Vaginoplasty Technique Research Articles

Laparoscopic Technique for Peritoneal Pull-Through Vaginoplasty in the Transfeminine Patients

Laparoscopic Technique for Peritoneal Pull-Through Vaginoplasty in the Transfeminine Patients

Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty.

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

The Effect of Obesity on Vaginoplasty Outcomes.

Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.

Histological Features of Neovaginal Epithelium after Vaginoplasty in Mayer-Rokitansky-Küster-Hauser Syndrome

To analyze the features of the epithelia coating neovaginas after vaginoplasty in women affected by Mayer-Rokitansky-Küster-Hauser syndrome STUDY DESIGN: We conducted a retrospective analysis of prospectively collected data. Women affected by Rokitansky syndrome who underwent neovaginal biopsy after vaginoplasty (McIndoe surgery, intestinal vaginoplasty, Vecchietti surgery, and Davydov surgery) were included. Macroscopic mucosal features were assessed through clinical examination and the Schilling test. Each biopsy specimen was prepared for examination by light microscopy and in some cases by scanning electron microscopy (SEM). Thirty-six patients (4 McIndoe, 2 intestinal vaginoplasty, 14 Vecchietti, and 16 Davydov) were included. All biopsies were performed without complications. In McIndoe's neovaginas, the mucosal microscopic features were similar to normal skin, with large areas of preserved epithelium, heterogeneous presence of dermal papillae, and superficial keratinization. The characteristics of the intestinal neovagina's surface were similar to those of a sigmoid colon, with well-shaped glands, cylindrical cells, and a secreting mucosa. In Vecchietti neovaginas, the surface the epithelium was flat and multilayered, highly similar to that of a normal vagina, with the presence of glycogen and superficial desquamation. On medium SEM magnification evaluation, the epithelium presented flattened polygonal cells. Finally, in Davydov neovaginas, none of the specimens had persistent mesothelial elements. The squamous neo-epithelium had regular aspects of differentiation with the presence of glycogen. At greater SEM magnification, microridges were evident, with a regular distribution. Each different technique of vaginoplasty leads to unique histological and structural features of the neovagina's mucosa. Knowledge of these elements must be the basis for the choice of the most appropriate intervention.

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

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

(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, &amp;lt;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&amp;lt;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&amp;lt;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

V09-02 ROBOTIC PERITONEAL FLAP VAGINOPLASTY FOR VAGINAL HYPOPLASIA AND AGENESIS

You have accessJournal of UrologyCME1 Apr 2023V09-02 ROBOTIC PERITONEAL FLAP VAGINOPLASTY FOR VAGINAL HYPOPLASIA AND AGENESIS Dora Jericevic Schwartz, Ashley Alford, Benjamin M Brucker, and Lee C Zhao Dora Jericevic SchwartzDora Jericevic Schwartz More articles by this author , Ashley AlfordAshley Alford More articles by this author , Benjamin M BruckerBenjamin M Brucker More articles by this author , and Lee C ZhaoLee C Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Congenital anomalies of the vagina including vaginal agenesis and hypoplasia can pose a reconstructive challenge. Vaginoplasty techniques using skin grafts, flaps, intestine and peritoneum have been described. Most recently, vaginoplasty techniques have been applied to gender-affirming surgery. In cases where revision is warranted, peritoneal flaps have proven to be efficacious for augmenting the neovaginal canal. Our reconstructive technique, outlined here, is a laparoscopic robotically-assisted adaptation of the techniques we apply in our gender-affirming surgeries. METHODS: We show the procedure on a 36 year old female with mixed gonadal dysgenesis (46 XY/XO) and vaginal agenesis who presents with vaginal stenosis after ileal vaginoplasty in 2010. After exam under anesthesia and genitogram to delineate the patient’s anatomy, the plan was to create a continuous opening between the patient's vaginal remnant and the ileal vagina to relieve the vaginal stenosis. In the setting of significant adhesions from prior pelvic surgeries, the da Vinci Single Port (SP)® dissection was facilitated externally through the use of vaginoscopy, vaginal dilators and a second surgeon to perform the distal most aspect of the anastomosis at the genital hiatus. Colpopexy was performed to fix the neovagina into the proper position between the bladder and rectum. Closure of the neovaginal vault was achieved through the use of peritoneal flaps. RESULTS: This procedure has been performed in 4 cisgender patients to date, 2 of whom had prior failed vaginoplasty attempt(s). The other 2 patients underwent robotic vaginoplasty with placement of biologic implant (AlloDermTM) in addition to the use of peritoneal flaps. All 4 patients were patent at last followup. None have required further procedures. CONCLUSIONS: Peritoneal flap vaginoplasty is an established gender-affirming surgery technique. Here we demonstrate that it is also a good surgical option for cisgender women with congenital vaginal agenesis, many of whom may have failed prior vaginoplasty attempts. The result is a well-vascularized neovagina without the morbidity of intestinal harvest or the need for skin flaps or grafts. Our technique using the robotic SP platform facilitates low morbidity, excellent cosmesis and expedient recovery. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e837 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dora Jericevic Schwartz More articles by this author Ashley Alford More articles by this author Benjamin M Brucker More articles by this author Lee C Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

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 ...

PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES

You have accessJournal of UrologyCME1 Apr 2023PD12-09 OUTCOMES OF 429 PRIMARY ROBOTIC PERITONEAL FLAP GENDER AFFIRMING VAGINOPLASTY CASES Gaines Blasdel, Charles Dubach-Reinhold, Elijah Castle, Rachel Bluebond-Langner, and Lee Zhao Gaines BlasdelGaines Blasdel More articles by this author , Charles Dubach-ReinholdCharles Dubach-Reinhold More articles by this author , Elijah CastleElijah Castle More articles by this author , Rachel Bluebond-LangnerRachel Bluebond-Langner More articles by this author , and Lee ZhaoLee Zhao More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003259.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Gender affirming robotic peritoneal flap vaginoplasty is a promising adaptation of established vaginoplasty techniques that has been performed since 2017. We report perioperative factors and patient reported outcomes for all consecutive cases at one center. METHODS: Records of patients undergoing primary robotic peritoneal flap gender affirming vaginoplasty with the senior authors from 9/2017-8/2022 were retrospectively reviewed. Operative time, length of stay, complications, self-report of orgasm and dilation, and date of last follow up were recorded for all patients. Clavien-Dindo grading for severity of complications were organized according to occurrence prior or after 90 days postoperatively. For outcomes with incidence greater than 5%, statistical analysis for change over years was performed using nonparametric tests. RESULTS :Primary robotic peritoneal flap gender affirming vaginoplasty was performed on 429 patients with median follow up of 369 days (interquartile range 186-607). Of these, 413 patients (96%) had 90 day or longer follow up and 16 (4%) had a Clavien-Dindo 3a or 3b complication within that period (Table 1). 245 patients had a follow up of 1 year or greater, and 9 patients (4%) had Clavien-Dindo 3a or 3b complications after 90 days in this cohort. Overall elective revision rate was 17%, with 1% revision for vaginal depth. Significant decrease in operative time was observed (p<.0001), with a mean operative time of 101 mins for cases 400-429 . Rate of dilating using the largest dilator to the deepest dot increased over these first 300 cases (p<.001) and rate of elective revision decreased (p <.001). CONCLUSIONS: Primary robotic peritoneal flap gender affirming vaginoplasty has low morbidity and complication rates with durable vaginal depth and orgasmic function at long term follow up. Source of Funding: none © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e403 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gaines Blasdel More articles by this author Charles Dubach-Reinhold More articles by this author Elijah Castle More articles by this author Rachel Bluebond-Langner More articles by this author Lee Zhao More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopic Assisted Vaginoplasty with Amnion Graft

Background: Around 1 in 400–5000 live births of females result in vaginal agenesis, a malformation of the female genital tracts. Using an amnion graft to treat vaginal agenesis is a straightforward, widely accessible, economically advantageous, and physiological surgery that leaves no additional scars on the body. This study sought to ascertain whether individuals with vaginal agenesis may successfully undergo laparoscopic-assisted vaginoplasty utilising amnion as a transplant to create a neovagina. Methods:Ten cases of vaginal agenesis linked to Mayor-Rokitansky-Kuster-Hauser (MRKH) Syndrome were included in this case series and were hospitalised within a year. The ladies with MRKH condition were either previously married or unable to consummate their marriage due to a blind vagina when they were brought for surgical intervention. To maintain the patency of the neo-vagina, a laparoscopically guided vaginoplasty was carried out as part of the care. Results:In all but one of the patients, laparoscopy-guided vaginoplasty with an amnion graft was effective. The procedure was stopped when the rectum was hurt, and the harm to the rectum was repaired. Except for one example, the functional outcomes of the neovagina were quite good. None experienced any major postoperative problems. The patients were happy with the postoperative results. Also, the neovagina was psychologically acceptable and sufficiently patent for sexual function. Conclusion: Over the past few years, the new vaginoplasty technique has developed. The most common practice, however, is a laparoscopic approach using several graft materials. A safe and efficient method for treating MRKH syndrome patients with vaginal agenesis is vaginoplasty with amnion grafts. J Bangladesh Coll Phys Surg 2023; 41: 177-182

