal skin we achieve vaginal depth comparable to techniques that augment with peritoneum. We suggest that peritoneum is rarely to never necessary at primary vaginoplasty, and should be reserved for use as a salvage surgery if and when it is needed. We also suggest that the urachus flap is a safer alternative to the Davydov technique if and when PV fails and salvage intestinal vaginoplasty must be undertaken. Disclosure No.

Evaluation of the Efficacy of Magnetic Resonance Imaging for Feminizing Gender Affirmation Genital Surgery: A Novel Approach.

Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the postoperative anatomical changes in AMAB individuals who underwent GAS using magnetic resonance imaging (MRI) and to compare it with cis-females, thereby assessing the efficacy of the surgical technique in achieving pelvic anatomy similar to cis-females. Methodology This was a prospective observational study done in a tertiary care hospital. AMAB individuals who underwent gender affirmation genital surgery using single-stage solely penile skin inversion vaginoplasty were included after informed consent and approval by the Institutional Human Ethics Committee. Patients with complications such as deep space surgical site infection (SSI) and neo-vaginal prolapse were excluded. All the study participants were advised a vaginal self-dilatation regimen, reviewed three months after the surgery, and subjected to an MRI of the pelvis with a vaginal tutor. Parameters such as neo-vaginal depth, alpha (α) angle, rectovaginal thickness, and remnant of corpora cavernosa were measured and compared with cis-female parameters measured from images in the archives from the Department of Radiology. Result A total of 21 patients were included in the study, with a mean age of 27±4.7. Between the study group and cis-females, no significant difference was seen in vaginal depth, and cis-females had significantly higher values in other parameters. There was a significant difference between the subgroups, i.e., defaulters and non-defaulters in soft tissue parameters such as vaginal depth (p=0.001), αangle (p=0.002), and rectovaginal thickness (p=0.002) with the non-defaulter patients having higher values. Conclusion Single-stage penile skin inversion vaginoplasty is capable of producing anatomical parameters, importantly neo-vaginal depth, which is fairly comparable with cis-female, as evident in the non-defaulter subgroup patients. Proper compliance with the vaginal dilatation regimen plays a significant role in the maintenance of soft tissue pelvic anatomical parameters.

(042) Bilateral Orchiectomy as a Standalone Gender-Affirming Procedure: Does it Compromise Skin Grafts Available for Later Vaginoplasty?

Abstract Introduction Penile inversion vaginoplasty is the gold-standard gender-affirming surgical technique for creating a neovaginal canal. While bilateral simple orchiectomy (BSO) is usually completed at the same time as vaginoplasty, long wait times associated with vaginoplasty have highlighted pre-vaginoplasty BSO as a more immediate opportunity to mitigate gender dysphoria, decrease estrogen dosages, and completely eliminate antiandrogen hormone therapy. The impact of standalone BSO on later vaginoplasty is defined by a single study that associated BSO with a decrease in scrotal skin and a need for extragenital skin grafts-findings that have fueled hesitation around pre-vaginoplasty BSO. Objective To provide a detailed comparison of pre- and intraoperative skin graft measurements and postoperative neovaginal depth between patients who underwent BSO prior to versus concurrent with vaginoplasty. Methods All consecutive patients who underwent penile inversion vaginoplasty at a single institution were identified in a retrospective chart review. Demographic characteristics and the following measurements of vaginoplasty skin grafts were collected and compared between groups: preoperative stretched penile length (measured from base to 1cm proximal to the glans ridge on gentle stretch), preoperative stretched scrotal skin length (measured on gentle stretch in two parts: from the penoscrotal junction to mid scrotum, then from midscrotum to mid perineum), and intraoperative scrotal skin tube length (defined as the amount of scrotal skin that could be harvested and tubularized on a metal dilator (Figure 1A)). Results 57 patients completed penile inversion vaginoplasty between August 2017 and May 2023: 17(30%) completed pre-vaginoplasty BSO and 40(70%) BSO concurrent with vaginoplasty (mean age ± SD = 36.6 ± 12.6y and 37.4 ± 12.8y, p>0.05). Notably, there was no significant difference in length of preoperative scrotal skin or intraoperative tubularized scrotal skin grafts (Figure 1B). While pre-vaginoplasty BSO patients had less neovaginal depth (p<0.05), they also had significantly less preoperative penile skin (p<0.01). Conclusions Contrary to the singular study in the literature, we found no between-group differences in scrotal skin measurements. Furthermore, zero patients required extragenital skin grafts to achieve mean neovaginal depth of 14.4±1.0cm, which approximates the average depth among studies reporting routine use of extragenital skin. Less neovaginal depth amongst BSO patients is expected, as this group had less penile skin available to line the canal. Findings from this study may help address patient and provider fears that BSO decreases scrotal skin available for later vaginoplasty, thereby lessening the decision-making burden of balancing the pros and cons of early BSO. Disclosure No.

