Surgical conversion of the genitalia in transwomen has evolved since the use of skin grafts for creation of a neovagina in cases of vaginal agenesis. The use of pedicled penile and scrotal flaps was described over 40 years ago, and despite technical refinements, remains the mainstay for neovaginal construction. The vascular basis of these flaps is derived from 1 of 2 sources: (1) the femoral artery (deep and superficial external pudendal arteries) and (2) the internal pudendal artery (perineal branches, branches to the bulb and urethra of the penis, and the deep and dorsal penile branches) ( Fig. 5.1 ).
Although a functional vaginoplasty is performed in a single stage, further feminization of the mons pubis can be performed at a second surgical stage. The labiaplasty, which can be performed under local anesthesia as an outpatient procedure 3 months after vaginoplasty, creates a convergent anterior labial commissure and provides additional clitoral hooding. However, with recent trends toward hair removal of the mons pubis, fewer individuals opt to proceed with secondary labiaplasty ( Fig. 5.2 ).
The surgical options for vaginoplasty consist of 1 of 3 approaches: penile disassembly and inversion vaginoplasty, intestinal vaginoplasty, or nongenital flaps ( Box 5.1 ). Most centers perform primary vaginoplasty with the penile disassembly and inversion vaginoplasty technique using an anteriorly based penile skin flap combined with a posteriorly based scrotal-perineal flap and/or skin graft. However, intestinal vaginoplasty, typically reserved for revision cases, is a first-line surgical therapy at some centers. The advantage of intestinal vaginoplasty is the creation of a vascularized 12- to 15-cm vagina with a moist lining, lessening the requirements for postoperative vaginal dilation as well as the need for lubrication during intercourse. However, the drawbacks of intestinal vaginoplasty include the need for an intra-abdominal operation with a bowel anastomosis and the potential for excess neovaginal secretions with a malodorous discharge. Because of their soft tissue bulk, nongenital flaps are typically considered for reconstruction following oncologic resections, traumatic repair, or reconstruction following infection. Alternatively, some individuals undergoing vaginoplasty for gender dysphoria do not contemplate vaginal intercourse. Sometimes referred to as a “zero-depth” procedure, this method is used to construct external genitalia (mons pubis, labia majora, labia minora and vestibular lining, and clitoris) without a vaginal canal.
When vaginoplasty is performed for gender dysphoria, most centers use the penile disassembly and inversion vaginoplasty technique. In revision cases, or for primary cases with inadequate penile length, an intestinal vaginoplasty may be chosen. When vaginoplasty is performed for oncologic reconstruction, nongenital flaps are most often used.
Penile disassembly and inversion vaginoplasty
Full-length scrotoperineal flap (± skin graft)
Limited scrotoperineal flap (± skin graft)
Oncologic, traumatic, infectious
Primary versus revision
Some individuals may undergo an orchiectomy as an independent procedure before vaginoplasty. Orchiectomy may assist with partial relief of dysphoria as well as reducing medication dosages. In such cases, an incision at the penoscrotal junction is preferred to an inguinal approach. The penoscrotal incision allows access to both the right and the left testicles and spermatic cords while preserving the vascular supply to the penile flap should later vaginoplasty be requested ( Fig. 5.3 ).
Regardless of the technique used, hormones are discontinued approximately 2 weeks before surgery to reduce the risk of venous thromboembolism, and a preoperative bowel preparation is administered ( Box 5.2 ). Before surgery, sequential compression devices (SCD) are placed, and intravenous antibiotics are administered. Following induction of general anesthesia, chemoprophylaxis for venous thromboembolism is administered subcutaneously (either fractionated or unfractionated heparin depending on institutional policies); the patient is positioned in lithotomy position; bony prominences are padded; the arms are abducted on foam rests with flexion at the elbows; an upper body forced-air surgical warming blanket is placed; and an indwelling urinary catheter is inserted under sterile conditions after the patient is prepared and draped ( Fig. 5.4 ). The patient’s position may vary when an intestinal vaginoplasty is performed robotically.
The same bowel preparation is used for vaginoplasty, metoidioplasty, and phalloplasty procedures. Ingredients are available over the counter:
Magnesium citrate (10 oz.)
MiraLAX 238 g
Can of 7-Up or Diet 7-Up
Gatorade (if diabetic, Propel Fitness Water)
The day before surgery, you must have a clear liquid diet (apple juice, soda, Jell-O, chicken broth, and tea) for the entire day. Red dye–colored products should be avoided.
At 11 am , drink a full bottle of magnesium citrate mixed equally with 7-Up or Diet 7-Up; drink this within 15 minutes.
For lunch, continue on a clear liquid diet.
At 3 pm , mix MiraLAX 238 g with Gatorade (or Propel) 64 oz. and drink within 2 hours.
For dinner, continue on a clear liquid diet.
Do not drink any liquids containing red dye.
Nothing to eat or drink after midnight.
