Health of Transgender Women: Gynecological, Hormonal, Sexual and Psychological Management

healthtransgenderwomenkapak

MINIMALLY INVASIVE NEOVAGINAL TECHNIQUES AND CARE IN TRANSGENDER WOMEN

Mesut Ali Halisçelik

Gazi Yaşargil Education and Research, Department of Gynecology and Obstetrics, Diyarbakır, Türkiye

Halisçelik MA. Minimally Invasive Neovaginal Techniques and Care in Transgender Women. Balsak D, Aksin Ş, eds. Health of Transgender Women: Gynecological, Hormonal, Sexual and Psychological Management. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.47-58.

ABSTRACT

Gender-affirming surgery for transgender women represents a pivotal step toward psychosocial adaptation and personal well-being. Among these interventions, neovagina construction (vaginoplasty) is frequently chosen to achieve both functional and aesthetic alignment with the patient’s gender identity. While the traditional penile inversion technique has proven effective in individuals with sufficient genital tissue, the adoption of minimally invasive surgical methods—such as laparoscopic or robotic-assisted procedures—has expanded rapidly. These techniques commonly provide advantages including reduced postoperative pain, faster recovery, and lower complication rates. Laparoscopic bowel segment usage (particularly sigmoid colon), laparoscopic peritoneal flap creation, and the robotic Davydov method enable adequate vaginal canal formation even in cases with limited or compromised penile-scrotal tissue.

The main objective of these minimally invasive approaches is to create a functional, deep, moist, and infection-resistant vaginal cavity. Peritoneal flap vaginoplasty employs intra-abdominal tissue to form a resilient vaginal lining, whereas bowel segment–based approaches offer inherent lubrication and robust tissue integrity. The high-definition visualization and precise dissection afforded by laparoscopic or robotic platforms help preserve crucial neurovascular structures while minimizing the risk of inadvertent injury to adjacent organs. Moreover, preoperative hormone therapy planning, venous thromboembolism (VTE) prophylaxis, and diligent postoperative dilation protocols remain vital in preventing late complications such as stenosis, fistula, or graft failure.

These procedures necessitate a multidisciplinary strategy, incorporating experts from urology, plastic surgery, gynecology, psychiatry, and endocrinology. After evaluating a patient’s anatomical considerations and personal expectations, selecting the most appropriate technique significantly enhances surgical success. For instance, patients with high body mass index (BMI) or extensive abdominal adhesions may benefit from alternative laparotomic or perineal approaches. Nevertheless, laparoscopic and robotic-assisted procedures performed in experienced centers substantially improve patient satisfaction. In conclusion, minimally invasive neovaginal surgeries constitute a safe and effective option, offering higher comfort and favorable outcomes when patient selection, surgical planning, and postoperative care are meticulously managed. Expanding clinical series and focusing on long-term results will further enrich the scientific foundation and clinical efficacy of these innovative practices.

Keywords: Transgender women’s health; Minimally invasive surgery; Neovaginal techniques; Gender-affirming surgery; Postoperative care

