1
|
Bene NC, Ferrin PC, Xu J, Dy GW, Dugi D, Peters BR. Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty. J Clin Med 2024; 13:2760. [PMID: 38792302 PMCID: PMC11122258 DOI: 10.3390/jcm13102760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.
Collapse
Affiliation(s)
- Nicholas C. Bene
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
| | - Peter C. Ferrin
- Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA
| | - Jing Xu
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
| | - Geolani W. Dy
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Urology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Daniel Dugi
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Urology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Blair R. Peters
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
| |
Collapse
|
2
|
Berger LE, Lava CX, Spoer DL, Huffman SS, Martin T, Bekeny JC, Fan KL, Lisle DM, Del Corral GA. The Effect of Obesity on Vaginoplasty Outcomes. Ann Plast Surg 2024; 92:447-456. [PMID: 38319959 DOI: 10.1097/sap.0000000000003808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND Some surgeons use body mass index criteria within the patient selection processes before vaginoplasty, thereby limiting access to select obese patients. We sought to better characterize the effect of obesity on postoperative outcomes across multiple vaginoplasty techniques. METHODS A single-center retrospective review of all transfeminine patients undergoing primary vaginoplasty procedures from December 2018 to July 2022 was conducted. Patients were stratified into cohorts according to the World Health Organization Obesity Class criteria. Data regarding demographics, comorbidities, operative details, postoperative complications, and all-cause revision were collected. RESULTS A total of 237 patients met the inclusion criteria. Average follow-up duration was 9.1 ± 4.7 months. Multivariate regression revealed that patients with class I and class II/III obesity were associated with higher odds of developing vaginal stenosis (class I: odds ratio [OR], 7.1 [ P = 0.003]; class II/III: OR, 3.4 [ P = 0.018]) and all-cause revision (class I: OR, 3.7 [ P = 0.021]; class II/III: OR, 4.8 [ P = 0.027]). Undergoing either robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (peritoneal: OR, 0.2 [ P < 0.001]; intestinal: OR, 0.2 [ P = 0.011]). Lastly, adherence to dilation regimen was negatively associated with development of vaginal stenosis (OR, 0.04; P < 0.001). CONCLUSIONS Patients with obesity may be at a higher risk of developing vaginal stenosis after vaginoplasty, which may ultimately necessitate operative revision. Although patients with obesity may remain surgical candidates, proper preoperative counseling and adherence to postoperative vaginal dilation regimens are critical to optimizing outcomes.
Collapse
Affiliation(s)
| | | | | | | | - Taylor Martin
- Georgetown University School of Medicine, Washington, DC
| | - Jenna C Bekeny
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Kenneth L Fan
- From the Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - David M Lisle
- Division of Colorectal Surgery, Department of General Surgery, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Gabriel A Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center, Washington, DC
| |
Collapse
|
3
|
Hu W, Tehri I, Kinn H, Henry AS, Rouanet M, Pop A, Vais B, Claudic Y, Saraoui W, Perruisseau-Carrier A. [Description of a vaginoplasty technique using a peritoneal flap harvested by coelioscopic approach for male-to-female gender affirmations (MtF)]. ANN CHIR PLAST ESTH 2023; 68:455-461. [PMID: 37596142 DOI: 10.1016/j.anplas.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
AIM The aim of this article is to provide a comprehensive description of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery, particularly in cases of insufficient depth after penile inversion vaginoplasty. RESULTS Our short-term results reveal that the peritoneal flap vaginoplasty, adapted from the Davydov procedure, has shown significant potential for improving functional and aesthetic outcomes, including the creation of a self-lubricating neovagina. However, the complexity of the procedure requires advanced surgical expertise and appropriate postoperative care. Patient selection also plays an essential role as not all patients are ideal candidates for this procedure. CONCLUSION Despite its promises, the widespread adoption of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery is hindered by several challenges, including the need for specialized training and potential postoperative complications. Thus, this technique should be considered as an alternative or complement to traditional methods, depending on individual patient factors. Further research and extensive clinical trials are needed to better understand its potential and limitations in order to enhance the arsenal of effective surgical options for MtF gender affirmation surgery.
