dilation after gender reassignment surgery

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• Dilation after gender-affirming surgery

This material is for your education and information only. This content does not replace medical advice, diagnosis and treatment. If you have questions about a medical condition, always talk with your health care provider.

Narrator: Vaginal dilation is important to your recovery and ongoing care. You have to dilate to maintain the size and shape of your vaginal canal and to keep it open.

Jessi: I think for many trans women, including myself, but especially myself, I looked forward to one day having surgery for a long time. So that meant looking up on the internet what the routines would be, what the surgery entailed. So I knew going into it that dilation was going to be a very big part of my routine post-op, but just going forward, permanently.

Narrator: Vaginal dilation is part of your self-care. You will need to do vaginal dilation for the rest of your life.

Alissa (nurse): If you do not do dilation, your vagina may shrink or close. If that happens, these changes might not be able to be reversed.

Narrator: For the first year after surgery, you will dilate many times a day. After the first year, you may only need to dilate once a week. Most people dilate for the rest of their life.

Jessi: The dilation became easier mostly because I healed the scars, the stitches held up a little bit better, and I knew how to do it better. Each transgender woman's vagina is going to be a little bit different based on anatomy, and I grew to learn mine. I understand, you know, what position I needed to put the dilator in, how much force I needed to use, and once I learned how far I needed to put it in and I didn't force it and I didn't worry so much on oh, did I put it in too far, am I not putting it in far enough, and I have all these worries and then I stress out and then my body tenses up. Once I stopped having those thoughts, I relaxed more and it was a lot easier.

Narrator: You will have dilators of different sizes. Your health care provider will determine which sizes are best for you. Dilation will most likely be painful at first. It's important to dilate even if you have pain.

Alissa (nurse): Learning how to relax the muscles and breathe as you dilate will help. If you wish, you can take the pain medication recommended by your health care team before you dilate.

Narrator: Dilation requires time and privacy. Plan ahead so you have a private area at home or at work. Be sure to have your dilators, a mirror, water-based lubricant and towels available. Wash your hands and the dilators with warm soapy water, rinse well and dry on a clean towel. Use a water-based lubricant to moisten the rounded end of the dilators. Water-based lubricants are available over-the-counter. Do not use oil-based lubricants, such as petroleum jelly or baby oil. These can irritate the vagina. Find a comfortable position in bed or elsewhere. Use pillows to support your back and thighs as you lean back to a 45-degree angle. Start your dilation session with the smallest dilator. Hold a mirror in one hand. Use the other hand to find the opening of your vagina. Separate the skin. Relax through your hips, abdomen and pelvic floor. Take slow, deep breaths. Position the rounded end of the dilator with the lubricant at the opening to your vaginal canal. The rounded end should point toward your back. Insert the dilator. Go slowly and gently. Think of its path as a gentle curving swoop. The dilator doesn't go straight in. It follows the natural curve of the vaginal canal. Keep gentle down and inward pressure on the dilator as you insert it. Stop when the dilator's rounded end reaches the end of your vaginal canal. The dilators have dots or markers that measure depth. Hold the dilator in place in your vaginal canal. Use gentle but constant inward pressure for the correct amount of time at the right depth for you. If you're feeling pain, breathe and relax the muscles. When time is up, slowly remove the dilator, then repeat with the other dilators you need to use. Wash the dilators and your hands. If you have increased discharge following dilation, you may want to wear a pad to protect your clothing.

Jessi: I mean, it's such a strange, unfamiliar feeling to dilate and to have a dilator, you know to insert a dilator into your own vagina. Because it's not a pleasurable experience, and it's quite painful at first when you start to dilate. It feels much like a foreign body entering and it doesn't feel familiar and your body kind of wants to get it out of there. It's really tough at the beginning, but if you can get through the first month, couple months, it's going to be a lot easier and it's not going to be so much of an emotional and uncomfortable experience.

Narrator: You need to stay on schedule even when traveling. Bring your dilators with you. If your schedule at work creates challenges, ask your health care team if some of your dilation sessions can be done overnight.

Alissa (nurse): You can't skip days now and do more dilation later. You must do dilation on schedule to keep vaginal depth and width. It is important to dilate even if you have pain. Dilation should cause less pain over time.

Jessi: I hear that from a lot of other women that it's an overwhelming experience. There's lots of emotions that are coming through all at once. But at the end of the day for me, it was a very happy experience. I was glad to have the opportunity because that meant that while I have a vagina now, at the end of the day I had a vagina. Yes, it hurts, and it's not pleasant to dilate, but I have the vagina and it's worth it. It's a long process and it's not going to be easy. But you can do it.

Narrator: If you feel dilation may not be working or you have any questions about dilation, please talk with a member of your health care team.

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Use It or Lose It: The Importance of Dilation Following Vaginoplasty

Julie Vu with her set of Soul Source dilators. Source: YouTube.

Vaginoplasty is a Gender Reassignment Surgery procedure that transforms the transgender person's genitalia into female genitals, including a neo-vagina. Post-operative vaginal dilation is an integral part of the initial surgery recovery and the regular maintenance of a transgender person's neo-vagina. Typically, dilation begins a few days after surgery and is almost always required for life. Without proper dilation, the skin graft inside the vagina tends to contract which leads to narrowing, shortening or closure of the neo-vagina . This is an irreversible result—one cannot regain the original vaginal depth by simply resuming or doing more dilation. Dilation may not be pleasant but it's essential to follow your surgeon's dilation protocol in order to prevent loss of depth of your new vagina.

Dilation Explained

The purpose of dilation is to maintain the depth of the neo-vagina. Dilation helps prevent contraction of the skin graft inside vagina and also improves the elasticity of vaginal wall in order to comfortably accommodate penetrative sex.

Dilation involves inserting a lubricated dilator into the neo-vagina and keeping it in there for a specified amount of time. The size of dilator and the length of dilation time varies depending on the surgeon's protocol and patient's needs. Your surgeon will advise about the proper use and frequency of post-op dilation and it's important to follow their advice above all as it may be specific to your case.

Initially, one can expect dilation to take up to 2-2.5 hours per day, with the time and frequency decreasing after you reach 18-24 months post-op. Yes, it's a commitment!

"All I wanted to do was sleep, but I couldn't sleep since I had to wake up and dilate endlessly. It was so much dilation that I would dream about it many nights." — Autumn Asphodel

Dilation is also not as comfortable as one might hope. "[The dilators are] hard, they're plastic, they're cold, they're uncomfortable to be inside you,' said Julie Vu on YouTube .

Does Sex Count? There's some debate as to whether or not sexual intercourse can count as a dilation session. 'If [after a year post-op] you have sex once every week, you're good to go, you don't have to dilate with these instruments,' says Vu. Maddy McKenna concurs , "The only bonus it that if I have a sexual companion, 30 minutes of sex counts as 30 minutes of dilation."

"You have to dilate once a week for the rest of your life, unless you're having sex," says Nomi Ruiz , a transgender singer and host of the podcast Allegedly NYC . "So now when I'm not having sex, it's kinda sad, because you're really reminded of it. You're like, 'Oh, God, I have to dilate now because I'm not getting laid. Fuck.'" However, sexual intercourse in place of dilation may not be sufficient. This is something that you should discuss with your surgeon.

To begin, patients dilate with the largest dilator that comfortably fits inside the neo-vagina. As the weeks progress after surgery, larger dilators are introduced and the length of time with the largest dilator is gradually increased.

"So, there are four dilator sizes I have. The first one is 1?", the second one is 1¼", the third is 1?", and the largest one is 1½". I don't use the first one at all anymore. But, I have to start with the second one and then work up to the largest one. I can't just use the third or fourth one without working up to it. UHHHHH, I hate the largest one so much. It tears me up, literally. I just wanna throw it out the window. [Glass break]" — Autumn Asphodel

Dilation Isn't Fun But It's Worth It

"The only part in my vagina self-care regimen that differs from a natal vagina is that I have to dilate. When I first came out of surgery, my body naturally registered my neo vagina as a wound and, because of that, it wanted to heal and close up. No thank you!" — Maddy McKenna

When dilation isn't done according to the recommended routine, the skin graft inside the vagina can contract and close up which leads to the shortening—and even closure—of the neo-vagina. Unfortunately, once this happens it can't be fixed by simply resuming or doing more dilation. A revision surgery is usually necessary.

"Vaginal openings are similar to pierced ears in that if you don't use earrings regularly, the piercings will eventually close," says Dr. Rumer . "So we always say, 'DILATE!!! DILATE!!! DILATE!!!'"

" [Dilation is] very important. Very important. Can't say that enough. Your vagina will close up if you don't dilate. I did have a patient who didn't dilate for two weeks. She went back to the doctor, and she had closed up. And they couldn't reverse back. So, it's very important. Not to scare you, but just do it." — JD Davids

Dilation Tips

Follow your surgeon's dilation guidelines!

Find ways that help make the process go by faster.

"I dilated a lot to TV shows. They tell you to dilate for 20 minutes a day. But you're so scared that it's going to close up that you probably dilate -- well, I dilated till like an hour. I would watch the Atlanta Housewives, and I would get in my bathtub. Because at first it was the only place that I could dilate. So, I would get my pillow. I would sit in my tub. I would have my iPad, and I would watch The Real Housewives of Atlanta while I was dilating. I'd watch the whole episode. Then I was done." — Nyala Moon

Use a lot of lube. (Water-based, not silicone.)

Stretch before and after dilating.

"All that dilating made my hip get out of place because it's an uncomfortable position to be in multiple times a day. So, it's always best to stretch before and after." — Autumn Asphodel

You will need several towels or waterproof pads to place under you while dilating. Chux pads or puppy training pads are a good solution if you don't have laundry facilities.

You can take a painkiller after dilating, but not before because it would increase the chance of hurting yourself.

Try urinating or having a bowel movement before your dilation session as it can make it more comfortable.

More dilation tips at Transgender Map »

WATCH: Dr. Gabriel Del Corral's Dilation Instructional Video (sign-in required)

"The average canal can be anywhere between four and six and a half, seven inches. Certainly with good discipline using the dilators, you'd be able to accommodate a regular sized penis. It just takes work after a Vaginoplasty. It takes a lot of discipline. And it takes a lot of time to be able to dilate three times a day for the first couple months post-surgery." — Dr. Gabriel Del Corral

WATCH: Dr. Heidi Wittenberg on Basic Equipment & Positioning to Optimize Dilation

Where to Buy Dilators

You should receive everything you need to dilate before you leave the hospital or recovery facility, from your surgeon. You will use several dilators of different lengths and widths during your recovery and beyond.

