Vaginal Stenosis After Vaginoplasty
Is Robotic Peritoneal Flap Revision the Best-In-Class Treatment?
What Is Vaginal Stenosis?
Vaginal stenosis is one of the most common complications
following gender-affirming Vaginoplasty surgery. Vaginal stenosis
is characterized by a narrowing and/or shortening or total closure
of the vaginal canal. This loss of girth and depth can make sexual
intercourse difficult and painful. In some cases, vaginal stenosis
can be managed through regular dilation but surgical repair is
often necessary. The emerging best practice for surgically
correcting vaginal stenosis is a robotic approach using a
peritoneal flap.
Typically, vaginal stenosis is the result of non-compliance with
or an inadequate post-operative dilation regimen. Vaginal
dilation is integral to recovery from Vaginoplasty and the
regular maintenance of the neovagina. Dilation begins a few days
after surgery and is often required for life.
Minimizing the Risk of Vaginal Stenosis
Clearly, it's in patients' best interest to minimize the risk of vaginal stenosis. Both surgeons and patients play critical roles in this and it starts with clear communication. Compared to Penile Inversion Vaginoplasty, the Sigmoid Colon Vaginoplasty technique has a lower risk of vaginal stenosis2 but comes with trade offs that should be a focus of discussion between the surgeon and patient. If the Penile Inversion method is selected and the donor flap is large enough to create a vagina with the desired depth, then a graft isn't necessary and the risk of vaginal stenosis is reduced. However, if the donor flap is not large enough and vaginal depth is important to the patient, then a graft would be necessary. In this case, the patient must accept the higher risk of vaginal stenosis and commit to the dilation plan recommended by the surgeon.
Dilation helps prevent contraction of the skin graft inside the vagina. It involves inserting a lubricated dilator into the vagina and keeping it there for a specified amount of time. The size of the dilator and the length of dilation time varies depending on the surgeon's protocol and the patient's needs. Your surgeon will advise you about the proper use of dilators and the frequency of dilation and it's important to follow their advice as it may be specific to your case. Initially, one can expect dilation to take up to 2-2.5 hours per day, with the time and frequency decreasing after you reach 18-24 months post-op.
Dilation is a commitment and it can be difficult to follow-through despite best intentions.
"It just takes work after a Vaginoplasty," says Dr. Gabriel Del
Corral, a gender surgeon practicing in Washington D.C. and
Baltimore, Maryland. "It takes a lot of discipline. And it takes a
lot of time to be able to dilate three times a day for the first
couple months post-surgery."3
Work schedules and a lack of privacy are common barriers. Patients with a high BMI may find it difficult to access the vaginal area for dilation because of abdominal size. Post-operative complications such as granulation tissue or rectovaginal fistula can also contribute to non-adherence to dilation.
Pain is another reason why some people don't do enough dilation or discontinue it altogether. Pelvic floor dysfunction is often a root cause of this pain and a surprisingly high number of patients seeking Vaginoplasty have pelvic floor conditions.4 Pelvic floor physiotherapy is a highly effective pre- and post-operative treatment that helps resolve the pain associated with these conditions, allowing patients to maintain their dilation regimen and thus reducing the likelihood of developing vaginal stenosis. As such, pelvic floor physiotherapists play an important role in improving Vaginoplasty outcomes and should be part of the care team for the Vaginoplasty patient.
Whatever the reason, if you are running into issues keeping up with dilation, it's critical to communicate this with your surgeon so that together you can come up with a plan to get back on track and reduce the risk of developing vaginal stenosis.
Treatment of Vaginal Stenosis
Treatment options for vaginal stenosis vary depending on severity. Mild stenosis can be resolved with more frequent dilation. In many cases though, surgical intervention to reconstruct the vaginal canal is required. Repairing vaginal stenosis can be more challenging than the original Vaginoplasty surgery because there is more scar tissue. While the best approach to this type of repair has yet to be established, robotic peritoneal flap revision Vaginoplasty is emerging as the method of choice.
