Vaginoplasty

Vaginoplasty is any type of genitoplasty—surgical procedures to the vagina, vulva or related structures; this includes those carried out on the labia majora, labia minora, clitoris, urethra, cervix, uterus, Bartholin's gland, rectum, perineal musculature, lymphatics, urethral sphincter, anal sphincter, large blood vessels, and nerve tissue. Malignant growths and abscesses are removed and vaginoplasty recreates a normal vaginal structure and function. Vaginoplasty is also used to correct congenital defects to the vagina, urethra and rectum. Vaginoplasty can correct uterine and vaginal prolapse. Often, a vaginoplasty is performed to repair the vagina and its attached structures due to trauma. It will correct protrusion of the urinary bladder into the vagina and protrusion of the rectum into the vagina.^[1]

Congenital disorders such as congenital adrenal hyperplasia can affect the structure and function of the vagina and sometimes the vagina is absent; these can be reconstructed or formed, using a vaginoplasty. ^[2][3] Other reasons for the surgery include issues involving a microphallus, those who have Müllerian agenesis resulting in vaginal hypoplasia, and women who have had a vaginectomy after malignancy or trauma.^[4][5] It is done to reduce the size of the entrance of the vagina in some cases. In some instances, it is used to alter the appearance of the vulvar region.

Medical uses

Vaginoplasty is the description of the following surgical interventions:

• treatment of Congenital adrenal hyperplasia.^[3]
• separation of congenitally fused urethra and vagina^[6]
• repair of a urethra that is short^[6]
• vaginal construction^[4][7]
• vaginal reconstruction^[4][7]
• vaginal vault prolapse^[8]
• vaginal suspension and fixation^[4][7]
• operations on cul-de-sac^[4][7]
• repair of cystocele^[4][7]and rectocele^[4]
• genital prolapse
• retropubic paravaginal repair^[8]
• the repair of a cystocele using a graft or prosthesis^[4]
• the repair of a cystocele and a rectocele in the same procedure using a graft or prosthethic device^[4]
• the repair of a rectocele using a graft or prosthetic material^[4]
• the vaginal construction using a graft or prosthetic material^[4]
• the vaginal reconstruction using a graft or prosthetic material^[4]
• the vaginal suspension and stabilization using with graft or prosthetic material
• hymenorrhaphy

The grafts used in vaginoplasty can be an allogenic, a heterograph, an autograft, xenograft, or a autologous material.^[9]

Risks and complications

In adults, rates and types of complications varied with gender reassignment vaginoplasty. Necrosis of the clitoral region was 1-3%. Necrosis of the surgically created vagina was 3.7-4.2%. Vaginal shrinkage occurred was documented in 2-10% of those treated. Stricture, or narrowing of the vaginal orifice was reported in 12-15% of the cases. Of those reporting stricture, 41% underwent a second operation to correct the condition. Necrosis of two scrotal flaps has been described. Posterior vaginal wall is rare complication. Genital pain was reported in 4-9%. Rectovaginal fistula is also rare with only 1% documented. Vaginal prolapse was seen in 1-2% of people assigned male at birth undergoing this procedures.^[5]

The ability of emptying the bladder was affected after this procedure with 13% reporting improvement, 68% said that there was no change and 19% reported that voiding got worse.Those reporting a negative outcome experienced in which loss of bladder control and urinary incontinence were 19%. Urinary tract infections occurred in 32% of those treated.^[5]

Techniques

Non-surgical vagina creation was used in the past to treat the congenital absence of a vagina. The procedure involved the wearing of a saddle-like device and the use of increasing-diameter dilators. The procedure took several months and was sometimes painful. It was not effective in every instance.^[2]

Reconstructive surgery for congenital adrenal hyperplasia

Adrenal hyperplasia is a congential endocrine disorder in genotypical females that influences the formation of the external genitalia. Most parents choose reconstructive surgery for their infant females to reverse the virilization effects of the disorder. The virilization occurs because there is a 21-hydroxylase deficiency. Corrective vaginoplasty is scheduled at the age of one to two-years-old as single feminizing genitoplasty. Specific procedures include: clitoral reduction, labiaplasty, normalizing appearance, vagina creation. initiating vaginal dilation. When the girl enters puberty, a reevaluation is done and continued dilation is performed by the girl. A normal sized vagina can be achieved in months.^[3]

Reconstructive surgery after cancer treatment

Radiological cancer treatment can result in the destruction or alteration of vaginal tissues. Vaginoplasty is often performed to reconstruct the vagina and other genital structures. In some cases, normal sexual function can be restored.^[4]

McIndose surgical technique

A canal is surgically constructed between the urinary bladder and urethra in the anterior portion of the pelvic region and the rectum. A skin graft is used from another area of the person's body. The graft is removed from the thigh, buttocks, or inguinal region. It is then wrapped around a mold and placed into the surgically created canal. Other materials have been used to create the lining of the newly created vagina. These have been cutaneous skin flaps, amniotic membranes, and buccal muscosa.^[4]

Bowel vaginoplasty

Bowel vaginoplasty is one commonly used surgical method to create an artificial vagina.^[5]

Sex reassignment surgery

Sex reassignment surgery to create a vagina consists of using segments from the large intestine or small intestine. In addition, penile-scrotal skin flaps are also used. Nongenital full-thickness graft (FTG) or split-thickness skin grafts from other parts of the body have been used. Inversion of the penile skin is the method most often selected by surgeons performing gender reassignment surgery. The inverted penile skin uses inferior pedicle skin or abdominal skin for the lining of the created vagina. The skin is cut to form an appropriate-sized flap. The skin flap is sometimes combined with a scrotal or urethral flap.^[5] Sex reassignment therapy is often part of the treatment plan.

