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Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

Introduction and hypothesis The aim of this study is to compare the perioperative, anatomical and functional outcomes of patients with Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS), undergoing Sheares vaginoplasty, vaginoplasty using acellular porcine small intestinal submucosa (SIS) graft or laparoscopic peritoneal (Davydov) vaginoplasty. Methods In this retrospective study, a total of 117 patients with MRKHS undergoing creation of a neovagina from 2017 to 2020 were retrospectively investigated. Comparisons between continuous variables were performed using Student’s t -test and between qualitative variables using chi-squared tests. Results The operative time, return of bowel activity and return to work were the longest in the laparoscopic Davydov group ( P < 0.001). The total cost was the highest in the SIS graft group ( P < 0.001). The length of the neovagina was 7.9 ± 1.2 cm in the Sheares group, 7.1 ± 0.8 cm in the SIS graft group and 8.1 ± 1.1 cm in the laparoscopic Davydov group. The difference in the length of the neovagina was significant ( P < 0.001). There was significant difference in the duration of continuous mould wearing ( P < 0.001). There were no significant differences in the total female sexual function index (FSFI) scores or in the satisfaction scores of the male partner among the three groups. Conclusion Sheares vaginoplasty and the vaginoplasty using SIS graft caused less trauma and provided similar functional results to laparoscopic peritoneal vaginoplasty. However, the patients in the Sheares group and SIS graft group needed to wear the mould for a longer duration post-surgery. Sheares vaginoplasty can provide a valuable and economic alternative method for the creation of a neovagina in patients with MRKHS.

Abstract Background Both surgery and exogenous estrogen use are associated with increased risk of venous thromboembolism (VTE). However, it is not known whether estrogen hormone therapy (HT) exacerbates the surgery-associated risk among transgender and gender nonbinary (TGNB) individuals. The lack of published data has contributed to heterogeneity in perioperative protocols regarding estrogen HT administration for TGNB patients undergoing gender-affirming surgery. Methods A single-center retrospective chart review was performed on all TGNB patients who underwent gender-affirming surgery between November 2015 and August 2019. Surgery type, preoperative HT regimen, perioperative HT regimen, VTE prophylaxis management, outcomes, and demographic data were recorded. Results A total of 919 TGNB patients underwent 1858 surgical procedures representing 1396 unique cases, of which 407 cases were transfeminine patients undergoing primary vaginoplasty. Of the latter, 190 cases were performed with estrogen suspended for 1 week prior to surgery, and 212 cases were performed with HT continued throughout. Of all cases, 1 patient presented with VTE, from the cohort of transfeminine patients whose estrogen HT was suspended prior to surgery. No VTE events were noted among those who continued HT. Mean postoperative follow-up was 285 days. Conclusions Perioperative VTE was not a significant risk in a large, homogenously treated cohort of TGNB patients independent of whether HT was suspended or not prior to surgery.

Women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome do not have proper performance and sexual satisfaction because of physical problems. MRKH syndrome leads to psychological and identity problems and has a negative effect on self-concept. This study aimed to compare the sexual satisfaction and self-concept of women with MRKH syndrome before and after vaginoplasty with normal women. The current study was a case study with a pre-test, post-test design and a control group. Fifteen people were selected using the purposeful sampling method, and 15 normal newly married women were also selected as a control sample group. In both groups, sexual satisfaction and self-concept questionnaires were administered; after the relevant vaginoplasty surgery, only in the test group, and after six months, both groups completed the sexual satisfaction and self-concept questionnaires as a post-test. Hudson's sexual satisfaction questionnaire and Rogers' self-concept questionnaire were used to collect the data. Data were analyzed using multivariate covariance analysis. The results indicated that the average levels of sexual satisfaction and self-concept in women with MRKH syndrome significantly increased after vaginoplasty in comparison to their preoperative scores; but compared to the women of the control group, it is lower. To increase sexual satisfaction and improve the self-concept of women with MRKH syndrome, vaginoplasty surgery can be used as an effective treatment and an efficient program.

