Pelvic anatomy and transgender vaginoplasty surgery: Proposed anatomy and physiologic-based considerations to guide pre-operative counseling, surgical approach, self-dilation, and douching

Surgical techniques to perform vaginoplasty vary. Description of particular techniques is often limited to the "how to", but necessarily the "why"- or "why not". Answers to the latter can be especially enriching for... [ view full abstract ]

Surgical techniques to perform vaginoplasty vary.

Description of particular techniques is often limited to the "how to", but necessarily the "why"- or "why not". Answers to the latter can be especially enriching for surgeons, and particularly for those learning how to do gender surgeries.

We highlight here several observations about genetic male pelvic anatomy as it relates to vaginoplasty for MtF transgender women, and describe how studies using anatomic dissection and histology suggest the value of specific approaches described herein.

1. We review the anatomic basis for a sharp surgical approach, instead of a blunt and limited sharp-dissection approach, through the terminus of Denonvillier's Fascia upon the posterior aspect of the prostate gland for access... [ view full abstract ]

1. We review the anatomic basis for a sharp surgical approach, instead of a blunt and limited sharp-dissection approach, through the terminus of Denonvillier's Fascia upon the posterior aspect of the prostate gland for access to the surgical plane for the creation of the neovaginal space

2. We describe anatomic findings using fresh cadavers after vaginoplasty surgery which suggest a more optimal dilator shape and technique

3. We describe anatomic findings using fresh cadavers after vaginoplasty surgery to highlight challenges associated with common douching techniques

Aim 1: A. We describe our surgical technique. B. We resected blocks of tissue that contained posterior prostate, Denonvilliers Fasica (DVF), and anterior rectum, from 5 cadavers, and performed immunohistochemistry to allow us... [ view full abstract ]

Aim 1: A. We describe our surgical technique.
B. We resected blocks of tissue that contained posterior prostate, Denonvilliers Fasica (DVF), and anterior rectum, from 5 cadavers, and performed immunohistochemistry to allow us to count blood vessels, nerves, and collagen anterior and posterior to DVF) .

Aims 2 & 3:
A. We prosected 15 fresh male cadavers and then performed vaginoplasty via penile inversion.

B. Cadavers were then lightly embalmed using a novel technique we developed which allows for preservation of tissue flexibility and size.
We then performed saggital dissection of the pelves.

C. We also performed imaging studies of the vaginal vault in our clinic.

Aim 1: Cadaveric genetic male pelvis tissues subjected to immunohistochemistry after vaginoplasty surgery via penile inversion Aim 2: Imaging studies of living women and cadaveric anatomic dissections of human pelvises after... [ view full abstract ]

Aim 1: Cadaveric genetic male pelvis tissues subjected to immunohistochemistry after vaginoplasty surgery via penile inversion

Aim 2: Imaging studies of living women and cadaveric anatomic dissections of human pelvises after vaginoplasty surgery

Aim 1: Immunohistochemistry results showed that the sharp dissection we describe is associated with incision through significantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach.... [ view full abstract ]

Aim 1:
Immunohistochemistry results showed that the sharp dissection we describe is associated with incision through significantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. Use of the sharp dissection we describe is entirely under direct visualization (without 'blind' dissection), expeditious, and by providing immediate access to the neovaginal cavity, any uncontrolled bleeding (typically from peri-prostatic veins) can be addressed immediately and with good visualization. In our hands, this technique resulted in a significant decrease in recto-neovaginal fistula rate (to <1%).

Aims 2 & 3:
Imaging studies in living trans women and fresh cadavers after vaginoplasty suggest that the shape of the neovaginal cavity is S-shaped.
Furthermore, these findings also suggest that it is less likely that the apex of the vaginal vault is effectively irrigated with douching using conventional douche devices and techniques.

Anatomy suggests that dissection posterior to DVF should be avoided in order to minimize risk of laceration and/or development of fistulae between the neovagina and rectum. Our findings suggest that a sharp surgical approach... [ view full abstract ]

Anatomy suggests that dissection posterior to DVF should be avoided in order to minimize risk of laceration and/or development of fistulae between the neovagina and rectum.
Our findings suggest that a sharp surgical approach that gains access to a surgical plane anterior to DVF as distally as possible, poses less risk to immediate or delayed injury to the rectum, and injures fewer collateral nerves (many of which are likely sensory) during direction of the neovaginal space.

Our findings related to the shape of the neovagina suggest that it is S-shaped and not straight or U-shaped. These findings suggest that a potentially more suitable dilator material wold be something that offers a balance of sufficient rigidity and flexibility for subtle bending.
Our findings also suggest that a long anteriorly-facing neovagina vault is unlikely to be irrigated with douching. Douching techniques and devices should address this to ensure the vault is washed, as poor hygiene of the vault may contribute to general poor hygeine of the neovagina, and granulation tissue of the vault (a common location).