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Principles and outcomes of gender-affirming vaginoplasty

Nature Reviews Urology volume 20, pages 308–322 (2023)Cite this article

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Abstract

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Key points

  • Vaginoplasty is the most frequently performed genital gender-affirming surgery for gender-diverse people.

  • Preoperative management of patients choosing to undergo vaginoplasty includes hormone management, pelvic floor physiotherapy and hair removal, in addition to standard preoperative preparation.

  • The two types of vaginoplasty most often performed are penile inversion vaginoplasty and intestinal vaginoplasty; peritoneal-based vaginoplasties are also becoming widely used.

  • Minimal-depth vaginoplasty is an option for patients who do not desire construction of a full-depth vagina.

  • Postoperative care includes strict dilation regimens, vaginal rinses and pelvic floor physiotherapy.

  • Clinical and patient-reported outcomes that require monitoring include sensation, urinary divergence, vaginal depth, lubrication and patient satisfaction.

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Fig. 1: Penile inversion vaginoplasty technique.
Fig. 2: The clitoral neurovascular bundle elevation planes.
Fig. 3: Formation of the clitoris.

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References

  1. Winter, S. et al. Transgender people: health at the margins of society. Lancet 388, 390–400 (2016).

    Article  PubMed  Google Scholar 

  2. Coleman, E. et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int. J. Transgend. 13, 165–232 (2012).

    Article  Google Scholar 

  3. Horbach, S. E. et al. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J. Sex. Med. 12, 1499–1512 (2015). The penile skin inversion technique is the most researched surgical procedure, but although the outcome of bowel vaginoplasty has been reported less frequently, it does not seem to be inferior.

    Article  PubMed  Google Scholar 

  4. Colebunders, B., Brondeel, S., D’Arpa, S., Hoebeke, P. & Monstrey, S. An update on the surgical treatment for transgender patients. Sex. Med. Rev. 5, 103–109 (2017).

    Article  PubMed  Google Scholar 

  5. Gooren, L. J. Clinical practice. Care of transsexual persons. N. Engl. J. Med. 364, 1251–1257 (2011). Overview of the multidisciplinary care for gender dysphoric clients.

    Article  CAS  PubMed  Google Scholar 

  6. Coleman, E. et al. Standards of care for the health of transgender and gender diverse people, version 8. Int. J. Transgend. Health 23(sup1), S128–S137 (2022). World Professional Association for Transgender Health Standards of Care Version 8.

    Article  Google Scholar 

  7. James, S. E. et al. The Report of the 2015 U.S Transgender Survey. National Center for Equality. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf (2016).

  8. Karim, R. B., Hage, J. J. & Mulder, J. W. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann. Plast. Surg. 37, 669–675 (1996).

    Article  CAS  PubMed  Google Scholar 

  9. Opsomer, D. et al. Creation of clitoral hood and labia minora in penile inversion vaginoplasty in circumcised and uncircumcised transwomen. Plast. Reconstr. Surg. 142, 729e–733e (2018).

    Article  CAS  PubMed  Google Scholar 

  10. Bizic, M. et al. An overview of neovaginal reconstruction options in male to female transsexuals. Sci. World J. 2014, 638919 (2014).

    Article  Google Scholar 

  11. Zak, P. W. et al. The use of a Hartmann’s pouch for bowel vaginoplasty: a case report. Plast. Reconstr. Surg. Glob. Open. 29, e3546 (2021).

    Article  Google Scholar 

  12. Baldwin, J. F. X. I. V. The formation of an artificial vagina by intestinal transplantation. Ann. Surg. 40, 398–403 (1904).

    CAS  PubMed  PubMed Central  Google Scholar 

  13. Abraham, F. Genitalumwandlung an zwei männlichen Transvestiten. Z. Sexualwis Sexualpol. 18, 223–226 (1931).

    Google Scholar 

  14. Gillies, H. D. & Millard, D. R. in Principles and Art of Plastic Surgery 368–388 (Little Brown and Co., 1957).

  15. Hage, J. J., Karim, R. B. & Laub, D. R. Sr On the origin of pedicled skin inversion vaginoplasty: life and work of Dr Georges Burou of Casablanca. Ann. Plast. Surg. 59, 723–729 (2007).

    Article  CAS  PubMed  Google Scholar 

  16. Jarolim, L. et al. Gender reassignment surgery in male-to-female transsexualism: a retrospective 3-month follow-up study with anatomical remarks. J. Sex. Med. 6, 1635–1644 (2009).

