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The ultimate goal of Vaginoplasty is a vagina that is secretory, flexible, hairless and pink, approximately 4" in depth and about 1-1.5" in diameter, with erogenous sensation and a urethra that enables urination while sitting. Because Vaginoplasty includes removal of the testes (Orchiectomy), it's possible to stop or reduce testosterone blockers or reduce estrogen dose after Vaginoplasty.

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Source: Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques. Horbach, Sophie E.R. et al. The Journal of Sexual Medicine , Volume 12 , Issue 6 , 1499 - 1512

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Penile Inversion is the most commonly performed version of gender-affirming Vaginoplasty in the United States today. It's also the most well-researched. That said, the optimal surgical technique for Vaginoplasty has not yet been identified, as outcomes of the different techniques have not been adequately compared in academic studies.

Hair removal prior to surgery may or may not be necessary, depending on your surgeon's technique. Dr. Kathy Rumer performs a Modified Penile Inversion Vaginoplasty technique that doesn't require hair removal of the genital area before surgery.

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To create the vagina, the majority of skin from the shaft of the penis is inverted and used to line the vaginal cavity created in the perineum. If additional tissue is required to create a vagina of acceptable depth, skin grafts can be harvested from the abdomen or scrotum. Erectile tissue is removed so that sexual arousal doesn't cause narrowing of the vaginal opening or protrusion of the urethral opening and clitoris.

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Referred to as the "gold standard" Vaginoplasty technique, Penile Inversion is often performed as a one-stage procedure, incorporating Orchiectomy, partial Penectomy, penile dissection and creation of the vaginal cavity, Labiaplasty and Clitoroplasty. Some surgeons delay Labiaplasty and Clitoroplasty until stage 2, particularly in patients who have an insufficient amount of left over tissue to construct the inner labia and clitoral hood.

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Dr. Jonathan Keith, a Gender Surgeon in New Jersey, uses a robotic approach with Vaginoplasty. Robotic Vaginoplasty offers superior safety and decreased rates of stricture, and is a minimally invasive method for harvesting a peritoneal graft which functions as vaginal mucosa.

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All Vaginoplasty techniques carry the risk of complications. Narrowing of the vagina, changes in urine stream and heightened risk of urethral infection are common complications. Rare but serious complications include tissue necrosis, rectal injuries, fistulas, deep vein thrombosis and pulmonary embolism.

The urethra is shortened and the urethral meatus is relocated to the appropriate female position. A small, sensate clitoris is created from a small portion of the glans which is left attached to its nerve and blood supply. Labia minora and majora are constructed from prepuce or penile skin and scrotal skin.

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The prostate gland, which is typically well-atrophied from hormone replacement therapy, is not touched. The vagina is created behind the prostate. Any future required examination of the prostate would thus occur via the vagina.

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MTF Vaginoplasty is a gender-affirming surgery procedure that transforms natal male genitals into a functional, aesthetically pleasing vagina and vulva. With a qualified surgeon, patients can expect normal urination, sexual sensation and minimal scarring.

In general, obesity has been shown to be a risk factor for surgical complications, including delayed wound healing, infection and postoperative venous thromboembolic events (VTEs). Those who have a BMI of more than 35 or 40 may also have a harder time accessing the vaginal area for post-operative dilation. Both of these factors can lead to a less than satisfactory Vaginoplasty result. However, relying on BMI as a sole selection criteria for surgical candidacy is falling out of favor.

Post-operative use of vaginal dilators for at least 6 months is required after surgery to maintain depth and diameter, though Penile Inversion Vaginoplasty has a lower risk of vaginal contraction versus techniques that employ non-genital, split-thickness skin grafts. (Bizic, 2014)

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The choice of which Vaginoplasty technique to pursue is dependent upon a number of factors, including your surgeon's experience with a particular technique, your anatomy, and most importantly, your goals. Consider the advantages and disadvantages of the techniques, as well as what's most important to you with your surgery outcome, and bring your questions and concerns to your surgery consult. Together, you and your surgeon can make the final decision about the right Vaginoplasty technique for you.

In patients who have had any type of radical prostatectomy for prostate cancer it can be difficult to create the vaginal canal because critical tissues have been radiated. These patients can get a MRI to evaluate the area to see if Vaginoplasty remains an option and if not, can choose to proceed with Vulvoplasty instead.

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Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization. The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data.

Smoking increases the risk of poor wound healing significantly. Most surgeons require smoking cessation before surgery and some also order a pre-operative nicotine test to confirm cessation.

There are multiple MTF Vaginoplasty techniques used around the world, with the most common being Penile Inversion Vaginoplasty. Other techniques include Peritoneal Vaginoplasty / Peritoneal Pull Through and Rectosigmoid Vaginoplasty. Understanding the basics of each technique will empower you during your surgery consultation and help you make a more informed decision about which one is right for you.