Gender affirming surgery: Vaginoplasty and clitoroplasty with modified peno-scrotal flap technique

Introduction & Objectives: Surgical management of female-to-male transsexual patients has been recently discussed.There is no consensus about the best surgical technique to obtain satisfying aesthetic and functional results. In this video we aim to describe step by step our surgical technique for vaginoplasty with inverted penoscrotal flap and clitoroplasty with urethral flap and report aesthetic and functional outcomes according to our post-operative care program. Materials & Methods: In 2011 we introduced a new technique of neoclitoroplasty aimed to improve functional and aesthetic results. We reviewed retrospectively data stored in a perspective maintained database of 37 patients who underwent male-to-female gender affirming surgery in our tertiary referral hospital between April 2014 and September 2018. Results: 37 Patients new recruited in this study. Median age at surgery was: 35 years (24-46). All patients had taken hormone therapy for at least one year before surgery. 36 Patients were heterosexual, 1 was homosexual. Median follow-up was 28,5 months (6-58). Median intraoperative neovaginal depth was 11 cm (7,5-13,5). At 3 months follow up 35 patients were continuing daily dilation program, median neovaginal depth was 12cm (3-14 cm). 2 Patients discontinued dilation program after surgery and both developed neovaginal stenosis. 7 Patients had erogenous sensitivity and ability to achieve orgasm, 6 patients referred penetrative vaginal intercourse. 6 Patients reported history of sporadic or recurrent cystitis. At 6 months follow-up 32 patients were continuing daily dilation program, median neovaginal depth was 11,5 cm (0-14 cm). 3 Patients discontinued daily dilation program but referred frequent penetrative sexual intercourses and to perform dilation once or twice per week: all of them maintained neovaginal depth, none developed neovaginal stenosis. 20 Patients had penetrative sexual intercourse and 18 of them also erogenous sensitivity and ability to achieve orgasm. 5 patients referred history of sporadic or recurrent cystitis. In the group of 19 patients with follow-up >24 months, 14 patients referred satisfying neovaginal penetrative intercourse with ability to achieve orgasm. Conclusions: Over the years many techniques have been proposed and are currently in use but research is still ongoing in order to achieve better possible results in terms of functional and aesthetical outcomes. All patients treated who were interested in penetrative neovaginal intercourse and regularly followed vaginal dilation program referred comfortable sexual relationships, 90% of them are able to achieve orgasm. To our experience importance of daily vaginal dilation should be stressed before sex reassignment surgery and during follow-up. Considering these results the technique presented could be considered a valid option to create an aesthetically pleasant neovagina with erogenous sensitivity.