(147) Gender-Affirming Bilateral Orchiectomy as a Standalone Procedure: Does it Compromise Skin Grafts Available for Later Vaginoplasty?

Abstract Introduction Gender-affirming penile inversion vaginoplasty is the gold-standard technique for creating a neovaginal canal. While bilateral simple orchiectomy (BSO) is typically completed intraoperatively with vaginoplasty, long wait times associated with vaginoplasty have highlighted pre-vaginoplasty BSO as a more immediate opportunity to mitigate gender dysphoria, decrease estrogen dosages, and completely eliminate antiandrogen hormone therapy. The impact of standalone BSO on later vaginoplasty is defined by a single study that associated BSO with a decrease in scrotal skin and a need for extragenital skin grafts-findings that have fueled hesitation around pre-vaginoplasty BSO. Objective Given that neovaginal depth is dependent on penile and scrotal skin available during vaginoplasty, this study aims to provide a detailed comparison of pre- and intraoperative skin graft measurements and postoperative neovaginal depth between patients who underwent BSO prior to versus concurrent with vaginoplasty. Methods A retrospective chart review identified all consecutive patients who underwent penile inversion vaginoplasty at a single institution. In addition to demographic characteristics, the following measurements of vaginoplasty skin grafts were collected and compared between groups: preoperative stretched penile length (measured from base to 1cm proximal to the glans ridge on gentle stretch), preoperative stretched scrotal skin length (measured on gentle stretch in two parts: from the penoscrotal junction to mid scrotum, then from midscrotum to mid perineum), and intraoperative scrotal skin tube length (defined as the amount of scrotal skin that could be harvested and tubularized on a metal dilator (Figure 1A)). Results A total of 57 patients completed penile inversion vaginoplasty between August 2017 and May 2023: 17(30%) completed pre-vaginoplasty BSO and 40(70%) BSO concurrent with vaginoplasty (mean age ± SD = 36.6 ± 12.6y and 37.4 ± 12.8y, p>0.05). Notably, there was no significant difference in length of preoperative scrotal skin or intraoperative tubularized scrotal skin grafts (Figure 1B). While pre-vaginoplasty BSO patients had less neovaginal depth (p<0.05), they also had significantly less preoperative penile skin (p<0.01). Conclusions Contrary to the previously described study, we found no between-group differences in scrotal skin measurements. Furthermore, zero patients required extragenital skin grafts to achieve mean neovaginal depth of 14.4±1.0cm, which approximates the average depth among studies reporting routine use of extragenital skin. Less neovaginal depth amongst BSO patients is expected, as this group had less penile skin available to line the canal. Findings from this study may help address patient and provider fears that BSO decreases scrotal skin available for later vaginoplasty, thereby lessening the decision-making burden of balancing the pros and cons of early BSO. Disclosure No.

(002) Transfeminine Genital Reconstructive Surgery Complications Based on Insurance Claims Data