Dr. Rumer provides a Dilator Kit for patients, which includes dilators made specifically for trans women by Soul Source . $40-55 each.

Note on materials: Some believe that dilators shouldn't be made out of silicone or other soft materials. Dilators should be rigid and hard enough to provide the rigidity necessary to stretch forming scar tissue.

This section contains affiliate links.

BioMoi's Silicone Vaginal Trainers with BioCote Protection (Full Set) The "best quality" vaginal dilators on the market, made of US Platinum silicone. $129.99.

VuVa Smooth Set of 5 dilators made of medical grade polycarbonate plastic, with Instructions and pouch. Made in the USA.

VWell Set of 5 dilators made of silky smooth medical grade silicone, BPA and paraben-free.

Amielle Care Set of Vaginal Dilators Set of 4 graduated dilators with a universal handle to make insertion and removal easier, lubricant and a discreet bag.

Vaginal Trainer Set These dilators are smooth and comfortable, easy to control, light-weight, latex-free, washable and safe. 6 gradual sizes plus an ergonomic solid-lock handle. HopeandHer.com

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Last updated: 02/04/21

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Home » Blog » How does dilation work after Gender Confirmation Surgery?

How does dilation work after Gender Confirmation Surgery?

Both the patient and the surgeon share a key responsibility in achieving the best surgical outcome and maintaining functional vaginal depth following gender confirmation surgery (GCS). During your procedure, your surgeon utilises the penile and scrotal flaps safely to create the maximum depth of the vaginal canal and form the internal lining of the vagina.

As the patient, it is your responsibility to ensure you strictly follow the Vaginal Dilation Schedule to maintain the depth and calibre of your vagina. The stretching effect from vaginal dilation can prevent wound contraction, in addition to providing optimal elasticity of the vaginal walls to accommodate penetration. Without adequate and consistent dilation, the skin inside the vagina will shrink and contract, which may ultimately lead to shortening and/or narrowing of the vaginal canal; this is known as stenosis.

A shortened vaginal canal resulting from contraction inside the vagina is an irreversible process which means you cannot regain your original vaginal depth by resuming or increasing vaginal dilation.

Everything you need to know about Gender Confirmation Surgery

According to our surgeon’s GCS technique, packing will be used to stabilise the skin flaps inside the vagina, which is then removed at approximately 5 days post-operation. When the vaginal pack is removed, a speculum is inserted into the vagina to examine the healing of the skin flaps.

Following this, your first vaginal dilation will be demonstrated by your surgeon or a senior member of the clinical team. Your vaginal depth will be confirmed by the measurement scale on the dilator shaft; this is measured at the point of the vaginal opening.

You will be provided with a set of vaginal dilators prior to your discharge from the hospital. These dilators will vary in diameter and you will be advised by your surgeon or a senior member of the clinical team which sized dilators to use during your vaginal dilation. It is recommended that you continue with daily vaginal dilation up to 3 months following your GCS. After 3 months, once a week or alternative weeks as required is acceptable. Once vaginal intercourse is commenced, you may only need to dilate once a month as necessary.

Dilation essentials

Wash your hands and dilators both before and after vaginal dilation using warm water and mild soap. The use of water-based lubricating jelly is mandatory for the first year following your surgery to prevent tearing of the delicate skin inside the vagina. Prior to commencing dilation, plenty of lubricating jelly must be applied to the tip and shaft of the dilator, as well as the vaginal opening to ease insertion. Please re-apply more lubricating jelly during dilation if necessary.

Lie on your back in a semi-recumbent and comfortable position with your knees slightly bent. Position the lubricated dilator against the vaginal opening. Slowly push the dilator at an angle toward your lower back or tailbone until it occupies the full depth of your vagina. Whilst inserting the dilator, slow and gentle rotation can help expand the vaginal opening.

Gentle and constant pressure is required in order to sufficiently stretch the skin and maintain vaginal depth. You should frequently check the measurement scale on the shaft of the dilator to ensure you are maintaining depth with at least the smallest size dilator supplied. You must not attempt to push or force the vaginal dilator against the end of your vaginal canal to increase existing depth; this can result in tearing of the vaginal wall, bleeding, or a vaginal fistula.

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Gender Confirmation Surgery

Gentle, safe, discreet care for postsurgery and beyond.

We don’t need to tell you that changing your physical sex as an adult by undergoing gender confirmation surgery (aka sex reassignment surgery or genital reassignment surgery) is a huge decision. It takes genuine inner strength to become who you are and we want to congratulate and celebrate you, wherever you are on your journey.

If you’re preparing to take the last step to transition from male to female (MtF) with gender confirmation surgery, The Pelvic Hub can help you take care for yourself after surgery, and help you maintain your neo vagina in the long term.

• Written by Emma McGeorge

Related Conditions

Want to learn more about related conditions? Follow the links below to gain a better understanding of the symptoms and treatments.

After Your SRS Surgery

Each person’s experience of MtF gender confirmation surgery— and the recovery that follows— is different. Everyone heals at a different pace. As with any surgery, it’s normal to have symptoms like swelling and soreness.

Vaginas are complex things, and generally higher maintenance than penises. Your neo vagina may be susceptible to yeast infections and urinary tract infections, just like a natal vagina is.

Dilation Therapy for Transgender Patients

After surgery, it’s normal for your body to register your neo vagina as a wound. And similar to with a new piercing, your body will try to heal. Because of this, your neo vagina may start to shrink or develop scar tissue called granulation.

Dilation therapy is an absolute must to keep your neo vagina functional, to minimize scars from forming in your vaginal lining, and to prevent you from losing vaginal depth and width. Usually, MtF transgender patients start using vaginal dilation a few days after surgery and continue to use vaginal dilators, to some degree, for the rest of their lives.

Your surgeon will let you know how to safely use a vaginal dilators, what size to use, and how often you need to employ post-operative vaginal dilation to maintain your neo vagina. If they don’t, you should definitely ask.

Recommended Products for Post-Op Care

We love that these products can help you take care of yourself discreetly from home. However,  we always recommend that you check with your surgeon or physician before using any products on your neo vagina or inside your vaginal opening.

Natural cooling relief

Reusable perineal cooling pads are perfect for cooling the most sensitive and delicate area of your body. Comfortable, cooling and discreet, they are perfect for reducing pain and swelling post-surgery. Also great if you’re prone to yeast infections or urinary tract infections.

Comfortable sitting

You may need a little help sitting without pain in the first few weeks after surgery. A foldable travel pelvic cushion or deluxe foldable travel pelvic cushion are uniquely designed to take the pressure off your neo vagina, helping you sit a little more comfortably.

Gentle, worry-free sex

Using an intimate wearable that allows you to control the depth of penetration into your neo vagina during sex can help you manage any pain you may experience during sexual intercourse. The Ohnut is designed to not just comfortably accommodate penetrative sex but also to feel just like skin. It’s so comfortable (like a gentle hug) you and your partner will barely notice it’s there. And because you no longer have to worry about whether penetration will hurt, this wearable allows both you and your partner to focus on what matters most, connection, enjoyment, and fun.

Are you looking for top-of-the-range, world-class transgender dilators?

Intimate Rose’s vaginal dilators were designed by a pelvic floor health physical therapist and are made from a smooth, body safe, medical grade silicone that's 100% BPA free and designed to glide into your neo vagina for more comfortable use during dilator therapy. They are designed to maintain your neo vagina’s integrity and vaginal depth and are recommended by pelvic floor specialists around the world. Not only are the Intimate Rose vaginal dilators more comfortable and easier to use, but they are also the only FDA registered vaginal silicone dilator and are used in the official Academy of Pelvic Health training courses.

They can also be chilled to help with post-surgical swelling, or used at room temperature. Always check with your surgeon or physician before using any dilator in your neo vagina to make sure you have the size, technique and frequency that is safe for your body, as dilation involves inserting into your neo vaginal canal for maintaining vaginal depth. Your doctor can recommend a dilation regimen that will provide you the most support during the healing process and beyond.

Invest in your health and yourself

Gender confirmation surgery is a big investment, and it doesn’t end when you leave the hospital. It’s  important to take gentle care of yourself after surgery and in the long term.

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Postoperative complications of male to female sex reassignment surgery: A 10-year French retrospective study

Affiliations.

• 1 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Paris Diderot university, Sorbonne Paris, Paris, France; Plastic and aesthetic surgery department, hôpital Tenon, Paris, France.
• 2 Plastic and reconstructive surgery, Conception hospital, 147, boulevard Baille, 13005 Marseille, France.
• 3 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France.
• 4 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Paris Diderot university, Sorbonne Paris, Paris, France.
• 5 Plastic and aesthetic surgery department, hôpital Tenon, Paris, France.
• 6 Department of plastic, reconstructive and aesthetic surgery, Saint-Louis hospital, avenue Claude-Vellefaux, 75475 Paris cedex 10, France; Plastic and reconstructive surgery, François-Mitterand hospital, 14, rue Paul-Gaffarel, 21079 Dijon, France. Electronic address: [email protected].
• PMID: 30269882
• DOI: 10.1016/j.anplas.2018.08.002

In primary male to female (MTF) sex reassignment surgery (SRS), the most frequent postoperative functional complications using the penoscrotal skin technique remain neovaginal stenosis, urinary meatal stenosis and secondary revision surgery. We aimed to retrospectively analyze postoperative functional and anatomical complications, as well as secondary procedures required after MTF SRS by penile skin inversion. All patients operated on for MTF SRS, using the inverted technique, from June 2006 to July 2016, were retrospectively reviewed. The minimum follow-up was one year (five-years maximum follow-up). Soft postoperative dilationprotocol was prescribed until complete healing of the vagina. We did not prescribe long-term hard dilation systematically. Possible short-depth neovaginas were primarily treated with further temporary dilation using a hard bougie. Among the 189 included patients, we reported a 2.6% of rectovaginal wall perforations. In 37% of patients we had repeated compressive dressings and 15% of them required blood transfusions. Eighteen percent of patients presented with hematoma and 27% with early infectious complications. Delayed short-depth neovagina occurred in 21% of patients, requiring additional hard dilatation, with a 95.5% success rate. Total secondary vaginoplasty rate was 6.3% (4.7% skin graft and 3.7% bowel plasty). Secondary functional meatoplasty occurred in 1% of cases. Other secondary cosmetic surgery rates ranged between 3 to 20%. A low rate of secondary functional meatoplasty was showed after MTF SRS by penile skin inversion. Hard dilation was prescribed in case of healed short-depth vagina, with good efficiency in most of cases. Secondary vaginoplasty was required in cases of neovagina stenosis or persisting short-depth neovagina after failure of hard dilation protocol.

