Surgical Therapy for Transwomen




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 ).






Fig. 5.1


( A ) Anatomy of the superficial femoral artery and femoral vein. The relevant branches include the external pudendal vessels, the superficial inferior epigastric vessels, the superficial circumflex iliac vessels, and the great saphenous vein. ( B ) Anatomy of the internal pudendal artery and vein and its branches.

(Copyright © 2016. Used with permission of Elsevier. All rights reserved. www.netterimages.com .)


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 ).




Fig. 5.2


( A ) Postoperative vaginoplasty with penile disassembly and inversion technique. The arrow indicates the urethral flap inset within the penile flap, helping to form the labia minora and clitoral hood. Preoperative markings for secondary labiaplasty (dilator in place demonstrating neovaginal depth). ( B ) Postoperative vaginoplasty, before labiaplasty. ( C ) Postoperative labiaplasty performed to provide additional convergence of anterior labial commissure.


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.



Box 5.1


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.




  • Options




    • Penile disassembly and inversion vaginoplasty




      • Full-length scrotoperineal flap (± skin graft)



      • Limited scrotoperineal flap (± skin graft)




    • Intestinal vaginoplasty



    • Nongenital flaps




  • Considerations




    • Indication




      • Gender dysphoria



      • Oncologic, traumatic, infectious




    • Patient goals




      • Vaginal intercourse



      • “Zero depth”




    • Penile length




      • (±) Circumcision




    • Primary versus revision




Surgical options for vaginoplasty


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 ).




Fig. 5.3


Preferred incision, at penoscrotal junction, when bilateral orchiectomies are performed without vaginoplasty. An incision at the penoscrotal junction maintains the ability to perform a vaginoplasty using a scrotoperineal flap, and it also preserves the blood supply to the subsequent penile flap. An inguinal incision may divide the blood supply to the penile flap (pudendal vessels) should a vaginoplasty be requested at a later date.


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.



Box 5.2


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.


Bowel preparation regimen



Fig. 5.4


Lithotomy position. SCD boots are placed; the arms are abducted on foam rests with flexion at the elbows, and an upper body forced-air surgical warming blanket is placed.


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.




Fig. 5.5


Area of depilation includes the skin from the anus to the central scrotum as well as the penile shaft. The marked area corresponds to the approximate dimensions of the scrotoperineal flap. This tissue will form the posterior vaginal wall.


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.




Fig. 5.6


( A ) Preoperative markings for penile flap. The incision is extended a variable length along the ventral penile shaft ( white arrow ). ( B ) Preoperative markings for scroto-perineal flap, when the flap is used to form the entire posterior vaginal wall. The asterisk indicates the position of the central tendon. This is the location at which the vaginal introitus will be located. ( C ) The insert demonstrates the position of the urogenital and anal triangles in relation to the scroto-perineal flap.

([ C ] Copyright © 2016. Used with permission of Elsevier. All rights reserved. www.netterimages.com .)



Fig. 5.7


Postoperative vaginoplasty performed with the penile disassembly and inversion technique. The neoclitoris is formed from the dorsal glans penis; the vaginal lining is created with the penile and scroto-perineal flaps; and the labia majora are created with the scrotum. The urethra is shortened, spatulated, and everted to create the urethra, urethral meatus, and portions of the labia minora and vestibular lining.


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 ).




Fig. 5.8


( A ) Preoperative markings for the scrotoperineal flap, when the flap is used to form the entire posterior vaginal wall. Note that (1) the flap borders, indicated by the black arrow, are maintained within the footprint of the lateral scrotum, indicated by the white arrow; (2) a “V”-shaped extension is designed at the planned level of the vaginal introitus; and (3) the base of the flap will maintain a broad subcutaneous pedicle without creating a rectangular appearance to the posterior labial commissure. The asterisk indicates the position of the central tendon, corresponding to the location of the vaginal introitus. ( B ) Preoperative markings for limited scrotoperineal flap. This flap is used when the distal penile skin remains tubularized. In this case, the scrotoperineal flap is shorter and only forms a portion of the posterior vaginal wall. The limited scrotoperineal flap is inset into the penile flap. ( C ) Limited scrotoperineal flap with full-thickness skin graft. In this case, the distal penile skin will remain tubularized, and additional scrotal skin will be harvested as a full-thickness skin graft.