    Article  PubMed  Google Scholar 

  17. Markland, C. & Hastings, D. Vaginal reconstruction using cecal and sigmoid bowel segments in transsexual patients. J. Urol. 111, 217–219 (1974).

    Article  CAS  PubMed  Google Scholar 

  18. Goddard, J. C. et al. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int. 100, 607–613 (2007).

    Article  PubMed  Google Scholar 

  19. Selvaggi, G. et al. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plast. Reconstr. Surg. 116, 135e–145e (2005).

    Article  PubMed  Google Scholar 

  20. di Summa, P. G. et al. Colic-based transplant in sexual reassignment surgery: functional outcomes and complications in 43 consecutive patients. J. Sex. Med. 16, 2030–2037 (2019).

    Article  PubMed  Google Scholar 

  21. Wilczynski, C. & Emanuele, M. A. Treating a transgender patient: overview of the guidelines. Postgrad. Med. 126, 121–128 (2014).

    Article  PubMed  Google Scholar 

  22. Gaither, T. W. et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J. Urol. 199, 760–765 (2018).

    Article  PubMed  Google Scholar 

  23. Lawrence, A. A. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch. Sex. Behav. 35, 717–727 (2006).

    Article  PubMed  Google Scholar 

  24. Nolan, I. T., Haley, C., Morrison, S. D., Pannucci, C. J. & Satterwhite, T. Estrogen continuation and venous thromboembolism in penile inversion vaginoplasty. J. Sex. Med. 18, 193–200 (2021).

    Article  CAS  PubMed  Google Scholar 

  25. Kozato, A. et al. No venous thromboembolism increase among transgender female patients remaining on estrogen for gender-affirming surgery. J. Clin. Endocrinol. Metab. 106, e1586–e1590 (2021).

    Article  PubMed  Google Scholar 

  26. Rochlin, D. H., Morrison, S. D. & Kuzon, W. M. Jr A call for consideration of gender identity in venous thromboembolism risk assessment. Ann. Surg. 274, e191–e192 (2021).

    Article  PubMed  Google Scholar 

  27. Boskey, E. R., Taghinia, A. H. & Ganor, O. Association of surgical risk with exogenous hormone use in transgender patients: a systematic review. JAMA Surg. 154, 159–169 (2019).

    Article  PubMed  Google Scholar 

  28. Hontscharuk, R. et al. Perioperative transgender hormone management: avoiding venous thromboembolism and other complications. Plast. Reconstr. Surg. 147, 1008–1017 (2021).

    Article  CAS  PubMed  Google Scholar 

  29. Pannucci, C. J., Swistun, L., MacDonald, J. K., Henke, P. K. & Brooke, B. S. Individualized venous thromboembolism risk stratification using the 2005 Caprini score to identify the benefits and harms of chemoprophylaxis in surgical patients: a meta-analysis. Ann. Surg. 265, 1094–1103 (2017).

    Article  PubMed  Google Scholar 

  30. van der Sluis, W. B. et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J. Sex. Med. 13, 702–710 (2016).

    Article  PubMed  Google Scholar 

  31. Selvaggi, G. & Bellringer, J. Gender reassignment surgery: an overview. Nat. Rev. Urol. 8, 274–282 (2011).

    Article  PubMed  Google Scholar 

  32. Reed, H. M. Aesthetic and functional male to female genital and perineal surgery: feminizing vaginoplasty. Semin. Plast. Surg. 25, 163–174 (2011).

    Article  PubMed  PubMed Central  Google Scholar 

  33. Pan, S. & Honig, S. C. Gender-affirming surgery: current concepts. Curr. Urol. Rep. 19, 62 (2018).

    Article  PubMed  Google Scholar 

  34. Zhang, W. R., Garrett, G. L., Arron, S. T. & Garcia, M. M. Laser hair removal for genital gender affirming surgery. Transl. Androl. Urol. 5, 381–387 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  35. Thoreson, N., Marks, D. H., Peebles, J. K., King, D. S. & Dommasch, E. Health insurance coverage of permanent hair removal in transgender and gender-minority patients. JAMA Dermatol. 156, 561–565 (2020).

    Article  PubMed  Google Scholar 

  36. Bustos, S. S. et al. Complications and patient-reported outcomes in transfemale vaginoplasty: an updated systematic review and meta-analysis. Plast. Reconstr. Surg. Glob. Open 9, e3510 (2021). Updated systematic review on complications and patient-reported outcomes after genital gender-confirming surgery.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Buncamper, M. E. et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast. Reconstr. Surg. 138, 999–1007 (2016). Intraoperative and postoperative complications after penile inversion vaginoplasty in a major center in the Netherlands.

