The objective of this video is to describe our technique for performing male-to-female vaginoplasty for the transgender woman. This procedure includes penectomy, orchiectomy, urethroplasty, vaginoplasty, clitoroplasty, and labioplasty. Our secondary objective is to describe important perioperative considerations. Male-to-female vaginoplasty is performed for transgender women who desire gender affirmation surgery and meet the World Professional Association for Transgender Health Standards of Care for Surgical Transition. Several techniques exist, and in this video we describe the penile inversion vaginoplasty technique using penile and squirtle skin flaps to create the vulva and vagina. Prior to surgery, exogenous estrogen is held for four weeks. Preoperative labs are obtained, including a complete blood count, type and screen, and a complete metabolic panel. Subcutaneous heparin and sequential compression devices are used for venous thromboembolism prophylaxis. Intravenous cefazolin is administered for antibiotic prophylaxis. Patients are positioned in high lithotomy with a generous amount of padding using adjustable stirrups. The procedure begins by marking and harvesting the squirtle flap, which will later be used to line the neovagina. The borders of the flap include the base of the penile shaft, the lateral demarcations of the scrotum, approximately two centimeters medial to the groin creases, and the perineum, four to five centimeters above the anus. The flap is incised using a ten-blade scalpel. Alice clamps are placed on the edges for traction, and the flap is removed from the underlying subcutaneous tissue using sharp dissection and electrosurgery. Once the flap is removed, it is handed off and kept moist with saline-soaked sponges. If testes are present, a bilateral orchiectomy is performed. The testis is grasped with a towel clamp and placed on traction. The spermatic cord is skeletonized, then double clamped and suture ligated at the level of the external inguinal ring, which is easily identified. The inguinal ring is then closed with permanent suture to prevent future small bowel herniation. The procedure is performed bilaterally. Excess subcutaneous tissue is then removed, and the tissues are skeletonized down to Buck's fascia to expose the underlying penile structures. Next, a circumferential incision is made proximal to the glans penis. If adequate penile and squirtle skin is present to line the neovagina, excess skin of the distal penile shaft and prepuce may be left on the glans side of the incision for later construction of the labia minora and formation of the clitoral hood. The penile tissues are deepithelialized, leaving a penile tube, which will later be used to create a portion of the neovagina. The suspensory ligament of the penis is released. Next, the penile structures are deconstructed to form a dorsal flap containing the neovascular supply to the neoclitoris and a ventral urethral flap. The mid-portion containing the corpora cavernosa is excised. The corpus spongiosum is transected distally, and a Foley catheter is placed. Sharp dissection and electrosurgery are used to separate the spongiosum from the cavernosa. If desired, the cavernosa may be injected with dilute vasopressin to assist with hemostasis. Alternatively, the branches of the deep penile arteries can be sutured at the level of the crura of the corpus cavernosa. The neoclitoris is marked out on the glans penis. Bux fascia is entered, and electrosurgery is used to create a dorsal clitoral flap, maintaining the dorsal neurovascular structures of the neoclitoris within the tunica sheath. The crura are clamped bilaterally with Coker clamps, and the corpora cavernosa are amputated. The crura are then oversewn, which also helps achieve hemostasis. The excess glans is trimmed from the clitoral flap. The flap is folded on itself to ensure that the neoclitoris is positioned approximately five centimeters above the location of the intended neourethral meatus. The flap is secured to the underlying fascia with absorbable sutures. While insetting this flap, care must be taken to avoid kinking its blood supply, as this could lead to necrosis of the neoclitoris. Interrupted absorbable sutures are used to shape the neoclitoris. With a Foley catheter in place, the distal urethra and remaining corpus spongiosum are incised in the midline. The incision is carried down to the level of the pubic bone, and the urethra is then spatulated and secured to the underlying fascia. The neourethral meatus should lie flush with the bony pelvis. The remaining urethral flap is trimmed and secured, creating a mucosal surface between the urethral meatus and the neoclitoris. To create the neo-vagina, a transverse incision is made at the level of the perineum, and the perineal tendon is transected below the bulbous urethra. A cavity is created initially with sharp dissection, and further dissection is performed bluntly in the potential space between the rectum and the prosthetic urethra. Techniques vary, but our preference is to keep one finger inside of the rectum during the dissection to ensure that the proper space is being dissected and to avoid injury to the rectum. To avoid injury to the bladder and urethra, the Foley catheter is palpated and used as a guide during the dissection, which is carried past the level of the prosthetic urethra until the vesicoperitoneal fold is encountered. A natural avascular plane exists anterior to denonvilliers fascia, which is found between the prostate and the rectum. A total neo-vaginal length of 15 centimeters is usually obtained. Previous prosthetic surgery or infection can make this dissection challenging, and an understanding of the anatomic landmarks is important. Once the neo-vaginal caliber and length is determined to be adequate, meticulous hemostasis is achieved, and temporary packing is placed. Attention is turned to the scrotal flap. The subcutaneous tissue and dartose muscle is removed sharply, creating a split thickness skin graft. The flap is sewn onto a large vaginal stent, creating a neo-vaginal tube. Electrolysis or laser therapy is recommended prior to surgery to avoid hair growth in the neo-vagina. In addition, electrosurgical coagulation of the hair follicles is performed once the graft is sewn onto the stent. The stent is then passed through the penile tube, which is then anastomosed to the scrotal flap. The temporary packing is removed from the neo-vaginal cavity, and copious irrigation with dilute Bacitracin solution is performed. The vaginal tube and stent are placed into the neo-vaginal cavity. Mattress sutures are placed at the neo-entroitis to take tension off of the entroidal incision. The neo-vagina is tightly packed. A vertical incision is made through the anterior vulvar flap, exposing the neo-clitoris, the mucosal urethral flap, and the neo-urethral meatus. The edges of the flap are secured. Labia minora and a clitoral hood are created using the preserved distal penile skin and perfuse. Two Jackson Pratt drains are placed in the labia majora prior to closing the labial incisions. The subcutaneous layer is closed over the drains with interrupted sutures. The epithelial edges are closed in a running fashion. During closure, the direction of the suture line is altered as needed for cosmesis and to avoid undesirable dog ears. Post-operatively, venous thromboembolism and antibiotic prophylaxis are continued for up to 10 days. Intravenous patient-controlled analgesia is administered for the first 24 hours for pain control, then advanced to oral narcotic pain medication. Activity is restricted to strict bedrest and beach chair position for up to three days after surgery, and then modified bedrest is recommended following discharge. The Foley catheter and vaginal packing are removed on post-operative day 6 or 7, and patients are then taught how to perform vaginal dilation. Dilation is initially performed three times per day for 12 weeks, then daily or until the patient is regularly sexually active. Estrogen may be restarted no earlier than two weeks after surgery and when the patient is regularly ambulating. Patients are seen as needed during the post-operative period, and all patients return to the office 12 weeks after surgery. Virtual visits may be useful for out-of-town patients, but contact with a local provider is essential for any issues which may require immediate attention. Patients are counseled pre-operatively on expected outcomes and cosmetic results, which vary by body type and availability of skin to create labial flaps. Satisfaction is highest amongst patients who are well counseled and motivated to comply with post-operative dilation. As gender affirmation surgery becomes more common, gynecologic specialists are encouraged to become familiar with transgender vaginoplasty procedures and appropriate perioperative care.

male-to-female vaginoplasty

perioperative considerations

penile inversion vaginoplasty

exogenous estrogen

neovagina