Penile inversion vaginoplasty

What is a penile inversion vaginoplasty?

The standard vaginoplasty procedure consists of creating a cutaneous neovagina using the inverted skin of the penis and scrotum. The aim is to create as feminine as possible a genital complex from the anatomical, aesthetic and functional viewpoints.

The reconstructed vagina has variable dimensions that depend on three of the transsexual patient’s characteristics: penis size, skin elasticity and the patient’s height – which determines the cavity to house the new vagina. Furthermore, Dr Mañero and his team use a scrotum graft to increase vaginal depth, so the amount and type of scrotum are also important in establishing this depth.

Who can undergo a penile inversion vaginoplasty?

It is the surgeon, along with their medical team, who decides the most suitable technique for each particular patient, analysing each patient’s physical and social characteristics. However, the patient will have all the information so as to take part in the final decision on the chosen technique.

As a general rule, for any transsexual patient who complies with the standards of care and decides to undergo a vaginoplasty, this will be the first technique to take into account.

In order to undergo a penile inversion vaginoplasty, the transsexual patient must have a penis of certain minimum dimensions (it must measure more than 12 centimetres when pulling the penis skin taut and measuring from the penis-pubic angle to the penis head) and good penile skin quality. In any case, it will always be the surgeon who must weigh up both the patient’s medical history and the suitability of the technique to be employed.

The preparations

Stopping hormone treatment

Patients must stop hormone treatment some four weeks prior to the operation, since oestrogens (female hormones) in the bloodstream increase the risk of deep vein thrombosis (blood clots within the veins) with all their associated risks and problems. The process of hormonal reduction should be gradual. This means patients should reduce their intake of oestrogens little by little. For the four weeks prior to the procedure, patients should completely refrain from taking any type of hormone treatment.

The effects of stopping hormone treatment will be apparent to patients. Although they vary from one person to another, symptoms range from sharp mood swings, dizziness and nausea, to the appearance of clearly masculine traits (facial hair, involuntary erections, etc.). Shortly, the situation will stabilise and any discomfort will disappear. The more gradual the hormonal reduction, the more bearable the change.

Admission

The patient is admitted to hospital the day before the procedure. Over the course of the day, the relevant tests are performed and the colon (large intestine) is cleaned out by taking laxatives and antibiotics. During surgery it is vulnerable to injury, so it should be as clean and free from bacteria as possible.

The operation

Penile inversion vaginoplasty requires at least a week in hospital so the medical team can better monitor the patient’s progress.

The operation generally lasts from three to five hours, plus pre-anaesthesia and patient preparation time, as well as post-operative recovery. The operation is always performed under general anaesthesia, unless undertaken using spinal anaesthesia.

It begins by cutting open the penis down the middle, revealing the corpora cavernosa and the neurovascular pedicle. Part of the glans is used to form the clitoris while most of the penile skin is relocated to form the vaginal walls. The remaining parts, comprising the corpora cavernosa (whose function is to achieve an erection) and part of the penile urethra are removed.

The urethra (urinary tract) is shortened and redirected to emerge at the normal position in a woman’s body, or just above the new vaginal opening. Excess erectile tissue around the urethra is partially removed to prevent it from increasing in size during sexual stimulation and thereby hindering the correct opening of the vagina. Wherever possible, Dr Mañero uses a large part of the urethra to line the labia minora and internal walls of the vaginal vulva, thereby recreating the female vulva’s pink, mucous appearance.

The spermatic chords are cut, and the testicles removed, although the skin of the scrotum surrounding them and skin from adjacent areas is used to form the labia majora and minora. In certain cases, remaining scrotum is used to form a tube of skin that is added to the end section of the penis so as to increase the vagina’s depth by a few centimetres.

The anatomical space where the vagina will be situated is located between the urinary bladder and the rectum (end of the large intestine). This is the most technically challenging part of the procedure, as there is a risk of perforating the intestine.

Once the space where the vagina will be located has been formed, the inverted penile skin is implanted, thereby forming the vaginal walls. Vaginal depth will depend on each patient and the elements determining this are the amount of penile skin available (depending on the penis’s initial size and the amount of scrotal skin available to graft) and the anatomical arrangement of the internal organs, although we should aim for a depth of not less than 15 centimetres. Once the vagina is in place, a special dressing is inserted to keep the inverted skin within the vaginal cavity until it heals.

The next phase of surgery consists of reconstructing the clitoris using the portion of the glans that has been retained along with its nerves and blood vessels so as to maintain sensitivity and the capacity for full sexual satisfaction. The clitoris will be located above the urethral meatus and a hood constructed to cover it. The latter is created during the operation or afterwards, on the surgeon’s judgement depending on the inflammation present and other factors evaluated during surgery.

Surgery is concluded after constructing the vaginal labia: part of the scrotal skin is fashioned into the labia majora and, if extra skin remains, two additional folds can be formed to simulate the labia minora and a hood for the clitoris. (In most cases the entire surgical procedure can be performed in one operation, but in certain special cases, aesthetic vaginal surgery may be postponed until a second operation.)

Afterwards, compression bandages are applied and the patient will have a urinary catheter in place for about two weeks.

Admission to the hospital centre

The patient will remain admitted for seven days post-operative, to be evaluated daily by medical team at IM CLINIC Gender Unit and to ensure the patient’s peace and comfort after such a complicated process.

During the post-operative visits, a supervision protocol will be followed in all possible cases, monitoring vital signs, overseeing increasing dietary intake, rotation of analgesics and antibiotics orally, monitoring early mobility and managing pain. During the hospital admission, the patient will receive subcutaneous enoxaparin to avoid thrombi growth.

On the last day of admission, a doctor from the Gender Unit will conduct the first dilatation of the neovagina under a standardised protocol and will instruct the patient so that she can perform the recommended dilatations at home.

As well as correct post-operative monitoring, the medical team will at all times assess each patient’s social support and vulnerability individually.

Hospital discharge

The urinary catheter remains in place until the tenth day or until periurethral inflammation is minimal, so the patient is discharged with the catheter in place.

The patient undertakes to perform the dilatations indicated by the physician, and to follow the recommended analgesic treatment and antibiotic therapy.

Once at home, the patient should contact the endocrinologist who supervises their hormone treatment to restart it (after around four weeks) and readjust the dosage. Under no circumstances should the patient readjust the hormone treatment dosage themselves as this could cause health problems.

Possible complications

Any procedure entails a risk of complications. The most common in this procedure are infection, bleeding or haematoma and urine retention. In the late post-operative phase, vaginal introitus stenosis, urethral or meatal stenosis, recto-vaginal fistulae, clitoris pain, venous thrombosis or blood clots may appear.

A member of the medical team will instruct the patient on how to avoid these possible complications and what to do if they appear.

The results

After the vaginoplasty and recovery, the patient will have a functional, anatomical vagina, aesthetically similar to that of a biological woman. This new vagina will be suitable for maintaining satisfactory sexual activity and free of painful scarring while possessing enough sensitivity to provide satisfactory erogenous stimulation during sexual relations.

Post-operative visits

It is very important not to miss any of the post-operative consultations with any member of the medical team. Only they can assess the evolution of recovery from the vaginoplasty.

As a general rule, the patient’s next visit will be scheduled more or less three weeks after the hospital discharge (one month after the operation). The patient will have access to a phone number for post-operative support at all times, to resolve any doubts that may arise.

The following medical visits will be at approximately three months, six months and one year after the operation.