Curr Obstet Gynecol Rep (2017) 6:133–139 DOI 10.1007/s13669-017-0203-5

CARE FOR THE TRANSGENDER PATIENT (C UNGER, SECTION EDITOR)

Vaginoplasty for the Transgender Woman Tonya N. Thomas 1 & Cecile A. Unger 1

Published online: 20 April 2017 # Springer Science+Business Media New York 2017

Abstract Purpose of Review The purpose of this review was to describe the most common male-to-female vaginoplasty surgical techniques, and to review important perioperative considerations, outcomes, and complications associated with these surgeries. Recent Findings Vaginoplasty for the transgender woman may be performed using a variety of techniques. Most commonly, the penile inversion vaginoplasty technique is used, but in some cases, the intestinal segment vaginoplasty is indicated. Intraoperative complications of vaginoplasty surgery include bleeding and injury to the bladder, urethra, and/or rectum. Immediate postoperative complications include hematoma or seroma formation, infection or abscess, wound dehiscence, flap necrosis, and venous thromboembolism. Delayed postoperative complications include neovaginal stenosis or shortening of the neovagina, rectovaginal or genitourinary fistula formation, urethral meatal stenosis or abnormal urine stream, neuropathy, and sexual dysfunction including dyspareunia and anorgasmia. Most patients are satisfied with the functional and esthetic outcomes of vaginoplasty, but sexual dysfunction may be common. The risk of regret following vaginoplasty seems to be low, and certain risk factors for this unfavorable outcome have been identified.

This article is part of the Topical Collection on Care for the Transgender Patient * Tonya N. Thomas [email protected]

1

Center for Urogynecology and Pelvic Reconstructive Surgery, Center for LGBT Care, Obstetrics, Gynecology & Women’s Health Institute, Cleveland Clinic, 9500 Euclid Avenue/A81, Cleveland, OH 44195, USA

Summary Outcomes appear to be satisfactory following vaginoplasty surgery for transgender women, but robust prospective, long-term data are lacking. Keywords Male-to-female vaginoplasty . Transgender vaginoplasty . Transgender surgery . Gender confirmation surgery . Vaginoplasty surgical technique

Introduction Gender dysphoria is defined as “distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/ or primary and secondary sex characteristics)” [1••]. Transgender individuals feel a strong sense of incongruity between their natal sex and their gender identity, and may desire surgical transition to their affirmed gender [2]. Vaginoplasty surgery, which usually includes partial penectomy, orchiectomy, vaginoplasty, clitoroplasty, and labiaplasty/vulvoplasty, may be performed for transgender women who desire surgical transition. This type of surgery is now more commonly referred to as gender confirmation or affirmation surgery, and it is considered irreversible. Therefore, careful patient selection is crucial for favorable outcomes. The World Professional Association for Transgender Health (WPATH) has published guidelines that serve as a framework for health professionals caring for transgender individuals [1••]. These standards of care include criteria for genital surgery: (1) well-documented, persistent gender dysphoria, (2) two letters of referral from mental health professionals well versed in the care of transgender patients, (3) capacity of the patient to engage in informed decisionmaking and consent, (4) well-controlled comorbid medical and mental health conditions, (5) 12 continuous months of

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hormone therapy, and (6) 12 continuous months of experience living in the gender role consistent with the patient’s gender identity. Additionally, regular follow-up with a mental health or medical care provider is recommended. Vaginoplasty Techniques Two main techniques exist for male-to-female vaginoplasty: penile inversion vaginoplasty and intestinal segment vaginoplasty [3•]. Other less common techniques may involve the use of skin grafts from various donor sites [4–6]. The goal of all techniques is to construct a functional and esthetic vagina, clitoris, and vulva, capable of intercourse and orgasm. The most researched and most commonly performed technique is the penile inversion vaginoplasty, in which the components of the penis are deconstructed and the penile and scrotal skin is used to line the neovagina [3•]. Alternatively, intestinal segment vaginoplasty, in which a segment of sigmoid colon or ileum is used to create a neovagina, can be performed when penile inversion vaginoplasty fails, or when there is insufficient peno-scrotal skin, which can occur in transgender women who transition early in life, and are treated with pubertysuppressing therapy [3•, 7]. In these patients, the penile inversion technique is still often performed with additional skin grafting techniques. In general, the intestinal vaginoplasty has fallen out of favor as a primary surgery for confirmation surgery, and is more commonly performed in transgender women who require revision surgery for neovaginal stenosis or contracture. The technique of penile inversion vaginoplasty has been widely described, and various modifications have been made over time [8–10]. In brief, the technique includes deconstruction of the penis, formation of a neoclitoris from a portion of the glans with an intact dorsal neurovascular pedicle, creation of a neourethral meatus, dissection of the neovagina, lining of the neovagina with peno-scrotal skin, and labiaplasty/ vulvoplasty with use of various peno-scrotal skin flaps [9, 11]. Our preferred technique is described later in this paper. The main advantages of the penile inversion vaginoplasty include avoidance of an abdominal procedure and the use of local flaps that maintain their neurovascular supply. Disadvantages include the need for compliance with postoperative dilation, the possibility of insufficient skin to achieve adequate neovaginal dimensions, and hair growth in the neovagina if a scrotal flap is used, and permanent depilatory procedures (e.g., electrolysis, laser) are not performed preoperatively. Intestinal vaginoplasty may be performed through an open abdominal incision, by hand-assisted laparoscopy, or by total laparoscopy [12]. Reported advantages of the procedure include achievement of adequate vaginal depth and a vaginal tube that has natural lubrication. Disadvantages of this technique include excessive mucus production that may be

