Genital Hypoplasia in Gender-affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning

Abstract

Purpose:Penile inversion vaginoplasty uses genital skin to construct the neovaginal canal. When genital skin is insufficient, extragenital tissue is needed. The purpose of this study is to evaluate which demographic factors and intraoperative anatomical measurements are associated with skin availability and the need for extragenital tissue.Materials and Methods:This was a prospective cohort study of patients undergoing penile inversion vaginoplasty from May 2016 through January 2021. Preoperative variables included patient demographics, orchiectomy and circumcision status, and stretched penile and scrotal skin lengths. Outcomes included measurements of available scrotal skin surface area and need for extragenital skin graft.Results:A total of 235 patients were included. Patients with prior orchiectomy and shorter stretched scrotal and penile lengths had less scrotal skin available (P < .002) and were more likely to require extragenital skin grafts (P < .001). Patients with prior orchiectomy had 3 times greater odds of needing additional skin grafts. Length of time exposed to gender-affirming hormones did not predict scrotal skin availability (P = .8).Conclusions:Factors associated with need for extragenital skin grafting with penile inversion vaginoplasty were prior orchiectomy and stretched penile skin length <8 cm. Scrotal skin length >10 cm was associated with low risk for needing additional graft. Considering these factors can help with preoperative planning and patient counseling.

Gender‐affirming vaginoplasty: Technical considerations in patients with genital skin deficiency

“…Further, the prevalence of genital trauma or debridement due to infections or ischemic conditions is also not well studied. Some articles have suggested the use of stretched penile length of 7–12 cm to determine the need of full‐thickness skin grafting 8,26 . Others report a goal‐oriented approach to achieve neovaginal length of about 8 cm 27 .…”

“…Often, patients seeking vaginoplasty present for surgical evaluation have undergone prior bilateral orchiectomy, leading to scrotal atrophy and/or scarring. This increases the odds of requiring additional skin grafting 26 . Use of laser hair removal, electrolysis, pressure necrosis from penile tucking, and history of scrotal lesions or infections, can also impact the quality of genital tissue.…”

“…Some articles have suggested the use of stretched penile length of 7-12 cm to determine the need of full-thickness skin grafting. 8,26 Others report a goal-oriented approach to achieve neovaginal length of about 8 cm. 27 In any case, the surgeon should assess the quality of the genital skin preoperatively to be used for reconstruction.…”

“…Quality of genital skin is of utmost importance in achieving satisfactory outcomes. Insufficient penile and scrotal skin can be seen in clinical conditions such as circumcised status, scrotal orchiectomy for gender affirmation, and long‐term prepubertal hormonal treatment 26 . However, the true prevalence of these conditions is not known and can vary based on societal norms and cultural practices.…”

“…Insufficient penile and scrotal skin can be seen in clinical conditions such as circumcised status, scrotal orchiectomy for gender affirmation, and long-term prepubertal hormonal treatment. 26 However, the true prevalence of these conditions is not known and can vary based on societal norms and cultural practices. Further, the prevalence of genital trauma or debridement due to infections or ischemic conditions is also not well studied.…”