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Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia: A Prospective Cohort Study of Surgical Outcomes and Follow-Up of 42 Patients
Abstract
Background:
In young transgender women previously treated with puberty-suppressing hormones, penoscrotal hypoplasia can make penoscrotal inversion vaginoplasty unfeasible. The aim of this study was to prospectively assess surgical outcomes and follow-up of total laparoscopic sigmoid vaginoplasty as primary reconstruction in a cohort of transgender women with penoscrotal hypoplasia.
Methods:
Baseline demographics, surgical characteristics, and intraoperative and postoperative complications of all performed total laparoscopic sigmoid vaginoplasty procedures were prospectively recorded.
Results:
From November of 2007 to July of 2015, 42 transgender women underwent total laparoscopic sigmoid vaginoplasty as primary vaginal reconstruction. The mean age at the time of surgery was 21.1 ± 4.7 years. Mean follow-up time was 3.2 ± 2.1 years. The mean operative duration was 210 ± 44 minutes. There were no conversions to laparotomy. One rectal perforation was recognized during surgery and immediately oversewn without long-term consequences. The mean length of hospitalization was 5.7 ± 1.1 days. One patient died as a result of an extended-spectrum beta-lactamase-positive necrotizing fasciitis leading to septic shock, with multiorgan failure. Direct postoperative complications that needed laparoscopic reoperation occurred in three cases (7.1 percent). In seven cases (17.1 percent), long-term complications needed a secondary correction. After 1 year, all patients had a functional neovagina with a mean depth of 16.3 ± 1.5 cm.
Conclusions:
Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery. Primary total laparoscopic sigmoid vaginoplasty is a feasible gender-confirming surgical technique with good functional outcomes for transgender women with penoscrotal hypoplasia.
Clinical questio/level of evidence:
Therapeutic, IV.
... Penoscrotal hypoplasia was defined as a penile length of less than 8 cm when erect and an insufficient amount of scrotal skin to further line the neovaginal cavity to achieve functional depth. 15 In 1892, Sneguireff was the first to use the rectum to reconstruct a vagina. Baldwin 16 performed a vaginoplasty using the ileum in 1904, but his patients had problems such as excessive mucous discharge, bleeding, and pain during intercourse. ...
... Laparoscopic harvest of bowel has been described by Wedler and associates in 2004, 20 when it already has shown many intraoperative and postoperative advantages over open surgery. 21 Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery 15 and is the procedure of choice in our center (Figs. 1-5) 22 . ...
... Based on retrospective studies, intestinal vaginoplasty seems to be associated with a low rate of adverse events. 15,19 Bouman and colleagues 37 performed a review of the literature focusing on clinical outcomes of intestinal vaginoplasty including 21 studies. The prevalence and severity of procedure-related complications were low. ...
The major steps in vaginoplasty are orchiectomy, penile amputation, creation of the neovaginal cavity with lining, and reconstruction of urethral meatus, labia, and clitoris. During pedicled intestinal transfer, an intestinal segment is transferred in a dissected cavity between the bladder and rectum. The bowel harvest is performed by a total laparoscopic technique. It is imperative to create the labia majora and minora, the clitoris, and a clitoral hood to achieve the physiologic and aesthetic equivalent of female external genitalia. Intestinal vaginoplasty seems to be associated with a low rate of adverse events. Life-long vaginal hygiene and dilatation is recommended.
... Penoscrotal hypoplasia was defined as a penile length of less than 8 cm when erect and an insufficient amount of scrotal skin to further line the neovaginal cavity to achieve functional depth. 15 In 1892, Sneguireff was the first to use the rectum to reconstruct a vagina. Baldwin 16 performed a vaginoplasty using the ileum in 1904, but his patients had problems such as excessive mucous discharge, bleeding, and pain during intercourse. ...
... Laparoscopic harvest of bowel has been described by Wedler and associates in 2004, 20 when it already has shown many intraoperative and postoperative advantages over open surgery. 21 Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery 15 and is the procedure of choice in our center (Figs. 1-5) 22 . ...
... Based on retrospective studies, intestinal vaginoplasty seems to be associated with a low rate of adverse events. 15,19 Bouman and colleagues 37 performed a review of the literature focusing on clinical outcomes of intestinal vaginoplasty including 21 studies. The prevalence and severity of procedure-related complications were low. ...
... Penoscrotal hypoplasia was defined as a penile length of less than 8 cm when erect and an insufficient amount of scrotal skin to further line the neovaginal cavity to achieve functional depth. 15 In 1892, Sneguireff was the first to use the rectum to reconstruct a vagina. Baldwin 16 performed a vaginoplasty using the ileum in 1904, but his patients had problems such as excessive mucous discharge, bleeding, and pain during intercourse. ...
... Laparoscopic harvest of bowel has been described by Wedler and associates in 2004, 20 when it already has shown many intraoperative and postoperative advantages over open surgery. 21 Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery 15 and is the procedure of choice in our center (Figs. 1-5) 22 . ...
... Based on retrospective studies, intestinal vaginoplasty seems to be associated with a low rate of adverse events. 15,19 Bouman and colleagues 37 performed a review of the literature focusing on clinical outcomes of intestinal vaginoplasty including 21 studies. The prevalence and severity of procedure-related complications were low. ...
... Penoscrotal hypoplasia was defined as a penile length of less than 8 cm when erect and an insufficient amount of scrotal skin to further line the neovaginal cavity to achieve functional depth. 15 In 1892, Sneguireff was the first to use the rectum to reconstruct a vagina. Baldwin 16 performed a vaginoplasty using the ileum in 1904, but his patients had problems such as excessive mucous discharge, bleeding, and pain during intercourse. ...
... Laparoscopic harvest of bowel has been described by Wedler and associates in 2004, 20 when it already has shown many intraoperative and postoperative advantages over open surgery. 21 Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery 15 and is the procedure of choice in our center (Figs. 1-5) 22 . ...
... Based on retrospective studies, intestinal vaginoplasty seems to be associated with a low rate of adverse events. 15,19 Bouman and colleagues 37 performed a review of the literature focusing on clinical outcomes of intestinal vaginoplasty including 21 studies. The prevalence and severity of procedure-related complications were low. ...
... Thirty-five studies reported surgical complications, whereas 18 studies included patient-reported outcomes 5,14,15,[18][19][20]24,[32][33][34]41,43,[46][47][48][49][50][51][52] and 12 studies reported vaginal length. 5,14,15,18,19,21,22,25,28,30,31,38,[40][41][42][43][44][45][46][51][52][53][54][55] Thirty-seven (80.8%) studies used the penile inversion technique with or without scrotal flap. [14][15][16][17][26][27][28][29][30][31][32][33][34][35][36][37][38][39][47][48][49][50]53,56,57 Nine (26.5%) used a bowel pedicle flap, [16][17][18][19][20][21][22][23]38 of which 3 used the sigmoid colon as a conduit, 18,19,[22][23][24] 3 used the ileum, 20,21 and 1 used the transverse colon. ...
... 5,14,15,18,19,21,22,25,28,30,31,38,[40][41][42][43][44][45][46][51][52][53][54][55] Thirty-seven (80.8%) studies used the penile inversion technique with or without scrotal flap. [14][15][16][17][26][27][28][29][30][31][32][33][34][35][36][37][38][39][47][48][49][50]53,56,57 Nine (26.5%) used a bowel pedicle flap, [16][17][18][19][20][21][22][23]38 of which 3 used the sigmoid colon as a conduit, 18,19,[22][23][24] 3 used the ileum, 20,21 and 1 used the transverse colon. 58 There were 3408 (91.7%) reported cases using the penile inversion technique compared with 308 (8.3%) intestinal flaps. ...
... 5,14,15,18,19,21,22,25,28,30,31,38,[40][41][42][43][44][45][46][51][52][53][54][55] Thirty-seven (80.8%) studies used the penile inversion technique with or without scrotal flap. [14][15][16][17][26][27][28][29][30][31][32][33][34][35][36][37][38][39][47][48][49][50]53,56,57 Nine (26.5%) used a bowel pedicle flap, [16][17][18][19][20][21][22][23]38 of which 3 used the sigmoid colon as a conduit, 18,19,[22][23][24] 3 used the ileum, 20,21 and 1 used the transverse colon. 58 There were 3408 (91.7%) reported cases using the penile inversion technique compared with 308 (8.3%) intestinal flaps. ...
Introduction:
There is an increased need for evidence-based practices in male-to-female (MtF) transgender vaginoplasty. Although there are a multitude of surgical techniques, there is a paucity of data comparing these procedures. A systematic review of retrospective studies on the outcomes of MtF vaginoplasty was conducted to minimize surgical complications and improve patient outcomes for transgender patients.
Methods:
Applying the Preferred Reporting Items for Systematic Review and Meta-Analysis, a comprehensive search of several databases from 1985 to November 7, 2017, was conducted. The databases included PubMed, Ovid MEDLINE Epub Ahead of Print, Ovid Medline In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, and Web of Science. The resulting publications were screened, and those that met our specified inclusion/exclusion criteria were analyzed. The DerSimonian and Laird random-effects model was used to pool complications and patient-reported outcomes.
Results:
A total of 471 articles were initially identified, of which 46 met our eligibility criteria. A total of 3716 cases were analyzed. Overall incidence of complications included the following: 2% (1%-6%) fistula, 14% (10%-18%) stenosis and strictures, and 1% (0%-6%) tissue necrosis, and 4% (2%-10%) prolapse (upper and lower limits of the 95% confidence interval). Patient-reported outcomes included a satisfaction rate of 93% (79%-100%) with overall results, 87% (75%-96%) with functional outcomes, and 90% (79%-98%) with esthetic outcomes. Ability to have orgasm was reported in 70% (54%-84%) of patients. The regret rate was 1% (0%-3%). The length of the vaginal cavity was 12.5 cm (6.3-4.4 cm).
Conclusions:
Multiple surgical techniques have demonstrated safe and reliable means of MtF vaginoplasty with low overall complication rates and with a significant improvement in the patient's quality of life. Studies using different techniques in a similar population and standardized patient-reported outcomes are required to further analyze outcomes among the different procedures and to establish best-practice guidelines.
... For those who progress with gender-affirming surgeries after receiving PS and CSH, surgical approaches strongly depend on physical development of the breasts 9,10 or penis. 11 Severe penoscrotal hypoplasia reduces the feasibility of standard penile inversion vaginoplasty (because of the limited penile skin to create a vaginal cavity and limited prepuce to create labia minora) and can require other types of vaginoplasty, such as intestinal vaginoplasty, with an additional complication risk of colorectal surgery. 11 No data on breast hypoplasia after PS are available, but if feminine breast development is adequately suppressed, transgender men can refrain from undergoing chest surgery. ...
... 11 Severe penoscrotal hypoplasia reduces the feasibility of standard penile inversion vaginoplasty (because of the limited penile skin to create a vaginal cavity and limited prepuce to create labia minora) and can require other types of vaginoplasty, such as intestinal vaginoplasty, with an additional complication risk of colorectal surgery. 11 No data on breast hypoplasia after PS are available, but if feminine breast development is adequately suppressed, transgender men can refrain from undergoing chest surgery. Recognizing the importance of informed decisionmaking by (parents of) transgender adolescents, accurate information on the long-term effects of PS on the development of sex characteristics, the surgical implications, and psychological gains is of great importance. ...
... Preoperative physical examination by trained specialists included the examination of breasts in transgender men and genitals in transgender women (penile length and testes descended) by using standardized classification and report forms. [9][10][11] Physical examination of the breasts was conducted according to conventional principles and included visual assessment of the breast cup and combined visual`and manual assessment of breast ptosis (level of breast sagging and nipple position relative to inframammary fold [IMF]) and elasticity (elastic ability of the skin). Lastly, surgical reports were reviewed for the surgical techniques applied by using predefined standardized case report forms. ...
Objectives:
Puberty suppression (PS) is a cornerstone of treatment in youth experiencing gender dysphoria. In this study, we aim to inform prescribing professionals on the long-term effects of PS treatment on the development of sex characteristics and surgical implications.
Methods:
Participants received PS according to the Endocrine Society guideline at Tanner 2 or higher. Data were collected from adolescents who received PS between 2006 and 2013 and from untreated transgender controls. Data collection pre- and post-PS and before surgery included physical examination and surgical information.
