What is involved in a penile inversion vaginoplasty, including penectomy, bilateral orchiectomy (removal of both testes), clitoroplasty, labiaplasty, and urethroplasty, with or without skin grafts?

From the Guidelines

Penile inversion vaginoplasty, including penectomy, bilateral orchiectomy, clitoroplasty, labiaplasty, urethroplasty, with or without skin grafts, is a highly effective and satisfying gender-affirming surgical procedure for transgender women, as evidenced by a systematic review showing improved quality of life and decreased gender dysphoria 1.

Procedure Overview

The procedure involves using penile skin to create a vaginal canal, removing the testicles (orchiectomy), creating a clitoris from penile tissue (clitoroplasty), forming labia from scrotal tissue (labiaplasty), and repositioning the urethra (urethroplasty).

Key Considerations

• The surgery typically takes 3-6 hours under general anesthesia, with a hospital stay of 5-7 days.
• Recovery requires 6-8 weeks before returning to non-strenuous activities, with dilation of the neovagina beginning 1-2 weeks post-surgery and continuing regularly to maintain depth and width.
• Potential complications include bleeding, infection, wound healing issues, urinary problems, and changes in sensation.
• Most patients report high satisfaction rates with improved gender dysphoria, as shown in a study where trans women experienced significant improvements in body satisfaction and positivity 1.

Recommendations

• This procedure should be performed by surgeons specializing in gender-affirming care.
• Patients should undergo appropriate psychological evaluation and hormone therapy before surgery, following WPATH Standards of Care guidelines.
• Postoperative psychological support is crucial, and offering spiritual care following GAS can add a layer of support during the recovery process 1.
• The Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) is a validated survey instrument that can be used to measure patient-reported outcomes and perceptions of their GAS 1.

Outcomes

• A systematic review of 27 studies reported little evidence (1%) of significant regret following GAS, and in studies that reported patient regret, the regret was due to negative social factors following surgery such as poor family support, mistreatment at work, suboptimal cosmetic outcome, and poor sexual function 1.
• Hormonal therapy can be associated with improved mental health for trans people, and gender-affirming surgery is a means for TGD people to align their bodies with their gender identities, leading to improved quality of life and decreased gender dysphoria 1.

From the Research

Penile Inversion Vaginoplasty Procedure

• Penile inversion vaginoplasty is a technique of gender-affirming genital surgery that uses primarily genital skin to construct the vulva and neovagina for patients assigned male sex at birth 2.
• The procedure includes penectomy, bilateral orchiectomy, clitoroplasty, labiaplasty, urethroplasty, with or without skin grafts.

Postoperative Complications

• Postoperative complications after penile inversion vaginoplasty can include granulation tissue, vaginal pain, wound separation, labial asymmetry, vaginal stenosis, fistula formation, urinary symptoms, infection, vaginal fissure or vaginal bleeding 3.
• A study of 330 patients found that 95 (28.7%) presented with a postoperative complication, with a median time to complication of 4.4 months 3.
• Another study compared single-stage and two-stage penile skin inversion vaginoplasty techniques and found that the single-stage technique had significantly lower complication and revision rates, shorter recovery time, and superior esthetic and functional outcomes 4.

Satisfaction and Outcomes

• Penile inversion vaginoplasty is associated with high post-operative satisfaction, even when complications occur 5.
• A study found that up to one-third of patients undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty, with common revisions including posterior introital web release, clitoroplasty, labiaplasty, and urethroplasty 6.
• Outcome measures to assess patient satisfaction after penile inversion vaginoplasty are important to evaluate the success of the procedure 5.

Surgical Techniques

• Different surgical techniques for penile inversion vaginoplasty have been described, including single-stage and two-stage approaches 2, 4.
• The choice of technique may depend on individual patient factors and surgeon preference 2, 4.
• Optimizing the vaginoplasty surgical technique and postoperative protocol is crucial to minimize complications and improve outcomes 4.