Genital gender-affirming surgery, or bottom surgery, is a medically necessary treatment for some transgender and gender diverse (TGD) individuals. Techniques and outcomes of penile inversion vaginoplasty are the most well-documented type of feminizing bottom surgery in the literature. The outcomes of vulvoplasty, in which no vaginal canal is created, are less clear. The aim of this study was to systematically review the literature on outcomes and experience of vulvoplasty. Embase, PubMed, CINAHL, and SCOPUS were searched from inception to October 22, 2022. Three search concepts were applied covering (1) population: TGD individuals assigned male at birth, (2) intervention: vulvoplasty, and (3) outcomes: surgical outcomes, patient-reported outcomes, and surgeons’ assessment of advantages and disadvantages of the procedure. Only publications in Danish or English were included with no other restrictions imposed. Data were pooled when feasible. The search generated 1713 titles after the removal of duplicates. Five studies were included for data analysis. The studies were of low quality and with small sample sizes, and analyses were limited by methodological heterogeneity. Thus, reliable conclusions could not be made. The scarce literature, however, suggests promising outcomes and satisfaction following vulvoplasty, and further, vulvoplasty is described as having some distinct advantages and disadvantages. Further investigation using larger study populations is needed.
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References
1.
CheungAS, OoiO, LeemaqzS, et al.Sociodemographic and clinical characteristics of transgender adults in Australia. Transgend Health, 2018; 3(1):229–238; doi: 10.1089/trgh.2018.0019
2.
DelamareAL, LyngholmL, MiltersenE, et al.Kønsbekraeftende nedre kirurgi for transpersoner i Danmark (Gender-confirming bottom surgery for trans persons in Denmark. [LGB] + Danmark: Denmark; 2021.
3.
DhejneC, ÖbergK, ArverS, et al.An analysis of all applications for sex reassignment surgery in Sweden, 1960–2010: Prevalence, incidence, and regrets. Arch Sex Behav, 2014; 43(8):1535–1545; doi: 10.1007/s10508-014-0300-8
4.
ScottKB, ThumanJ, JainA, et al.Gender-affirming surgeries: A national surgical quality improvement project database analyzing demographics, trends, and outcomes. Ann Plast Surg, 2022; 88(5 Suppl 5):S501–S507; doi: 10.1097/sap.0000000000003157
5.
WiepjesCM, NotaNM, de BlokCJM, et al.The Amsterdam cohort of gender dysphoria study (1972–2015): Trends in prevalence, treatment, and regrets. J Sex Med, 2018; 15(4):582–590; doi: 10.1016/j.jsxm.2018.01.016
6.
DhejneC, Van VlerkenR, HeylensG, et al.Mental health and gender dysphoria: A review of the literature. Int Rev Psychiatry, 2016; 28(1):44–57; doi: 10.3109/09540261.2015.1115753
7.
FrischM, MoseholmE, AnderssonM, et al.Sex i Danmark. Nøgletal fra projekt SEXUS 2017–2018 (Sex in Denmark. Key findings from project SEXUS 2017-2018).Statens Serum Institut, Denmark & Aalborg Universitet: Denmark; 2019.
8.
HaasA, RodgersP, HermanJ. Suicide Attempts Among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey. The Williams Institute, Los Angeles, USA & American Foundation for Suicide Prevention: Washington, USA; 2014.
9.
MassieJ, MorrisonS, Van MaasdamJ, et al.Predictors of patient satisfaction and postoperative complications in penile inversion vaginoplasty. Plast Reconstr Surg, 2018; 141(6):911e–921e; doi: 10.1097/PRS.0000000000004427
10.
BreidensteinA, HessJ, HadaschikB, et al.Psychosocial resources and quality of life in transgender women following gender-affirming surgery. J Sex Med, 2019; 16(10):1672–1680; doi: 10.1016/j.jsxm.2019.08.007
11.