Results:
In total, 300 individuals (184 transgender men and 116 transgender women) were included. Of these, 43 individuals started PS treatment at Tanner 2/3, 157 at Tanner 4/5, and 100 used no PS (controls). Breast development was significantly less in transgender men who started PS at Tanner 2/3 compared with those who started at Tanner 4/5 and controls. Mastectomy was more frequently omitted or less invasive after PS. In transgender women, the mean penile length was significantly shorter in the PS groups compared with controls (by 4.8 cm [Tanner 2/3] and 2.1 cm [Tanner 4/5]). As a result, the likelihood of undergoing intestinal vaginoplasty was increased (odds ratio = 84 [Tanner 2/3]; odds ratio = 9.8 [Tanner 4/5]).
Conclusions:
PS reduces the development of sex characteristics in transgender adolescents. As a result, transgender men may not need to undergo mastectomy, whereas transgender women may require an alternative to penile inversion vaginoplasty. These surgical implications should inform decision-making when initiating PS.
... Out of the 34 articles eight studies presented results of laparoscopic procedures [8][9][10][11][12][13]45,48,49,51]. One of the studies was a prospective randomized comparison study including the laparoscopic sigmoid vaginoplasty and laparoscopic peritoneal vaginoplasty [45]. ...
... One of the studies was a prospective randomized comparison study including the laparoscopic sigmoid vaginoplasty and laparoscopic peritoneal vaginoplasty [45]. One series reported a prospective cohort study on total laparoscopic approach for sigmoid vaginoplasty for 42 transgender women with penoscrotal hypoplasia [48]. Another We are moderately confident in the effect estimate: ...
... All of the included articles reported creation of a functional vagina. The construction of a self-lubricated vagina is reported as a positive outcome in several studies [27,29,[38][39][40][41]48,49,51]. The outcome of a neovagina without the need of routine dilatation is presented as well as a positive result in the series of Kim et al. [11], Khen et al. [29], Kapoor et al. [36] and Tillem et al. [38]. ...
Among surgical procedures for constructing a neovagina, positive outcomes are reported in literature for bowel vaginoplasty for male-to-female transgenders and patients with vaginal aplasia. This systematic review shows outcomes of bowel vaginoplasty procedures, and rates the quality of evidence of the included studies. A search of the literature was performed in PubMed, Medline, Cochrane Library and SveMed+, in accordance with the PRISMA statement, between January 2016 and February 2018. The PICOS (patients, intervention, comparator, outcomes and study design) approach was used as inclusion criteria. Among 251 analyzed studies only 34 met inclusion criteria. Quality of evidence and methodology were rated according to GRADE and MINORS, respectively. Data from the included studies were extracted based on study characteristics, participants? specifics, type of intervention/treatment and type of outcome measures into data extraction forms. All studies were non-randomized with a high risk of bias and very low quality of evidence according to GRADE. Vaginal reconstruction with isolated bowel segments provides a self-lubricating neovagina with low rates of failure and revision, and without routine dilatation need. Furthermore, the use of laparoscopic techniques offers a better postoperative cosmetic appearance of the abdomen and a shorter hospital stay. Vaginoplasty using bowel segment is a safe and effective procedure that obtains excellent long-term results as reported by the included studies. Despite that further researches are needed improving methodology with larger populations, retrospective qualitative studies and report of outcome measurements using standardized evaluation tools as the Female Sexual Function Index.
... However, these are generally recognized as inferior to penile inversion. 17,18 In the literature, the overall technical and subjective success rate of penile inversion vaginoplasty is 80%-90%. Complication rate of penile inversion is generally regarded at approximately 20%-30%, while complication rate of alternative procedures is typically 35%-60%. ...
... Complication rate of penile inversion is generally regarded at approximately 20%-30%, while complication rate of alternative procedures is typically 35%-60%. [17][18][19][20][21][22] Penile inversion is preferred due to the neovagina vault being mostly hairless and partially lubricated via urethral mucosa. The most commonly cited shortfall of this reconstruction method is that the neovaginal depth is often insufficient and may require revisions with either enteric mucosa or a full thickness skin graft. ...
... Possible causes for this effect are that patients underwent penile inversion vaginoplasty regardless of penile length, used as a surgical selection criterion in the literature. 7,[9][10][11][12]14,17 Based on the literature and our experience, intraoperative packing of the neovagina and regular and aggressive postoperative dilation regimens are found to be strongly correlated with optimal neovaginal depth Additionally, skin grafting is not carried out in primary surgery. As described in the methods section, a vascularized flap from the midportion of the scrotum is used to augment the penile skin and urethral mucosa for neovaginal lining. ...
Background:. To detail the early experience with and results of a transfeminine (TF) genital reconstruction at an established plastic surgery practice in Western New York.
Methods:. Between June 2016 and June 2019, 30 patients underwent penile inversion vaginoplasty for TF gender reassignment. All patients fulfilled World Professional Association for Transgender Health and NY State criteria for reassignment surgery. All surgeries were carried out at a large, government-owned tertiary care center.
Results:. There were 30 patients in this retrospective study, with a mean age of 37 years (SD 5.4) and a mean body mass index of 27.3 kg/m2 (SD 3.2 kg/m2). Nineteen patients never smoked, 4 were former smokers, and 7 were current smokers. Primary surgery was an orchiectomy and modified single-stage penile inversion vaginoplasty. Mean operative time was 6.0 hours. Mean initial hospital stay was 8.2 days. Three of the 30 (10%) patients required transfusion. There were 6 (20%) complications. Three complications (10%) required reoperation: 1 patient for wound dehiscence on postoperative day 7, 1 for rectal perforation identified on postoperative day 10, and 1 for urethrovaginal fistula. All complications were addressed without sequalae. Twenty of the 30 (66%) patients have undergone revision surgery. Indications for revision were prolapse correction/deepening, labiaplasty, clitoral hood construction/revision, meatal asymmetry, urinary fistula repair, and posterior vaginal flap revision. Twenty-one of 28 (75%) revisions were outpatient surgeries. There were no complications from these procedures. Overall satisfaction via survey was 92% (24 respondents).
Conclusions:. TF gender reassignment is a novel, challenging set of procedures for the specialty of plastic surgery. With appropriate consideration and technique, penile inversion vaginoplasty is a safe, effective means of achieving this goal.
... All of our sexually active patients reported sufficient depth for both sexual function and satisfaction. There were two instances of introital stenosis (17%) compared to an 8.6% stenosis rate reported in pooled data [16] and 14.6% in Bouman et al. 's recent series [27]. Both patients were successfully treated with dilation under anesthesia. ...
... Our limited follow-up time may not have captured every complication or management thereof that may have occurred in this cohort. The rate of complications in our series was 33%, compared with 6.4% in pooled data [16] and 42% [27]. Like Bouman et al. 's recent study, we encountered few intraoperative or postoperative abdominal complications [27]. ...
... The rate of complications in our series was 33%, compared with 6.4% in pooled data [16] and 42% [27]. Like Bouman et al. 's recent study, we encountered few intraoperative or postoperative abdominal complications [27]. Clearly, the ability to carry out simultaneous intraabdominal and perineal operations maximizes visualization and safe retraction of important structures, and this may contribute to lower rates of bowel injury. ...
Background
Many techniques have been described for reconstruction of the vaginal canal for oncologic, traumatic, and congenital indications. An increasing role exists for these procedures within the transgender community. Most often, inverted phallus skin is used to create the neovagina in transwomen. However, not all patients have sufficient tissue to achieve satisfactory depth and those that do must endure cumbersome postoperative dilation routines to prevent contracture. In selected patients, the sigmoid colon can be used to harvest ample tissue while avoiding the limitations of penile inversion techniques.
Methods
Records were retrospectively reviewed for all transwomen undergoing primary sigmoid vaginoplasty with the University of Miami Gender Reassignment service between 2014 and 2017.
Results
Average neovaginal depth was 13.9 +/− 2.0 centimeters in 12 patients. 67% were without complications, and all maintained tissue conducive to sexual activity. No incidences of bowel injury, anastomotic leak, sigmoid necrosis, prolapse, diversion neovaginitis, dyspareunia, or excessive secretions had occurred at last follow-up.
Conclusions
Sigmoid vaginoplasty is a reliable technique for achieving a satisfactory vaginal depth that is sexually functional. Using a collaborative approach, it is now our standard of care to offer this surgery to transwomen with phallus length less than 11.4 centimeters.
... Use of feminizing and puberty-suppressing hormones prior to GS is common among TF persons but may negatively affect the availability of penile and scrotal skin for grafting as a result of suppression or atrophy of the penis and testes. Thus, these individuals may benefit from primary intestinal interposition or potentially peritoneal vaginoplasty [8,[18][19][20][21][22]. ...
... Variations on the technique also have been applied for both primary and revision vaginoplasty in TF persons [22]. Intestinal vaginoplasty is both safe and efficacious, though it generally has been reserved as a second-line option to PIV [19,20,23]. Advantages include the ability to create a self-lubricating neovagina of adequate depth. ...
... Adequate neovaginal depth and width are important for those patients who wish to have penetrative intercourse. Neovaginal depth and width are dependent on the adequacy of the cavity created by blunt dissection of the retroprostatic and anterior rectal space, as well as the amount of natal penile skin available for grafting at the time of surgery [20]. Over-dissection of this space may leave behind an insufficient rectovaginal septum (< 3 mm) or result in inadvertent rectal enterotomy, both of which increase the risk for rectoneovaginal fistulae [15,27,[29][30][31]. ...
Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.
... 4 Prolonged hormonal intake leads to penoscrotal hypoplasia making penoscrotal inversion vaginoplasty not feasible. 10,[15][16][17][18][19] Thus, we aimed to describe in this article our modified technique which has nearly overcome the functional inadequacy of the existing techniques and has addressed the esthetic issues of reconstructed outer genitalia and vagina. It has now become the technique of choice for MtF gender affirmation surgery for our patients. ...
... 7,9,26 Prolonged hormonal intake leads to penoscrotal hypoplasia making penoscrotal inversion vaginoplasty not feasible. 10,[15][16][17][18][19] To overcome the limitation of inadequate vaginal depth in transsexuals, the use of skin graft was introduced by Abraham. 27 The use of full-thickness skin graft from penile skin was first reported by Fogh-Anderson 28 and refined by Preecha 11 and Motta et al. 29 Limitations of skin graft split skin graft (SSG)/full thickness graft (FTG) vaginoplasty are inadequate graft take up, contraction of vagina due to scarring and graft shrinkage, long and painful postoperative aftercare and long-term dilation (even lifetime), introducing skin into a Fig. 2. a, Sculptured labia minora with well-defined clitoris and hood. ...
Background:. Current male-to-female (MtF) sex-reassignment-surgery techniques have not been fully successful to achieve the ideal objectives. The ordeal of multiple procedures, associated complications, and suboptimal results leads to high rate of dissatisfaction. We have tried to overcome functional inadequacy and address the esthetic issues for outer genitalia and vagina with our innovative “true shape sigma-lead SRS: Kaushik’s technique,” which has now become the technique of choice for MtF genital SRS for our patients.
Methods:. Between April 2007 and April 2017, authors performed 386 sigma-lead SRS in MtF transsexuals. Results were analyzed based on complications, resurgeries, and esthetic/functional outcomes. Corrective SRS using rectosigmoid constituted 145 cases and is not a part of this study.
Results:. Maximum follow-up was 7 years (average 34 months). Seventy-eight (20.2%) patients had complications, majority being minor (97.4%). Forty-four (11.4%) required resurgeries, 10 (2.6%) were corrective for introital stricture and mucosal prolapse, whereas 34 (8.8%) opted for optional minor esthetic enhancement. The overall satisfaction rate for cosmetic and functional outcomes was 4.7 out of 5. In addition to review of the literature, innovations in the technique have been explained.
Conclusions:. Kaushik’s sigma-lead MtF SRS technique is a step short to become the gold standard of genital SRS because it has proven to be safe and reliable. It allows faster healing, minimal dilation, and nearly natural cosmetic results in the form of clitoris/clitoral hood, labia minora, labia majora along with self-lubricating, fully deep, and sensate neovagina with orgasmic capabilities. This is perhaps the largest reported series of rectosigmoid use in transsexuals carried out for primary vaginoplasty.
