Genital Remodeling: A Safe & Effective Alternative to Neovaginoplasty
Daniel J. Koh, BA1, Sasha J. Nickman, BA1, Annie Heyman, BA1, Nikhil Sobti, MD2, Pamela Klein, RN, MSN3, Daniel S. Roh, MD, PhD4, Ricardo Munarriz, MD5, Jaromir Slama, MD4, Robert Oates, MD5.
1The Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA, 2Department of Plastic and Reconstructive Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA, 3Center for Transgender Medicine and Surgery, Boston Medical Center, Boston, MA, USA, 4Division of Plastic and Reconstructive Surgery, Boston Medical Center, Boston, MA, USA, 5Division of Urology, Boston Medical Center, Boston, MA, USA.
Background: Penile inversion neovaginoplasty (NVG) remains the most common genital procedure performed for male-to-female gender affirmation. NVG includes orchiectomy, clitoroplasty, urethroplasty, creation of a neovagina, and labiaplasty. At our institution, Genital Remodeling (our own term; GR), also known as vulvoplasty or zero depth vaginoplasty, is offered as an alternative to neovaginoplasty. GR differs from NVG intraoperatively in that a neovaginal space is not developed and the penile skin (flap) and scrotal skin (graft) are not used to create the neovagina. GR and NVG are similar in construction of the neoclitoris, clitoral hood, labia minora and majora, mucosal strip, and urethral meatus. While the rationale for selection and outcomes of NVG have been comprehensively characterized, those for GR remain poorly described. Therefore, this study aims to characterize the demographics, selection rationale, complications, and sexual endpoints of patients undergoing GR using the largest patient population to date. Materials & Methods: This study is a retrospective analysis of 63 patients who had their GR between January 1, 2016 and February 28, 2023. Demographics, surgical characteristics, reasons for selection of GR, complications, and sexual outcomes were analyzed. All intra- and post-operative complications were classified using the five tier Clavien-Dindo grading system. Results: A total of 63 patients were included in this study. The average age of patients was 52.88±17.15 years. The mean BMI was 28.06±5.07 kg/m2. The primary reason for selection of GR, and not NVG, was a lack of interest in neovaginal penetrative sexual activity (87.3%). Of the total cohort, 28.6% either solely or additionally felt that a neovagina was not necessary to address their gender dysphoria. In addition, 14.3% also cited concerns with neovaginal dilation/maintenance, 14.3% mentioned older age-related concerns, 9.5% cited a desire for less post-operative burden and rehabilitation, and 7.9% had concerns regarding their comorbid medical conditions. Intraoperative and postoperative complications were experienced by 11 out of 63 patients (17.5%). Of the 12 complications, 10 were Grade I or II (83%). Out of the two Grade IIIb complications that occurred, one was hematoma and the second was wound dehiscence, both of which required re-operative intervention within the first days post-operatively. Sexual outcome endpoints were fully collected for 55 patients, of which 91% reported satisfaction with their external genitals. A sensate clitoris was reported by 94% (51/54) of those who had self-stimulated. An orgasmic response was experienced by 76.9% (30/39) of patients who desired that outcome. Conclusion: In this long-term retrospective analysis, we found that GR is a safe and effective gender affirming procedure for those that do not desire a neovagina. Genital remodeling has high rates of sexual outcome satisfaction and low incidences of intraoperative and post-operative adverse events. Reasons for selecting genital remodeling are numerous, varied, and deeply personal.
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