Gender Surgery

Vaginoplasty

Vaginoplasty refers to a surgical procedure to construct a neovagina to allow male-to-female transgender individuals to have sexual intercourse in the same manner as a natal female. The procedure also includes the construction of external female genitalia, including clitoroplasty, labiaplasty, urethroplasty, and orchiectomy.

Criteria before GAS Vaginoplasty

1. Must have a diagnosis of gender dysphoria, certified by two psychiatrists.
2. Aged 20 (Patients aged over 18 but less than 20 must also provide parental consent).
3. Must have sufficient understanding of the surgery and competence to sign the consent.
4. No comorbid conditions preventing surgery or anesthesia.
5. Individuals with a concomitant psychiatric disorder must be treated until the symptoms are well controlled prior to surgical intervention.
6. Must have taken feminizing hormone therapy for at least 12 months (unless there are contraindications that prevent individuals from using hormonal therapy)
7. Have been successfully living a life as a female in society for at least 12 months.

Techniques of Vaginoplasty

Techniques of vaginoplasty vary based on the type of tissue used to line the neovaginal wall. In cases where the patient has enough penile or scrotal skin, the standard method is penile skin inversion with scrotal skin graft extension. This method is relatively simple and uncomplicated. However, a drawback of this technique is that the neovagina must be constantly dilated to prevent vaginal stenosis. Other underlying complications that may arise include keloid formation, wound dehiscence, urethral stenosis or split urinary stream, loss of sexual arousal or inability to reach orgasm, and rectovaginal fistula.

If penile or scrotal skin is insufficient, such as secondary to prior circumcision or orchiectomy, alternative options for neovaginal lining include colonic flap, peritoneal flap, or skin grafting from a different area.

Common vaginoplasty techniques

• Penile skin inversion
• Penile skin inversion with scrotal skin graft extension
• Total scrotal skin grafting
• Colonic vaginoplasty
• Peritoneal vaginoplasty
• Vaginoplasty using skin from other areas, such as the groin or thighs

Colonic vaginoplasty is a surgical procedure in which the colon is used to construct a neovagina. An advantage of the technique is that the neovagina can be deeper and has a lower probability of stenosis. Moreover, colonic mucosa naturally produces mucus, which serves as a lubricant. However, main drawbacks of this technique include scars in the abdominal area, a more complex surgery, longer recovery time, and has a risk of having more severe complications. Moreover, adhesions may occur and may result in gut obstruction. Colonic vaginoplasty is suitable for patients who do not have enough penile and scrotal skin, prefer a deep neovagina, or need secondary correction of neovaginal stenosis.

Peritoneal vaginoplasty is widely used to treat women with vaginal agenesis. However, this technique is now frequently used to construct a neovagina for transgender women. An advantage of this technique is it results in a neovagina that is smooth with a similar consistency to biologic vaginas and that contains a small amount of lubricant. However, this procedure's drawback is that it requires abdominal surgery (which may cause adhesions) and creates abdominal scars. Furthermore, the neovagina constructed from the peritoneal tissue can stenose and also requires regular dilation.

Skin grafting from groin or thigh is typically used as a corrective surgery in cases where the neovagina has minor stenosis. It also can be used as the primary procedure if the patient does not have enough penile and scrotal skin but wants to avoid abdominal surgery. A drawback of this procedure is surgical scars at the donor area.

Choosing a vaginoplasty technique depends on various factors, such as the patient’s needs, the amount of available penile and scrotal skin, history of genital surgery such as prior circumcision or orchiectomy, and the patient’s pelvic size that determines the depth of neovaginal construction. The surgeon must explain the advantages, drawbacks, and possible complications that may arise and to help guide patients towards a final decision together.

Metoidioplasty

Metoidioplasty is the construction of microphallus from the existing clitoris that has been enlarged through testosterone treatment. This technique allows patients to urinate standing. However, they are usually not capable of penetrative sexual intercourse. This technique is suitable for those who want to avoid a complicated surgery and prefer a less costly procedure. Patients who have undergone a metoidioplasty can later opt for a phalloplasty if a larger penis is desired.