Abstract Introduction Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Currently, various vaginoplasty techniques are performed by different surgeons across the United States. Surgical outcomes of individual surgeons and groups have been published in the literature, however complications using an insurance claims database have yet to be reported. Objective Our objective is to present post-vaginoplasty complication rates among surgeons in the United States using a large claims database. Methods A retrospective review was conducted of all transgender women who underwent vaginoplasty using IBM MarketScan insurance claims database between 2011-2020. Baseline patient characteristics, including age, obesity, smoking status, Charlson Comorbidity Index (CCI) and the region the surgery was performed were obtained. Patients were followed after surgery to identify complications. Common surgical complications, such as bleeding/hematoma, wound dehiscence, postsurgical infection, DVT, PE, and MI, and complications specific to gender affirming surgery, such as pelvic pain, dyspareunia, rectal injury, urinary issues, urethral stricture, loss of neovaginal depth, and prolapse, were investigated using ICD-9/ICD-10 and CPT codes. Hazard ratios (HRs) were calculated to determine how baseline factors influenced complications. Results A total of 1588 privately insured patients who underwent vaginoplasty for gender affirmation with 414 different surgeons were identified. The mean age was 34 years (22-53 years), 16% were obese and 8% were smokers. The majority (70%) of patients had a CCI of 0. Overall, at a mean follow-up of 14 months (5-28 months), 66% of patients had a complication. A common surgical complication occurred in 19% of patients and a gender affirming surgery complication occurred in 61% of patients. Among those with a gender affirming surgery complication, 17% had pelvic pain, 3% had dyspareunia, <1% had a rectal injury, 21% had urinary issues, 19% had a urethral stricture, 16% had loss of neovaginal depth and 15% had prolapse. A CCI of 2 had a HR of 1.82 (p=0.004) for a common complication and age had a HR of 1.01 (p<0.001) for a gender affirming complication. Smoking was associated with a statistically significant HR for both common complications and gender affirming complications (1.48 and 1.26, respectively; P<0.05). Conclusions Post-vaginoplasty, the majority of patients have at least one complication based on insurance claims data. All patients should be counseled on smoking cessation prior to surgery to potentially decrease the risk of complications. Disclosure No

MP02-17 COMPLICATIONS FOLLOWING VAGINOPLASTY FOR GENDER AFFIRMATION USING A CLAIMS DATABASE

You have accessJournal of UrologyCME1 Apr 2023MP02-17 COMPLICATIONS FOLLOWING VAGINOPLASTY FOR GENDER AFFIRMATION USING A CLAIMS DATABASE Jessica Schardein, Liem Snyder, Masaya Jimbo, Kevin Hebert, Joshua Horns, Nathan Driggs, Rupam Das, Jeremy Myers, and James Hotaling Jessica SchardeinJessica Schardein More articles by this author , Liem SnyderLiem Snyder More articles by this author , Masaya JimboMasaya Jimbo More articles by this author , Kevin HebertKevin Hebert More articles by this author , Joshua HornsJoshua Horns More articles by this author , Nathan DriggsNathan Driggs More articles by this author , Rupam DasRupam Das More articles by this author , Jeremy MyersJeremy Myers More articles by this author , and James HotalingJames Hotaling More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003213.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Currently, various vaginoplasty techniques are performed by surgeons across the United States. While surgical outcomes have been previously reported by individual surgeons and groups, complications using an insurance claims database have yet to be reported. Our objective is to present complication rates among surgeons using a large claims database. METHODS: A retrospective review was conducted of all transgender women who underwent vaginoplasty using IBM MarketScan claims database between 2011-2020. Baseline patient characteristics such as age, obesity, smoking status, Charlson Comorbidity Index (CCI) and the region surgery was performed were obtained. Patients were followed after surgery to identify complications. Common surgical complications, including bleeding/hematoma, wound dehiscence, postsurgical infection, DVT, PE, and MI, and complications specific to gender affirming surgery, such as rectal injury, urinary issues, urethral stricture, loss of neovaginal depth, and prolapse, were investigated using ICD-9/ICD-10 and CPT codes. Hazard ratios (HRs) were calculated to determine how baseline factors influenced complications. RESULTS: A total of 1588 privately insured patients who underwent vaginoplasty for gender affirmation with 414 different surgeons were identified. Mean age was 34 years (22-53 years), 16% were obese and 8% were smokers. The majority (70%) of patients had a CCI of 0. Overall, at a mean follow-up of 14 months (5-28 months), 66% of patients had a complication. A common surgical complication occurred in 19% and a gender affirming surgery complication occurred in 61%. Among those with a gender affirming surgery complication, <1% had a rectal injury, 21% had urinary issues, 19% had a urethral stricture, 16% had loss of neovaginal depth and 15% had prolapse (Table 1). Smoking was the only factor that was found to have a statistically significant HR for both common and gender affirming complications (1.48 and 1.26, respectively; p<0.05). CONCLUSIONS: Post-vaginoplasty, the majority of patients have at least one complication based on claims data. All patients should be counseled on smoking cessation prior to surgery to potentially decrease the rate of complications. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e18 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jessica Schardein More articles by this author Liem Snyder More articles by this author Masaya Jimbo More articles by this author Kevin Hebert More articles by this author Joshua Horns More articles by this author Nathan Driggs More articles by this author Rupam Das More articles by this author Jeremy Myers More articles by this author James Hotaling More articles by this author Expand All Advertisement PDF downloadLoading ...