Keywords: Chirurgie de changement de sexe; Complications postopératoires; Follow-up; Postoperative complications; Sex reassignment surgery; Suivi.

Copyright © 2018 Elsevier Masson SAS. All rights reserved.

• Blood Transfusion / statistics & numerical data
• Middle Aged
• Postoperative Complications
• Retrospective Studies
• Sex Reassignment Surgery / adverse effects*
• Young Adult

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September 04, 2019 | Caroline Knight

Why Using Dilators is Important After Gender Confirmation Surgery

Today, more people than ever are unhappy with their gender and choose to opt for gender confirmation surgery. although this is not a decision to be taken lightly, it’s becoming increasingly common. you might also have heard gender confirmation surgery referred to as sex reassignment surgery or genital reassignment surgery; when a man changes to female gender (mtf), the operation is called vaginoplasty..

As you might imagine, vaginoplasty is an incredibly complex operation that requires a great deal of aftercare to ensure long-term success. Anyone who is considering gender confirmation surgery should be aware of the aftercare implications, and we’re here to help with that. One of the most important aspects is the use of vaginal dilators , which we’ll also cover in this article.

Post-operative care for gender confirmation surgery

After MtF gender confirmation surgery (vaginoplasty), each person takes a variable amount of time to recover. It is normal to experience some soreness and swelling, and believe it or not, a ‘neo vagina’ is also susceptible to yeast infections and urinary tract infections… so consistent care is needed to prevent these.

After gender confirmation surgery, it is normal for either gauze packing or a stenting device to be placed inside the neo vagina, to be kept in place for up to a week afterward. After this is removed, it is time to start using vaginal dilators . Vaginal dilation is incredibly important after vaginoplasty, but different surgeons will recommend different protocols. Below we’ll offer a common guideline for transgender dilation.

Why are dilators important after gender confirmation surgery?

Post gender confirmation surgery, your body is likely to register your vagina as a wound, and therefore try to heal it. This would result in some shrinkage at the very least – if not total closure and/or development of scar tissue. For this reason, transgender dilation therapy is crucial; it can prevent all of these possibilities from happening.

You will want to maintain the depth and width of your new vagina, so your surgeon is likely to recommend using dilators a few days after surgery is complete. From this point, you will need to keep using the vaginal dilators ongoing - but less often as time goes on, of course.

Guidelines for using a dilator after vaginoplasty

Your surgeon should have the final say on this, so do check with them before starting dilation therapy. Also ensure that you are using the right sized dilators, according to your surgeon’s recommendation.

• Clean your dilator with warm soapy water, then rinse and dry it (the same goes after each use!)
• Use a water-based lubricant to coat the dilator before insertion
• Gently insert your dilator at a 45 degree angle; when it is under the pubic bone, continue insertion in a straight direction
• Once you have inserted it fully and are experiencing some resistance, leave the dilator in place for ten minutes
• Dilate three times each day for a period of three months, as soon as the gauze has been removed
• After three months, stat using a larger dilator for a further three months
• At between three and six months, use the dilator once per day for ten minutes
• After six months, use it two or three times per week for ten minutes
• After nine months, use it once or twice per week

Note that if your neo vagina seems tight at any point, you can increase the frequency of dilation. It’s also important to stop dilator therapy if you are experiencing excessive resistance, pain or tenderness – a little is normal, a lot is not.

A final word on genital reassignment surgery

We thought you might be interested in this helpful tip for resuming sexual intercourse: you may find the Ohnut ring useful, since this intimate wearable helps your partner to control the depth of penetration. Using an Ohnut ring means you’re less likely to feel any pain, and your partner will barely notice it.

The bottom line is that gender confirmation surgery requires regular self-care, so you’ll need to be disciplined with your dilator use. VuvaTech stock a range of vaginal dilators and we’re always happy to help, so feel free to ask if you have any questions!

Other VuVa Helpful Links:

7 Reasons for a Tight Vagina and How to Loosen 

How to use Vaginal Dilators 

How to Relax Vaginal Muscles, Vaginismus & Sex 

Vaginal Stretching - Keeping in Shape with Dilators 

Do Dilators Really Work? Yes, and They can Improve Your Sex Life!

Shop for VuVa Vaginal Dilators

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• Review Article
• Published: 02 June 2020

Urethral complications after gender reassignment surgery: a systematic review

• N. Nassiri 1 ,
• M. Maas   ORCID: orcid.org/0000-0001-9677-9917 1 ,
• M. Basin 1 ,
• G. E. Cacciamani 1 &
• L. R. Doumanian 1  

International Journal of Impotence Research volume  33 ,  pages 793–800 ( 2021 ) Cite this article

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The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms ((“Transsexualism”[Mesh])) AND (“Sex Reassignment Surgery”[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19–54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

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Nassiri, N., Maas, M., Basin, M. et al. Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res 33 , 793–800 (2021). https://doi.org/10.1038/s41443-020-0304-y

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DOI : https://doi.org/10.1038/s41443-020-0304-y

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Overview of surgical techniques in gender-affirming genital surgery

Mang l. chen.

1 GU Recon, Los Angeles, CA, USA;

Polina Reyblat

2 Southern California Permanente Medical Group, Los Angeles, CA, USA

Melissa M. Poh

Amanda c. chi.

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.

Introduction

The rise in social awareness of gender dysphoria has led to an increased recognition of the medical and surgical needs of the transgender population. It is estimated that 0.5–1.3% of the population in the United States has gender dysphoria ( 1 ). Hormone treatment and breast reconstruction for transgender and gender non-conforming (TGNC) individuals has a longer care history than genitourinary surgery, and is therefore more accessible with more providers able to offer these services. Urologic care for gender-related genitourinary surgery (GRGUS), however, remains sparsely available and has only recently gained nationwide traction. The most common surgeries are vaginoplasty for the transfeminine population, and phalloplasty and metoidioplasty for transmasculine patients. Vaginoplasty involves penectomy, orchiectomy, partial urethrectomy, neovaginal canal creation between the rectum and the lower urinary tract, formation of perineogenital complex for patients who desire a functional vaginal canal, labiaplasty, and clitoroplasty. Phalloplasty involves vaginectomy, urethroplasty, neophallus creation, scrotoplasty, perineal reconstruction, and glansplasty. Metoidioplasty is similar to phalloplasty except for the neophallus creation. Each of these primary GRGUSs carries their own unique urologic risks that require reconstructive urologic follow up. Examples of reconstructive procedures after vaginoplasty include urethroplasty to correct urethral bulging, clitoroplasty and labiaplasty. After phalloplasty, urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction, and prosthetic surgery may be required. We will review the peri-operative assessment, the surgical techniques employed, and the complications of vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures. Thereafter, the urologic implications and management will be described in detail.

Transfeminine genitourinary surgery

Preoperative assessment.

Patients presenting for surgical consultation should satisfy WPATH guidelines by the time of planned genitourinary surgery. Preoperative assessment of the patient also includes discussion of the patient’s surgical goals and understanding of the risks associated with surgery. Patients may desire a full depth vaginoplasty, which encompasses bilateral orchiectomy, penile disassembly, creation of neovaginal cavity between the rectum and the urogenital structures (prostate and bladder), labiaplasty, clitoroplasty, and urethral reconstruction. Other patients, such as those with previous perineal surgery or radiation, those who do not wish or cannot physically dilate, or those who do not desire penetrative intercourse may also choose a shallow depth or zero depth vaginoplasty. This includes all of the steps of a full-depth vaginoplasty minus the actual creation of the neovagina. Surgeons should perform a thorough history and physical exam, taking special note of factors that may affect penile skin flap/scrotal skin graft availability and viability, hair removal status, and prior surgical history that may make neovaginal dissection and creation more difficult. The three main techniques are: (I) genital skin flap vaginoplasty; (II) intestinal vaginoplasty; and (III) non-genital skin flap vaginoplasty. The genital skin flap method, specifically, the penile inversion approach, is the most popular technique. Our discussion will focus on evaluating factors most relevant to penile inversion vaginoplasty.

Assessment of the laxity and size of the penile shaft skin and the scrotum can help counsel patients on the potential need for full thickness skin grafts from other donor sites. Of note, the usable length of the penile shaft is limited by the location of the circumcision scar in circumcised individuals. In vaginoplasty techniques supplemented with other tissue flaps, such as peritoneal flaps as described for the Davydov procedure ( 2 ), patients may not need additional skin grafts.

Permanent hair removal should be completed in areas that will be used to create the neovagina and introitus. This includes the perineum, penile shaft, central portion of the scrotum, and ring of skin around the base of the penis. Hair growth in the vaginal canal may lead to an increase in discharge, discomfort with dilation or intercourse, unpleasant odor, formation of nests of hair, and concretions. Intraoperative scraping of residual hair follicles has been described, but leads to graft thinning and may increase the risk of graft loss or postoperative canal stenosis. While laser hair removal is better tolerated, it may not be permanent and works best in patients with dark hair and light skin. In our practice, we prefer electrolysis for permanent hair removal. Depilation evaluations are conducted preoperatively to assess adequacy.

Bowel preparation is completed two days prior to surgery to facilitate repair of rectal injury should it occur during the neovaginal canal dissection. Patients should stop the use of nicotine containing products and all inhalational products for at least three months prior to and after surgery to reduce wound healing complications and maximize graft take.

Patients with prior pelvic surgeries in the rectoprostatic plane, such as radical prostatectomy, proctectomy, as well as patients who have had pelvic radiation, should be counseled on the increased difficulty in dissection of the neovaginal canal. This may increase the risk of rectal, bladder, and/or urethral injury, leading to the possibility of urethroneovaginal and/or rectoneovaginal fistula formation. In circumstances where risk of significant complication is high, patients should be well-informed and advised that shallow-depth vaginoplasty may be a good option for a feminine appearing perineogenital complex without potential morbidity associated with creating a neovaginal canal. While prior history of penile urethral stricture may not affect urinary function post vaginoplasty, those with bulbous urethral or more proximal strictures may require additional urethral reconstruction at the time of vaginoplasty.

Estrogen supplementation is stopped two weeks prior to surgical procedure, to help minimize risks contributing to deep venous thrombosis and pulmonary embolism. Preoperative anticoagulation with subcutaneous heparin, intraoperative sequential compression device, as well as perioperative chemical prophylaxis is used.

