November 29, 2021/Cleveland Clinic Florida

Transfemale Vaginoplasty Study Shows High Success Rates Over Time

Increased demand for procedures will require more data, training and a multidisciplinary approach


As society expands its awareness of gender-related health issues, the number of people undergoing gender affirmation surgery is rising and expected to continue to grow. A recent research review examining transfemale vaginoplasty affirms that the two most common procedures yield high rates of patient satisfaction and low incidence of complications.

Andres Mascaro Pankova, MD, a surgeon in the Department of Plastic and Reconstructive Surgery at Cleveland Clinic Florida, was among the authors of “Complications and Patient-Reported Outcomes in Transfemale Vaginoplasty,” which was published earlier this year in Plastic and Reconstructive Surgery ­– Global Open.


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An increase in numbers of people seeking bottom surgery as part of a comprehensive treatment plan for gender dysphoria has resulted in more research studies, which the authors have mined for the new literature review. Building upon previous studies that date back to the 1980s, their comprehensive meta-analysis aims to hone treatment practices as the field expands.

This is especially important for care of people in the transgender community, the authors note, which has experienced a history of discrimination across institutions, including healthcare.

Study confirms generally positive outcomes

The new analysis includes comparisons of patient satisfaction data and complications for penile skin inversion and intestinal-based surgeries for creating functional female genitalia. A database search of vaginoplasty surgeries among transgender and nonbinary individuals added case data from 2017 through 2020. Excluded were patients who had undergone partial construction of the vagina, corrective surgeries or labiaplasty.

Results confirm previous results showing the procedures to be generally successful. More than 4,680 cases are now part of the meta-analysis.

“Penile inversion makes up about 80% of the procedures and pedicle intestine techniques are about 12% to 14%,” Dr. Mascaro says. “There are other clinical flaps that can be used as well.”


Among the two most common surgeries, penile inversion is often regarded as the most straightforward, but it is not right for everyone, Dr. Mascaro says. “Certain conditions, such as micropenis, can make it unsuitable, because the vaginal canal should have some length to it. If it doesn’t, that becomes an area of dissatisfaction for patients.”

The study notes that procedures that use intestinal segments to create the vaginal canal add advantages in texture, length and lubrication, but carry potential risks including colitis, peritonitis, obstructions and an additional vulnerability to sexually transmitted infection.

In both of the main procedures, rates of complications have been relatively small. About 1% of patients who had had either of the two main procedures developed fistulas; 11% developed stenosis and or/strictures; 4% developed tissue necrosis; and 3% experienced prolapse.

The techniques earned an average 91% in overall patient satisfaction, 87% in regard to functional outcomes and 90% for aesthetic outcomes.


Finally, Dr. Mascaro notes, regret rates for the procedures are low: about 2% overall.

As demand for procedures increase, more data will be needed

While the new data did not significantly change the understanding of the success of gender reassignment vaginoplasty procedures, it will be important to continue to track results in order to better serve this patient population.

“The surgical techniques are pretty standard by now,” Dr. Mascaro says. “Penile inversion has been around for 30-plus years. From a technical standpoint, while there will always be some space for improvement, the important advancements are unlikely to come from that. But as we collect and consolidate more data, and include patient-reported outcomes, we support this field and remove the taboo.”

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