A Retrospective Cohort Study Evaluating Surgical Aptitude Over Time in a New Male-To-Female Penoscrotal Vaginoplasty Program

Abstract

Background Given the burgeoning demand for gender affirmation surgery, there are few studies examining both surgical process variables and patient outcome variables. Knowing the learning curve for surgical teams who are beginning to perform this procedure will be important for patient safety and presurgical patient counseling as more institutions open transgender surgical programs. Aim The purpose of this study was to determine the demographics of patients pursuing penoscrotal vaginoplasty, to determine their postoperative course, and to determine a learning curve for the surgical team performing penoscrotal vaginoplasty. Methods We retrospectively reviewed charts of all 43 patients who underwent penoscrotal vaginoplasty from the commencement of a new male-to-female penoscrotal vaginoplasty program in March 2018 through July 2019. Outcomes Primary outcomes included mean hemoglobin decrease from surgery and operative time. Mean time to neoclitoral sensation, length of hospital admission, complication rates, reoperation rates, length of narcotic use after surgery, and demographics were also evaluated. Associations between surgical team experience and outcomes were assessed with Spearman's rho and Cox regression, and curve-fitting procedures were applied to determine the relationship. Results The mean operative time from initial incision to procedure finish was 225 minutes, and the mean decrease in hemoglobin was 3.3 g/dL. The mean time to neoclitoral sensation was 0.72 months. The time until neoclitoral sensation decreased as the surgical cases performed increased (Spearman's rho, −0.577 [P < .001]), with a power function best describing the learning curve. Operative time did not change with case number (Spearman's rho, 0.062 [P = .698]) but overall time in the operating room did (Spearman's rho, 0.631 [P < .001]). Mean length of hospital admission was 2.9 days. There were no intraoperative complications. 18 patients (42%) experienced a postoperative complication. 8 of 43 patients underwent reoperation (20%). Narcotics were used a mean of 9.5 days after surgery. Clinical Implications A learning curve can be demonstrated in penoscrotal vaginoplasty for time to neoclitoral sensation and overall time in the operating room, plateauing between 30 and 40 cases. Strengths and Limitations Strengths include assessing a learning curve for time to neoclitoral sensation, length of hospital stay, and length of postoperative narcotic use after penoscrotal vaginoplasty, which, to our knowledge, has not been reported elsewhere. Limitations include our overall low number of patients. Conclusion Despite a low number of cases, length of hospital stay was short and the postoperative complication rate was similar to that of long-standing penoscrotal vaginoplasty programs.

Penile inversion vaginoplasty outcomes: Complications and satisfaction

“…Post-operative wound infection rates range from 0% to 27%. 15,20,22,[24][25][26][27]30,34 COVID-19 induces respiratory-predominant multiorgan dysfunction, including myocardial, renal, enteric and hepatic dysfunction, which coincides with the tissue expression of ACE2. 3 Meanwhile, several studies have shown that ACE2 is expressed in human testes (eg spermatogonia, Leydig cells and Sertoli cells), 4,5 suggesting that the testes may be another organ affected by COVID-19.…”

“…Ferrando and Whynott did not find an association between surgeon experience and complications that occurred in the immediate postoperative period; the authors postulated that early complications are "common and inherent" to the procedure. 24,27 Most studies show that the rate of serious complications following vaginoplasty is low and comparable to complications of other genitourinary reconstruction surgeries. 17,19,23,24 Reported rates of adverse intraoperative complications, such as rectal or genitourinary injury or need for intraoperative blood transfusion, range from 1.5% to 2.6%.…”

“…28,29,32 Tissue loss may be associated with wound dehiscence, and most often occurs at points of maximum tissue tension, such as at the vaginal introitus. 20 The reported incidence of tissue necrosis ranges from 0.6% to 24.6%, 15,27,32,33 with minor tissue necrosis (ie, resolved without reoperation under general anesthesia) accounting for the higher reported incidence in some studies. 15 Minor cases of tissue necrosis can often be treated with local wound care, 32 whereas more major tissue loss may require surgical debridement.…”

“…15 Neovaginal stenosis may refer to introital stenosis or stenosis of the vaginal canal and represents the most frequently reported complication of the vaginal canal. 18,21,31,35 Rates of neovaginal stenosis range from 0% to 12% 14,15,18,20,23,24,[26][27][28][29][30][31][32]36 with introital stenosis ranging from 2.5% to 15%. 14,15,20,24,28,32 Lack of compliance with post-operative dilation is the most common reason cited for both introital and neovaginal stenosis, 15,29,32 but some studies postulate that local infection and ischemia may play a role.…”

“…Rates of hematoma range from 1.6% to 21%, 15,20,23,27,28,30,32,35 with up to one third of patients requiring reoperation. 27 Most cases, however, are treated non-operatively with pressure dressings.…”