    Article  CAS  PubMed  Google Scholar 

  38. Shoureshi, P. & Dugi, D. III Penile inversion vaginoplasty technique. Urol. Clin. North. Am. 46, 511–525 (2019).

    Article  PubMed  Google Scholar 

  39. Soli, M. et al. Male to female gender reassignment: modified surgical technique for creating the neoclitoris and mons veneris. J. Sex. Med. 5, 210–216 (2008).

    Article  PubMed  Google Scholar 

  40. Dy, G. W., Sun, J., Granieri, M. A. & Zhao, L. C. Reconstructive management pearls for the transgender patient. Curr. Urol. Rep. 19, 36 (2018).

    Article  PubMed  Google Scholar 

  41. Vazquez, I. M., Garcia-Senosiain, O., Labanca, T. & Gil, E. G. Aesthetic refinement in the creation of the clitoris, its preputial hood, and labia minora in male-to-female transsexual patients. Ann. Plast. Surg. 81, 393–397 (2018).

    Article  Google Scholar 

  42. Fang, R. H., Chen, C. F. & Ma, S. A new method for clitoroplasty in male-to-female sex reassignment surgery. Plast. Reconstr. Surg. 89, 679–682 (1992).

    Article  CAS  PubMed  Google Scholar 

  43. Rehman, J. & Melman, A. Formation of neoclitoris from glans penis by reduction glansplasty with preservation of neurovascular bundle in male-to-female gender surgery: functional and cosmetic outcome. J. Urol. 161, 200–206 (1999).

    Article  CAS  PubMed  Google Scholar 

  44. Hage, J. J., Karim, R. B., Bloem, J. J., Suliman, H. M. & van Alphen, M. Sculpturing the neoclitoris in vaginoplasty for male-to-female transsexuals. Plast. Reconstr. Surg. 93, 358–364 (1994).

    Article  CAS  PubMed  Google Scholar 

  45. Perovic, S. V., Stanojevic, D. S. & Djordjevic, M. L. J. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 86, 843–850 (2000).

    Article  CAS  PubMed  Google Scholar 

  46. Amend, B., Seibold, J., Toomey, P., Stenzl, A. & Sievert, K. D. Surgical reconstruction for male-to-female sex reassignment. Eur. Urol. 64, 141–149 (2013).

    Article  PubMed  Google Scholar 

  47. Dreher, P. C. et al. Complications of the neovagina in male-to-female transgender surgery: a systematic review and meta-analysis with discussion of management. Clin. Anat. 31, 191–199 (2018).

    Article  PubMed  Google Scholar 

  48. Raigosa, M. et al. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J. Sex. Med. 12, 1837–1845 (2015).

    Article  PubMed  Google Scholar 

  49. Wagner, S. et al. Male-to-female transsexualism: technique, results and 3-year follow-up in 50 patients. Urol. Int. 84, 330–333 (2010).

    Article  PubMed  Google Scholar 

  50. Rude, T. et al. Robot assisted penile inversion vaginoplasty: a novel technique. J. Urol. 197, E1058–E1058 (2017).

    Article  Google Scholar 

  51. Krege, S., Bex, A., Lummen, G. & Rubben, H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 88, 396–402 (2001).

    Article  CAS  PubMed  Google Scholar 

  52. Rossi Neto, R., Hintz, F., Krege, S., Rubben, H. & Vom Dorp, F. Gender reassignment surgery — a 13 year review of surgical outcomes. Int. Braz. J. Urol. 38, 97–107 (2012).

    Article  CAS  PubMed  Google Scholar 

  53. Opsomer, D. et al. Fifteen-year experience with the ghent technique of penile inversion vaginoplasty. Plast. Reconstr. Surg. 148, 416e–424e (2021). Fifteen-year overview of the intraoperative and postoperative complications after 384 penile inversion vaginoplasties performed by S. Monstrey.

    Article  CAS  PubMed  Google Scholar 

  54. Hage, J. J. & Karim, R. B. Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals. Plast. Reconstr. Surg. 101, 1512–1515 (1998).

    Article  CAS  PubMed  Google Scholar 

  55. Buncamper, M. E. et al. Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft? Plast. Reconstr. Surg. 139, 649e–656e (2017).

    Article  CAS  PubMed  Google Scholar 

  56. Salim, A. & Poh, M. Gender-affirming penile inversion vaginoplasty. Clin. Plast. Surg. 45, 343–350 (2018).

    Article  PubMed  Google Scholar 

  57. Bouman, M. B. et al. Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function. J. Sex. Med. 11, 1835–1847 (2014). Literature review on surgical techniques and clinical outcomes of intestinal vaginoplasty.

