Penile Inversion Vaginoplasty Research Articles

Enhanced Recovery Protocol Decreases Postoperative Opioid Use after Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) entails considerable soft-tissue dissection to the perineal region and involves complex tissue rearrangement. This study examines the role of an enhanced recovery after surgery (ERAS) pathway after PIV in reducing opioid use and controlling postoperative pain. A retrospective study of 50 transfemale patients who underwent PIV at a single institution from June 2021 to January 2023 was completed. The study compared 2 groups of patients who were given different postoperative pain management regimens: group A received standard postoperative analgesics and group B received ERAS. Variables such as postoperative pain scores on the numeric pain rating scale (0-10), use of opioid medication, length of hospital stay, and patient comorbidities were recorded and compared across the 2 groups. The average hospital stay length was 4.92 (±0.85) days. Group A had a slightly longer average stay compared with group B. The average pain level in both groups was 4.25 (SD ±1.51). Group A exhibited a slightly higher average pain level of 4.31 (±1.53), whereas group B exhibited 4.16 (SD±1.51) (P = 0.77). Although pain levels did not significantly vary between the 2 groups, there was a statistically significant decrease in the amount of opioid medication used in group B with a P value of 0.009. ERAS protocol is effective in decreasing opioid usage in the immediate postoperative setting after PIV.

Penile Inversion Vaginoplasty: An Evolving Technique.

Penile inversion vaginoplasty (PIV) is the most common surgical technique used in "gender-affirming bottom surgery." During this process, penile tissue is used to create a functional neo-vagina, allowing the individual to experience a more aligned physical manifestation of their "gender" identity. In this technical note, we describe the steps and nuances used by the senior author to ensure reliable aesthetic and functional outcomes, contributing to the overall well-being and satisfaction of transgender patients.

Individually customized gender affirming genital procedures: techniques and considerations.

Gender-affirming surgery is being increasingly performed for transgender and gender-diverse individuals diagnosed with gender dysphoria. However, there is a group of patients who may seek outcomes that are either a combination of or altogether different from those of binary procedures such as penile inversion vaginoplasty or phalloplasty. We describe surgical techniques for less commonly performed gender-affirming genital procedures, in order to introduce these procedures to the medical and surgical community. Operative techniques for phallus-preserving vaginoplasty, vagina-preserving phalloplasty, and removal of genitalia with creation of perineal urethrostomy are described. Demographic characteristics and complications of these procedures in 16 patients are reported. Individually customized gender-affirming genital procedures, such as phallus-preserving vaginoplasty, vaginal-preserving phalloplasty, and removal of genitalia and creation of perineal urethrostomy, may better affirm the identities of some gender-diverse patients, and may also preserve desired sexual function of natal genitalia.

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.

Reply to Editorial Comment on “Rectal Injury During Penile Inversion Vaginoplasty”

Reply to Editorial Comment on “Rectal Injury During Penile Inversion Vaginoplasty”

The lived experiences of transgender and gender-diverse people in accessing publicly funded penile-inversion vaginoplasty in Canada.

Canada's health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. We used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women's College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen's framework of lived body, lived time, lived space, and lived human relations. We interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women (n = 13) and White (n = 14). Participants lived in rural (n = 4), suburban (n = 5), or urban (n = 6) locations. Their median age was 32 (range 27-67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples' lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants' intersecting identities and emotional pain (lived body); participants' experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants' understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants' experiences of loss of trust and connection (lived human relations). Our findings reveal TGD patients' lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes.

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

Rectal Injury During Penile Inversion Vaginoplasty

ObjectiveTo evaluate the incidence, management and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. MethodsWe performed a retrospective review of pre-operative, intra-operative and post-operative findings of all patients with RI during GAV from January 2016-September 2022. Descriptive statistics were calculated using Microsoft Excel. ResultsRI occurred in nine of 1011 primary GAV and colorectal surgery (CRS) consulted in five cases, which included sigmoidoscopy with an air leak test in four and with temporary bowel diversion in two. Of the nine, six proceeded with full depth GAV, and three were converted to minimal depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full depth GAV developed vaginal stenosis postoperatively. ConclusionsRI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full depth GAV. It is reasonable to complete the full depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Editorial Comment on “Rectal Injury During Penile Inversion Vaginoplasty”

Editorial Comment on “Rectal Injury During Penile Inversion Vaginoplasty”

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.

D147. Cost Effectiveness of Incisional Negative Pressure Wound Therapy in Penile Inversion Vaginoplasty

D147. Cost Effectiveness of Incisional Negative Pressure Wound Therapy in Penile Inversion Vaginoplasty

Role of allogeneic placental tissues in penile inversion vaginoplasty

Role of allogeneic placental tissues in penile inversion vaginoplasty

(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.