Background Penile skin inversion vaginoplasty (PIV) and sigmoid colon vaginoplasty (SCV) are both regarded as surgical options for gender reassignment surgery (GRS) to improve quality of life (QoL) in male-to-female (MTF) individuals. As no studies have compared the QoL between PIV and SCV techniques, this study aimed to evaluate the differences in QoL among MTF individuals who received PIV and SCV. Methods A cross-sectional study was conducted on patients who underwent GRS using PIV and SCV techniques at King Chulalongkorn Memorial Hospital (KCMH) from January 2002 to December 2022. The calibrated Thai version of Short-Form 36-Question Health Survey version 2 (SF-36v2) was used to assess QoL across eight health domains and to compare QoL between two surgical techniques. Results Of the 278 eligible MTF patients, who received GRS from 2002 to 2022, 57 completed the questionnaires; 37 and 20 MTF patients underwent PIV and SCV, respectively. Statistically significant difference was found in the Mental Component Summary ( p -value = 0.02) of postoperative QoL between the two groups. SCV statistically outperformed PIV in seven out of eight domains. Conclusion In terms of QoL, MTF who underwent SCV showed better achievement than those who underwent PIV in most of the domains. Due to limitations of this study, further studies on a larger scale are needed to confirm the findings and compare other aspects of the surgical techniques. Level of Evidence: Level III, Therapeutic.

Background Penile inversion vulvo-vaginoplasty is the most commonly performed genital gender-affirming surgery for transfeminine individuals. Sexual function following vulvo-vaginoplasty has been primarily assessed using instruments developed and validated for cis women. This study aimed to evaluate postoperative sexual function outcomes using the only validated tool specifically designed for trans women. Additionally, potential associations with psychosocial factors were explored. Methods Data from trans women who underwent penile inversion vulvo-vaginoplasty without scrotal skin grafts at Klinik Landstraße Vienna were retrospectively analyzed. Sexual function was assessed using the Operated Male-to-Female Sexual Function Index ( oMtFSFI ), while psychosocial factors were explored through selected items from the Essener Transgender Lebensqualitäts-Inventar ( ETLI ). Peri- and postoperative complications were extracted from digital medical records and classified according to the Clavien-Dindo classification. Spearman’s r was used to analyze correlations between sexual function and both clinical and psychosocial outcomes. Results The study included 42 participants ( M age = 41 years). While general satisfaction was high, sexual function was suboptimal in several domains. Mild to moderate sexual dysfunction ( M  = 40.6, SD  = 8.5) was reported, with the highest scores observed for sexual pain ( M  = 9.8, SD  = 4.0). The observed complications were generally minor and managed conservatively. Significant correlations were found between sexual dysfunction and family acceptance ( r  = − .48, p  ≤ .05), as well as between sexual dysfunction and the ability to openly express one's trans identity ( r  = − .57, p  ≤ .01). Conclusion Penile inversion vulvo-vaginoplasty without scrotal skin grafts is a generally safe procedure, with satisfactory aesthetic outcomes. However, postoperative sexual function remains suboptimal, particularly in terms of sexual pain and genital self-image. These findings suggest that psychosocial factors play a crucial role in postoperative sexual function. Future studies should investigate the impact of surgical techniques, postoperative care, and psychosocial support on sexual health outcomes following gender-affirming vulvo-vaginoplasty.

IntroductionThe first-line approach for the management of distal vaginal atresia involves a pull-through vaginoplasty. If the proximal vagina is 3 cm or more from the introitus, the risk of stenosis is high, and an interposition graft may be necessary. We describe a safe, low-cost, and accessible approach for distal vaginal atresia ≥ 3 cm that we call the “modified balloon vaginoplasty” and validate the technical feasibility and anatomical outcomes.MethodsTen patients who underwent modified balloon vaginoplasty were retrospectively evaluated. Age, symptoms at presentation, length of atresia, operation time, and postoperative complications were analyzed.ResultsAll the cases were successfully performed without any intraoperative morbidity. The postoperative complications included one case of stenosis ring in the distal vagina because not right used vagina model. All the girls had regular menstruation and were satisfied with the surgical outcome.ConclusionModified balloon vaginoplasty allows further distention of the distal vagina or thinning of the septum, which may decrease the risk of stenosis, is a beneficial choice for patients with distal vaginal atresia ≥ 3 cm.