    Article  PubMed  Google Scholar 

  58. Hadj-Moussa, M., Agarwal, S., Ohl, D. A. & Kuzon, W. M. Jr Masculinizing genital gender confirmation surgery. Sex. Med. Rev. 7, 141–155 (2019).

    Article  PubMed  Google Scholar 

  59. De Cuypere, G. et al. Sexual and physical health after sex reassignment surgery. Arch. Sex. Behav. 34, 679–690 (2005).

    Article  PubMed  Google Scholar 

  60. Huang, T. T. Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals. Plast. Reconstr. Surg. 96, 921–930 (1995).

    Article  CAS  PubMed  Google Scholar 

  61. Siemssen, P. A. & Matzen, S. H. Neovaginal construction in vaginal aplasia and sex-reassignment surgery. Scand. J. Plast. Reconstr. Surg. Hand Surg. 31, 47–50 (1997).

    Article  CAS  PubMed  Google Scholar 

  62. Nijhuis, T. H. J. et al. The bilateral pedicled epilated scrotal flap: a powerful adjunctive for creation of more neovaginal depth in penile inversion vaginoplasty. J. Sex. Med. 17, 1033–1040 (2020).

    Article  PubMed  Google Scholar 

  63. Dessy, L. A. et al. The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study. Plast. Reconstr. Surg. 133, 158–161 (2014).

    Article  CAS  PubMed  Google Scholar 

  64. Seyed-Forootan, K., Karimi, H. & Seyed-Forootan, N. S. Autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery. Aesthet. Plast. Surg. 42, 491–497 (2018).

    Article  Google Scholar 

  65. Li, Y. A. et al. Bone marrow mesenchymal stem cells could acquire the phenotypes of epithelial cells and accelerate vaginal reconstruction combined with small intestinal submucosa. Cell Biol. Int. 39, 1225–1233 (2015).

    Article  CAS  PubMed  Google Scholar 

  66. Hensle, T. W. & Seaman, E. K. Vaginal reconstruction in children and adults. Tech. Urol. 1, 174–180 (1995).

    CAS  PubMed  Google Scholar 

  67. Filipas, D. Vaginal reconstruction/fistulae. Curr. Opin. Urol. 11, 267–270 (2001).

    Article  CAS  PubMed  Google Scholar 

  68. Grunberger, V. & Behawetz, J. Wertheim’s radical operation with vaginal reconstruction by means of the signoid colon in young women. [author’s translation]. Wien. Klinische Wochenschr. 87, 671–674 (1975).

    CAS  Google Scholar 

  69. Kwun Kim, S. et al. Long-term results in patients after rectosigmoid vaginoplasty. Plast. Reconstr. Surg. 112, 143–151 (2003).

    Article  PubMed  Google Scholar 

  70. Hage, J. J., Karim, R. B., Asscheman, H., Bloemena, E. & Cuesta, M. A. Unfavorable long-term results of rectosigmoid neocolpopoiesis. Plast. Reconstr. Surg. 95, 842–848 (1995).

    Article  CAS  PubMed  Google Scholar 

  71. Bouman, M. B. et al. Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast. Reconstr. Surg. 138, 614e–623e (2016).

    Article  CAS  PubMed  Google Scholar 

  72. Bouman, M. B., Buncamper, M. E., van der Sluis, W. B. & Meijerink, W. J. Total laparoscopic sigmoid vaginoplasty. Fertil. Steril. 106, e22–e23 (2016).

    Article  PubMed  Google Scholar 

  73. Djordjevic, M. L., Stanojevic, D. S. & Bizic, M. R. Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases. J. Sex. Med. 8, 3487–3494 (2011).

    Article  PubMed  Google Scholar 

  74. de Vries, A. L. et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics 134, 696–704 (2014).

    Article  PubMed  Google Scholar 

  75. Hensle, T. W., Shabsigh, A., Shabsigh, R., Reiley, E. A. & Meyer-Bahlburg, H. F. Sexual function following bowel vaginoplasty. J. Urol. 175, 2283–2286 (2006).

    Article  PubMed  Google Scholar 

  76. Ozkan, O., Akar, M. E., Ozkan, O., Mesci, A. & Colak, T. Microvascular augmented pedicled jejunum transfer for vaginal reconstruction using a laparoscopy-assisted technique. Microsurgery 28, 671–675 (2008).