Barriers to Completing Preoperative Hair Removal for Penile Inversion Vaginoplasty.

Penile inversion vaginoplasty (PIV) is a gender-affirming surgical procedure where the skin of the penis and scrotum is reconstructed into the neovaginal lining. To prevent hair-bearing skin from becoming incorporated into the neovaginal canal, transgender patients are encouraged to undergo hair removal of their external genitalia. The goal of this preoperative hair removal is to minimize the risk of potential hair-related complications after vaginoplasty. To better support patients seeking preoperative hair removal and identify current treatment barriers, we surveyed patients about their progress and satisfaction with hair removal. A cross-sectional survey was constructed to assess patient experiences with hair removal in advance of PIV. Sixty-seven patients met the inclusion criteria, of which 46 participated (68.7%). Both laser hair removal (LHR) and electrolysis were used. Although all patients had completed some preoperative hair removal at the time of survey (average of 14 sessions), the cohort completed only two-thirds of their total expected hair clearance. Multiple peri-procedural pain management therapies were employed, but overall satisfaction with pain management was low (57.4 ± 5.0 out of 100). LHR was associated with significantly lower procedural pain compared to electrolysis (p < .001). The average global satisfaction with the hair removal process was 57.9 ± 5.7 and incidents of mistreatment were associated with a statistically significant reduction in overall satisfaction (p = .02). Most patients felt that hair removal was important prior to surgery. Overall, LHR and electrolysis were both utilized as effective preoperative hair removal modalities; however, LHR has better pain tolerability than electrolysis.

Vaginal Stenosis After Gender-affirming Vaginoplasty: A Systematic Review

To review the literature and report the incidence of vaginal stenosis (VS) after vaginoplasty and compare the incidence rates by surgical technique and follow-up duration. We performed a systematic literature review according to PRISMA guidelines. Original research on primary vaginoplasty was included. Exclusion criteria included non-English studies, mixed cohorts without subgroup analysis, revision vaginoplasty, and papers without stenosis rates. The search was ran in Pubmed, Embase, Scopus, and Cochrane on September 9, 2022. Stenosis rates were compared with descriptive statistics using SPSS. Fifty-nine studies with a cumulative 7338 subjects were included. The overall incidence of VS was 5.83% (range 0%-34.2%). Combining VS with introital stenosis (IS) and contracture results in a cumulative incidence of 9.68%. The rate of VS in the penile inversion vaginoplasty subgroup (PIV) was 5.70%, compared to 0.20% in primary intestinal vaginoplasty. The rate of IS in the PIV group was 3.13% and 4.7% in the intestinal vaginoplasty subgroup. The overall rate of VS was 5.83%, which is lower than previously documented. This may be related to the inclusion of more recent studies and analysis limited to primary vaginoplasty. The similar rate of IS in PIV and intestinal vaginoplasty subgroups may be secondary to multiple suture lines and the need for dilation through this anastomosis. Our research demonstrates a need for a standardized definition of VS.

(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&amp;gt;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&amp;lt;0.05), they also had significantly less preoperative penile skin (p&amp;lt;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.

Hypergranulation management following penile inversion vaginoplasty.

To summarize current knowledge regarding management of hypergranulation in the context of gender-affirming vaginoplasty. There have been no studies to date examining hypergranulation treatment options following vaginoplasty. Evidence from the literature on this complication in other settings and the opinions of authorities and experts in this area were used to inform this review. Hypergranulation is a common complication of vaginoplasty, but many care providers may not know how to identify or treat it. This short report will review hypergranulation after vaginoplasty, including risk factors, identification, and treatment options such as douching, silver nitrate, and topical steroids. By increasing clinicians' knowledge of this pervasive complication, patients' postsurgical care and outcomes can be improved.

Neovaginal Healing after Penile Inversion Vaginoplasty with Full-Thickness Skin Grafting in Transwomen: A Descriptive Study

In 1956, Dr. Georges Burou independently developed the anteriorly pedicled penile skin inversion vaginoplasty, a technique that would later become the gold standard

Follow-up results of the “modified” penile inversion vaginoplasty technique

Follow-up results of the “modified” penile inversion vaginoplasty technique

The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series

Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47±13.5 years, and the body mass index mean was 31±4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89±1.76 and the time to first revision mean was 15.89±14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48±8.66 months. A mean of 6.77±5.35cm was gained after the Integra® revision (4.92±4.1cm before versus 12.54±3.07cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34±4.65cm. Overall, the depth gain mean was 7.48±5.77cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.