Hi. My name is Bella Avanessian, and I'm a surgeon at Mount Sinai Center for Transgender Medicine and Surgery in New York. I work alongside Dr. Justin. My gender pronouns are she and her. In this session, I will be talking about trans feminine genital surgery. The learning objectives for this session are to learn about the role of surgery in the care of transgender patients, to discuss the goals of surgery, and to review surgical options for genital feminization surgery. This includes: orchiectomy, penile-inversion vaginoplasty, and intestinal or rectosigmoid vaginoplasty. First, what should you know about surgery? Surgery is a proven therapy for patients who identify as transgender. Surgery is medically necessary and it should be covered by insurance. A multi-disciplinary team approach is best for optimal surgical outcomes. Looking at goals of surgery, we aim to improve the patient's comfort with themselves, as well as their personal experience, to achieve a result that is both functional and has a natural appearance, and to minimize complications throughout the process. What's possible in transfeminine surgery? Here we will focus on surgery of the genitalia. orchiectomy, penile-inversion vaginoplasty, and intestinal vaginoplasty. Orchiectomy. Orchiectomy is the removal of the testicles. Because this procedure is sterilizing, preoperative discussion with the patient about reproductive options and fertility preservation options is a must. Benefits of orchiectomy include: being able to reduce the testosterone production and allowing the patient to come off of anti-androgen therapy. Penile-inversion vaginoplasty. From a patient's perspective, the goals of vaginoplasty are to achieve orgasm, be able to urinate, have a functional usable vagina, and have symmetric, natural-appearing genitals. Also it is always important to minimize scarring and avoid complications. For a surgeon, the goals of vaginoplasty are to remove male genitalia, to shorten and reposition the urethra, to create and line the vagina, to create an erogenous clitoris, and the external structures of the vulva including the clitoral hood, the labia minora, and the labia majora. All in all, we want to create a natural appearance, and we need to take into consideration the quantity and elasticity of the skin, hair distribution, and the patient's readiness for this surgery. Dilation. Dilation is an important postoperative commitment following surgery. It is the act of inserting a vaginal dilator and allowing it to stay inside the vagina for 20 to 40 minutes. This keeps the vagina open and functional. Dilation recommendations vary by surgeon. Usually, it is done at least once daily for a period of at least several months to a year. Compliance and commitment to dilation is critical for maintaining the long term surgical result. Without dilation, the vagina will narrow and close. So, this is a long term commitment. Now, we will talk about vaginoplasty technique. These are preoperative patient photos. These highlighted areas are the targets for hair removal prior to surgery. This is because, this skin is used to line the vagina and not removing hair in these areas prior to surgery can result in a vagina with hair growth. Now, we will look at the markings for the scrotal skin graft. In the first photo, the markings have been made for planned scrotal skin graft harvest. In the second photo, the skin graft is being harvested. Next, the skin graft is being prepared on the back table, and finally the skin graft has been wrapped around a dilator and sewn together to form a sock of skin. This is saved for later in the case. Orchiectomy. Orchiectomy is the process of removing the testicle and in this case the spermatic cord. In the first photo, the arrows pointing to the testicle and in the second, the testicle and it's spermatic cord have been removed. This is done bilaterally. Creating the vaginal canal. In making the canal for the vagina, we go between the rectum and the urethrine bladder in a space which is positioned here. This is a narrow space, and as you can see in this diagram, it goes right along the passage marked with blue. Here are photos of the creation of the vaginal canal. Again, this is the most complex part of the surgery, and this is where injuries to either the rectum, urethra, or bladder can happen. In the image on the right, the dissection is complete and a dilator is sitting within the new vaginal canal, and here it's at a depth of approximately seven inches. How do we make a functional clitoris? First, we need the neurovascular pedicle. Basically, the glans of the penis is kept alive by nerves and blood vessels that run along the dorsal or back aspect of the penis. These nerves are protected by a dense tissue called buck's fascia during the dissection. When we isolate the clitoris with its neurovascular pedicle, all of this is marked in yellow. We cut away and discard the tissues marked in red, which are the corpora cavernosa or erectile pillars of the penis, and the corpus spongiosum which houses the urethra. In creating the functional clitoris, we first have to get exposure of the underlying penile structure. We cut the skin to free the skin envelope of the penis. In the second photo here, you can see the streaking on the backside of the penis. This streaking represents the nerves and blood vessels that is important to preserve. In the following photo, the penis is being delivered out of the skin envelope. In the final photo, it's completely freed from the skin envelope. Next, we have to separate the erectile tissues off of this neurovascular pedicle. That's what's happening in the first two photos here. In the third photo, the erectile tissue has been