Vaginoplasty

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Vaginoplasty
ICD-9-CM 70.64, 70.62, 70.64, 70.94, 70.6, 70.95
MeSH D013509

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 may correct protrusion of the urinary bladder into the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina. [1] Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

Contents

Congenital disorders such as adrenal hyperplasia can affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty. [2] Other candidates for the surgery include babies born with a microphallus, people with Müllerian agenesis resulting in vaginal hypoplasia, trans women, and women who have had a vaginectomy after malignancy or trauma. [3] [4]

Medical uses

Vaginoplasty is the description of the following surgical interventions:

In some instances, extra tissue is needed to reconstruct or construct the vagina. These grafts used in vaginoplasty can be an allotransplantation, a heterograft, or an autologous material. [9] [10] A woman can use an autologous in vitro cultured tissue taken from her vaginal vestibule as transplanted tissue to form the lining of the reconstructed vagina. [9] A reconstructed or newly constructed vagina is called a neovagina. [11]

Vaginoplasties in children

Conditions such as congenital adrenal hyperplasia virilize genetic females due to a 21-hydroxylase deficiency. Specific procedures include: clitoral reduction, labiaplasty, normalizing appearance, vagina creation, initiating vaginal dilation. [12] Vaginal atresia, or congenital absence of the vagina, can be another reason for surgery to construct a normal and functional vagina. [13] Vaginoplasty is used as part of the series of surgeries needed to treat those girls and women born with the bladder located outside of their abdomen. After the repairs, women have been able to give birth but are at risk of prolapse. [1]

There are human rights concerns about vaginoplasties and other genital surgeries in children who are not old enough to consent, [14] [15] including concern with post-surgical sexual function, [16] and assumptions of cisnormativity. [17] There is no consensus attitude among clinicians about their necessity, timing, method or evaluation. [12] Vaginoplasties may be performed in children or adolescents with intersex conditions or disorders of sex development. [18]

Techniques

Non-surgical vagina creation was used in the past to treat the congenital absence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameter dilators. The procedure took several months and was sometimes painful. It was not effective in every instance. [2] Uncommon growths, cysts, septums in the vagina can also require vaginoplasty. [19]

Reconstructive surgery after cancer treatment

Radiological cancer treatment can result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored. [3]

McIndoe surgical technique

A canal is surgically constructed between the urinary bladder and urethra in the anterior portion of the pelvic region and the rectum. A skin graft is used from another area of the person's body. The graft is removed from the thigh, buttocks, or inguinal region. Other materials have been used to create the lining of the new vagina. These have been cutaneous skin flaps, amniotic membranes, and buccal mucosa. [3] [9]

Gender-affirming surgery

Several techniques may be used in gender-affirming surgery to create a neovagina.

Neovagina - penile inversion vaginoplasty.png
Neovagina - penile inversion vaginoplasty 2.png
The results of a penile inversion vaginoplasty, two years after surgery. Inner labia vary aesthetically based on surgeon; here, they are very minimal. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. A faded surgical scar comes up from the perineum and follows the outer labia in a curved Y.

Penile inversion

Inversion of the penile skin is the method most often selected to create a neovagina by surgeons performing gender-affirming surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the neovagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap. [4]

The penile inversion technique was pioneered by Georges Burou in his Morocco clinic in the 1950s. [20] By the 1970s he had performed hundreds of them, and gave his first public presentation of his technique to a conference at Stanford University in 1973, [21] after which it gradually became the predominant technique worldwide.

Bowel vaginoplasty

This section is an excerpt from Feminizing surgery § Bowel vaginoplasty.[ edit ]

Bowel vaginoplasty is another common vaginoplasty technique. It is also used for vaginoplasty in cisgender women. [22] As with penile inversion vaginoplasty, the testicles and scrotum are removed, the glans made into a clitoris, and the neovulva constructed from scrotal, penile and urethral tissue. However, in bowel vaginoplasty a segment of rectosigmoid colon is grafted into a surgically created canal to form the neovagina. [23]

As bowel vaginoplasty uses colon to construct the neovagina, post-operative depth is not dependent on the length of the penis prior to surgery. This makes it appropriate for individuals who have already undergone penectomy, orchiectomy, or who had a penis smaller than the desired depth of the neovagina prior to surgery. [24] Unlike penile inversion vaginoplasty, the neovagina created through bowel vaginoplasty is self-lubricating and does not require further dilation once fully healed. [24]

Peritoneal vaginoplasty

This section is an excerpt from Feminizing surgery § Peritoneal vaginoplasty.[ edit ]

