Vaginoplasty surgery is performed for individuals born and assigned male at birth who affirm or identify as female. The most commonly performed technique is the penile inversion technique, which includes orchiectomy, deconstruction of the penile structures, reconstruction creating a vulva, labia, and clitoris, and creation of a neovagina. Creation of the neovagina is considered the most challenging part of vaginoplasty surgery. This part of the surgery is associated with significant morbidity if it is not performed correctly. It requires expert understanding of the anatomy and surgical skill set. The objective of this video is to show our technique for creating the neovaginal cavity in transgender women undergoing vaginoplasty surgery and to discuss the risk of neovaginal fistula associated with this procedure. At this point in the surgery, the scrotal skin has been removed to be used later as a graft to line the neovagina. An orchiectomy has been performed and the penile structures have been skeletonized and can be visualized here. We can see the corpus spongiosum and the right and left crura of the underlying corpora cavernosa. A Foley catheter is placed. This is a key step in the neovaginal dissection as the course of the catheter and the location of the Foley bulb are landmarks that can be used. The central tendon of the perineum is a pyramidal, fibromuscular mass in the middle line of the perineum at the junction between the urogenital triangle and the anal triangle. In natal males, it is found between the bulb of the penis and the anus. Entry into the perineum can be done using either the bovie cautery or the sharp scissors. The handheld ligature device can be used to help achieve hemostasis, transect the crura at the level of the ischiopubic rami, and to open the distal pelvic floor musculature in order to create enough width for the neovagina. The bulbous urethra is retracted upwards to help with visualization. Blunt dissection is done to help visualize the tissue planes. A finger is kept in the rectum during dissection. The rectum is in very close proximity, as shown. Avoiding a rectal injury is a crucial goal during this portion of the surgery. Once a significant portion of the dissection is completed, a right-angle retractor can be placed to help with visualization. Confirmation of hemostasis is done. It is our recommendation to achieve hemostasis as you proceed with the dissection, which optimizes visualization and prevents unrecognized bleeding and postoperative hematoma formation. The ligature is used to continue transecting the peripheral levator anti-muscles, widening the caliber of the space. The retractor is removed and further dissection is done. Once the prostate capsule has been entered, the risk of rectal injury is markedly lowered. Rep or electro-surgical dissection is then performed through the lower pole of the prostate until denovia's fascia is reached, always with the urethra intermittently palpated. Once the bilateral superior prostatic arteries are encountered near the superior aspect of the prostate capsule, blunt dissection can normally complete the dissection. The stent is then placed. The stent measures 15 centimeters in length, which is the goal neovaginal length. A retractor is placed back into the cavity and hemostasis is achieved. For improved visualization, lighted retractors can be used. Inspection of the cavity is done all the way to the apex. The peritoneal reflection can be seen here. We also demonstrate the full length of the cavity, which measures approximately 15 centimeters. The vagina is then packed until it is time to line the vagina with the graft. After the penile structures are deconstructed and then partially reconstructed, the stent is passed through the penile tube. The scrotal graft has been sewn onto the stent and it is anastomosed to the penile tube. It is then inverted into the neovaginal cavity and secured in place. The vulva is then created. Rectoneovaginal fistula is considered the worst complication associated with vaginoplasty surgery. The largest retrospective analysis looking specifically at fistula was recently published in Obstetrics and Gynecology. The incidence of rectoneovaginal fistula is shown in this table. The overall incidence was 1.2%. Rectoneovaginal fistula was much more common after revision surgery vaginoplasty, commonly performed for vaginal stenosis. The incidence for primary surgery was 0.8% and for revision surgery was 6.3%. In this cohort, the incidence of intraoperative rectal injury was 2.3%. Of the patients who had a rectal injury, 17% developed a fistula. Thirty-eight percent of fistula cases were presumed to be from unrecognized rectal injuries. Most patients with a fistula required surgery to repair it. The median time to surgery was three months. In most cases, fistulactomy with primary closure or local advancement flap was sufficient to repair the fistula. Four patients underwent fecal diversion with a direct or delayed fistula repair. Patients are taught neovaginal dilation after surgery. They are required to dilate three times daily for three months and then twice daily up to six months. Thereafter, they are advised to dilate once daily. At six months post-op, the neovagina is well-healed. At times, there is granulation tissue that needs to be cauterized, especially in the setting of persistent vaginal bleeding or discharge. Patients who fail to comply with their dilation regimen will suffer from vaginal stenosis. They may be candidates for revision surgery, but these surgeries can be challenging and, as previously mentioned, place patients at higher risk for rectal injury and fistula formation. In summary, dissection of the vesicle-rectal space is considered the most challenging portion of vaginoplasty surgery. Understanding of the anatomy and an expert skill set is necessary for neovaginal surgery in order to avoid morbidity associated with this procedure. For more information, visit www.FEMA.gov

vaginoplasty surgery

neovagina creation

penile inversion technique

rectoneovaginal fistula

post-surgery care