... Minimally invasive methods such as laparoscopic sigmoid vaginoplasty are gaining popularity with all the advantages of endoscopic surgery such as smaller abdominal incisions, shorter hospital stay and less blood loss compared to conventional laparotomy [33]. In one of the largest series consisting of 42 patients, Bouman reported outcomes of transgender women with penoscrotal hypoplasia undergoing primary total laparoscopic intestinal vaginoplasty [34]. In this prospective study, one patient had a lethal necrotizing fasciitis, three patients required re-laparoscopy for post-operative complications (one with anastomosis-leakage and two with intra-abdominal bleeding) and another patient experienced rectal injury which was handled intraoperatively. ...
... In a recent study by van der Sluis, 64% of patients with bowel vaginoplasties presented with mild to moderate findings in colonoscopic follow-up of their bowel neovagina but most of the patients were symptom-free and these findings were only a colonoscopic diagnosis [37]. In a series of 42 transgender patients undergoing total laparoscopic vaginoplasties, two patients experienced mild colitis and required treatment [34]. In our study, we observed no diversion colitis since we did not need to perform routine colonoscopy of the neovagina. ...
Although vaginal reconstructions with intestinal segments require particularly complex surgical procedures, this technique has become popular with respect to fairly good functional and esthetic outcomes. This study describes cases of vaginal reconstruction performed using a modified rectosigmoid colon held in an ischemic state in order to reduce secretion and denervated in order to prevent defecation problems. Vaginal reconstructions with rectosigmoid colon were performed on 43 patients. In this retrospective study, 34 patients had Müllerian agenesis, while nine had undergone male to female sex reassignment surgery in which adequate vaginal depth had not been achieved. A rectosigmoid colon with its vascular pedicle was used and left in an ischemic state. All nerve structures within the pedicle were excised intraoperatively. Follow-up period was between 12 and 60 months. Partial necrosis occurred in one patient which was reconstructed with local flap. Hematoma developed beneath the skin incision in two cases, but resolved with conservative treatment. A good esthetic outcome was achieved in all cases. Sexual function was assessed using the Female Sexual Function Index (FSFI) in 15 patients. Fourteen out of 15 patients scored above 26.5 on this scale and were determined as having no sexual dysfunction (FSFI score ≥26.5). In conclusion, vaginal reconstruction with denervated rectosigmoid held in an ischemic state appears to be a reasonable option among several available reconstruction techniques.
... A consequence of using bowel in vaginoplasty is mucus production which provides moisture and lubrication. 4 However it is ever more important to regularly dilate the introitus to avoid stenosis and mucocele formation as a result. ...
... Another alternative for tissue is an intestinal substitution. For example, a sigmoid neovagina has been described given its proximity to the pelvis (11,12). Other positives include its hairless nature and self-lubrication. ...
Gender affirmation surgery is paramount in the treatment of gender dysphoria for transgender individuals. For transgender women, vaginoplasty offers the opportunity for removal of masculine-appearing genitalia and replacement with a gender-congruent appearance. While numerous techniques have been described in the past, approaches have standardized considerably. Herein, we describe a technique to penile inversion vaginoplasty and focus on some of the critical steps of the procedure to try to optimize patient outcomes. We also review relevant literature regarding perioperative outcomes.
... A number of recent reports exist in the literature concerning outcomes of vaginoplasty in male-to-female transgender for both penile skin and intestinal techniques. 3,8,10,[12][13][14][15][16] However, to the best of our knowledge, no articles exist in the literature comparing outcomes between primary penile skin, and secondary intestinal based neovaginoplasty. Because our series included patients who had benefited from different techniques (P and S 2 after P), we tried to highlight differences among groups, perhaps unveiling the reasons driving the recent shift toward sigmoid-based vaginoplasties. ...
Introduction:
The "traditional" method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion.
Aim:
The aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion.
Methods:
This is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups.
Main outcome measure:
Patient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina.
Results:
Our findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance).
Clinical implications:
The use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty.
Strength & limitations:
This study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction.
Conclusion:
This study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar. di Summa PG, Watfa W, Krähenbühl S, et al. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med 2019;XX:XXX-XXX.
... Important considerations with vaginoplasty include the presence of penile and scrotal hypoplasia in patients previously treated with puberty-suppressing hormones [41], which makes penoscrotal inversion vaginoplasty challenging. Alternatives include use of full-thickness skin grafts, pedicled flaps, peritoneum, and sigmoid colon [42]. Non-genderaffirming urologic treatments also have significant implications. ...
Purpose of Review
The review is aimed at determining critical factors in the preoperative and postoperative care of transgender patients undergoing gender-affirming surgery. General and procedure-specific considerations are summarized to improve the longitudinal perioperative care of transgender patients.
Recent Findings
Surgical providers should follow World Professional Association for Transgender Health (WPATH) guidelines regarding eligibility for surgery. Important elements in preoperative evaluation include mental health screening, fertility discussion, and adjustment of hormone replacement therapy. Postoperative considerations include proper cancer screening, mental health support, appropriate outcomes assessment, and awareness of potential procedure specific complications.
Summary
Proper perioperative care for transgender patients undergoing gender-affirming surgery involves a multidisciplinary approach to healthcare to create a comprehensive treatment environment at an institutional level.
... Pedicled intestinal vaginoplasties (sigmoid, ileum, jejunum) are typically reserved for individuals with inadequate tissue for penile inversion vaginoplasty, or for salvage procedures [17][18][19][20][21][22]. By using bowel, the surgeon is able to construct a neovagina with sufficient depth without being constrained by the available length of penile and scrotal skin. ...
Purpose of review:
A growing number of transgender patients are seeking gender-affirming genital reconstructive surgery (GRS). These complex procedures have high complication rates. We describe common surgical pitfalls in GRS and approaches for minimizing complications.
Recent findings:
Penile inversion vaginoplasty has been associated with excellent cosmetic and functional outcomes. A robotic-assisted dissection may minimize risk of rectal injury. As a younger transgender population chooses pubertal suppression, alternative sources for lining the vaginal canal, such as enteric vaginoplasties, may be more widely utilized. Since adoption of microvascular techniques in phalloplasty, transmasculine individuals have potential for a sensate neophallus and penetrative intercourse. Urethral complications are common and challenging to manage; techniques using flap coverage may minimize ischemia-related strictures. Innovations in prosthesis placement require adaptations to neophallus anatomy. A growing number of transgender individuals are seeking genital reconstruction. Ongoing innovation in surgical technique is needed to improve patient outcomes.
... a Creëren van de vaginaholte; b situatie na deglovement van de penis, mobiliseren van de neurovasculaire bundel, creëren van de clitoris met clitorishoed, het verwijderen van het corpus spongiosum, de corpora cavernosa en de testikels; c inversie van de penishuid, fixeren van de clitoris, inhechten van de meatus urethra; d eindresultaat met de labia majora, labia minora, clitoris met clitorishoed, introïtus en de meatus van de urethra met transurethrale katheter. (Illustratie: Dana Hamers Scientific Art) derontwikkeld mannelijk genitaal door op jonge leeftijd te starten met pubertijdsremmers en hormonale therapie of bij status na circumcisie) of bij secundaire vaginaplastieken na een mislukte penisinversietechniek, wordt een darmvagina gebruikt [4]. De darm-vaginaplastieken zijn gecombineerde sessies waarbij de plastisch chirurg de uitwendige genitalia reconstrueert en de holte maakt voor de vagina, terwijl de gastro-enterologische chirurgie simultaan laparoscopisch een stuk darm (sigmoïd of ileum) vrijprepareert. ...
Genderdysforie kenmerkt zich door incongruentie tussen het geboorte- en het gewenste geslacht. Transgenders zijn patiënten met genderdysforie die genderbevestigende medische behandelingen willen ondergaan. De medische zorg van mensen met genderdysforie gebeurt multidisciplinair volgens de Standards of Care (SOC) van the World Professional Association for Transgender Health (WPATH). Op basis van shared decision making worden de medicamenteuze en operatieve behandelingen ingesteld. De afdeling Urologie is medeverantwoordelijk voor functionele en esthetische resultaten van de genitale geslachtsaanpassende operaties bij de transgenders.
... Another option for patients with insufficient penoscrotal skin is performing intestinal vaginoplasty, with concomitant risks of intra-abdominal bowel surgery. 4,5 The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an adjunctive technique and may serve as a solution for the aforementioned disadvantages of non-vascularized FTGs when used as an adjunct to the inverted penile skin flap. The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. ...
Background
Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon.
Aim
To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty.
Methods
Perioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes).
Outcomes
The main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications.
Results
A total of 42 transgender women were included (median age: 28 years (range 18–66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%).
Clinical Implications
The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery.
Strengths & Limitations
Strenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time.
Conclusion
The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting.
Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;XX:XXX–XXX.
... 14 Intestinal (mostly sigmoidal) vaginoplasty is the most commonly used procedure after failed PSI. 15 Davydov peritoneal vaginoplasty was first introduced in 1974 to construct vaginas in patients with MRKH syndrome. 1,2 There are many advantages of using the peritoneum for vaginal reconstruction, because it is moist, expansible, of adequate size, and lined by nonhairy, nonkeratinized stratified squamous epithelium. ...
Peritoneal vaginoplasty has been used for the reconstruction of vaginas in females born with congenital vaginal agenesis. Some authors reported successful use of a sliding pull-down peritoneal flap (Davydov procedure) for augmenting neovaginal length in a postsurgical transgender woman. Peritoneal vaginoplasty has become an exciting procedure for transwomen who are unable to undergo (or have failed) penile skin inversion. We present the case of a transwoman with penoscrotal hypoplasia who underwent primary vaginoplasty by using a single pedicled peritoneal flap.
... Those with negative perceptions about colovaginoplasty, however, cite the more invasive nature of the procedure (i.e. pelvic and abdominal surgery), need for bowel anastomosis, and potential for prolapse and "diversion colitis" of the vaginal segment as unnecessary risks unique to intestinal procedures [17,18,25,26]. Our approach is to offer right colon vaginoplasty as either a salvage procedure whenin the entire vaginal canal/ space must be replaced, or, as a primary surgery option for occasional cases where a patient has insufficient penile and scrotal skin for penile inversion vaginoplasty. ...
Introduction
Various methods have been described to create a functional neovagina with feminizing (male-to-female) gender affirming surgery. Intestinal vaginoplasty using ileal or colon segments confers natural mucus production and greater canal depth with primary vaginoplasty. In this work we describe an alternative approach to primary and salvage vaginoplasty using right colon. We focus on relative advantages compared to use of other bowel segments, and we review patient outcomes.
Methods
Transgender women who had previously undergone primary vaginoplasty underwent laparoscopic right colon vaginoplasty at our center between 12/2017 and 7/2019. Demographic, medical, outcome, and satisfaction data was collected and retrospectively reviewed.
Results
Twenty-two consecutive transgender women patients underwent laparoscopic right colon vaginoplasty. Mean age was 39.3 years. There were two intraoperative complications:1 injury of the ileocolic pedicle, and 1 minor bladder injury. Four of 22 patients (18.2%) had short-term complications (< 30 days): 3 had postoperative ileus/small bowel obstruction and 1 had intra-abdominal hemorrhage. All were managed conservatively. Six of 22 patients (27.3%) experienced a total of 14 long-term complications (> 30 days): 1 developed Crohn’s (not involving the neovagina); 1 developed late small bowel obstruction (SBO) (managed conservatively); 5 developed neovagina prolapse; 4 developed stenosis (2 at the vaginal introitus, and 2 had extrinsic obstruction at the recto-vaginal junction (all underwent successful laparoscopic surgical correction); and 3 were diagnosed with diversion neovaginitis (all treated conservatively). All complications were successfully treated with conservative and/or surgical intervention. All (100%) patients reported satisfaction with neovagina function and appearance.
Conclusion
This is the only outcomes series of transgender women patients who have undergone right colon vaginoplasty, to date. Our study finding suggests that laparoscopic right colon for primary or salvage vaginoplasty has several important advantages over use of Sigmoid colon or Ileum, and is a reliable technique whose complications can be managed successfully, with favorable, satisfactory long-term outcomes.
