Discussion

Main findings

Non-surgical MRKH-treatment is likely still favored, as included article quantity was low despite higher prevalence. High intercontinental diversity showed no European or North-American MRKH-vaginoplasties, likely due to pre-adolescent surgeries that are less common in Asia by religion and tradition.101
Intestinal-vaginoplasty was performed significantly less in GD-patients, likely due to preferred local tissue alternatives. GAS-vaginoplasty duration was longer, as complete vulva and neovagina opposed to partial vagina were formed, and increased with graft quantity.
Hemorrhage was only reported after GAS and originated from vascularized tissue (i.e., corpus spongiosum), likely due to estrogen continuation and higher surgery complexity.23 MRKH-vaginoplasty predominantly reported intercourse-related bleeding.62
Tissue necrosis was associated with maximum tissue tension (i.e., introitus).
Prolapse was often reported, affects 50% of parous women55 and mostly vaginoplasty patients ≥50 years. Pelvic floors are sex-specific,102 so long-term hormonal treatment might affect prolapse.55 In our center we occasionally treat transwomen for long-term prolapse (10-20 post-operative years).103 Prolapse is believed to increase with postoperative-time.42,104
Stenosis was most common and hampered QoL through sexual dysfunction and dissatisfaction. Higher GAS-reports might relate to inherent skin properties that cause narrowing, incomplete corpus spongiosum resection or inclusion of meatal stenosis.
Gastrointestinal complications are rare and severe, especially perineal dissection and less invasive surgery make intra-operative observation of fistula hard.
Revisions were reported only and for all GAS-techniques and were inversely proportional to graft size (through stenosis, necrosis and dyspareunia) and likely related to dissatisfaction due to surgical complexity from anatomical dissimilarity. MRKH-patients showed higher overall and complete anatomical satisfaction, even for ‘unsuccessful’ lengths.
McIndoe-, Peritoneal- and Intestinal-surgery reported vaginal discharge, which is prevented in skin-based vaginoplasty-methods by inherent tissue differences. Genital pain hampered QoL-improvement after GAS and urinary issues hampered satisfaction and correlated to small prostates and pelvic floor dysfunction.
Penile-inversion- and Penoscrotal-GAS reported 1-4% (sporadic or surgery-unrelated) regret. Many transgender-care opponents use regret as an argument. Strict WPATH-regulations should prevent regret and likely explain the presence of only GAS-investigated regret.
GD-patients were less sexually active. However, definition varied gravely between studies, from ‘any activity’ to ‘regular introital penetration with a man’. This presents a bias.
A large variety of evaluation was used. Complications, vaginal discharge and hair were derived from patient follow up reports. Self-made questionnaires were mostly used. Established questionnaires for fecal- and urinary-issues,51–54 overall dissatisfaction and aesthetic satisfaction were applied. The FSFI-questionnaire allowed reliable comparison of dyspareunia and satisfaction with sexual function.
Many established QoL forms are available and have been applied (SF-36, BDI, FLZ, PHQ-4, RSES, SHS, SWLS and CLL).

Strength and limitations

This is the first systematic review with meta-analysis on nine vaginoplasty techniques with MRKH- and GD-patients and a wide diversity of complications, satisfaction and function were assessed with Clavien-Dindo classification. The methodological quality, in line with PRISMA-guidelines, formed a strength. Diverse assessment scales for sexual function and coitus-centered, 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, variation in definitions, 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, MRKH-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 today’s 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 M. van Wely for her assistance on the statistical analysis.

Disclosure of interest

None.

References

1. 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
2. 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
3. Frank RT. The formation of an artificial vagina without operation.Am J Obstet Gynecol . Published online 1938:1052-1055.
4. D’Alberton, Alberto; Santi F. Formation of a neovagina by coitus.Letters . 1972;40(5):763.
5. Ingram JM. The bicycle seat stool in the treatment of vaginal agenesis and stenosis: a preliminary report. Am J Obstet Gynecol . 1981;140:867.