Collapse
Affiliation(s)
- W Hu
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmoulins, 29238 Brest, France.
| | - I Tehri
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - H Kinn
- Service de chirurgie viscérale et digestive, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - A S Henry
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - M Rouanet
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmoulins, 29238 Brest, France
| | - A Pop
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - B Vais
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - Y Claudic
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - W Saraoui
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - A Perruisseau-Carrier
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalo-universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmoulins, 29238 Brest, France
| |
Collapse
|
4
|
Bertrand B, Perchenet AS, Casanova D. [The history of vaginoplasty: Technical and sociological advances]. ANN CHIR PLAST ESTH 2023; 68:389-396. [PMID: 37735028 DOI: 10.1016/j.anplas.2023.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 09/23/2023]
Abstract
Technical advances in gender-affirming genital surgery have allowed the modern surgeon to create a vagina, vulva and clitoris from a male sex. This surgery, commonly known as vaginoplasty, should in fact be identified as aidopoiesis, since it is not a question of improving an already existing vagina but of creating a female sex. Numerous technical advances made since 1930 throughout the world now offer a safe and proven surgical strategy for female genital gender affirmation. Most of these techniques are derived from advances in intersex genital surgery. The first vaginoplasties described in the context of gender affirmation were performed in Berlin in the 1930s. After the Second World War, the greatest advances in vaginoplasty were made in Denmark. It was not until Geroges Burou in Casablanca and Harold Gillies, aided by Ralph Millard in England, in the mid-fifties that the modern technique of invagination of the penile skin took over from neo-vaginal grafting techniques. The creation of the clitoris from the glans penis and a more aesthetic vulva were the major advances from the 1970s. Other flap or intestinal transplant techniques were also developed, often to correct the failure of penile skin invagination. Some of the patients who benefited from these early technical advances, such as Lili Elbe and Christine Jorgensen later on, helped to make this surgery, which had long remained taboo, popular with the general public. Pioneers such as the gynaecologist Georges Burou in Casablanca have contributed, with the greatest discretion, to the well-being of gender-affirmed people by improving these techniques. Today, this hard-won heritage cannot be ignored by surgeons interested in vaginoplasty.
Collapse
Affiliation(s)
- Baptiste Bertrand
- Service de chirurgie plastique, réparatrice et esthétique, hôpital de la conception, Assistance publique-Hôpitaux de Marseille, Marseille, France.
| | - Anne-Sophie Perchenet
- Service de chirurgie plastique, réparatrice et esthétique, Hôpital Saint-Anne du service de santé des Armées, Toulon, France
| | - Dominique Casanova
- Service de chirurgie plastique, réparatrice et esthétique, hôpital de la conception, Assistance publique-Hôpitaux de Marseille, Marseille, France
| |
Collapse
|
5
|
Burns HR, McLennan A, Xue EY, Yu JZ, Selber JC. Robotics in Microsurgery and Supermicrosurgery. Semin Plast Surg 2023; 37:206-216. [PMID: 38444959 PMCID: PMC10911899 DOI: 10.1055/s-0043-1771506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Microsurgery has changed the ability to perform highly precise and technical surgeries through the utilization of high-powered microscopes and specialized instruments to manipulate and repair anatomical structures as small as a few millimeters. Since the first human trials of robotic-assisted microsurgery in 2006, the expansion of microsurgery to supermicrosurgery (luminal diameter less than 1 mm) has enabled successful repair of previously inaccessible structures. Surgical robotic systems can offer two distinct operative advantages: (1) minimal access surgery-by entering body cavities through ports, flap harvest can be redesigned to affect a minimally invasive approach for flaps such as the rectus abdominis muscle, the latissimus flap, and the deep inferior epigastric perforator flap; and (2) precision-by eliminating physiologic tremor, improving ergonomics, increasing accessibility to difficult spaces, and providing motion scaling, precision is significantly enhanced. Robotic-assisted microsurgery is a promising application of robotics for the plastic surgeon and has played an important role in flap harvest, head and neck reconstruction, nerve reconstruction, gender-affirming surgery, and lymphatic reconstruction-all the while minimizing surgical morbidity. This article aims to review the history, technology, and application of microsurgery and supermicrosurgery in plastic surgery.
