Gender Affirming Vaginoplasty

1st Edition - April 16, 2025
Imprint: Academic Press
Editors: Gennaro Selvaggi, Miroslav L Djordjevic
Language: English
Paperback ISBN:
9 7 8 - 0 - 4 4 3 - 2 1 7 7 6 - 0
eBook ISBN:
9 7 8 - 0 - 4 4 3 - 2 1 7 7 7 - 7

Gender Affirming Vaginoplasty is a novel reference of the latest research on those who present with Gender Dysphoria and desire surgery. The book describes the history of Gender Af… Read more

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Gender Affirming Vaginoplasty is a novel reference of the latest research on those who present with Gender Dysphoria and desire surgery. The book describes the history of Gender Affirming Vaginoplasty (GAV), including social, legal, and ethical aspects of GAV, and explains updated Standards of Care. Users will find sections on preparation for surgery, different surgical techniques available (inclusive with the most recent developments), surgical results and complications, ways to solve complications, and finally, surgical procedures for persons who are requesting nonbinary genital surgery, and for those who are requesting reversal surgery.

This is an unprecedented resource for all surgeons from various specialties already involved in gender-affirmative surgery and colleagues interested to gain state-of-the-art knowledge and experience in this field included plastic surgeons, urologists and gynecologists. Gender centers and trainees, scientists, researchers in transgender health, and organizations involved in trans health.