Referanslar

  1. Pariser JJ, Kim N. Transgender vaginoplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):241-7. [Crossref]  [PubMed]  [PMC]
  2. Zhang WR, Garrett GL, Arron ST, Garcia MM. Laser hair removal for genital gender affirming surgery. Transl Androl Urol. 2016;5(3):381-7. [Crossref]  [PubMed]  [PMC]
  3. Haedersdal M, Wulf HC. Evidence-based review of hair removal using lasers and light sources. J Eur Acad Dermatol Venereol. 2006;20(1):9-20. [Crossref]  [PubMed]
  4. Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res. 2010;126(1):5-11. [Crossref]  [PubMed]
  5. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative Complications following Primary Penile Inversion Vaginoplasty among 330 Male-toFemale Transgender Patients. J Urol. 2018;199(3):760-5. [Crossref]  [PubMed]
  6. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int. 2007;100(3):607-13. [Crossref]  [PubMed]
  7. Horbach SE, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of Vaginoplasty in Maleto-Female Transgenders: A Systematic Review of Surgical Techniques. J Sex Med. 2015;12(6):1499-512. [Crossref]  [PubMed]
  8. Weyl A, Chantalat E, Daniel G, Bordier B, Chaynes P, Doumerc N, Malavaud B, Vaysse C, Roumiguié M. Transvaginal minimally invasive approach: An update on safety from an anatomical, anatomopathological and clinical point of view. J Gynecol Obstet Hum Reprod. 2021 Jan;50(1):101941. [Crossref]  [PubMed]
  9. Fedele L, Bianchi S, Zanconato G, Raffaelli R. Laparoscopic creation of a neovagina in patients with Rokitansky syndrome: analysis of 52 cases. Fertil Steril. 2000 Aug;74(2):384-9. [Crossref]  [PubMed]
  10. Ramm O, Kenton K. Robotics for Pelvic Reconstruction. Curr Bladder Dysfunct Rep. 2011 Jun 30;6(3):176-181. [Crossref]  [PubMed]  [PMC]
  11. Chaudhary A, Acharya S, Dahal A, Basnet R, Basnet A, Chaudhary A, Basnyat RS, Dongol A. Mayer-Rokitansky-Küster-Hauser syndrome managed with McIndoe's vaginoplasty: a case series and literature review. Ann Med Surg (Lond). 2024 Mar 18;86(6):3206-3210. [Crossref]  [PubMed]  [PMC]
  12. Liu Y, Mao M, Bai J, Cai M, Wang Q, Fu H, Zhao M, Wang C, Si L, Guo R. Is robotic-assisted vaginectomy a better choice in vaginal high-grade squamous intraepithelial lesions than conventional laparoscopic surgery? BMC Womens Health. 2024 Jan 13;24(1):36. [Crossref]  [PubMed]  [PMC]
  13. Shakir NA, Zhao LC. Robotic-assisted genitourinary reconstruction: current state and future directions. Ther Adv Urol. 2021 Jul 31;13:17562872211037111. [Link]
  14. Ricchiuti D, Cerone J, Shie S, Jetley A, Noe D, Kovacik M. Diminished suture strength after robotic needle driver manipulation. J Endourol. 2010 Sep;24(9):1509-13. [Crossref]  [PubMed]
  15. Morris B. Robotic surgery: applications, limitations, and impact on surgical education. MedGenMed. 2005 Sep 27;7(3):72. [PMC]
  16. Boskey ER, Taghinia AH, Ganor O. Association of Surgical Risk With Exogenous Hormone Use in Transgender Patients: A Systematic Review. JAMA Surg. 2019;154(2):159-69. [Crossref]  [PubMed]
  17. Kozato A, Fox GWC, Yong PC, Shin SJ, Avanessian BK, Ting J, et al. No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-Affirming Surgery. J Clin Endocrinol Metab. 2021;106(4):e1586-e90. [Crossref]  [PubMed]
  18. Nolan IT, Haley C, Morrison SD, Pannucci CJ, Satterwhite T. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med. 2021;18(1):193-200. [Crossref]  [PubMed]
  19. Castanon CDG, Matic S, Bizic M, Stojanovic B, Bencic M, Grubor N, et al. Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women. Urology. 2022;166:301-2. [Crossref]  [PubMed]
  20. Grieco DL, Anzellotti GM, Russo A, Bongiovanni F, Costantini B, D'Indinosante M, et al. Airway Closure during Surgical Pneumoperitoneum in Obese Patients. Anesthesiology. 2019;131(1):58-73. [Crossref]  [PubMed]