6. 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
7. 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
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. Tsoi WF. The prevalence of transsexualism in Singapore. Acta Psychiatr Scand . 1988;78(4):501-504.
11. Sohn M, Bosinski HA. Gender identity disorders: diagnostic and surgical aspects. J Sex Med . 2007;4(5):1193-1207.
12. 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
13. Bakker A, van Kesteren PJM, Gooren LJG, Bezemer PD. The prevalence of transsexualism in the Netherlands. Acta Psychiatr Scand . 1993;87(4):237-238. doi:10.1111/j.1600-0447.1993.tb03364.x
14. 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.
15. 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
16. 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
17. 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
18. 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
19. Georgas K, Belgrano V, Andreasson M, Elander A, Selvaggi G. Bowel vaginoplasty: a systematic review. J Plast Surg Hand Surg . 2018;52(5):265-273. doi:10.1080/2000656X.2018.1482220
20. Manrique OJ, Adabi K, Martinez-Jorge J, Ciudad P, Nicoli F, Kiranantawat K. Complications and Patient-Reported Outcomes in Male-to-Female Vaginoplasty-Where We Are Today: A Systematic Review and Meta-Analysis. Ann Plast Surg . 2018;80(6):684-691. doi:10.1097/SAP.0000000000001393
21. Tilt A, Black CK, Fan KL, Del GA. A Systematic Review of Primary Vaginoplasty Techniques and Outcomes in the Male-to-Female Transgender Population : A Call to Action Presenter : Elizabeth G . Zolper , BS Co-Authors : Chris Devulapalli , MD ; Affiliation : Georgetown University School Harv. :77.
22. Kloer C, Parker A, Blasdel G, Kaplan S, Zhao L, Bluebond-Langner R. Sexual health after vaginoplasty: A systematic review. Andrology . 2021;9(6):1744-1764. doi:10.1111/andr.13022
23. 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
24. Karim RB, Hage JJ, Bouman FG, De Ruyter R, Van Kesteren PJM. Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals. Ann Plast Surg . 1995;35(3):279-284. doi:10.1097/00000637-199509000-00010
25. 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
26. Rock, John A.; Azziz R. Genital Anomalies in Childhood. Clin Obstet Gynecol . 1987;30(3).
27. 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
28. 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
29. Salvatore CA, Lodovicci O, Paulo S. VAGINAL AGENESIS: An Analysis of Ninety Cases. Acta Obs Gynecol Scand . 1978;57(10):89-94.
30. 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
31. Dindo D. Treatment of Postoperative Complications After Digestive Surgery . (Cuesta MA, Bonjer HJ, eds.). Springer London; 2014. doi:10.1007/978-1-4471-4354-3
32. Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien-Dindo Classification of Surgical Complications. Ann Surg . 2009;250(2):187-196. doi:10.1097/SLA.0b013e3181b13ca2
33. 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
34. 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
35. 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
36. Dersimonian R, Laird N. Meta-Analysis in Clinical Trials *.Control Clin Trials . 1986;7:177-188.
37. 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
38. 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
39. 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.
40. 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
41. 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
42. 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
43. Uncu G, Özerkan K, Ata B, et al. Anatomic and Functional Outcomes of Paramesonephric Remnant-Supported Laparoscopic Double-Layer Peritoneal Pull-Down Vaginoplasty Technique in Patients with Mayer-Rokitansky-Küster-Hauser Syndrome: Uncu Modification. J Minim Invasive Gynecol . 2018;25(3):498-506. doi:10.1016/j.jmig.2017.10.015
44. Thabet SMA, Ali AH. New attempt using labio-vestibular flap technique to manage circumcised women with Rokitansky syndrome.Acta Obstet Gynecol Scand . 2008;87(1):94-98. doi:10.1080/00016340701778922
45. Gupta R, Gupta R. Achieving Correct Axis and Good Depth in Gender Affirming Vaginoplasties by Penile-Perineoscrotal Flap Vaginoplasty.Indian J Plast Surg . 2022;55(2):188-195.
