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Vaginoplasty

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Vaginoplasty
ICD-9-CM70.64,70.62,70.64,70.94,70.6,70.95
MeSHD013509

Vaginoplastyis any surgical procedure that results in the construction or reconstruction of thevagina.It is a type ofgenitoplasty.Pelvic organ prolapseis often treated with one or more surgeries to repair the vagina. Sometimes a vaginoplasty is needed following the treatment or removal ofmalignant growthsorabscessesto restore a normal vaginal structure and function. Surgery to the vagina is done to correctcongenital defectsto the vagina,urethraandrectum.It may correct protrusion of theurinary bladderinto the vagina (cystocele) and protrusion of the rectum (rectocele) into the vagina.[1]Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma or injury.

Congenital disorderssuch asadrenal hyperplasiacan affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty.[2]Other candidates for the surgery include babies born with a microphallus, people withMüllerian agenesisresulting invaginal hypoplasia,trans women,and women who have had a vaginectomy after malignancy or trauma.[3][4]

Medical uses

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Vaginoplasty is the description of the following surgical interventions:

In some instances, extra tissue is needed to reconstruct or construct the vagina. These grafts used in vaginoplasty can be anallotransplantation,aheterograft,or anautologousmaterial.[9][10]A woman can use an autologous in vitro cultured tissue taken from her vaginal vestibule as transplanted tissue to form the lining of the reconstructed vagina.[9]A reconstructed or newly constructed vagina is called aneovagina.[11]

Vaginoplasties in children

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See also:Intersex medical interventions

Conditions such ascongenital adrenal hyperplasiavirilize genetic females due to a21-hydroxylasedeficiency. Specific procedures include: clitoral reduction,labiaplasty,normalizing appearance, vagina creation, initiating vaginal dilation.[12]Vaginal atresia,or congenital absence of the vagina, can be another reason for surgery to construct a normal and functional vagina.[13]Vaginoplasty is used as part of the series of surgeries needed to treat those girls and women born with thebladder located outside of their abdomen.After the repairs, women have been able to give birth but are at risk of prolapse.[1]

There are human rights concerns about vaginoplasties and other genital surgeries in children who are not old enough to consent,[14][15]including concern with post-surgical sexual function,[16]and assumptions ofcisnormativity.[17]There is no consensus attitude among clinicians about their necessity, timing, method or evaluation.[12]Vaginoplasties may be performed in children or adolescents withintersexconditions ordisorders of sex development.[18]

Techniques

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Non-surgical vagina creation was used in the past to treat thecongenitalabsence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameterdilators.The procedure took several months and was sometimes painful. It was not effective in every instance.[2]Uncommon growths, cysts, septums in the vagina can also require vaginoplasty.[19]

Reconstructive surgery after cancer treatment

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Radiological cancer treatmentcan result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored.[3]

McIndoe surgical technique

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A canal is surgically constructed between theurinary bladderandurethrain the anterior portion of the pelvic region and therectum.A skin graft is used from another area of the person's body. The graft is removed from thethigh,buttocks,oringuinalregion. Other materials have been used to create the lining of the new vagina. These have been cutaneousskin flaps,amniotic membranes,andbuccal mucosa.[3][9]

Gender-affirming surgery

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Several techniques may be used ingender-affirming surgeryto create a neovagina.

A close-up image of a neovagina's outer labia
A close-up image of a neovagina, held open to reveal inner labia
The results of a penile inversion vaginoplasty, two years after surgery. Inner labia vary aesthetically based on surgeon; here, they are very minimal. The clitoris is tactile rather than visual, another aesthetic difference by surgeon. A faded surgical scar comes up from the perineum and follows the outer labia in a curved Y.

Penile inversion

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Inversion of the penile skin is the method most often selected to create a neovagina by surgeons performing gender-affirming surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the neovagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap.[4]

The penile inversion technique was pioneered byGeorges Burouin his Morocco clinic in the 1950s.[20]By the 1970s he had performed hundreds of them, and gave his first public presentation of his technique to a conference at Stanford University in 1973,[21]after which it gradually became the predominant technique worldwide.

Bowel vaginoplasty

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Bowel vaginoplasty is another commonly used method to create a neovagina in gender-affirming surgery.[4]

Other methods

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Penile-scrotalskin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used.[citation needed]

Elective vaginoplasty

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Critics have labeled such surgery as the "designer vagina". TheAmerican College of Obstetricians and Gynecologistsissued a warning against these procedures in 2007[22]as did theRoyal Australian and New Zealand College of Obstetricians and Gynaecologists,[23]and a commentary in theBritish Medical Journalstrongly criticized the "designer vagina" in 2009.[23][24]TheSociety of Obstetricians and Gynaecologists of Canadapublished a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013.[25]

The World Health Organization describes any medically unnecessary surgery to the vaginal tissue and organs asfemale genital mutilation.[26]

Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance.[24]

Hymen surgical procedures

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Further information:Hymenorrhaphy

Animperforate hymenis the presence of tissue that completely covers the vaginal opening. It is cut to allow menstrual flow to exit during a short surgical procedure.[1]Ahymenorrhaphyis the surgical procedure that reconstructs the hymen.

