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.
References
1. Frank RT. The formation of an artificial vagina without operation.Am J Obstet Gynecol . Published online 1938:1052-1055.
2. D’Alberton, Alberto; Santi F. Formation of a neovagina by coitus.Letters . 1972;40(5):763.
3. Ingram JM. The bicycle seat stool in the treatment of vaginal
agenesis and stenosis: a preliminary report. Am J Obstet Gynecol .
1981;140:867.
4. Liao LM, Doyle J, Crouch NS, Creighton SM. Dilation as treatment for
vaginal agenesis and hypoplasia: A pilot exploration of benefits and
barriers as perceived by patients. J Obstet Gynaecol (Lahore) .
2006;26(2):144-148. doi:10.1080/01443610500443527
5. Callens N, Weyers S, Monstrey S, et al. Vaginal dilation treatment in
women with vaginal hypoplasia: a prospective one-year follow-up study.Am J Obstet Gynecol . 2014;211(3):228e1-229e12.
doi:10.1016/j.ajog.2014.03.051
6. Panici PB, Ruscito I, Gasparri ML, Maffucci D, Marchese C, Bellati F.
Vaginal reconstruction with the Abbè-McIndoe technique: From dermal
grafts to autologous in vitro cultured vaginal tissue transplant.Semin Reprod Med . 2011;29(1):45-54. doi:10.1055/s-0030-1268703
7. Ding JX, Chen LM, Zhang XY, Zhang Y, Hua KQ. Sexual and functional
outcomes of vaginoplasty using acellular porcine small intestinal
submucosa graft or laparoscopic peritoneal vaginoplasty: A comparative
study. Hum Reprod . 2015;30(3):581-589. doi:10.1093/humrep/deu341
8. Kolle A, Taran F -a., Rall K, Scholler D, Wallwiener D, Brucker SY.
Neovagina creation methods and their potential impact on subsequent
uterus transplantation : a review. BJOG An Int J Obstet
Gynaecol . 2019;126:1328-1335. doi:10.1111/1471-0528.15888
9. Jasonni VM. Vaginal agenesis: surgical and nonsurgical strategies.Rev Obstet Gynecol . 2012;7(3):281-289.
10. McIndoe, AH; Banniser J. An operation for the cure of congenital
absence of the vagina. J Obs Gynaecol Br Emp . 1938;45:490-494.
11. Abbe R. New method of creating a vagina in a case of congenital
absence. Med Rec . 1898;54:836-838.
12. Benjamin H. Transvestism and transsexualism. Int J Sexol .
1953;7:12-14.
13. Cauldwell DO. Psychopathia transexualis. Sexology .
1949;16:274-280.
14. Buncamper ME, Honselaar JS, Bouman MB, Özer M, Kreukels BPC,
Mullender MG. Aesthetic and Functional Outcomes of Neovaginoplasty Using
Penile Skin in Male-to-Female Transsexuals. J Sex Med .
2015;12(7):1626-1634. doi:10.1111/jsm.12914
15. Lebreton M, Courtois F, Journel NM, Beaulieu-prévost D. Genital
Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty
in Male-to-Female Transgender Women. J Sex Med . 2017;14:274-281.
doi:10.1016/j.jsxm.2016.12.005
16. Arcelus J, Bouman WP, Noortgate W Van Den, Claes L, Witcomb G.
Systematic review and meta-analysis of prevalence studies in
transsexualism. Eur Psychiatry . 2015;30:807-815.
doi:10.1016/j.eurpsy.2015.04.005
17. De Cuypere G, Van Hemelrijck M, Michel A, et al. Prevalence and
demography of transsexualism in Belgium. Eur Psychiatry .
2007;22(3):137-141. doi:10.1016/j.eurpsy.2006.10.002
18. Bakker A, van Kesteren PJ, Gooren LJ, Bezemer PD. The prevalence of
transsexualism in the Netherlands. Acta Psychiatr Scand .
1993;87(4):237-238.
19. Sohn M, Bosinski HA. Gender identity disorders: diagnostic and
surgical aspects. J Sex Med . 2007;4(5):1193-1207.
20. Tsoi WF. The prevalence of transsexualism in Singapore. Acta
Psychiatr Scand . 1988;78(4):501-504.
21. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-V) .; 2013.
22. Amend B, Seibold J, Toomey P, Stenzl A, Sievert K. Surgical
Reconstruction for Male-to-Female Sex Reassignment. Eur Urol .
2013;64(1):141-149.
