Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques

Abstract

Introduction Gender reassignment surgery is the keystone of the treatment of transgender patients. For male-to-female transgenders, this involves the creation of a neovagina. Many surgical methods for vaginoplasty have been opted. The penile skin inversion technique is the method of choice for most gender surgeons. However, the optimal surgical technique for vaginoplasty in transgender women has not yet been identified, as outcomes of the different techniques have never been compared. Aim With this systematic review, we aim to give a detailed overview of the published outcomes of all currently available techniques for vaginoplasty in male-to-female transgenders. Methods A PubMed and EMBASE search for relevant publications (1995–present), which provided data on the outcome of techniques for vaginoplasty in male-to-female transgender patients. Main Outcome Measures Main outcome measures are complications, neovaginal depth and width, sexual function, patient satisfaction, and improvement in quality of life (QoL). Results Twenty-six studies satisfied the inclusion criteria. The majority of these studies were retrospective case series of low to intermediate quality. Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization. Conclusions The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data.

Surgical Satisfaction, Quality of Life, and Their Association After Gender-Affirming Surgery: A Follow-up Study

“…Most studies point out the substantial risks of these surgeries (Horbach et al, 2015), whereas data collection via surveys obtained similarly high self-reported complication rates (Lawrence, 2006). The high number of satisfied respondents found in the present study is comparable to earlier studies (Bouman et al, 2016;Buncamper et al, 2015;De Cuypere et al, 2005;Horbach et al, 2015;Lawrence, 2003;Lawrence, 2006;Nelson, Whallett, & McGregor, 2009;Rehman et al, 1999;Smith et al, 2005;Weigert et al, 2013) and emphasizes the effectiveness of gender-affirming procedures. Yet, most treatment evaluation studies have collected data in a clinical setting, whereas the present study reports on a cohort that was surveyed in their home environment with limited dependence on clinicians (although the participants were invited through the clinics).…”

“…For various GAS procedures, QoL improvement is reported as well. Although many studies have methodological limitations, trans women rate their QoL after vaginoplasty higher than before surgery (Horbach et al, 2015). Similarly, QoL is also higher in trans women who have undergone facial feminization surgery, compared to trans women without surgery (Ainsworth & Spiegel, 2010).…”

“…Minor regret is considered as disappointment and can overlap with dissatisfaction. In general, the literature gives high percentages of satisfaction with GAS procedures: breast augmentation 87% to 100% (De Cuypere et al, 2005;Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005;Weigert, Frison, Sessiecq, Al Mutairi, & Casoli, 2013), vaginoplasty 83% to 100% (De Cuypere et al, 2005;Horbach et al, 2015;Lawrence, 2003;Rehman, Lazer, Benet, Schaefer, & Melman, 1999;Smith et al, 2005), subcutaneous mastectomy 92% to 100% (De Cuypere et al, 2005;Nelson, Whallett, & McGregor, 2009;Smith et al, 2005), and phalloplasty 100% (De Cuypere et al, 2005). Clinical evaluation studies show positive appraisal of both genital functionality and aesthetics after surgery, whereas sexual outcomes were found to be less positive (Bouman et al, 2016;Buncamper et al, 2015).…”

Priorities for transgender medical and healthcare research

“…Outcomes research on other transition related interventions, including speech therapy, are scattered throughout the literature [51,52,53]. Studies exist on patient satisfaction with surgical outcomes [54,55], but not on satisfaction with hormonal treatment outcomes separate from overall surveys of access to care or satisfaction with overall health care services in a given setting. Studies eliciting patient identified objective outcomes and priorities are themselves lacking.…”

Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women

“…Each technique and graft type has its own advantages; however, the risk of short-term (infection, flap necrosis, neovaginal abscesses, fistulas) and long-term (stenosis, prolapse, urethral meatus stenosis) complications exists in every technique. 2,3 Neovaginal fistulas are uncommon but may cause significant discomfort to patients after vaginal (re)constructive surgery. Although rare, rectoneovaginal fistula may be a sign of underlying malignancy in the neovagina.…”