V10-06: Gender-affirming vaginectomy and colpocleisis
In the United States, surgeons are performing increasing numbers of gender-affirming procedures for transgender patients. At our institution, trans men undergo multiple procedures doing their gender-affirming bottom surgery--vaginectomy and colpocleisis, urethral lengthening, scrotoplasty, and free-flap phalloplasty or metoidioplasty. We demonstrate the gender-affirming vaginectomy and colpocleisis in this video and its key differences from the procedure for pelvic organ prolapse.
We present a 23-year-old transgender male undergoing gender-affirming phalloplasty, scrotoplasty, and urethral lengthenging. Vaginectomy and colpocleisis are routinely performed as part of this operation. The patient has had previous hysterectomy and bilateral mastectomy. We begin the procedure excising the vaginal mucosa from the underlying muscularis and rectum posteriorly, the pelvic floor laterally, the pubocervical fascia anteriorly, and the vaginal cuff proximally. We preserve the labia minora and the anterior vaginal wall with a “U” incision for later urethral lengthening. Colpocleisis incorporates the prerectal fascia, pelvic floor, and pubocervical fascia from proximal to distal. Distally, the levators and bulbocavernosus muscles are incorporated to close the genital hiatus.
Due to the chronic testosterone exposure, we excise a thicker layer of vaginal mucosa since it tears easily. These patients are often younger and bleed more from testosterone exposure. The combination of testosterone and lack of prolapse makes the pelvic floor musculature more robust and prominent than in a colpocleisis for prolapse.
As transgender surgery becomes more common, surgeons with Female Pelvic Medicine and Reconstructive Surgery background may perform vaginectomy and colpocleisis in a younger population as part of their transgender surgery. Vaginectomy decreases the likelihood of retained mucocele and may be safer than blind fulguration of the vagina, which is another common practice. This video demonstrates the key steps in this procedure as well as differences from a prolapse colpocleisis.