Collapse
Affiliation(s)
- Heather R. Burns
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Alexandra McLennan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Erica Y. Xue
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Texas Children's Hospital, Houston, Texas
| | - Jessie Z. Yu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jesse C. Selber
- Department of Plastic Surgery, Corewell Health, Grand Rapids, Michigan
| |
Collapse
|
6
|
Robinson IS, Zhao LC, Bluebond-Langner R. Robotics in Gender Affirming Surgery: Current Applications and Future Directions. Semin Plast Surg 2023; 37:193-198. [PMID: 38444954 PMCID: PMC10911895 DOI: 10.1055/s-0043-1771302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.
Collapse
Affiliation(s)
- Isabel S. Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Lee C. Zhao
- Department of Urology, New York University Langone Health, New York, New York
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| |
Collapse
|
7
|
Blickensderfer K, McCormick B, Myers J, Goodwin I, Agarwal C, Horns J, Hotaling J. Gender-affirming Vaginoplasty and Vulvoplasty: An Initial Experience. Urology 2023; 176:232-236. [PMID: 36931571 DOI: 10.1016/j.urology.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/17/2023] [Accepted: 03/01/2023] [Indexed: 03/17/2023]
Abstract
OBJECTIVE To describe the initial outcomes of a new multidisciplinary gender-affirming surgery (GAS) program comprised of plastic and urologic surgeons. METHODS We retrospectively examined consecutive patients who underwent gender-affirming vaginoplasty or vulvoplasty between April 2018 and May 2021. We used logistic regression modeling to analyze associations between preoperative risk factors and postoperative complications. RESULTS Between April 2018 and May 2021, 77 genital GAS (gender-affirming surgery) procedures were performed at our institution (56 vaginoplasties, 21 vulvoplasties). All surgeries were performed in combination with urology and plastic surgery primarily using the perineal penile inversion technique. Mean patient age was 39.6 years, and mean BMI was 26.2 (Table 1a). The most common pre-existing conditions were hypertension and depression, with nearly 14% of patients reporting a previous suicide attempt. The complication rate for vaginoplasty was 53.7% within the first 30 days (Table 4). The most common complications were yeast infection (14.8%) and hematoma (9.3%). For vulvoplasty, the 30-day complication rate was 57.1%, with urinary tract infection (14.3%) and granulation tissue (9.5%) being the most common. 88.1% and 91.7% of the complications were Clavien-Dindo grade I or II for vaginoplasties and vulvoplasties, respectively. No association was found between preoperative patient factors and postoperative complications. Revision surgeries were performed for 38.9% of vaginoplasty patients during the study period, most commonly including urethral revision (29.6%), labia majoraplasty (20.4%), and labia minoraplasty (14.8%). CONCLUSION Collaboration between urology and plastic surgery is a safe and effective means to establish a GAS program.
Collapse
Affiliation(s)
| | | | - Jeremy Myers
- Division of Urology , University of Utah, Salt Lake City, UT
| | - Isak Goodwin
- Division of Plastic Surgery, University of Utah, Salt Lake City, UT
| | - Cori Agarwal
- Division of Plastic Surgery, University of Utah, Salt Lake City, UT
| | | | - James Hotaling
- Division of Urology , University of Utah, Salt Lake City, UT
| |
Collapse
|
8
|
Parker A, Brydges H, Blasdel G, Bluebond-Langner R, Zhao LC. Mending the Gap: AlloDerm as a Safe and Effective Option for Vaginal Canal Lining in Revision Robotic Assisted Gender Affirming Peritoneal Flap Vaginoplasty. Urology 2023; 173:204-208. [PMID: 36642117 DOI: 10.1016/j.urology.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.
Collapse
Affiliation(s)
| | - Hilliard Brydges
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Gaines Blasdel
- Department of Urology, NYU Langone Health, New York, NY; University of Michigan Medical School, Ann Arbor, MI
| | | | - Lee C Zhao
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY; Department of Urology, NYU Langone Health, New York, NY.
| |
Collapse
|
9
|
Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol 2023; 20:308-322. [PMID: 36726039 DOI: 10.1038/s41585-022-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 02/03/2023]
Abstract
Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.
