Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients
Pietro G. di Summa MD, PhD; William Watfa MD; Swenn Krähenbühl MD; Clara Schaffer MD; Wassim Raffoul MD; Olivier Bauquis, MD
FIRST PUBLISHED: October 24, 2019 – The Journal of Sexual Medicine
In male-to-female surgical transitions, the “traditional” approach to vaginoplasty has been inverting penoscrotal skin to create a neovagina. The technique is satisfactory for some patients, but complications like stenosis, retraction, painful intercourse, and fistulas are possible. Patients may require secondary corrective surgery.
Another surgical option is laparoscopy-assisted sigmoid vaginoplasty, during which a neovagina is created from intestinal segments. This approach allows for greater vaginal depth and lubrication. The method has become more common in patients undergoing a secondary procedure. However, there are disadvantages, including higher risk for diversion colitis, and ulcerative colitis.
The current study compared the two techniques and focused on technical aspects and complications. Functional, sexual, and aesthetic outcomes were also analyzed.
Patients and Methods
The study involved 43 patients who underwent male-to-female genital surgery between 2007 and 2017 at one location. One surgeon performed all of the surgeries.
Chart Review and Patient Questionnaires
Retrospective medical records were reviewed. All participants received a 5-question survey in the mail. Patients answered questions on aesthetics and general function after surgery. They also reported on the ease of achieving orgasm, location of orgasm, and pain during intercourse.
Patients who underwent a secondary vaginoplasty after a penile inversion procedure answered questions for both procedures.
Penile-skin inversion was the preferred technique at this clinic until 2014. Afterward, a rectosigmoid vaginoplasty was preferred unless the patient’s penis shaft was long enough to create a neovagina.
Vaginoplasty by Penile Skin Inversion
The penile skin inversion technique was described as follows (please note quoted material in italics):
In the lithotomy position, surgery started by orchiectomy and penile amputation while preserving scrotal and penile skin. Care was taken to ligate the spermatic cord close to the inguinal canal. The urethra was prepared and separated from its attachments to the corpus cavernous before the insertion of a Siliconed Foley catheter. The glans neurovascular pedicle was preserved, as it would become the clitoris. The next step was creating the neovagina cavity by blunt dissection in dissecting a virtual plane between the rectum and bladder up to the peritoneal fold. Care was taken to avoid any visceral breach during this dissection. Identification and sparing of the prostate and bulbourethral glands was performed. Once the cavity was ready, penile skin was inversed and inserted in the cavity. The shorter urethra and the clitoris were then exteriorized at the desired location on the penile skin. In the final step, external labia were created by suturing the penile cutaneous flaps together.
Patients were discharged at day 7 postoperatively and follow-up was performed at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Dilation started after packing was removed during hospital stay and patients were instructed for the following dilatational regime: 3 times/day for 10 minutes each time for the first 3 months, once per day for 10 minutes for 3−6 months after surgery, 2−3 times per week for 10 minutes after 6 months, and 1−2 times per week for 10 minutes after 9 months.
Vaginoplasty by Sigmoid Transplant
The sigmoid transplant technique was quoted as follows (please note quoted material in italics):
This procedure was performed synchronously with the laparoscopic general surgery team. In the lithotomy position, surgery started by excising the old vaginal cavity. In parallel, using laparoscopy, the general surgery team harvested a 12−15 cm rectosigmoid portion with its superior hemorrhoidal artery pedicle. An end-to-end anastomosis was done using a stapler through the rectum to re-establish intestinal continuity. Dissection was carried on further into the vaginal cavity toward the peritoneum until arrival to the intraperitoneal cavity. Once the tunnel was completed and allowed the comfortable passage of 2 fingers, the pedicled rectosigmoid was pulled through, avoiding any twist or kinking through the tunnel to the vagina entrance where it could be attached by sutures. Only the neovaginal cavity was transformed. No changes were performed on the external genitalia (including the neoclitoris). Patients were discharged at day 7 postoperatively and follow-up was performed at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Vaginal dilatation started at 3 weeks postoperatively. The dilation regime was the same as for the penile-skin patients (described above).
Results and Discussion
Of the 43 patients who underwent surgery, 38 (88.4%) had penile inversion procedures and 5 (11.6%) were referred from other clinics for secondary sigmoid-based vaginoplasty.
Overall, 13 secondary rectosigmoid neovagina procedures were performed.
Patient age ranged from 22 to 69, with an average of 42 years. All had been on hormonal therapy before their surgery. Follow-up lengths ranged from 14 months to 5 years after surgery.
Seventeen patients (39.5%) had complications that required reoperation. The most common complications were the following:
- Vaginal stenosis. (17 patients: 13 from penile-skin group and 4 from secondary sigmoid group)
- Postoperative bleeding. (1 patient from penile-skin group, none from secondary sigmoid group)
- Partial necrosis of the vulva. (4 patients: 3 from penile-skin group, 1 from secondary sigmoid group)
- Urethral stenosis. (2 patients, both from penile-skin group)
- Rectovaginal fistula. (3 patients: 1 from penile-skin group and 2 from secondary sigmoid group)
The most common complication, vaginal stenosis, might be explained by poor compliance with the vaginal dilation protocol. Most patients indicated that they had trouble with the prescribed dilation protocol.
Patient-Reported Functional and Cosmetic Satisfaction
Twenty-eight patients (65%) completed the questionnaires. Of these, 20 had had penile-inversion procedures and 8 had had secondary sigmoid vaginoplasty after penile-inversion procedures.
- Aesthetic appearance of the vulva. Eighty-nine percent of the patients said they were “satisfied” or “very satisfied.” There were no significant differences in satisfaction between groups. It appears that “choice of technique does not affect the cosmetic external result.”
- Functional assessment. Answers between the groups were not statistically different, although the sigmoid-based group tended to have more positive answers.
- Ease of orgasm reach. There was no statistical difference in answers between the two groups. In answers ranging from A (“very easy to reach”) to D (“never reach,”) the median answer was B (“easy to reach.”)
- Anatomic location of orgasm. Among 28 patients reporting on penile-skin inversion surgery, 54% said they had mostly clitoral orgasms, and 29% indicated orgasm in both the vagina and clitoris. In 8 patients who had a secondary neovagina, 63% could feel orgasm in both the vagina and clitoris.
- Pain during intercourse. Patients who eventually had a secondary vaginoplasty reported more pain after penile-inversion than those who did not have a secondary procedure. After their second surgery, they reported less pain and had results comparable to those in the penile-inversion group who did not have secondary surgery.
Several limitations were acknowledged:
- The study was retrospective in nature.
- Only 65% of the patients completed the questionnaire.
- Patients who had had secondary surgery answered questions about both their first and second procedures. Results might have been more accurate if they had completed the questionnaire between surgeries.
Patients who underwent penile skin inversion and sigmoid vaginoplasty had similar cosmetic and functional results. Pain during intercourse was a common reason for dissatisfaction after penile-inversion surgery. “This sometimes undervalued symptom should become part of the general clinical assessment in the particular delicate field of transgender genital surgery.”