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V77: Gender confirmation vaginoplasty: The Chicago technique

Speaker
H. Vigneswaran, Chicago (US)
Authors
Kocjancic E. 1 , Vigneswaran H. 1 , Sofer L. 1 , Jaunarena J. 1 , Whitehead D. 2 , Morgantini L.A. 1 , Schechter L. 2
Institutions
1University of Illinois at Chicago, Dept. of Urology, Chicago, United States of America, 2Weiss Memorial Hospital, Dept. of Plastic Surgery, Chicago, United States of America, 3
Event
33rd Annual EAU Congress Copenhagen
Date – time - Location
19 March 2018, 15:45 - 17:15, Green Area, eURO Auditorium (Level 0)
Session
Video Session 11 - Complex reconstructive genital surgery
Topic
Urethral strictures, urethroplasty and reconstruction of the external genitalia

Introduction & Objectives

Penile skin inversion technique is the current gold standard in vaginoplasty for gender confirmation. This surgery has three main challenges: maximal vaginal length, prevention of neovaginal prolapse and optimal cosmetic appearance. The objective of this video is to show our technique for vaginoplasty using scrotal graft and a modified dissection that prevents neovaginal prolapse, avoiding sacrospinal fixation.

Materials & Methods

The patient was prepped and draped in lithotomy position. A full–thickness skin graft was harvested from the scrotum, encapsulated, defatted, and sutured over a vaginal dilator. Scroto-perineal flap and penile flaps were designed and elevated, and the penis was degloved. Bilateral orchiectomy was performed. The vaginal cavity was then created using a combination of blunt and sharp dissection with the aid of the Lowsley retractor allowing to fit a 15 x 4cm vaginal dilator. The neoclitoris was fashioned from the dorsal glans penis and dissected on the dorsal neurovascular pedicle incorporating Buck’s fascia. The bulbospongiosus and ischiocavernosus muscles were resected, and the corpus spongiosum was separated from the corpora cavernosa, completely dissecting the latter. The spongiosa from the urethral bulb was then resected. Neurovascular bundle of glans was plicated and then stabilized with a suture to the rectus fascia. The urethra was shortened and spatulated ventrally to create a neomeatus. The penile skin flap was then sutured to the scrotal perineal flap in a layered fashion. The scrotal skin graft was sutured to the penile flap with multiple W-plasties. The distal portion of the urethra is then used to create the vestibulum. An incision was made in this portion of the urethral plate to expose the neoclitoris. Two penrose drains were placed in the vagina. The labia majora were then closed in a layered fashion. The vagina was packed with two Sulfamylon–soaked vaginal packs and lubricating jelly.

Results

The case took 360 minutes. EBL was 200 mL. Vaginal packing was removed on day 5, and the patient was discharged on day 6. The final vaginal length was 13cm.
Out of our 46 cases in the last two years, only one morbidly obese patient experienced a degree of neovaginal prolapse.

Conclusions

The combination of perineal flap and scrotal graft allows for a significant lengthening of the neovaginal cavity.
The extended dissection of the recto-prostatic space, up to the level of the pouch of Douglas, allows for the omission of sacrospinal fixation, thus reducing the risk of damage to the pudendal neurovascular bundle.