Achieving Correct Axis and Good Depth in Gender Affirming Vaginoplasties by Penile-Perineoscrotal Flap Vaginoplasty

Abstract

Objectives Vaginoplasty as a part of feminizing genitoplasty (FG) in transwomen helps alleviate gender dysphoria and improves mental health, sexual and psychosocial functioning, and quality of life in these individuals. Penile inversion technique (PSFV) remains the gold standard procedure for FG with least morbidity but has inherent limitations often resulting in inadequate depth and incorrect (posteroinferior) vaginal axis, precluding sexual intercourse. Material and Methods Over the past 27 years, the senior author has refined his technique considerably incorporating several modifications penile perineo-scrotal flap vaginoplasty (PPSFV) to overcome the limitations in PSFV. Most of these modifications were in place by March 2015. Out of 630 primary FGs, retrospective review of all PPSFV with minimum 6 months follow-up operated during the period March 2015 to July 2020 was done for intra and postoperative complications. Results There were 183 patients who underwent PPSFV during the study period. Average follow-up was 31 (6–62) months. There were no cases of injury to bladder, rectum, urethral stenosis, or neovaginal prolapse. Average operative time was 4 hours and eight (4.37%) patients required blood transfusion. The vaginal depth was 13 to 14 cm or more in 159 (86.88%), 10 to 12 cm in 17 (9.29%), and 7.5 to 9 cm in seven (3.82%) patients. Ten (5.46%) patients complained of intravaginal hair growth. Touch up procedures in the form of anterior commissure and labia plasty were required in 13 (7.10%) patients. All (100%) patients had good clitoral sensitivity and preserved posterosuperior vaginal axis. One-hundred thirty nine (75.96%) patients were able to have satisfactory penetrative sexual intercourse, while 39 (21.31%) had not attempted intercourse and five (2.73%) complained of poor sexual experience on account of inadequate vaginal dimensions. Conclusion PPSFV addresses the limitations in PSFV and results in good vaginal depth and posterosuperior axis, which facilitates penetrative sexual intercourse, at the same time, avoiding potential complications of procedures such as intestinal vaginoplasties.

Gender-Affirming Surgery in Low- and Middle-Income Countries: A Systematic Review

“…Following abstract screening, 98 articles underwent full-text review and assessment in accordance with the inclusion/exclusion criteria. Following final review, a total of 34 studies [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ], encompassing n = 5064 patients, were included in the final analysis. Figure 1 shows the PRISMA flow diagram.…”

“…A total of 12 studies (35.3%) [ 17 , 18 , 19 , 21 , 29 , 31 , 32 , 33 , 34 , 35 , 39 , 46 ] were from lower-middle-income countries and 22 studies (64.7%) [ 16 , 20 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 30 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 47 , 48 , 49 ] were from upper-middle-income countries. No studies originated from low-income countries.…”

“…The mean patient age was 30 years (absolute range: 24.4–41.0). A total of 16 (47.1%) studies included patients’ medical histories [ 16 , 17 , 20 , 21 , 22 , 23 , 29 , 31 , 38 , 39 , 40 , 41 , 44 , 46 , 47 , 49 ] and 31 (91.2%) reported on post-operative outcomes [ 16 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 ]. The mean post-operative follow-up was 48 months (absolute range: 6–94 months).…”

Vaginoplasty for Gender Dysphoria and Mayer-Rokitansky-Küster-Hauser Syndrome: A Systematic Review and Meta-analysis

“…Vaginal hair growth was reported 5% by Gupta and Gupta 45 after Combined-GAS and 26.3% by Gentile et al 46 through a patient satisfaction questionnaire.…”

“…Sexual activity varied gravely as 21-100% at 1-132 post-operative months during assessment (Figure S6A/B). The definitions of sexual activity in the included articles varied as regular activity, 58,73,74,77 any 14,17,[78][79][80]41,44,60,61,66,70,72,75 in the last month, 47,62 vaginal intercourse 43,45,81,82 with a man 25 or married with sexual activity. 83 Sexual function was assessed most often with the Female Sexual Function Index (FSFI).…”