Elective Vaginoplasty

Critics have labeled such surgery as the "designer vagina". The American College of Obstetricians and Gynecologists issued a warning against these procedures in 2007^[10] as did the Royal Australian College of Gynaecologists,^[11] and a commentary in the British Medical Journal strongly criticized the "designer vagina" in 2009.^[11][12] The Society of Obstetricians and Gynaecologists of Canada published a policy statement against elective vaginoplasty based upon the risks associated with unnecessary cosmetic surgery in 2013.^[13]

The World Health Organization describes any medically unnecessary surgery to the vaginal tissue and organs as Female genital mutilation.^[14]

Vaginal rejuvenation is a form of elective plastic surgery. Its purpose is to restore or enhance the vagina's cosmetic appearance.^[12]

Labiaplasty

The pre-operative aspect (left), and the post-operative aspect (right) of a labial reduction

Labiaplasty corrects the congenital absence of the labia in female infants with congenital adrenal hyperplasia.^[3] It can be performed as a discrete surgery, or as a subordinate procedure within a vaginoplasty.^[15] Some surgeries are needed for discomfort occurring from chronic labial irritation that develops from tight clothing, sex, sports, or other physical activities. The post-operative outcome of vaginoplasty is variable; it usually allows coitus (sexual intercourse) after a week, although sensation might not always be present. In fertile women, menstruation and fertilization may be possible when the uterus and the ovaries are functioning.

Hymen surgical procedures

A hymenorrhaphy is the surgical procedure that reconstructs the hymen.

Balloon vaginoplasty

In this procedure, a foley catheter is laparoscopically inserted to the rectouterine pouch whereupon gradual traction and distension are applied to create a neovagina.^[16]

Laparoscopic peritoneal pull through vaginoplasty

A simple new laparoscopic peritoneal vaginoplasty was described in a series of 36 patients with long term replicable excellent results culminating in normal vaginal development. A total of 36 patients with congenital absence of vagina (MRKH syndrome) were treated with laparoscopic peritoneal pull through technique of Dr. Mhatre (modification of Davidov’s procedure) between 2003 and 2012. The new technique of laparoscopic peritoneal vaginoplasty described by the author has not only produced excellent results due to peritoneal metaplasia, but it has also resulted in the formation of normal vagina. This new surgical technique is comparatively simple with no morbidity. The neovagina has an acidic pH and normal cytology. Average operative time was 1-1.5 hrs. Average hospital stay was three days; there were no intra-operative and post-operative complications. All the patients had adequate vaginal length of about 7 to 8 cm, admitting a full-size Sims’ speculum. The neovagina offers patients good coital function with natural lubrication and pleasure, a function which is otherwise denied by nature in the context of their earlier quandary.

Vecchietti procedure

In treating müllerian agenesis, the Vecchietti procedure is a laparoscopic surgical technique that produces a vagina of dimensions (depth and width) comparable to those of a normal vagina (ca. 8.0 cm. deep).^[17][18] A small, plastic sphere (“olive”) is threaded (sutured) against the vaginal area; the threads are drawn though the vaginal skin, up through the abdomen, and through the navel. There, the threads are attached to a traction device, and then daily are drawn tight so that the “olive” is pulled inwards and stretches the vagina, by approximately 1.0 cm. per day, thereby creating a vagina, approximately 7.0 cm. deep by 7.0 cm. wide, in 7 days. The mean operating room (OR) time for the Vecchietti vaginoplasty is approximately 45 minutes; yet, depending upon the patient and her indications, the procedure might require more time.^[19] The outcomes of Vecchietti technique via the laparoscopic approach are found to be comparable to the procedure using laparotomy.^[20] In vaginal hypoplasia, traction vaginoplasty such as the Vecchietti technique seems to have the highest success rates both anatomically (99%) and functionally (96%) among available treatments.^[21]

Wilson Method

The penile-inversion technique of the Wilson Method is different from the traditional penile-inversion technique in that it is a three-stage surgery, comprising a two-stage initial vaginoplasty. The Wilson Method surgery is initially performed like a traditional penile inversion, until the vaginal-vault creation step, in which the vault of the vagina is left unfinished, as a raw surface, and is packed with a sterile stent, which, after 5–7 days, then is lined with a skin graft harvested from the buttocks. The penile skin is used to create the labia minora, clitoral hooding, and the anterior fourchette (frenulum); the glans penis is used to create the clitoris, and the scrotum is used to create the labia majora.

Research

The success of vaginoplasty to treat the virilization associated with congenital adrenal hyperplasia has been investigated in Hong Kong. Those participating in the study evaluated the surgery as either good or satisfactory.^[3]

See also

• Female genital mutilation
• Sex reassignment surgery male-to-female
• List of transgender-related topics

References