46. Gentile G, Martino A, Nadalin D, et al. Penile-scrotal flap vaginoplasty versus inverted penile skin flap expanded with spatulated urethra: A multidisciplinary single-centre analysis. Arch Ital di Urol e Androl . 2020;92(3):186-191. doi:10.4081/AIUA.2020.3.186
47. Buncamper ME, Van Der Sluis WB, De Vries M, Witte BI, Bouman MB, Mullender MG. Penile Inversion Vaginoplasty with or without Additional Full-Thickness Skin Graft: To Graft or Not to Graft? Plast Reconstr Surg . 2017;139(3):649e-656e. doi:10.1097/PRS.0000000000003108
48. 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
49. 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
50. Sigurjónsson H, Möllermark C, Rinder J, Farnebo F, Lundgren TK. Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery. J Sex Med . 2017;14(2):269-273. doi:10.1016/j.jsxm.2016.12.003
51. Postma R, Bicanic I, van der Vaart H, Laan E. Pelvic floor muscle problems mediate sexual problems in young adult rape victims. J Sex Med . 2013;10(8):1978-1987. doi:10.1111/jsm.12196
52. Jackson S, Donovan J, Brookes S, Eckford S, Swithinbank L, Abrams P. The bristol female lower urinary tract symptoms questionnaire: Development and psychometric testing. Br J Urol . 1996;77(6):805-812. doi:10.1046/j.1464-410x.1996.00186.x
53. Hiller L, Radley S, Mann CH, et al. Development and validation of a questionnaire for the assessment of bowel and lower urinary tract symptoms in women. BJOG An Int J Obstet Gynaecol . 2002;109(4):413-423. doi:10.1111/j.1471-0528.2002.01147.x
54. Bradshaw HD, Hiller L, Farkas AG, Radley S, Radley SC. Development and psychometric testing of a symptom index for pelvic organ prolapse.J Obstet Gynaecol (Lahore) . 2006;26(3):241-252. doi:10.1080/01443610500537989
55. 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
56. Kaushik N, Jindal O, Bhardwaj DK. Sigma-lead Male-to-Female Gender Affirmation Surgery: Blending Cosmesis with Functionality. Plast Reconstr Surg - Glob Open . 2019;7(4):1-7. doi:10.1097/GOX.0000000000002169
57. Kanhai RCJ. Sensate Vagina Pedicled-Spot for Male-to-Female Transsexuals: The Experience in the First 50 Patients. Aesthetic Plast Surg . 2016;40(2):284-287. doi:10.1007/s00266-016-0620-2
58. 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
59. Blanchard R, Legault S, Lindsay WRN. Vaginoplasty outcome in male-to-female transsexuals. J Sex Marital Ther . 1987;13(4):265-275. doi:10.1080/00926238708403899
60. De Pablos-Rodríguez P, Torremadé Barreda J, Etcheverry Giadrosich B, et al. Impact of the initial experience in the penile inversion vaginoplasty technique on satisfaction levels: a pilot retrospective cohort study. Transl Androl Urol . 2022;11(8):1096-1104. doi:10.21037/tau-22-108
61. Hayashida SA, Soares-Jr JM, Costa EMF, et al. The clinical, structural, and biological features of neovaginas: A comparison of the Frank and the McIndoe techniques. Eur J Obstet Gynecol Reprod Biol . 2015;186:12-16. doi:10.1016/j.ejogrb.2014.12.025
62. 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
63. Weyers S, Elaut E, De Sutter P, et al. Long-term assessment of the physical, mental, and sexual health among transsexual women. J Sex Med . 2009;6(3):752-760. doi:10.1111/j.1743-6109.2008.01082.x
64. Wang Y yi, Duan H, Zhang X ning, Wang S. Neovagina Creation: A Novel Improved Laparoscopic Vecchietti Procedure in Patients with Mayer-Rokitansky-Küster-Hauster Syndrome. J Minim Invasive Gynecol . 2021;28(1):82-92. doi:10.1016/j.jmig.2020.04.006
