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Neovaginal Canal Dissection in Gender-Affirming Vaginoplasty.

PURPOSE
Gender-affirming vaginoplasty creates the vulva and vaginal canal for those people assigned male sex at birth who have gender dysphoria. Dissection of the neovaginal space can be particularly challenging, with risk of injury to anal and urethral sphincters, urethra, and rectum. We present an anatomic-based technique for vaginal canal dissection.


MATERIALS AND METHODS
Retrospective cohort analysis of all patients who underwent gender-affirming vaginoplasty with a single surgeon between May 2016 and July 2019. We describe our technique for dissection and report relevant outcomes.


RESULTS
We performed 200 vaginoplasty procedures during the study period. Patient age ranged 15 - 70 (median 41). BMI ranged 16 - 50.5 (median 27). The vaginal depth ranged 10 - 16cm, with a median of 14cm, and mean of 13.7 cm. Vaginal depth was slightly greater for patients BMI >=30 vs BMI <=30 (p=0.0145). Operative complications included 2 patients (1.0%) with a full-thickness rectal injury, and 3 (1.5%) with partial-thickness rectal injury. Two of these patients (1.0%) progressed to a rectovaginal fistula (1 full- and 1 partial-thickness injury); one urethral injury (0.5%); 8 (4.0%) with vaginal stenosis; 3 (1.5%) with introital stenosis; 10 patients (5.0%) had stress urinary incontinence that later resolved.


CONCLUSIONS
Neovaginal canal dissection in gender-affirming vaginoplasty is technically challenging. An anatomic-based approach is associated with a low complication rate in our center.