Important Notes:

Permanent laser hair removal is a fundamental step in this surgical technique to prevent hair growth within the neovagina or other reconstructed structures, with the risk of causing infections or constrictions. This is usually performed in the weeks and months prior to the surgery, but in some cases, manual removal of the follicular units is performed by the surgeon during the primary vaginoplasty procedure.

Orchiectomies are performed in all versions of gender-affirming surgeries. They can also be done ahead of time. This allows part of the overall swelling to reduce giving surgeons a better understanding of how much tissue there is to work with. Having an Orchiectomy done before the gender-affirming surgery allows for a possible reduction in overall compilations and risks. Without testosterone therapy without testicles will not be able to achieve an erection (normally). This will also cause the penis to reduce in size as well.

Prostates are usually not removed during surgery; this is because it constitutes an internal erogenous structure that is similar to the female g-spot. For this reason, patients will have to check the prostate regularly or by GP’s advice.

Common Techniques

1. Penile inversion vaginoplasty (PIV)

This is the standard procedure for a male to female gender-affirming surgery, the PIV is a surgical technique that includes an orchiectomy, a partial penectomy, penile dissection with the creation of the neovaginal canal, a labiaplasty, and a clitoroplasty.

The surgery begins with the insertion of a urinary catheter. An incision is made along the scrotal raphe, the midline of the scrotum, and the orchiectomy is performed.

The penis is then dissected the glans are separated from the shaft and the dorsal neurovascular bundle is dissected from the underlying corpora cavernosa. The Corpus spongiosum is then removed by performing an incision at the base of the penis; this is done to avoid possible swelling due to stimulation during sexual intercourse. Corpora cavernosa are removed as well, but a small portion is left to construct the base of the neo clitoris, which will be reconstructed using the dorsal part of the glans previously dissected. An internal pouch is then created in the region between the penis and the rectum, the penile skin is inverted and stitched at the end to create the vaginal lining and is then inserted in the space created. The urethra is then shortened, and a new urinary meatus is created. The neo clitoris is then positioned and the clitoral hood is reconstructed as well as the labia minora. Scrotal skin is used to reconstruct the labia majora and a stent is inserted in the neovagina to keep it dilated.

The urinary catheter and the vaginal stent are left in place for the first 4-7 days. Once the stent is removed, the patient will begin the dilation of the neovagina by daily inserting expanders for the first 6 months. During the first days, the patient will be bedridden receiving anticoagulant injections to prevent venous thromboembolism. Once the stent will be removed, the patient will be allowed to walk. The neovagina will be cleaned daily with antiseptic solutions such as betadine.

At or about seven to ten days after surgery, the patient is usually discharged from the hospital. After 6 to 8 weeks from surgery and once the surgeon’s approval is received, it will be possible to have penetrative sexual intercourse.

Advantages of the penile inversion vaginoplasty

The advantage of using this technique is the avoidance of the risks involved with abdominal and intestinal surgery. As well as the most widely used form of gender-affirming surgery.

Disadvantages of the penile inversion vaginoplasty

The disadvantage of this technique is that to obtain an adequately sized neovagina, you need an adequately sized penis. This might not be possible for patients with smaller penises, patients who started feminizing hormone replacement therapy (HRT) before puberty, and circumcision.

This type of surgery results in the lack of natural secretions and lubrication. The use of a lubricant will be necessary to allow sexual intercourse.

2. Sigmoid colon vaginoplasty or intestinal vaginoplasty

With this technique, the neovagina is reconstructed starting from a portion of the intestine, usually a section of the sigmoid colon when the large intestine is chosen, but sometimes the small intestine is chosen and in that case, a portion of the ileum is resected. The benefit of using the sigmoid colon over the ileum is the larger diameter and the reduced secretions, far more abundant in other parts of the gastrointestinal tract.

A 12-15 cm section of the sigmoid colon with its vascular pedicle still intact is removed; an internal pouch in the perineal regions is created by the surgeon and the intestinal section is transposed where the neovagina is intended to be. One of the ends is sutured to the opening of the neovagina, whilst the opposite end is sutured closed; the whole segment is anchored internally to the pelvis to avoid migration or torsion. The intestinal tract is anastomosed and checked for possible leaks.

Since part of the colon is used to create the neovagina, after surgery it is advised to follow international guidelines regarding screening, conduction of regular checks, and prevention of colon tumors.

Sigmoid colon vaginoplasty is often the first choice as an operative technique in secondary vaginoplasty, when the primary vaginoplasty failed or did not yield the expected results. Is also used in reconstructive vaginoplasty after a collapsed penile inversion vaginoplasty

Advantages of sigmoid colon vaginoplasty

The advantage of this technique is that the neovagina will surely have sufficient dimensions to be functional, it will have a mucosa as internal lining which is physiologically lubricated and there will be reduced need of following a dilating regimen post-op. The appearance and the consistency of the tissues are also much more like the ones from a cisgender vagina.