Title of Book
Cover image
Title page
Table of Contents
Copyright
Contributors
About the editors
Foreword
Preface
Chapter 1. A history of gender-affirming surgery
Eunuchs
Early surgical changes of sex: Berlin and Beyond
Midcentury gender surgery: The slow emergence
The “sexual revolution”: Implications for gender-affirming surgery
Contemporary pioneers
Pressing forward: The future
Chapter 2. The impact of the eighth version of WPATH standards of care on gender-affirming vaginoplasty
Introduction
Terminology
Surgery and postoperative care
Tracking surgical outcomes
Preoperative assessment for adults
Surgery for adolescents
Surgical care for nonbinary people
Postoperative care plan
Conclusion
Chapter 3. Cultural aspects of transgenderism
Introduction
Gender as a concept
The gender binary
Colonialism and eugenics
Hijras of India
The Pacific Islands—Mahu and RaeRae
Kathoeys in Thailand
Gender nonconformity in sub-Saharan Africa
The medical magnifying glass and conformity as survival
Chapter 4. Orchiectomy in transgenders and gender-diverse people
Introduction
Indications and contraindications
Surgical technique
Preoperative workup
Surgical procedure
Additional perioperative considerations
Postoperative care
Discussion
Conclusions
Chapter 5. Psychological support around gender-affirming vaginoplasty
Introduction
Mental health assessment
Surgical decision-making
Psychological care prior to surgery and during clinical admission
Psychological care during recovery
Future directives
Chapter 6. Patient preparation for gender-affirming vaginoplasty
Introduction
WPATH SOC
Preoperative psychological and social support
The role of the psychologist during surgery preparation
Preoperative consultations
First consultation
Informing
Physical examination
Preadmission consultation with the nurse specialist
Preoperative instrumental examinations
Magnetic resonance imaging
Colonoscopy
Epilation
Laser versus electrolysis hair removal
Suspension of hormone therapy
Conclusions
Chapter 7. Relevant anatomy of penile inversion vaginoplasty
Female genital anatomy review
Pelvic anatomy
Penile anatomy
Scrotal anatomy
Anal triangle
Perineal body anatomy
Rectal anatomy
Neurovascular supply
Chapter 8. Bowers gender-affirming vaginoplasty: Modified penile inversion technique
Introduction
Preoperative requirements
Operative procedure
Deconstruction
Dissection
Reconstruction
Chapter 9. Cavity dissection: Personal approach (Dr. Bellringer)
A history of the development of the perineal approach
Development of the surgical technique for neovaginal cavity creation
Stepwise surgical technique for neovaginal cavity creation
Supplementary material
Chapter 10. Cavity dissection: Personal approach (Prof. Buncamper)
Introduction
Technique
Supplementary material
Chapter 11. Cavity dissection: Personal approach (Dr. Brassard)
Introduction
Technical aspects of neovagina cavity dissection following the Montreal approach (Dr. Brassard)
Planning, positioning, and instruments
Surgical dissection
Supplementary material
Chapter 12. Cavity dissection: Personal approach (Dr. Bowers)
Supplementary material
Chapter 13. Cavity dissection: Discussion and personal approach
Introduction
Damage to the rectum and surgical anatomy
Comparison of approaches and techniques
Personal learning curve
Personal approach to cavity dissection
Complicated cases and switching of the technique
Re-do cases
Conclusion
Chapter 14. Scrotal flap and skin grafts in gender-affirming vaginoplasty
Introduction
Considerations for the surgeon
How much depth can normally be achieved with vaginoplasty?
Our algorithm deciding on what skin and surgical technique to use
Two approaches for using scrotal skin to augment neovaginal canal depth: the scrotal skin pedicle flap and the scrotal skin full thickness skin graft
Comparison of techniques: scrotal skin pedicle flap versus scrotal skin FTSG
Use of extragenital tissues, and management of loss of vaginal depth
Conclusions
Chapter 15. Shallow-depth vaginoplasty: Nomenclature, patient decision-making, and surgical technique
Introduction
Nomenclature for this surgery: What, why, and why is it important?
Are SDV and FDV “very” different?
What terminology do patients prefer, and why?
How should our field approach surgical terminology?
Should both SDV and FDV be always offered?
How to help patients with surgery-choice decision-making
Surgical technique
How to create the dimple when an FTSG or SSPF is used?
Postoperative satisfaction with SDV
Conclusion
Chapter 16. Cosmetic aspects in gender-affirming vaginoplasty
Introduction
Vulva introitus
Mons pubis
Labia majora
Clitoris
Clitoral hood, column and frenulum
Labia minora
Posterior fourchette
Conclusion
Chapter 17. The use of bowel in gender-affirming vaginoplasty
Introduction
History
Potential benefits of bowel in the gender-affirming vaginoplasty
Contraindications
Preoperative preparations
Perioperative considerations
Surgical technique
Primary versus secondary bowel vaginoplasty
Ileum
Ileal vaginoplasty: Surgical technique
Use of the colon segments
Indications
Right colon
Left colon (sigmoid)
Robotic Sigmoid Vaginoplasty: Surgical technique
Limitations and complications
Ileum
Right colon
Sigmoid
Postoperative care and follow-up
Sexual satisfaction
Ileum
Right colon
Sigmoid
Conclusion
Chapter 18. Peritoneal flap gender-affirming vaginoplasty
Introduction
Brief history
Preoperative Considerations
Surgical Technique
Robotic Assisted Peritoneal Flap Gender Affirming Vaginoplasty
Position and Preparation
Perineal Dissection
Scrotal Dissection and Graft Harvest
Penile Degloving
Urethrectomy and Corporotomy
Perineal Exposure
Intraabdominal Dissection
Creation of the Vaginal Lining
External Reconstruction
Clitoroplasty
Labiaplasty
Closure
Revision RPGAV
Postoperative Care
Postoperative Outcomes
Patient Reported Measures
Surgical Complications
Conclusions
Chapter 19. Complications following genital gender-affirming surgery in AMAB: Review of the literature
Introduction
Disclaimer on outcome reporting
Complication classification
Vulvoplasty
Wound disruption, wound infections, and tissue necrosis
Clitoral complications
Vaginoplasty complications
Bleeding and hematoma
Meatal stenosis, urethral injuries, and urethroneovaginal fistula
Rectal injuries and rectoneovaginal fistula
Penile inversion (perineal) vaginoplasty—Scrotal/skin grafts
Peritoneal vaginoplasty
Intestinal/sigmoid vaginoplasty
Venous thromboembolism
Pelvic floor disorders and lower urinary tract symptoms
Pain
External genital revision
Conclusion
Chapter 20. Rectovaginal fistula following gender-affirming vaginoplasty: Prevention, management, and surgical corrections
Introduction
Prevalence
Etiology
Diagnosis
Management
Cisgender women
RVF in transgender individuals
Conservative management
Fecal diversion
Surgical closure of recto-vaginal fistulas
Direct suture repair
Endorectal advancement flaps
Axial flap-based repairs
Colo-anal anastomosis with neovaginal preservation
Revision vaginoplasty
RVF treatment failure
Author's recommendations for RVF management
Summary
Chapter 21. Sexual wellbeing and sexual health following vaginoplasty
Introduction
Gender-affirning vaginoplasty
Sexual health
Sexually transmitted infections
Sexual dysfunctions
Pelvic pain
Sexual violence
Sexual wellbeing
Sexual activity
Sexual response cycle
Genital and sexual function
Genital sensitivity
Lubrication
Vaginal dimensions
Sexual pleasure
Sexual satisfaction
Complications
Limitations in research of sexual wellbeing in transgender women post gender-affirming vaginoplasty
Recommendations for research and practice
Conclusion
Chapter 22. Pelvic floor physical therapy for AMAB persons undergoing gender-affirming vaginoplasty
Introduction
Evidence to support involvement of pelvic floor physical therapy
Neovaginal dilation
Recommendations for dilation
Positioning
Progression of dilator size
Additional interventions
Pelvic floor exercise
Aerobic activity
Abdominal, vulva and vaginal manual therapy
Electrical stimulation
Water based lubricant and wound healing
Long term: Threemonths postoperative forward
Vaginal stenosis
Pelvic, vulvar, and vaginal pain
Conclusions
Chapter 23. Individually customizable procedures for patients Assigned Male at Birth (AMAB)
Introduction
General preoperative clinical counseling
Patient population and gender identities
WPATH Standards of Care
Scrotectomy and/or orchiectomy
Introduction
Clinical counselling for orchiectomy
Clinical counseling for scrotectomy
Orchiectomy, with or without scrotal preservation
Technique—Orchiectomy with scrotal preservation
Technique—Orchiectomy with scrotectomy
Scrotectomy with testicular preservation
Technique
Pearls and pitfalls
Phallus-preserving vaginoplasty
Introduction
Clinical counselling for PPV
Phallus-preserving vaginoplasty
Technique—PPV and variations
Pearls and pitfalls
Penectomy and nullification
Introduction
Clinical counseling for penectomy and nullification
Penectomy without orchiectomy/scrotectomy
Technique—Isolated penectomy
Technique—Penectomy variants
Nullification
Technique—Nullification
Pearls and pitfalls
Other procedures
Chapter 24. Reversal surgery: Vaginoplasty after phalloplasty; phalloplasty after vaginoplasty
Introduction
Gender dysphoria
The regret phenomenon
Preoperative evaluation of patients with reversal requests—General points
Our center's preoperative evaluation of patients seeking reversal GAS
Reversal surgery: Phalloplasty following vaginoplasty
Neophallic reconstruction for patients AMAB
Belgrade experience in the treatment of regretting AMAB patients
Preoperative workup of patients seeking masculinizing reversal GAS in the Belgrade center
Surgical technique
First stage of MLD neophallic reconstruction
Second stage of MLD neophallic reconstruction
Third stage of MLD neophallic reconstruction
Reversal surgery: Vaginoplasty following phalloplasty
Vaginal reconstruction for patients AFAB
Our center's preoperative workup of patients seeking feminizing reversal GAS
Surgical technique
First stage of feminizing reversal GAS
Second stage of feminizing reversal GAS
Third stage of feminizing reversal GAS
Discussion
Evaluation
Risks encountered by authors
Surgery
Future perspectives
Conclusions
Conclusion
Conclusions
Summary of key points
Expertise perspectives
Medical and psychological outcomes
Ethical and societal implications
Future directions
Final reflections
Call to action
Index