Gender-affirming vaginoplasty: Technical considerations in patients with genital skin deficiency.

Gender dysphoria affects over 1 million American adults.Vaginoplasty is a critical step in gender affirmation, and many patients have insufficient genital skin for full-depth penile inversion vaginoplasty (PIV). We reviewed the literature for technical considerations addressing this and present our data supporting the use of peritoneal flaps (Davydov technique). A comprehensive review of modern literature was conducted. Second, we present a retrospective case review of our experience with PIV, including data from procedures utilizing peritoneal flaps. We identified 20 original articles, including retrospective and prospective case and cohort studies. Approaches included the application of local soft tissue grafts and flaps, peritoneal flaps, and intestinal segments. Between June 2018 and February 2021, 47 patients at our institution, underwent PIV for the treatment of gender dysphoria. Nineteen of those patients underwent robotic-assisted peritoneal flap procedure in addition to PIV. In this cohort, the mean follow-up was 200.6 ± 124.8 days. Mean neovaginal depth was 13.1 ± 3.0 cm intra-operatively and 11.0 cm at the last follow-up. Twenty-six percent of complications were Clavien Grade 1 or 2; others included wound dehiscence (30.4%), perianal and urethral fistula (13.0%), and neovaginal stenosis (8.7%). The majority of patients reported satisfactory results in terms of sexual function with intact tactile and erogenous sensation. Almost half were able to have penetrative vaginal intercourse at the last follow-up. We did not aim to perform statistical calculations to compare the outcomes of PIV with and without robotic-assisted peritoneal flap augmentation, as the groups were not constructed in that manner. However, it is evident that anatomical and functional results as well as the distribution of postoperative complications seem similar. Vaginoplasty is indicated in a growing population of patients with a wide range of medical histories and anatomic variations. Genitourinary reconstructive surgeons must have several methods to achieve full-depth vaginoplasty in cases of inadequate genital skin. Peritoneal flaps serve as a versatile, safe, and functionally advantageous solution.

A single pedicled robotic peritoneal flap in penile inversion vaginoplasty augmentation.

To develop a surgical technique to achieve greater depth of the neovaginal cavity in transgender patients undergoing scrotovaginoplasty, and to propose a method for restoring neovaginal integrity in case of lack of genital skin or reduction of the depth due to scarring after infections or ischaemic processes. Eight patients were selected to undergo scrotovaginoplasty with scrotal graft and peritoneal flap augmentation in one operating session as a modification of Zhao's original technique. The age of the patients ranged from 25 to 65 years. The first step of the procedure was standard penile inversion vaginoplasty, avoiding suturing of the superior side of the skin cylinder. The skin cylinder was pushed into the abdominal cavity through the perineal access. Afterwards a laparoscopic/robotic approach was used: a single peritoneal flap was harvested from the posterior bladder surface, incised, dissected, pedicled on the neovaginal dome, overturned and and sutured all-round to the neovagina. The sides were adapted to obtain a 'cul-de-sac'. The average operating time was 6± 1.5 h, and patients' hospitalization lasted 6 days. There were no intra- or postoperative complications. Postoperative management was the same as that usually reported in BJUI for patients undergoing standard scrotovaginoplasty. The use of this technique represents a good solution for increasing neovaginal depth by harvesting a large peritoneal vascularized flap, without significantly affecting postoperative management or increasing complications, as frequently observed using the colovaginoplasty technique.

An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap.