Disadvantages of a sigmoid colon vaginoplasty

The main disadvantage of this technique is the fact that it involves abdominal and intestinal surgery, with an intestinal anastomosis, which carries all risks related to this type of surgery. Another disadvantage of this technique is the fact that the secretions produced by the neovagina might be too abundant or with an unpleasant odor; this is more likely when the ileum is used instead of the sigmoid colon. Moreover, this surgery will leave some visible abdominal scars due to the need of performing abdominal incisions.

Sigmoid colon vaginoplasty also carries the following risks:

Abdominal adhesions:

Abdominal adhesions are scar tissue that forms between abdominal tissues and organs that causes your tissues and organs to stick together. Surgery of the abdomen is the main cause of this scar tissue.

Anastomotic leaks:

An anastomotic leak is a failure in the connection of two organs that causes fluids to leak. Surgery will be required to resolve this issue. Which also will have its own recovery time.

3. Scrotal skin graft vaginoplasty

This technique is not widely used and uses scrotal skin for the reconstruction of the vaginal canal, using groin skin flaps if scrotal skin is not sufficient. The penile skin is used instead to reconstruct the labia minora, the clitoral hood, and other aesthetical details of the external genitalia. This technique is generally capable of obtaining a neovagina of greater dimensions when compared to the penile skin inversion technique; it is considered superior from the aesthetics’ and erogenous sensation’s side due to the usage and preservation of tissues that are each other’s embryologic analogs in male and female development. Moreover, while dissecting the surgeon retains the Cowper’s glands (bulbourethral glands), in the neovagina, hence guaranteeing natural lubrication when sexual arousal occurs.

4. Non-genital skin flaps vaginoplasty

This technique was used in the past to perform secondary vaginoplasties when the primary vaginoplasty with penile skin inversion did not provide satisfactory results. It utilizes flaps harvested from the medial region of the thigh or from the inguinal region to create the neovagina, sometimes combined with penile flaps by using sutures for the creation of a single flap of greater dimensions.

The advantage of this technique is that non-genital flaps contract less after surgery, so they require less post-op dilatation. The main disadvantage is the possible complication to the flap donor site, scarring where di flap is harvested, unnatural consistency of the reconstructed tissues. Moreover, there are no structures that allow for natural lubrication of the neovagina.

5. Genital graft vaginoplasty 

This technique was used in the past utilizing skin grafts harvested from the penis or from the scrotum to reconstruct the neovagina. The advantage of the penile graft over the scrotum one is that it has fewer hair follicles, nevertheless, it is a rarely used technique since it is possible to achieve better results by using penile skin as a pedunculated flap. Scrotal grafts instead are used currently when the penile skin obtained from penis dissection is not sufficient to create a neovagina of functional and acceptable dimensions.

6. Non-genital skin graft vaginoplasty

This is one of the first techniques ever used to perform vaginoplasty in transgender patients. It utilizes non-genital skin grafts to create the neovagina; the grafts usually come from the abdomen skin. The advantage is that there is no risk of having insufficient tissue for the reconstruction of a functional neovagina, the limited presence or absence of hair follicles, and the low risk of post-op complications. The disadvantage is the tendency of the skin grafts to shrink, the suboptimal sensitivity, the absence of natural secretions, and the scarring of the donor area.

Recently, the use of grafts harvested from the buccal mucosa is being investigated. In some cases, grafts or micro-grafts have been harvested and then stitched together to obtain a graft of the desired dimensions. In other cases, a small portion of tissue has been harvested and then cultured in the lab to increase the number of cells and the size of the graft. This technique is not yet widely used but has the advantage of having a high survival rate and the presence of natural secretions, the reason for which it might be utilized in the future.

7. Zero Depth Vaginoplasty (ZDV)

This technique utilizes the tissues harvested from the male sexual organs to create an aesthetically pleasing and accurate vulva (the external female genitalia) like the above surgical procedures, retaining erogenous and tactile sensitivity. However, the vaginal canal is not reconstructed hence penetrative sexual intercourse is not possible.

This is the ideal surgery for all those patients not interested in having vaginal sexual intercourse. The advantages are shorter surgery time, less expensive surgery, lower risks, and no need for continuous dilatation of the neovagina or daily cleaning of the reconstructed vaginal canal.

Risks and complications of the vaginoplasty in MtF Gender affriming surgeries.