Penile disassembly and inversion
Hair removal, whether by electrolysis or laser, is completed as thoroughly as possible from the penile shaft and central perineum and scrotum ( Fig. 5.5 ) before penile inversion vaginoplasty. Preoperative depilation helps to prevent intravaginal hair growth. Adequate hair removal can take 3 to 6 months to complete and should not be performed within 2 weeks of surgery.
Primary vaginoplasty surgery most commonly involves penile disassembly and inversion with an anteriorly based penile flap. Although a variety of technical modifications are described in the literature, the penile disassembly and inversion technique uses the penile skin and a second, posteriorly based, scrotal-perineal flap to construct the vaginal cavity ( Fig. 5.6 ). The author’s preferred technique is described herein: the labia majora are formed from the lateral aspects of the scrotum; the neoclitoris is formed from the dorsal glans penis; and the labia minora and vestibular lining are formed with the creation of a urethral flap inset within the penile flap. The penile urethra is shortened, spatulated, and everted to create the urethra, urethral meatus, and portions of the labia minora and vestibular lining ( Fig. 5.7 ). Depending on the length of the penis and previous surgical history (ie, circumcision), skin grafts may be required for additional vaginal depth. Full-thickness skin grafts may be harvested from discarded portions of the scrotum. If this is insufficient, additional full-thickness skin grafts may be harvested with a Pfannenstiel incision. Alternatively, split-thickness skin grafts may be harvested from the lower abdomen or mons region. However, the donor site of the split-thickness skin grafts may be left with areas of hypopigmentation depending on the depth of harvest and the patient’s skin tone.
The procedure is begun with the creation of a posteriorly based scrotal-perineal flap. The dimensions of this flap may vary, depending on whether the scrotal-perineal flap forms the entire posterior vaginal wall or, alternatively, is inset into the penile flap. For individuals who are not circumcised, a smaller, limited scrotal-perineal flap is typically chosen. If used to form the entire posterior vaginal wall, the flap typically measures approximately 15 cm in length, has a base diameter of 3 to 4 cm, and is approximately 6 to 8 cm in the largest transverse dimension. The flap needs to be of sufficient width so as not to limit the vaginal introitus. However, the borders of the flap are maintained within the boundaries of the scrotum to create a smooth, graded, and contiguous appearance to the newly formed labia majora. In addition, the lateral aspect of the flap is designed in a “V-shaped” fashion so as not to create a circular introitus, thereby minimizing the chance of introital contracture. The flap is centered cephalad to the anus and elevated in an extrasphincteric plane, with care taken not to injure the external anal sphincter ( Fig. 5.8 ). The flap should be thin, and its base is elevated so as to maintain a broad subcutaneous pedicle without creating a rectangular appearance to the posterior labial commissure ( Fig. 5.9 ).
Following elevation of the scrotoperineal flap, the penile flap is developed with an incision on the ventral aspect of the phallus, located along the midline raphe ( Fig. 5.10 ). The length of the incision along the ventral penis depends on the length of the phallus, and whether the individual has been circumcised. If there is sufficient penile skin, the incision ends approximately halfway along the ventral phallus. This incision design will leave the distal penile flap tubularized. In such instances, the limited scrotoperineal flap is inset into the tubularized penile flap.
Following elevation of both the penile and the scrotoperineal flaps, access to the testicles and spermatic cords is established, allowing the performance of bilateral orchiectomies. The orchiectomies, including resection of the spermatic cords, are carried out at the level of the external inguinal ring ( Figs. 5.11 and 5.12 ). Resection of the spermatic cord at this level allows the spermatic cord to retract within the inguinal canal and prevents a palpable bulge in the groin area. The skin of the penile shaft is then circumferentially incised at the junction of the glans and penile shaft, facilitating elevation of the penile flap ( Fig. 5.13 ). This facilitates separation of the penile skin from the underlying corpora cavernosa and corpora spongiosum, as well as the underlying muscles, the ischiocavernosus and bulbospongiosus muscles, respectively ( Fig. 5.14 ).
The vaginal cavity is developed by dissection between the prostate and rectum ( Fig. 5.15 ). During this dissection, injury to the rectum may occur. Dissection follows Denonvilliers fascia until the peritoneal reflection is reached. Most of the dissection is performed bluntly; however, release of the attachments between the prostate and rectum may require sharp division. The levator ani muscles are incised with electrocautery to allow further lateral expansion of the neovaginal cavity ( Fig. 5.16 ). Adequate dissection of the neovaginal space is essential in creating and maintaining adequate vaginal depth and width. Once the vaginal cavity is created, the superficial perineal muscles are resected. Resection of the bulbospongiosus and ischiocavernosus muscles aids with expansion of the introitus and exposure of the underlying corpora spongiosum and corpora cavernosa ( Fig. 5.17 ). At this point, the corpora spongiosum is separated from the corpora cavernosa ( Fig. 5.18 ). In order to further open the vaginal cavity, the corpora spongiosum is resected and oversewn at the level of the urethral bulb ( Fig. 5.19 ). If excess erectile tissue is not removed, this tissue may become engorged during sexual arousal and restrict entry into the vaginal cavity.