Sabbagh, P, Richard, C, Bourillon, A, Cornu, J.N, Lebret, T, Morel Journel, N, Peyronnet, B, Schirmann, A, Freton, L, Madec, F.X

Vulvo-vaginoplasty, trans women, gender affirming surgery

A transgender individual's gender identity differs from the one assigned at birth. Hormonal and surgical interventions for transgender individuals have notably enhanced their quality of life, reducing suicide rates, and resulting in minimal cases of regret1.

Over 75% of trans women express a desire for gender-affirming genital surgery2. Among the techniques available, penile skin inversion stands as the established standard for vulvo-vaginoplasty in individuals assigned male at birth. This procedure has exhibited variability in its descriptions across literature. Its core steps involve creating the vaginal cavity through perineal dissection, delineating the structures between the prostate, bladder, and rectum until reaching the Douglas pouch; subsequent dissection of the penis to form external genitalia (clitoris, urethrostomy, vulva); and forming a neovagina covered by the penile skin flap. Augmenting the procedure with a complete scrotal skin graft enhances the depth of the vaginal cavity3.

According to a recent review4, more than 80% of operated patient are satisfied with this procedure1,5. The patient-related aesthetic satisfaction is 90%, and sexual satisfaction is close to 80%; more than 70% of the operated patients are sexually active after surgery. This procedure, which is particularly complex, carries complications that are mostly considered minor according to Clavien-Dindo classification, and require surgical revision in 8 to 37% of cases4.

This procedure is increasingly attracting the attention of young urologists; its apprenticeship is primarily through guided mentorship in reference centers. Surgeons seeking to perform this operation should be diligent in managing their learning curve. Herein, we present the surgical technique of vulvo-vaginoplasty performed by two practicing surgeons who have recently embarked on this procedure and who learned from the same urologist. Between July 2020 and December 2022, 76 procedures were carried out by two young urologists in two reference French centers; 15.8% experienced major early post-operative complications, while 3% encountered major late post-operative complications. No complication was classified 4 or 5 in Clavien-Dindo scale. Most early complications were related to issues in vulvar healing, which did not compromise long-term aesthetic results. Patients-reported satisfaction was 82% after the procedure.

The authors acknowledge Dr Nicolas Morel-Journel for the apprenticeship of this procedure, his accessibility and his professionalism.

1. Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. Int J Transgender Health. 2022;23(3):255-273. doi:10.1080/26895269.2022.2038334

2. Van Der Sluis WB, Schäfer T, Nijhuis THJ, Bouman MB. Genital gender-affirming surgery for transgender women. Best Pract Res Clin Obstet Gynaecol. 2023;86:102297. doi:10.1016/j.bpobgyn.2022.102297

3. Buncamper ME, van der Sluis WB, de Vries M, Witte BI, Bouman MB, Mullender MG. Penile Inversion Vaginoplasty with or without Additional Full-Thickness Skin Graft: To Graft or Not to Graft? Plast Reconstr Surg. 2017;139(3):649e-656e. doi:10.1097/PRS.0000000000003108

4. Madec FX, Sabbagh P, Schirmann A, Morel-Journel N, Neuville P. Genital gender affirming surgery in trans women: Vulvo-vaginoplasty review. Ann Chir Plast Esthet. 2023;68(5-6):468-476. doi:10.1016/j.anplas.2023.08.002

5. Ding C, Khondker A, Goldenberg MG, et al. Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis. Can Urol Assoc J. 2022;17(4). doi:10.5489/cuaj.8108