Balloon vaginoplasty

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In this procedure, aFoley catheterislaparoscopicallyinserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina.[citation needed]

Pull through or Vecchietti procedure

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In treatingMüllerian agenesis,the Vecchietti procedure is alaparoscopicsurgical technique that produces avaginaof dimensions (depth and width) comparable to those of a normal vagina (ca. 8 cm deep).[27][28]A small, plastic sphere called an olive is threaded (sutured) against the vaginal area; the threads are drawn though the vaginal skin, up through theabdomen,and through thenavel.There, the threads are attached to a traction device, and then daily are drawn tight so that the olive is pulled inwards and stretches the vagina, by approximately 1 cm per day, thereby creating a vagina, approximately 7 cm deep by 7 cm wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time.[29]The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy.[30]Invaginal hypoplasia,traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments.[31][19]

Other surgical techniques that have been developed include ileal neovagina (Monti's technique), Creatsas vaginoplasty, Wharton–Sheares–George neovaginoplasty, or the Davydov procedure. The most widely used is the Vecchietti laparoscopic procedure. Sometimes sexual intercourse can result in the dilation of a newly constructed vagina.[9]

Vaginal dilators and expanders

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Vaginal expander ZSI 200 NS
ZSI 200 NS vaginal expander stretching the female vagina
Main article:Vaginal dilator

The most techniques of vaginoplasty are using inflatable vaginal expanders or vaginal stents to design the vaginal diameter and length.[32][33]At the end of the procedure the device stays in place to maintain the neovagina against the pelvic wall which also favors the process of microscopic neovascularization and reduces the risks of hematoma. In post-operative setting the expander can be used regularly to prevent post-operative vaginal retraction.[34]Solid vaginal dilators can also be used immediately after surgery to keep the passage from attachments, and regularly thereafter to maintain the viability of the neovagina. The frequency required to use decreases over time, however remains obligatory lifelong.[35][36]

Risks and complications

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Reconstructive vaginoplasty in children and adolescents carries the risk ofsuperinfection.[19]

In adults, rates and types ofcomplicationsvaried with gender-affirming surgery.Necrosisof the clitoral region was 1–3%. Necrosis of the surgically created vagina was 3.7–4.2%. Vaginal shrinkage occurred was documented in 2–10% of those treated.Stricture,or narrowing of the vaginal orifice was reported in 12–15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of twoscrotalflaps has been described. Posterior vaginal wall is a rare complication.Genital painwas reported in 4–9%. Rectovaginalfistulais also rare with only 1% documented. Vaginal prolapse was seen in 1–2% of peopleassigned male at birthundergoing this procedure.[4]

The ability of emptying thebladderwas affected for some patients after this procedure: 13% reported improvement, 68% said that there was no change and 19% reported thatvoidinggot worse. Those reporting a negative outcome who experienced loss of bladder control andurinary incontinencewere 19%.Urinary tract infectionsoccurred in 32% of those treated.[4]

History

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Reports of people seeking vaginoplasty go back to the 2nd century.[37][38]The first modern vaginoplasty was performed in 1931 onDora Richter.[37][39][40]Lili Elbealso underwent a vaginoplasty the same year.[41]