    Article  PubMed  Google Scholar 

  77. Emiroglu, M., Gultan, S. M., Adanali, G., Apaydin, I. & Yormuk, E. Vaginal reconstruction with free jejunal flap. Ann. Plast. Surg. 36, 316–320 (1996).

    Article  CAS  PubMed  Google Scholar 

  78. Schneider, W., Nguyen-Thanh, P., Dralle, H. & Mirastschijski, U. Ileal J-pouch vaginoplasty: reconstruction of a physiologic vagina with an ileal J-pouch. Am. J. Obstet. Gynecol. 200, 694.e1–4 (2009).

    Article  PubMed  Google Scholar 

  79. Hensle, T. W. & Reiley, E. A. Vaginal replacement in children and young adults. J. Urol. 159, 1035–1038 (1998).

    Article  CAS  PubMed  Google Scholar 

  80. Shimamura, Y. et al. Perforation of the neovagina in a male-to-female transsexual: a case report. J. Med. Case Rep. 9, 24 (2015).

    Article  PubMed  PubMed Central  Google Scholar 

  81. Franz, R. C. Sigmoid colon vaginoplasty: a modified method. Br. J. Obstet. Gynaecol. 103, 1148–1155 (1996).

    Article  CAS  PubMed  Google Scholar 

  82. Imparato, E., Alfei, A., Aspesi, G., Meus, A. L. & Spinillo, A. Long-term results of sigmoid vaginoplasty in a consecutive series of 62 patients. Int. Urogynecol. J. Pelvic Floor Dysfunct. 18, 1465–1469 (2007).

    Article  PubMed  Google Scholar 

  83. Li, S., Sun, C., Shi, B., Li, M. & Liu, L. Laparoscopic vaginoplasty using a sigmoid graft through the umbilical single-incision hybrid transperineal approach: our initial experience. J. Laparoendoscopic Adv. Surg. Tech. A 24, 354–358 (2014).

    Article  Google Scholar 

  84. Fotopoulou, C., Neumann, U., Klapp, C., Lichtenegger, W. & Sehouli, J. Long-term effects of neovaginal reconstruction with sigmoid loop technique on sexual function and self image in patients with gynecologic malignancies: results of a prospective study. Gynecol. Oncol. 111, 400–406 (2008).

    Article  PubMed  Google Scholar 

  85. Zhong, C. X., Wu, J. X., Liang, J. X. & Wu, Q. H. Laparoscopic and gasless laparoscopic sigmoid colon vaginoplasty in women with vaginal agenesis. Chin. Med. J. 125, 203–208 (2012).

    PubMed  Google Scholar 

  86. Ekinci, S. et al. Sigmoid colon vaginoplasty in children. Eur. J. Pediatr. Surg. 16, 182–187 (2006).

    Article  CAS  PubMed  Google Scholar 

  87. Rawat, J. et al. Vaginal agenesis: experience with sigmoid colon neovaginoplasty. J. Indian Assoc. Pediatr. Surg. 15, 19–22 (2010).

    Article  PubMed  PubMed Central  Google Scholar 

  88. Kapoor, R. et al. Sigmoid vaginoplasty: long-term results. Urology 67, 1212–1215 (2006).

    Article  PubMed  Google Scholar 

  89. Garcia, M. M. et al. Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes. Surg. Endosc. 35, 5643–5654 (2021).

    Article  PubMed  Google Scholar 

  90. Wedler, V., Meuli-Simmen, C., Guggenheim, M., Schneller-Gustafsson, M. & Kunzi, W. Laparoscopic technique for secondary vaginoplasty in male to female transsexuals using a modified vascularized pedicled sigmoid. Gynecol. Obstet. Invest. 57, 181–185 (2004).

    Article  CAS  PubMed  Google Scholar 

  91. Kohler, C. et al. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol. Oncol. 95, 52–61 (2004).

    Article  PubMed  Google Scholar 

  92. Zhao, Y. Z. et al. Laparoscope-assisted creation of a neovagina using pedicled ileum segment transfer. World J. Surg. 35, 2315–2322 (2011).

    Article  PubMed  Google Scholar 

  93. Jacoby, A. et al. Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J. Urol. 201, 1171–1176 (2019).

    Article  PubMed  Google Scholar 

  94. Dy, G. W., Jun, M. S., Blasdel, G., Bluebond-Langner, R. & Zhao, L. C. Outcomes of gender affirming peritoneal flap vaginoplasty using the Da Vinci single port versus Xi Robotic Systems. Eur. Urol. 79, 676–683 (2021). Outcomes of peritoneal flap vaginoplasty from a single centre.

