Introduction

Vaginoplasty - General

When a vagina is absent or malformed by a congenital or acquired disease, various treatment options exist. Vaginoplasty should create a vagina with normal anatomy and function, and prevent scars, stenosis or contracture.1,2 Non-surgical methods (like dilation and traction) are often successful and avoid surgery-related risks,3–5 but lead to prolapse, shorter neovaginas, low satisfaction, long-term agony and mental/emotional stress.6,7 Many prefer surgery, as non-surgical approaches take 2-24 months and successive surgical corrections are common for (improved) sexual activity and severe defect restoration with extra-vaginal tissue. A growing annual 48,000-685,000 surgeries are performed11 Based on 3,904,727,342 female and 3,970,238,390 male inhabitants in 2021, this results in 39,047-650,788 MRKH-surgeries and 8,822-34,226 GD-surgeries for 10-25% surgical vaginoplasty treatment.267,8 by over 20 methods, each with specific (dis)advantages and without golden standard.9 Vaginoplasty techniques are generally specified as cavity dissection with specific donor graft.

Vaginoplasty – Gender Dysphoria

Individuals with Gender Dysphoria (GD) express an inconsistency between their gender and sex. Documented prevalence gravely vary with geographical location between 1:2,900-45,000 genotypical males.10–14 Penile-inversion- and Penoscrotal-surgery are Male-to-Female (MtF-)specific methods,15 but local skin volume is not always sufficient due to hypoplasia.16 Alternatively, skin, bowel,17,18 amnion, oral mucosa or decellularized tissue is applied. Surgeons prefer Penoscrotal-vaginoplasty, but without consensus on the ideal technique. Complication- and outcome-reports are sparse and reviews compare at best two techniques19,20and lack meta-analyses.21–23 Initially, male pronounces were applied and surgery aimed for genitalia removal without new partner awareness of previous sex, but today female identity is recognized, with emphasis on aesthetics and functionality. The neovagina requires to be hairless, moist and minimally 11 cm deep and 3 cm wide, with labia minora, majora and a sensate clitoris.24,25

Vaginoplasty –Mayer-Rokitansky-Küster-Hauser

Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome presents as congenital aplasia of uterus and upper two-thirds of the vagina, with prevalence estimated as 1:1,500-10,000 genotypical females.26Davydov-, McIndoe-, Vecchietti- and Wharton-Sheares-George-surgery are MRKH-specific methods and apply stretching, spontaneous epithelization by local vaginal epithelial cells, split-thickness skin or female peritoneum grafts for partial neovagina creation. Few reviews compare complications or outcomes and none compare surgical techniques. Initially, vaginoplasty outcome was assessed by anatomy, sexual activity and satisfaction of patient or partner.27–29 Today, sexual function and satisfaction are assessed by extensive patient-centered questionnaires.

Objective

We evaluated peri- and post-operative outcomes of nine vaginoplasty techniques for anatomy, complications, complaints, satisfaction, sexual function and Quality of Life with MRKH- and GD-indication. We hope that by highlighting weaknesses and strengths, this will aid well-educated decision making by patients and healthcare professionals. By revealing current information gaps, focal points for future research can be determined.