Fig. 5.9


Scrotoperineal flap is elevated. The flap should be thin, and its base should maintain a broad subcutaneous pedicle without creating a rectangular appearance to the posterior labial commissure.


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.




Fig. 5.10


The ventral penis is incised; the scrotoperineal flap is elevated and retracted posteriorly, and the testicles are exposed. The white arrow indicates the scroto-perineal flap, and the yellow arrow indicates the 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 ).




Fig. 5.11


Bilateral orchiectomies, including resection of the spermatic cords, are performed at the level of external inguinal ring. Resection of the spermatic cord at this level allows the ligated stump to retract into the inguinal canal and helps to prevent a palpable bulge.



Fig. 5.12


Following bilateral orchiectomies. The superficial perineal musculature is exposed by retraction of the penile and scrotoperineal flaps. The bulbospongiosus muscle, indicated by the yellow arrow, overlies the corpora spongiosum; the ischiocavernosus muscles, indicated by the white arrow, overlie the corpora cavernosa, and the superficial transverse perinei muscle, indicated by the black arrow, inserts into the perineal body. The introitus is created at the location of the central tendon.



Fig. 5.13


( A ) Penile degloving with elevation of the anteriorly based penile flap. This exposes the underlying corpora cavernosa dorsally, and the corpora spongiosum ventrally. ( B and C ) The glans penis represents an extension of the corpora spongiosum and is anatomically distinct from the corpora cavernosa. This allows the glans penis to be separated from the corpora cavernosa. The glans, elevated on the dorsal neurovascular pedicle, remains viable and innervated, and it will ultimately be used to create the neoclitoris.

([ B ] Copyright © 2016. Used with permission of Elsevier. All rights reserved. www.netterimages.com ; and [ C ] From Schechter L. Surgery for gender identity disorder. In: Neligan PC, editor. Plastic surgery. 3rd edition. Philadelphia: Elsevier; 2013; with permission.)



Fig. 5.14


Schematic of superficial perineal compartment musculature. The bulbospongiosus muscle, indicated by the black arrow, assists with emptying of the urethra and with erection of the corpora spongiosum and penis. The ischiocavernosus muscles, indicated by the red arrow, compress the crus of the penis, impedes venous return, and helps to maintain an erection. The superficial transverse perinei muscle, indicated by the yellow arrow, inserts into the perineal body. The superficial muscles are resected in order to widen the introitus.

(Copyright © 2016. Used with permission of Elsevier. All rights reserved. www.netterimages.com .)


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.




Fig. 5.15


( A ) Sagittal section demonstrating the anatomic location of the neovagina ( arrow ) between the urethra, prostate, and bladder anteriorly and the rectum posteriorly. Dissection follows Denonvillier fascia. During dissection of the vaginal cavity, injury to the rectum may occur. ( B and C ) Development of the neovagina with dilator in place. ( D ) Retractor placed in the neovaginal cavity. Note the anal sphincter ( arrow ). The dissection of the vaginal cavity is performed in an extrasphincteric plane.

([ A ] Copyright © 2016. Used with permission of Elsevier. All rights reserved. www.netterimages.com .)



Fig. 5.16


( A ) Coronal section demonstrating levator ani. The release of the levator ani, indicated by the black arrows, aids with expansion of the neovaginal cavity. However, the natal male pelvis is narrower than that of the natal female pelvis. In some individuals, the bony pelvis may be a limiting factor in neovaginal width. ( B ) Vaginal speculum in place providing exposure for release of the levator ani muscles, bilaterally. The release of the levator ani allows expansion of the vaginal cavity.

([ A ] Courtesy of Netter medical illustration ; with permission of Elsevier .)



Fig. 5.17


( A ) Elevation of the bulbospongiosus muscle, indicated by the white arrow, from the underlying corpora spongiosum. The corpora cavernosa are exposed following resection of the ischiocavernosus muscles, indicated by the yellow arrow. ( B ) Vaginal cavity developed (laparotomy sponge in place) and bulbospongiosus muscle resected.

Jul 8, 2019 | Posted by in General Surgery | Comments Off on Surgical Therapy for Transwomen
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