... used ileal, and 1 (1.9%) used transverse colon as conduit. [55][56][57][58][59][60][61][62][63][64][65][66][67] One study (1.9%) reported both techniques, 68 and another study (1.9%) reported outcomes using amnion grafts with and without fibroblasts. 69 A total of 3930 (84.0%) cases used the penile skin inversion technique with or without scrotal graft or skin graft, whereas 726 (15.5%) cases used bowel pedicle flaps. ...
Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes.
Methods:
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.
Results:
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.
Conclusions:
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.
... Transgender women with penoscrotal hypoplasia (i.e., those women placed on puberty blockers at the onset of puberty) or those who have failed a primary penile inversion vaginoplasty procedure may be candidates for intestinal vaginoplasty [5,6]. ...
Purpose of Review
This paper aims to review the current data that exist on the urogynecologic needs of the transgender patient and to relay important clinical pearls that may be useful to assist providers in caring for this patient population.
Recent Findings
In one study, 7.5% of transgender women who had undergone vaginoplasty surgery had a stage 2 or greater prolapse; 3.8% required surgery to repair their prolapse; 47% reported voiding dysfunction; 25 and 17% reported urinary urgency and urge incontinence, respectively; and 23% had stress incontinence. In a large cohort of patients who had undergone vaginoplasty, the overall incidence of rectoneovaginal fistula was 1.2% (95% CI 0.6, 2.1) and revision surgery was more likely to be associated with the development of a fistula. The complications most associated with phalloplasty procedures performed in female-to-male patients are urethrocutaneous fistulae (22 to 75%) and urethral stricturing (25 to 58%).
Summary
Data on pelvic floor disorders as they relate to transgender patients is sparse; however, as we begin to see more and more of these patients in academic centers, their medical needs are being studied and the literature on this patient population is slowly becoming more robust.
In recent years, greater acceptance of transgender individuals in society and the inclusion of medical coverage for gender-affirmation surgeries has led to an increasing number of patients seeking gender-affirming vaginoplasty. Since the first descriptions of neovaginal reconstruction for gender affirmation were described in the early and mid-1900s, various techniques and revisions have been introduced. This article provides a brief historical perspective, defines the goals of surgical treatment within a multidisciplinary approach adhering to World Professional Association for Transgender Health standards, and focuses on issues related to what is currently the most common approach to primary neovaginal reconstruction, the penile inversion vaginoplasty.
Complications after vaginoplasty surgery for the transgender woman exist. These adverse outcomes can be minor and easily treatable, whereas others are considered major events and require ongoing care. Adverse outcomes can be immediate or remote after surgery and include bleeding, hematoma, infection, delayed wound healing, neovaginal stenosis, visceral injury, and fistula. Patients may also experience pelvic floor disorders after surgery. Providers performing these surgeries and those providers caring for postoperative patients should be aware of the incidence of these complications and the treatment options that exist to manage them.
Gender dysphoria, or the distress caused by the incongruence between a person's assigned and experienced gender, can lead to significant psychosocial sequelae and increased risk of suicide (>40% of this population) and assault (>60% of this population). With an estimated 25 million transgender individuals worldwide and increased access to care for the transgender population, trauma surgeons are more likely to care for patients who completed or are in the process of medical gender transition. As transgender health is rarely taught in medical education, knowledge of the unique health care needs and possible alterations in anatomy is critical to appropriately and optimally treat transgender trauma victims. Considerations of cross-gender hormones and alterations of the craniofacial, laryngeal, chest, and genital systems are offered in this review. Further research on the optimal treatment mechanisms for transgender patients is needed.
Gender dysphoria, defined as the persistent discomfort with one's gender identity or biological sex, affects between 0.5%‐1.4% of adult males.1 Treatment aims at congruence, to allow those who experience it to find comfort within their gendered self, which optimises psychological wellbeing and self‐fulfilment.2 Whilst many experiencing gender dysphoria require partial treatment or social transition, others only find comfort following surgical intervention to change their external genitalia and sexual characteristics. Traditionally, infertility has been an unfortunate consequence of the realignment of a transgender person's body with their gender identity. This article is protected by copyright. All rights reserved.
Introduction:
Vaginal reconstruction and vaginoplasty are indicated in vaginal agenesis, following pelvic tumor resection, trauma and for gender confirmation surgery. Different surgical options have been described when using these techniques. Herein, we present the clinical outcomes and sexual function evaluation using the pedicle transverse colon flap (TCF) for gender confirmation surgery in transgender women.
Methods:
This is a retrospective chart review of all transgender women who underwent gender confirmation surgery using the pedicle TCF. Demographics, etiology, procedure specifics and surgical outcomes were recorded and analyzed. Sexual function was measured using the Female Sexual Function Index (FSFI) and the female genital self-image scale (FGSIS) one year after surgery.
Results:
15 patients underwent gender confirmation surgery using the pedicle transverse colon flap. Average age was 20, (range: 18-32 years), average OR time was 10.1 hours; (8-12.5 hrs.). The average length and width of the flaps was 15 cm and 2.8 cm respectively. During a 12-year follow-up, two complications were reported: one patient had pain due to narrowing at the introitus vaginalis, which required intervention and one patient had excessive amount of secretions in the first month which subsided at the third month after surgery. The mean FSFI score was 28.6 (range 24-31). All patients achieved a normal sexual function as indicated by a FSFI score of 25 or more. For the FGSIS, the mean total score was 20.0 ± 4.5 (range: 7- 28).
Conclusion:
The pedicle transverse colon flap is another valuable alternative method for vaginoplasty with promising results and minor complications.
Transgender women often transition with cross-sex hormone therapy and some opt to further affirm themselves with breast augmentation, facial feminization procedures, and/or vaginoplasty surgery. When considering medical and surgical transition for the transgender woman, careful preoperative evaluation and individual assessment is imperative and the World Professional Association for Transgender Health (WPATH) Standards of Care provide the framework from which health care providers and surgeons may assess eligibility for affirming treatments. Vaginoplasty for the transgender woman may be performed by a variety of techniques, mainly penile inversion vaginoplasty or intestinal segment vaginoplasty. Surgical outcomes vary according to technique, and the unique risks, advantages, and disadvantages must be considered. Outcomes appear to be satisfactory following vaginoplasty surgery, but prospective, long-term data are still lacking. Providers should be aware of the peri- and postoperative management of the transgender women after genital surgery, as many women require ongoing care and management after surgery.
This was a single-centre, retrospective study of transgender women undergoing genital gender-affirming surgery. A chart study was conducted, recording individual demographics, all genital surgical procedures, and surgical techniques. Procedure incidence, techniques employed, and demographic variations over the years were analysed.
Learning objectives:
After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty.
Summary:
Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.
Background
This study aimed to evaluate the technical feasibility and outcomes of total laparoscopic sigmoid vaginoplasty (TLSV) in women with congenital absence of the vagina.
Methods
We investigated 10 women with congenital absence of the vagina, who underwent TLSV at Guangdong Provincial People's Hospital between April 2013 and July 2016.
Results
All 10 women were unmarried, the mean age was 22.8 (range 17–33) years, mean estimated blood loss was 149.2 ± 54.8 (60–170) mL, mean operative time was 108.4 ± 52.6 (130–210) min, mean post‐operative hospital stay was 8.0 ± 2.8 (6–12) days and the mean neovaginal length was 13.4 ± 3.0 (12–16) cm. Eight of the 10 women were heterosexually active. Trocar port site infection and neovaginal stenosis occurred 3 months after TLSV in one patient; a vaginal mould was used to relieve the stenosis.
Conclusion
TLSV is an optimal minimally invasive procedure to treat women with congenital absence of the vagina and is associated with rapid recovery and acceptable cosmetic effects.
Background:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
Background
Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature.
Methods
PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of “gender affirming,” “gender confirming,” “transgender,” and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized.
Results
Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery.
Conclusion
Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.
Genitourinary reconstruction for transgender/gender non-binary (TGNB) individuals often involves perineal dissection with challenging surgical exposure. Robotic transabdominal approaches to vaginoplasty or vaginectomy allow for enhanced visualization, improved access to deep pelvic structures, and potential for new reconstructive techniques. We describe novel techniques and preliminary outcomes of robotic-assisted genital gender affirming surgery (GAS). These procedures include primary and revision peritoneal flap vaginoplasty, enteric vaginoplasty, and vaginectomy with vaginal mucosal flap and graft harvest for urethral lengthening. Further optimization of emerging techniques, assessment of long-term results, and the development of standardized outcome measures are critical future directions for robotic GAS.
For many trans*women, the surgical assignment of the male genital into a female is a fundamental part of the transition. Erogenous sensation of the neoclitoris is achieved by meticulous preparation of the penile glans with the neurovascular bundle. Several techniques are available for the formation of a neovagina, the penile inversion technique developed by Burou in the 1950s being the gold standard. With this technique, the inverted penile shaft skin is used as a pedicled flap to line the neovaginal canal. Alternatively, free skin grafts can be used, which serve primarily as a technique for redo procedures. Another technique is the use of intestinal segments to line the vaginal canal. This method is mostly used for redo procedures, but can also be performed primarily if penile skin is too small. Due to the numerous steps involved in the preparation, a wide variety of complications must be expected. Injury to the rectum during dissection of the neovaginal space, with an incidence of 4.5%, represents the greatest challenge. The most common complications are urethra-associated; hereby both a deviation of the urinary stream and strictures of the urethra are possible. The subjective satisfaction of trans*women with the surgical outcome is high and is reported in various studies to be 72-92%. On the basis of validated questionnaires it could also be shown that gender reassignment surgery leads to an increase in the trans*specific quality of life and promotes both subjectively perceived well-being and sexual satisfaction.
Context:
Genital reconstructive surgery (GRS) is a necessary part of transitioning for many transwomen, and there is evidence of positive effects on a person's well-being and sexual function. Surgical techniques have evolved, from pursuing aesthetic outcome to now functional outcome with natal females as the standard.
Objective:
To systematically review the evidence, identifying the surgical techniques used in primary GRS, their complications, functional outcomes, and the tools used to assess them.
Evidence acquisition:
The clinical question was designed using the standard PICOS format. The search complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 statement and was performed by two independent reviewers.
Evidence synthesis:
Europe, USA, and Thailand favour the penoscrotal technique for vaginoplasty, whereas in the UK, the penile inversion (PI) technique predominates. Primary vaginoplasty using a segment of bowel is less common, and all three techniques have comparable rates of intraoperative rectal injury. The incidence of rectovaginal fistula is reportedly higher in the PI technique. Wound haematoma and vaginal prolapse rates are comparable. Higher rates of clitoral necrosis, urethral meatal stenosis, and wound infection are reported in PI. However, the ability to orgasm, ability to have penetrative sexual intercourse, and satisfaction with aesthetic result are better with PI.
Conclusions:
The evidence for GRS complications and functional outcomes is of low level. Standardised nomenclature reporting of adverse events and robust patient-reported outcome measures (PROMs) are lacking. PROMs are a powerful assessment tool, and standardised definitions of adverse events and functional outcomes should be a priority of future research.
Patient summary:
We looked at all studies published on genital reconstructive surgery from 1950 to the present day. We assessed each surgical technique and their associated complication rates, sexual and urinary function outcomes, and how they were reported. We found the evidence to be low and weak. We suggest more robust ways of reporting complications, and the impact on patients' quality of life should be investigated.
Dr. Georges Burou führte 1956 die erste erfolgreiche, genitalangleichende Operation bei einer Mann-zu-Frau-transsexuellen Patientin durch. Seitdem galt bei Mann-zu-Frau geschlechtsangleichenden Eingriffen die penile Invaginationsmethode lange Zeit als goldener Standard. Eine Weiterentwicklung dieser Technik wurde notwendig, um alle Bestandteile einer Vulva mit ausreichender Tiefe der Neovagina gewährleisten zu können. Das Kapitel schildert den geschichtlichen Ursprung der Methodik sowie die Weiterentwicklung der operativen Technik mit Darstellung der Kombinierten Methode zur chirurgischen genitalen Angleichung bei Mann-zu-Frau Transsexualität.
