Vaginectomy

Last updated
Vaginectomy
ICD-9-CM 70.4
Diagram of female genitalia Vagina 1.jpg
Diagram of female genitalia

Vaginectomy is a surgery to remove all or part of the vagina. It is one form of treatment for individuals with vaginal cancer or rectal cancer that is used to remove tissue with cancerous cells. [1] It can also be used in gender-affirming surgery. Some people born with a vagina who identify as trans men or as nonbinary may choose vaginectomy in conjunction with other surgeries to make the clitoris more penis-like (metoidioplasty), construct of a full-size penis (phalloplasty), or create a relatively smooth, featureless genital area (genital nullification). [2] [3] [4] [5] [6]

Contents

If the uterus and ovaries are to remain intact, vaginectomy will leave a canal and opening suitable for draining menstrual discharge. Otherwise, as in genital nullification, a hysterectomy must be performed to avoid the danger of retaining menstrual discharge within the body. [7] In the latter case, thorough removal of vaginal lining is necessary to avoid continued secretion within the body. [8]

In addition to vaginectomy in humans, there have been instances of vaginectomy in other animals to treat vaginal cancer. [9]

Uses

Vaginal intraepithelial neoplasia

Total or partial vaginectomy along with other procedures like laser vaporization can be used in the treatment of vaginal intraepithelial neoplasia. These procedures remove the cancerous tissue and provide tissue samples to help identify underlying/invasive cancer while maintaining structure and function of the vagina. This surgery along with radiation therapy used to be the optimal treatment for high-grade vaginal intraepithelial neoplasia. However, high rates of recurrence and severe side effects such as vaginal shortening, bleeding and sepsis have narrowed its uses. A partial upper vaginectomy is still the treatment of choice for certain cases of vaginal intraepithelial neoplasia as it has success rates ranging from 69 to 88%. [10]

Rectal cancer

A vaginectomy is often necessary to remove all cancerous tissue associated with rectal cancer. Depending on the extent of rectal cancer, a total or partial vaginectomy may be indicated to improve long-term survival. Following the surgery and removal of rectal tumors, vaginal and rectal reconstructive surgery can improve healing and may help with self-image and sexual function. [11]

Genital gender-affirming surgery

Although there has not been a consensus on the standard treatment for penis construction in transgender men, a vaginectomy is a vital step in many of the various techniques. Depending on the reconstructive surgeon and which method is used, the basic outline of the procedure involves taking skin from an area of the body like the forearm or abdomen followed by glans sculpture, vaginectomy, urethral anastomosis, scrotoplasty and finished with a penile prosthesis implantation. The ideal outcome of this procedure, as described by the World Professional Association for Transgender Health (WPATH), is to provide an aesthetically appealing penis that enables sexual intercourse and sensitivity. Complications do arise from this procedure which may include tissue death, urethral complications, and infection. [12]

Radial Forearm Free Flap (RAFFF) is one of the techniques considered for total phallic construction. [12] Developed and performed in 1984, RAFFF consists of three stages and a complete vaginectomy is the second stage of RAFFF. The preferred technique is ablation vaginectomy with simultaneous scrotoplasty, which will close the labia majora along the midline. [13]

Recurrent gynecologic malignancies

An anterior pelvic exenteration with total vaginectomy (AETV) is a procedure that removes the urinary system (kidneys, ureters, bladder, urethra) as well as the gynecologic system (ovaries, fallopian tubes, uterus, cervix, vagina) and is used as treatment of recurrent gynecologic cancers. A total pelvic exenteration can also be used as treatment which involves the removal of the rectum in addition to the urinary and gynecologic systems. The decision between the two procedures depends on extent of the cancer. Potential benefits of an AETV over a total pelvic exenteration include reduced risk of intestinal injury. [14]

Reversal of vaginoplasty

Neovaginectomy has been performed to remove the neovagina following vaginoplasty, for instance in transgender women who experience neovaginal complications or those who choose to detransition. [15]

Contraindications

The safety of vaginectomy can depend on individual medical conditions and the subsequent risks they pose. For example, for people with diabetes mellitus, potential contraindications for vaginectomy include wound-healing difficulty; for people who prefer to not undergo hormone therapy, potential contraindications include gonad removal (oophorectomy or orchiectomy). [16]

Risks/complications

Many people who undergo vaginectomy do so for sexual health and intimacy. However, risks of vaginectomy include post-operative sensory issues that range from lack of sensation to excessive sensation, such as hypersensitivity or even pain. [16] To address this, skin grafting is often done with vaginectomy to allow recovery of sexual function. [17]

