OBJECTIVE: To describe the incidence of pelvic floor dysfunction in transgender women undergoing gender-affirming vaginoplasty and outcomes in a program providing pelvic floor physical therapy (PT). METHODS: We conducted a retrospective, single-institution study on vaginoplasty patients between May 1, 2016, and February 28, 2018; all were referred for pelvic floor PT. We reviewed medical records for baseline demographics, medical comorbidities, prior surgeries, insurance data, attendance at pelvic floor PT, and dilation success at 3 and 12 months. RESULTS: Seventy-two of 77 patients (94%) attended pelvic floor PT at least once. Preoperative pelvic floor PT identified a high incidence of potential problems: 42% had pelvic floor dysfunction, 37% had bowel dysfunction. Of those patients found to have dysfunction preoperatively, the rate of resolution by the first postoperative visit of pelvic floor and bowel dysfunction were 69% and 73%, respectively. There were significantly lower rates of pelvic floor dysfunction postoperatively for those patients who attended pelvic floor PT both preoperatively and postoperatively compared with only postoperatively (28% vs 86%, P=.006). Patients reporting a history of abuse had a significantly higher rate of preoperative pelvic floor muscle dysfunction (91% vs 31%, P<.001). Successful dilation at 3 months in all patients was 89%. CONCLUSION: Pelvic floor physical therapists identify and help patients resolve pelvic floor-related problems before and after surgery. We find strong support for pelvic floor PT for patients undergoing gender-affirming vaginoplasty.

flap for use in urethral lengthening. The vaginal space was closed by purse-string sutures. We evaluated operative time, estimated blood loss (EBL), procedural complications, and the learning curve of this procedure in a historical cohort study of patients undergoing TVC at our institution. RESULTS: In 2 years, 30 TVC procedures were performed as part of 11 metoidioplasties and 19 phalloplasties. The average age of our cohort was 36.5 þ/-11.6yr, 28 (93%) had a hysterectomy, mean BMI was 27 þ/-4.27, and all were on testosterone. Median follow up length was 13mo (IQR 5-31mo). Two underwent concomitant hysterectomy early in the series, before it became our policy to not combine these procedures. The operative time for TVCs was 158 þ/-46min, with a significantly shorter times in later years (p[ 0.015) (Figure 1). The mean total vaginal length was 8 þ/-1.3cm and the mean genital hiatus diameter was 2 þ/-0.6cm. Operative time was longer with longer vaginal length (p [ 0.027). The peritoneum was entered in 12/30 (40%) of cases and closed without additional sequelae. The anterior vaginal mucosal flap was viable and thus incorporated in the urethroplasty in 21/25 (84%) applicable cases. Two (6.7%) patients required transfusion. One patient had C difficile colitis. There were no visceral injuries, fistulae, or mucoceles. CONCLUSIONS: This is the largest series describing vaginectomy by total vaginal excision. TVC takes approximately 2.5 hours after a learning curve period and has a low complication rate. Despite the longer operative time, TVC may have advantages over mucosal fulguration such as lack of fistulae between urinary tract and vaginal space noted in prior studies.