Modern aspects of surgical transformation of the perineum in patients with male transsexualism (literature review)

Purpose of the study: a comparison of various vaginoplasty techniques and results in patients with transsexualism based on the analysis of data from the world scientific literature.Material and methods. The seeking of published research results placed in open databases by keywords. A total of 391 articles were initially analyzed of which 33 have met our acceptability criteria. A total of 3716 cases were analyzed where patients have undergone penile inversion, flap surgery (scrotal flap, free flap, rotational flap), endoscopic method and other modifications of vaginoplasty. The method includes comparing of the presented surgery techniques, their functional and aesthetic results, and complications rate.Results. Due to the involvement of different criteria for the results of surgical treatment evaluation by different scientific teams, as well as the insufficient number of objective studies on some methods, it is difficult to match the methods, their outcome, and complications. However, based on the described experience of practitioners and researchers, it can be concluded that the penile inversion technique is the most examined one and has a stable and appropriate results. Laparoscopic methods are equally effective but have a few specificities. The scrotal flap seems to be the most promising method that meets all the criteria for vaginoplasty in transsexuals. Free flaps or the rotational flaps usage has historical importance and could be used in certain circumstances.Conclusion. Various surgical techniques have demonstrated the safety and reliability of vaginoplasty in MtoF patients providing the low number of complications and a significant improvement in the patient's quality of life. Studies using different methods in a similar population and standardized results obtained from patients are required to further analyze the results of various methods to highlight the main principles for use in practice.

Genital Hypoplasia before Gender-Affirming Vaginoplasty: Does the Robotic Peritoneal Flap Method Create Equivalent Vaginal Canal Outcomes?

Insufficient genital tissue has been reported as a barrier to achieving depth in gender-affirming vaginoplasty. The authors sought to characterize vaginal depth and revision outcomes in patients with genital hypoplasia undergoing robotic peritoneal flap vaginoplasty. Retrospective case-control analysis of patients undergoing robotic peritoneal vaginoplasty between September of 2017 and August of 2020 was used. All 43 patients identified as having genital hypoplasia (genital length <7 cm) were included with 49 random controls from the remaining patients with greater than 7 cm genital length. Baseline clinical characteristics and perioperative variables were recorded to identify potential confounders. Outcomes measured included vaginal size reported at last visit and undergoing revision surgery for depth or for vulvar appearance. Patients were well matched other than median body mass index at the time of surgery, which was greater in the hypoplasia cohort by 3.6 kg/m 2 ( P < 0.0001). Patients had a median of 1-year of follow-up, with a minimum follow-up of 90 days. No significant differences in outcomes were observed, with a median vaginal depth of 14.5 cm (interquartile range, 13.3 to 14.5 cm), and a median width of dilator used of 3.8 cm (interquartile range, 3.8 to 3.8 cm). No depth revisions were observed, and an 11% ( n = 10) rate of external revision occurred. Patients with genital hypoplasia had equivalent dilation outcomes in a case-control analysis with consistent follow-up past 90 days. The robotic peritoneal flap vaginoplasty technique provides vaginal depth of 14 cm or greater regardless of genital tissue before surgery. Further investigation with patient-reported outcome measures is warranted. Risk, II.

Urinary complications after penile inversion vaginoplasty in transgender women Systematic review and meta-analysis.

Penile inversion vaginoplasty (PIV) remains the gold standard technique for vaginoplasty, a gender-affirming feminizing surgery, but has been associated with urinary complications; however, there is little literature synthesizing urinary complications after PIV surgery, and there is a need to compile these complications to counsel patients pre- and postoperatively on managing surgical expectations. In this systematic review, we summarize the prevalence of urinary complications following PIV. We searched the MEDLINE, EMBASE, CINAHL, and Scopus databases in July 2020. The primary outcome was the prevalence of urinary and surgical complications in patients after penile inversion vaginoplasty. Pooled prevalence was determined from extrapolated data. ROBINS-I tool was used to assess study quality. The study was prospectively registered on PROSPERO (CRD 42020204139). Of 843 unique records, 27 articles were pooled for synthesis, with 3388 patients in total. Overall patient satisfaction ranged from 80-100%. The most common urological complications included poor/splayed stream (11.7%, 95% confidence interval [CI] 5.7-19.3), meatal stenosis (6.9%, 95% CI 2.7-12.7), and irritative symptoms (frequency, urgency, nocturia) (11.5%, 95% CI 2.6-25.1). Other urinary complications included retention requiring catheterization (5.1%, 95% CI 0.3-13.8), incontinence (8.7%, 95% CI 3.4-15.6), urethral stricture (4.6%, 95% CI 1.2-9.8), and urinary tract infection (5.6%, 95% CI 2.7-9.4). Most pooled studies had moderate risk of bias. The available evidence suggests that there is a low prevalence of urinary complications following PIV. Overall, there is a need for standardization of data in transgender surgical care to better understand surgical outcomes and improve postoperative management.