23. James SE, Herman J., Rankin S, Keisling M, Mottet L, Anafi M.The Report of the U.S. Transgender Survey 2015 .; 2016.
http://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF
24. Hess J, Rossi Neto R, Panic L, Rubben H, Wolfgang S. Satisfaction
With Male-to-Female Gender Reassignment Surgery Results of a
Retrospective Analysis. Dtsch Arztebl Int . 2015;111(47):795-801.
doi:10.3238/arztebl.2014.0795
25. Karim RB, Hage JJ, Bouman FG, de Ruyter R, van Kesteren PJ.
Refinements of pre-, intra-, and postoperative care to prevent
complications of vaginoplasty in male transsexuals. Ann Plast
Surg . 1995;35(3):279-284.
26. Neto RR, Hintz F, Krege S. Gender reassignment surgery - a 13 year
review of surgical outcomes. Int Brazilian J Urol .
2012;38(1):97-107.
27. Coleman E, Bockting W, Botzer M, et al. Standards of Care for the
Health of Transsexual, Transgender, and Gender-Nonconforming People,
Version 7. Int J Transgenderism . 2012;13(4):165-232.
doi:10.1080/15532739.2011.700873
28. Manrique OJ, Diya Sabbagh M, Ciudad P, et al. Gender-confirmation
surgery using the pedicle transverse colon flap for vaginal
reconstruction: A clinical outcome and sexual function evaluation study.Plast Reconstr Surg . 2018;141(3):767-771.
doi:10.1097/PRS.0000000000004122
29. Bouman MB, van der Sluis WB, van Woudenberg Hamstra LE, et al.
Patient-Reported Esthetic and Functional Outcomes of Primary Total
Laparoscopic Intestinal Vaginoplasty in Transgender Women With
Penoscrotal Hypoplasia. J Sex Med . 2016;13(9):1438-1444.
doi:10.1016/j.jsxm.2016.06.009
30. Bouman MB, Van Der Sluis WB, Buncamper ME, Özer M, Mullender MG,
Meijerink WJHJ. Primary Total Laparoscopic Sigmoid Vaginoplasty in
Transgender Women with Penoscrotal Hypoplasia: A Prospective Cohort
Study of Surgical Outcomes and Follow-Up of 42 Patients. Plast
Reconstr Surg . 2016;138(4):614e-623e. doi:10.1097/PRS.0000000000002549
31. Horbach SER, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG.
Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic
Review of Surgical Techniques. J Sex Med . 2015;12(6):1499-1512.
doi:10.1111/jsm.12868
32. Byne W, Bradley SJ, Coleman E, et al. Report of the American
psychiatric association task force on treatment of gender identity
disorder. Arch Sex Behav . 2012;41(4):759-796.
doi:10.1007/s10508-012-9975-x
33. Kȕster H. Uterus bipartitus solidus rudimentarius cum vagina solida.Z Geburtsh Gynȁk . 1910;67:692-718.
34. von Rokitansky K. Ȕber die sogenannten Verdoppelungen des Uterus.Med Jahrb Ost Statt . 1838;26:39.
35. Mayer C. Ȕber Verdoppelungen des Uterus und ihre Arten, nebst
Bemerkungen ȕber Hasenscharte und Wolfsrachen. J Chir Augenheilk .
1829;13:525.
36. Schreiner, G.A. Hauser WE. Das Mayer-Rokitansky-Kȕster syndrom.Schweiz med Wochenschr . 1961;91:381-384.
37. Imparato E, Alfei A, Aspesi G, Meus AL, Spinillo A. Long-term
results of sigmoid vaginoplasty in a consecutive series of 62 patients.Int Urogynecol J . 2007;18(12):1465-1469.
doi:10.1007/s00192-007-0358-0
38. Karapınar OS, Özkan M, Okyay AG, Şahin H, Dolapçıoğlu KS. Evaluation
of vaginal agenesis treated with the modified mcindoe technique: A
retrospective study. J Turkish Ger Gynecol Assoc .
2016;17(2):101-105. doi:10.5152/jtgga.2016.16013
39. Rock, John A.; Azziz R. Genital Anomalies in Childhood. Clin
Obstet Gynecol . 1987;30(3).