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bothersome to patients, introital stenosis, malodor, and the potential morbidity associated with an abdominal procedure and creation of a bowel anastomosis [13•]. The abdominal portion of the surgery includes harvest of an intestinal segment (usually sigmoid or ileum) on its vascular pedicle, creation of a neovaginal tube, and anastomosis for restoration of bowel continuity. The perineal portion of the surgery includes partial penectomy, orchiectomy, dissection of the neovaginal cavity, bowel-perineal anastomosis, clitoroplasty, labiaplasty/ vulvoplasty, and in some cases, a suspension procedure for prevention of prolapse [13•]. Outcomes and Complications Intraoperative complications of vaginoplasty surgery include excessive bleeding and need for transfusion, and injury to the bladder, urethra, and/or rectum. Immediate postoperative complications include bleeding, hematoma or seroma formation, infection or abscess, wound dehiscence, flap necrosis, and venous thromboembolism. Delayed postoperative complications of vaginoplasty include neovaginal stenosis or shortening of the neovagina, rectovaginal or genitourinary fistula formation, urethral meatal stenosis or abnormal urine stream, neuropathy, and sexual dysfunction including dyspareunia and anorgasmia. In a recently published systematic review of postoperative outcomes following male-tofemale vaginoplasty using the modified penile inversion technique, Horbach et al. reported the following rates of complications: stricture of the neovaginal introits in 12% (4.2–15%) of patients, partial necrosis of the neovagina in 2.7–4.2%, clitoral necrosis in 1–3%, rectal injury in 2–4.2%, rectovaginal fistula in 1% (0.8–17%), urethral meatal stenosis in 5% (1– 6%), wound dehiscence in 12–33%, abscess in 5%, hematoma in 4–6%, and surgical bleeding in 3.2–10% [3•]. Review of the literature on the intestinal segment vaginoplasty technique performed specifically for transgender patients is more limited, as this procedure is less frequently performed [3•]. In transgender patients, the incidence of neovaginal stenosis after intestinal vaginoplasty has been reported to be as high as 43%, which is much higher than reported rates in non-transgender patients undergoing this type of procedure [3•]. Necrosis of the neovagina and rectovaginal fistula appear to be rare complications associated with this surgery [3•]. Other reported complications included mucosal prolapse and bothersome discharge and malodor. In a systematic review of intestinal vaginoplasty performed for multiple indications (including gynecologic), an overall complication rate of 6.4% was reported for sigmoid vaginoplasty (N = 686) with a 0.6% severe complication rate, and 8.3% for ileal segment vaginoplasty (N = 169) with no severe complications reported [13•]. Both introital and diffuse vaginal stenoses were reported, in 8.6 and 3.5%, respectively, in the sigmoid vaginoplasty group, and 1.2 and 3.0% in the ileal segment