Operative principles in vaginoplasty

In our penile inversion vaginoplasty, we use a superiorly based penile skin flap supplemented with a scrotal skin graft to line the neovagina ( Figure 1 ). The patient is placed in dorsal lithotomy position. The scrotal skin is harvested and thinned to make a full thickness graft. It will be tubularized around a dilator and anastomosed to the penile skin that is inverted. A small posteriorly based perineal flap ( Figure 2A,B,C ) is made to create a high posterior fourchette and decrease the risk of introital stenosis. We then proceed with bilateral orchiectomy, followed by dissection of the neovaginal canal.

Skin marking depicting scrotal skin graft used penile inversion vaginoplasty.

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.

Lone Star elastic stays (Cooper Surgical, Trumbull, CT, USA) are used to maintain exposure in the perineum. The bulbospongiosus muscles are kept in situ until dissection of the canal is complete. Bulbospongiosus muscle protects the corpus spongiosum from retraction injury during this portion of the dissection and can be used as a muscle flap in the event of a rectal injury. We use a Lowsley (V. Mueller & Co., Chicago, IL, USA) retractor placed into the bladder to aid in identification of the plane between the prostate and the rectum by rotating the prostate and bladder anteriorly and into the surgical field. A combination of sharp dissection and electrocautery is carried through the central tendon and around the curve of the bulbous corpora cavernosum. Following the course of the urethra and the outline of posterior prostate, dissection is carried along Denonvilliers’ fascia. Once the correct plane has been established, the neovaginal canal can be gently and bluntly opened by using two Heaney retractors anteriorly and posteriorly. A rectal exam is performed intermittently throughout the dissection of the neovaginal canal to confirm integrity of the rectal wall.

Wide dissection of the pelvic floor muscles laterally is important in order to develop adequate width of the introitus. Failure to divide the anterior levator ani muscles may lead to difficulty in dilation and a narrow introitus. This dissection is best performed with slow and meticulous cautery. Bleeding from branches of the internal pudendal artery typically occurs, requiring suture ligation of these vessels in addition to electrocautery. In our experience, hemostasis is best controlled with 2-0 Vicryl on UR-6 needles, which allow placement of sutures at these steep angles. Hemostasis of the neovaginal space is critical prior to placement of the penile skin flap/scrotal skin graft complex into the canal. While the packing placed into neovagina will aid with tight apposition between the skin graft and surrounding tissue bed in the retroprostatic space, formation of a hematoma in the neovaginal canal can prevent take of the skin flap and graft, and lead to vaginal prolapse or graft necrosis. In the long term, graft loss can lead to the development of granulation tissue and possible vaginal stenosis.

The phallus is then disassembled. Bulbospongiosus is removed completely to decrease bulk in this area if not needed as a local flap for rectal repair. The penis is degloved proximal to the corona, taking care to leave as much dartos layer with penile skin flap as possible. Corpus spongiosum is then dissected off corpora cavernosa, and the attachment of the corpus spongiosum to the crus of the corpora cavernosa should be separated so the urethra can point in a downward position when the patient sits to urinate. Circumventing this step can result in an anteriorly directed stream, where the patient would complain of messy and non-hygienic voiding.

The urethra is transected below the glans and kept temporarily long. The final length is determined prior to maturing urethral neomeatus. Bilateral ventral corporal cavernosal tissue is removed as proximally as possible. Tunica albuginea of the remaining crura of the cavernosum is closed with running sutures for hemostasis. The spongy tissue is excised off the remaining corpora cavernosum for both bulk reduction and hemostasis. The remaining dorsal strip of tunica albuginea carrying neurovascular bundle and connected to the glans is then narrowed with care taken not to damage the bundle. Finally, the redundant corpus spongiosum tissue at bulbous urethra should be tapered. If not adequately tapered, a periurethral bulge ( Figure 3 ) that protrudes into the distal anterior vaginal canal can present in patients post operatively. Patients describe it as a sensation of engorged erectile tissue around the urethra and vaginal opening, particularly during arousal, causing problems with intercourse, pain, discomfort or dysphoria. The excessive tissue is trimmed parallel to the urethra, as delineated by an indwelling catheter. The edges of the trimmed corpus spongiosum can be closed with 4-0 Vicryl suture.

Urethral bulge that protruding into anterior vagina.

The mons and the adjacent inferior abdominal wall are elevated in order to achieve a tension-free advancement of the penile skin flap. The glans is trimmed and rearranged into the neoclitoris ( Figure 4A,B ). The tissue on the deep surface including any remaining distal corpus cavernosal tissue is resected in order to thin out the neoclitoris and reduces bulk and projection of the neoclitoris. The pedicle to the neoclitoris is then folded gently on itself ( Figure 5 ) to set the neoclitoris at the level of the adductor longus tendons. The anatomical positioning of the neoclitoris provides a set point for the position of the urethral neomeatus and neovaginal introitus. If the neomeatus is positioned too superiorly, the neoclitoris tends to protrude and can become easily irritated by overlying clothing. The pedicle is secured to the fascia on the mons with only two laterally placed sutures at the edge of the pedicle to minimize injury to the neurovascular bundle. It is vital to ensure the pedicle follows a gentle curve and that there is no tension on the pedicle once the neoclitoris is set anterior to the urethra. We create the clitoral hood by folding the prepuce skin over the neoclitoris and closing it at the level of the neoclitoral body ( Figure 6 ).

Glans is rearranged to construct the neoclitoris.

Pedicle of the neoclitoris is folded gently on itself.

Clitoral hood is formed by folding the prepuce skin.

The penile skin flap with scrotal skin graft cap is then inverted and tunneled into the neovaginal canal and tightly packed with lubricated vaginal packing. Meticulous hemostasis in the neovaginal canal prior to placement of graft is critical to prevent hematoma formation. Hematoma inside the neovaginal canal affects graft take and can lead to neovaginal prolapse or graft loss. Some surgeons choose to place colpopexy-type suture with the aim to prevent potential neovaginal prolapse; this has not been necessary in our experience. A posterior midline incision is made into the inverted penile skin flap to reduce the tension of the advanced flap. The perineal flap is then inset into this opening and tacked carefully to the muscle at the posterior introitus to lessen the anterior retraction of the flap. Drains are placed under the mons region and the labia majora.

After completion of clitoroplasty and labiaplasty, and the position of the neomeatus has been determined, the urethra is trimmed to the appropriate length. In our practice, the distance between the neoclitoris and urethral meatus is spanned by the lateral limbs of the rearranged glans, rather than with dorsal urethral plate ( Figure 7 ). The central portion of the neoclitoris is sewn together leaving the two lateral limbs open so that the urethra can be inset in between these two limbs. The amount of closure depends on the distance desired between the neoclitoral body and the urethra and the size of the glans. In our experience, the urethra will retract slightly with healing. We suspect that excessive retraction and resultant tension may contribute to the development of meatal stenosis. Therefore, the urethra should be transected just distal to surrounding tissue and spatulated at ventrally. Eversion of urethral mucosa and hemostasis is obtained with running 5-0 Maxon. The urethral meatus is then matured with interrupted 4-0 Vicryl. A foley catheter is maintained until vaginal packing has been removed.

Position of the neomeatus relative to the neoclitoris, prior to transection of the urethra.

Immediately postoperatively, the labia majora are sewn together to maintain vaginal packing in place. A pressure dressing is applied over bilateral labial and mons; it is kept in place for 48 to 72 hours ( Figure 8A,B ).

Post vaginoplasty pressure dressing. (A) Labia majora sewn together to keep vaginal packing in place; (B) pressure dressing.

Reconstruction after vaginoplasty

Vaginal stenosis.

Neovaginal stenosis is a complication that may be caused by one or a combination of factors: poor adherence to the dilation protocol; difficulty/pain with dilation; progressive scar contracture associated with lack of graft take and/or granulation tissue development. Pain and pelvic floor dysfunction could be due to insufficient dissection of the levator ani complex at the time of the neovaginal canal formation. In addition, preexisting pelvic floor dysfunction can contribute to difficulty in relaxing pelvic floor muscles during dilation. In a recent retrospective review by Jiang et al. , 42% of patients undergoing vaginoplasty had preexisting pelvic floor dysfunction that were identified preoperatively ( 3 ). Timely intervention with pelvic floor physical therapy demonstrated improvement in pelvic floor function leading to successful dilation ( 3 ). In patients who experience pain with dilation due to granulation tissue, therapy should focus on treatment of granulation tissue while maintaining a consistent dilation schedule.

Neovaginal stenosis may be divided into introital or canal stenosis. Introital stenosis—or narrowing of the neovaginal opening—can lead to loss of depth of the canal due to difficulty with complete dilation. Symptomatic narrowing of the introitus was reported in 12% (4.2–15%) of the cases ( 4 ) and may be managed by stricturoplasty with local advancement flaps. In some instances, additional skin grafts may be required to enlarge the circumference of the introitus. Neovaginal canal stenosis may occur in 7% (1–12%) of patients ( 3 , 4 ), and management is similar to introital stenosis except for the higher likelihood of needing epidermal autografts after incision of the stenotic portion of the canal. On occasion, gastrointestinal or peritoneal flaps are required. We must emphasize that reported neovaginal stenosis rates are likely under-reported given that many patients are geographically distant from where their surgeries were performed. Many patients may also lack resources or interest in pursuing further intervention.

Neovaginal canal stenosis requires surgical intervention for re-establishment of the full-length canal. Pedicled intestinal segment and peritoneal flap vaginoplasty ( 5 ) have become the two most commonly employed options which avoid external scars and use of skin grafts elsewhere on the body. It is well-established that repeat dissection in the rectoprostatic space, particularly from a perineal approach, carries an increased risk of rectal and bladder injury when compared to primary vaginoplasty ( 6 ). Secondary intestinal vaginoplasty has higher rates of revision surgeries [79% ( 6 ) vs. 21.7% ( 7 )] and has additional risks and potential complications associated with intra-abdominal surgery. Examples include bowel obstruction, anastomotic leak, diversion colitis, and mucocele due to a closed blind loop of intestine if stenosis reoccurs. In some cases, the intestinal neovagina had to be removed due to infection leading to necrosis of the colonic segment and recurrent stenosis related to ischemia ( 6 ). Peritoneal flap vaginoplasty has emerged as a safer option for these challenging cases. This approach utilizes a combined transabdominal and perineal approach similar to the one described by Davydov in 1969 ( 2 ) as a treatment for vaginal agenesis. Similar to intestinal vaginoplasty, peritoneal flap vaginoplasty may also play a significant role as a primary surgery, particularly for patients with limited amounts of genital skin ( 5 ).

