SRS MtF operations
Lack of vagina has a devastating impact on the life of biological women, but it particularly affects transsexual MtF people. In such patients it is important to create a normal functioning neovagina with satisfactory sexual function and aesthetic appearance.
Indications for reconstruction
Vaginal reconstruction is carried out in the case vaginal non-development or other sexual developmental disorders, transsexualism, defects resulting from genital cancer surgery and perineal trauma. There are several surgical procedures that are used and the final result is related to the postoperative healing process, anatomical structure and functional conditions before surgery.
- Popular methods of operation include:
- 1 skin grafts,
- 2 bladder, cheek or penile mucous membrane grafts,
- 3 skin patches of the anal region,
- 4 local genital lobes
- 5 intestinal lobes.
Skin grafts are often used because of their simplicity and the fact that they are associated with fewer complications.
In transsexual patients with preserved penis and scrotum the use of penis and scrotum lobes remains the method of choice. The discussion among physicians is still ongoing due to the large number of described surgical techniques, and there is still considerable controversy over which option is best.
Indications and contraindications
Aesthetic, sensory and functional results of vaginoplasty are different between different centres. Surgeons differ significantly in skills, experience and techniques, also patient tissues differ in flexibility and healing ability. The final aesthetic result is undoubtedly influenced by earlier surgery in the perineum, postoperative complications such as infections, blood loss or nerve damage. In the case of the best aesthetic results, after full recovery, it is often very difficult for other women, including women gynaecologists, to say that the patient had undergone vaginal reconstruction.
We present our vaginoplasty technique based on the inversion of penile and scrotum lobes in transsexual MtF patients. Vaginoplasty of the penis lobe has several advantages. The skin of the penis as a tissue lobe is less prone to shrinkage, exhibits better innervation and sensitivity, and ensures a hairless appearance and natural colour of the neovagina. You can have a normal sex life after surgery, though the level of satisfaction in the population of patients after surgery differs. Psychosocial and psychosocial outcomes lead us to understand the importance of surgical reconstruction and its impact on the life of the patient and her partner after surgery. Sometimes postoperative complications cause physical or mental problems. It is important that they are detected early and corrected in good time.
Planning and preoperational preparation
Before SRS surgery, each patient must read and agree to the full information about the treatment in accordance with the current standard of care . The preoperative assessment of each patient includes a clinical examination of the external genitalia, ultrasound, and a full range of laboratory tests. The patient needs to clean her intestine with an enema the day before the operation. Antibiotics are administered intravenously. Pre-operative planning involves estimating the appropriate size and position of neoclitoris based on patient preference. For penile hairy skin, preoperative laser hair removal is recommended to prevent hairy neovagina.
The operation starts with a simple bilateral orchectomy (removal of the testicles), after which the penis is divided into individual anatomical elements: cavernous bodies, glans with urethra and neurovascular bundle and vascular skin of the penis. In this way, tissues from all elements of the penis (except cavernous bodies) will be used to reconstruct the vulva, clitoris and vagina.
The glans with the neurovascular bundle and the urethra are separated from the cavernous bodies together with Buck’s fascia with completely preserved nerves. Then the stem of the glans is divided into parts. The dorsal part of the glans is reduced by excision of centrally located tissue, the sides of the glans are left behind. These tissues are used to produce neoclitoris, a clitoris, and are deeply modeled and stitched to produce a conical shape and size with adequate blood supply and sensitivity. The division of the penis also ensures the separation of cavernous bodies, which are removed at their attachments to the pubic bone arms. The remaining short stretches of cavernous bodies (erectile tissue) are also destroyed to prevent postoperative erections that could hinder sexual intercourse.
A vascularised urethral lobe is necessary for vaginoplasty. The urethra is of sufficient length and therefore never a limiting factor for vaginal reconstruction. The separation of the urethra from the penis and the spongy body must be precise. The urethra is then used to form the anterior part of the neovaginal mucosa. The urethral lobe gives a natural look to the neovagina, especially at the entrance. Then a female urethra is produced and the neoclitoris is attached above the new urethra outlet.
During the reconstruction of a new vagina, the skin of the penis and foreskin (if present) is shaped into a vascularised tube. A hole is made at the base for the transposition of the urethral lobe and neoclitoris. An incision is made on the dorsal side of the penis skin. The urethral lobe is pushed through the opening and then sewn onto the incision in the tube. The tube, which already consists of the skin of the penis and the urethral lobe, is inverted, creating a new vagina. If the skin of the penis is insufficient (small and/or circumcised penis) and the urethral lobe is long – they will be disproportionate. In this case, the vagina is formed by free skin grafts from the scrotum area. Vascularised urethral lobes play a key role in creating a new vagina.