65. Tabassi KT, Djavan B, Hosseini J, Ghoreifi A, Ershadi M, Hosseini E. Fold-back perineoscrotal flap plus penile inversion vaginoplasty for male-to-female gender reassignment surgery in circumcised subjects.Eur J Plast Surg . 2015;38(1):43-48. doi:10.1007/s00238-014-1038-1
66. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: A technique, results and long-term follow-up in 66 patients. BJU Int . 2001;88(4):396-402. doi:10.1046/j.1464-410X.2001.02323.x
67. Fakin RM, Giovanoli P. A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes. J Sex Med . 2021;18(2):391-399. doi:10.1016/j.jsxm.2020.09.014
68. di Summa PG, Watfa W, Krähenbühl S, Schaffer C, Raffoul W, Bauquis O. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med . 2019;16(12):2030-2037. doi:10.1016/j.jsxm.2019.09.007
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. Djordjevic ML, Stanojevic DS, Bizic MR. Rectosigmoid Vaginoplasty: Clinical Experience and Outcomes in 86 Cases. J Sex Med . 2011;8(12):3487-3494. doi:10.1111/j.1743-6109.2011.02494.x
71. Thalaivirithan B, Sethu M, Ramachandran D, Kandasamy M, Janardhanam J. Application of embryonic equivalents in male-to-female sex reassignment surgery. Indian J Plast Surg . 2018;51(2):155-166. doi:10.4103/ijps.IJPS_62_18
72. Zhao XW, Ma JY, Wang YX, Zhang H, Zhang J, Kang S. Laparoscopic vaginoplasty using a single peritoneal flap: 10 years of experience in the creation of a neovagina in patients with Mayer-Rokitansky-Küster-Hauser syndrome. Fertil Steril . 2015;104(1):241-247. doi:10.1016/j.fertnstert.2015.04.014
73. Zhao X, Wang R, Wang Y, Li L, Zhang H, Kang S. Comparison of two laparoscopic peritoneal vaginoplasty techniques in patients with Mayer–Rokitansky–Küster–Hauser syndrome. Int Urogynecol J Pelvic Floor Dysfunct . 2015;26(8):1201-1207. doi:10.1007/s00192-015-2675-z
74. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-Female Genital Reassignment Surgery: A Retrospective Review of Surgical Technique and Complications in 60 Patients. J Sex Med . 2015;12(8):1837-1845. doi:10.1111/jsm.12936
75. Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Male-to-Female Reassignment Surgery. Aesthetic Plast Surg . 2018;42(2):491-497. doi:10.1007/s00266-018-1088-z
76. Zhang W, Li C, Cheng W, et al. Application of mesocolon rotation and reverse puncture in total laparoscopic sigmoid vaginoplasty. Exp Ther Med . Published online 2019:3191-3196. doi:10.3892/etm.2019.7920
77. Zavlin D, Schaff J, Lellé JD, et al. Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes.Aesthetic Plast Surg . 2018;42(1):178-187. doi:10.1007/s00266-017-1003-z
78. Zhang X, Qiu J, Ding J, Hua K. Comparison of neovaginoplasty using acellular porcine small intestinal submucosa graft or Interceed in patients with Mayer–Rokitansky–Küster–Hauser syndrome. Arch Gynecol Obstet . 2019;300(6):1633-1636. doi:10.1007/s00404-019-05352-0
79. Han SE, Go JY, Choi DS, Seo GH, Lim SY. Experience with specially designed pored polyacetal mold dressing method used in McIndoe-style vaginoplasty. J Pediatr Urol . 2017;13(6):621.e1-621.e6. doi:10.1016/j.jpurol.2017.05.014
80. Yang X, Zhu L, Wang YJ, et al. Comparison of the modified laparoscopic Vecchietti and Davydov colpoplasty techniques in Mayer-Rokitansky-Küster-Hauser syndrome: A long-term follow-up analysis.J Obstet Gynaecol Res . 2022;48(7):1930-1937. doi:10.1111/jog.15262