Rectoneovaginal fistula

A rectoneovaginal fistula is a devastating complication that can occur after an unrecognized rectal injury or after a failed repair of a recognized rectal injury. In a retrospective review of records of 1,082 transgender women by van der Sluis et al. ( 6 ), 8 of 997 (0.8%) patients who underwent primary vaginoplasty developed rectoneovaginal fistuli. The rate of fistula formation was higher, at 6.25%, in secondary vaginoplasties. Out of 21 patients who had rectal injuries that were repaired intraoperatively, 4 (19%) still developed rectoneovaginal fistula shortly after the operation, implying immediate repair is helpful for many but patients will need to be monitored closely for fistula recurrence. Others fistuli are thought to be due to unrecognized rectal injury at the time of dissection ( 6 ). These can initially be managed with low residue diets. Unfortunately, this rarely works and most patients require surgical repair of the fistula employing various interposition grafts or flaps ( 6 ).

Diagnosis of the rectoneovaginal fistula requires clinical suspicion and congruent physical exam findings. Patients typically will describe stool or gas emanating from the neovaginal canal. Presence of fecal matter in the neovaginal vault should prompt neovaginal speculum exam and rectal exam in order to confirm the presence of fistula. Imaging studies such as gastrografin enema, endoscopy, CT, or MRI, can support the diagnosis, but are rarely necessary. Similar to treatment of any rectovaginal fistula, fecal diversion with temporary colostomy is typically necessary to optimize chance of resolution. Failure of resolution of fistula with conservative measures requires excision of the fistula and repair of rectal and neovaginal defect with interpositioning local tissue flaps. Patients should be counseled on the potential of neovaginal canal stenosis if neovaginal dilation is interrupted for a prolonged period of time. In the past, patients were instructed to cease dilation to allow the neovaginal canal to close, thus treating the fistula but leading to loss of the neovaginal canal. We have repaired a rectoneovaginal fistula through a transvaginal approach and using gracilis flap interposition ( Figure 9A,B,C ). The repair was completed 3 months after the patient underwent diverting colostomy, corresponding to 6 months after her initial vaginoplasty. We re-established a dilation schedule performed by the surgeon at 1 month post repair and then allowed the patient to resume dilation on her own at 3 months post repair. In this manner, the patient’s width and depth of her neovaginal canal was preserved.

Transvaginal repair of rectoneovaginal fistula with gracilis interposition flap. (A) Gracilis interposition flap; (B,C) insetting the gracilis flap.

Urethroneovaginal fistula

Reported incidence for urethroneovaginal fistula range from 0.8–3.9% ( 5 , 8 - 10 ). This likely occurs due to unrecognized urethral injury or breakdown of a repaired urethral injury. In patients with a distal urethroneovaginal fistula, one can consider excising the distal bridge of tissue, resulting in a more recessed urethral meatus. In the case of a more proximal fistula, the fistula can be repaired transvaginally to close the neovaginal defect and urethral defect with local interpositioning flaps.

Urethral stricture and urethral malposition

The most likely location of a urethral stricture post vaginoplasty is at the urethral meatus. The reported incidence of meatal stenosis varies widely, with most authors noting 1–6% ( 9 , 11 , 12 ) and one group noting 40% ( 10 ). The rates of meatal stenosis in vaginoplasty techniques that transect the urethra at the meatus versus those that preserve the posterior urethral plate to span between the neoclitoris and urethral meatus have not been parsed out. Complaints of new onset obstructive urinary symptoms such as weak stream or feeling of incomplete emptying should raise suspicion for urethral stricture disease, particularly in those patients who did not have these symptoms prior to vaginoplasty. Patients with urethral strictures can also present with urinary retention and frequent urinary tract infections. Meatal stenosis can usually be diagnosed on physical exam ( Figure 10 ). In patients who are not in urinary retention and maintain normal renal function, we prefer to avoid dilation of the stenotic segment and plan for definitive surgical reconstruction. Dilation will alter anatomy, making it more difficult for the surgeon to ensure that the entire narrowed segment has been excised. During urethroplasty, a small caliber catheter is placed via the stenotic meatus to help delineate urethra. A circumscribing incision is made and corpus spongiosum and urethra are dissected sharply away from surrounding tissue. Care is taken to develop the plane along the corpus spongiosum to maintain blood supply to the urethra and adjacent skin flap. The stenotic segment is transected sharply and urethral edge is spatulated ventrally to ensure a large caliber urethral meatus. We place a running suture circumferentially to evert urethral mucosa and for hemostasis. A V flap is created from the anterior neovaginal wall and advanced into the posteriorly spatulated portion of the urethra. Urethral meatus is then matured with interrupted 4-0 Vicryl sutures. A catheter remains in place for 5–7 days postoperatively.

Pinpoint neomeatus.

The urethral meatus can also be anteriorly malpositioned, leading to deviation of the urine stream in a forward direction when the patient sits to void. This issue frequently presents as a complaint of urine spraying over the edge of the toilet seat, a need to bend the torso forward, or the use a deflective device (e.g., towel) to direct the urine stream downwards. This anterior urethral angle can be corrected by an approach similar to the one described above. In some instances where the attachment of the corpus spongiosum to the crus of the corpora cavernosum was not dissected adequately at the time of the initial operation, more significant periurethral dissection is needed to free up the urethra. Once the urethra has been mobilized adequately to allow it to drop into a position suitable to generate a downward stream, the meatus can be matured as described above. The skin or tissue anterior to the new meatus position has to be closed to compensate for the change urethral position.

Urethral bulb bulge

A periurethral bulge that protrudes into the distal anterior vaginal canal can present in patients when there is inadequate tapering of corpus spongiosum tissue at bulbous urethra at the time of the vaginoplasty. Patients describe it as a sensation of engorged erectile tissue around the urethra and vaginal opening, particularly during arousal, causing problems with intercourse, pain, discomfort or dysphoria. In addition to inadequately tapered corpus spongiosum, the bulge can also be due to incompletely resected bulbospongiosus muscle. Correction of the bulge can be achieved transvaginally, typically with a incision through the penile skin flap that overlies the urethra. The skin flaps are raised and dissection is carried more deeply to expose any remaining bulbospongiosus muscle, which should be excised completely. If there is excessive corpus spongiosum, an indwelling catheter should be placed to delineate the course of the urethra and the ventral aspect of the spongiosum can be tapered to parallel the urethra. The edges of the trimmed corpus spongiosum can be closed with 4-0 Vicryl. In our practice, we maintain vaginal packing and urethral catheter for approximately 5 days in patients with large anterior neovaginal wall incisions to help with adherence of the overlying penile skin flap. If needed, this intervention can be combined with urethral repositioning, labiaplasty, clitoroplasty, or other cosmetic revisions of the perineogenital complex ( 13 ).

Clitoral exposure/cosmesis

Requests for revision due to external genitalia cosmetic appearance are common and generally not considered as a complication. Rate of revision of the perineogenital complex ranges from 25% to 50% ( 4 , 14 , 15 ). These revisions can include additional clitoral coverage by reconstruction of clitoral hood, formation of more defined labia minora, or reduction of labia majora. Timing of revisions should be at least three months from the date of the original surgery to allow for tissues to settle and edema to resolve. In some cases, the posterior fourchette forms a ridge making dilation and intercourse more difficult. This ridge can be revised by re-advancing the perineal flap. Clitoroplasty and labiaplasty can be completed as an outpatient surgery and can be combined with revision of urethral meatus or an urethral bulb bulge.

Penile inversion vaginoplasty provides a safe and effective technique in appropriately selected patients to achieve the goals of constructing a functional neovaginal and a feminine-appearing perineogenital complex. Post vaginoplasty patients can presents with a variety of complications ranging from minor and non-operative to those that may require multiple surgical interventions. Thorough preoperative discussions with the patient and even supporting friends and family are extremely important to ensure patients’ understanding of the possible short term and long term complications related to this procedure. Broadening medical school and post-graduate curriculum to improve understanding of gender affirming surgical procedures and related anatomy can strength the ability of healthcare providers to provide care for these patients.

Transmasculine genitourinary surgery

By the time patients schedule their consultation, many will have already been on hormone therapy for over 1 year and will have established mental and primary health care. Many will also have had double mastectomy and hysterectomy. Patients want to explore their options for GRGUS, which for transmasculine individuals, includes metoidioplasty and phalloplasty, with variable desires for vaginectomy, scrotoplasty, and urethroplasty. Most patients will want all of these procedures; some will want to exclude part of the genitourinary reconstruction for individualized reasons. For example, some patients do not want urethroplasty to avoid the risks of urethral reconstruction, while others avoid vaginectomy. During the history portion of the consultation, ascertainment of the patient’s surgical goals is vital to determining which surgery is most appropriate. Patients opting for metoidioplasty generally do not want donor site morbidity and accept a small phallus; patients seeking phalloplasty want a larger and physiologic appearing phallus. For patients whose primary goal is standing micturition, phalloplasty with full length urethroplasty is the more appropriate choice, although clitoral enlargement from hormone therapy may allow thin patients with minimal surrounding genital tissue to void standing after metoidioplasty with urethral lengthening.

As with all surgeries, a thorough history and physical is important. A history of hypertrophic scarring or keloids negatively impacts postoperative complications—specifically, urethral strictures. Smoking tobacco, use of nicotine products, or inhalational products of any kind increases wound and other perioperative complications ( 16 - 19 ) to the point where surgery may be cancelled if there is evidence of smoking within 3 months of surgery. Diseases treated with immunotherapy such as steroids may also affect wound healing and are strong contraindications to surgical therapy. Obesity with specific adipose distribution to the pannus or mons pubis and thighs may also prevent safe surgery and at the minimum, negatively impact overall aesthetics and function. A suggested body mass index (BMI) cutoff is 35 kg/m 2 for patients desiring radial forearm free flap (RFFF) phalloplasty; ideal body weight is suggested for patients interested in metoidioplasty and anterolateral thigh (ALT) phalloplasty. Despite these guiding principles, BMI alone is a poor indicator for metoidioplasty and ALT phalloplasty candidacy. Physical exam assessment of the surgical sites offers far more accurate predictions of postoperative aesthetics and function.