Gennaro Selvaggi

Dr. Selvaggi, Associate Professor in Plastic Surgery, PhD on Gender Affirming Procedure (Ghent, 2010), and currently directing the Gender Unit at Sahlgrenska University Hospital in Gothenburg, Sweden. He published circa 70 titles in peer reviewed manuscripts (circa half of those are related to Gender Affirming Care) and 9 book chapters (all specific on gender affirming surgical procedures).

Affiliations and expertise

University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Department of Plastic Surgery, Sahlgrenska University Hospital, Sweden

Miroslav L Djordjevic

Dr Miroslav L Djordjevic is a Professor of Urology and Surgery at the School of Medicine, University of Belgrade, Serbia and Icahn School of Medicine at Mount Sinai, New York. The main field of his multidisciplinary work is urogenital reconstructive surgery, encompassing treatment of all anomalies of the genital system, regardless of gender or age. Professor Djordjevic has been multiply awarded for his comprehensive scientific work. He is the Editor of many leading Journals and Books, and a member of all relevant international associations in the field of urology and genital reconstructive surgery. Professor Djordjevic has been invited lecturer and Visiting Professor on many universities all around the world. As a member of humanitarian societies, he actively participated in humanitarian missions over the world. Finally, he is the founder and leader of Belgrade Center for Genital Reconstructive Surgery, which is chosen as a fellowship program center by 20-30 foreign colleagues every year. He is the former President of GURS (Genitourinary Reconstructive Surgeons Society). From 2019, Professor Djordjevic joined Urology Department, Icahn School of Medicine at Mount Sinai in New York, United States. From 2022 he is a gender affirming consultant surgeon at Chelsea and Westminster Hospital, London, UK.

Affiliations and expertise

Belgrade Center for Genitouronary Reconstructive Surgery, School of Medicine, Belgrade, Serbia Icahn School of Medicine at Mount Sinai, New York, United States

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