Let’s be honest this procedure is not one that should be done in light of heart as it is permanent. Reversal is not back to what you once had. Neovaginas can be closed but the penis cannot be repaired back to what it once was.

Risks and complications of male to female sex reassignment surgery include general risks which are shared with any surgery. Risks related to general anesthesia, intra-operative and post-operative bleeding, infections, scarring, delayed healing, accidental damage to surrounding tissues.

There are specific risks related to Gender Affirming surgery, there are:

Urethral strictures:

A urethral stricture involves scarring that narrows the tube that carries urine out of your body. A stricture restricts the flow of urine from the bladder and can cause a variety of medical problems in the urinary tract, including inflammation or infection.

Narrowing of the neovagina:

The narrowing of the neovagina can be caused by a lack of proper dilation, surgical complications, and scar tissue buildup. As primary reasons for this to occur. Though there are techniques to resolve these issues.

Meatal stenosis of the new urethra:

When the opening at the end of the urethra is narrower than normal after surgery. Those with this condition can experience symptoms like such as pain or burning urination. It can also result in a narrow or fast urine stream, spraying of urine, difficulty directing the stream, and frequent urination.

Rectovaginal fistulae:

A rectovaginal fistula is an abnormal connection between the lower portion of your large intestine — your rectum — and your neovagina. Bowel contents can leak through the fistula, allowing gas or stool to pass through the neovagina. Which can also lead to graft necrosis.

Graft necrosis:

Necrosis is a form of cell injury which results in the premature death of cells in living tissue by autolysis. Necrosis is caused by factors external to the cell or tissue, such as infection, or trauma which result in the unregulated digestion of cell components.

In a more simplistic view, cells die all the time. But with Necrosis cells are dying without new ones replacing them at a rate that is not manageable by the body. This also leads to an infection that will require antibiotics at the very least. With the extreme of amputation or removal of the skin affected. Without proper care, it can lead to disfigurement or death.

Loss of sensitivity:

What most doctors do not talk about is the full extent of the loss of sensitivity. We must understand there are a number of issues when talking about this subject. The first is understanding the new location of the areas of sensitivity in comparison to what once was while the penis was in its earlier state. We must also understand that there is an area of unreal expectations in regards to naturally born genetic females. Whereas naturally born genetic females have 8,000 nerve endings in the clitoris alone. Where the tip of the penis also has the same amount of endings but is then reduced to create the clitoris. It is not possible to compress those nerves into the same dimensions as a naturally created clitoris.
The vaginal canal also contains different types and locations of nerves when compared to the shaft of the penis. We must also understand depending on scar tissue amount and locations there might also be a loss of sensations.

It is in my opinion (not medically) that the use of a sexologist as part of rehab after surgery. This will assist in allowing the patient to understand the new locations of erogenous zones and the mental side of the connection with new forms of sexual stimuli as well as the mental side.

Unsatisfactory dimensions of the neovagina:

The old adage that one size fits all is not true in the case of the neovagina. This may come as somewhat a bit of a surprise that there is a rather large difference between a cis-gendered vagina and the neovagina. This is more than evident in the case of musculature. Whereas the pelvic floor can be trained via exercise and tightened. The neovagina does not have this ability. Then when it comes to depth the issue lies not only with the previous size of the penis but the proper use of dilators after surgery.

Post-op information after vaginoplasty

Daily dilatation is usually recommended for the first 6 months post-op. After 6 months, if the patient has regular sexual intercourse the use of dilators will not be needed.

The dilation regimen requires the use of tutors increasing in diameter from 20mm to 32mm with a length of about 13cm; initially, they are used three times a day for about 50 minutes each time. Once the desired dimensions are reached, it will be sufficient to use them 2-3 times a week, or less if the patient has regular sexual intercourse. It is required to apply a generous amount of water-based lubricant before using the dilators, to avoid tissue damage and pain.

Surgical wounds are cleaned daily and have to be kept dry and clean until complete healing. The vaginal canal will require daily hygiene to avoid complications and infections.

When surgeries are requested it is usually to improve the aesthetics of the results, but sometimes a secondary vaginoplasty is indicated to improve the functionality of the neovagina.

Pregnancy

Until the transplant of the female reproductive organs will be made possible by medical advances, pregnancy is not possible for transgender women. Let’s also be honest about this part of gender-affirming surgery. Even if there was the technology to give a Transwoman the reproductive system that is part of a genetic female. That person would not only be on anti-rejection drugs for the rest of their lives. They would also have to contend with the issue of being immune-compromised. On top of that then there is the issue that unless the donor is a sibling there will not be a genetic match for any child born. Then due to bone structures, all children born would have to be done via C-section. This is due to the size and structure of the pelvic region.

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