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.