Gender-affirming peritoneal vaginoplasty has been described, and previous descriptions are modifications of the Davydov technique. To describe our alternative technique for gender-affirming peritoneal vaginoplasty (PV) using a single-pedicled, urachus-peritoneal hinge flap, discussing proposed advantages. Retrospective review of all consecutive transfeminine patients with neovaginal shortening after prior penile inversion vaginoplasty (PIV) who underwent our PV technique from May 2019 to July 2022. PV was performed via combined transperineal and laparoscopic (robot-assisted) approaches. After spatulation of the neovaginal remnant, a midline, inferiorly based urachus-peritoneal hinge flap was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The free end of the flap was flipped posteriorly and sutured to posterior edge of the open canal remnant, forming a peritoneal pouch. The lateral edges of the pouch were sutured together for water-tight closure. Patients resumed dilation on POD 6 and douching on POD 10. Ten transfeminine patients underwent PV, with good outcomes. We measured: Pre-op penile and scrotal skin lengths, intra-op tubularized scrotal skin length, pre and post-op vaginal depth and width (immediate and at last follow-up). Pre-op: mean neovaginal depth was 9.2cm (SD 1.5); width was 12cm. Immediate post-op: mean depth was 15.1 cm (SD 2.2 cm, mean net increase: 5.9 cm). At mean follow-up of 18.3 months, mean depth was 12.5 cm (SD 2.1 cm, mean net increase: 3.3 cm) and width was 12 cm. There were no immediate post-op complications. Eight (80%) of the 10 patients report satisfactory vaginal receptive intercourse. The other 2 have not yet attempted vaginal receptive intercourse. Advantages of the proposed technique over existing techniques include no tension on peritoneal suture lines and total exclusion of the rectum. Strengths include a short learning curve for urologic surgeons with robotic experience. The study is limited by small sample size. Our PV technique is a safe and effective option for salvage peritoneal vaginoplasty after primary PIV. Smith SM, Yuan N, Stelmar J, et al. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022;10:100572.

Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty.

No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is important to patients and is determined by available skin and available anatomic space within the pelvis and varies with surgical technique. We endeavored to create a nomogram to predict expected postoperative vaginal depth. Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n=60). Pre-op: Dorsal penile and midline scrotal skin length were measured. Intra-op: Tubularized scrotal skin length measured on a dilator. Immediate post-op: Final vaginal depth measured with a dilator. The amount of available penile and scrotal skin was not associated with vaginal depth. The only variable that did significantly increase depth was the use of penile+scrotal skin, as compared to penile skin alone. (P < .001) RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 ± 1.9 cm) was 87% of pre-op measured penile skin length (15.3 ±- 3.0 cm). In patients who underwent PIV+SS, pre-op penile skin length was 11.1 ± 4.7±cm and pre-op midline scrotal length was 22.8 ± 2.6 cm. with a final post-op vaginal canal depth of 15.2 ± 1.3 cm. In 45/46 (98%) surgeries utilizing SS grafts, SS tube length exceeded the length necessary to achieve maximal vaginal depth, and required trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be surgically dissected, and was not limited by the amount of available skin. Our findings suggest that for most patients it should not be necessary to include additional tissue sources (eg, peritoneum) to create a vaginal canal during primary vaginoplasty. Any penile skin that was discarded due to poor quality (eg, tight phimosis, poor viability) was not measured and accounted for. This likely resulted in a slight overestimation of the contribution of the penile skin to the final vaginal depth, but did not change the overall finding that final depth was not limited by available skin. SS grafts, when harvested and tubularized using optimized technique, supplied an excess of skin necessary to line a vaginal canal space of maximal achievable depth. We found that additional tissue sources can, instead, be reserved for future salvage surgery if it becomes necessary to augment depth. Smith SM, Yuan N, Stelmar J, et al. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022;10:100569.

Three cases utilizing the Hidden Incision Endoscopic Surgery approach to port placement during penile inversion vaginoplasty utilizing a peritoneal flap

Younger transgender patients undergoing penile inversion vaginoplasty (PIV) after pubertal suppression often require modified techniques to augment neovaginal tissue. Peritoneal flap vaginoplasty (PFV) is a well-established technique for improving neovaginal depth. Utilizing a Hidden Incision Endoscopic Surgery (HIdES) approach to port placement improves cosmetic outcomes of this identity-affirming procedure. This video shows the efficacy of the HIdES port placement configuration on the daVinci robot for peritoneal flap creation and closure during PIV using the modified laparoscopic Davydov procedure. Three young adult transgender females who had not undergone laser hair removal/epilation underwent PIV with robotic PFV utilizing HIdES port placement. The anterior superior iliac spine (ASIS) was demarcated bilaterally, and ports were placed at or below these lines. Two surgical teams, external genitoplasty and internal peritoneal flap closure via daVinci Xi robot, worked simultaneously. All patients underwent successful robotic assisted PIV with HIdES port placement. All patients had similar postoperative courses of return of bowel function with flatus on postoperative day (POD) 2, vaginal dressing, urethral catheter removal, and initiation of vaginal dilation on POD 5-6, and hospital discharge between POD 5-8. We present our initial experience with robotic/laparoscopic PFV using a hidden incision approach. This technique allows for excellent neovaginal depth with improved abdominal wound aesthetics.