Metoidioplasty

Patients desiring metoidioplasty want masculine-appearing genitalia without the morbidity associated with a donor site. This procedure involves chordee release with or without vaginectomy, urethroplasty, scrotoplasty, and perineal reconstruction. A simple metoidioplasty is chordee release, neurovascular pedicle reposition, and ventral phallus skin closure. A full metoidioplasty, in contrast, includes simple metoidioplasty procedures with vaginectomy, scrotoplasty, and urethroplasty. The ideal candidate for metoidioplasty is a thin, healthy patient with minimal surrounding genital tissue and pronounced clitoral enlargement from hormone therapy. The surgical technique employed for patients wanting a full metoidioplasty starts first with vaginectomy. Vaginectomy requires the excision and/or destruction of the vaginal mucosa, followed by a colpocleisis to obliterate the canal ( Figure 11A,B ). Thick polydioxanone (PDS) suture is used during vaginectomy to decrease the risk of urethral pseudodiverticulum formation at the native urethral anastomotic site. Care is taken to preserve neighboring labia minora tissue as this is used to lengthen the urethra from the native urethral meatus to the glans clitoris ( Figure 12 ). Our urethroplasty technique is modeled after the “ring” flap metoidioplasty first described by Takamatsu ( 20 ). During dissection of the ring flap, the chordee is released via transection of the ventral attachments down to the corporal bodies of the clitoris, creating a gap between the base of the clitoris and the urethral meatus. The peri-urethral fornices flanking the urethral meatus are excised ( Figure 13A,B ) and the inferior portion of the ring flap is divided and then sewn to the dorsal aspect of the native urethral meatus, filling the gap ( Figure 14A, B ). The dorsal urethral plate is sewn in several layers, with the first layer securing the submucosal flap tissue to the tissue surrounding the corpora cavernosa ( Figure 15 ). Further urethral reconstruction around the meatus is completed, followed by ventral closure and tubularization of the urethra to the glans clitoris ( Figure 16 ). At the native urethral meatus, the ventral anastomosis with the ring flap will often have excess tissue that can be de-epithelialized and used to directly cover the urethral suture line at this location ( Figure 17 ). Excess labia minora skin is then similarly de-epithelialized, creating a subepithelial vascular layer that can be used to cover the urethral suture line ( Figure 18 ). The remaining labia minora skin is then closed ventrally to create a cylindrical phallus. The inferior aspect of the labia majora is then incised via a “U” shaped incision to create flaps that are lifted, rotated and sewn to create a pouch like scrotum just inferior to the base of the phallus ( Figure 19 ). The perineal wound is then closed with several layers of absorbable suture. We place a suprapubic (SP) tube that remains for 2–3 weeks. We close the urethra around a Coude catheter that is removed immediately postoperatively to avoid the risk of catheter related traumatic hypospadias. There are numerous other metoidioplasty techniques described ( 21 - 26 ), but we favor the ring flap technique as it avoids dorsal clitoral dissection, corporal dissection, and urethral grafts.

Vaginectomy. (A) After distal sharp mucosal excision, the remainder of the vaginal mucosa is fulgurated; (B) colpocleisis is carried out with thick polydioxanone suture.

Markings demonstrate tissue used for pars fixa urethroplasty.

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.

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.

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.

Pars fixa urethroplasty is completed with ventral closure.

De-epithelialized portions of the labia minora flaps are preserved and used as additional coverage over the native urethral-to-ring flap anastomosis.

Vascular de-epithelialized flaps from the labia minora tissue not used for urethroplasty are preserved for coverage of the pars fixa urethral suture line.

Immediate postoperative photo of patient after metoidioplasty with urethral lengthening, vaginectomy, scrotoplasty, and perineal reconstruction.

Patients undergoing metoidioplasty are either discharged home later that day or watched overnight; rarely do patients require longer hospital stays. We advise patients regarding expected phallus swelling and incisional drainage of serosanguinous fluid. They are advised to ambulate slowly but regularly and notify us of any worsening symptoms. At their first postoperative visit one week later, if the phallus swelling is minimal, patients can attempt a voiding trial. If they are able to void reliably well with minimal post void residuals, the SP tube may be removed on their subsequent visit. If there is significant postoperative swelling, a voiding trial is delayed a week. During their voiding trial, if an urethrocutaneous fistula is noted, voiding trial is delayed for an additional week. Most fistulas are small and heal spontaneously with good wound care and nutrition. On rare occasion, fistula repairs are required. The SP tube is removed if the patient can void successfully. Some urologists will perform voiding cystourethrograms (VCUGs) or retrograde urethrograms (RUGs) prior to SP tube removal. Patients are thereafter counseled to watch for obstructive voiding symptoms as about 10% of patients are prone to stricture formation within the first year (unpublished data). A recent meta-analysis reported metoidioplasty associated urethral complication rate to be around 25% ( 27 ).

About six months after metoidioplasty, some patients will want/need additional procedures, the most common of which is testicular implant insertion with or without monsplasty and upper labia majora fold reduction. This is an outpatient procedure and involves strategic dermatolipectomy of the mons pubis and upper majora tissue to reduce the surrounding tissue around the phallus. Testicular implants can be placed dependently in the scrotum via the labia majora incisions with a purse-string type suture placed superiorly to decrease the risk of cephalad migration of the implant.

For patients who develop strictures or who have fistulas that do not heal, urethral reconstruction is required. Fistula repair involves the excision of the fistula tract followed by multi-layered closure of the site. This can often be completed in a single stage.

Phalloplasty

Patients seeking phalloplasty often desire a proportionally sized phallus with neophallus sensation, the ability to urinate standing, and eventual penetrative sexual function via a penile prosthetic. There are a multitude of techniques and surgical staging options available for phalloplasty ( 28 - 52 ). The most common of technique is a single-stage RFFF phalloplasty with vaginectomy, urethroplasty, scrotoplasty, and perineal reconstruction. The distinct advantages of the radial forearm donor site are the tissue’s similarity to genital skin, skin innervation, and a highly reliable neurovascular supply. The major disadvantages are the conspicuous donor site scar and potential for diminished hand function. Patients with an intact palmar arch without prior history of prohibitive radial forearm trauma or intravenous drug use are candidates for the RFFF—widely considered the gold standard for phalloplasty. The second most common donor site is the ALT pedicled or free flap. The advantage of this sensory flap is its more concealable donor site. The main disadvantage is that few patients have the anatomy sufficient for a single staged “tube in tube” ALT phalloplasty as this flap is frequently thicker and will require multiple stages of neophallus and neourethral reconstruction to achieve a functional, more aesthetic and proportionally sized phallus. Other flap options include the musculocutaneous latissimus dorsi free flap, the tibial free flap, and abdominal or groin pedicle flaps ( 40 , 44 , 53 , 54 ). These flaps are not offered in our practice given their lack of sensory innervation and their need for staged urethral and neophallus reconstruction. In nearly all RFFF phalloplasty patients, full length urethroplasty and physiologic aesthetics are achievable in the first stage, minimizing the need for multiple stages of neophallus and urethral reconstruction.

The surgical team is composed of microsurgeons and a reconstructive urologist. The patient is positioned in dorsal lithotomy position with the arms perpendicular to the body. The microsurgeons harvest the flap and create the pars pendulans (PP) urethra and neophallus with or without glansplasty depending on the flap used and the patient’s specific anatomy. We avoid primary (immediate) glansplasty in ALT flaps and thin RFFFs due to the risk of distal flap necrosis. Thicker RFFF neophalluses accommodate concomitant glansplasty due to a reliable distal flap blood supply from the more abundant adipose tissue. During flap harvesting and neophallus creation, the reconstructive urologist performs the vaginectomy, pars fixa (PF) urethroplasty, scrotoplasty, and perineal reconstruction in a fashion similar to the methods utilized during metoidioplasty. The key differences are the following: clitoris shaft and glans de-epithelialization, dorsal nerve dissection, transposition of the clitoris and PF urethra, and a more extensive scrotoplasty with perineal reconstruction. The clitoris de-epithelialization is required to expose one of the two dominant dorsal nerve branches ( Figure 20 ). This is dissected free and later coapted to the antebrachial cutaneous nerve(s) of the RFFF. The neophallus recipient site in front of the mons pubis is created and the clitoris and PF urethra is translocated to this region. The complex scrotoplasty is then performed by raising labial majora flaps based on the external pudendal blood supply that arises superiorly. The flaps are then lifted and rotated to create a pouch-like scrotum ( Figure 21 ). The perineal reconstruction focuses first on urethral suture line coverage with local flaps. The bulbospongiosus fibromuscular layer covers the PF urethral suture line directly ( Figure 22 ) followed by perineal fat and inner thigh skin approximation to create a flat, male appearing perineum ( Figure 23 ).

Dorsal nerve dissected free from one side of a de-epithelialized clitoris.

Pouch-like anteriorly positioned scrotum after labia majora flap elevation, rotation, and advancement.

Bulbospongiosus muscle layer is used to cover the proximal pars fixa urethroplasty suture line.

Inner thigh skin is brought towards the midline to complete the perineal reconstruction.

The patient is then repositioned supine upon completion of the phalloplasty, vaginectomy, urethroplasty, scrotoplasty, and perineal reconstruction. Groin dissection of the contralateral femoral vessels is carried out by the microsurgeons. The urologist then passes a Coude catheter into the bladder through the PP and PF urethra. This facilitates the PF and PP urethral anastomosis, which is performed with 5-0 PDS suture ( Figure 24 ). The adipofascial extension from the flap covers the urethral suture line at this location ( Figure 25 ). The microsurgeons then coapt the nerves and complete the vascular anastomoses under an operating microscope. The groin wound and donor site are then closed, and split thickness skin grafts (STSG) from the thigh are used to cover the donor site. The phallus is attached to the scrotum and prepubic skin ( Figure 26 ).

PF and PP urethral anastomosis. PF, pars fixa; PP, pars pendulans.

Adipofascial flap from the RFFF covers the PF-PP urethral suture line. RFFF, radial forearm free flap; PF, pars fixa; PP, pars pendulans.

Immediate postoperative appearance of neophallus and scrotum after RFFF phalloplasty, urethroplasty, vaginectomy, scrotoplasty, and perineal reconstruction. RFFF, radial forearm free flap.

Patients are hospitalized for an average of 5 days, with 4 days of bedrest followed by ambulation. The first two days require every 1–2 hour Doppler checks of the phallus. On day 5, patients are encouraged to walk. If they are walking well with good pain control and gastrointestinal function, they are discharged from the hospital with the urethral and suprapubic catheter. Thereafter, they are followed weekly for 4 weeks. At the first postoperative visit, the urethral catheter is removed. At the second visit, if there is minimal neophallus swelling and the incisions continue to heal well, patients are instructed to void with the SP tube clamped. If they are voiding well with minimal post void residuals, the SP catheter is removed at their third postoperative visit. Some urologists will perform VCUGs or RUGs prior to catheter removal.

