Neovaginal Canal Dissection in Gender-Affirming Vaginoplasty

PURPOSE: Gender-affirming vaginoplasty creates the vulva and vaginal canal for individuals assigned male sex at birth who have gender dysphoria. Dissection of the neovaginal space can be particularly challenging, with risk of injury to the anal and urethral sphincters, urethra and rectum. We present an anatomically based technique for vaginal canal dissection. MATERIALS AND METHODS: We retrospectively analyzed a cohort of patients who underwent gender-affirming vaginoplasty by a single surgeon between May 2016 and July 2019. We describe our technique for dissection and report relevant outcomes. RESULTS: We performed 200 vaginoplasty procedures during the study period. Patient age ranged from 15-70 years (median 41). Body mass index ranged from 16-50.5 kg/m2 (median 27). The vaginal depth ranged from 10-16 cm, with a median of 14 cm and a mean of 13.7 cm. Vaginal depth was slightly greater for patients with a body mass index of ≥30 vs <30 kg/m2 (p=0.0145). Operative complications were observed in 2 patients (1.0%) with a full thickness rectal injury and in 3 (1.5%) with a partial thickness rectal injury. Two of these patients (1.0%) had progression to a rectovaginal fistula (1 full and 1 partial thickness injury), 1 patient (0.5%) had a urethral injury, 8 patients (4.0%) had vaginal stenosis, 3 patients (1.5%) had introital stenosis and 10 patients (5.0%) had stress urinary incontinence that later resolved. CONCLUSIONS: Neovaginal canal dissection in gender-affirming vaginoplasty is technically challenging. An anatomically based approach is associated with a low complication rate at our center.