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vaginoplasty group. In both groups, discharge was noted to be acceptable by 6 months, with excessive discharge continuing in 0.7% of sigmoid patients. Prolapse of the neovagina occurred in 7.7% of sigmoid vaginoplasty patients (6.5% mucosal prolapse). Sexual activity was resumed in 1–2 months postoperatively and was satisfactory in 85.7% of sigmoid vaginoplasty patients, and 100% of ileal segment vaginoplasty patients; however, standardized measures were used to assess this outcome, which may limit the reproducibility of this finding. A 24.7% rate of dyspareunia was reported [13•]. A survey using standardized questionnaires of transgender women who underwent penile inversion vaginoplasty showed that the majority were satisfied with their functional and esthetic outcomes; however, Female Sexual Function Index scores fell into the sexual dysfunction range in 56% of respondents, mainly due to sexual inactivity, or issues related to lubrication or discomfort [14]. This high rate of sexual dysfunction should alert professionals caring for transgender patients to the need for improvement in both surgical technique and postoperative education and management of sexual function. We also suspect that these results could reflect the lack of validated questionnaires specific to the transgender population, and work is currently underway to address this and to help assist us in studying these important postoperative outcomes. In a separate study, the vibratory and tactile sensitivities of the neoclitoris have been described and correlated to orgasm and sexual function [15]. Pressure thresholds of the neoclitoris in these patients have been found to be somewhat lower than the male glans penis, but higher than the female clitoris. At an average follow-up of 37 months, 86% of transgender women who underwent vaginoplasty reported having had an orgasm, and 86% reported no pain. The majority of these patients were satisfied with their surgery [15]. In a comprehensive review of the historical literature, 20 cases of regret were identified in male-to-female transgender patients [16]. Some overlap was identified in the reported cases, and not all reported cases had undergone surgery. In the 14 cases of regret after surgery, three factors were identified as potential risk factors for this unfavorable outcome: inappropriate diagnostic indication for surgery, not enough time spent living in the desired gender role, and perception of a poor outcome following the surgical procedure. In a survey of 232 postoperative male-to-female vaginoplasty patients, no participants reported consistent regret, but 6% (n = 15) did report that they were sometimes regretful, and 2 participants (1%) reported reversion to living in a male gender role following surgery [17]. In this study, surgical outcome was identified as an important predictor of satisfaction [17]. Most providers offering surgical services to patients adhere to the WPATH Standards of Care [1••]. The criteria for surgical transition set forth by the society have been carefully chosen by experts in the field to mitigate potential risk factors for postoperative

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regret and to assist providers in choosing appropriate candidates for surgery. Preoperative Planning and Perioperative Care For penile inversion vaginoplasty utilizing peno-scrotal skin flaps, it is important for the patient to undergo permanent depilatory procedures (e.g., electrolysis or laser) prior to surgery. To optimize results, hair should be removed from the scrotum, which will be used to line the neovagina. Other genital hair-bearing areas may be left intact if the patient desires pubic hair following surgery. Electrolysis produces destruction of the hair follicle by directing an electric current into the hair follicle through insertion of a needle or probe [18]. In laser hair removal, a laser light source is used to target the pigmented hair, creating thermal injury which destroys the hair follicle [18]. Lidocaine jelly or lidocaine/prilocaine cream may be prescribed to reduce discomfort with hair removal procedures. Multiple treatment sessions are required for either technique, as the procedures are most effective on hairs in the anagen (growth) phase [18]. Generally, we recommend that hair removal procedures be stopped 4–6 weeks prior to surgery. There is a paucity of data in the literature concerning the risk of venous thrombotic events (VTE) in transgender patients in the perioperative period; however, available evidence suggests a higher incidence of VTE in the male-to-female transgender population [19]. First, most patients have been on long-term exogenous estrogen which significantly increases their baseline risk for VTE. Second, vaginoplasty procedures may take anywhere from 2.5 to 6 h depending on surgeon and patient factors and this prolonged immobilization under anesthesia certainly places patients at increased risk for perioperative VTE. Third, many surgeons place their patients on modified bed rest in the immediate postoperative period which further increases the risk of VTE. The Endocrine Society Clinical Practice Guideline recommends that the surgeon and endocrinologist collaborate concerning hormone use in the perioperative period and during the month prior to surgery [20]. In our practice, estrogen is held for 3–4 weeks prior to surgery, and may be restarted 3–4 weeks following surgery, provided the patient has returned to her baseline light activity level. Subcutaneous heparin and sequential compression devices are used for venous thromboembolism prophylaxis preoperatively and postoperatively, and in the immediate postoperative period, subcutaneous enoxaparin is used for 1 week following hospital discharge. Appropriate antibiotic prophylaxis for urogenital procedures is administered prior to surgery [21]. In our practice, perioperative intravenous cefazolin is administered, followed by oral trimethoprim/sulfamethoxazole for 1 week after hospital discharge to prevent infection in the setting of an indwelling Foley catheter and vaginal packing. Specific guidelines for