IntroductionVarious methods have been described to create a functional neovagina with feminizing (male-to-female) gender affirming surgery. Intestinal vaginoplasty using ileal or colon segments confers natural mucus production and greater canal depth with primary vaginoplasty. In this work we describe an alternative approach to primary and salvage vaginoplasty using right colon. We focus on relative advantages compared to use of other bowel segments, and we review patient outcomes.MethodsTransgender women who had previously undergone primary vaginoplasty underwent laparoscopic right colon vaginoplasty at our center between 12/2017 and 7/2019. Demographic, medical, outcome, and satisfaction data was collected and retrospectively reviewed.ResultsTwenty-two consecutive transgender women patients underwent laparoscopic right colon vaginoplasty. Mean age was 39.3 years. There were two intraoperative complications:1 injury of the ileocolic pedicle, and 1 minor bladder injury. Four of 22 patients (18.2%) had short-term complications (< 30 days): 3 had postoperative ileus/small bowel obstruction and 1 had intra-abdominal hemorrhage. All were managed conservatively. Six of 22 patients (27.3%) experienced a total of 14 long-term complications (> 30 days): 1 developed Crohn’s (not involving the neovagina); 1 developed late small bowel obstruction (SBO) (managed conservatively); 5 developed neovagina prolapse; 4 developed stenosis (2 at the vaginal introitus, and 2 had extrinsic obstruction at the recto-vaginal junction (all underwent successful laparoscopic surgical correction); and 3 were diagnosed with diversion neovaginitis (all treated conservatively). All complications were successfully treated with conservative and/or surgical intervention. All (100%) patients reported satisfaction with neovagina function and appearance.ConclusionThis is the only outcomes series of transgender women patients who have undergone right colon vaginoplasty, to date. Our study finding suggests that laparoscopic right colon for primary or salvage vaginoplasty has several important advantages over use of Sigmoid colon or Ileum, and is a reliable technique whose complications can be managed successfully, with favorable, satisfactory long-term outcomes.

ABSTRACTBackgroundCanada’s health care systems underserve people who are transgender and gender diverse (TGD), leading to unique disparities not experienced by other patient groups, such as in accessing gender-affirmation surgery. We sought to explore the experiences of TGD people seeking and accessing gender-affirmation surgery at a publicly funded hospital in Canada to identify opportunities to improve the current system. MethodsWe used hermeneutic phenomenology according to Max van Manen to conduct this qualitative study. Between January and August 2022, we conducted interviews with TGD people who had undergone penile-inversion vaginoplasty at Women’s College Hospital, Toronto, Ontario, since June 2019. We conducted interviews via Microsoft Teams and transcribed them verbatim. We coded the transcripts using NVivo version 12. Using inductive analysis, we constructed themes, which we mapped onto van Manen’s framework of lived body, lived time, lived space, and lived human relations. ResultsWe interviewed 15 participants who had undergone penile-inversion vaginoplasty; they predominantly self-identified as transgender women ( n = 13) and White ( n = 14). Participants lived in rural ( n = 4), suburban ( n = 5), or urban ( n = 6) locations. Their median age was 32 (range 27–67) years. We identified 11 themes that demonstrated the interconnected nature of TGD peoples’ lived experiences over many years leading up to accessing gender-affirmation surgery. These themes emphasized the role of the body in experiencing the world and shaping identity, the lived experience of the body in shaping human connectedness, and participants’ intersecting identities and emotional pain (lived body); participants’ experiences of the passage of time and progression of events (lived time); environments inducing existential anxiety or fostering affirmation, the role of technology in shaping participants’ understanding of the body, and the effect of liminal spaces (lived space); and finally, the role of communication and language, empathy and compassion, and participants’ experiences of loss of trust and connection (lived human relations). InterpretationOur findings reveal TGD patients’ lived experiences as they navigated a lengthy and often difficult journey to penile-inversion vaginoplasty. They suggest a need for improved access to gender-affirmation surgery by reducing wait times, increasing capacity, and improving care experiences.

Redo surgeries for persistent urogenital sinus repair are challenging, often requiring innovative techniques to address complications like fistula formation and vaginal stenosis. This case report describes the successful management of a complex redo persistent urogenital sinus repair in a 5-year-old girl. Her initial repair at age 1 resulted in an iatrogenic rectovaginal fistula, severe narrowing of the vagina, and required a sigmoid colostomy and tube colpostomy. At age 5, surgical reconstruction involved excising the stenosed urethra, re-anastomosing it to the introitus, and fistula closure. Due to the fragile and thin-walled vagina, a sigmoid interposition vaginoplasty was performed. Extensive pelvic adhesions made direct suturing impossible, so a Foley catheter was used innovatively as a stent to approximate the vaginal wall to the sigmoid interposition. One year later, the vagina and urethra remain patent, and the child is continent following colostomy closure. The catheter stent technique proved effective in ensuring alignment and patency.