The peritoneal flap comes from the peritoneum, which is the inside lining of the abdomen. Through small incisions on the abdomen, the surgeon performs robotic-assisted laparoscopy to access the peritoneal tissue. Peritoneal flaps are used in both primary and revision Vaginoplasty. Benefits include a concealed donor site and hairless tissue. The robotic approach gives the surgeon excellent visualization of the bladder and rectum, minimizing the risk of injury, and provides excellent access to harvest the peritoneum.
Dr. Del Corral specializes in revisional procedures after complications from primary Vaginoplasty. "We have had good experience using Peritoneal Vaginoplasty for revision cases for patients who have lost the canal for different reasons," he says.
However, Dr. Del Corral stresses that long term data is needed before this procedure can be crowned as the best practice in vaginal stenosis repair. "What we don’t know is how long is that canal is going to stay open. There’s no data so far. And does it require dilation for longer than a year?"
Peritoneal flap revision Vaginoplasty is also not appropriate for patients who have had previous extensive abdominal surgeries.5
In the future, use of experimental techniques with biomaterials such as Nile Tilapia Fish Skin as well as 3-D printed vaginal scaffolding may help prevent vaginal stenosis.
The development of vaginal stenosis after Vaginoplasty is highly distressing for patients. Prevention through communication and diligent dilation is ideal but in some cases vaginal stenosis may be unavoidable. It is essential for individuals experiencing symptoms of vaginal stenosis to consult with their surgeon for an accurate diagnosis and appropriate treatment.
Related Studies
Vaginal
Stenosis of the Neovagina in Transfeminine Patients after
Gender-affirming Vaginoplasty Surgery
Aki Kozato, BS, Subha Karim, BS, Sumanth Chennareddy, BA,
Uchechukwu O. Amakiri, BS, Jess Ting, MD, Bella Avanessian, MD,
Joshua D. Safer, MD, FACP, FACE, James Eckert, PA-C, Marissa Kent,
MD, Rajveer S. Purohit, MD, and John H. Pang, MD. Plast
Reconstr Surg Glob Open. 2021 Oct; 9(10 Suppl): 75.
Gender-affirming vaginoplasty is a safe procedure, but vaginal
stenosis of the neovagina occurs at a noninsignificant rate.
Patients with neovaginal stenosis were more likely to have
experienced difficulty with postoperative dilation than to have
traditional risk factors known to affect wound healing.
Robotic
Peritoneal Flap Revision of Gender Affirming Vaginoplasty: a
Novel Technique for Treating Neovaginal Stenosis
Geolani W. Dy, Gaines Blasdel, Nabeel A. Shakir, Rachel
Bluebond-Langner, Lee C. Zhao. Urology, Volume 154, August
2021, Pages 308-314.
Robotic peritoneal flap revision vaginoplasty is a safe, minimally
invasive approach for the management of vaginal stenosis after
failed primary penile inversion vaginoplasty and revisions with
minimal donor site morbidity.
References
1. Li JS, Crane CN, Santucci RA. Vaginoplasty tips and tricks. Int Braz J Urol. 2021 Mar-Apr;47(2):263-273.
2. Salgado CJ, Nugent A, Kuhn J, Janette M, Bahna H. Primary Sigmoid Vaginoplasty in Transwomen: Technique and Outcomes. P Biomed Res Int. 2018 May 10;2018:4907208.
3. Everett, E. Gender Affirming Surgery with Dr. Gabriel Del Corral. Exclusively Inclusive Podcast. 2020, September 22
4. Jiang DD, Gallagher S, Burchill L, Berli J, Dugi D 3rd. Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstet Gynecol. 2019 May;133(5):1003-1011.
5. Shoham M, Pang JH, Satterwhite T. Considerations for secondary vaginoplasty. Transl Androl Urol. 2022;11(11):1480-1483
Last updated: 01/11/24