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antibiotic prophylaxis in the transgender surgical population do not exist currently, and the duration of antibiotic prophylaxis is based on expert opinion. Guidelines for intraoperative antibiotic re-dosing should be followed to reduce the risk of perioperative infection. Other important perioperative considerations include careful patient positioning and padding due to the potential extended length of the procedure. We utilize egg crate foam padding on the operating room table, and adhesive foam dressings on the sacrum and heels to prevent pressure sores. The arms are left untucked and out at the patient’s sides, allowing the anesthesia team access throughout the procedure. The legs are placed in high lithotomy position in padded adjustable stirrups, keeping the ankle, knee, and hip joints in alignment and avoiding hyperflexion or hyperextension of the hips and knees. There are no data to support use of a mechanical bowel preparation prior to surgery. The decision to prep patients is surgeon-dependent and may be helpful in the rare case of intraoperative rectal injury and to help delay the initial postoperative bowel movement. In our practice, patients are asked to consume a clear liquid diet on the day preceding surgery, and all patients perform a modified bowel preparation in the evening. Postoperatively, intravenous patient-controlled analgesia is administered for the first 24 h for pain control, then patients are transitioned to oral narcotic medication. Activity is restricted to bed rest in beach chair position initially, until the vulvar pressure dressing is removed on postoperative day 3 when patients are given permission to ambulate. Following discharge, the Foley and vaginal packing are removed on postoperative day 6 and vaginal dilation is taught on postoperative day 7. Dilation is initially performed three times daily for 12 weeks, then daily, using progressively larger dilators. Prior to hospital discharge, it is imperative to coordinate both in-person follow-up with the primary surgeon and local follow-up for patients traveling long distances for surgery [1••]. We have found that virtual visits are useful in the postoperative care of our patients who do not live locally. Our Surgical Technique In our practice, a split thickness scrotal skin flap is used to line the neovagina, and is harvested at the beginning of the procedure. The margins of the graft are composed of the ventral base of the penile shaft, the lateral demarcations of the scrotum (approximately 2 cm medial to the groin creases), and the perineum 4–5 cm above the anus. The flap is incised using a 10-blade scalpel, and excised from the underlying subcutaneous tissue with the use of electrosurgery. The graft is prepared by sharply excising the subcutaneous tissue and Dartos muscle, creating a split thickness skin graft. Permanent depilatory treatment (e.g., electrolysis or laser) is recommended prior to surgery to avoid hair growth in the neovagina, but if not

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performed, electrosurgical coagulation of the hair follicles may be performed during preparation of the graft. The graft is kept moist with saline-soaked sponges. Excess subcutaneous tissue is removed, exposing Buck’s fascia and the penile structures, and a bilateral orchiectomy is performed if testes are present (Fig. 1). Next, a circumferential penile incision is made proximal to the glans. If adequate penile and scrotal skin is present to line the neovagina, excess skin of the distal penile shaft and prepuce is left intact with the glans to construct labia minora and a clitoral hood. The penile structures are de-epithelized, creating a penile skin tube. The penile structures are divided, separating the ventral proximal penile urethra and corpus spongiosum and excising the corpora cavernosa, leaving a dorsal flap with the neoclitoris, which is shaped from the proximal glans, preserving the dorsal neurovascular structures of the neoclitoris within the tunica sheath (Fig. 1b, c). The clitoral flap is folded on itself to position the neoclitoris approximately 5 cm above the location of the intended neourethral meatus, but below the level of the inferior margin of the pubic symphysis to maintain an anatomic position. The proximal penile urethra and remaining corpus spongiosum are incised on the ventral side in the midline over the Foley catheter, and the urethra is then spatulated and secured to the underlying fascia allowing the urethral meatus to lie flush with the bony pelvis. The ventral urethral flap is trimmed at the level of the neoclitoris, creating a mucosal surface between the neourethral meatus and the neoclitoris (Fig. 1d, e). To create the neovagina, a transverse incision is made below the bulbous urethra, transecting the perineal tendon at the level of the ischial spines. A cavity is created initially with sharp dissection, and further dissection is performed bluntly in the potential space between the rectum and the prostatic urethra. Techniques vary, but our preference is to keep one finger inside of the rectum during the dissection to ensure that the proper space is being dissected and to avoid injury to the rectum. To avoid injury to the bladder and urethra, the Foley catheter is palpated and used as a guide during the dissection, which is carried past the level of the prostatic urethra until the vesicoperitoneal fold is encountered. A natural avascular plane exists anterior to Denonvilliers’ fascia, which is found between the prostate and the rectum. A total neovaginal length of 15 cm is usually obtained. Previous prostatic surgery or infection can make this dissection challenging, and an understanding of the anatomic landmarks is important. Once the neovaginal caliber and length is determined to be adequate, meticulous hemostasis is achieved and copious irrigation with dilute bacitracin solution is performed. A temporary packing is placed. Next, the neovaginal space is lined. The previously prepared scrotal flap is sewn onto a large vaginal stent, passed through the penile tube, and sewn to the penile skin (Fig. 1f). The temporary packing is removed from the neovagina. The