    Article  PubMed  Google Scholar 

  95. Dy, G. W., Blasdel, G., Shakir, N. A., Bluebond-Langner, R. & Zhao, L. C. Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis. Urology https://doi.org/10.1016/j.urology.2021.03.024 (2021).

    Article  PubMed  Google Scholar 

  96. Garcia, M. M. Men’s health and transgender surgery: a urologist’s perspective. Transl. Androl. Urol. 5, 225–227 (2016).

    Article  PubMed  PubMed Central  Google Scholar 

  97. Garcia, M. M. Sexual function after shallow and full-depth vaginoplasty: challenges, clinical findings, and treatment strategies — urologic perspectives. Clin. Plast. Surg. 45, 437–446 (2018).

    Article  PubMed  Google Scholar 

  98. Hadj-Moussa, M., Ohl, D. A. & Kuzon, W. M. Jr. Feminizing genital gender-confirmation surgery. Sex. Med. Rev. 6, 457–468 e452 (2018).

    Article  PubMed  Google Scholar 

  99. Jiang, D., Witten, J., Berli, J. & Dugi, D. III Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J. Sex. Med. 15, 902–906 (2018).

    Article  PubMed  Google Scholar 

  100. Milrod, C., Monto, M. & Karasic, D. H. Recommending or rejecting “the Dimple”: WPATH-affiliated medical professionals’ experiences and attitudes toward gender-confirming vulvoplasty in transgender women. J. Sex. Med. 16, 586–595 (2019).

    Article  PubMed  Google Scholar 

  101. Jiang, D. D., Gallagher, S., Burchill, L., Berli, J. & Dugi, D. III Implementation of a pelvic floor physical therapy program for transgender women undergoing gender-affirming vaginoplasty. Obstet. Gynecol. 133, 1003–1011 (2019).

    Article  PubMed  Google Scholar 

  102. Buncamper, M. E. et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J. Sex. Med. 12, 1626–1634 (2015). Retrospective survey study to assess whether penile skin inversion neovaginoplasty performed in trans women meet the objectives strived for, by determining functional and aesthetic outcomes, as well as physical and sexual well-being and satisfaction.

    Article  PubMed  Google Scholar 

  103. Bouman, M. B. et al. Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. J. Sex. Med. 13, 1438–1444 (2016). Survey study on patient-reported functional and esthetic outcomes, quality of life, satisfaction, and sexual well-being after primary total laparoscopic intestinal vaginoplasty in trans women.

    Article  PubMed  Google Scholar 

  104. Roberts, M. M. & Park, T. A. Pelvic floor function/dysfunction and electrodiagnostic evaluation. Phys. Med. Rehabil. Clin. North. Am. 9, 831–851 (1998).

    Article  CAS  Google Scholar 

  105. Bharucha, A. E. Pelvic floor: anatomy and function. Neurogastroenterol. Motil. 18, 507–519 (2006).

    Article  CAS  PubMed  Google Scholar 

  106. Wu, J. M. et al. Prevalence and trends of symptomatic pelvic floor disorders in U.S. women. Obstet. Gynecol. 123, 141–148 (2014).

    Article  PubMed  PubMed Central  Google Scholar 

  107. Morrison, S. D. et al. Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery. Plast. Reconstr. Surg. 136, 386–394 (2015).

    Article  CAS  PubMed  Google Scholar 

  108. Blanchard, R., Legault, S. & Lindsay, W. R. Vaginoplasty outcome in male-to-female transsexuals. J. Sex. Marital. Ther. 13, 265–275 (1987).

    Article  CAS  PubMed  Google Scholar 

  109. Schober, J. M., Meyer-Bahlburg, H. F. & Ransley, P. G. Self-assessment of genital anatomy, sexual sensitivity and function in women: implications for genitoplasty. BJU Int. 94, 589–594 (2004).

    Article  PubMed  Google Scholar 

  110. O’Connell, H. E., Sanjeevan, K. V. & Hutson, J. M. Anatomy of the clitoris. J. Urol. 174, 1189–1195 (2005).

    Article  PubMed  Google Scholar 

  111. Schilt, K. & Westbrook, L. Doing gender, doing heteronormativity “gender normals,” transgender people, and the social maintenance of heterosexuality. Gend. Soc. 23, 440–464 (2009).

    Article  Google Scholar 

  112. Hess, J., Neto, R. R., Panic, L., Rubben, H. & Senf, W. Satisfaction with male-to-female gender reassignment surgery. Dtsch Arztebl. Int. 111, 795–801 (2014).

