(034) Shallow-Depth Vaginoplasty: Patient Demographics, Preoperative Goals, and Postoperative Satisfaction
Authors: Stelmar J , Garcia M , Smith S , Lee G 
Published: May 2023

Abstract

Introduction
Shallow-depth vaginoplasty (SDV) is an excellent genital gender-affirming surgery (gGAS) option for patients who are not interested in the factors associated with full-depth vaginoplasty (FDV), which include the ability to engage in receptive vaginal intercourse (RVI), increased surgical risks, longer wound healing, and/or strict, lifelong postoperative maintenance requirements (i.e., regular vaginal dilation and douching). Despite the many compelling reasons for a patient to select SDV, this surgery is seldom offered and severely underrepresented in the medical literature. We define SDV as “vaginoplasty without a canal” or “vulvoplasty,” and FDV as “vaginoplasty with a canal.”

Objective
To (1) describe patient demographics; (2) understand which specific decision-guiding factors are most important for patients (ordered by priority) when selecting SDV over FDV; and (3) assess postoperative satisfaction across various domains, among the largest documented cohort of patients to undergo SDV to date.

Methods
A total of 119 patients underwent feminizing gGAS at our institution between April 2017 and April 2022, of which 44 (37%) underwent SDV and 75 (63%) FDV. All 44 SDV patients were emailed a link to an anonymous, electronic survey via Qualtrics®, which assessed preoperative priorities and postoperative satisfaction. Eight decision-guiding factors were identified via patient interviews and a comprehensive literature search.

Results
Thirty-one respondents (mean ± SD age and BMI: 51.2±15.8y and 27.2±5.5) completed the survey (response rate = 70.5%). Analysis of demographics and sexual history (Table 1) revealed a diverse range of backgrounds and preferences; however, all respondents met one or more of the following characteristics: (1) exclusively feminine-identifying sexual partner(s); (2) middle/older age; and/or (3) have not been sexually active in 4 years. While 66.7% of SDV patients reported they would engage in RVI if they had a vaginal canal, respondents with feminine-identifying partners were significantly less likely to express this interest (p*=0.0479). Interestingly, 71.4% of respondents who expressed an interest in engaging in RVI felt it was not sufficiently important to them to have to commit to long-term vaginal canal dilation. Ranking of the eight decision-guiding factors patients commonly consider revealed prioritization of long-term over short-term outcomes (Figure 1). Overall, patients reported high postoperative satisfaction across three domains (Figure 2). When asked if they “had to do it all over again,” all respondents indicated they would complete genital gender-affirming surgery again: 93.5% would select SDV and 6.5% FDV.

Conclusions
SDV was associated with high postoperative satisfaction and low decisional regret amongst the diverse cohort of patients we surveyed. This, combined with the fact that patients’ sexual practices are often not known to the provider, underscores why providers should always offer SDV as a standard option to all patients considering feminizing gGAS. Despite the diversity in patient backgrounds/identities, we identified three of the highest-priority long-term decision-guiding factors: elimination of male genital anatomy, preservation of erogenous sensation, and desire for normal appearance. Nevertheless, the variability in prioritization ratings reflects the highly individual nature of surgery decision-making, and highlights the need for thorough patient education that addresses the individual expectations of each patient who seeks femininizing gGAS.

Disclosure
No