34.1 Introduction

This chapter is conceptualized to give gynecologists more in-depth information about vaginoplasty necessary to understand postoperative complications and to prevent or solve problems. Special attention is paid to (neo-)vaginal stenosis as one of the most burdensome complications of vaginoplasty. This chapter does not intend to comprehensively describe the penile inversion technique for vaginoplasty or compare the available techniques.

Neovaginal stenosis is one of the most reported complications of vaginoplasty. In this chapter, we review methods to prevent this complication after penile inversion vaginoplasty and the use of biomaterials. Peritoneal and intestinal vaginoplasty techniques are also mentioned as alternatives to the penile inversion technique, as they have historically been used in cases of inadequate penile skin for neovaginal cavity creation and have their own respective rates of neovaginal stenosis. The optimal type of dilator and schedule for self-dilation is also discussed, as these are important factors in the prevention of this surgical complication. While diligent dilation is important in preventing neovaginal stenosis (see also Chapters 16 and 35), vaginal canal loss can still occur, and risk factors that make excessive scarring after vaginoplasty more likely in these cases are also discussed. We then outline surgical and nonsurgical repair options for patients who experience neovaginal stenosis after vaginoplasty, as well as solutions to other potential postoperative complications that can arise after the procedure. These include dehiscence, postoperative bleeding, fistula formation, urinary symptoms, unique complications following intestinal vaginoplasty, and chronic pain.

34.2 Overview

Neovaginal stenosis, or the loss of width and depth of the introitus or neovaginal canal, represents one of the most reported complications of vaginoplasty [Reference Dreher, Edwards and Hager1,Reference Horbach, Bouman and Smit2]. Vaginal measurements today are mainly based on studies from Master and Johnson from the 1960s. To date, the total vaginal length (TVL) is measured according to the Pelvic Organ Prolapse Quantification (POP-Q) System, which takes into consideration the ethnic group of the cisgender female of reproductive age when determining length [Reference Pendergrass, Reeves, Belovicz, Molter and White3]. On average, the length ranges from 7–8.25 cm in an unstimulated state to up to 10.5–12 cm in an arousal state. Surgeons consider the creation of a neovagina with a minimum depth of 11 cm and width of 3 cm necessary to enable vaginal penetration with a penis [Reference Slater, Vinaja and Aly4]. While stenosis is highly individual and not solely dependent on length and width, a width of less than 3 cm mostly causes dyspareunia and may cause complaints of vaginal stenosis. Stenosis of the neovagina occurs in 4–15% of patients following penile inversion vaginoplasty, with a mean incidence of 12% [Reference Dreher, Edwards and Hager1,Reference Horbach, Bouman and Smit2,Reference Levy, Edwards and Cutruzzula-Dreher5]. Neovaginal canal stenosis (as opposed to the less severe problem of narrowing of just the introitus) occurs in 1–12% of these patients, with a mean incidence of 7% [Reference Chen, Reyblat, Poh and Chi6]. Additionally, it has been reported in 9–43% of patients following sigmoid vaginoplasty [Reference Horbach, Bouman and Smit2,Reference Ferrando7] and in 1–6% of patients following ileal vaginoplasty [Reference Horbach, Bouman and Smit2]. In a retrospective study of 15 patients who underwent vaginoplasty using a novel pudendal-groin flap technique, 13% of patients developed mild to moderate vaginal stenosis [Reference Mukai, Watanabe, Sugimoto, Kimata and Namba8]. Neovaginal stenosis is reported to be the reason for subsequent surgical revision in 2–5% of patients following penile inversion vaginoplasty [Reference Dreher, Edwards and Hager1,Reference Levy, Edwards and Cutruzzula-Dreher5] and in 1–4% of patients following intestinal vaginoplasty [Reference Ferrando7].

Neovaginal stenosis rates are underreported due to patients often being geographically distant from their surgical center, lacking the resources to pursue further treatment, being without insurance coverage, choosing to have a vagina solely for improvement of self-esteem as a woman without intending to have penetrative sex, or choosing sexual activities that do not require much vaginal depth and width [Reference Levy, Edwards and Cutruzzula-Dreher5,Reference Selvaggi and Bellringer9]. This complication has been associated with lower satisfaction rates after vaginoplasty [Reference Lawrence10].

The most significant factor that predicts this complication is patient nonadherence to postoperative dilation schedules, which will result in reduction of the vaginal cavity in nearly every case. Yet, even with diligent self-dilation, stenosis can be caused by granulation tissue, scar contracture, lack of graft adherence, local infection, and tissue contraction from decreased blood supply [Reference Dreher, Edwards and Hager1]. Smoking has also been associated with higher rates of vaginal stenosis, and all patients are advised to avoid nicotine products before and after surgery [Reference Ferrando7]. While obesity has been associated with an increased risk of surgical complications in many procedures, BMI has not been found to be a predictor of postoperative complications in penile inversion vaginoplasty patients [Reference Gaither, Awad and Osterberg11,Reference Ives, Fein and Finch12].

