V04-08: Simplified Penile Inversion Vaginoplasty
Surgical treatment of gender dysphoria has clear social and psychological benefit for transgender females. There is an increasing demand for vaginoplasty in the United States, but access remains limited due to the lack of properly trained surgeons to perform this complex surgery and insurance and social barriers. We present a simplified penile inversion vaginoplasty that preserves function, minimizes risk, and decreases OR time while achieving high patient satisfaction.
The operation consists of 3 phases: penile and scrotal disassembly, creation of a neovaginal pocket, and vaginal assembly with cosmesis. The patient is placed in a dorsal lithotomy position and two teams are ideally employed, one focused on construction of the neovagina augmented with scrotal graft and the other on penile disassembly and creation of the neovaginal pocket. Epilated scrotal grafts and penile skin flaps are harvested to construct the vaginal cavity. Bilateral orchiectomy is completed after isolation of the urethra, a neoclitoris is created from the glans, and the penis is inverted and brought through the perineum. The neurovascular bundle is left attached to the corpora to minimize inadvertent neural injury and minimize OR time. Corporal spongiosus tissue is excised to prevent pain with arousal. A neovaginal cavity is carefully created after incision of the central tendon and above the rectum, allowing placement of the scrotal graft. Lastly, we demonstrate an easy technique of labia majora and minora construction after defining the clitoris and clitoral hood.
Total time of operation is 3 hours. Patients ambulate in 2 days and are usually discharged in 3 days. Receptive intercourse is possible with vaginal depths typically in excess of 6 inches, and orgasm is usually possible within 2-3 weeks. Lifetime daily vaginal dilation and lubrication with receptive intercourse is required.
The Simplified Penile Inversion Vaginoplasty demonstrates strategies to simplify this complex operation while preserving excellent function and cosmesis.