  21. Jacoby A, Maliha S, Granieri MA, Cohen O, Dy GW, Bluebond-Langner R, et al. Robotic Davydov Peritoneal Flap Vaginoplasty for Augmentation of Vaginal Depth in Feminizing Vaginoplasty. J Urol. 2019;201(6):1171-6. [Crossref]  [PubMed]
  22. Suwajo P, Ratanalert W, Sooksatian K, Uerpairojkit K, Dusitanond N, Chaovanalikit T, et al. Pedicled Peritoneal Flap Vaginoplasty in Male-to-Female Gender Affirmation Surgery: A Case Report. Female Pelvic Med Reconstr Surg. 2020 Aug;26(8):e23-e26. [Crossref]  [PubMed]  [PMC]
  23. Fedele L, Frontino G, Restelli E, Ciappina N, Motta F, Bianchi S. Creation of a neovagina by Davydov's laparoscopic modified technique in patients with Rokitansky syndrome. Am J Obstet Gynecol. 2010;202(1):33.e1-6. [Crossref]  [PubMed]
  24. Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems. Eur Urol. 2021;79(5):676-83. [Crossref]  [PubMed]
  25. Jiang DD, Gallagher S, Burchill L, Berli J, Dugi D, 3rd. Implementation of a Pelvic Floor Physical Therapy Program for Transgender Women Undergoing Gender-Affirming Vaginoplasty. Obstet Gynecol. 2019;133(5):1003-11. [Crossref]  [PubMed]
  26. Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism. 2012;13(4):165-232. [Crossref]
  27. Manrique OJ, Adabi K, Huang TC, Jorge-Martinez J, Meihofer LE, Brassard P, et al. Assessment of Pelvic Floor Anatomy for Male-to-Female Vaginoplasty and the Role of Physical Therapy on Functional and Patient-Reported Outcomes. Ann Plast Surg. 2019;82(6):661-6. [Crossref]  [PubMed]
  28. van der Sluis WB, Bouman MB, Buncamper ME, Pigot GLS, Mullender MG, Meijerink W. Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women. Obstet Gynecol. 2016;127(6):1118-26. [Crossref]  [PubMed]
  29. Claes KEY, Pattyn P, D'Arpa S, Robbens C, Monstrey SJ. Male-to-Female Gender Confirmation Surgery: Intestinal Vaginoplasty. Clin Plast Surg. 2018;45(3):351-60. [Crossref]  [PubMed]
  30. van der Sluis WB, Tuynman JB, Meijerink WJ, Bouman M-B. Laparoscopic intestinal vaginoplasty in transgender women: an update on surgical indications, operative technique, perioperative care, and short-and long-term postoperative issues. Urologic Clinics. 2019;46(4):527-39. [Crossref]  [PubMed]
  31. Dargent D, Marchiolè P, Giannesi A, Benchaïb M, Chevret-Méasson M, Mathevet P. [Laparoscopic Davydov or laparoscopic transposition of the peritoneal colpopoeisis described by Davydov for the treatment of congenital vaginal agenesis: the technique and its evolution]. Gynecol Obstet Fertil. 2004;32(12):1023-30. [Crossref]  [PubMed]
  32. Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg. 2022 Mar;92(3):373-378. [Crossref]  [PubMed]
  33. Davydov SN, Zhvitiashvili OD. Formation of vagina (colpopoiesis) from peritoneum of Douglas pouch. Acta Chir Plast. 1974;16(1):35-41. [PubMed]
  34. Davydov SN. [Colpopoeisis from the peritoneum of the uterorectal space]. Akush Ginekol (Mosk). 1969;45(12):55-7. [PubMed]
  35. Wang YY, Duan H, Zhang XN, Wang S. Neovagina Creation: A Novel Improved Laparoscopic Vecchietti Procedure in Patients with Mayer-Rokitansky-Küster-Hauster Syndrome. J Minim Invasive Gynecol. 2021;28(1):82-92. [Crossref]  [PubMed]
  36. Acar O, Sofer L, Dobbs RW, Greenwald DT, Halgrimson WR, Crivellaro S, et al. Single Port and Multiport Approaches for Robotic Vaginoplasty With the Davydov Technique. Urology. 2020 Apr;138:166-173. [Crossref]  [PubMed]
  37. Fedele L, Bianchi S, Berlanda N, Fontana E, Raffaelli R, Bulfoni A, et al. Neovaginal mucosa after Vecchietti's laparoscopic operation for Rokitansky syndrome: structural and ultrastructural study. Am J Obstet Gynecol. 2006;195(1):56-61. [Crossref]  [PubMed]
  38. Bizic MR, Stojanovic B, Djordjevic ML. Genital reconstruction for the transgendered individual. J Pediatr Urol. 2017;13(5):446-52. [Crossref]  [PubMed]