Other risks may involve consequences of the procedure itself. For example, possible injuries include rectal injury (due to the proximity of the structures), development of a fistula (an abnormal connection between two body parts), or, for people who have phalloplasty done in conjunction with vaginectomy, irritation or even erosion of the skin of the phallus. Some of these locations may be suture sites; irritation of these sites may increase likelihood of infection. [18]

There are pre- and post-operative steps that can be taken to minimize complications from vaginectomy. For example, other procedures that are often performed in conjunction with vaginectomy, such as metoidioplasty and phallourethroplasty, can be performed in two stages to increase the likelihood of a favorable cosmetic outcome. [19] Also, waiting for a period of time after completing a procedure, usually a minimum of 4 months, ensures that the person undergoing the surgery is clear of infections or risk thereof. Thus, procedures towards the end of the gender-affirming process, such as penile prosthesis placement, are usually done separately. [19]

For people with vaginal cancer, vaginectomy can be done partially, instead of radically, depending on the individual person's need as determined by the tumor's size, location, and stage. For example, some people had simple hysterectomy (a procedure that removes a uterus) and then discovered cervical cancer. At this point, upper vaginectomy - along with other suggested procedures such as lymphadenectomy (a procedure that removes lymph nodes) - may be suggested to people who would prefer to keep ovarian function intact. [20] This is an option depending on the invasiveness and severity of the disease and is specifically for individuals with stage I cancer in the upper vagina. [21]

Techniques

Vaginectomy procedures are described by the amount of vaginal tissue removed from an individual which is dependent on the reason for surgery.

Removal of cancerous tissue

For vaginectomy as a treatment to cancer, tissue is removed in response to the extent of the cancer. [7] A partial vaginectomy removes only the outer most layers of tissue and is performed if the abnormal cells are only found at the skin level. For example, individuals with rectal cancer that has spread to vaginal tissue may undergo a partial vaginectomy in which the posterior wall of the vagina near the anus is removed. A surgeon will make an incision on the abdomen in order to reach the vagina for removal. The operation to remove vaginal tissue will typically happen with at the same time as a colostomy and a abdominoperineal resection in which a portion of the colon is rediverted into a colostomy bag and the rectum is removed. A partial vaginectomy leaves much of the muscles in the vagina intact and can be followed by a vaginal reconstruction surgery. [22]

If more invasive cancer is found, a more complete vaginectomy is performed to remove all cancerous tumors and cells. [23]

Gender-affirming surgery

In vaginectomy for gender-affirming surgeries, the tissue from the vaginal wall is removed while outer labial flaps are sometimes left in place for other reconstructive surgeries. [24] The procedure gives people who were assigned female sex at birth but do not identify as female, such as transmasculine or nonbinary individuals, genitalia that aids in reducing gender dysphoria and affirming their gender identity through their physical appearance. [3] [19] Counseling is often provided to people considering gender-affirming surgeries prior to procedures in order to limit regret later down the line. [25] In the context of gender-affirming surgery, procedures are categorized as either colpocleisis or total vaginectomy. [26]

Colpocleisis only removes a layer of epithelium or the outer most tissue in the vaginal canal. The walls of the vaginal canal are then sutured shut, but a small channel and the perineum area between the vagina and anus is typically left open to allow for discharge to be emitted from the body. A colpoclesis procedure is sometimes preceded by an oophorectomy and or a hysterectomy to remove the ovaries and uterus which reduces risks of complications from leaving these structures intact and reduces the amount of vaginal discharge. If the ovaries and uterus are left intact there are greater levels of vaginal discharge remain that can contribute to further gender dysphoria in individuals. [26]

Total vaginectomy is becoming the more common form of vaginectomy in gender-affirming surgeries. It involves removal of the full thickness of vaginal wall tissue and can be approached vaginally, as in a transvaginal or transperineal vaginectomy, or abdominally through the area near the stomach, as in an abdominal vaginectomy. In addition to a greater degree of tissue removal, total vaginectomy also involves a more complete closure of the space in the vaginal canal. In comparison to colpocleisis, it is more often preceded by separate oophorectomy and hysterectomy procedures and proceeded by a separate gender reconstruction surgery such as to create a neophallus. [6] Total vaginectomy surgery is sometimes performed using robotic assistance which allows for increased speed and precision for a procedure with less blood loss and a quicker recovery time. [26]