See also

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References

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  1. ^abcBaggish,p. 779-798.
  2. ^abGundeti, Mohan (2012).Pediatric Robotic and Reconstructive Urology a Comprehensive Guide.City: Wiley-Blackwell.ISBN9781444335538.
  3. ^abcdefghijklmnHoffman, Barbara (2012).Williams gynecology.New York: McGraw-Hill Medical.ISBN9780071716727.
  4. ^abcdeHorbach, Sophie E.R.; Bouman, Mark-Bram; Smit, Jan Maerten; Özer, Müjde; Buncamper, Marlon E.; Mullender, Margriet G. (2015). "Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques".The Journal of Sexual Medicine.12(6): 1499–1512.doi:10.1111/jsm.12868.ISSN1743-6095.PMID25817066.
  5. ^abHiort, O (2014).Understanding differences and disorders of sex development (DSD).Basel: Karger.ISBN9783318025590;]{{cite book}}:CS1 maint: postscript (link)
  6. ^abcdefg"2016 ICD-10-PCS Procedure Code 0UQG0ZZ: Repair Vagina, Open Approach".ICD10Data.Retrieved3 March2016.
  7. ^Baggish,p. 467-474.
  8. ^Baggish,p. 409-412.
  9. ^abcdefAcién, Pedro; Acién, Maribel (1 January 2016)."The presentation and management of complex female genital malformations".Human Reproduction Update.22(1): 48–69.doi:10.1093/humupd/dmv048.ISSN1355-4786.PMID26537987.
  10. ^"Online ICD9/ICD9CM codes".World Health Organization.Retrieved1 March2016.
  11. ^Unger, Cecile A.; Paraiso, Marie Fidela R. (16 October 2014)."18. Construction of the Neovagina".In Farzeen Firoozi (ed.).Female Pelvic Surgery.New York: Springer. pp. 267–.ISBN978-1-4939-1504-0.OCLC941369411.Retrieved31 May2018.
  12. ^abLee PA, Nordenström A, Houk CP, Ahmed SF, Auchus R, Baratz A, et al. (2016)."Global Disorders of Sex Development Update since 2006: Perceptions, Approach and Care".Horm Res Paediatr.85(3): 158–80.doi:10.1159/000442975.ISSN1663-2818.PMID26820577.
  13. ^"Müllerian Agenesis: Diagnosis, Management, and Treatment – ACOG".acog.org.Archived fromthe originalon 13 December 2017.Retrieved26 December2017.
  14. ^Office of the High Commissioner for Human Rights(24 October 2016),End violence and harmful medical practices on intersex children and adults, UN and regional experts urge
  15. ^"The Social Construction of Female Circumcision: Gender, Equality, and Culture".femalecircumcision.2 February 2018. Archived fromthe originalon 12 February 2018.Retrieved11 February2018.
  16. ^Liao LM, Wood D, Creighton SM (September 2015). "Parental choice on normalising cosmetic genital surgery".BMJ.351:h5124.doi:10.1136/bmj.h5124.ISSN1756-1833.PMID26416098.S2CID20580500.
  17. ^Report of the UN Special Rapporteur on Torture,Office of the UN High Commissioner for Human Rights,February 2013.
  18. ^Lee, P. A.; Houk, C. P.; Ahmed, S. F.; Hughes, I. A. (2006)."Consensus statement on management of intersex disorders".Pediatrics.118(2): e488–500.doi:10.1542/peds.2006-0738.PMC2082839.PMID16882788.
  19. ^abcEmans.
  20. ^Hage, J Joris; Karim, Refaat B.; Laub, Donald R. Sr (December 2007). "On the Origin of Pedicled Skin Inversion Vaginoplasty: Life and Work of Dr Georges Burou of Casablanca".Annals of Plastic Surgery.59(6).Wolters Kluwer:723–729.doi:10.1097/01.sap.0000258974.41516.bc.ISSN0148-7043.PMID18046160.S2CID25373951.In 1956, the gynecologist Dr Georges Burou (1910–1987) independently developed the anteriorly pedicled penile skin flap inversion vaginoplasty in his Clinique du Parc in Casablanca. This technique was to become the gold standard of skin-lined vaginoplasty in transsexuals.
  21. ^Goddard, Jonathan Charles; Vickery, Richard M.; Terry, Tim R. (2007). "Development of Feminizing Genitoplasty for Gender Dysphoria".The Journal of Sexual Medicine.4(4, Part 1): 981–989.doi:10.1111/j.1743-6109.2007.00480.x.ISSN1743-6095.PMID17451484.
  22. ^Zimmerman, Rachel (31 August 2007)."Genital Procedure Draws Warning".Wall Street Journal.
  23. ^abBourke, Emily (12 November 2009)."Designer vagina craze worries doctors".Australian Broadcasting Corporation.Retrieved5 March2016.
  24. ^abLiao, Lih Mei; Sarah M Creighton (24 May 2007)."Requests for cosmetic genitoplasty: how should healthcare providers respond?".BMJ.334(7603).British Medical Journal:1090–1092.doi:10.1136/bmj.39206.422269.BE.PMC1877941.PMID17525451.