The metoidioplasty procedure consists of separating the clitoral hood and suspensory ligament to increase the clitoral length and elevating its position anteriorly while preserving erectile tissue and sexual sensation. A neourethra will need to be constructed which opens at the microphallus tip. If metoidioplasty is performed with colpectomy, the surgeon will use the anterior vaginal flap to construct a urethra. However, if the patient has had previous colpectomy, they may need to undergo skin or mucosal grafting (such as from the buccal mucosa) instead.

The surgeon should counsel the patient that not every case can urinate standing (successful in approximately 90 - 95% of all patients). Metoidioplasty patients should have a clitoral length of at least 3 cm after full anterior stretching preoperatively to ensure a successful surgery. A major complication of metoidioplasty is urethral stricture or fistulas, which occur in 5% and 15% of all cases, respectively.

Phalloplasty

Phalloplasty is a surgical construction of a penis that is near the size of an adult erect penis (neophallus). This procedure is done using vascularized flaps from other body parts, such as the arms, legs, abdomen, or groin.59 Phalloplasty enables patients to urinate while standing and to have sexual intercourse. It can be done as the first surgery or after metoidioplasty.

The most widely used techniques for phalloplasty are the radial forearm free flap and anterolateral thigh flap. These require both vascular and neuronal anastomoses between the neophallus and clitoris to allow for sensation during intercourse.60 Erectile function can be created by penile prosthesis implantation, of either the rigid or inflatable type. Some authors reported the use of the fibula free flap phalloplasty so that there is no implanted foreign body.

Complications that may arise from phalloplasty include

1. Issues involving the urinary system, such as urethral stricture or fistulas, incomplete bladder emptying, hair growth in the urethra (in cases where skin grafting was used), or vesicoureteral reflux.
2. Flap failure
3. Lack of sensation at the constructed neophallus or inability to have sexual intercourse.
4. Donor site morbidity
5. Other complications, such as bleeding, infection, wound dehiscence or non-healing wound.

Phalloplasty is quite a complicated procedure and may require staged operations to ensure a successful outcome. For example, the urethra may be constructed first, followed by construction of the neophallus. For this reason, this operation is not yet currently popularized in the trans population. In addition, individual preferences play an important role: some trans men may place more importance on the size and appearance of the neophallus rather than on erectile function and sexual sensation. Those who wish to undergo this surgical procedure should undergo extensive counseling with a surgeon to first be educated on both benefits and possible complications of the surgery before deciding.

Criteria for female-to-male GAS Metoidioplasty/phalloplasty

1. Must have a diagnosis of gender dysphoria, certified by two psychiatrists.
2. Aged 20 (Patients aged over 18 but less than 20 must also provide parental consent).
3. Must have sufficient understanding of the surgery and competence to sign the consent.
4. No comorbid conditions preventing surgery or anesthesia.
5. Individuals with a concomitant psychiatric disorder must be treated until the symptoms are well controlled prior to surgical intervention.
6. Must have taken masculinizing hormone therapy for at least 12 months (unless there are contraindications that prevent individuals from using hormonal therapy)
7. Have been successfully living the life as a male in society for at least 12 months.

Scrotoplasty

A scrotoplasty can be performed using skin from the labia majora, along with testicular silicone implantation. This procedure can be performed together with metoidioplasty or phalloplasty, or as an isolated procedure. The most common technical challenge in a scrotoplasty is that usage of the labia majora skin results in a scrotum that is too posteriorly located which may require advancement of the major labia. In cases with insufficient labial skin, a tissue expander may need to be placed prior to implant insertion.

Refer: Gender Affirmation Surgery - The Thai Handbook of Transgender Healthcare Services, Center of Excellence in Transgender Health, Chulalongkorn University