An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap

ABSTRACT Introduction Peritoneal vaginoplasty (PV) has been reported for congenital and primary gender-affirming cases, but few have reported its use as secondary vaginoplasty to treat post-op neovaginal canal shortening after penile-inversion vaginoplasty (PIV). Recent adaptations of PV have been modifications of the Davydov procedure, wherein peritoneum adherent to the bladder and rectum are incorporated to line the new terminal apex of the vaginal canal. Objective We describe our alternative technique using a urachus-peritoneal hinge flap and discuss proposed advantages. Methods We performed retrospective review of all trans-female patients who underwent our PV technique for revision/salvage vaginoplasty from May 2019 to August 2020 (minimum 10 months follow-up). Patients were asked questions about their experience and satisfaction. All cases were performed via combined trans-perineal and laparoscopic (robot-assisted) approaches. Pre-op and post-op neovaginal depth/circumference were recorded. After incision and spatulation of the terminal neovagina, a midline, inferiorly based peritoneal hinge flap (minimum 8-cm width) was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The flap's free end was flipped posteriorly and sutured to the posterior edge of the open canal remnant to form a peritoneum-lined pouch. The pouch's lateral edges were sutured together, using a vaginal dilator as a guide. Results Five patients underwent peritoneal vaginoplasty with our technique from 5/2019 to 8/2020. Mean age was 32. All previously underwent PIV for primary vaginoplasty, with loss of neovaginal depth. Pre-op: mean neovaginal depth was 8.6 (±1.8) cm and girth was 12 cm. Immediate post-op: mean depth was 16.8 (±1.2) cm (mean net increase from pre-op: 8.2 cm) and girth was 12 cm. At mean follow-up of 1.4 years, mean depth was 12.8 (±2.4) cm (mean net increase from pre-op: 4.2 cm) and girth was 12 cm. There were no immediate complications. One patient developed anastomotic stenosis at 6 weeks post-op, managed conservatively with dilation under anesthesia. One patient stopped dilating due to a mental-health crisis and lost significant postoperative depth. Three of the 5 (60%) patients report satisfactory vaginal receptive intercourse. The other 2 have not yet attempted vaginal receptive intercourse. Conclusions Our PV vaginoplasty technique is a safe and effective option to treat neovaginal shortening after PIV. Advantages include no tension on peritoneal suture lines when vaginal canal is empty and total exclusion of the rectum. This technique also allows for omental interposition. We recognize the natural limited availability of peritoneum and so reserve this technique only for cases where there is adequate residual canal girth and at least 6-7 cm of residual depth. Disclosure No

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review.

Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the "Y" shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9-13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien-Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis

A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed. After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%-2%] of fistula, 11% (95% CI 8%-14%) of stenosis and/or strictures, 4% (95% CI 1%-9%) of tissue necrosis, and 3% (95% CI 1%-4%) of prolapse. Overall satisfaction was 91% (81%-98%). Regret rate was 2% (95% CI <1%-3%). Average neovaginal depth was 9.4 cm (7.9-10.9 cm) for the penile skin inversion and 15.3 cm (13.8-16.7 cm) for the intestinal vaginoplasty. Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

Gender affirmation surgeries in transgender women: Aesthetic, sexual, and urinary results of an initial series of vaginoplasties

Introduction and objectivesGender dysphoria is associated with mental health comorbidity, such as depression and suicide. “Gender affirming surgeries” improve sexuality and psychosocial well-being. The goal of vaginoplasty is for the genitalia to resemble in form and function to a biological vagina with a depth of at least 11 cm and a sensitive clitoris. In addition, the urethra must be shortened and allow voiding in a sitting position. Our objective is to describe the aesthetic, sexual and urinary results. Patients and methodRetrospective study of all patients undergoing feminizing genitoplasty, at Hospital Sótero del Río between 2018 and 2019, that met WPATH requirements. Vaginal dimensions, neo-clitoral sensitivity, aesthetic and sexual satisfaction of the neovagina, questionnaires Female Sexual Function Index (FSFI) and the Female Genital Self-Image Scale (FGSIS), IPSS-QoL, uroflowmetry and post-void residue were evaluated. Results10 women who underwent feminizing genitoplasty were identified. The neovaginal depth average was 14.2 cm. There was no rectal injury or reoperation. There was 100% of Neoclitoris sensitivity and 88% satisfaction with the neovaginal width.The FGSIS averaged 25.4 points and the FSFI averaged 16 points. The IPSS was 6.7 points, the average Qmax was 22 ml/s and post-void residual volume average was 22 ml. There was no neomeatal stenosis. ConclusionsFeminizing Genitoplasty is a complex, demanding and not completely standardized surgery. However, it is a relatively safe procedure that achieves adequate aesthetic, sexual and urinary results.

