Before and After of Vaginoplasty: A Case Study

Indications of vaginoplasty 

This plastic surgery procedure is performed for both reconstructive and cosmetic reasons. The indications include:

1. Intersex conditions like congenital adrenal hyperplasia, and gonadal dysgenesis
2. Vaginal atresia as in imperforate hymen or vaginal agenesis as in Rokitansky Syndrome
3. Vaginal prolapse or increased vaginal laxity due to multiple childbirth, aging, or trauma
4. Extensive surgeries of pelvic tumors or abscesses that involve removal of vaginal tissue  

Penile inversion procedure

The penile inversion procedure is one of the most common constructive cases where vaginoplasty is employed to create a vulva and vagina out of the existing penile and scrotal tissue. The technique is the final stage of the gender-confirming process for many transgender women. This surgery is carried out in a way that the vaginal area has the depth as well as the appearance of a biologically developed vagina. This technique is considered as the gold standard for genital reconstruction among plastic surgeons. Ideally, this procedure provides a vaginal vault of sufficient size, adequate opening for introitus, and external appearance of a normally developed vulva. Moreover, the outcome is aimed at providing brilliant long-term function as well as minimal morbidity. 

Before

Before the procedure, all patients undergo an extensive process of history taking and physical examination. The laboratory workup includes an ultrasonographic assessment of the abdomen and the pelvis, karyotyping, endocrinological assessment.

After

The penile inversion surgery is performed under general anesthesia. In this technique of vaginoplasty, the skin of the penis is used to construct the lining of the vagina. The vaginal canal is carved out in the space between the rectum and the urethra. If there is not enough skin to create the vaginal lining, skin grafts may be taken from different sites such as the inner thigh, lower abdomen, or the upper part of the buttock.

The skin of the penis is removed, inverted, and sutured into the cavity. The sensitive triangular skin at the tip of the penis is used to construct the clitoris and the scrotal skin is used to create the labia majora. The prostate gland is left intact where it acts as an erogenous zone like the G-spot in non-transgender females. This also prevents the complications of urinary incontinence or urethral strictures. The testicles are entirely removed and discarded in a process called orchidectomy. 

Another way of constructing the vaginal wall is the use of the lining of the colon instead of the penile skin. In this procedure, a section of the sigmoid colon is mobilized and resected from the large intestine. The edges of the vaginal opening are sutured to the distal end of the sigmoid colon. Although the knowledge of this procedure and the outcome is limited, the advantage of this approach is the natural lubrication which in the case of penile skin has to be provided artificially. This technique of vaginoplasty also eliminates the necessity of long term use of vaginal dilators. 

After this surgery, additional surgery is planned to further operate on the healed skin and manipulate and correct the positioning of the labia, the urethra, and vaginal canal, also known as secondary labiaplasty. The urethra is also shortened and repositioned to provide the smaller urethra found in females in front of the vagina. 

The risks and complications of this procedure infection, bleeding, necrosis of the penile tissue used to create clitoris, rupture of the sutures causing vaginal prolapse, and fistulas due to damage to peripheral structures such as urethra or rectum. The postoperative complications are generally common but are minor and can be managed easily.

Vaginoplasty procedure ends up with a lifetime of commitment where post-operatively, the patient has to regularly dilate their vagina to keep it open. Initially, the vagina needs to be dilated multiple times during the day which then becomes less frequent as the healing process continues. Furthermore, the hospital stay significantly depends on the extent of manipulation done during the surgery. It usually is for almost a week. The patient is encouraged to urinate from a catheter for almost two weeks, return for regular follow-ups, and not perform strenuous exercises for almost six weeks after the surgery. For these reasons, the patient is also counseled on how to identify signs of urinary tract infection or surgical site infection and report immediately.  

References:

1. Shoureshi P, Dugi D. Penile inversion vaginoplasty technique. Urologic Clinics. 2019 Nov 1;46(4):511-25.
2. Buncamper ME, van der Sluis WB, van der Pas RS, Özer M, Smit JM, Witte BI, Bouman MB, Mullender MG. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plastic and reconstructive surgery. 2016 Nov 1;138(5):999-1007.
3. Small MR. Penile and scrotal inversion vaginoplasty for male to female transsexuals. Urology. 1987 Jun 1;29(6):593-7.
4. 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?. Plastic and reconstructive surgery. 2017 Mar 1;139(3):649e-56e.
5. Garcia MM, Shen W, Zhu R, Stettler I, Zaliznyak M, Barnajian M, Cohen J, Sarin A, Nasseri Y. Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes. Surgical Endoscopy. 2020 Oct 13:1-2.
6. Selvaggi G, Ceulemans P, De Cuypere G, VanLanduyt K, Blondeel P, Hamdi M, Bowman C, Monstrey S. Gender identity disorder: general overview and surgical treatment for vaginoplasty in male-to-female transsexuals. Plastic and Reconstructive Surgery. 2005 Nov 1;116(6):135e-45e.