  25. ^Shaw MBChB, Dorothy; Lefebvre MD, Guylaine; Bouchard MD, Celine; Shapiro MD, MHSc, Jodi; Blake MD, Jennifer; Allen MD, Lisa; Cassell MD, Krista (December 2013)."Female Genital Cosmetic Surgery"(PDF).Journal of Obstetrics and Gynaecology Canada.35(12). Society of Obstetricians and Gynaecologists of Canada: 1108–1112.doi:10.1016/S1701-2163(15)30762-3.PMID24405879.Archived fromthe original(PDF)on 10 March 2016.Retrieved7 March2016.
  26. ^"Female genital mutilation".World Health Organization. 2016.Retrieved7 March2016.
  27. ^Vecchietti G (1965). "[Creation of an artificial vagina in Rokitansky-Küster-Hauser syndrome]".Attual Ostet Ginecol(in Italian).11(2): 131–47.PMID5319813.
  28. ^Fedele L, Bianchi S, Tozzi L, Borruto F, Vignali M (November 1996)."A new laparoscopic procedure for creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser syndrome".Fertil. Steril.66(5): 854–7.doi:10.1016/S0015-0282(16)58653-1.PMID8893702.
  29. ^Fedele, Luigi; Bianchi, Stefano; Zanconato, Giovanni; Raffaelli, Ricciarda; Zatti, Nicoletta (March 2000)."Laparoscopic creation of a neovagina in a woman with a kidney transplant: Case Report".Human Reproduction.15(3): 692–693.doi:10.1093/humrep/15.3.692.PMID10686221.Retrieved28 May2018.
  30. ^Borruto, F; Chasen, ST; Chervenak, FA; Fedele, L (February 1999). "The Vecchietti procedure for surgical treatment of vaginal agenesis: comparison of laparoscopy and laparotomy".International Journal of Gynaecology and Obstetrics.64(2): 153–8.doi:10.1016/s0020-7292(98)00244-6.PMID10189024.S2CID2851401.
  31. ^Callens, N.; De Cuypere, G.; De Sutter, P.; Monstrey, S.; Weyers, S.; Hoebeke, P.; Cools, M. (2014)."An update on surgical and non-surgical treatments for vaginal hypoplasia".Human Reproduction Update.20(5): 775–801.doi:10.1093/humupd/dmu024.ISSN1355-4786.PMID24899229.
  32. ^Coskun, Ayhan; Coban, Yusuf Kenan; Vardar, Mehmet Ali; Dalay, Ahmet Cemil (10 July 2007)."The use of a silicone-coated acrylic vaginal stent in McIndoe vaginoplasty and review of the literature concerning silicone-based vaginal stents: a case report".BMC Surgery.7(1): 13.doi:10.1186/1471-2482-7-13.PMC1947946.PMID17623058.
  33. ^Barutçu, Ali; Akgüner, Muharrem (November 1998). "McIndoe Vaginoplasty with the Inflatable Vaginal Stent".Annals of Plastic Surgery.41(5): 568–9.doi:10.1097/00000637-199811000-00020.PMID9827964.
  34. ^Antoniadis, N; Charles, G; Mejías, I; Pabón, R (March 2011)."Vaginoplastia: modificación de la técnica de McIndoe usando esponja de gel hemostático"[Vaginoplasty: modification to McIndoe techique [sic] using hemostatic gel sponge].Cirugía Plástica Ibero-Latinoamericana.37(1): 73–77.doi:10.4321/S0376-78922011000100010.
  35. ^The encyclopedia of cosmetic and plastic surgery.New York: Facts On File. 12 May 2010. p. 195.ISBN978-1-4381-2702-6.
  36. ^Textbook of plastic, maxillofacial, and reconstructive surgery(2nd ed.). Baltimore, Maryland: Williams & Wilkins. 1992.ISBN978-0-683-03454-7.
  37. ^abSmith, Shannon; Han, Justin (1 April 2019)."The trans-formation of gender confirming surgery: a brief history".The Journal of Urology.201(4S): e244.doi:10.1097/01.JU.0000555394.71572.8e.S2CID149966616.
  38. ^Goldberg, Abbie E.; Beemyn, Genny, eds. (2021). "Ancient and Medieval Times".The SAGE Encyclopedia of Trans Studies.United States: SAGE Publishing. p. 32.doi:10.4135/9781544393858.n188.ISBN9781544393810.S2CID242422061.
  39. ^Mancini, Elena (8 November 2010).Magnus Hirschfeld and the Quest for Sexual Freedom: A History of the First International Sexual Freedom Movement(1st ed.). New York: Palgrave Macmillan.ISBN978-0-230-11439-5.OCLC696313936.
  40. ^Kaye, Hugh (16 November 2021)."The incredible story of the first known trans woman to undergo gender confirmation surgery".Attitude.Retrieved31 January2022.
  41. ^Erickson-Schroth, L.; Davis, B. (2021).Gender: What Everyone Needs to Know®.Oxford University Press. p. 74.ISBN978-0-19-088003-3.Retrieved20 June2023.

Bibliography

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  • Baggish, Michael (2016).Atlas of pelvic anatomy and gynecologic surgery.Philadelphia, PA: Elsevier.ISBN9780323225526.
  • Emans, Herriot (2011).Emans, Laufer, Goldstein's pediatric & adolescent gynecology.Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins Health.ISBN9781608316489.electronic book, no page numbers.
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