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Fig. 1 a Skeletonized penile structures following excision of the scrotal skin flap and bilateral orchiectomy. b The ventral proximal penile urethra has been dissected off the corpora cavernosa to the level of the pubic bone. c The corpora cavernosa have been excised, leaving the dorsal flap with intact neurovascular supply to the glans (neoclitoris). The

ventral urethral flap is also shown. d The urethral flap is spatulated. e The clitoris has been positioned and the urethral flap is secured. f The scrotal flap has been sewn to the penile skin tube and is shown with the vaginal stent in place

vaginal tube and stent are placed into the neovaginal cavity, and the stent is removed. Mattress sutures are placed at the

neo-introitus to take tension off of the neovaginal flap. The neovagina is tightly packed.

Fig. 2 a Immediate postoperative results depicting creation of labia minora from the distal penile skin and prepuce. b Postoperative results at 12 weeks

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A vertical incision is made through the anterior skin of the penile tube, exposing the neoclitoris, urethral flap, and neourethral meatus. The vulvar structures are then created. Labia minora and a clitoral hood are created by suturing the residual distal penile skin and prepuce in place, lining the central mucosal flap on either side (Fig. 2a, b). Two 7F Jackson-Pratt drains are placed to drain the labia majora. The labia majora are closed in layers, and the epithelial edges are trimmed, altering the direction of the suture line as needed for cosmesis and to avoid dog ears. A vulvar compression dressing is applied and sewn into place to prevent hematoma formation. Office Management of the Postoperative Vaginoplasty In the postoperative period, vaginal spotting and bleeding with dilation may be due to the presence of granulation tissue, which may be treated with silver nitrate or local excision [22]. A trial of vaginal estrogen may be considered if the spotting becomes bothersome and chronic, although there is no evidence to support this intervention. Vaginal discharge and/or malodor should alert the medical care provider to a possible yeast vaginitis. Skin sloughing from the epithelial neovaginal lining, and the warm, moist environment may contribute to this. Regular douching with a vinegar or povidone/ iodine solution or with a mixture of baby soap and warm water may help maintain hygiene [22]. Unwanted neovaginal hair growth may lead to knotting and entanglement which may require removal, which is why hair removal procedures are recommended prior to surgery. Vaginal stenosis and contracture may occur if proper neovaginal dilation is not performed. In our practice, dilation is taught on postoperative day 7, initially three times daily for 12 weeks, then daily, using progressively larger dilators. If vaginal caliber is not satisfactory, soft silicone dilators may be used initially with later transition to rigid dilators as the patient becomes more comfortable with dilation. If there are signs of graft contracture and/or patients are having trouble dilating, one helpful tip is to have the patient soak a tampon in mineral oil or baby oil then place it in the vagina for 30 min prior to dilation, allowing for softening of the skin and greater stretching with dilation. In a survey of postsurgical transgender patients, change in voiding was reported in 32% (n = 10) of male-to-female respondents [23]. Of those surveyed, 19.3% (n = 6) reported worse voiding, and 19.3% (n = 6) reported some degree of incontinence [23]. In other studies, neourethral meatal stenosis has been reported to occur in approximately 5% of postoperative patients [3•]. Postsurgical changes in the urethra may also result in an upward or splayed urinary stream which can sometimes be bothersome to patients. These urinary changes are often temporary and resolve as postoperative swelling improves, but persistent urinary stream issues should be

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addressed by the primary surgeon and may involve a minor surgical revision. Other cosmetic concerns that may require surgical revision include perineal scarring, or atrophy of the labial structures.

Conclusions When considering surgical transition with vaginoplasty for the transgender woman, careful preoperative evaluation and individual assessment is imperative and the WPATH Standards of Care provide the framework from which healthcare providers and surgeons may assess eligibility for genital surgery. Vaginoplasty for the transgender woman may be performed by a variety of techniques, mainly penile inversion vaginoplasty or intestinal segment vaginoplasty. Surgical outcomes vary according to technique, and the unique risks, advantages, and disadvantages must be considered. Our preferred technique for primary vaginoplasty is a modified version of the penile inversion vaginoplasty with a peno-scrotal neovaginal flap, and our technique has been described in this paper. Outcomes appear to be satisfactory following vaginoplasty surgery, but prospective, long-term data are still lacking. Gynecologic care providers should be aware of the perioperative and postoperative management of the transgender women after genital surgery, as many women require ongoing care and management after surgery. Compliance With Ethical Standards Conflict of Interest Tonya N. Thomas and Cecile A. Unger declare that they have no conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

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