Creation of a neovagina is usually necessary in the following cases: congenital absence of the vagina, vaginal contracture and stenosis, reconstruction following neoplastic resective surgery or radiotherapy, and gender affirmation surgery. While there is no standard procedure for neovaginal reconstructive surgery, there exist many surgical and nonsurgical techniques that are often used to create the vagina. These techniques include vaginal dilation methods, the McIndoe vaginoplasty procedure with the use of split-thickness skin grafts, modified McIndoe procedures using full-thickness skin and mucosal grafts, transpositional skin graft techniques, laparoscopic techniques including the Davydov and Vecchietti operations, myocutaneous and fasciocutaneous pedicled flap surgeries, and intestinal flap surgeries. The ideal reconstructive method should provide a patent vaginal canal of adequate length, width, and texture that will allow for sexual intercourse, provide a cosmetically appealing appearance with minimal morbidity of both the recipient and donor surgical sites, and have a low incidence of overall complications. Construction of the neovagina can be very complex and challenging. Each method of repair has its advantages and disadvantages, which should be carefully weighed with the desired treatment goals as well as the surgeon’s experience with various surgical techniques.
Objective:
To assess the feasibility of intraoperative use of indocyanine green (ICG) fluorescent angiography in laparoscopic intestinal vaginoplasty to determine intestinal segment perfusion and viability.
Design:
Intestinal vaginoplasty may be performed as a vaginal (re)construction procedure. During surgery, a pedicled intestinal segment is transferred caudally to line the neovaginal cavity. Most commonly, a sigmoid or ileal segment is used. In obtaining adequate mobility of the segment, arterial structures sometimes have to be sacrificed, with possible detrimental effects on segment perfusion and subsequently viability. ICG may be used as an aid to assess segment perfusion. We present a case series of six consecutive patients who underwent intestinal vaginoplasty with intraoperative use of ICG.
Setting:
Tertiary university hospital.
Patient(s):
Six transgender women undergoing laparoscopic sigmoid vaginoplasty with intraoperative use of ICG from October 2017 to October 2018.
Intervention(s):
Intraoperative use of ICG in laparoscopic sigmoid vaginoplasty to determine sigmoid segment perfusion and viability.
Main outcome measure(s):
Value and feasibility of ICG in this reconstructive procedure.
Result(s):
Intraoperative use of ICG demonstrated segment viability in five patients. In one patient, vascularization of the segment was deemed to be inadequate and reconstruction was aborted.
Conclusions:
ICG fluorescent angiography may be used intraoperatively to assess perfusion of the pedicled sigmoid segment during sigmoid vaginoplasty.
"Surgical (re)construction of a vagina (vaginoplasty) is performed in biological women with congenital or postablative vaginal absence and in transgender women. Penile inversion vaginoplasty is the gold surgical standard for genital Gender Affirmation Surgery in transgender women. In absence of sufficient penoscrotal skin, due to penoscrotal hypoplasia, circumcision, penile trauma with loss of penile skin quantity and/or quality, or when primary vaginoplasty has failed, intestinal vaginoplasty can be performed. This article provides an update on surgical indications of intestinal vaginoplasty, operative technique, perioperative care, and short- and long-term postoperative issues. A review of recent literature is performed."
Improvements to vulvar aesthetics, particularly the clitoral complex and labia minora reconstruction, are difficult and remain the challenge of genital reconstructive surgeons. Various modifications of penile inversion technique have been introduced to improve vulvar aesthetics in recent years. Generally penile inversion vaginoplasty leaves limited penile tissue to reconstruct the natural labia minora. This article describes improvements made to overcome substantial limitations of the widely used traditional penile inversion vaginoplasty technique, with emphasis on creating a realistic vulvar aesthetic appearance in all respects, without compromising sexual sensation or vaginal depth.
Introduction:
The aim of this study is to accomplish a systematic review on the surgical techniques available for male-to-female gender assignment surgery (MtoF GAS) published in the last 15 years, from January 2002 to May 2017, assessing advantages and disadvantages.
Evidence acquisition:
A specific search on MEDLINE, Scopus and Web of Science databases included vaginoplasty for gender exchange. Preoperative (age, gender, body mass index, prior surgery), intraoperative (mean operating time, intraoperative complications, transfusion rate, conversion rate), postoperative (hospital stays, readmission rate, early and late complication rate), postoperative sexual activity, subjective satisfaction, vaginal depth, and long-term outcomes (vaginal stenosis, prolapse, dyspareunia and labial abscess) data of vaginoplasty for sexual exchange were collected. 29 articles were included (2.402 patients).
Evidence synthesis:
Out of the 29 papers, 19 studies assessed penile skin inversion and 10 evaluated intestinal vaginoplasty. No comparative studies were found. Penile skin inversion vaginoplasty reported slightly shorter operative time compared to intestinal vaginoplasty (109-420 vs 145-420 minutes). Intraoperative complications for penile skin inversion vaginoplasty not exceeded an incidence of 10%. No significant differences in terms of postoperative complications or hospitalization time were reported. Intestinal vaginoplasty provides a deeper neovagina. Female Sexual Function Index score was significantly higher in patients undergoing intestinal vaginoplasty.
Conclusions:
A standardized data collection may allow a better understanding of effectiveness and outcomes of different techniques.
Gender-affirming surgeries expand the options for physical transition among transgender patients, those whose gender identity is incongruent with the sex assigned to them at birth. Growing medical insight, increasing public acceptance, and expanding insurance coverage have improved the access to and increased the demand for gender-affirming surgeries in the United States. Procedures for transgender women, those patients with feminine gender identity, include breast augmentation using implants and genital reconstruction with vaginoplasty. Some transgender women receive medically unapproved silicone injections for breast augmentation or other soft-tissue contouring procedures that can lead to disfigurement, silicone pulmonary embolism, systemic reactions, and even death. MRI is preferred over CT for postvaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men, patients with a masculine gender identity, include chest masculinization (mastectomy) and genital reconstruction (phalloplasty or metoidioplasty, scrotoplasty, and erectile device implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as leaks and fistulas. Despite a sizeable growth in the surgical literature about gender-affirming surgeries and their outcomes, detailed descriptions of the imaging features following these surgeries remain sparse. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation. Online supplemental material is available for this article.©RSNA, 2019.
Introduction:
Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Sexual health post-vaginoplasty is an important aspect of quality of life that can have a significant impact on overall well-being.
Objectives:
The objective of this review is to provide a summary of the literature on the sexual outcomes of transgender females post-vaginoplasty and identify treatment strategies for those experiencing sexual dysfunction.
Methods:
A literature review was conducted with a focus on sexual health outcomes in transgender females post-vaginoplasty as well as treatment options for sexual dysfunction.
Results:
Penile inversion vaginoplasty with or without free skin grafts or local tissue flaps and intestinal vaginoplasty are the options available to patients interested in transfeminine genital reconstructive surgery with a neovagina. Sexual satisfaction post-vaginoplasty is high regardless of the vaginoplasty technique, however up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance. Hormone treatment, pelvic floor physical therapy, sex therapy, and sex surrogacy are treatment options for patients with sexual dysfunctions.
Conclusion:
Patient reported outcome measures appropriately validated for this patient population are necessary to better understand sexual function outcomes, sexual dysfunction and treatment options for post-vaginoplasty patients. Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.
For transgender women, genital adjustment surgery involves removal of the natal reproductive organs and creation of a neovagina, vulva and clitoris. We conducted a review of the medical literature in order to summarise the issues that can affect the health of the neovagina in the long term, and to make recommendations on how to manage these issues.
To clarify whether bowel preparation use or its individual components [mechanical bowel preparation (MBP)/oral antibiotics] impact specific outcomes after colorectal surgery.
National Surgical Quality Improvement Program-targeted colectomy data initiated in 2012 capture information on the use/type of bowel preparation and colorectal-specific complications. For patients undergoing elective colorectal resection, the impact of preoperative MBP and antibiotics (MBP+/ABX+), MBP alone (MBP+/ABX-), and no bowel preparation (no-prep) on outcomes, particularly anastomotic leak, surgical site infection (SSI), and ileus, were evaluated using unadjusted/adjusted logistic regression analysis.
Of 8442 patients, 2296 (27.2%) had no-prep, 3822 (45.3%) MBP+/ABX-, and 2324 (27.5%) MBP+/ABX+. Baseline characteristics were similar; however, there were marginally more patients with prior sepsis, ascites, steroid use, bleeding disorders, and disseminated cancer in no-prep. MBP with or without antibiotics was associated with reduced ileus [MBP+/ABX+: odds ratio (OR) = 0.57, 95% confidence interval (CI): 0.48-0.68; MBP+/ABX-: OR = 0.78, 95% CI: 0.68-0.91] and SSI [MBP+/ABX+: OR = 0.39, 95% CI: 0.32-0.48; MBP+/ABX-: OR = 0.80, 95% CI: 0.69-0.93] versus no-prep. MBP+/ABX+ was also associated with lower anastomotic leak rate than no-prep [OR = 0.45 (95% CI: 0.32-0.64)]. On multivariable analysis, MBP with antibiotics, but not without, was independently associated with reduced anastomotic leak (OR = 0.57, 95% CI: 0.35-0.94), SSI (OR = 0.40, 95% CI: 0.31-0.53), and postoperative ileus (OR = 0.71, 95% CI: 0.56-0.90).
These data clarify the near 50-year debate whether bowel preparation improves outcomes after colorectal resection. MBP with oral antibiotics reduces by nearly half, SSI, anastomotic leak, and ileus, the most common and troublesome complications after colorectal surgery.
Gender reassignment (which includes psychotherapy, hormonal therapy and surgery) has been demonstrated as the most effective treatment for patients affected by gender dysphoria (or gender identity disorder), in which patients do not recognize their gender (sexual identity) as matching their genetic and sexual characteristics. Gender reassignment surgery is a series of complex surgical procedures (genital and nongenital) performed for the treatment of gender dysphoria. Genital procedures performed for gender dysphoria, such as vaginoplasty, clitorolabioplasty, penectomy and orchidectomy in male-to-female transsexuals, and penile and scrotal reconstruction in female-to-male transsexuals, are the core procedures in gender reassignment surgery. Nongenital procedures, such as breast enlargement, mastectomy, facial feminization surgery, voice surgery, and other masculinization and feminization procedures complete the surgical treatment available. The World Professional Association for Transgender Health currently publishes and reviews guidelines and standards of care for patients affected by gender dysphoria, such as eligibility criteria for surgery. This article presents an overview of the genital and nongenital procedures available for both male-to-female and female-to-male gender reassignment.
Learning objectives:
After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism.
Background:
Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons.
Methods:
The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism.
Results:
Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined.
Conclusions:
This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.
Objective:
To assess the endoscopic characteristics of the sigmoid-derived neovagina, which have been scarcely described.
Design:
Prospective observational study.
Setting:
University tertiary medical center.
Patient(s):
Patients that underwent sigmoid vaginoplasty.
Intervention(s):
Patients were invited yearly to undergo neovaginoscopy and sigmoidoscopy, preceded by taking a medical history and physical examination, as routine follow-up.
Main outcome measure(s):
Endoscopic signs of neovaginal inflammation.
Result(s):
Thirty-four patients with a sigmoid neovagina underwent a total of 43 combined neovaginoscopies and sigmoidoscopies. After a mean postoperative time of 23 months, the most notable endoscopic features of the sigmoid-derived neovagina comprised a diminished vascular pattern, edema, granularity, friability, decreased resilience, and erythema. In the control rectosigmoidoscopy images, no concurrent abnormalities were observed. When applying the MAYO score to the neovaginal images, 12 (35%) patients scored MAYO 0, 19 (56%) MAYO I, 3 (9%) MAYO II, and none MAYO III. The presence of neovaginal discharge and malodor correlated with inflammatory endoscopic alterations.
Conclusion(s):
The endoscopic appearance of a sigmoid segment after use in neovaginoplasty differs significantly from that of the remaining rectosigmoid. Inflammatory changes of the sigmoid-derived neovagina were observed in most patients. Clinically, the inflammatory changes appear similar to those encountered in diversion colitis.
Aims:
Autologous intestinal grafts are used to (re)create a vagina in selected patients. The risk of diversion colitis is mentioned as a disadvantage, although its prevalence remains unclear. This study aimed to assess the histopathological characteristics of the sigmoid-derived neovaginal epithelial lining after diverting surgery and correlate these with clinical findings.