A rare subset of patients have an unusual form of reversible vaginal stenosis that appears only when sexually aroused. This is hypothesized to occur from residual erectile tissue derived from retained bulbospongiosus muscle that was not sufficiently removed. Higher levels of surgical experience have been associated with fewer cases of vaginal stenosis with sexual arousal, potentially from more complete removal of periurethral erectile and muscle tissue [Reference Lawrence10].

Psychosocial barriers to successful maintenance of neovaginal dilation after vaginoplasty include lack of motivation to adhere to the dilation schedule (potentially due to lack of desire for penetrative intercourse), unstable relationships, interpersonal conflicts, sociocultural factors, and mental health disorders. Underlying learning disabilities and low comprehension of the process have also been implicated in cases of limited compliance with the dilation plan. Furthermore, logistical issues play a role in preventing patients from being successful with their dilation regimens, including a limited ability to travel to the clinic, inadequate instruction from the healthcare team on how to perform neovaginal dilation, and a lack of privacy at work or home. Patients should therefore be thoroughly counseled and undergo an assessment to determine their readiness to adhere to a postoperative dilation plan prior to vaginoplasty [Reference Amies Oelschlager, Kirby and Breech13].

34.3 Preventing Stenosis during Penile Inversion Vaginoplasty Surgery

Anatomic differences exist between a cisgender male and female pelvis that can pose challenges during vaginoplasty. For one, the cisgender female pelvis has a more rounded frame than the male pelvis, and the subpubic angle of the pubic arch where the two rami meet is nearly a right angle in the cisgender female pelvis, whereas it is approximately 30 degrees narrower in the cisgender male pelvis [Reference Leong14]. Therefore, it is imperative that special attention is made to creating a deep and wide vaginal space within the confines of this narrower pelvis when performing vaginoplasty to reduce the risk of neovaginal stenosis. Other intraoperative techniques to reduce this risk include carefully preserving the penile flap, transposing it using a tensionless approach, and subsequently augmenting the length of the neovaginal canal using a scrotal split thickness skin graft. We routinely create a vaginal space at least 14 cm deep and 6 cm wide, although some wound contraction will always occur after even the most efficient vaginoplasty. To achieve a deep and wide neovaginal canal, the pelvic floor muscles should be widely dissected during the procedure to maximize the recto-prostatic space. Additionally, lateral ½–1 cm incisions into the anterior levator ani muscles may be required to further widen the space, for optimal result. Meticulous hemostasis of the neovaginal space is critical before placing the penile skin flap and scrotal skin graft into the canal, as hematoma formation can cause graft loss and later, vaginal stenosis [Reference Chen, Reyblat, Poh and Chi6]. The ischiocavernosus muscles can also be incised after the vaginal cavity is formed to enlarge its width, and some surgeons suture the graft to the sacrospinal ligament to ensure good graft fixation [Reference Raigosa, Avvedimento and Yoon15], although we have not found this necessary. A vaginal depth less than 6 cm is associated with an increased need for secondary revision surgery [Reference Li, Crane and Santucci16].

Once the dissection is completed, the penile skin flap should be carefully excised and transferred into the canal. The mons and inferior abdominal wall are elevated judiciously to achieve a tensionless advancement of the penile skin flap into the neovaginal canal [Reference Chen, Reyblat, Poh and Chi6]. The complete resection of periurethral erectile tissue should be performed to reduce the rate of vaginal narrowing with sexual arousal following vaginoplasty. (While this step was not emphasized in early reports of vaginoplasty technique, it is now known that excess remnant corporal cavernosa tissue can at times lead to vaginal stenosis, especially when aroused [Reference Dreher, Edwards and Hager1].) Some centers have attempted to augment the vaginal cavity by adding portions of the spatulated penile urethra to further improve neovaginal depth and width [Reference Dreher, Edwards and Hager1,Reference Raigosa, Avvedimento and Yoon15,Reference Perovic and Djinovic17], but as we use the urethra to create a moist/pink peri-clitoral area, we have not adopted this approach. A small perineal flap can also be formed to create a spatulated posterior fourchette, which may further decrease the risk of introital stenosis [Reference Chen, Reyblat, Poh and Chi6]. This highlights the several steps to create a deep/wide vaginal space and also avoid vaginal stenosis later:

1. 
   

   1. Create a deep vaginal cavity

   
   
2. 
   

   2. Create a wide vaginal cavity

   
   
3. 
   