Space for the new vagina is created in the crotch. Usually a tunnel is made on both sides at the centre of the perineal arch, then the rectum muscles are cut, allowing access to a deep and wide perineal cavity between the urethra, bladder and rectum. Special care should be taken during this manoeuvre to avoid damage to the rectum, bladder and large blood vessels. This manoeuvre is particularly difficult in the male pelvis, as is the case in transsexual MtF patients. Good teamwork at this crucial moment helps to ensure adequate exposure of the surgical field and prevent damage to the rectum, pudendal nerve, internal pudendal artery and pelvic veins. This part of the operation requires a great deal of experience and manual skill of the surgeon. A technically correct inversion ensures good positioning of the neovagina and reduces the risk of organ prolapse.
Vulvoplasty involves the formation of smaller and larger vulvar lips. The rest of the base of the penis skin is used to form the vulvar lips, which are sewn into the deeper neoclitoris area and thus covered by the vulvar lips. Excess scrotum skin is removed and the rest is used to create larger labia.
After the operation.
In the perineum area after the operation we use surgical drainage, which is left for 3 days. The patient is discharged on the third day after the procedure with a permanent Foley catheter, which is removed usually after 5-7 days. Antibiotics are administered up to 14 days after surgery. The vaginal tampon (a condom filled with a soft gauze moistened with vaseline) is placed in the vaginal cavity after the procedure for 1 week, and then vaginal stenting at night for 6 weeks. On discharge from the hospital, patients are instructed on how to maintain hygiene and how to use neovaginal dilation. Neovaginal dilation is mandatory with a vaginal dilation kit once a day for 6 months.
Depth and diameter of the neovagina
The most important features of the new vagina are depth and width. In our study, the results indicate that the mean depth was 11.6 cm (in the range of 9±18). Accurate measurement of vaginal width is difficult. In our patients, we use a vaginal dilator in the evaluation. This allowed us to classify them as small, medium and large with diameters of 2.7 cm, 3.5 cm and 4.5 cm respectively.
Moisturization, orgasm and sensitivity of neovagina
An important feature of a new vagina is the feeling of moisturization – lubrication and the possibility of experiencing orgasms. In our vaginal plastic surgery method, a vascularised urethral lobe is essential to produce and maintain the moisturization and sensitivity of neovagina. Patients are satisfied with their sensitivity to touch, caresses and the possibility of experiencing orgasm. In our studies, 96% and 83% of patients reported good sensitivity and full orgasm, respectively.
Aesthetic appearance of the external genitalia
After surgeries, patients feel a significant degree of satisfaction with the aesthetic appearance of the external genitals. Despite the high satisfaction with the final results of vaginal plastic surgery, sometimes in some patients the appearance of clitoris and labia may be less acceptable. However, minor correction procedures solve all the problems presented.
After surgery, urination is generally satisfactory in all our patients. A small number may experience some disorders, such as a narrowing of the urine stream, a high position of the new urethra or a slightly lateral position of the urethra. We know from experience that with a minimally invasive procedure, correction is possible.
We recommend resuming sexual intercourse 3-6 months after vaginal surgery. We confirmed that 79% of our patients are capable of experiencing normal sexual intercourse, but despite the correct structure of vulva and vagina some patients abstained from intercourse. In sexually active patients, 81% reported satisfactory sexual satisfaction.
Transgenital MtF surgery is a difficult and complicated treatment, so similarly to other serious surgeries all postoperative complications can be observed. In the review of the literature on vaginal reconstruction conducted below we present all the rare and the most frequent postoperative complications, whose frequency of occurrence fluctuates between 10%-20%
The experience of Timeless Clinic shows that general complications can be prevented by a wide range of pre-operative tests, which enable detection of unrecognized, latent diseases before surgery, as well as targeted application of active and passive perioperative prophylaxis. The presented data show that the majority of complications occur at the site of surgery and can be detected early, treated and effectively corrected. We know from statistics that the risk of postoperative complications will never reach zero. We firmly believe in the patient’s awareness that the treatment takes place in a team of well-trained, committed doctors and nurses who offer the best care, which will help alleviate the significant stress often experienced by transgendered persons on their way to achieving their goals.
Female genital reconstruction in transgendered MtF patients is generally a safe and reasonable choice with an acceptable number of complications and very good aesthetic and functional results. We know that it will never be possible to reach a consensus on the ideal method of vaginoplasty. Nevertheless, care should be taken to choose the most optimal method, tailored individually to the patient. Although the vaginoplasty by inversion of penile skin patches is largely standardized as a basic option, we strive to improve known techniques to meet the specific patient requests for neovagina function and ideal aesthetic outcome. We firmly believe that every transgendered person in the course of their transition deserves to be treated by a team of well-trained, committed and understanding professionals.