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.