    PubMed  PubMed Central  Google Scholar 

  113. LeBreton, M. et al. Genital sensory detection thresholds and patient satisfaction with vaginoplasty in male-to-female transgender women. J. Sex. Med. 14, 274–281 (2017).

    Article  PubMed  Google Scholar 

  114. Selvaggi, G. et al. Genital sensitivity after sex reassignment surgery in transsexual patients. Ann. Plast. Surg. 58, 427–433 (2007).

    Article  CAS  PubMed  Google Scholar 

  115. Bleustein, C. B., Eckholdt, H., Arezzo, J. C. & Melman, A. Quantitative somatosensory testing of the penis: optimizing the clinical neurological examination. J. Urol. 169, 2266–2269 (2003).

    Article  PubMed  Google Scholar 

  116. Bleustein, C. B., Arezzo, J. C., Eckholdt, H. & Melman, A. The neuropathy of erectile dysfunction. Int. J. Impot. Res. 14, 433–439 (2002).

    Article  CAS  PubMed  Google Scholar 

  117. Cordeau, D., Belanger, M., Beaulieu-Prevost, D. & Courtois, F. The assessment of sensory detection thresholds on the perineum and breast compared with control body sites. J. Sex. Med. 11, 1741–1748 (2014).

    Article  PubMed  Google Scholar 

  118. Lief, H. I. & Hubschman, L. Orgasm in the postoperative transsexual. Arch. Sex. Behav. 22, 145–155 (1993).

    Article  CAS  PubMed  Google Scholar 

  119. Trombetta, C., Liguori, G. & Bertolotto, M. Management Of Gender Dysphoria (Springer, 2015).

  120. Hoebeke, P. et al. Impact of sex reassignment surgery on lower urinary tract function. Eur. Urol. 47, 398–402 (2005).

    Article  PubMed  Google Scholar 

  121. Van der Sluis, W. B., Bouman, M. B., Buncamper, M. E., Mullender, M. G. & Meijerink, W. J. Revision vaginoplasty: a comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thickness skin graft vaginoplasty. Plast. Reconstr. Surg. 138, 793–800 (2016).

    Article  PubMed  Google Scholar 

  122. Dawson, S. J., Sawatsky, M. L. & Lalumiere, M. L. Assessment of introital lubrication. Arch. Sex. Behav. 44, 1527–1535 (2015).

    Article  PubMed  Google Scholar 

  123. Meier, D. Assessment of the quality of life. Ther. Umsch. Rev. Ther. 54, 321–325 (1997).

    CAS  Google Scholar 

  124. The World Health Organization Quality of Life Assessment (WHOQOL): development and general psychometric properties. Soc. Sci. Med. 46, 1569–1585 (1998).

  125. Cardoso da Silva, D. et al. WHOQOL-100 before and after sex reassignment surgery in Brazilian male-to-female transsexual individuals. J. Sex. Med. 13, 988–993 (2016).

    Article  PubMed  Google Scholar 

  126. Lawrence, A. A. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch. Sex. Behav. 32, 299–315 (2003).

    Article  PubMed  Google Scholar 

  127. Saylor, L., Bernard, S., Vinaja, X., Loukas, M. & Schober, J. Anatomy of genital reaffirmation surgery (male-to-female): vaginoplasty using penile skin graft with scrotal flaps. Clin. Anat. 31, 140–144 (2018).

    Article  PubMed  Google Scholar 

  128. Ruppin, U. & Pfafflin, F. Long-term follow-up of adults with gender identity disorder. Arch. Sex. Behav. 44, 1321–1329 (2015).

    Article  PubMed  Google Scholar 

  129. Landen, M., Walinder, J., Hambert, G. & Lundstrom, B. Factors predictive of regret in sex reassignment. Acta Psychiatr. Scand. 97, 284–289 (1998).

    Article  CAS  PubMed  Google Scholar 

  130. Djordjevic, M. L., Bizic, M. R., Duisin, D., Bouman, M. B. & Buncamper, M. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J. Sex. Med. 13, 1000–1007 (2016).

    Article  PubMed  Google Scholar 

  131. Massie, J. P., Morrison, S. D., Van Maasdam, J. & Satterwhite, T. Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast. Reconstr. Surg. 141, 911e–921e (2018).

    Article  CAS  PubMed  Google Scholar 

  132. Suchak, T., Hussey, J., Takhar, M. & Bellringer, J. Postoperative trans women in sexual health clinics: managing common problems after vaginoplasty. J. Fam. Plan. Reprod. Health Care 41, 245–247 (2015).