Methods and results:
Biopsy specimens were obtained from the epithelial lining of the sigmoid-derived neovagina and remaining rectosigmoid as regular follow-up from 26 patients with a median age of 22 years (range 19-52) and median postoperative follow-up of 13 months (range 6-52). Medical history, neovaginal symptoms and sexual activity were documented. An experienced gastrointestinal histopathologist assessed the specimens using a descriptive item-score, comprising signs of chronic and active inflammation. Inflammatory changes were observed in 21 (80.7%) neovaginal and 1 (3.8%) rectosigmoid specimens. The neovaginal appearance was characterized by an increase of lymphoid aggregates and lymphoplasmacellular infiltrate. Other common features were presence of polymorphonuclear neutrophils and Paneth cell metaplasia. Neovaginal discharge was correlated with the presence of inflammatory changes (p=0.008, Spearmans rho=0.506).
Discussion:
Acute and chronic inflammation of the sigmoid-derived neovagina was commonly observed and consistent with a proposed diagnosis of diversion neovaginitis. Neovaginal discharge correlates with this histopathological entity. This article is protected by copyright. All rights reserved.
Favorable outcomes of rectosigmoid neocolporrhaphy have previously been reported. Unfortunately, rectosigmoid transfers are still perceived negatively, usually relegated to secondary vaginoplasties. This study aims to provide an objective investigation into the safety and efficacy of rectosigmoid neocolporrhaphy for vaginoplasty in male-to-female transsexual patients.
A retrospective review was performed on male-to-female patients who had undergone rectosigmoid neocolporrhaphy performed by the senior author. Patient data including demographics, medical history, complications, and the need for revision surgery were obtained. Direct inquires were conducted to determine patients' level of satisfaction with appearance, sexual function, and ease of postoperative recovery.
Eighty-three patients were included over the course of 22 years, with an average clinical follow-up of 2.2 years (83 patients) and phone interview follow-up of 23 years (21 patients). Overall, the patients were healthy, with minimal comorbidities. Forty-eight patients (58 percent) had complications, but the majority (83.3 percent) were minor and consisted mainly of introital stricture or excessive protrusion of the corpus spongiosum. Smoking was associated with higher complication rates (p = 0.05), especially stricture formation. Excessive mucorrhea occurred in 28.6 percent but resolved after the first year. Overall patient satisfaction with appearance and sexual function was high.
This study is one of the largest and longest reported series of rectosigmoid transfers for vaginoplasty in transsexual patients. Rectosigmoid neocolporrhaphies have many times been recommended for secondary or revision surgery when other techniques, such as penile inversion, have failed. However, the authors believe the rectosigmoid transfer is safe and efficacious, and it should be offered to male-to-female patients for primary vaginoplasty.
Therapeutic, IV.
Absence of a vagina owing to congenital Mullerian defects or other acquired causes requires reconstruction of the female genital passage. We present our experience using various bowel segments.
Bowel vaginoplasty was performed in 55 patients from January 2004 through May 2014 for cervicovaginal atresia (20), Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome (20), distal vaginal atresia (8), cloaca (2), cervical atresia (1), complex urogenital sinus (1), transverse vaginal septum (1), rhabdomyosarcoma of the vagina (1), and traumatic stricture of the vagina (1). The bowel segments used were sigmoid (50), ileum (2), anorectovestibular fistula ( 2), and loop rectovaginoplasty (1).
Thirty-nine patients who had the proximal vagina or uterus anastomosed to the bowel segment reported regular menstrual flows. Three patients are sexually active with satisfactory coital function. None of our patients developed pyometra. Five patients had neovaginal mucosal prolapse. Two patients had severe stenosis requiring excision of the neovagina. Seven patients had mild stenosis requiring dilatations in 6 patients and V-Y meatoplasty for 1 patient. One patient had a descending colon anastomotic leak requiring a diversion ileostomy.
Genital reconstruction with bowel vaginoplasty is a highly skilled operation that provides a durable and lubricated replacement of the vagina with good outcomes. Utero-coloneovaginoplasty is a safe procedure preserving the menstrual flow in patients with a functional uterine fundus.
Introduction:
Gender reassignment surgery is the keystone of the treatment of transgender patients. For male-to-female transgenders, this involves the creation of a neovagina. Many surgical methods for vaginoplasty have been opted. The penile skin inversion technique is the method of choice for most gender surgeons. However, the optimal surgical technique for vaginoplasty in transgender women has not yet been identified, as outcomes of the different techniques have never been compared.
Aim:
With this systematic review, we aim to give a detailed overview of the published outcomes of all currently available techniques for vaginoplasty in male-to-female transgenders.
Methods:
A PubMed and EMBASE search for relevant publications (1995-present), which provided data on the outcome of techniques for vaginoplasty in male-to-female transgender patients.
Main outcome measures:
Main outcome measures are complications, neovaginal depth and width, sexual function, patient satisfaction, and improvement in quality of life (QoL).
Results:
Twenty-six studies satisfied the inclusion criteria. The majority of these studies were retrospective case series of low to intermediate quality. Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization.
Conclusions:
The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data.
To determine the association between preoperative bowel preparation and 30-day outcomes after elective colorectal resection.
Patients from the 2012 Colectomy-Targeted American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database who underwent elective colorectal resection were included for analysis and assigned to 1 of 4 groups based on the type of preoperative preparation they received [combined mechanical and oral antibiotic preparation (OAP), mechanical preparation only, OAP only, or no preoperative bowel preparation]. The association between preoperative bowel preparation status and 30-day postoperative outcomes was assessed using multivariate regression analysis to adjust for a robust array of patient- and procedure-related factors.
A total of 4999 patients were included for this study [1494 received (29.9%) combined mechanical and OAP, 2322 (46.5%) received mechanical preparation only, 91 (1.8%) received OAP only, and 1092 (21.8%) received no preoperative preparation]. Compared to patients receiving no preoperative preparation, patients who received combined preparation demonstrated a lower 30-day incidence of postoperative incisional surgical site infection (3.2% vs 9.0%, P < 0.001), anastomotic leakage (2.8% vs 5.7%, P = 0.001), and procedure-related hospital readmission (5.5% vs 8.0%, P = 0.03). The outcomes of patients who received either mechanical or OAP alone did not differ significantly from those who received no preparation.
Combined bowel preparation with mechanical cleansing and oral antibiotics results in a significantly lower incidence of incisional surgical site infection, anastomotic leakage, and hospital readmission when compared to no preoperative bowel preparation.
Background:
Laparoscopy has increasingly become the standard of care for patients who undergo colorectal surgery for both benign and malignant disease. On the basis of this growing experience, there is now an expanded role for laparoscopic approach to postoperative complications after primary colorectal resection. However, there is little literature specific to this topic. We report a ten-year experience with laparoscopic treatment of early complications following laparoscopic colorectal surgery.
Methods:
From January 2003 to December 2012, a total of 1,292 patients underwent elective laparoscopic colorectal surgery in our department. One hundred and two (7.9%) patients required reoperation for a postoperative complication. Laparoscopy has been also adopted as the preferred procedure for management of postoperative complications. A retrospective review of 84 patients who had relaparoscopy (RL) for postoperative complications, including peritonitis, ureteral injury, bowel obstruction, and bleeding, was performed.
Results:
Reoperation was carried out laparoscopically in 79 (94.0%) patients. Five (6.0%) conversions were necessary because of massive colonic ischemia, generalized fecal peritonitis, and lack of working space. The most common finding at RL was anastomotic leakage (57.1%) that was managed by peritoneal lavage and ileostomy in 91.7% of cases. Six percent of patients had negative RL. Overall morbidity rate was 25.0%. Five patients required additional surgery: four (5.1%) after RL and one after a converted procedure. There were five (6.0%) deaths from septic shock, myocardial infarction, and pulmonary embolism.
Conclusions:
Laparoscopy is a safe and effective tool for management of complications following laparoscopic colorectal surgery. In this setting, RL represents the first step of re-exploration and treatment, with no delay to conversion to open procedure even in skilled laparoscopic hands.
Background:
In recent years, puberty suppression by means of gonadotropin-releasing hormone analogs has become accepted in clinical management of adolescents who have gender dysphoria (GD). The current study is the first longer-term longitudinal evaluation of the effectiveness of this approach.
Methods:
A total of 55 young transgender adults (22 transwomen and 33 transmen) who had received puberty suppression during adolescence were assessed 3 times: before the start of puberty suppression (mean age, 13.6 years), when cross-sex hormones were introduced (mean age, 16.7 years), and at least 1 year after gender reassignment surgery (mean age, 20.7 years). Psychological functioning (GD, body image, global functioning, depression, anxiety, emotional and behavioral problems) and objective (social and educational/professional functioning) and subjective (quality of life, satisfaction with life and happiness) well-being were investigated.
Results:
After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.
Conclusions:
A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provides gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.
Introduction:
Vaginal (re)construction is essential for the psychological well-being of biological women with a dysfunctional vagina and male-to-female transgender women. However, the preferred method for vagina (re)construction with respect to functional as well as aesthetic outcomes is debated. Regarding intestinal vaginoplasty, despite the asserted advantages, the need for intestinal surgery and subsequent risk of diversion colitis are often-mentioned concerns. The outcomes of vaginal reconstructive surgery need to be appraised in order to improve understanding of pros and cons.
Aims:
To review literature on surgical techniques and clinical outcomes of intestinal vaginoplasty.
Methods:
Electronic databases and reference lists of published articles were searched for primary studies on intestinal vaginoplasty. Studies were included if these included at least five patients and had a minimal follow-up period of 1 year. No constraints were imposed with regard to patient age, indication for vaginoplasty, or applied surgical technique. Outcome measures were extracted and analyzed.
Main outcome measures:
Main outcome measures were surgical procedure, clinical outcomes, and outcomes concerning sexual health and quality of life.
Results:
Twenty-one studies on intestinal vaginoplasty were included (including 894 patients in total). All studies had a retrospective design and were of low quality. Prevalence and severity of procedure-related complications were low. The main postoperative complication was introital stenosis, necessitating surgical correction in 4.1% of sigmoid-derived and 1.2% of ileum-derived vaginoplasties. Neither diversion colitis nor cancer was reported. Sexual satisfaction rate was high, but standardized questionnaires were rarely used. Quality of life was not reported.
Conclusion:
Based on evidence presently available, it seems that intestinal vaginoplasty is associated with low complication rates. To substantiate these findings and to obtain information about functional outcomes and quality of life, prospective studies using standardized measures and questionnaires are warranted.
The purpose of this article is to report on the most recent findings on the current surgical treatments for sex reassignment surgery for both male-to-female and female-to-male transsexuals.
For male-to-female sex reassignment surgery, researches aim to refine the inverted peno-scrotal flap surgical technique in order to increase the neovaginal length and width, prevent complications and ameliorate the cosmetic outcome.Bowel segment vaginoplasty, used mainly for secondary cases, is becoming more and more common.For female-to-male sex reassignment surgery, the radial forearm flap is the only procedure that has proved to fulfil most of the patient expectations; however, because of a high complications rate, long recovery time and a large number of the required operations, and the absence of guarantee that patients will be satisfied, the free radial forearm flap is not the best option for every patient. Alternatives such as abdominal/groin flap, thigh flap and metaidoioplasty are very much used.
In order to provide the best care for transsexual patients, centres performing sex reassignment surgery should co-operate and implement both the refinements and the new techniques offered and/or requested.
Introduction and hypothesis:
The aim of this study was to compare the effectiveness and long-term anatomic and functional results of laparoscopic peritoneal vaginoplasty and laparoscopic sigmoid vaginoplasty.
Methods:
From January 2002 to December 2010, 40 patients with congenital vaginal agenesis were prospectively randomized to undergo either laparoscopic peritoneal vaginoplasty (26 cases) or laparoscopic sigmoid vaginoplasty (14 cases) in 2:1 ratio. Pre- and postoperative examination findings, Female Sexual Function Index (FSFI) questionnaire responses, and sexual satisfaction rates are reported.