Complications are common ( 35 , 55 - 60 ). Fortunately, most are minor, including open wounds and urinary tract or skin infections. These are minimized by instructing patients to ambulate with small steps and minimize large range of motion movements, especially when getting in and out of cars and when sitting from a standing position. Patients are also advised to keep the surgical sites clean and position the phallus about 45 degrees from the plane of their body. Intermediate grade complications often involve the urethra, including fistulas and strictures. About one-third of our RFFF phalloplasty patients develop a fistula and/or stricture, and about half of these patients will require surgical repair 3–6 months after phalloplasty. In our experience, these risks and others are higher in single stage ALT phalloplasties compared to single stage RFFF. Major complications will require surgery during their hospitalization and includes problems such as vascular thrombus formation and/or groin or perineal expanding hematomas. Fortunately, these complications are rare. Patients are at risk for stricture formation for about 1 year (and perhaps longer) after surgery given the natural history of wound maturation ( 61 ). We recommend that patients get an uroflow and post void residual determination every 3–4 months postoperatively.

Around 12 months after phalloscrotoplasty or urethroplasty, patients who are stricture recurrence free with neophallus sensation may want penile and testicular implants. Patients who desire further neophallus reconstruction via glans revisions or neophallus size reduction or shaping are encouraged to do so about 6 months prior to implant insertion to minimize risk of penile implant complications—specifically, erosion and infection.

Urethral reconstruction after phalloplasty and metoidioplasty

Urethral strictures and fistulas are relatively common, averaging around 50% in phalloplasty patients and 25% in metoidioplasty patients ( 20 , 23 - 27 , 55 - 57 , 59 , 62 - 64 ). In metoidioplasty patients, most fistulas are ventral to the shaft of the phallus and are seen more frequently in patients without abundant labia minora tissue. The second most common location is behind the scrotum at the perineum-scrotum junction. Strictures in metoidioplasty patients are less common, and when present, are usually of the proximal portion of the labia minora urethroplasty—just distal to the native urethral meatus. In phalloplasty patients, the areas at highest risk for urethral fistula or stricture formation are at the PF-PP urethral anastomosis and the neophallus urethral meatus. These are the vascular watershed areas. For patients with prolonged neophallus swelling, fistulas can occur along the ventrum of the shaft several months after phalloplasty. They have a natural history of opening and closing; if they don’t close by around 4 months, repair is required.

Fistulas that are small (5 mm or less) and persist beyond 4 months postoperatively can be repaired primarily. Patients who are at risk of fistula formation often have minimal labia minora tissue, which then leads to minimal sub-epithelial flap availability for urethral suture line closure during the initial metoidioplasty. Therefore, the primary strategy for fistula repair is separation of the urethral epithelium from the phallus epithelium, with interposition of additional tissue. The urethral epithelium can be closed with inverting sutures followed by coverage with a dermal interposition graft, which can be harvested from the groin. The phallus skin is then closed over the graft. Proximal fistulas with often have dartos equivalent tissue for closure and don’t require an interposition graft. Larger fistulas (>5 mm) may require an epidermal autograft from the groin or mouth depending on the fistula location to cover the defect. Urethras made from labia minora have mucosal like epithelium and may respond better to oral grafts; skin urethras from a neophallus respond about equally well to skin or oral grafts. Exceptionally large defects, or defects without sufficient neighboring vascularized tissue, may require a staged approach: the first stage is creation of a vascularized sufficiently wide urethral plate followed 6 months later by urethral tubularization.

Some patients desire urethral lengthening without vaginectomy. This is not a commonly desired surgery, but it frequently leads to urethrovaginal fistulas ( 62 ). Patients are counseled appropriately prior to undergoing this procedure and understand the expected need for fistula repair postoperatively. Treatment for this is similar to fistula repair at other urethral locations. The main difference is that definitive treatment may require vaginectomy, as this allows the development of local flaps to cover the urethrovaginal fistula repair site.

Strictures of the proximal labia minora urethra in metoidioplasty patients are frequently short and can be treated with anastomotic or Heineke-Mikulicz type repairs. Strictures associated with phalloplasty are commonly seen at the PF-PP anastomosis or distal urethra. Strategies for treatment are similar to strategies utilized for cis-men urethroplasties: it depends on length and location of the strictures ( 65 ). Distal strictures with minimal scar tissue can be treated with staged Johanson urethroplasty or Asopa type urethroplasty ( 56 , 66 , 67 ). Short PF-PP urethral strictures are amenable to anastomotic or Heineke-Mikulicz urethroplasties ( 65 ); longer strictures require substitution urethroplasty with oral or skin grafts; long and obliterative strictures benefit from staged urethroplasties, and on rare occasion, a free flap urethroplasty ( 68 - 70 ). The appropriate timing of repair is usually about 3–4 months from initial metoidioplasty or phalloplasty to allow tissue maturation and vascularization. For stricture recurrences after urethroplasty, 3–4 months is suggested prior to repeat urethroplasty. When patients have recurrences before the 3–4 month period, SP tube urinary diversion is recommended until the appropriate time.

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 carry a significant risk as a large percentage of patients will require corrective surgeries from complications that arise. Despite this, there are more patients needing and wanting surgery than there are providers able to perform them. There is also a parallel and exponentially increasing need for patients to find capable care for postoperative issues that arise. Fortunately, there is a favorable trend towards more centers, health systems, and surgeons offering services for TGNC individuals.

Acknowledgments

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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

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Benefits of Dilator Therapy after Gender Affirmation Surgery

The medical world continues to make advancements, but one area that is growing in both knowledge, practice, and acceptance is that of gender affirmation surgeries. More and more primary care physicians are learning about gender dysphoria and affirmation therapies and procedures, and you don’t necessarily need to go to a big city anymore to get high-quality surgical care for complicated procedures, such as vaginoplasty. Vaginal dilation after gender affirmation surgery is a must, which is where we come in to help you get the most out of your surgery.

What is a Vaginoplasty?

Vaginoplasty is the surgical procedure known by the transgender community as “bottom surgery.” Put simply, the surgeon uses the penis and scrotum tissue to create a vagina and labia. The technique utilizes skin grafts from your existing tissue which then grow inside the new vaginal canal for 5 days.

How to Improve Recovery

Because the body is designed to heal from trauma, the body usually responds to this procedure as it would any natural wound response. It sends messages to the immune system to close the new hole. Similar to the way the body sometimes handles a piercing, your new vagina may start to shrink, close, or scar while it’s healing. This can cause vaginal stenosis, which is the narrowing and tightening of the vagina. It’s because of the healing response, as well as the muscles trying to move back into their original positions, that vaginal dilation  is necessary. If your consultation doesn’t naturally include a conversation about vaginal dilation after gender affirmation surgery, be sure to bring it up.

Regular use of vaginal dilators  will keep the new vagina functioning as it should, but it will also help minimize the formation of scar tissue, make the tissue more elastic, and prevent you from losing depth and width. It’s common for MTF (male-to-female) transgender patients to start using vaginal dilators as soon as just a few days after surgery. Between dilation sessions, the new vagina relaxes and contracts, which forms wrinkles that start to heal together. This process narrows the diameter over time while the body is trying to heal, which is even more reason to diligently dilate. Your surgeon might even recommend it become a permanent part of vaginal maintenance. If you’ve already lost depth and width, getting into a dilation routine can increase the depth and width of your vagina through the use of progressively larger dilators. Purchasing a BioMoi dilator set  can be a beneficial investment to continue the therapy progression.

It’s a slow process, but it’s an effective one. Everyone’s surgery and recovery experiences will be different, and it’s certainly normal to experience swelling and soreness. It’s also normal to have questions. Vaginas are complex, and your new vagina is even susceptible to urinary tract infections and yeast infections, which is why it’s important to choose an antimicrobial dilator. Follow the instructions given by your surgeon about vaginal dilation after gender affirmation surgery, and you’ll be well on your way to seeing and feeling the body that’s right for you.

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MTF Gender Confirmation: Genital Construction

The specifics, the takeaway.

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As part of a transgender individual’s transition, genital reassignment surgery alters male genitalia into female genitalia.

Written By: Erin Storm, PA-C

Published: October 07, 2021

Last updated: February 18, 2022

• Procedure Overview
• Ideal Candidate
• Side Effects
• Average Cost

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• Can Help Complete A Gender Affirmation Journey

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Invasiveness is graded based on factors such as anesthesia practices, incisions, and recovery notes common to this procedure.

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$ 7000 - $ 24000

What is a male to female (MTF) gender reassignment surgery?

Male to female (MTF) gender reassignment surgery is also known as sex reassignment surgery (SRS), genital construction, and generally as Gender Confirmation Surgery. These procedures are used to remove and alter male genitalia into traditional female genitalia. Plastic surgeons will remove the scrotum, perform a penile inversion to create the neovagina, remove and alter penile erectile tissue to form the clitoral tissue of the clitoris, and construct labia usually from scrotal tissue. The prostate gland is left intact. These procedures create fully functional female genitalia in transgender patients.

Typically gender reassignment surgery is performed as a last step in a transgender individuals transition journey. Guidelines from The World Professional Association for Transgender Health (WPATH) state candidates must have letters of recommendation from their mental health provider and physician, have been living full time as a woman for one year, and have completed one year of hormonal therapy to be eligible.

Information on facial feminization surgeries, top surgeries (like a breast construction), and other male to female gender affirming surgeries as part of a gender transition for transwomen can be found in our comprehensive guide to MTF gender affirmation solutions .

What concerns does a MTF gender reassignment surgery treat?

• Transfeminine Bottom Surgery & Genital Construction : Male to female gender reassignment surgery creates female genitalia that are aesthetically authentic and functional. A vaginoplasty, penectomy, orchiectomy (testicle removal), clitoroplasty, and labiaplasty are typically performed.

Who is the ideal candidate for a MTF gender reassignment surgery?

The ideal candidate for MTF gender reassignment surgery is a transgender women seeking to complete her physical embodiment of her gender identity. This reconstructive genital surgery creates functioning female genitalia.

MTF gender reassignment surgery is not recommended for those who have not been on hormone therapy for one year, have not been living full time as a woman for one year, do not have letters of recommendation from their mental health provider and physician, children under the age of 18, and those with certain chronic medical conditions.