Updates on feminizing genital affirmation surgery (vaginoplasty) techniques.

Vaginoplasty is a gender affirming surgery performed for transgender women who desire feminizing genital reconstruction. Over the last decade, access to surgical care has improved for patients, and vaginoplasty has been increasingly performed. Several vaginoplasty techniques exist, many of which are modifications of the traditional penile inversion vaginoplasty. In this paper, we review the penile inversion vaginoplasty, the intestinal segment vaginoplasty and the peritoneal flap vaginoplasty. An overview of the techniques employed to perform these procedures is provided, as well as an update on their published outcomes and complications.

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.

Evaluation of the surgical and functional outcomes of secondary vaginoplasties with free skin mesh graft in patients following transfeminine genital reconstructive surgery.

BackgroundGender-affirming surgery is classically done using the penile inversion vaginoplasty technique, however in some patients it may not promote adequate depth. In patients whose vaginal conduits became short or stenotic, we propose to perform a secondary vaginoplasty using an abdominal free skin mesh graft. In this study, we present ours results of a series of cases using this technique.MethodsA retrospective review of patients undergoing secondary vaginoplasty with free skin mesh graft from 2000 to 2017 at our hospital was performed. Demographic data, surgical characteristics, complications, personal satisfaction and neovagina functionality (defined as the ability to have satisfactory sexual intercourse) were evaluated.ResultsOf 186 patients who were submitted to primary vaginoplasty, 36 patients (19.3%) were then submitted to secondary vaginoplasty. This study sample included 35 patients. The average age of patients was 41.0 years (37.0 to 50.5) and the average time between gender affirmation surgery and secondary vaginoplasty was 6 months (4–24). Ten patients (28.6%) developed postoperative complication, the most frequent being: neovagina introitus stenosis (22.9%), rectal fistula (8.6%), tissue dehiscence (2.9%), and urethral fistula (2.9%). Subjective personal satisfaction and neovagina functionality of patients was reported by 77.1% of the sample.ConclusionsOur study demonstrates that secondary vaginoplasty surgery using a free skin mesh graft has good results and is a functional option with low complexity and low rate of serious complications.

Cosmetic Revision Surgeries after Transfeminine Vaginoplasty

BackgroundVaginoplasty is the most frequent genital gender-affirming surgery. Although both functional and aesthetic outcomes after transfeminine vaginoplasty have improved over the years, cosmetic revision surgeries demand after transfeminine vaginoplasty appears to be increasing and requires updated knowledge.MethodsAll patients who underwent vulvar cosmetic revision surgeries at our institution following transfeminine vaginoplasty from January 2014 to April 2022 were studied. The prevalence, topography and surgical techniques of cosmetic revision surgeries after transfeminine genital gender-affirming surgery were examined using clinical charts review and statistical analysis.ResultsDuring the study period, 354 patients underwent gender-affirming vaginoplasty at our single institution (212 penile inversion vaginoplasty, 122 colovaginoplasty and 20 penile inversion vaginoplasty with scrotal skin graft patients). Forty out of these 354 patients (11.29%) required cosmetic revision surgery after transfeminine vaginoplasty; additionally, 44 patients with vaginoplasty performed at other centres also underwent vulvar cosmetic revision surgery at our clinic during the study period. From all performed cosmetic revision surgeries, most of them (31.42%) were labia corrections, followed by clitoris (23.26%) repair surgeries. Mons Venus (10.20%), urethral meatus (9.38%), spongiosus tissue remnants (8.57%) and introitus (6.53%) revisions followed in frequency. Corrections of peri-inguinal scars (5.30%), anterior commissure (2.84%) and inferior fourchette (2.42%) were less prevalent. No differences were found among the different studied vaginoplasty techniques regarding cosmetic revision surgery prevalence or topography following transfeminine vaginoplasty (p < 0.05).ConclusionsCosmetic revision surgeries after transfeminine vaginoplasty are frequent. In our large and long-term cohort study, labiaplasty followed by clitoroplasty were found as the most required cosmetic revision surgical procedures. Further multicentre, prospective and controlled studies are necessary to improve cosmetic outcomes and scientific evidence after transfeminine vaginoplasty.Level of evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Functional, aesthetic, and sensory postoperative complications of female genital gender affirmation surgery: A prospective study