Recovery

Individuals should expect to experience some pain in the first week after the operation. The average hospital stay after operation was a week and all individuals are discharged with a catheter, which is removed after 2–3 weeks. [8] At discharge, individuals learn how to take care of the incisions and must limit their physical activity for the initial 2–3 weeks. Swelling of the abdominal area or abdominal pain are signs of complications during recovery. Some common complications that occur are urethral fistulas and strictures in individuals who undergo vaginectomy and phallic reconstruction for gender-affirming surgeries. This is due to poor blood supply and improper width of the new urethra. [27]

History

Vaginal surgeries have been around throughout medical history. Even before the invention of modern surgical techniques such as anesthesia and sterile tools, there have been many reports of vaginal surgery to treat problems such as prolapse, vaginal fistula, and poor bladder control. For example, the first documented vaginal hysterectomy was performed in 1521 during the Italian Renaissance. [28] Surgical techniques and medical knowledge developed slowly over time until the invention of anesthesia and antisepsis allowed for the age of modern surgery in the mid-nineteenth century. Since then, many techniques and instruments were developed specifically for vaginal surgery like the standardization of sutures in 1937 which greatly improved survival rates by lowering risk of infection. [29] Noble Sproat Heaney developed the "Heaney Stitch" in 1940 to standardize the technique for vaginal hysterectomy. The first documented case of radical vaginal surgery was in February 2003 where a person underwent a radical hysterectomy with vaginectomy and reconstruction. [30]

Other animals

Vaginectomies are also performed outside of the human species. Similarly to humans, animals may also undergo vaginectomies to treat cancer of the vagina. Domesticated animals and pets such as dogs, cats, and horses are more likely to receive a vaginectomy because of its complicated procedure. [9]

Dogs

Total and partial vaginectomies aren't commonly done on dogs as they are complex and aren't considered first line therapy however, if other procedures don't work a vaginectomy can be performed on a dog. The most common reasons for a dog to get a vaginectomy include cancer and chronic infection of the vagina. Tumors on the vagina and vulva of the dog accounts for 2.5%-3% of cancers affecting dogs and vaginectomies are one of the treatments to remove and cure the dog. [31] Possible complications from the surgery include loss of bladder control, swelling, and improper skin healing. [9] However, loss of bladder control was fixed spontaneously within 60 days of the operation and the dogs survived at least 100 days with no disease. [31]

See also

Related Research Articles

Obstetrics and gynaecology is the medical specialty that encompasses the two subspecialties of obstetrics and gynecology. The specialization is an important part of care for women's health.

<span class="mw-page-title-main">Genital modification and mutilation</span> Permanent or temporary changes to human sex organs

Genital modifications are forms of body modifications applied to the human sexual organs, such as piercings, circumcision, or labiaplasty.

Gender-affirming surgery is a surgical procedure, or series of procedures, that alters a person's physical appearance and sexual characteristics to resemble those associated with their identified gender. The phrase is most often associated with transgender health care and intersex medical interventions, however many such treatments are also pursued by cisgender and non-intersex individuals. It is also known as sex reassignment surgery, gender confirmation surgery, and several other names.

In medicine, prolapse is a condition in which organs fall down or slip out of place. It is used for organs protruding through the vagina, rectum, or for the misalignment of the valves of the heart. A spinal disc herniation is also sometimes called "disc prolapse". Prolapse means "to fall out of place", from the Latin prolabi meaning "to fall out".

<span class="mw-page-title-main">Hysterectomy</span> Surgical removal of the uterus

Hysterectomy is the partial or total surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), fallopian tubes (salpingectomy), and other surrounding structures. Partial hysterectomies allow for hormone regulation while total hysterectomies do not.

Gender-affirming surgery for female-to-male transgender people includes a variety of surgical procedures that alter anatomical traits to provide physical traits more comfortable to the trans man's male identity and functioning.

Gender-affirming surgery for male-to-female transgender women or transfeminine non-binary people describes a variety of surgical procedures that alter the body to provide physical traits more comfortable and affirming to an individual's gender identity and overall functioning.

<span class="mw-page-title-main">Rectocele</span> Bulging of the rectum into the vaginal wall

In gynecology, a rectocele or posterior vaginal wall prolapse results when the rectum bulges (herniates) into the vagina. Two common causes of this defect are childbirth and hysterectomy. Rectocele also tends to occur with other forms of pelvic organ prolapse, such as enterocele, sigmoidocele and cystocele.