LindqvistEK, SigurjonssonH, MöllermarkC, et al.Quality of life improves early after gender reassignment surgery in transgender women. Eur J Plast Surg, 2017; 40(3):223–226; doi: 10.1007/s00238-016-1252-0
12.
PapadopulosNA, LelléJD, ZavlinD, et al.Quality of life and patient satisfaction following male-to-female sex reassignment surgery. J Sex Med, 2017; 14(5):721–730; doi: 10.1016/j.jsxm.2017.01.022
13.
ColemanE, RadixAE, BoumanWP, et al.Standards of Care for the health of transgender and gender diverse people, Version 8. Int J Transgend Health, 2022; 23,(Suppl 1):S1–S259; doi: 10.1080/26895269.2022.2100644
14.
White HughtoJM, ReisnerSL, PachankisJE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med, 2015; 147:222–231; doi: 10.1016/j.socscimed.2015.11.010
15.
AlmazanAN, KeuroghlianAS. Association between gender-affirming surgeries and mental health outcomes. JAMA Surg, 2021; 156(7):611–618; doi: 10.1001/jamasurg.2021.0952
16.
WernickJA, BusaS, MatoukK, et al.A systematic review of the psychological benefits of gender-affirming surgery. Urol Clin North Am, 2019; 46(4):475–486; doi: 10.1016/j.ucl.2019.07.002
17.
TugnetN, GoddardJC, VickeryRM, et al.Current management of male-to-female gender identity disorder in the UK. Postgrad Med J, 2007; 83(984):638–642; doi: 10.1136/pgmj.2007.060533
18.
GarciaMM. Sexual function after shallow and full-depth vaginoplasty: Challenges, clinical findings, and treatment strategies- urologic perspectives. Clin Plast Surg, 2018; 45(3):437–446; doi: 10.1016/j.cps.2018.04.002
19.
LiVY, DemzikA, SnyderL, et al.Genital gender affirming surgery. Am Surg, 2022; 88(12):2817–2822; doi: 10.1177/00031348221109479
20.
van der SluisWB, SteensmaTD, TimmermansFW, et al.Gender-confirming vulvoplasty in transgender women in the Netherlands: Incidence, motivation analysis, and surgical outcomes. J Sex Med, 2020; 17(8):1566–1573; doi: 10.1016/j.jsxm.2020.04.007
21.
MilrodC, MontoM, KarasicDH. Recommending or rejecting “the dimple”: WPATH-affiliated medical professionals’ experiences and attitudes toward gender-confirming vulvoplasty in transgender women. J Sex Med, 2019; 16(4):586–595; doi: 10.1016/j.jsxm.2019.01.316
22.
ManriqueOJ, AdabiK, Martinez-JorgeJ, et al.Complications and patient-reported outcomes in male-to-female vaginoplasty-where we are today: A systematic review and meta-analysis. Ann Plast Surg, 2018; 80(6):684–691; doi: 10.1097/sap.0000000000001393
23.
OlesN, DarrachH, LandfordW, et al.Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (part 2: Genital reconstruction). Ann Surg, 2022; 275(1):e67–e74; doi: 10.1097/sla.0000000000004717
24.
BuncamperME, van der SluisWB, van der PasRS, et al.Surgical outcome after penile inversion vaginoplasty: A retrospective study of 475 transgender women. Plast Reconstr Surg, 2016; 138(5):999–1007; doi: 10.1097/PRS.0000000000002684
25.
GaitherTW, AwadMA, OsterbergEC, et al.Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. J Urol, 2018; 199(3):760–765; doi: 10.1016/j.juro.2017.10.013
JiangD, WittenJ, BerliJ, et al.Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med, 2018; 15(6):902–906; doi: 10.1016/j.jsxm.2018.03.085
28.
HorbachSE, BoumanMB, SmitJM, et al.Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med, 2015; 12(6):1499–1512; doi: 10.1111/jsm.12868
29.
