Transfeminine Gender Confirmation Surgery with Penile Inversion Vaginoplasty: An Initial Experience

Abstract

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/m 2 (SD 3.2 kg/m 2 ). 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.

Penile inversion vaginoplasty outcomes: Complications and satisfaction

“…As such, some patients may not report (or recognize) loss of vaginal depth. Despite this, Loree et al 25 reported that in their initial experience of 30 patients, vaginal deepening was the main reason for revision surgery. Furthermore, Schardein, Zhao & Nikolavsky reported that 5% of their reoperations were for augmentation of vaginal depth 32 …”

“…19,20,23,25,27,30,31 The decrease in incidence has been attributed to a change of surgical technique, 17,23,25 such as spatulation of the urethral meatus, 17,23 "simple anastomosis [of the urethral meatus] to [the] external genitalia" (presumably referring to a less ischemic suture), 17 and minimal manipulation of the internal anatomy of the urethra. 25 Rossi et al 28 hypothesized that scar formation and decreased local vascularity were contributory factors in all their cases of meatal stenosis. In addition, some authors postulate that Foley catheters that are removed too early (defined by some authors as before post-operative day five) or too late (defined by some authors as after post-operative day five) may contribute to meatal stenosis.…”

“…28,34,36 Urethroneovaginal fistula may result from intraoperative urethral injury. 42 The incidence of urethroneovaginal fistulae range from 0% to 4%, 15,19,24,25,28,34,37 with the incidence of urethral injury ranging from 0% to 1.1%. 15,20,24,30…”

“…Minor wound healing issues 3.3-33% 19,[22][23][24][25][27][28][29][30][31][32] Local wound care 32 Tissue necrosis 0.6-24.6% 15,27,32,33 Local wound care, surgical debridement 28,32 Granulation tissue 7-26% 19,20,27,30,32 Silver nitrate 32 Infection 0-27% 15,20,22,[24][25][26][27]30,34 Antibiotics, surgical drainage, suture removal 15,26,28 Neovaginal stenosis 0-12% 14,15,18,20,23,24,[26][27][28][29][30][31][32]36 Dilation, lateral wall incisions, Z-plasty, revision with recreation of the neovaginal...…”

“…Loss of vaginal depth has also been reported to occur secondary to skin graft or skin flap loss. Reported rates range from 0% to 15% 14,23–28,30,39 and are associated with vaginal slough 27 . Failure to dilate after surgery is likely a major contributing factor 28,38 .…”