Results:
All surgical procedures were performed successfully, with no intraoperative complications. The laparoscopic peritoneal vaginoplasty group had significantly less blood loss and a surgery shorter on average than the laparoscopic sigmoid colovaginoplasty group. Postoperative course was uneventful for all patients in both groups, though postoperative retention time and hospital stay were less for peritoneal vaginoplasty patients than for sigmoid vaginoplasty patients. Mean neovaginal length, excessive mucous production, sexual life initiation time, and sexual satisfaction rate were similar between groups. Patient complaints of abdominal discomfort, unusual odor from vaginal secretions, and vaginal contraction during intercourse were higher in the sigmoid colovaginoplasty group (p < 0.005 vs. peritoneal vaginoplasty). Postoperative FSFI scores did not differ significantly between groups.
Conclusions:
Relative to laparoscopic sigmoid colovaginoplasty, laparoscopic peritoneal vaginoplasty provides good anatomic and functional results and excellent patient satisfaction.
In the past several decades we have seen multiple advances in the reconstruction for girls born with vaginal agenesis. This study aimed to evaluate the technical feasibility, anatomical and functional outcomes of one-stage laparoscopic and gasless laparoscopic vaginoplasty with sigmoid colon for the patients of vaginal agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome).
We did a retrospective review of a total of 150 women with Mayer-Rokitansky-Kuster-Hauser syndrome treated at Beijing Anzhen Hospital, Capital Medical University from March 2006 to August 2010. The patients were divided into the CO2 pneumoperitoneum laparoscopic group and the abdominal wall lift of gasless laparoscopic group. Sigmoid colon vaginoplasty approaches were performed in all of the patients. The surgical techniques, perioperative results, complications, anatomical and functional outcomes of vaginoplasty were recorded.
All procedures were performed successfully. Significant differences in the operative time and intraoperative blood loss existed in the laparoscopic vaginoplasty group compared with the gasless laparoscopic vaginoplasty group. The patients who underwent sigmoid colon vaginoplasty had good cosmetic results without the problem of excessive mucus production. The postoperative complications were minimal. During a mean follow-up of 15.6 months, no stenosis or shrinkage was encountered. The subjective sexual satisfaction rate with the surgical outcomes in all patients was 83.3%.
Laparoscopic or gasless laparoscopic vaginoplasty with sigmoid colon are effective and feasible approaches for women with congenital vaginal agenesis. The procedures have satisfactory anatomical and functional results.
Prolapse of a sigmoid neovagina, created in patients with congenital vaginal aplasia, is rare. In correcting this condition, preservation of coital function and restoration of the vaginal axis should be of primary interest. A 34-year-old woman with vaginal agenesis underwent vaginoplasty using sigmoid colon. Almost 6 years after the initial operation, she started complaining of a bearing-down sensation and an increase in vaginal discharge. She underwent 2 open surgeries and one vaginal surgery to treat the prolapse with no success. She came to our service and at vaginal examination the neovagina protruded approximately 5 cm beyond the hymen. The prolapse was treated successfully using a laparoscopic approach to suspend the neovagina to the sacral promontory (laparoscopic promontofixation). Prolapse of an artificially created vagina is a rare occurrence, without a standard treatment. Laparoscopy may be an alternative approach to restore the neovagina without compromising its function.
There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue.
To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence.
Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures. Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires.
Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%).
Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.
To identify predictive risk factors for intra- and postoperative complications in patients undergoing laparoscopic colorectal surgery.
In emergency situations or in elective open and laparoscopic colorectal surgery, there are many risk factors that should be recognized by the surgeon to reduce complications and initiate adequate treatment. Most available data, thus far, refer to open colorectal surgery and literature that focuses mainly on a laparoscopic approach is still rare.
Univariate and multivariate analyses of a prospectively gathered database (1993-2006) were performed on a consecutive series of patients (1316) undergoing laparoscopic colorectal surgery who were operated at a single institution (first referral center). Patients were assessed for demographic data, operative indications, type of resection, and intra- and postoperative complications. Altogether, we analyzed 20 potential risk factors to identify significant influence on the intra- and postoperative outcome.
Significant risk factors that led to intraoperative complications consisted of age > or = 75 years and malignant neoplasia. Increased postoperative rate of surgical complications was significantly influenced by male gender, age > or = 75 years, American Society of Anesthesiology class > or = III, malignant neoplasia, and the experience of the surgeon. The analysis of specific medical postoperative complications revealed even more significant predictive risk factors. In addition, our analysis showed that specific risk factors predict specific complications such as postoperative bleeding, anastomotic leakage, and surgical site infections. The type of surgical procedure performed also influenced patient outcome.
This large single center study provides the first evidence of the significance of predictive risk factors for intra- and postoperative complications in laparoscopic colorectal surgery.
Background/purpose:
The absence of vagina is rare in the pediatric population. It can occur as a result of congenital malformations such as an aplasia of mullerian ducts (46,XX Mayer-Rokitansky-Küster-Hauser syndrome) or a complete androgen insensitivity syndrome (46,XY testicular feminizing syndrome). Intersex patients, who underwent reassessment of a female sex, need a genital reconstruction toward a feminine phenotype. Patients with congenital adrenogenital syndrome with high urogenital sinus could have a severe hypoplastic vagina. In all these cases, a vaginal replacement is required. We reviewed our experience of vaginal replacement using a sigmoid conduit.
Methods:
In 34 years, we evaluated 47 patients. The observation period was from 1 to 34 years (mean: 12 years). The preoperative diagnosis was Mayer-Rokitansky-Küster-Hauser syndrome in 17 cases, androgen insensitivity syndrome in 24 cases, adrenogenital syndrome with high urogenital sinus in 5 and 1 patient was affected by penile agenesis. Forty-six patients were treated with vaginal reconstruction by interposition of sigmoid colon. Only in 1 case we performed a vaginal construction with an ileal loop: in this case, the sigmoid colon was extremely dilated by a chronic constipation secondary to a high anorectal malformation corrected at birth.
Results:
The outcome for 47 patients is excellent: 18 are sexually active and 4 are married. Only 1 patient with adrenogenital syndrome died of endocrine problems. Complications occurred in 17 cases: in 1 patient a necrosis of the replaced vagina occurred, thus requiring vaginal exeresis; now she is waiting for a second operation. Another patient had an abdominal abscess, which was surgically treated. In 12 cases a second procedure was required: 6 had stenotic new-vaginal introitus, 4 had new-vaginal prolapse, and 2 had intestinal obstruction.
Conclusions:
We believe that the preferable technique for vaginal replacement is the use of intestinal conduit. The sigmoid colon is the best intestinal tract to be used owing to its size, location and preserved blood supply. Our experience leads us to believe that the sigmoid segment is the segment of choice, although we consider ileal loop as a good alternative when the sigmoid colon is not available.
To investigate the long-term effects of intestinal vaginoplasty in cases with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.
Prospective study.
Division of Pelvic Reconstructive Surgery, Department of Gynecology and Obstetrics, at a women's and children disease education and research hospital.
Between 2003 and 2009, 29 patients with MRKH syndrome underwent intestinal vaginoplasty.
Two of the patients were treated with ileal and 27 with sigmoid vaginoplasty.
The age, marital status, associated anomalies, method used for bowel transposition (isoperistaltic/antiperistaltic), type of abdominal incision, and intra- and postoperative complications were evaluated.
One of the patients for whom ileal vaginoplasty was performed had 40 cm ileal necrosis requiring bilateral ileostomy for 2 months. Introital stenosis was detected in 15 cases (79%) who were unmarried, while none of the married cases had introital stenosis. However, all patients responded to finger-dilatation. All married patients were sexually satisfied after operation. An intraluminal abscess developed in the proximal segment of the neovagina owing to stricture occurring above abdominoperineal tunnel 2 years after operation. In another patient who had a rudimentary uterine horn, hematometra developed 3 years after operation and treated with resection.
In our experience, sigmoid vaginoplasty seems to be a favorable procedure which provides excellent long-term results for the patients with vaginal agenesis.
Vaginoplasty for congenital vaginal atresia, a component of the Mayer-Rokitansky-Kuster syndrome, or for gender confirmation, may be achieved by several techniques. This report focuses on the efficacy of rectosigmoid neocolporrhaphy (RSNC) performed either primarily or secondarily after failure of another procedure.
Sixty patients underwent isoperistaltic RSNC, three primarily and 57 secondarily. The indication was vaginal atresia in 1 patient and gender dysphoria in 59 patients.
All 60 patients survived and have a functional neovagina. One major complication, an anastomotic leak with colovaginal fistula, was treated by a temporary colostomy and later reconstruction through a combined anterior and posterior approach. Late complications were reversible stomal stenosis (six patients), reversible conduit narrowing (five patients), transient rhabdomyoblastosis (one patient), and temporary mucosal bleeding from hyperplasia (three patients). Thirty patients have regular intercourse, 12 patients have occasional intercourse, and the others feel "whole," with their intact desired sexual anatomy awaiting a suitable partner.
The number of patients seeking vaginoplasty is increasing. Primary or secondary RSNC is a safe and effective method.
For correction of the absence of vagina, sigmoidal colpoplasty is believed to provide a neovagina immediately adequate and with permanent patency. We present one of the largest series and discuss advantages and drawbacks of this procedure.
Our personal technique is described and 16 consecutive cases are reviewed. Anatomical (depth and width of the neovagina) and functional (existence of discharge and coital function) aspects are addressed.
An adequate neovagina was obtained in every case, however, in nine cases iterative dilatations were previously required. Two prolapses of the nevagina were noticed and required surgical treatment. The follow up ranges from 6 to 36 months. At this point, only nine patients report intercourse. In five cases a psychological brake is strongly suspected to interfere. Four patients experience significant discharge.
Despite satisfactory anatomical results, the sigmoid neovagina is not always immediately suitable. Complete adequacy for coital function often requires prolonged care and support.
The use of sigmoid colon segments to repair congenital deformities of the vagina is well established. There are little data, however, on complications or functional results in these patients. The purpose of this study was to evaluate complication rates and long-term patient outcomes in the use of sigmoid segments in vaginal reconstruction for congenital anomalies.
The authors identified 28 patients who underwent vaginal reconstruction with sigmoid colon segments between 1985 and 2000 at their institution. Patient charts were reviewed for surgical technique, complication rates, cosmetic results, functional results, and psychosocial development. Patients were recalled for physical examinations and personal interviews to assess current status.
Of the 28 patients, 13 had male pseudohermaphroditism, 6 had Mayer-Rokitansky-Kuster-Hauser syndrome, 2 had true hermaphroditism, 2 had mixed gonadal dysgenesis, 2 had common urogenital sinus syndrome, 2 had adrenogenital syndrome, and 1 had penile agenesis. Mean patient age was 16 years (range, 6 to 21 years). Mean follow-up was 6.2 years (range, 2 months to 15 years). Postoperative complications included introital stenosis (4 patients), mucosal prolapse (4), partial small bowel obstruction (2), perineal wound hematoma (2), superficial wound infection (2), and vaginal prolapse (1). None of the complications have affected long-term patency or cosmesis of the neovagina, nor has mucous production significantly affected quality of life. Fourteen of 16 (88%) adult patients are heterosexually active, 1 is homosexually active, and 1 is asexual. Of the 14 heterosexually active patients, 11 (79%) are "very satisfied" with their psychosexual development and 3 are "comfortable." Four patients are married, and 1 has carried a child to term. All adult patients felt that the appropriate time to undergo surgery was in adolescence.
Reconstruction with sigmoid segments is an effective approach for many congenital conditions requiring vaginal reconstruction. Although surgical outcomes are not perfect, appropriately timed reconstructive vaginal surgery can provide most patients with an improved quality of life. For the best long-term results, a multidisciplinary team must be available from infancy to supply comprehensive support.
