Presentation Authors: Helen Hougen*, Daniel Dugi, Kamran Sajadi, Portland, OR
Introduction: Total vaginectomy and colpocleisis (TVC) are performed as part of gender-affirming genital surgery in transgender men. The procedure can be performed by total excision of the vaginal mucosa, fulguration of the mucosa, or a combination of both, followed by closure of the vaginal space. At our institution, the entire vaginal mucosa is excised; this is performed concomitantly with a metoidioplasty or as part of a one- or two-stage phalloplasty. We describe the procedural outcomes of vaginectomy by total vaginal excision.
Methods: TVC was performed by excising the vaginal mucosa from the introitus distally to the vaginal cuff proximally, with the exception of the distal anterior vaginal wall which was mobilized as a flap for use in urethral lengthening. The vaginal space was closed by purse-string sutures. We evaluated operative time, estimated blood loss (EBL), procedural complications, and the learning curve of this procedure in a historical cohort study of patients undergoing TVC at our institution.
Results: In 2 years, 30 TVC procedures were performed as part of 11 metoidioplasties and 19 phalloplasties. The average age of our cohort was 36.5 +/- 11.6yr, 28 (93%) had a hysterectomy, mean BMI was 27 +/- 4.27, and all were on testosterone. Median follow up length was 13mo (IQR 5-31mo). Two underwent concomitant hysterectomy early in the series, before it became our policy to not combine these procedures. The operative time for TVCs was 158 +/- 46min, with a significantly shorter times in later years (p= 0.015) (Figure 1). The mean total vaginal length was 8 +/- 1.3cm and the mean genital hiatus diameter was 2 +/- 0.6cm. Operative time was longer with longer vaginal length (p = 0.027). The peritoneum was entered in 12/30 (40%) of cases and closed without additional sequelae. The anterior vaginal mucosal flap was viable and thus incorporated in the urethroplasty in 21/25 (84%) applicable cases. Two (6.7%) patients required transfusion. One patient had C difficile colitis. There were no visceral injuries, fistulae, or mucoceles.
Conclusions: This is the largest series describing vaginectomy by total vaginal excision. TVC takes approximately 2.5 hours after a learning curve period and has a low complication rate. Despite the longer operative time, TVC may have advantages over mucosal fulguration such as lack of fistulae between urinary tract and vaginal space noted in prior studies.