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.
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.
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.
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.