Collapse
|
10
|
Morelli G, Zucchi A, Ralph D, Perotti A, Sollazzi E, Bartoletti R. A single pedicled robotic peritoneal flap in penile inversion vaginoplasty augmentation. BJU Int 2023; 131:125-129. [PMID: 36263846 DOI: 10.1111/bju.15922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES To develop a surgical technique to achieve greater depth of the neovaginal cavity in transgender patients undergoing scrotovaginoplasty, and to propose a method for restoring neovaginal integrity in case of lack of genital skin or reduction of the depth due to scarring after infections or ischaemic processes. METHODS Eight patients were selected to undergo scrotovaginoplasty with scrotal graft and peritoneal flap augmentation in one operating session as a modification of Zhao's original technique. The age of the patients ranged from 25 to 65 years. The first step of the procedure was standard penile inversion vaginoplasty, avoiding suturing of the superior side of the skin cylinder. The skin cylinder was pushed into the abdominal cavity through the perineal access. Afterwards a laparoscopic/robotic approach was used: a single peritoneal flap was harvested from the posterior bladder surface, incised, dissected, pedicled on the neovaginal dome, overturned and and sutured all-round to the neovagina. The sides were adapted to obtain a 'cul-de-sac'. RESULTS The average operating time was 6 ± 1.5 h, and patients' hospitalization lasted 6 days. There were no intra- or postoperative complications. Postoperative management was the same as that usually reported in BJUI for patients undergoing standard scrotovaginoplasty. CONCLUSIONS The use of this technique represents a good solution for increasing neovaginal depth by harvesting a large peritoneal vascularized flap, without significantly affecting postoperative management or increasing complications, as frequently observed using the colovaginoplasty technique.
Collapse
Affiliation(s)
- Girolamo Morelli
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alessandro Zucchi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - David Ralph
- Andrology Department, University College London Hospital, London, UK
| | - Alessandro Perotti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Eleonora Sollazzi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Riccardo Bartoletti
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| |
Collapse
|
11
|
Smith SM, Yuan N, Stelmar J, PA-C GL, Gupta A, Kim HL, Garcia MM. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022; 10:100572. [PMID: 36183656 PMCID: PMC9780766 DOI: 10.1016/j.esxm.2022.100572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 08/19/2022] [Accepted: 08/26/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Gender-affirming peritoneal vaginoplasty has been described, and previous descriptions are modifications of the Davydov technique. AIM To describe our alternative technique for gender-affirming peritoneal vaginoplasty (PV) using a single-pedicled, urachus-peritoneal hinge flap, discussing proposed advantages. METHODS Retrospective review of all consecutive transfeminine patients with neovaginal shortening after prior penile inversion vaginoplasty (PIV) who underwent our PV technique from May 2019 to July 2022. PV was performed via combined transperineal and laparoscopic (robot-assisted) approaches. After spatulation of the neovaginal remnant, a midline, inferiorly based urachus-peritoneal hinge flap was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The free end of the flap was flipped posteriorly and sutured to posterior edge of the open canal remnant, forming a peritoneal pouch. The lateral edges of the pouch were sutured together for water-tight closure. Patients resumed dilation on POD 6 and douching on POD 10. MAIN OUTCOME MEASURES Ten transfeminine patients underwent PV, with good outcomes. We measured: Pre-op penile and scrotal skin lengths, intra-op tubularized scrotal skin length, pre and post-op vaginal depth and width (immediate and at last follow-up). RESULTS Pre-op: mean neovaginal depth was 9.2cm (SD 1.5); width was 12cm. Immediate post-op: mean depth was 15.1 cm (SD 2.2 cm, mean net increase: 5.9 cm). At mean follow-up of 18.3 months, mean depth was 12.5 cm (SD 2.1 cm, mean net increase: 3.3 cm) and width was 12 cm. There were no immediate post-op complications. Eight (80%) of the 10 patients report satisfactory vaginal receptive intercourse. The other 2 have not yet attempted vaginal receptive intercourse. CLINICAL IMPLICATIONS Advantages of the proposed technique over existing techniques include no tension on peritoneal suture lines and total exclusion of the rectum. STRENGTHS AND LIMITATIONS Strengths include a short learning curve for urologic surgeons with robotic experience. The study is limited by small sample size. CONCLUSIONS Our PV technique is a safe and effective option for salvage peritoneal vaginoplasty after primary PIV. Smith SM, Yuan N, Stelmar J, et al. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022;10:100572.