<span class="mw-page-title-main">Vaginoplasty</span> Surgical procedure

Vaginoplasty is any surgical procedure that results in the construction or reconstruction of the vagina. It is a type of genitoplasty. Pelvic organ prolapse is often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal of malignant growths or abscesses to restore a normal vaginal structure and function. Surgery to the vagina is done to correct congenital defects to the vagina, urethra and rectum. It will correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury. Labiaplasty, which alters the appearance of the vulva, can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty.

<span class="mw-page-title-main">Cystocele</span> Medical condition

The cystocele, also known as a prolapsed bladder, is a medical condition in which a woman's bladder bulges into her vagina. Some may have no symptoms. Others may have trouble starting urination, urinary incontinence, or frequent urination. Complications may include recurrent urinary tract infections and urinary retention. Cystocele and a prolapsed urethra often occur together and is called a cystourethrocele. Cystocele can negatively affect quality of life.

<span class="mw-page-title-main">Scrotoplasty</span> Type of surgery to create or repair the scrotum

Scrotoplasty, also known as oscheoplasty, is a type of surgery to create or repair the scrotum. The history of male genital plastic surgery is rooted in many cultures and dates back to ancient times. However, scientific research for male genital plastic surgery such as scrotoplasty began to develop in the early 1900s. The development of testicular implants began in 1940 made from materials outside of what is used today. Today, testicular implants are created from saline or gel filled silicone rubber. There are a variety of reasons why scrotoplasty is done. Some transgender men and intersex or non-binary people who were assigned female at birth may choose to have this surgery to create a scrotum, as part of their transition. Other reasons for this procedure include addressing issues with the scrotum due to birth defects, aging, or medical conditions such as infection. For newborn males with penoscrotal defects such as webbed penis, a condition in which the penile shaft is attached to the scrotum, scrotoplasty can be performed to restore normal appearance and function. For older male adults, the scrotum may extend with age. Scrotoplasty or scrotal lift can be performed to remove the loose, excess skin. Scrotoplasty can also be performed for males who undergo infection, necrosis, traumatic injury of the scrotum.

<span class="mw-page-title-main">Pelvic organ prolapse</span> Descent of the pelvic organs from their normal positions

Pelvic organ prolapse (POP) is characterized by descent of pelvic organs from their normal positions into the vagina. In women, the condition usually occurs when the pelvic floor collapses after gynecological cancer treatment, childbirth or heavy lifting. Injury incurred to fascia membranes and other connective structures can result in cystocele, rectocele or both. Treatment can involve dietary and lifestyle changes, physical therapy, or surgery.

<span class="mw-page-title-main">Uterine prolapse</span> Medical condition

Uterine prolapse is a form of pelvic organ prolapse in which the uterus and a portion of the upper vagina protrude into the vaginal canal and, in severe cases, through the opening of the vagina. It is most often caused by injury or damage to structures that hold the uterus in place within the pelvic cavity. Symptoms may include vaginal fullness, pain with sexual intercourse, difficulty urinating, and urinary incontinence. Risk factors include older age, pregnancy, vaginal childbirth, obesity, chronic constipation, and chronic cough. Prevalence, based on physical exam alone, is estimated to be approximately 14%.

Vaginal cancer is an extraordinarily rare form of cancer that develops in the tissue of the vagina. Primary vaginal cancer originates from the vaginal tissue – most frequently squamous cell carcinoma, but primary vaginal adenocarcinoma, sarcoma, and melanoma have also been reported – while secondary vaginal cancer involves the metastasis of a cancer that originated in a different part of the body. Secondary vaginal cancer is more common. Signs of vaginal cancer may include abnormal vaginal bleeding, dysuria, tenesmus, or pelvic pain, though as many as 20% of women diagnosed with vaginal cancer are asymptomatic at the time of diagnosis. Vaginal cancer occurs more frequently in women over age 50, and the mean age of diagnosis of vaginal cancer is 60 years. It often can be cured if found and treated in early stages. Surgery alone or surgery combined with pelvic radiation is typically used to treat vaginal cancer.

Female genital disease is a disorder of the structure or function of the female reproductive system that has a known cause and a distinctive group of symptoms, signs, or anatomical changes. The female reproductive system consists of the ovaries, fallopian tubes, uterus, vagina, and vulva. Female genital diseases can be classified by affected location or by type of disease, such as malformation, inflammation, or infection.

Genitoplasty is plastic surgery to the genitals. Genitoplasties may be reconstructive to repair injuries, and damage arising from cancer treatment, or congenital disorders, endocrine conditions, or they may be cosmetic.

