Introduction

Vaginoplasty

Various neovagina creation methods are available, when a normal vagina is absent due to congenital or acquired diseases. Non-surgical methods (like vaginal dilation and traction) used to be the first choice of treatment, they are successful and avoid surgery-related risks.1–3 However, non-surgical methods are associated with vaginal prolapse, shorter vaginal depths, low patients’ satisfaction, long-term agony and mental as well as emotional stress.4,5 Vaginoplasty should arguably result in an anatomically and functionally normal vagina, be minimally or non-invasive, avoid dilation necessity and prevent scars, stenosis or contracture.6,7 Many physicians and patients prefer surgery, as non-surgical vaginoplasty takes 2-24 months and surgical correction is often required to improve or allow sexual activity and to restore severe defects with extra-vaginal tissue. Surgical vaginoplasty is therefore gaining interest as therapeutic strategy for women with absent vagina or vaginal malformation, with 39,000-650,000 estimated annual surgeries11 Based on 3,904,727,342 female inhabitants in 2021 with 1:1,500-10,000 MRKHS patients, this results in 39,047-650,788 vaginoplasty surgeries for 10-25% surgical vaginoplasty treatment..5,8 Over 20 vaginoplasty methods have been advocated the past centuries, each with specific (dis)advantages and so the ideal method is a matter of debate.9 These surgical approaches are generally specified as cavity dissection procedure with or without grafting technique.
Vaginoplasty techniques generally differ with respect to applied donor tissue, with penile-inversion- and penoscrotal surgery as MtF-specific methods.27 However, skin volume is not always sufficient, especially with hypoplasia due to hormone therapy initiation in early adolescence.28 Alternative methods use skin flap- or (laparoscopic) bowel segment approaches29,30or experiment with amnion grafts, oral mucosa or decellularized tissue. Gender surgeons prefer the inverted penoscrotal technique, but no consensus exists on the ideal technique. Publications of complications and patient-reported outcomes are limited, with only one review comparing outcome of various surgical techniques.31,32Initially, publications referred to MtF patients as male transsexuals with male pronounces, which gradually changed to female identity recognition. Initially, surgery aimed for male genitalia removal and measured post-surgical marriage quantity without partner awareness of original genitals. Today, patient-reported outcomes emphasis on aesthetics and functionality and require the neovagina to be hairless, moist and minimally 11 cm deep and 3 cm wide, with labia minora, majora and a sensate clitoris.14,25
MRKH vaginoplasty methods are Davydov-, Intestinal-, McIndoe-, Skin flap-, Vecchietti- or Wharton-Sheares-George technique. There are few MRKHS comparative reviews on complications and patient-related outcomes and non to compare surgical techniques. Earlier, vaginoplasty outcome was assessed by neovagina length, sexual activity and whether patient or current partner was sexually satisfied.43–45 Today, sexual function and vaginoplasty satisfaction are assessed through extensive patient-centred questionnaires.

Objective

We attempted to evaluate peri-operative- and post-operative outcomes of MRKH- and GD-patients for various vaginoplasty techniques based on anatomy, complications, satisfaction, Quality of Life (QoL), sexual functioning and complaints. We hope this comparison will facilitate in further vaginoplasty development by highlighting weaknesses and strengths and that it will aid in well-educated decision making by patients and healthcare professionals when selecting a procedure. By revealing current information gaps, focal points for future research can be determined.