Vaginoplasties for transgender women have been performed for a little over 80 years. The first known surgery was in 1931. Those early surgeries (link includes surgical images) were a little crude by modern standards. The patients in question already had penectomy (removal of the penis) and orchiectomy (removal of the testes) performed so most erogenous sensation was lost. No labia were formed as far as I can tell, and the vagina was made of skin from the inner thigh.
In the 80-some-odd years that have followed those first surgeries, the techniques have improved tremendously. However there’s little evidence to suggest which techniques are the best. Studies have been small and inconsistent in the factors they examine. Study results may be inaccurate. Without more data, and more consistent measures, nothing can be said for certain. Still, a recent meta analysis pulled what data we do have together into one document. And today I’ll translate and summarize their summary.
There are three basic techniques for vaginoplasty for trans women:
- Penile inversion. The tissue of the penis itself is used to line the vagina and labia. Parts of the scrotum and/or urethra may also be used.
- Intestinal graft, either from the ileum (part of the small intestine) or rectosigmoid region (end of the large intestine). This is less common among US surgeons than among non-US surgeons.
- Non-penile skin graft. This is an older technique, primarily used before 2000. Grafts were often taken from the inner thigh or abdomen.
Penile inversion is the most common technique in the United States today. It’s also the most well researched. In contrast, intestinal grafts are rarely performed by surgeons who specialized in transgender vaginoplasty in the United States today. Intestinal grafts are more commonly performed by non-US surgeons or for individuals who do not have a penis to invert. Lastly, the non-penile skin graft is an older technique that does not appear to be used much anymore.
All three techniques appears to produce overall satisfactory results. The average depth was around 10cm to 13.5 cm, and the vast majority of trans women were satisfied with their depth. The majority of women were also able to have vaginal intercourse (75%) and obtain orgasm (70%+). A majority were also aesthetically pleased by their results (90%) and had an improvement in their quality of life.
All techniques had their own levels of complications. Overall the most common complication was narrowing of the vagina (anywhere from 12%-43% of patients depending on technique). Urine stream changes and increases in risk of urethral infection were also fairly common, affecting 1 in 3 women. Rare serious complications included tissue death, rectal injuries, fistulas, deep vein thrombosis, and pulmonary embolism.
Comparisons between techniques was difficult because the details of each technique differed and the outcome measurements differed too. It does seem that, as far as the researchers could tell, there were fewer complications for intestinal graft vaginoplasties than for penile inversion vaginoplasties.However abdominal discomfort and “foul” vaginal secretions during intercourse have been reported for intestinal graft vaginoplasties, largely with rectosigmoid vaginoplasty. For penile inversion vaginoplasties, using urethral or scrotal skin in addition to penile skin was associated with more complications as well.
More research in general, and more standardized research, is crucial to understanding the best surgical techniques. Patients deserve the best results and the safest surgeries possible. Surgeons have already made great strides. Time to make more!
Want to read the study for yourself? The abstract is publicly available!