Discussion
Main
findings
Non-surgical MRKH-treatment is likely still favored, as included article
quantity was low despite higher prevalence. High intercontinental
diversity showed no European or North-American MRKH-vaginoplasties,
likely due to pre-adolescent surgeries that are less common in Asia by
religion and tradition.101
Intestinal-vaginoplasty was performed significantly less in GD-patients,
likely due to preferred local tissue alternatives. GAS-vaginoplasty
duration was longer, as complete vulva and neovagina opposed to partial
vagina were formed, and increased with graft quantity.
Hemorrhage was only reported after GAS and originated from vascularized
tissue (i.e., corpus spongiosum), likely due to estrogen continuation
and higher surgery complexity.23 MRKH-vaginoplasty
predominantly reported intercourse-related bleeding.62
Tissue necrosis was associated with maximum tissue tension (i.e.,
introitus).
Prolapse was often reported, affects 50% of parous
women55 and mostly vaginoplasty patients ≥50 years.
Pelvic floors are sex-specific,102 so long-term
hormonal treatment might affect prolapse.55 In our
center we occasionally treat transwomen for long-term prolapse (10-20
post-operative years).103 Prolapse is believed to
increase with postoperative-time.42,104
Stenosis was most common and hampered QoL through sexual dysfunction and
dissatisfaction. Higher GAS-reports might relate to inherent skin
properties that cause narrowing, incomplete corpus spongiosum resection
or inclusion of meatal stenosis.
Gastrointestinal complications are rare and severe, especially perineal
dissection and less invasive surgery make intra-operative observation of
fistula hard.
Revisions were reported only and for all GAS-techniques and were
inversely proportional to graft size (through stenosis, necrosis and
dyspareunia) and likely related to dissatisfaction due to surgical
complexity from anatomical dissimilarity. MRKH-patients showed higher
overall and complete anatomical satisfaction, even for ‘unsuccessful’
lengths.
McIndoe-, Peritoneal- and Intestinal-surgery reported vaginal discharge,
which is prevented in skin-based vaginoplasty-methods by inherent tissue
differences. Genital pain hampered QoL-improvement after GAS and urinary
issues hampered satisfaction and correlated to small prostates and
pelvic floor dysfunction.
Penile-inversion- and Penoscrotal-GAS reported 1-4% (sporadic or
surgery-unrelated) regret. Many transgender-care opponents use regret as
an argument. Strict WPATH-regulations should prevent regret and likely
explain the presence of only GAS-investigated regret.
GD-patients were less sexually active. However, definition varied
gravely between studies, from ‘any activity’ to ‘regular introital
penetration with a man’. This presents a bias.
A large variety of evaluation was used. Complications, vaginal discharge
and hair were derived from patient follow up reports. Self-made
questionnaires were mostly used. Established questionnaires for fecal-
and urinary-issues,51–54 overall dissatisfaction and
aesthetic satisfaction were applied. The FSFI-questionnaire allowed
reliable comparison of dyspareunia and satisfaction with sexual
function.
Many established QoL forms are available and have been applied (SF-36,
BDI, FLZ, PHQ-4, RSES, SHS, SWLS and CLL).
Strength and
limitations
This is the first systematic review with meta-analysis on nine
vaginoplasty techniques with MRKH- and GD-patients and a wide diversity
of complications, satisfaction and function were assessed with
Clavien-Dindo classification. The methodological quality, in line with
PRISMA-guidelines, formed a strength. Diverse assessment scales for
sexual function and coitus-centered, sexual activity assessment and
uncorrected cohort variation, need to be considered for result
reliability. These discrepancies invalidate quantitative comparison and
emphasize need for standardized validation tools. More criticism was
reported amongst GD-patients especially on aesthetics and penetration
depth, where perhaps fertility restoration is more important for
MRKH-patients. Most comprised studies had medium risk of bias and lacked
control groups, blinding of assessors and cofounder assessment. Lastly,
high cohort size diversity, variation in definitions, technique article
quantity, (loss at) follow-up, recruitment and outcome assessment, are
points of consideration.
Interpretation
It is impossible to identify one ideal vaginoplasty technique, due to
lacking high-quality evidence and study heterogeneity. Tissue
engineering alternatives were not included and could bring unexpected
success, that should be further clarified in future research.
Conclusions
Vaginoplasty developments are rapidly evolving. However, MRKH-patients
and transwomen have to face incomprehension, ignorance and internal
challenges daily. Vaginoplasty forms a relatively safe and acceptable
solution that improves their QoL and self-image. This meta-analysis
showed weaknesses and strength of technique specific (patient-reported)
outcomes, by inconsistencies, information gaps, lack of standardization
and of comparative research with similar cohorts for well-informed
decision-making. No ideal vaginoplasty method can be identified and a
technique is still selected based on an expertise-based rather than an
evidence-based decision. This, together with exploration of
tissue-engineering, is critical for future surgical advancements. We
sincerely hope that this review provides an overview of today’s options
for well-educated decision, and formed a starting point for further
background reading.
Supplementary data are available at BJOG online.
Contribution to
authorship
J.S.: conceptualization, methodology, formal analysis, investigation,
data curation, writing – original draft and visualization. F.G.: data
analysis, validation, writing – review & editing and supervision.
M.B.B.: Writing – review & editing. J.P.R.: Writing – review &
editing. R.d.V.: Investigation and data curation. T.S.:
conceptualization, supervision and writing – review & editing. J.H.:
conceptualization, supervision and writing – review & editing.
Acknowledgements
We like to thank M. van Wely for her assistance on the statistical
analysis.
Disclosure of
interest
None.
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