Transgender peritoneal vaginoplasty, a.k.a. peritoneal pull-down or pull-through (PPT), is based on neovaginal techniques documented in the 1970s and 80s [25] [26] [27] for cisgender women born without a vaginal canal due to agenesis/atresia, [28] [29] which were referred to as the "Davydov" procedure [29] [30] or "Rothman's" method. [31] A 2022 review states, "In the last 5 years, peritoneal flap vaginoplasty has emerged as a promising technique". [32]

This form of vaginoplasty utilizes tissue of the peritoneum to form the canal lining of the neovagina. [33] [29]

For trans women who had their puberty blocked, insufficient penile and scrotal skin may be available for traditional penile inversion. In such cases, peritoneal vaginoplasty remedies the issue of insufficient tissue. [33] [28] [29] [34] Peritoneal vaginoplasty can be used as a surgical revision to increase or restore vaginal depth in persons who have had a previous vaginoplasty. [33] [29] [34] [35] [36]

This technique has been reported to provide some degree of vaginal lubrication. [28] [29] [30] [37] This lubrication, however, is not responsive to sexual arousal, and functions more as regular vaginal discharge while not identical to natal vaginal fluids. [37]

Other methods

Penile-scrotal skin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used.[ citation needed ]

Elective vaginoplasty

Critics have labeled such surgery as the "designer vagina". The American College of Obstetricians and Gynecologists issued a warning against these procedures in 2007 [38] as did the Royal Australian and New Zealand College of Obstetricians and Gynaecologists, [39] and a commentary in the British Medical Journal strongly criticized the "designer vagina" in 2009. [39] [40] The Society of Obstetricians and Gynaecologists of Canada published a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013. [41]

The World Health Organization describes any medically unnecessary surgery to the vaginal tissue and organs as female genital mutilation. [42]

Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance. [40]

Hymen surgical procedures

An imperforate hymen is the presence of tissue that completely covers the vaginal opening. It is cut to allow menstrual flow to exit during a short surgical procedure. [1] A hymenorrhaphy is the surgical procedure that reconstructs the hymen.

Balloon vaginoplasty

In this procedure, a Foley catheter is laparoscopically inserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina.[ citation needed ]

Pull through or Vecchietti procedure

In treating Müllerian agenesis, the Vecchietti procedure is a laparoscopic surgical technique that produces a vagina of dimensions (depth and width) comparable to those of a normal vagina (ca. 8 cm deep). [43] [44] A small, plastic sphere called an olive is threaded (sutured) against the vaginal area; the threads are drawn though the vaginal skin, up through the abdomen, and through the navel. There, the threads are attached to a traction device, and then daily are drawn tight so that the olive is pulled inwards and stretches the vagina, by approximately 1 cm per day, thereby creating a vagina, approximately 7 cm deep by 7 cm wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time. [45] The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy. [46] In vaginal hypoplasia, traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments. [47] [19]

Other surgical techniques that have been developed include ileal neovagina (Monti's technique), Creatsas vaginoplasty, Wharton–Sheares–George neovaginoplasty, or the Davydov procedure. The most widely used is the Vecchietti laparoscopic procedure. Sometimes sexual intercourse can result in the dilation of a newly constructed vagina. [9]

Vaginal dilators and expanders

Vaginal expander ZSI 200 NS Inflatable vaginal expander.jpg
Vaginal expander ZSI 200 NS
ZSI 200 NS vaginal expander stretching the female vagina ZSI 200 NS Vaginal Expander in Vagina.jpg
ZSI 200 NS vaginal expander stretching the female vagina

The most techniques of vaginoplasty are using inflatable vaginal expanders or vaginal stents to design the vaginal diameter and length. [48] [49] At the end of the procedure the device stays in place to maintain the neovagina against the pelvic wall which also favors the process of microscopic neovascularization and reduces the risks of hematoma. In post-operative setting the expander can be used regularly to prevent post-operative vaginal retraction. [50] Solid vaginal dilators can also be used immediately after surgery to keep the passage from attachments, and regularly thereafter to maintain the viability of the neovagina. The frequency required to use decreases over time, however remains obligatory lifelong. [51] [52]

Risks and complications

Reconstructive vaginoplasty in children and adolescents carries the risk of superinfection. [19]

In adults, rates and types of complications varied with gender-affirming surgery. Necrosis of the clitoral region was 1–3%. Necrosis of the surgically created vagina was 3.7–4.2%. Vaginal shrinkage occurred was documented in 2–10% of those treated. Stricture, or narrowing of the vaginal orifice was reported in 12–15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two scrotal flaps has been described. Posterior vaginal wall is a rare complication. Genital pain was reported in 4–9%. Rectovaginal fistula is also rare with only 1% documented. Vaginal prolapse was seen in 1–2% of people assigned male at birth undergoing this procedure. [4]

The ability of emptying the bladder was affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported that voiding got worse. Those reporting a negative outcome who experienced loss of bladder control and urinary incontinence were 19%. Urinary tract infections occurred in 32% of those treated. [4]

History

Reports of people seeking vaginoplasty go back to the 2nd century. [53] [54] The first modern vaginoplasty was performed in 1931 on Dora Richter. [53] [55] [56] Lili Elbe also underwent a vaginoplasty the same year. [57]

See also

Related Research Articles

Masculinizing gender-affirming surgery for transgender men or transmasculine non-binary 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.

