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  • Review Article
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Principles and outcomes of gender-affirming vaginoplasty

Nature Reviews Urology volume 20, pages 308–322 (2023)Cite this article

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Abstract

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Key points

  • Vaginoplasty is the most frequently performed genital gender-affirming surgery for gender-diverse people.

  • Preoperative management of patients choosing to undergo vaginoplasty includes hormone management, pelvic floor physiotherapy and hair removal, in addition to standard preoperative preparation.

  • The two types of vaginoplasty most often performed are penile inversion vaginoplasty and intestinal vaginoplasty; peritoneal-based vaginoplasties are also becoming widely used.

  • Minimal-depth vaginoplasty is an option for patients who do not desire construction of a full-depth vagina.

  • Postoperative care includes strict dilation regimens, vaginal rinses and pelvic floor physiotherapy.

  • Clinical and patient-reported outcomes that require monitoring include sensation, urinary divergence, vaginal depth, lubrication and patient satisfaction.

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Fig. 1: Penile inversion vaginoplasty technique.
Fig. 2: The clitoral neurovascular bundle elevation planes.
Fig. 3: Formation of the clitoris.

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Author notes

  1. These authors contributed equally: Shane D. Morrison, Karel Claes, Martin P. Morris.

Authors and Affiliations

  1. Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center and Seattle Children’s Hospital, Seattle, WA, USA

    Shane D. Morrison

  2. Department of Plastic Surgery, Ghent University Hospital, Ghent, Belgium

    Shane D. Morrison, Karel Claes, Stan Monstrey & Marlon Buncamper

  3. Section of Plastic and Reconstructive Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, IL, USA

    Martin P. Morris

  4. Department of Urology, Ghent University Hospital, Ghent, Belgium

    Piet Hoebeke

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S.D.M., K.C. and M.P.M. researched data for the article. All authors contributed substantially to discussion of the content. S.D.M., K.C. and M.P.M. wrote the article. All authors reviewed and/or edited the manuscript before submission.

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Morrison, S.D., Claes, K., Morris, M.P. et al. Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol 20, 308–322 (2023). https://doi.org/10.1038/s41585-022-00705-y

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