40. Morcel K, Camborieux L, Guerrier D. Mayer-Rokitansky-Küster-Hauser
(MRKH) syndrome. Orphanet J Rare Dis . 2007;2(1):1-9.
doi:10.1186/1750-1172-2-13
41. Labus LD, Djordjevic ML, Stanojevic DS, Bizic MR, Stojanovic BZ,
Cavic TM. Rectosigmoid vaginoplasty in patients with vaginal agenesis:
Sexual and psychosocial outcomes. Sex Health . 2011;8(3):427-430.
doi:10.1071/SH10105
42. Benedetti Panici P, Maffucci D, Ceccarelli S, et al. Autologous In
Vitro Cultured Vaginal Tissue for Vaginoplasty inWomen With
Mayer-Rokitansky-Küster-Hauser Syndrome: Anatomic and Functional
Results. J Minim Invasive Gynecol . 2015;22(2):205-211.
doi:10.1016/j.jmig.2014.09.012
43. Folgueira G, Perez-medina T, Martinez-cortes L, Martinez-lara A.
Laparoscopic creation of a neovagina in Mayer-Rokitansky-Kuster-Hauser
syndrome by modified Vecchietti’s procedure. Eur J Obstet Gynecol
Reprod Biol . 2006;127(2):240-243. doi:10.1016/j.ejogrb.2005.11.039
44. Keser A, Bozkurt N, Taner OF, Sensoz O. Treatment of vaginal
agenesis with modified Abbe-McIndoe technique: long-term follow-up in 22
patients. Eur J Obstet Gynecol Reprod Biol . 2005;121(1):110-116.
doi:10.1016/j.ejogrb.2004.11.027
45. Salvatore CA, Lodovicci O, Paulo S. VAGINAL AGENESIS: An Analysis of
Ninety Cases. Acta Obs Gynecol Scand . 1978;57(10):89-94.
46. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for
reporting systematic reviews and meta-analyses of studies that evaluate
health care interventions: Explanation and elaboration. PLoS Med .
2009;6(7). doi:10.1371/journal.pmed.1000100
47. Sanderson S, Tatt ID, Higgins JPT. Tools for assessing quality and
susceptibility to bias in observational studies in epidemiology: A
systematic review and annotated bibliography. Int J Epidemiol .
2007;36(3):666-676. doi:10.1093/ije/dym018
48. Da Costa BR, Cevallos M, Altman DG, Rutjes AWS, Egger M. Uses and
misuses of the STROBE statement: Bibliographic study. BMJ Open .
2011;1(1). doi:10.1136/bmjopen-2010-000048
49. Stang A. Critical evaluation of the Newcastle-Ottawa scale for the
assessment of the quality of nonrandomized studies in meta-analyses.Eur J Epidemiol . 2010;25(9):603-605.
doi:10.1007/s10654-010-9491-z
50. Dersimonian R, Laird N. Meta-Analysis in Clinical Trials *.Control Clin Trials . 1986;7:177-188.
51. Newcombe RG. Interval estimation for the difference between
independent proportions: Comparison of eleven methods. Stat Med .
1998;17(8):873-890.
doi:10.1002/(SICI)1097-0258(19980430)17:8<873::AID-SIM779>3.0.CO;2-I
52. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring
inconsistency in knowledgebases. J Intell Inf Syst .
2006;27(2):159-184. doi:10.1007/s10844-006-2974-4
53. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of
Observational Studies in Epidemiology: A Proposal for Reporting -
Meta-analysis Of Observational Studies in Epidemiology (MOOSE) Group B.JAMA Neurol . 2000;283:2008-2012.
54. Zhong CX, Wu JX, Liang JX, Wu QH. Laparoscopic and gasless
laparoscopic sigmoid colon vaginoplasty in women with vaginal agenesis.Chin Med J (Engl) . 2012;125(2):203-208.
doi:10.3760/cma.j.issn.0366-6999.2012.02.008
55. Creatsas G, Deligeoroglou E, Christopoulos P. Creation of a
neovagina after Creatsas modification of Williams vaginoplasty for the
treatment of 200 patients with Mayer-Rokitansky-Kuster- Hauser syndrome.Fertil Steril . 2010;94(5):1848-1852.
doi:10.1016/j.fertnstert.2009.09.064
56. Hontscharuk R, Alba B, Hamidian Jahromi A, Schechter L. Penile
inversion vaginoplasty outcomes: Complications and satisfaction.Andrology . 2021;00(February):1-12. doi:10.1111/andr.13030
57. Cristofari S, Bertrand B, Leuzzi S, et al. Postoperative
complications of male to female sex reassignment surgery: A 10-year
French retrospective study. Ann Chir Plast Esthet .
2019;64(1):24-32. doi:10.1016/j.anplas.2018.08.002
58. Buncamper ME, Van Der Sluis WB, Van Der Pas RSD, et al. Surgical
Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of
475 Transgender Women. Plast Reconstr Surg . 2016;138(5):999-1007.
doi:10.1097/PRS.0000000000002684
59. Cantril H. The Pattern of Human Concern. Published online 1965:429.
60. Diener, Emmons, Larsen, Griffin. Satisfaction with Life Scale
(SWLS). A Compend Tests, Scales Quest . Published online
2020:658-660. doi:10.4324/9781003076391-182
61. Lyubomirsky S, Lepper H. A Measure of Subjective Happiness:
Preliminary Reliability and Construct Validation. Soc Indic Res .