Collapse
Affiliation(s)
- Shannon M. Smith
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute, Pasadena, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Grace Lee PA-C
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amit Gupta
- Beverly Hills Urology, Beverly Hills, CA, USA
| | - Hyung L. Kim
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maurice M. Garcia
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Departments of Anatomy and Urology, University of California San Francisco, San Francisco, CA, USA,Corresponding Author: Maurice M. Garcia, MD, MAS, 8635 W. Third St., Suite 1070W, Los Angeles, CA 90048, USA.
| |
Collapse
|
12
|
Robotic Peritoneal Flap vs. Perineal Penile Inversion Techniques for Gender-Affirming Vaginoplasty. Curr Urol Rep 2022; 23:211-218. [PMID: 36040679 DOI: 10.1007/s11934-022-01106-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To discuss perineal and robotic approaches to gender-affirming vaginoplasty. RECENT FINDINGS The Davydov peritoneal vaginoplasty has its origins in neovaginal reconstruction for vaginal agenesis. It has been adapted as a robotic-assisted laparoscopic procedure and provides an alternative to perineal canal dissection in gender-affirming vaginoplasty. Both techniques represent variations of penile inversion vaginoplasty with successful outcomes and overall low rates of major complications reported in the literature. However, there are differing advantages and considerations to each approach. A perineal approach has been the gold standard to gender-affirming vaginoplasty for many decades. Robotic peritoneal gender-affirming vaginoplasty (RPGAV) is an emerging alternative, with potential advantages including less reliance on extragenital skin grafts in individuals with minimal genital tissue, especially among patients presenting with pubertal suppression, and safer dissection in revision vaginoplasty for stenosis of the proximal neovaginal canal. Additional risks of RPGAV include those associated with robotic abdominal surgeries.
Collapse
|
13
|
Discussion: Common Revisions after Penile Inversion Vaginoplasty: Techniques and Clinical Outcomes. Plast Reconstr Surg 2022; 149:1202e. [PMID: 35613292 DOI: 10.1097/prs.0000000000009163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
Jimenez C, Stanton E, Sung C, Wong AK. Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery. JPRAS Open 2022; 33:76-91. [PMID: 35812356 PMCID: PMC9260262 DOI: 10.1016/j.jpra.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 01/28/2023] Open
Abstract
Background This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions. Methods A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery. Results The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review. Conclusions Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.
Collapse
Affiliation(s)
- Christian Jimenez
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Eloise Stanton
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Cynthia Sung
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA
| | - Alex K. Wong
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA,Corresponding author: Alex K. Wong, Division of Plastic and Reconstructive Surgery, City of Hope, 1500 E Duarte Rd, Duarte, CA 91010.
| |
Collapse
|
15
|
Zilavy AJ, Santucci RA, Gallegos MA. The History of Gender-Affirming Vaginoplasty Technique. Urology 2022; 165:366-372. [DOI: 10.1016/j.urology.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
|
16
|
Van Gerwen OT, Aryanpour Z, Selph JP, Muzny CA. Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review. Int J STD AIDS 2022; 33:106-113. [PMID: 34615399 PMCID: PMC9713597 DOI: 10.1177/09564624211046997] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.
Collapse
Affiliation(s)
- Olivia T Van Gerwen
- Department of Medicine, Division of Infectious Diseases, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zain Aryanpour
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
| | - John P Selph
- Department of Urology, 9968University of Alabama at Birmingham, Birmingham, AL, USA.Increase
| | - Christina A Muzny
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
| |
Collapse
|
17
|
Melancon DM, Walton AB, Mundinger G, Benson C. Surgical Outcomes and Complications of Genital Gender Affirmation Surgery. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|