Female genital gender affirmation surgeries have increased in recent years. Prospective studies with homogeneous standardized techniques and outcomes assessment are scarce in the current literature. This study aims to: 1) report the functional, aesthetic, and sensory postoperative complications (POCs) of primary genital gender confirmation surgeries performed on transgender women and 2) compare functional and aesthetic POCs amongst three vaginoplasty techniques: inverted penile skin, penoscrotal skin graft, and pedicled intestinal flap vaginoplasty. All (n=84) consecutive transfemale individuals who underwent primary genital gender confirmation surgery from January 2015 to December 2016 at IMCLINIC were prospectively followed. Functional, aesthetic, and sensory POCs were registered according to the Clavien-Dindo POC classification. Functional POC rates after vaginoplasty at our centre were 19%, 12%, 13%, and 1% at short (one month), mid-early (three months), mid-late (six months), and long-term (one year) follow-up visits, respectively. None of them were severe complications (grades IV-V), 25% were grade III, and less than 20% were low-grade complications (grades I-II). Overall, aesthetic satisfaction was high (90%). The total number of secondary surgeries needed to satisfy the cosmetic outcome was 20 (aesthetic POC grade IIIb). No differences regarding functional or aesthetic complication rates amongst vaginoplasty techniques were encountered. Twelve months after surgery, 81% of patients had initiated sexual intercourse, and 96% reported clitoral sensitivity. In our experience, female genital gender affirmation surgery is a feasible, low-complication surgery that offers high satisfaction in the long term. Further multicentric well-designed research is mandatory to improve outcomes.

Impact of the initial experience in the penile inversion vaginoplasty technique on satisfaction levels: a pilot retrospective cohort study.

BackgroundThere is a growing interest in reporting satisfaction levels of transgender women undergoing vaginoplasty surgery. The lack of information regarding satisfaction during the initial experience of the vaginoplasty technique, and the moderate morbidity related to the surgery, could discourage the immersion of new groups in initiating a program of this kind. Therefore, we aim to report patients' level of satisfaction during our initial experience in the penile inversion vaginoplasty technique.MethodsRetrospective study of patients who underwent penile inversion vaginoplasty in our center between September 2019 and August 2021. Surgery technique, demographic data, preoperative clinical variables, and short and long-term follow-up are described. Six months after surgery, a survey elaborated by the research team was conducted by phone. The score goes from 1 to 5, and it evaluates satisfaction on esthetics, functional, psychosocial, and global aspects.ResultsTwenty patients underwent penile inversion vaginoplasty in our center during the described period. The average age was 35.6 years old, the mean body mass index (BMI) was 24.7 kg/m2, and they presented low comorbidity. Half of the patients presented at least one complication, most of which were minor. One patient was urgently reoperated due to bleeding, and three patients were reoperated on a scheduled basis from minor surgeries. 90% of the patients answered the questionnaire. The most common answers to all four areas covered (esthetics, functional, psychosocial, and global) were satisfied or very satisfied, resulting in a mean over four points in each one of the sections. Lastly, 94.4% of the patients reported being satisfied with their choice of having undergone surgery.ConclusionsOur initial experience in penile inversion vaginoplasty reveals good satisfaction results at short follow up.

Comparison of modified McIndoe and Davydov vaginoplasty in patients with MRKH syndrome in terms of anatomical results, sexual performance and satisfaction.

To compare the modified McIndoe versus Davydov vaginoplasty techniques in terms of anatomical results, sexual performance, and satisfaction. From September 2019 to June 2021, a comparative study was conducted on 20 patients with MRKH syndrome who underwent either McIndoe vaginoplasty (McIndoe group, 10 cases) or Davydov vaginoplasty (Davydov group, 10 cases) in a university-based tertiary care hospital (Imam Khomeini Hospital) in terms of anatomical results, sexual performance, and satisfaction. Functional results were assessed using the Female Sexual Function Index (FSFI). All surgical procedures (n = 20) were performed successfully. Patients in the modified McIndoe group were similar to those in the Davydov group in terms of hospital stay and intraoperative complications. However, postoperative complications were higher in the McIndoe group. There were no significant differences in the neovaginal length and width of the two groups at the 6-month follow-up (P > 0.05). Other parameters (duration of mold use and blood transfusion) were similar for all patients in the two groups. At 12 months after surgery, all patients had regular sexual activity. No significant differences were found in either group. In terms of anatomical results, sexual performance, and satisfaction, the two techniques were similar.