A urogenital fistula is an abnormal tract that exists between the urinary tract and bladder, ureters, or urethra. A urogenital fistula can occur between any of the organs and structures of the pelvic region. A fistula allows urine to continually exit through and out the urogenital tract. This can result in significant disability, interference with sexual activity, and other physical health issues, the effects of which may in turn have a negative impact on mental or emotional state, including an increase in social isolation. Urogenital fistulas vary in etiology. Fistulas are usually caused by injury or surgery, but they can also result from malignancy, infection, prolonged and obstructed labor and deliver in childbirth, hysterectomy, radiation therapy or inflammation. Of the fistulas that develop from difficult childbirth, 97 percent occur in developing countries. Congenital urogenital fistulas are rare; only ten cases have been documented. Abnormal passageways can also exist between the vagina and the organs of the gastrointestinal system, and these may also be termed fistulas.

Vaginal stenosis is an abnormal condition in which the vagina becomes narrower and shorter due to the formation of fibrous tissue. Vaginal stenosis can contribute to sexual dysfunction, dyspareunia and make pelvic exams difficult and painful. The lining of the vagina may also be thinner and drier and contain scar tissue. This condition can result in pain during sexual intercourse or a pelvic exam. Vaginal stenosis is often caused by radiation therapy to the pelvis, an episiotomy, or other forms of surgical procedures. Chemotherapy can also increase the likelihood of developing vaginal stenosis. Vaginal stenosis can also result from genital reconstructive surgery in people with congenital adrenal hyperplasia.

Transvaginal mesh, also known as vaginal mesh implant, is a net-like surgical tool that is used to treat pelvic organ prolapse (POP) and stress urinary incontinence (SUI) among female patients. The surgical mesh is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder.

Pelvic abscess is a collection of pus in the pelvis, typically occurring following lower abdominal surgical procedures, or as a complication of pelvic inflammatory disease (PID), appendicitis, or lower genital tract infections. Signs and symptoms include a high fever, pelvic mass, vaginal bleeding or discharge, and lower abdominal pain. It can lead to sepsis and death.