What is the average recovery associated with a MTF gender reassignment surgery?

Most patients experience four to six weeks of recovery time following a MTF gender reassignment surgery. Patients can expect bruising, swelling, and tenderness following the procedure. A urinary catheter is placed for one week and vaginal packing as well which may cause a sensation of fullness. Vaginal dilation is a component of the procedure and the patient will be advised on how to complete this progressive dilation at home over the course of a few weeks.

What are the potential side effects of a MTF gender reassignment surgery?

Possible side effects following a MTF gender reassignment surgery include bleeding, swelling, bruising, site infection, altered sensation, difficulty urinating, difficulty with sexual function, prolonged edema, and complications from anesthesia or the procedure.

What can someone expect from the results of a MTF gender reassignment surgery?

The results of MTF gender reassignment surgery are permanent. This procedure creates functional female genitalia and removes all male genitalia. The prostate gland is left intact which is important for transgender individuals ongoing healthcare and preventative screenings.

What is the average cost of a MTF gender reassignment surgery?

What to expect.

A MTF Gender Reassignment Surgery creates female genitalia. Here is a quick guide for what to expect before, during, and after a MTF Gender Reassignment Surgery:

Before Surgery

• Prophylactic antibiotics or antivirals may be prescribed
• Stop taking blood thinning medications two weeks prior to surgery. Blood thinners may include, Advil, Tylenol, Aspirin, and prescription anticoagulants
• Stop smoking four weeks prior to the procedure and continue cessation for four weeks post op
• No alcohol two days prior to the procedure
• Do not eat or drink six hours before

During Surgery

• General anesthesia
• A penile inversion is performed to create the vaginal canal
• The scrotum is removed
• Skin grafts are used to create the labia and vulva
• Erectile tissue is removed from the new vaginal walls, and erectile tissue from the head of the penis is used to create the clitoris
• ​The urethra is shortened

Immediately After Treatment

• Swelling, bruising, and tenderness

1 - 30 After Treatment & Beyond

• Resume most activities after a few days
• Swelling typically resolves within a few weeks
• Avoid strenuous activity for two to four weeks
• Remove urinary catheter and vaginal packing after one week
• Continue progressive vaginal dilation

Result Notes

• Results are permanent
• Proper aftercare will ensure optimal results

Gender confirmation surgeries for transgender individuals are an important component of transgender health and in creating an embodied gender identity. Gender reassignment surgery allows transgender women who feel it is a part of their transition to more fully embrace their gender identity.

To learn more about our content creation practices,  visit our Editorial Process page .

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AEDIT uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.

• American Society of Plastic Surgeons Gender Confirmation Surgeries plasticsurgery.org
• Karel E Y Claes Chest Surgery for Transgender and Gender Nonconforming Individuals PubMed.gov ; 2018-07-02

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Original research article, male-to-female gender-affirming surgery: 20-year review of technique and surgical results.

• 1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
• 3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

Figure 1 . The initial circumferential subcoronal incision.

Figure 2 . The de-gloved penis being passed through the scrotal opening.

Figure 3 . The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

Figure 4 . The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

Figure 5 . The inverted penile skin flap.

Figure 6 . The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

Figure 7 . The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Figure 8 . Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Table 1 . Patient demographics.

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Table 2 . Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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PubMed Abstract | CrossRef Full Text | Google Scholar

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4. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int . (2007) 100:607–13. doi: 10.1111/j.1464-410X.2007.07017.x

5. Rossi NR, Hintz F, Krege S, Rübben H, Vom DF, Hess J. Gender reassignment surgery – a 13 year review of surgical outcomes. Eur Urol Suppl . (2013) 12:e559. doi: 10.1016/S1569-9056(13)61042-8

6. Silva RUM, Abreu FJS, Silva GMV, Santos JVQV, Batezini NSS, Silva Neto B, et al. Step by step male to female transsexual surgery. Int Braz J Urol. (2018) 44:407–8. doi: 10.1590/s1677-5538.ibju.2017.0044

7. Aydin D, Buk LJ, Partoft S, Bonde C, Thomsen MV, Tos T. Transgender surgery in Denmark from 1994 to 2015: 20-year follow-up study. J Sex Med. (2016) 13:720–5. doi: 10.1016/j.jsxm.2016.01.012

8. Perovic SV, Stanojevic DS, Djordjevic MLJ. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. (2001) 86:843–50. doi: 10.1046/j.1464-410x.2000.00934.x

9. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. (2001) 88:396–402. doi: 10.1046/j.1464-410X.2001.02323.x

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19. Salim A, Poh M. Gender-affirming penile inversion vaginoplasty. Clin Plast Surg. (2018) 45:343–50. doi: 10.1016/j.cps.2018.04.001

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24. Bartolucci C, Gómez-Gil E, Salamero M, Esteva I, Guillamón A, Zubiaurre L, et al. Sexual quality of life in gender-dysphoric adults before genital sex reassignment surgery. J Sex Med . (2015) 12:180–8. doi: 10.1111/jsm.12758

Keywords: transsexualism, gender dysphoria, gender-affirming genital surgery, penile inversion vaginoplasty, surgical outcome

Citation: Moisés da Silva GV, Lobato MIR, Silva DC, Schwarz K, Fontanari AMV, Costa AB, Tavares PM, Gorgen ARH, Cabral RD and Rosito TE (2021) Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results. Front. Surg. 8:639430. doi: 10.3389/fsurg.2021.639430

Received: 17 December 2020; Accepted: 22 March 2021; Published: 05 May 2021.

Reviewed by:

Copyright © 2021 Moisés da Silva, Lobato, Silva, Schwarz, Fontanari, Costa, Tavares, Gorgen, Cabral and Rosito. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Gabriel Veber Moisés da Silva, veber.gabriel@gmail.com

This article is part of the Research Topic

Gender Dysphoria: Diagnostic Issues, Clinical Aspects and Health Promotion

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Advocates: Ban on reassignment surgery for minors would have broad impact on NH health care

Apr. 26—CONCORD — Alice Wade, a transgender woman from Dover in her 20s, said she had to go to Washington to have gender reassignment surgery last summer, and the follow-up services she received at a local hospital here were "laughable."

Wade and many transgender activists said that passing legislation to ban these procedures for anyone under 18 would harm the entire LGBTQ+ community.

"New Hampshire needs to improve when it comes to trans health care, and bills like this will make it harder," Wade testified during a hearing last week on the House-passed ban HB 619.

State Rep. Erica Layon, R-Derry, said the prohibition is appropriate because of the risks and experimental nature of the surgeries, especially on young people.

Layon noted state law does not allow a minor to use a tanning bed until they turn 18.

"I want people to be their authentic selves, but minors having this surgery is a disservice to parents and to minors," Layon said.

If the bill becomes law, New Hampshire would join 23 states that outlaw gender reassignment surgery for minors.

Transgender people like Wade have left the state to get the surgery where it was legal and available.

A coalition of health care organizations also spoke out against the legislation, which would contain the first provision in New Hampshire law to block physicians from making a medical referral, presumably in this case to an out-of-state provider who could perform the surgery.

Those organizations included the New Hampshire Hospital Association, National Alliance for Mental Illness, NAMI New Hampshire, the New Hampshire Medical Society and New Futures, a public health advocacy group.

Dr. Keith Loud, director of the Children's Hospital at Dartmouth-Hitchcock, said it's already hard to attract medical professionals to perform specialized procedures even without such proposed laws.

"Bills like this have a chilling effect on the ability to recruit and retain highly skilled individuals," Loud told the Senate Judiciary Committee.

Sen. Becky Whitley, D-Hopkinton, a candidate for Congress, said she found the ban on referrals the most troubling.

"Why in this one case are we legislating the practice of medicine?" Whitley asked Layon at one point.

Layon said the state has created guardrails for some medical practices, including a ban on conversion therapy for gay people.

Chris Erchull, a lawyer with GLBTQ Legal Advocates & Defenders (GLAD) said a report from the Journal of the American Medical Association found from 2016-2021 there were 101 gender reassignment surgeries for minors under 18 in the U.S., about 20 a year.

Often this was a vaginoplasty for a 17-year-old trans person so the surgery and recovery was complete before the minor headed off to college, Erchull said.

"This targets a class of people and denies them access to treatment," he said. "It is unconstitutional to single out a group of people for treatment under the law."

Under the bill, minors could still have surgeries if needed to correct a "malformation, malignancy, injury or physical disease." Surgery would also be permitted for sex development disorders or circumcision of males.

The House passed the bill last January, 199-175. The vote was not along party lines.

House Republicans backed it, 186-2.

Rep. Dan Hynes, a Bedford Republican who changed to independent before later resigning from the House, also voted against the bill.

House Democrats opposed it, 172-11.

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Nh senate committee hears testimony on bill to ban some gender-confirmation surgery for children.

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Lawmakers in Concord heard testimony Thursday on a bill to ban genital gender-confirmation surgery for children under the age of 18.

The Senate Judiciary Committee heard hours of testimony on House Bill 619, amended legislation that would ban genital gender-confirmation surgery for children under 18. The bill has already passed the New Hampshire House.

The legislation would also class referrals for reassignment surgery outside the state as "unprofessional conduct."

"Children are, by definition, immature," said Jennifer Black, of Windham. "We don't allow them to vote, enter into contracts, get a tattoo or smoke, because we know they lack the capacity to understand what they are doing."

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Some argued that allowing children, with parental consent, to get an irreversible surgery at such a young age is a form of cruelty. Others noted that such procedures are only being performed on a small number of older teens nationwide.

"Twenty times per year in the United States, never in New Hampshire, and virtually all of these surgeries are vaginoplasty for 17-year-old transgender girls right before heading off to college, while they can still recover in their parents' home with their parents' love and support, rather than in a college dorm with other students who may not even know they're transgender," said Chris Erchull, of GLAD Legal Advocates & Defenders.

There is a battle over data in the debate. Lawmakers who sponsored the bill said there isn't enough data for patients or families to give informed consent with a full understanding of the risks involved.

"I'm not trying to say that to trivialize this, but if you have to wait until you're 18 to use a tanning bed with those known risks, why would be endorsing something with completely unknown risks that have many people talking about the challenges they never knew or expected from these surgeries?" said state Rep. Erica Layon, R-Derry.

Dr. Ketih Loud, chairman of the Dartmouth Health Department of Pediatrics, urging senators to reject the bill.

"We prefer to use scalpels, and this statute feels a little more like a machete and does not allow for the nuance that we need in clinical practice," Loud said.