No abstract

BACKGROUND: About 8,800-34,200 Gender Dysphoria (GD)- and 39,000-650,800 Mayer-Rokitansky-Küster-Hauser (MRKH)-patients undergo vaginoplasty annually. Various procedures are available, but comparisons are lacking. OBJECTIVES: To highlight information gaps, weaknesses and strengths of vaginoplasty techniques, to aid well-informed decision making by patients and healthcare professionals. SEARCH STRATEGY: A systematic search in Medline, EMBASE, Web of Science and Scopus until October 6, 2022, by PICO method and PROSPERO registration. SELECTION CRITERIA: Original retrospective studies on complete neovaginal creation in adult GD- and MRKH-patients and discussing anatomy, Quality of Life (QoL), satisfaction, sexual function, complications or complaints. DATA COLLECTION AND ANALYSIS: The 95% confidence intervals were calculated with DerSimonian and Laird random-effects. Methodological quality and potential bias were assessed. MAIN RESULTS: In total, 35 GD- and 16 MRKH-studies were eligible. Vagina length was 11.6 and 9.5 cm, respectively. In GD-patients, Hemorrhage (6%), prolapse (1%), gastrointestinal complications (1%), revisions (26%), pain (6%), regret (1%), fecal- (11%) and urinary issues (17%) were reported. Necrosis, stenosis, dyspareunia and revisions decreased, while duration increased with higher graft quantity. Intestinal-vaginoplasty reported 100% sensation. MRKH-patients reported more necrosis (17%) [McIndoe] and average satisfaction with sexual function (91%) and vaginal discharge (32%). They were more sexually active (86%) and had 100% anatomical satisfaction. Only Intestinal-vaginoplasty reported overall dissatisfaction. CONCLUSIONS: For GD- and MRKH-patients, multiple safe vaginoplasty techniques demonstrated acceptable outcomes, with significantly improved QoL and self-image. However, standardized validation tools are needed for well-informed decision-making. Direct technique comparisons per patient-cohort and exploration of tissue-engineering methods are critical for future surgical advancements.

When a healthy, full-size vagina is absent due to a disorder, various neovagina creation methods are available. Sometimes dilation or stretching of the vagina cavity is sufficient, but generally intestinal or dermal graft tissue is required. However, different inherent tissue properties cause complications. Therefore, when a body part is lost, it should be replaced by a similar material. The use of organ-specific acellular vaginal tissue carries great potential, as the similar architecture and matrix composition make it fit for vagina regeneration. We developed an optimized decellularization protocol for human vaginal tissue and determined suitability as tissue-mimicking scaffold for vagina reconstruction. Histological examination confirmed the preservation of structural features and minimal cellular residue was seen during fluorescence microscopy, DNA and RNA quantification and fragment-length examination. Biomechanical testing showed decreased (P<0,05) strain at rupture (23%), tensile stress (55%) and elastic modulus (68%) after decellularization. Fluorescence microscopy revealed preserved Fibronectin-I/II/III and Laminin-I/II, while Collagen-I and Ficolin-2B were decreased but mostly retained. The absence of cellular residue, minimally altered biomechanical ECM properties and mostly preserved structural proteins, appear to make our decellularized human vaginal matrix a suitable tissue-mimicking scaffold for vagina transplantation when tissue survival through vascularization and innervation are accomplished in the future.

BACKGROUND: About 430,000-1,000,000 Gender Dysphoria- and Mayer-Rokitanksy-Küster-Hauser-patients undergo vaginoplasty each year. Various surgical procedures are available, but direct comparisons are lacking. This inhibits well-informed decision making by patients and healthcare professionals. OBJECTIVES: Highlight information gaps, weaknesses and strengths of todays vaginoplasty techniques. SEARCH STRATEGY: A systematic search in Medline, EMBASE, Web of Science and Scopus until March 8, 2022 was conducted, by PICO method and PROSPERO registration. SELECTION CRITERIA: Original retrospective studies on complete neovaginal creation in adult Gender Dysphoria- and Mayer-Rokitanksy-Küster-Hauser-patients and discussing anatomical outcome, Quality of Life, satisfaction, sexual function, complications and/or complaints. DATA COLLECTION AND ANALYSIS: Data was extracted and methodological quality and potential bias were assessed. The 95% confidence intervals were calculated with DerSimonian and Laird random-effects. MAIN RESULTS: A total of 47 articles were eligible. Surgery took 198 minutes with 10.2 cm vaginal length. Major complications included 5% hemorrhage, 1% gastrointestinal complications, 1% prolapse, 3% tissue necrosis and 6% stenosis, with 31% revisions. Patients reported 25% excessive discharge, 6% pain, 11% fecal- and 17% urinary issues and one case of hair growth. Patients also reported 95% aesthetic- and 93% anatomical satisfaction, 10% overall dissatisfaction and 1% regret. Reports showed 75% sexual activity, 13% dyspareunia, 87% sensation and 84% overall functional satisfaction. CONCLUSIONS: Multiple vaginoplasty techniques demonstrated safe and acceptable outcomes, with significant improvement of Quality of Life and self-image. However, standardized validation tools are needed for well-informed decision-making. Direct technique comparisons with similar cohorts and exploration of tissue-engineering methods are critical for future surgical advancements.