Penile inversion vulvo-vaginoplasty with scrotal graft for trans women: surgical technique and results of initial experience
Authors: Sabbagh Paul , Richard Claire , Bourillon Alice , Cornu Jean-Nicolas , Lebret Thierry , Morel-Journel Nicolas , Peyronnet Benoît , Schirmann Aurélie , Freton Lucas , Madec François-Xavier 
Published: November 2024

Abstract

Background
A significant proportion of trans women is demanding for a genital gender-affirming surgery, with vulvo-vaginoplasty being the most frequently requested procedure. The gold standard for primary vaginoplasty in trans women is the penile skin inversion technique with scrotal skin graft, which allows for increased depth of the vaginal cavity.

Aims
The assessment of vulvo-vaginoplasty outcomes utilizing penile skin inversion and scrotal skin graft in individuals assigned male at birth in the surgeon’s learning curve involves evaluating aesthetics, functionality, and sexual aspects.

Methods
A total of 76 individuals assigned male at birth were included in 2 French university hospitals from 2020 to 2022. They underwent vulvo-vaginoplasty following 8 key steps: scrotal skin excision; bilateral orchiectomy; dissection between the rectum, bladder, and prostate; penile dissection; clitoroplasty; urethroplasty; penile skin inversion with scrotal skin graft; labioplasty. The average follow-up period was 12.4 months, with participants averaging 35.7 years of age. Each patient was invited to complete a questionnaire during follow-up.

Outcomes
The study’s outcomes encompassed the assessment of both early and late surgical complications, postoperative sexuality, aesthetic results, and voiding satisfaction.

Results
Of the total patients, 15.8% experienced major early postoperative complications, while 3% encountered major late postoperative complications. No complication was classified 4 or 5 in Clavien–Dindo scale. Most early complications were related to issues in vulvar healing, which did not compromise long-term aesthetic results. Patients-reported satisfaction was 82% after the procedure.

Clinical implications
Vulvo-vaginoplasty utilizing penile skin inversion and scrotal skin graft for individuals assigned male at birth is a reproductive surgery procedure that can be successfully performed by experienced urologist. It achieves high patient-reported satisfaction even during the learning curve.

Strengths and limitations
The surgical procedures were consistent, and the sizable cohort of patients accurately reflects the learning curve of both surgeons. However, extrapolating long-term complications is challenging due to the relatively brief follow-up period. Additionally, there is a lack of self-reported sexual function data, and the scales used to assess patient-reported quality of life and urinary satisfaction are not specifically validated for transgender patients.

Conclusion
Vulvo-vaginoplasty utilizing penile skin inversion and scrotal skin graft for individuals assigned male at birth is a complex surgical procedure. It appears to be achievable by experienced urologists during their learning curve, resulting in similar functional and surgical outcomes, along with high patient satisfaction.