Outcomes of Transperineal Gender-Affirming Vaginectomy and Colpocleisis

Abstract

Objectives There are multiple approaches to vaginectomy for the purpose of masculinizing gender-affirming genital surgery including mucosal fulguration and excision. The outcomes of the approaches are not well described. We aim to describe the surgical outcomes of gender-affirming vaginectomy and colpocleisis by complete mucosal excision. Methods We performed a case series study of 40 transmasculine patients who underwent gender-affirming vaginectomy and colpocleisis. Vaginectomy was performed by complete excision of the vaginal mucosa via a transperineal approach. We recorded perioperative outcomes and operative time. We performed a multivariate analysis to assess patient factors on operative outcomes. Results Forty vaginectomies were performed between September 2016 and April 2019, 27 (67.5%) in phalloplasty patients and 13 (32.5%) in metoidioplasty patients. Perioperative complications included 2 blood transfusions, 1 pelvic hematoma, and 1 Clostridium cifficile colitis. No urethral fistulae to the vaginal space, mucoceles, or visceral injures were seen with a median follow-up of 7.7 months. Operative time decreased significantly with later surgery year. Conclusions This is a large series studying the outcomes of gender-affirming vaginectomy by complete mucosal excision approach in the literature. Perioperative complications were low. Operative time decreased overtime such that after approximately 20 cases, the procedure fairly consistently takes 2 to 2.5 hours to perform.

Masculinizing Gender Affirming Surgery

“…Hougen et al reported no instances of fistula to the vaginal space, mucocele from the vaginal remnant, or visceral injury (bladder injury, bowel injury, ureteral obstruction) in a series of 40 transgender males undergoing total vaginectomy and colpocleisis. 37 In the largest series to date, Nikkels et al found that 15 (10%) of 143 patients had major perioperative complications, including 1 rectal injury and 9 bladder/urethral injuries. 36 Laparoscopic and robotic approaches to vaginectomy have also been described 31,38 with similarly low rates of major complications and with less blood loss.…”

A narrative review of outcomes following metoidioplasty: complications and satisfaction

“…Colpectomy is associated with significant blood loss [36] . However, there are limited reports of estimated blood loss during metoidioplasty procedures.…”

“…Nikkels et al evaluated 143 transgender patients undergoing colpectomy with or without additional procedures such as metoidioplasty and hysterectomy [36] . A bladder injury was reported in 6 patients (4%) and bowel (rectal) injury in 1 patient (1%).…”

Phalloplasty: understanding the chaos

“…Hysterectomy and salpingo-oophorectomy are commonly performed using a transvaginal or standard laparoscopic approach during a separate stage in advance of masculinizing genital surgical procedures [13] . A primary advantage of this staging is to avoid the longer operative times, increased procedural blood loss, and greater physiologic disturbance when combining these with other procedures [14] . Note that chest recontouring can be performed at the same time as hysterectomy and salpingo-oophorectomy.…”

“…For vaginectomy, there is variation in the specific technique used to ablate the vaginal mucosa. Although direct surgical excision may entail more blood loss, and although fulgarization may result in a higher chance of retained vaginal mucosa, at present, there appear to be limited data [14] indicating the superiority of any one of the three commonly employed methods: fulgarization [15] , direct surgical excision [16] , or dual-approach, robotically assisted excision [17] . The selected method depends on surgeon expertise and preference and on the staging and specific method of pars fixa construction.…”