Background : Gender-affirming vaginoplasty is a surgery to create the female vulva and vaginal canal for those people assigned male sex at birth who have gender dysphoria. Dissection of the neovaginal space can be particularly challenging, with risk of injury to anal and urethral sphincters, urethra, and rectum. We present our surgical technique for vaginal canal dissection in gender-affirming vaginoplasty.
Methods : Our technique for creation of the neovaginal space follows the Young approach to perineal prostatectomy. We sharply dissect a space between the anal canal/rectum and the urethra to the level of the apex of the prostate, then enter the potential space between the ventral rectal fascia and Denovillier's fascia. We then complete the dissection bluntly to the peritoneal reflection. A Lowsley retractor is used to guide the dissection through the ventral rectal fascia into the potential space between it and Denovillier's fascia, covering the dorsal surface of the prostate. Bimanual examination with a finger in the rectum is used throughout to confirm that we are not dissecting into the rectal wall.
Results : Out of 165 primary feminizing gender-affirming genital surgeries performed by the senior author between May 1, 2016 and November 1, 2018, 135 (82%) included dissection and construction of a neovaginal canal. The average patient age was 40.5 years old with an average body mass index of 27.4. At the time of surgery, the median vaginal depth was 14cm, and the mean was 13.7cm (range 10 - 15cm). Complications specific to this portion of the surgery include full-thickness rectal wall injury, recognized and repaired in two patients. One of these patients later developed a rectovaginal fistula. Two additional patients had recognized injury to the muscular wall of the rectum, repaired without further complication. One patient had a recognized urethral injury repaired, who later had minor stress urinary incontinence that resolved spontaneously.
Conclusions : Neovaginal canal dissection for gender affirming vaginoplasty can be challenging. Frequent palpation for the Lowsley retractor with digital rectal examination are important steps to guide safe dissection, and patience during dissection around the apex of the prostate is critical to avoid injury to the urethral sphincter or rectum.