BACKGROUND: About 8,800-34,200 Gender Dysphoria (GD)- and 39,000-650,800 Mayer-Rokitansky-Küster-Hauser (MRKH)-patients undergo vaginoplasty annually. Various procedures are available, but comparisons are lacking. OBJECTIVES: To highlight information gaps, weaknesses and strengths of vaginoplasty techniques, to aid well-informed decision making by patients and healthcare professionals. SEARCH STRATEGY: A systematic search in Medline, EMBASE, Web of Science and Scopus until October 6, 2022, by PICO method and PROSPERO registration. SELECTION CRITERIA: Original retrospective studies on complete neovaginal creation in adult GD- and MRKH-patients and discussing anatomy, Quality of Life (QoL), satisfaction, sexual function, complications or complaints. DATA COLLECTION AND ANALYSIS: The 95% confidence intervals were calculated with DerSimonian and Laird random-effects. Methodological quality and potential bias were assessed. MAIN RESULTS: In total, 35 GD- and 16 MRKH-studies were eligible. Vagina length was 11.6 and 9.5 cm, respectively. In GD-patients, Hemorrhage (6%), prolapse (1%), gastrointestinal complications (1%), revisions (26%), pain (6%), regret (1%), fecal- (11%) and urinary issues (17%) were reported. Necrosis, stenosis, dyspareunia and revisions decreased, while duration increased with higher graft quantity. Intestinal-vaginoplasty reported 100% sensation. MRKH-patients reported more necrosis (17%) [McIndoe] and average satisfaction with sexual function (91%) and vaginal discharge (32%). They were more sexually active (86%) and had 100% anatomical satisfaction. Only Intestinal-vaginoplasty reported overall dissatisfaction. CONCLUSIONS: For GD- and MRKH-patients, multiple safe vaginoplasty techniques demonstrated acceptable outcomes, with significantly improved QoL and self-image. However, standardized validation tools are needed for well-informed decision-making. Direct technique comparisons per patient-cohort and exploration of tissue-engineering methods are critical for future surgical advancements.

Objective: To evaluate the effect of iatrogenic menopause on the physiology of the vagina of the ewe, and to evaluate if vaginal changes in ewes can be translated to women with the genitourinary syndrome of menopause (GSM). Design: Animal study, randomised design for ovariectomy or control, blinded for allocation and outcome assessment. Setting: University of Cape Town, South Africa. Population or Sample: Twenty-five Dohne Merino ewes. Methods: Iatrogenic menopause was induced in 20 animals by bilateral ovariectomy. Five animals served as a control group (no intervention). Differences between groups were determined by linear regression analyses (adjusted for baseline scores) at 5 months after ovariectomy. Main Outcome Measures: Vaginal epithelial thickness, pH, vaginal maturation value, vaginal maturation index, epithelial glycogen accumulation, content of elastin fibres, collagen, and vascularity. Results: Ovariectomised ewes showed epithelial thinning of the vaginal wall from 146 µm to 47 µm (mean, p <0.001 ). In addition, epithelial glycogen accumulation (43%) and the vascularity (23%) of the vaginal wall significantly decreased as compared to the control group. No differences were found for vaginal pH, vaginal cytology outcomes, elastin fibres and collagen content. Conclusions: This study established the ewe as a suitable large animal model for GSM. Furthermore, the similar relevant outcomes in humans and ewes hold great value for future translational research for the evaluation and optimisation of different treatment modalities for GSM. Funding: None. Keywords: Atrophy, ewe, genitourinary syndrome of menopause, model, ovariectomy.

BACKGROUND: About 430,000-1,000,000 Gender Dysphoria- and Mayer-Rokitanksy-Küster-Hauser-patients undergo vaginoplasty each year. Various surgical procedures are available, but direct comparisons are lacking. This inhibits well-informed decision making by patients and healthcare professionals. OBJECTIVES: Highlight information gaps, weaknesses and strengths of todays vaginoplasty techniques. SEARCH STRATEGY: A systematic search in Medline, EMBASE, Web of Science and Scopus until March 8, 2022 was conducted, by PICO method and PROSPERO registration. SELECTION CRITERIA: Original retrospective studies on complete neovaginal creation in adult Gender Dysphoria- and Mayer-Rokitanksy-Küster-Hauser-patients and discussing anatomical outcome, Quality of Life, satisfaction, sexual function, complications and/or complaints. DATA COLLECTION AND ANALYSIS: Data was extracted and methodological quality and potential bias were assessed. The 95% confidence intervals were calculated with DerSimonian and Laird random-effects. MAIN RESULTS: A total of 47 articles were eligible. Surgery took 198 minutes with 10.2 cm vaginal length. Major complications included 5% hemorrhage, 1% gastrointestinal complications, 1% prolapse, 3% tissue necrosis and 6% stenosis, with 31% revisions. Patients reported 25% excessive discharge, 6% pain, 11% fecal- and 17% urinary issues and one case of hair growth. Patients also reported 95% aesthetic- and 93% anatomical satisfaction, 10% overall dissatisfaction and 1% regret. Reports showed 75% sexual activity, 13% dyspareunia, 87% sensation and 84% overall functional satisfaction. CONCLUSIONS: Multiple vaginoplasty techniques demonstrated safe and acceptable outcomes, with significant improvement of Quality of Life and self-image. However, standardized validation tools are needed for well-informed decision-making. Direct technique comparisons with similar cohorts and exploration of tissue-engineering methods are critical for future surgical advancements.

Objective: To compare the host and biomechanical response to a fully absorbable poly-4-hydroxybutyrate (P4HB) scaffold to the response to PP mesh in an animal model of vaginal POP surgery. Design: A study employing a sheep model Setting: KU Leuven Center for Surgical Technologies Population: 14 parous female Mule sheep Methods: P4HB scaffolds were surgically implanted in the posterior vaginal wall of sheep. The comparative PP mesh data were obtained from an identical protocol. Main outcome measures: Gross necropsy, histological and biomechanical evaluation of explants, and the in vivo P4HB scaffold degradation were evaluated at 60- and 180-days post-implantation. Results: Gross necropsy revealed no implant related adverse events using P4HB scaffolds. The tensile stiffness of the P4HB explants increased at 180-days (12.498 ± 2.66 N/mm (P=0.019)) as compared to 60-days (4.585 ± 1.57 N/mm) post-implantation, while P4HB degraded gradually. P4HB scaffolds exhibited excellent tissue integration with dense connective tissue and a moderate initial host response. P4HB scaffolds induced a significantly higher M2/M1 ratio (1.70 ± 0.67 SD, score 0-4), as compared to PP mesh (0.99 ± 0.78 SEM, score 0-4) at 180-days. Conclusions: P4HB scaffold facilitated a gradual load transfer to vaginal tissue over time. The fully absorbable P4HB scaffold, in comparison to PP mesh, has a favorable host response with comparable load bearing capacity. If these results are also observed at longer follow-up, a clinical study for vaginal POP surgery may be warranted to demonstrate efficacy. Key words: Pelvic organ prolapse, vaginal surgery, Poly-4-hydroxybutyrate, degradable scaffold, host response, biomechanics.