   3. Transfer well-vascularized penile flap tissue into the space

   
   
4. 
   

   4. Transfer additional well-prepared split thickness skin graft into the space, well held in place by vaginal packing to allow the graft to take; and

   
   
5. 
   

   5. Avoid inferior introital stenosis by the placement of healthy perineal skin into the introitus.

Once the penile flap is dissected free, a split thickness skin graft derived from the scrotum can be attached to the flap over a silicone mold to achieve additional depth of the canal (Figure 34.1). The scrotum, once removed, is painstakingly thinned on a separate sterile table and sewn as a “cap” onto the existing penile skin flap, over a vaginal mold, to provide significant additional depth. This has been proven to improve stenosis rates [Reference Dreher, Edwards and Hager1,Reference Levy, Edwards and Cutruzzula-Dreher5,Reference Raigosa, Avvedimento and Yoon15].

Figure 34.1 The penile skin has been removed from the phallus and is sewn to the thinned scrotal skin to create a large-sized composite flap/graft lining of the neovagina.

After completing the vaginoplasty (Figure 34.2), vaginal packing is placed in the neovaginal canal. Soaking the packing in copious lubricating jelly or estriol (E3) cream is crucial so that it does not adhere to the flap/graft when being removed. Use of local antibiotic foam theoretically decreases overgrowth of local flora during the 5–7 days that the packing is in place, however this topic is being actively debated worldwide and consensus about this practice is lacking. Placing the packing with forceps helps to fill the cavity evenly, and the packing is then sealed in place with a bolster dressing made of nonadherent petrolatum dressing over ABD-type dressing affixed to the skin with permanent suture [Reference Li, Crane and Santucci16] (Figures 34.2 and 34.3).

Figure 34.2 Immediate postoperative appearance after penile inversion vaginoplasty. Note excellent cosmetic result.

(Photo provided with permission by Dr. Ashley Deleon; Crane Center for Transgender Surgery)

Figure 34.3 Postoperative bolster dressing made of nonadherent petrolatum gauze over ABD-type dressing, sewn into place with silk sutures. This dressing and the vaginal packing stay in place for 5–7 days after surgery.

A minor source of potential vaginal obstruction may be seen in those with significant amounts of hair regrowth in the vagina after surgery. This is uncommon. Preoperative hair removal along the base of the phallus is expected to decrease the number, thickness, and length of hair in that area, although we have seen no clinical proof that any hair removal method is truly “permanent.” Significant hair regrowth in the vaginal cavity may cause vaginal discharge, discomfort with dilation/intercourse, and the potential for a hair ball to serve as a nidus for debris and infection. Several cycles of either laser hair removal or electrolysis are recommended before surgery. Electrolysis is widely perceived by patients and in the lay literature as being more effective than laser, although we have seen no scientific evidence to support that claim. In fact, a systematic review by Haedersdal et al. suggest that laser hair removal is superior to electrolysis [Reference Haedersdal, Matzen and Wulf18,Reference Pariser and Kim19]. Note that the laser energy is not well absorbed by light-colored hair, and laser depilation might not be possible in light-haired individuals. We avoid intraoperative “scraping” of residual hair follicles in the penile base because it can lead to graft thinning/devascularization [Reference Chen, Reyblat, Poh and Chi6] and violates our policy of maximum preservation of the integrity/blood supply of this critical flap.

34.4 Using Biomaterials to Optimize Vaginal Healing

Adjuvant biomaterials have been used to improve healing in a variety of body locations and tissues. In general, biomaterials provide scaffolding for the cell to better stimulate revascularization, cellular migration, and repopulation of injured tissue, and have been shown to improve healing rates in difficult healing environments such as diabetic and venous stasis ulcers [20]. As of now, more than 76 biological material products are currently on the market and are classified as being either cellular or acellular, dermal or dermal/epidermal. They can be made of human, animal, or synthetic source material. Acellular dermal substitutes derived from natural biological materials are the most common biomaterials on the market. This category includes human placental membranes, decellularized donated human debris, and animal tissue [Reference Snyder, Sullivan and Schoelles21].

These biological material products may be used by surgeons in an attempt to improve surgical healing and decrease scarring in the neovaginal vault. They are typically seeded onto the neovaginal cavity immediately before flap placement. Theoretically, the active cytokines contained in some of the biological material products are present in high amounts and in the correct ratios to improve local healing [Reference Li, Crane and Santucci16,Reference Drinane and Santucci22]. While many scientific reports support that the use of these types of materials could improve healing and decrease scarring, further research into their benefits are required to determine their actual effectiveness in vaginoplasty surgery [Reference Sheikh, Sheikh and Fetterolf23].

34.5 Alternative Surgical Techniques for Vaginoplasty