Laparoscopic Intestinal Vaginoplasty in Transgender Women

Management of vaginoplasty canal complications

PURPOSE OF REVIEW

Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques.

RECENT FINDINGS

Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options.

SUMMARY

Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.

Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty

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.

Improved sexuality and satisfactory lubrication after genital affirmation surgery using penile skin inversion in transgender women: A satisfaction study

INTRODUCTION

Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.

AIMS

Our aim was to evaluate transgender women's sexual function and lubrication after vaginoplasty by penile skin inversion.

METHODS

We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.

RESULTS

The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.

CONCLUSION

This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion's GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.

miR-126-3p-loaded small extracellular vesicles secreted by urine-derived stem cells released from a phototriggered imine crosslink hydrogel could enhance vaginal epithelization after vaginoplasty

Background

Due to the large area and deep width of the artificial neovagina after vaginoplasty, it takes a considerable amount of time to achieve complete epithelization of the neovagina. Currently, the clinical therapies for vaginal epithelization after vaginoplasty are still dissatisfactory. Recent studies showed that small extracellular vesicles (sEVs) derived from stem cells could accelerate wound epithelization. The sustained release of sEVs from optimized hydrogels may be a promising strategy to accelerate vaginal epithelization after vaginoplasty.

Methods

The efficacy of phototriggered imine crosslink hydrogels (piGEL) containing sEVs derived from human urine-derived stem cells (hUSC-sEVs, piGEL-sEVs) on vaginal mucosa defects in rabbits was assessed by wound closure rates, histological analysis and immunofluorescence staining analysis. Cell counting kit-8, 5-ethynyl-2′-deoxyuridine and scratch wound assays were performed to assess the effects of hUSC-sEVs on the proliferation and migration ability of vaginal epithelial cells (VK2/E6E7). Quantitative real-time polymerase chain reaction (qRT-PCR) was carried out to test the expression of epithelial differentiation markers in VK2 cells. Moreover, a microRNA (miRNA) microarray was used to find hUSC-sEVs-specific miRNAs that potentially affected the proliferation, migration and differentiation ability of VK2 cells.

Results

The in vitro release profile revealed that the piGEL could ensure sustained release of hUSC-sEVs. The in vivo results showed that piGEL-sEVs effectively promoted epithelization and angiogenesis of vaginal mucosa defects in rabbits. According to miRNA microarray and qRT-PCR results, miR-126-3p might be the crucial molecule among the various miRNAs contained in hUSC-sEVs. The data showed that hUSC-sEVs promoted the migration and differentiation of VK2 cells by delivering miR-126-3p to suppress the expression of Spred1 and PIK3R2, thereby activating the ERK1/2 and ATK signaling pathways.

Conclusion

The results indicated that piGEL-sEVs could be a novel promising approach for enhancing the epithelization of the neovagina after vaginoplasty and provided useful data for understanding the underlying mechanism of the effect of hUSC-sEVs on epithelization.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-03003-x.

Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice?

The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.

Gender dysphoria: laparoscopic sigmoid vaginoplasty. Another utility of indocyanine green

AIM

Gender dysphoria is the disagreement between the gender of birth and the one with which the patient identifies. For its management it is mandatory to have a multidisciplinary team. Gender confirmation surgery with penoscrotal skin flap is the procedure of choice, and a sigmoid vaginoplasty is a feasible alternative. The new technologies and the help of indocyanine green (ICG) fluorescence can help to guarantee a correct neovagina vascularization. The objective of this paper is to present the surgical technique of laparoscopic sigmoid vaginoplasty assisted by ICG.

METHODS

We present two patients with gender dysphoria and a history of stricture of the penoscrotal skin flap vaginoplasty. We performed sigmoid vaginoplasty by the laparoscopic approach. We began the procedure with the mobilization and section of 30 cm of sigmoid colon, selective ligation of the vessels assisted by ICG, 180° sigmoid rotation, externalized on antiperistaltic position, construction of colovestibular anastomosis and promontory fixation. We finished the procedure with virtual ileostomy construction and drain placement.

RESULTS

Patients recovered satisfactorily and were discharged on the seventh day after surgery without complications.

CONCLUSION

Sigmoid vaginoplasty is a safe and feasible procedure. ICG has great value, contributing to the selective ligation of the vessels, allowing 180° sigmoid rotation and guaranteeing the irrigation of the neovagina.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

Examination of current available methods for pain management after vaginoplasty procedures

Tweetable abstract As vaginoplasties become increasingly prevalent, it is imperative to develop efficient techniques to achieve adequate postoperative pain control. Currently available pain management methods following vaginoplasties are briefly discussed.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

BACKGROUND

To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited.

METHODS

A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion.

RESULTS

Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low.

CONCLUSIONS

Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

The effect of early puberty suppression on treatment options and outcomes in transgender patients

In the past 10-15 years, paediatric transgender care has emerged at the forefront of several general practice and subspecialty guidelines and is the topic of continuing medical education for various medical disciplines. Providers in specialties ranging from family medicine, paediatrics and adolescent medicine to endocrinology, gynaecology and urology are caring for transgender patients in increasing numbers. Current and evolving national and international best practice guidelines recommend offering a halt of endogenous puberty for patients with early gender dysphoria, in whom impending puberty is unacceptable for their psychosocial health and wellness. Pubertal blockade has implications for fertility preservation, transgender surgical care and psychosocial health, all of which must be considered and discussed with the patient and their family and/or legal guardian before initiation.