completely removed. Also, you will notice that the urethra has been shortened and is preserved with a catheter in place on posterior aspect of the photograph. Now we've created this thin pliable flap which houses the nerves and blood vessels that continue to supply these glands, which is now the new clitoris. Then, we fold it onto itself and secure it to the pubic bone. Here, we have completed the construction of the clitoris. This being connected to its nerves and blood vessels, will be able to continue to live and have erogenous sensibility. Now, creating the functioning urethral opening. All we do to create the new urethral meatus is split the existing urethra vertically down its midline. This allows us to fully the tissue open exposing the pink moist tissue that lines the urethra. This pink moist tissue is used to line the vulvar vestibule or the space between the clitoris and the vagina. The bottom of this opening is the new urethral meatus. Here, the structures are marked. Now, we will look into how everything comes together. Here again, we see the scrotal skin graft wrapped around the dilator. We then pass this dilator with a skin graft through our penile skin envelope, which is a flap. A graft on the other hand has been completely separated from the body and relies on the blood supply of its new location in the body to survive. Here, we have sewn together the penile skin flap and the scrotal skin graft. The graft will help line the deep vagina. We then dunk this structure into the new vagina and this graft flap structure becomes the new vaginal lining. In right hand photos, you see a speculum inserted into the vaginal canal within this flap and graft structure, and vaginal packing which has gauze in this scenario being packed into the vagina. This packing helps with the healing process and helps keep the lining against the vaginal walls. Here, we then split the skin of the flap and re-introduce our clitoris, our vulvar vestibule and the urethra back into our operative field. We then insert these structures into the skin flap. This forms the clitoral hood and the labia minora. Next, we start to secure the outside skin to the lateral aspects of the incisions, and this helps form the labia majora. Here, we're cutting away any excess skin and completing our inset by sewing the incisions up. In the final photo, we've applied the final enhancing stitches and the surgery is complete. Postoperative care, after surgery, a patient can expect to stay in a hospital for three or more days. Dressings are typically removed depending on the surgeon, either between five or seven days after surgery. As soon as the dressings have been removed, the patient is taught how to dilate. That is when their long-term commitment to dilation begins, and dilation continues at least daily, sometimes more. Vaginal discharge after surgery can vary. It can stabilize over a period of about a year. Hygiene is important and at times douching is a part of the regimen. Overall recovery with return to normal activities can be long, lasting at least three months. Vaginal intercourse becomes possible after a period of at least three months but usually closer to six months. When engaging in sexual activity after surgery, it's always important for the patient to use lubricant. These are some examples of how vaginoplasty results vary. Now, we will talk about intestinal or rectosigmoid vaginoplasty. This technique is typically saved for vaginal failure or closed vaginas. The way that it is done is, a piece of the intestine which stays attached to its blood supply is removed. The remaining segments are connected back together in what's called a primary anastomosis. The removed segment which again is a flap, meaning it has its own blood supply and can live in a different part of the body is moved into the position of the new vagina. The benefits of the surgery are that it restores a functional vagina. Another benefit is that it can produce a self lubricating vagina. There are many disadvantages to this surgery. One disadvantage is that lubrication is sometimes overproduced. Another is that, two sites of surgery are used during this procedure and there are high risks for serious complications, both short-term and long-term. For this reason, it's typically reserved for revision surgery, and as far as I'm aware, no centers are offering this surgery for primary vaginal pasty. Also importantly, the new vagina which has constructed from this intestine is susceptible to bouts of inflammation or malignancy. So, colon cancer screenings should continue within the vagina as well. So, in conclusion, surgery is a proven therapy for patients who identify as transgender. Surgery is medically necessary and should be covered by insurance. Surgery improves patient comfort and aims to achieve a natural appearance and good function. To review the surgeries specifically, we talked about orchiectomy, which is removal of the testicles. The benefit is that this reduces the body's testosterone production. Usually, this procedure is paired with vaginoplasty but can be a stand-alone procedure. Penile-inversion vaginoplasty. This creates a clitoris which is capable of erogenous sensitivity, a functional vagina and a natural appearing external genitalia. Postoperative dilation is critical to long-term success of this surgery and recovery is long keeping the patient away from normal activity for about three or more months. Intestinal and rectosigmoid vaginoplasty has significant morbidity and possible complications. For this reason, it's typically reserved as a revision procedure after vaginal failure. Thank you for joining me today. I hope this gave you some insight into transfeminine genital surgery.
