Discussion

Main findings

A high intercontinental diversity of patient-population and techniques was observed. No European or North-American MRKH-surgeries were performed, likely due to pre-adolescent surgeries.71In Asia tradition and religion gravely impact abstinence and inhibition of pre-marital sex and willingness to discuss these topics. SRS-surgeries were longer than most MRKH-surgeries, as complete female genitalia apposed to 1/3 of the vagina were recreated.
A single-centre Peritoneal-vaginoplasty and combined-SRS comparison, indicated a higher complexity of SRS. SRS mainly caused hemorrhage of vascularized tissue (i.e. corpus spongiosum),31whereas MRKH-patients predominantly showed intercourse-related bleeding.70 Bleeding-dependence on surgical experience has been suggested.
Gastrointestinal complications were reported after penile-inversion-, penoscrotal- and Davydov-vaginoplasty, but perineal dissection and less invasive surgery make intra-operative observation of fistula hard. Dependence on surgical experience is suggested and pre-operative bowel-preparation is important.72
Most SRS-techniques and intestinal-vaginoplasty in MRKHS-patients reported prolapse. Prolapse affects 50% of parous women73 and vaginoplasty patients mostly ≥50 years. Pelvic floor differ across gender,74 so long-term hormonal treatment might affect prolapse.73 Our transgender treatment centre occasionally treats transwomen for long-term prolapse (10-20 post-operative years),75which is believed to increase over time.58,76
Tissue necrosis (likely due to tissue tension) was reported after penile-inversion-, penoscrotal- and McIndoe-vaginoplasty. Avoiding corpus spongiosum resection minimized necrosis,72 that significantly hampered functional- and overall satisfaction.77
Stenosis was the most common complication and reported for most techniques. It hampered QoL through sexual dysfunction and dissatisfaction, often lead to revisions and decreased with surgical experience and graft quantity in transwomen. Higher SRS-reported stenosis might relate to inherent scrotal skin properties, causing narrowing by retraction and relocation after shortening or by incomplete corpus spongiosum resection.
Revisions were reported for all SRS- and none MRKH-techniques. Mixed patient-cohort showed higher MRKH-patient satisfaction, likely by population-specific expectations and surgical complexity due to anatomical dissimilarity. MRKH-patients were completely satisfied with anatomy, even for ‘unsuccessful’ lengths. SRS-patients were only anatomically satisfied after Penoscrotal-surgery (with ‘successful lengths’ ≥ 11 cm). Revisions were inverse proportional to graft size (through stenosis, retraction and necrosis).
McIndoe-, peritoneal- and intestinal-surgery for MRKH- and GD-patients reported vaginal discharge. Only penile-inversion- and penoscrotal-SRS reported genital pain, which hampered post-operative QoL-improvement. SRS reported urinary issues due to small prostates and pelvic floor dysfunction, that hampered overall satisfaction.
Penile-inversion- and Penoscrotal-techniques reported 1-4% patient regret. Regret is often used as argument by transgender-care opponents but strict WPATH-regulations should prevent this and likely explain why regret was only studied for GD-patients. Regret was sporadic or because of surgery-unrelated reasons.
Sexual activity was lowest for GD-patients, with 21-100% amongst MRKH-patients. McIndoe-surgery reported highest inactivity for a married-cohort, so a false negative could be present as adults undergo vaginoplasty to initiate sexual activity independent of marital status.

Strength and limitations

This is the first systematic review on nine vaginoplasty techniques with MRKH- and GD-patients and assessing a wide diversity of complications, satisfaction and function. The methodological quality, in line with PRISMA-guidelines, formed a strength. Diverse assessment scales for sexual function and coitus-centred, sexual activity assessment and uncorrected cohort variation, need to be considered for result reliability. These discrepancies invalidate quantitative comparison and emphasize need for standardized validation tools. More criticism was reported amongst GD-patients especially on aesthetics and penetration depth, where perhaps fertility restoration is more important for MRKH-patients. Most comprised studies had medium risk of bias and lacked control groups, blinding of assessors and cofounder assessment. Lastly, high cohort size diversity, technique article quantity, (loss at) follow-up, recruitment and outcome assessment, are points of consideration.

Interpretation

It is impossible to identify one ideal vaginoplasty technique, due to lacking high-quality evidence and study heterogeneity. Tissue engineering alternatives were not included and could bring unexpected success, that should be further clarified in future research.

Conclusions

Vaginoplasty developments are rapidly evolving. However, MRKHS-patients and transwomen have to face incomprehension, ignorance and internal challenges daily. Vaginoplasty forms a relatively safe and acceptable solution that improves their QoL and self-image. This meta-analysis showed weaknesses and strength of technique specific (patient-reported) outcomes, by inconsistencies, information gaps, lack of standardization and of comparative research with similar cohorts for well-informed decision-making. No ideal vaginoplasty method can be identified and a technique is still selected based on an expertise-based rather than an evidence-based decision. This, together with exploration of tissue-engineering, is critical for future surgical advancements. We sincerely hope that this review provides an overview of todays options for well-educated decision, and formed a starting point for further background reading.
Supplementary data are available at BJOG online.

Contribution to authorship

J.S.: conceptualization, methodology, formal analysis, investigation, data curation, writing – original draft and visualization. F.G.: data analysis, validation, writing – review & editing and supervision. M.B.B.: Writing – review & editing. J.P.R.: Writing – review & editing. R.d.V.: Investigation and data curation. T.S.: conceptualization, supervision and writing – review & editing. J.H.: conceptualization, supervision and writing – review & editing.

Acknowledgements

We like to thank R. de Vries for his assistance on the systematic bibliography search and M. van Wely for her assistance on the statistical analysis.

Disclosure of interest

None.

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