Many methods are used for vaginoplasty, including the split-thickness skin graft, full-thickness skin graft, and inverted penile skin flap. However, these procedures are not entirely satisfactory in cases of reconstructed vaginal stenosis, inadequate vaginal length, or poor lubrication. The small intestine, ascending colon, and sigmoid colon can be used in the intestinal flap method, and the authors modified the operation first described by Baldwin in which a loop of rectosigmoid is isolated, closed at one end, and brought down on its vascular pedicle as a neovagina and then anastomosed to the perineum. Vaginoplasty using the rectosigmoid was performed in 36 patients (28 male-to-female transsexual patients, five patients with congenital vaginal atresia, and three with cervical cancer). The follow-up period ranged from 1 to 10 years. The postoperative results were analyzed through physical examination and interview regarding the patient's functional status and satisfaction during sexual intercourse. The mean depth and width of the vaginal cavity were 12.5 cm and 3.9 cm, respectively. Excessive mucosal discharge was seen in 8.3 percent, and malodor was found in 8.3 percent. All patients who had partners were able to have sexual intercourse; 2.8 percent of patients used lubricants and 5.6 percent used dilators before intercourse for more than a year postoperatively. During intercourse, 88.9 percent of the patients experienced orgasm. The cosmetic and functional results of rectosigmoid vaginoplasty were excellent. Thus, the advantages of rectosigmoid vaginoplasty are (1) rare contraction of the reconstructed vagina, (2) vaginal width and depth maintained without long-term vaginal stent, (3) spontaneous mucus production facilitating sexual intercourse, (4) avoidance of the malodor frequently accompanying skin graft, and (5) texture and appearance similar to that of the natural vagina. The authors concluded that rectosigmoid vaginoplasty is the best choice for transsexual patients who have previously undergone penectomy and orchiectomy, patients with unfavorable previous vaginoplasty, those with short vaginal length after cervical cancer surgery, and patients with congenital vaginal atresia.
We report a 9-year experience with successful treatment of patients with vaginal atresia at a missionary hospital with decreased facilities in Bangladesh.
From 1995 to 2002, 20 patients 10 to 29 years old (average age 18.4) with Mayer-Rokitansky-Kuster-Hauser syndrome underwent total vaginal replacement. Ten of the 20 females were married and the anomaly was discovered after marriage. In the remaining 10 cases the diagnosis was suspected by the parents because of absent menstruation. In all patients the neovagina was created using a 12 to 14 cm segment of distal sigmoid colon.
Short-term morbidity was minimal. At the long-term followup, which was available for 16 patients, the neovagina had a good-appearing introitus. No stenosis, stones or colitis was reported. Six patients already had an active sexual life, which was reported to be satisfactory. Five couples had already adopted 1 or more children.
Good perioperative preparation and assistance, assurance of cyclical followup and a trained surgical team permitted successful treatment of a complex genital malformation at a missionary hospital with modest services. Sigmoid vaginoplasty in a developing country seems to be the best choice because of simple management and followup. Young women unable to procreate because of vaginal atresia seem to have an unexpected normal family and social acceptance in Bangladesh after complete vaginal replacement.
To assess the functional outcome and sexuality of patients after creation of a sigmoid neovagina.
Clinical study performed between 1992 and 2002, with a mean follow-up of 3.3 years (range, 6 months to 9 years).
Tertiary care center.
Sixteen consecutive patients with Rokitansky syndrome.
Creation of a neovagina with an antiperistaltic (n = 13) or isoperistaltic (n = 3) sigmoid graft and colovestibular anastomosis by interrupted suture (n = 11) or PCEEA forceps (n = 5). All patients had a neovaginal vault suspension (n = 16).
Functional results were evaluated in patients 6 or more months after the operation (n = 12) by using the standardized Female Sexual Function Index (FSFI). This index assesses four domains of sexual dysfunction: desire disorder, arousal disorder, orgasm disorder, and sexual pain disorder. Lubrification and "sexual" quality of life was also evaluated. Normal patients had a mean full FSFI score of 30 +/- 5 of 36.
The mean full FSFI score was 28 +/- 5 (range: 22-34). Seventy-two percent of patients had vaginal intercourse at least once a week; in this subset, the mean full FSFI score was 30 +/- 3 (range: 25-34).
Sigmoid neovagina allowed a normal sexual life in patients who had sexual relations.
To evaluate the long-term results of sigmoid vaginoplasty for Mayer-Rokitansky-Kuster-Hauser syndrome. The social and psychological acceptance of the procedure is also discussed in terms of a developing country scenario.
A total of 14 patients with Mayer-Rokitansky-Kuster-Hauser syndrome were treated at our institute from January 1995 to December 2004. Sigmoid vaginoplasty was performed in all patients. The procedure was performed using a combined abdominoperineal approach. Dissection was done between the urethra and rectum to create a bed for the neovaginal colon conduit. A 10-cm segment of sigmoid colon was raised on its vascular pedicle, delivered through the abdominoperineal tunnel, and fixed to the vaginal pit incision. The patient records were reviewed for surgical technique and postoperative complications. Patients underwent a personal interview to assess the postoperative results, social acceptance of the procedure, and sexual satisfaction.
The mean patient age at surgery was 16.8 years. The patients who underwent sigmoid vaginoplasty had good cosmetic results without the need for routine dilation or the problem of excessive mucus production. The postoperative morbidity was minimal. During a mean follow-up of 4.1 years, no stenosis or colitis was encountered. The subjective satisfaction rate with the surgical outcomes in all the patients was 8.01 on a scale of 0 to 10 (0, very disappointed to 10, satisfied).
Sigmoid vaginoplasty is an effective treatment for patients with vaginal atresia. Timed vaginal reconstruction in these patients allows for a better quality of life and social acceptance. It also enables the patient to lead a near-normal sexual life, with high satisfaction rates.
This study was conducted to evaluate the anatomical and functional results of sigmoid colon vaginoplasty. From June 2000 to June 2005, 26 patients with congenital vaginal agenesis were evaluated and treated with sigmoid colon reconstruction at Ain Shams University Maternity Hospital as a primary procedure in 17 patients and a secondary procedure in 9 patients after previous failed Abbe-McIndoe vaginoplasty elsewhere. The anatomical results were good in 22 patients, while 3 patients suffered from introital stenosis. Two of them were treated successfully by dilatation while one required Z-plasty. Eight patients were lost to follow-up and only ten patients are currently sexually active as the rest were divorced or remained unmarried. Of the sexually active patients, 8 (80%) had satisfactory intercourse whereas 2 (20%) complained of dyspareunia. Sigmoid colon vaginoplasty has satisfactory long-term anatomical and functional results and should be considered as primary option for the treatment of vaginal agenesis.
The Mayer-Rokitansky-Kuster-Hauser syndrome (Rokitansky syndrome) is a frequently misdiagnosed congenital anomaly of the female genital tract. Of several surgical treatments sigmoid vaginoplasty is among the few that provide a functional self-lubricating neovagina. We evaluated the results of sigmoid neovagina in girls affected by the Rokitansky syndrome.
We followed 26 patients with the Rokitansky syndrome between 1990 and 2005. Diagnosis was based on clinical examination, normal ovarian hormones and pelvic ultrasound or magnetic resonance imaging. Associated anomalies were detailed. Vaginoplasty was performed in 23 patients. Functional results and complications were assessed.
Renal anomalies were found in 11 patients (42%) and skeletal anomalies in 6 (23%). Six girls (23%) had a family history of the Rokitansky syndrome and/or renal agenesis. Vaginoplasty was performed at a mean age of 16 years (range 10.3 to 18.8). Median postoperative followup was 3.4 years. Postoperative complications included lower extremity compartment syndrome (1 patient), pelvic hematoma (1), mucosal prolapse (2), cystitis (2) and introital stenosis (1). Of the 23 patients undergoing surgery 9 (39%) had an active sex life postoperatively.
Sigmoid vaginoplasty is a valuable procedure in girls with the Rokitansky syndrome. We recommend reconstruction during adolescence because the local conditions are excellent and it allows adaptation of the anatomy to physical development.
We performed a historical cohort study of 62 consecutive patients who underwent abdomino-perineal vaginal re-construction with a segment of the sigmoid colon during a 25-year period. A dedicated database was reviewed for the aetiology of vaginal malformation, surgical complications and post-operative follow-up. Follow-up visits were scheduled 2, 6 and 12 months after discharge from hospital and annually thereafter. Fifty-eight (93.5%) patients were diagnosed as having Mayer-Rokitansky-Kuster-Hauser syndrome (MRKHS) and four (6.5%) had undergone previous demolitive surgery for gynaecologic malignancy. The mean operating time was 145 min (range 95 to 250 min). The mean hospital stay was 8.3 days (range 5 to 23 days). Post-operative complications requiring additional surgery occurred in 3 (4.8%) patients and were a case of necrotising fascitiis with leakage of the bowel anastomosis, a case of bowel occlusion and a case of neovaginal prolapse. The mean follow-up was 11.3 years (range 3 months to 24 years). We recorded 5 cases (8.1%) of sigmoid graft shrinkage treated successfully by dilation. The time interval between sigmoid vaginoplasty and first intercourse was 4 months (range 2 months to 4 years). During the follow-up, 32 (51.6%) women reported regular and 30 (48.4%) women reported occasional sexual intercourse; 80.6% (50/62) were "satisfied" with the surgical procedure. In this large series, laparotomic sigmoid vaginoplasty was a safe and acceptable technique to treat congenital absence of the vagina. This procedure allowed early sexual intercourse and was associated with a low incidence of shrinkage and a high rate of patients' satisfaction.
To evaluate the technical feasibility and anatomical and functional outcomes of laparoscopically assisted sigmoid colon vaginoplasty (LASV) in women with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome.
A retrospective review of prospectively collected data.
Shanghai First People's Hospital, Shanghai Jiao Tong University.
Twenty-six women with MRKH syndrome.
A record was made of mean operating time, length of hospital stay, perioperative complications and the anatomical and functional outcomes of surgery.
The perioperative results, complications and anatomical and functional outcomes of LASV (with median 20 months follow up, range 5-48 months).
The mean operating time and hospital stay were 238 minutes and 9.8 days, respectively. The mean fall in haemoglobin was 2.0 g/dl. The only significant perioperative complications were one case with blood transfusion and three cases with infection (one with urinary tract and two with adjunctive incision). A functioning vagina 10 to 15 cm in length and 4 cm in width was created in all women. Introital stenosis occurred in only two women (2 months later). Twenty-two women subsequently had intercourse and 20 women (91%) were satisfied with the surgery and subsequent sexual activity.
LASV is an effective approach for women with MRKH syndrome. Both the anatomical and functional outcomes are satisfactory.
To report our experiences of vaginal sacrospinous ligament fixation after vaginoplasty in male transsexual patients with the aim of preventing its postoperative prolapse.
From August 1997 through November 2005, a total of 62 male transsexual patients (mean age 26 years, range 18 to 58) underwent sacrospinous ligament fixation for neovaginal prolapse during male-to-female sex reassignment surgery. The neovagina was created from a penile skin tube flap combined with a urethral flap. A deep and wide perineal cavity between the urethra, bladder, and rectum was created by dissection of the tendineous center and rectourethral muscle. The right pararectal space was opened by penetrating the right pararectal fascia (rectal pillar) and right ischial spine was palpated. Using the ischial spine as a prominent landmark, the sacrospinous ligament was palpated. Long-handled Deschamps ligature was used to pierce the ligament medially to the ischial spine. Vaginopexy to the sacrospinous ligament was performed, and the neovagina was placed deep in the perineal cavity.
The median follow-up was 32 months (range 7 to 102). Sacrospinous ligament fixation was successfully performed in all patients. The mean vaginal length was 10.7 cm (range 9.5 to 16). Of the 62 patients, 42 (76%) were able to have normal sexual intercourse. The appearance of the neovagina was aesthetically acceptable in 52 patients. In 3 cases, a minor bulge of the anterior vaginal wall was easily resolved by simple excision.
Vaginal sacrospinous fixation is feasible in male transsexuals for neovaginal prolapse prevention. However, extensive experience with male pelvic surgery is required to avoid possible complications.
There is no unequivocal attitude to a laparoscopy as to the means in the diagnosis and treatment of postoperative surgical complications. Our study sought to determine the role of laparoscopy in the management of suspected postoperative complications.
We performed a retrospective review of the patients who underwent laparoscopy for complications of previous surgery over a 6-year period.
Sixty-four patients underwent laparoscopy for complications during the study period including 49 laparoscopies, 14 laparotomies, and 1 endoscopic procedure. The median delay between operations was 2 +/- 4.5 days. In 18 (28.1%) patients, laparoscopy did not find intra-abdominal pathology. The conversion to open surgery was necessary in 9 (14.1%) patients. Seven patients underwent more than 1 relaparoscopy. No cases of misdiagnosis were observed. Morbidity was 12.5%. There was no laparoscopy-related death.
Laparoscopy is an effective tool for the management of postoperative complications after open and laparoscopic surgery. It avoids diagnostic delay and unnecessary laparotomy.