AaenEK, HoejgaardAD, PopML, et al.Experience and outcomes of gender-confirming vulvoplasty as feminizing gender-confirming surgery: A systematic review. PROSPERO; 2022. Available from: crd.york.ac.uk/PROSPERO/display_record.php?RecordID=365578 [Last accessed: March 3, 2024].
30.
PageMJ, McKenzieJE, BossuytPM, et al.The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 2021; 372:n71; doi: 10.1136/bmj.n71
MunnZ, BarkerTH, MoolaS, et al.Methodological quality of case series studies: An introduction to the JBI critical appraisal tool. JBI Evid Synth, 2020; 18(10):2127–2133; doi: 10.11124/jbisrir-d-19-00099
33.
MunnZ, MoolaS, LisyK, et al.Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. Int J Evid Based Healthc, 2015; 13(3):147–153; doi: 10.1097/xeb.0000000000000054
34.
MaLL, WangYY, YangZH, et al.Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: What are they and which is better? Mil Med Res, 2020; 7(1):7; doi: 10.1186/s40779-020-00238-8
35.
GarciaMM. 010 A novel pre-surgery counseling aid for transgender patients undergoing mtof genital gender affirming surgery with vaginoplasty, to help manage patient expectations and to facilitate patient’s choice of surgery (full-depth or shallow-depth vaginoplasty) [abstract]. J Sex Med, 2019; 16(Supplement_1):S5–S6; doi: 10.1016/j.jsxm.2019.01.023
36.
BuncamperME, van der SluisWB, de VriesM, et al.Penile inversion vaginoplasty with or without additional full-thickness skin graft: To graft or not to graft? Plast Reconstr Surg, 2017; 139(3):649e–656e; doi: 10.1097/prs.0000000000003108
37.
JacobyA, MalihaS, GranieriMA, et al.Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J Urol, 2019; 201(6):1171–1176; doi: 10.1097/ju.0000000000000107
38.
Tavakkoli TabassiK, DjavanB, HosseiniJ, et al.Fold-back perineoscrotal flap plus penile inversion vaginoplasty for male-to-female gender reassignment surgery in circumcised subjects. Eur J Plast Surg, 2015; 38(1):43–48; doi: 10.1007/s00238-014-1038-1
39.
van der SluisWB, de NieI, SteensmaTD, et al.Surgical and demographic trends in genital gender-affirming surgery in transgender women: 40 years of experience in Amsterdam. Br J Surg, 2021; 109(1):8–11; doi: 10.1093/bjs/znab213
40.
DunfordC, BellK, RashidT. Genital reconstructive surgery in male to female transgender patients: A systematic review of primary surgical techniques, complication profiles, and functional outcomes from 1950 to present day. Eur Urol Focus, 2021; 7(2):464–471; doi: 10.1016/j.euf.2020.01.004
41.
KreinesFM, Hughes-HoganL, CifuentesM. Lower urinary tract symptoms after vaginoplasty: A review. Curr Bladder Dysfunct Rep, 2022; 17(2):76–80; doi: 10.1007/s11884-022-00648-5
42.
LevyJA, EdwardsDC, Cutruzzula-DreherP, et al.Male-to-female gender reassignment surgery: An institutional analysis of outcomes, short-term complications, and risk factors for 240 patients undergoing penile-inversion vaginoplasty. Urology, 2019; 131:228–233; doi: 10.1016/j.urology.2019.03.043
43.
KloerC, BlasdelG, MorrisM, et al.Overview of gender affirming surgery for the gynecologic surgeon. J Gynecol Surg, 2021; 37(4):269–274; doi: 10.1089/gyn.2021.0042
44.
FerrandoCA. Adverse events associated with gender affirming vaginoplasty surgery. Am J Obstet Gynecol, 2020; 223(2):267.E1–267.E6; doi: 10.1016/j.ajog.2020.05.033
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