Feminizing Gender-affirming surgery for 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.

Suporn Watanyusakul is a Thai plastic and reconstructive surgeon. He is considered by some to be a world leader in surgical procedures for transgender individuals. He performs facial feminization surgery and male-to-female (MTF) sex reassignment surgery (SRS).

Genital reconstructive surgery may refer to:

<span class="mw-page-title-main">Müllerian agenesis</span> Congenital malformation of female reproductive organs

Müllerian agenesis, also known as Müllerian aplasia, vaginal agenesis, or Mayer–Rokitansky–Küster–Hauser syndrome, is a congenital malformation characterized by a failure of the Müllerian ducts to develop, resulting in a missing uterus and variable degrees of vaginal hypoplasia of its upper portion. Müllerian agenesis is the cause in 15% of cases of primary amenorrhoea. Because most of the vagina does not develop from the Müllerian duct, instead developing from the urogenital sinus, along with the bladder and urethra, it is present even when the Müllerian duct is completely absent. Because ovaries do not develop from the Müllerian ducts, affected people might have normal secondary sexual characteristics but are infertile due to the lack of a functional uterus. However, biological motherhood is possible through uterus transplantation or use of gestational surrogates.

<span class="mw-page-title-main">Cystocele</span> Protrusion of the bladder into the vagina

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">Labiaplasty</span> Plastic surgery procedure for altering the labia minora

Labiaplasty is a plastic surgery procedure for creating or altering the labia minora and the labia majora, the folds of skin of the human vulva. It is a type of vulvoplasty. There are two main categories of women seeking cosmetic genital surgery: those with conditions such as intersex, and those with no underlying condition who experience physical discomfort or wish to alter the appearance of their vulvas because they believe they do not fall within a normal range.

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

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. 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.

Georges Burou was a French gynecologist who managed a clinic in Casablanca, Morocco, and is widely credited with innovating modern sex reassignment surgery for trans women.

<span class="mw-page-title-main">Vaginal dilator</span> Medical instrument used to stretch the vagina

A vaginal dilator is an instrument used to gently stretch the vagina. They are used when the vagina has become narrowed, such as after brachytherapy for gynecologic cancers, and as therapy for vaginismus and other forms of dyspareunia.

<span class="mw-page-title-main">Vaginal hypoplasia</span> Birth defect in which the vagina fails to completely form

Vaginal hypoplasia is the underdevelopment or incomplete development of the vagina. It is a birth defect or congenital abnormality of the female genitourinary system.

<span class="mw-page-title-main">Clitoral hood reduction</span> Cosmetic surgical procedure

Clitoral hood reduction, also termed clitoral hoodectomy, clitoral unhooding, clitoridotomy, or (partial) hoodectomy, is a plastic surgery procedure for reducing the size and the area of the clitoral hood in order to further expose the glans of the clitoris.

<span class="mw-page-title-main">Perineoplasty</span> Plastic surgery procedure

Perineoplasty denotes the plastic surgery procedures used to correct clinical conditions of the vagina and the anus. Among the vagino-anal conditions resolved by perineoplasty are vaginal looseness, vaginal itching, damaged perineum, fecal incontinence, genital warts, dyspareunia, vaginal stenosis, vaginismus, vulvar vestibulitis, and decreased sexual sensation. Depending upon the vagino-anal condition to be treated, there are two variants of the perineoplasty procedure: the first, to tighten the perineal muscles and the vagina; the second, to loosen the perineal muscles.

An enterocele is a herniation of a peritoneum-lined sac containing small intestine through the pelvic floor, between the rectum and the vagina. Enterocele is significantly more common in females, especially after hysterectomy.

Vaginal transplantation is procedure whereby donated or laboratory-grown vagina tissue is used to create a 'neovagina'. It is most often used in women who have vaginal aplasia.

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.

<span class="mw-page-title-main">Vaginal anomalies</span> Congenital defect; abnormal or absent vagina

Vaginal anomalies are abnormal structures that are formed during the prenatal development of the female reproductive system and are rare congenital defects that result in an abnormal or absent vagina.

<span class="mw-page-title-main">Vulvoplasty</span> Operation to construct or reconstruct a vulva

Vulvoplasty, also known as zero-depth vaginoplasty, is a plastic surgery procedure for altering the appearance of one's vulva or constructing a vulva from penile and scrotal tissue.

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