References

  1. ↑ Kulkarni A, Dogra N, Zigras T (April 2022). "Innovations in the Management of Vaginal Cancer". Current Oncology. 29 (5): 3082–3092. doi: 10.3390/curroncol29050250 . PMC   9139564 . PMID   35621640.
  2. ↑ "Non-Binary Options For Metoidioplasty". Metoidioplasty.net. 2020. Retrieved 28 June 2020.
  3. 1 2 Frey JD, Poudrier G, Chiodo MV, Hazen A (March 2017). "An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature". Plastic and Reconstructive Surgery. 139 (3): 728–737. doi:10.1097/PRS.0000000000003062. PMID   28234856.
  4. ↑ Walton AB, Hellstrom WJ, Garcia MM (October 2021). "Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions". Sexual Medicine Reviews. 9 (4): 605–618. doi:10.1016/j.sxmr.2021.07.002. PMID   34493480. S2CID   237440377.
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  7. 1 2 "Surgical Treatment of Vaginal Cancer". EMedicine Obstetrics and Gynecology. 26 August 2021.
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  9. 1 2 3 Zambelli D, Valentini S, Ballotta G, Cunto M (January 2022). "Partial Vaginectomy, Complete Vaginectomy, Partial Vestibule-Vaginectomy, Vulvo-Vestibule-Vaginectomy and Vulvo-Vestibulectomy: Different Surgical Procedure in Order to Better Approach Vaginal Diseases". Animals. 12 (2): 196. doi: 10.3390/ani12020196 . PMC   8773321 . PMID   35049818.
  10. ↑ Frega A, Sopracordevole F, Assorgi C, Lombardi D, DE Sanctis V, Catalano A, et al. (January 2013). "Vaginal intraepithelial neoplasia: a therapeutical dilemma". Anticancer Research. 33 (1): 29–38. PMID   23267125.
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  13. ↑ Yao A, Ingargiola MJ, Lopez CD, Sanati-Mehrizy P, Burish NM, Jablonka EM, Taub PJ (June 2018). "Total penile reconstruction: A systematic review". Journal of Plastic, Reconstructive & Aesthetic Surgery. 71 (6): 788–806. doi:10.1016/j.bjps.2018.02.002. PMID   29622476. S2CID   4591969.
  14. ↑ Kaur M, Joniau S, D'Hoore A, Vergote I (September 2014). "Indications, techniques and outcomes for pelvic exenteration in gynecological malignancy". Current Opinion in Oncology. 26 (5): 514–520. doi:10.1097/CCO.0000000000000109. PMID   25050632. S2CID   205546063.
  15. ↑ Adelowo, Amos; Weber-LeBrun, Emily E.; Young, Stephen B. (May 2009). "Neovaginectomy Following Vaginoplasty in a Male-to-Female Transgender Patient". Journal of Pelvic Medicine and Surgery. 15 (3): 101–104. doi:10.1097/SPV.0b013e3181aacc41. ISSN   1542-5983.
  16. 1 2 Blasdel G, Zhao LC, Bluebond-Langner R (2022). Keuroghlian AS, Potter J, Reisner SL (eds.). Surgical Gender Affirmation . Retrieved 2022-07-26.{{cite book}}: |work= ignored (help)
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  19. 1 2 3 Garcia MM (2020). McAninch JW, Lue TF (eds.). Genital Gender-Affirming Surgery: Patient Care, Decision Making, and Surgery Options . Retrieved 2022-07-26.{{cite book}}: |work= ignored (help)
  20. ↑ Garcia LM, Holschneider CH (2019). "Premalignant & Malignant Disorders of the Uterine Cervix". In DeCherney AH, Nathan L, Laufer N, Roman AS (eds.). CURRENT Diagnosis & Treatment: Obstetrics & Gynecology (12th ed.). New York, NY: McGraw-Hill Education. Retrieved 2022-07-28.
  21. ↑ Karam A (2019). "Premalignant & Malignant Disorders of the Vulva & Vagina". In DeCherney AH, Nathan L, Laufer N, Roman AS (eds.). CURRENT Diagnosis & Treatment: Obstetrics & Gynecology (12th ed.). New York, NY: McGraw-Hill Education. Retrieved 2022-07-28.
  22. ↑ Maingot R, Zinner M, Ashley SW, Hines OH (2019). Maingot's abdominal operations (Thirteenth ed.). New York. ISBN   978-0-07-184429-1. OCLC   1225946158.{{cite book}}: CS1 maint: location missing publisher (link)
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  24. ↑ Zeplin PH (2020). Reconstructive and aesthetic genital surgery. Stuttgart. ISBN   978-3-13-241306-1. OCLC   1080250689.{{cite book}}: CS1 maint: location missing publisher (link)
  25. ↑ Bustos VP, Bustos SS, Mascaro A, Del Corral G, Forte AJ, Ciudad P, et al. (March 2021). "Regret after Gender-affirmation Surgery: A Systematic Review and Meta-analysis of Prevalence". Plastic and Reconstructive Surgery. Global Open. 9 (3): e3477. doi:10.1097/GOX.0000000000003477. PMC   8099405 . PMID   33968550.
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  27. ↑ Rohrmann D, Jakse G (November 2003). "Urethroplasty in female-to-male transsexuals". European Urology. 44 (5): 611–614. doi:10.1016/S0302-2838(03)00356-7. PMID   14572764.
  28. ↑ Tizzano AP (2007). "Historical Milestones in Female Pelvic Surgery, Gynecology, and Female Urology". Urogynecology and Reconstructive Pelvic Surgery. Elsevier. pp. 3–14. doi:10.1016/b978-0-323-02902-5.50007-1. ISBN   9780323029025.
  29. ↑ Muffly TM, Tizzano AP, Walters MD (March 2011). "The history and evolution of sutures in pelvic surgery". Journal of the Royal Society of Medicine. 104 (3): 107–112. doi:10.1258/jrsm.2010.100243. PMC   3046193 . PMID   21357979.
  30. ↑ Ling B, Gao Z, Sun M, Sun F, Zhang A, Zhao W, Hu W (April 2008). "Laparoscopic radical hysterectomy with vaginectomy and reconstruction of vagina in patients with stage I of primary vaginal carcinoma". Gynecologic Oncology. 109 (1): 92–96. doi:10.1016/j.ygyno.2007.12.012. PMID   18237770.
  31. 1 2 Ogden JA, Selmic LE, Liptak JM, Oblak ML, Culp WT, de Mello Souza CH, et al. (August 2020). "Outcomes associated with vaginectomy and vulvovaginectomy in 21 dogs". Veterinary Surgery. 49 (6): 1132–1143. doi:10.1111/vsu.13466. PMID   32515509. S2CID   219549190.
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