1999;46:137-155. doi:10.1023/A
62. Ware JE. SF-36 Health Survey update. Spine (Phila Pa 1976) .
2000;25(24):3130-3139. doi:10.1097/00007632-200012150-00008
63. Schmitt DP, Allik J. Simultaneous administration of the Rosenberg
self-esteem scale in 53 nations: Exploring the universal and
culture-specific features of global self-esteem. J Pers Soc
Psychol . 2005;89(4):623-642. doi:10.1037/0022-3514.89.4.623
64. Papadopulos NA, Lellé JD, Zavlin D, et al. Psychological Pathologies
and Sexual Orientation in Transgender Women Undergoing Gender Confirming
Treatment. Ann Plast Surg . 2020;84(3):312-316.
doi:10.1097/SAP.0000000000002035
65. Löwe B, Wahl I, Rose M, et al. A 4-item measure of depression and
anxiety: Validation and standardization of the Patient Health
Questionnaire-4 (PHQ-4) in the general population. J Affect
Disord . 2010;122(1-2):86-95. doi:10.1016/j.jad.2009.06.019
66. Papadopulos NA, Kovacs L, Krammer S, Herschbach P, Henrich G, Biemer
E. Quality of life following aesthetic plastic surgery: a prospective
study. J Plast Reconstr Aesthetic Surg . 2007;60(8):915-921.
doi:10.1016/j.bjps.2007.01.071
67. Henrich G, Herschbach P. Questions on Life Satisfaction (FLZM) - A
Short Questionnaire for Assessing Subjective Quality of Life. Eur
J Psychol Assess . 2000;16(3):150-159. doi:10.1027//1015-5759.16.3.150
68. Daig I, Herschbach P, Lehmann A, Knoll N, Decker O. Gender and age
differences in domain-specific life satisfaction and the impact of
depressive and anxiety symptoms: A general population survey from
Germany. Qual Life Res . 2009;18(6):669-678.
doi:10.1007/s11136-009-9481-3
69. Papadopulos NA, Lellé JD, Zavlin D, et al. Quality of Life and
Patient Satisfaction Following Male-to-Female Sex Reassignment Surgery.J Sex Med . 2017;14(5):721-730. doi:10.1016/j.jsxm.2017.01.022
70. Vedovo F, Di Blas L, Aretusi F, et al. Physical, Mental and Sexual
Health Among Transgender Women: A Comparative Study Among Operated
Transgender and Cisgender Women in a National Tertiary Referral Network.J Sex Med . 2021;18(5):982-989. doi:10.1016/j.jsxm.2021.02.006
71. Wagner A, Brucker SY, Ueding E, et al. Treatment management during
the adolescent transition period of girls and young women with
Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS): A systematic literature
review. Orphanet J Rare Dis . 2016;11(152):1-11.
doi:10.1186/s13023-016-0536-6
72. Rossi Neto R, Hintz F, Krege S, Rübben H, vom Dorp F. Gender
reassignment surgery - A 13 year review of surgical outcomes. Int
Braz J Urol . 2012;38(1):97-107. doi:10.1590/S1677-55382012000100014
73. Kuhn A, Santi A, Birkhäuser M. Vaginal prolapse, pelvic floor
function, and related symptoms 16 years after sex reassignment surgery
in transsexuals. Fertil Steril . 2011;95(7):2379-2382.
doi:10.1016/j.fertnstert.2011.03.029
74. Hammer N, Steinke H, Slowik V, et al. The sacrotuberous and the
sacrospinous ligament – A virtual reconstruction. Ann Anat .
2009;191(4):417-425.
75. van der Sluis WB, Bouman MB, de Boer NKH, et al. Long-Term Follow-Up
of Transgender Women After Secondary Intestinal Vaginoplasty. J
Sex Med . 2016;13(4):702-710. doi:10.1016/j.jsxm.2016.01.008
76. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry
TR. Feminizing genitoplasty in adult transsexuals: Early and long-term
surgical results. BJU Int . 2007;100(3):607-613.
doi:10.1111/j.1464-410X.2007.07017.x
77. Lawrence AA. Patient-reported complications and functional outcomes
of male-to-female sex reassignment surgery. Arch Sex Behav .
2006;35(6):717-727. doi:10.1007/s10508-006-9104-9
78. Herlin MK, Petersen MB, Brännström M. Mayer-Rokitansky-Küster-Hauser
( MRKH ) syndrome : a comprehensive update. Orphanet J Rare Dis .
2020;15(214):1-16.