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Review
. 2019 Jun;8(3):191-208.
doi: 10.21037/tau.2019.06.19.

Overview of surgical techniques in gender-affirming genital surgery

Mang L Chen  1 , Polina Reyblat  2 , Melissa M Poh  2 , Amanda C Chi  2
Affiliations
Review

Overview of surgical techniques in gender-affirming genital surgery

Mang L Chen et al. Transl Androl Urol. 2019 Jun.

Abstract

Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.

Keywords: Transgender; metoidioplasty; phalloplasty; vaginoplasty.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Skin marking depicting scrotal skin graft used penile inversion vaginoplasty.
Figure 2
Figure 2
Creation of a posteriorly based perineal flap. (A) Midline incision made on posterior aspect of inverted penile skin flap; (B) small posteriorly based perineal flap; (C) perineal flap advanced into posterior fourchette.
Figure 3
Figure 3
Urethral bulge that protruding into anterior vagina.
Figure 4
Figure 4
Glans is rearranged to construct the neoclitoris.
Figure 5
Figure 5
Pedicle of the neoclitoris is folded gently on itself.
Figure 6
Figure 6
Clitoral hood is formed by folding the prepuce skin.
Figure 7
Figure 7
Position of the neomeatus relative to the neoclitoris, prior to transection of the urethra.
Figure 8
Figure 8
Post vaginoplasty pressure dressing. (A) Labia majora sewn together to keep vaginal packing in place; (B) pressure dressing.
Figure 9
Figure 9
Transvaginal repair of rectoneovaginal fistula with gracilis interposition flap. (A) Gracilis interposition flap; (B,C) insetting the gracilis flap.
Figure 10
Figure 10
Pinpoint neomeatus.
Figure 11
Figure 11
Vaginectomy. (A) After distal sharp mucosal excision, the remainder of the vaginal mucosa is fulgurated; (B) colpocleisis is carried out with thick polydioxanone suture.
Figure 12
Figure 12
Markings demonstrate tissue used for pars fixa urethroplasty.
Figure 13
Figure 13
Creation of smooth dorsal urethral plate. (A) There are indentations of mucosa flanking the native urethral meatus—the periurethral fornices; (B) the fornices are demucosalized.
Figure 14
Figure 14
Flap harvest for urethral lengthening. (A) The inferior aspect of the “ring” flap is divided to facilitate flap harvest; (B) labia minora flaps are elevated.
Figure 15
Figure 15
The dorsal urethral plate is created by bringing both parts of the original ring to the midline between the urethral meatus and the inferior aspect of the clitoris after chordee release.
Figure 16
Figure 16
Pars fixa urethroplasty is completed with ventral closure.
Figure 17
Figure 17
De-epithelialized portions of the labia minora flaps are preserved and used as additional coverage over the native urethral-to-ring flap anastomosis.
Figure 18
Figure 18
Vascular de-epithelialized flaps from the labia minora tissue not used for urethroplasty are preserved for coverage of the pars fixa urethral suture line.
Figure 19
Figure 19
Immediate postoperative photo of patient after metoidioplasty with urethral lengthening, vaginectomy, scrotoplasty, and perineal reconstruction.
Figure 20
Figure 20
Dorsal nerve dissected free from one side of a de-epithelialized clitoris.
Figure 21
Figure 21
Pouch-like anteriorly positioned scrotum after labia majora flap elevation, rotation, and advancement.
Figure 22
Figure 22
Bulbospongiosus muscle layer is used to cover the proximal pars fixa urethroplasty suture line.
Figure 23
Figure 23
Inner thigh skin is brought towards the midline to complete the perineal reconstruction.
Figure 24
Figure 24
PF and PP urethral anastomosis. PF, pars fixa; PP, pars pendulans.
Figure 25
Figure 25
Adipofascial flap from the RFFF covers the PF-PP urethral suture line. RFFF, radial forearm free flap; PF, pars fixa; PP, pars pendulans.
Figure 26
Figure 26
Immediate postoperative appearance of neophallus and scrotum after RFFF phalloplasty, urethroplasty, vaginectomy, scrotoplasty, and perineal reconstruction. RFFF, radial forearm free flap.
See this image and copyright information in PMC

References

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