81. Zhao X, Zhang Y, Zhang M, Zhang H, Tian Y, Kang S. Comparison of two laparoscopic vaginoplasties using a single peritoneal flap in patients with Mayer-Rokitansky-Küster-Hauser syndrome. Int Urogynecol J . Published online 2021. doi:10.1007/s00192-021-04921-9
82. Cocci A, Rosi F, Frediani D, et al. Male-to-Female (MtoF) gender affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty).Arch Ital di Urol e Androl . 2019;91(2):119-124. doi:10.4081/aiua.2019.2.119
83. Anagani M, Agrawal P, Meka K, Narayana RT, Bandameedipally R. Novel Minimally Invasive Technique of Neovaginoplasty Using an Absorbable Adhesion Barrier. J Minim Invasive Gynecol . 2020;27(1):206-211. doi:10.1016/j.jmig.2019.02.025
84. Çetin C, Soysal C, Ürünsak IF, Api M, Çetin T. Long-Term Outcomes of Laparoscopic Bean Vaginoplasty (Modified Vecchietti Procedure) for Mayer-Rokitansky-Kuster-Hauser Syndrome. J Laparoendosc Adv Surg Tech . 2016;26(8):591-595. doi:10.1089/lap.2016.0031
85. Brotto LA, Gehring D, Klein C, Gorzalka BB, Thomson S, Knudson G. Psychophysiological and subjective sexual arousal to visual sexual stimuli in new women. J Psychosom Obstet Gynecol . 2005;26(4):237-244. doi:10.1080/01443610400023171
86. Zhou JH, Sun J, Yang CB, Xie ZW, Shao WQ, Jin HM. Long-term outcomes of transvestibular vaginoplasty with pelvic peritoneum in 182 patients with Rokitansky’s syndrome. Fertil Steril . 2010;94(6):2281-2285. doi:10.1016/j.fertnstert.2010.02.010
87. Blasdel G, Kloer C, Parker A, Castle E, Bluebond-Langner R, Zhao LC. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty.J Sex Med . 2022;19(5):781-788. doi:10.1016/j.jsxm.2022.02.015
88. Richter P, Werner J, Heerlein A, Kraus A, Sauer H. On the validity of the Beck Depression Inventory. A review. Psychopathology . 1998;31(3):160-168. doi:10.1159/000066239
89. Aaronson NK, Muller M, Cohen PDA, et al. Translation, validation, and norming of the Dutch language version of the SF-36 Health Survey in community and chronic disease populations. J Clin Epidemiol . 1998;51(11):1055-1068. doi:10.1016/S0895-4356(98)00097-3
90. 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
91. 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
92. 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
93. 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
94. 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
95. 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
96. Diener, Emmons, Larsen, Griffin. Satisfaction with Life Scale (SWLS). A Compend Tests, Scales Quest . Published online 2020:658-660. doi:10.4324/9781003076391-182
97. Pavot W, Diener E. The Satisfaction With Life Scale and the emerging construct of life satisfaction. J Posit Psychol . 2008;3(2):137-152. doi:10.1080/17439760701756946
98. Cantril H. The Pattern of Human Concern. Published online 1965:429.
99. Ware JE. SF-36 Health Survey update. Spine (Phila Pa 1976) . 2000;25(24):3130-3139. doi:10.1097/00007632-200012150-00008
100. 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
101. 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
102. Hammer N, Steinke H, Slowik V, et al. The sacrotuberous and the sacrospinous ligament – A virtual reconstruction. Ann Anat . 2009;191(4):417-425.
103. 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
104. 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