A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes

BackgroundVaginoplasty is a crucial part of genital gender-affirming surgery with the number of trans women undergoing this intervention steadily, however, up to date, there is still no standardized vaginoplasty technique. AimThis retrospective single-center study compares single-stage vs two-stage penile skin inversion vaginoplasty techniques and their long-term outcomes. MethodsMedical records of 63 consecutive patients who underwent single-stage vaginoplasty, as described by Dr Preecha Tiewtranon, and 62 consecutive patients who underwent 2-stage vaginoplasty were reviewed. ResultsThe mean postoperative hospital stay was 7 days for patients who underwent single-stage vaginoplasty vs 16 days for patients who underwent 2-stage vaginoplasty. Neovaginal depth proved constant in patients who underwent single-stage vaginoplasty, whereas a loss of more than 30% was observed in patients who underwent 2-stage vaginoplasty during the first postoperative year. Early complications were more common than late-onset complications in both groups. The most common complication in the single-stage group was wound dehiscence (4.8%). There were significantly more complications in 2-stage collective, among which wound dehiscence (33.9%), unsatisfactory cosmetic outcome (25.8%), and urethral stenosis (14.5%) were the most common. In the single-stage cohort, 4 (6.4%) patients needed one revision surgery, whereas 35 (56.5%) patients in the 2-stage cohort necessitated one or more reoperations with up to 10 quaternary revisions. All patients reported to have sensitivity to neoclitoris in the single-stage group, whereas 3 (4.8%) patients in the 2-stage group were deprived of it because of neoclitoral necrosis. Clinical ImplicationsOptimizing a vaginoplasty surgical technique and its postoperative protocol. Strengths & LimitationsThe present retrospective study with a mean follow-up of more than 3.5 years offers the first ever comparison of 2 different PSI vaginoplasty surgical techniques performed in the same center. ConclusionSignificantly lower complication and revision rates, shorter recovery time, and superior esthetic and functional outcomes were observed in the single-stage than in the two-stage penile skin inversion vaginoplasty surgical technique.Fakin RM, Giovanoli P. A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes. J Sex Med 2021;18:391–399.

Cirugías de afirmación de género en mujeres trans: resultados estéticos, sexuales y urinarios de una serie inicial de vaginoplastias

Introduction and objectivesGender dysphoria is associated with mental health comorbidity, such as depression and suicide. “Gender affirming surgeries” improve sexuality and psychosocial well-being. The goal of vaginoplasty is for the genitalia to resemble in form and function to a biological vagina with a depth of at least 11 cm and a sensitive clitoris. In addition, the urethra must be shortened and allow voiding in a sitting position. Our objective is to describe the aesthetic, sexual and urinary results. Patients and methodRetrospective study of all patients undergoing feminizing genitoplasty, at Hospital Sótero del Río between 2018 and 2019, that met WPATH requirements. Vaginal dimensions, neo-clitoral sensitivity, aesthetic and sexual satisfaction of the neovagina, questionnaires Female Sexual Function Index (FSFI) and the Female Genital Self-Image Scale (FGSIS), IPSS-QoL, uroflowmetry and post-void residue were evaluated. Results10 women who underwent feminizing genitoplasty were identified. The neovaginal depth average was 14.2 cm. There was no rectal injury or reoperation. There was 100% of Neoclitoris sensitivity and 88% satisfaction with the neovaginal width.The FGSIS averaged 25.4 points and the FSFI averaged 16 points. The IPSS was 6.7 points, the average Qmax was 22 ml/s and post-void residual volume average was 22 ml. There was no neomeatal stenosis. ConclusionsFeminizing Genitoplasty is a complex, demanding and not completely standardized surgery. However, it is a relatively safe procedure that achieves adequate aesthetic, sexual and urinary results.

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

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.