Surgical Micro-dissection of the posterior commissure after during vaginoplasty: Observations to explain common post-operative complications and proposed strategies for their prevention

Tearing and stenosis of the posterior commissure of the neovagina are not uncommon after vaginoplasty. With the most common surgical approach for vaginoplasty, the penile inversion technique, the posterior commissure is... [ view full abstract ]

Tearing and stenosis of the posterior commissure of the neovagina are not uncommon after vaginoplasty.

With the most common surgical approach for vaginoplasty, the penile inversion technique, the posterior commissure is comprised of tissue from the base of penile shaft skin and posterior perineal tissue.

We propose that a combination of anatomic features of the posterior commissure, combined with features of surgical technique, contribute to these complications. We describe anatomic findings of the tissues of the posterior... [ view full abstract ]

We propose that a combination of anatomic features of the posterior commissure, combined with features of surgical technique, contribute to these complications.

We describe anatomic findings of the tissues of the posterior commissure as they relate to complications.

We review variations in technique that we believe contribute to complications.

Intra-operative observations from live surgeries and post-operative findings were recorded using photography and video among transgender women undergoing vaginoplasty. Surgical micro dissection was performed using cadaveric... [ view full abstract ]

Intra-operative observations from live surgeries and post-operative findings were recorded using photography and video among transgender women undergoing vaginoplasty.

Surgical micro dissection was performed using cadaveric tissues from the posterior commissure from un-embalmed human cadavers after complete vaginoplasty via penile inversion.

Observations were compared and reviewed to generate hypotheses.

Surgical micro-dissection and histologic analysis was performed.

Recorded intra-operative and post-operative photographs and video Patient self-reported outcomes Histologic analysis of posterior commissure tissues (H&E, Trichrome, and others) [ view full abstract ]

Recorded intra-operative and post-operative photographs and video

Patient self-reported outcomes

Histologic analysis of posterior commissure tissues (H&E, Trichrome, and others)

Intra-operatve and post-op observations suggest that dense constrictive bands of tissue exist in the base of the penile shaft skin. Anatomic micro-dissection of the these tissues reveals the presence of a dense semi-ordered... [ view full abstract ]

Intra-operatve and post-op observations suggest that dense constrictive bands of tissue exist in the base of the penile shaft skin.

Anatomic micro-dissection of the these tissues reveals the presence of a dense semi-ordered network of collagen bundles within the base of the penile shaft skin.

Tissue thickness is limited and thin

Posterior perineal tissue thickness and vascularity is excellent.

Intra-operatively, we observed that thorough ventral transection of these collagen bundles significantly improves the stretchability of the penile posterior commissure skin and decreases the likelihood of post-op stenosis

Tension at the posterior commissure appears to be the greatest at its posterior midline.

We also found that using "U-stitch" suture technique at midline, combined with clear instructions to patients to not attempt exceed vaginal dilation depth early post-op, served to lower the incidence of post-op tearing at the sutures.

Surgical micro-dissecton of the tissues of the posterior commissure after vaginoplasty suggests that dense collagen bundles in the penile skin are at least a contributing factor (if not the principal source) to obstructive... [ view full abstract ]

Surgical micro-dissecton of the tissues of the posterior commissure after vaginoplasty suggests that dense collagen bundles in the penile skin are at least a contributing factor (if not the principal source) to obstructive stenosis of the neovaginal introitus.

We recommend routinely incising these bundles at the ventral midline, and when needed, elsewhere along the penile skin tube before final insertion into the neovaginal cavity.

We hypothesize that these bundles are derived from the Suspensory Ligament"
of the penis.

Tension at suture entry sites within the posterior commissure tissues can be reduced significantly by placing U-stitch type sutures, as these distribute the net tension of the suture across a wider area.

Patients should be clearly instructed to avoid inserting their dilator overly deeply early during post-op recovery, so as to not place excessive tension on the posterior-commissure sutures.