Neovaginal Prolapse in Male-to-Female Transsexuals: An 18-Year-Long Experience

Abstract

Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.

Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery

“…Empirically, dilatation has limited effect in increasing depth but is necessary to prevent reduction of the vaginal space or, in worst case, even collapse and protrusion. 18 , 19 In comparison to surgical techniques using scrotal flaps or skin grafts, our postoperative dilatation protocol is not significantly different. 20 The use of pedicled intestinal tissue 7 , 21 may limit the need for postoperative dilatation but impose possible long-term risks of colitis 22 and a perceived increased morbidity by operating intraabdominally.…”

Penile inversion vaginoplasty outcomes: Complications and satisfaction

“…14,15,20,23,[26][27][28]32,34,36,37,39 Some surgeons perform a sacropexy (fixate the graft to the sacrospinous ligament) in an effort to reduce the possibility of prolapse, 35,39,42,43 while others advocate fixation of the penoscrotal apex to Denonvillier's fascia to lower the risk of post-operative prolapse. 44 Some studies report that the rate of vaginal prolapse increases over time. 15,26 Goddard et al 26 reported 6% vaginal prolapse in their patient cohort at late follow-up (median 36 months) despite having only 1.8% of vaginal prolapse documented in the early post-operative period.…”

Imaging Findings in Transgender Patients after Gender-affirming Surgery

“…The remaining penile, perineal, and scrotal skin is inverted and folded back to line a neovaginal tunnel created by blunt dissection of the perineum and retroprostatic space (42)(43)(44)(45)(46)(47) (Figs 6a, 7b). The neovaginal flap may be sutured to the sacrospinous ligaments to prevent prolapse and improve neovaginal depth (48). A sensate neoclitoris is formed from a portion of the glans penis and preserved native dorsal penile neurovascular structures (Fig 7b, 7c).…”

“…Neovaginal prolapse can be generally diagnosed at clinical examination. Surgical fixation of the neovaginal tube to the sacrospinous ligaments or fascial planes anterior and posterior to the neovaginal cavity may prevent this complication (48,62,63). Rarely, damage to the urethra during vaginoplasty may lead to urethroneovaginal fistulas, which may be diagnosed with fluoroscopic or CT cystourethrography and MRI (24,42,46,59).…”