    Article  Google Scholar 

  133. Li, J. S., Crane, C. N. & Santucci, R. A. Vaginoplasty tips and tricks. Int. Braz. J. Urol. 47, 263–273 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  134. Papadopulos, N. A. et al. Combined vaginoplasty technique for male-to-female sex reassignment surgery: operative approach and outcomes. J. Plast. Reconstr. Aesthet. Surg. 70, 1483–1492 (2017).

    Article  PubMed  Google Scholar 

  135. Wangjiraniran, B. et al. Male-to-female vaginoplasty: Preecha’s surgical technique. J. Plast. Surg. Hand Surg. 49, 153–159 (2015).

    Article  PubMed  Google Scholar 

  136. Ferrando, C. A. Vaginoplasty complications. Clin. Plast. Surg. 45, 361–368 (2018).

    Article  PubMed  Google Scholar 

  137. Falcone, M. et al. A single-center analysis on the learning curve of male-to-female penoscrotal vaginoplasty by multiple surgical measures. Urology 99, 234–239 (2017).

    Article  PubMed  Google Scholar 

  138. Van der Sluis, W. B. et al. Clinical characteristics and management of neovaginal fistulas after vaginoplasty in transgender women. Obstet. Gynecol. 127, 1118–1126 (2016).

    Article  PubMed  Google Scholar 

  139. Lenaghan, R., Wilson, N., Lucas, C. E. & Ledgerwood, A. M. The role of rectosigmoid neocolporrhaphy. Surgery 122, 856–860 (1997).

    Article  CAS  PubMed  Google Scholar 

  140. Sarrau, M., Casoli, V. & Weigert, R. Successful conservative management of traumatic post-coital recto-neovaginal fistula in male-to-female transsexual. J. Obstet. Gynaecol. 34, 747–748 (2014).

    Article  CAS  PubMed  Google Scholar 

  141. Altomare, D. F., Scalera, I., Bettocchi, C. & Di Lena, M. Graciloplasty for recurrent recto-neovaginal fistula in a male-to-female transsexual. Tech. Coloproctol. 17, 107–109 (2013).

    Article  CAS  PubMed  Google Scholar 

  142. Slater, M. W. et al. Neovaginal construction with pelvic peritoneum: reviewing an old approach for a new application. Clin. Anat. 31, 175–180 (2018).

    Article  PubMed  Google Scholar 

  143. Baral, S. D. et al. Worldwide burden of HIV in transgender women: a systematic review and meta-analysis. Lancet Infect. Dis. 13, 214–222 (2013).

    Article  PubMed  Google Scholar 

  144. Van der Sluis, W. B. et al. Neovaginal discharge in transgender women after vaginoplasty: a diagnostic and treatment algorithm. Int. J. Transgend. Health. 21, 367–372 (2020).

    Article  PubMed  PubMed Central  Google Scholar 

  145. Van der Sluis, W. B. et al. Symptomatic HPV-related neovaginal lesions in transgender women: case series and review of literature. Sex. Transm. Infect. 92, 499–501 (2016).

    Article  PubMed  Google Scholar 

  146. Coupe, V. M., Berkhof, J., Bulkmans, N. W., Snijders, P. J. & Meijer, C. J. Age-dependent prevalence of 14 high-risk HPV types in the Netherlands: implications for prophylactic vaccination and screening. Br. J. Cancer 98, 646–651 (2008).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  147. Gooren, L. & Morgentaler, A. Prostate cancer incidence in orchidectomised male-to-female transsexual persons treated with oestrogens. Andrologia 46, 1156–1160 (2014).

    Article  CAS  PubMed  Google Scholar 

  148. Schober, J. M. Cancer of the neovagina. J. Pediatr. Urol. 3, 167–170 (2007).

    Article  PubMed  Google Scholar 

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Author notes

  1. These authors contributed equally: Shane D. Morrison, Karel Claes, Martin P. Morris.

Authors and Affiliations

  1. Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center and Seattle Children’s Hospital, Seattle, WA, USA

    Shane D. Morrison

  2. Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium

    Shane D. Morrison, Karel Claes, Stan Monstrey & Marlon Buncamper

  3. Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA

    Martin P. Morris

  4. Department of Urology, Ghent University Hospital, Ghent, Belgium

    Piet Hoebeke

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S.D.M., K.C. and M.P.M. researched data for the article. All authors contributed substantially to discussion of the content. S.D.M., K.C. and M.P.M. wrote the article. All authors reviewed and/or edited the manuscript before submission.

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Morrison, S.D., Claes, K., Morris, M.P. et al. Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol 20, 308–322 (2023). https://doi.org/10.1038/s41585-022-00705-y

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