A new method of neovaginoplasty with simultaneous plasty of the vestibule of the neovagina

The dissertation is devoted to the development of a new method of neovaginoplasty with simultaneous vestibuloplasty of the neovagina in patients with the core form of transsexualism undergoing male-to-female transformation. The author proposes a modification of the penile inversion technique with corporotomy that preserves the dorsal neurovascular bundle and reduces the risk of necrosis of the skin sleeve. Particular attention is given to the formation of the vestibule of the neovagina and the labia minora using a free split-thickness urethral flap as the plastic material. The work describes the surgical technique, the principles of postoperative management, and a comparative analysis of the immediate and long-term aesthetic and functional results against previously known methods.

One of the areas in modern reconstructive surgery is gender correction in patients suffering from the core form of transsexualism.

The term "transsexualism" was first introduced at the beginning of the last century by Hirschfeld; however, for almost 50 years it was not accepted by the world scientific community until 1953, when Benjamin provided scientifically grounded criteria for this nosology (Milanov N.O., Adamyan R.T., Kozlov G.I. 1999).

The essence of this phenomenon lies in the distortion of patients' self-identification of sex and the presence of a persistent feeling of belonging to the opposite sex, which in all cases is accompanied by inversion of gender identity and gender socialisation of the personality, as well as a change in psychosexual orientation (Bukhanovsky A.O. 1994). Thus, patients suffering from transsexualism have a complex set of intrapersonal contradictions associated with the denial of biological sex and the formation of persistent dysmorphophobia, which in most cases cannot be resolved by the patients independently and prevents their full social and domestic adaptation. It is precisely this fact that is key in the manifestation of suicidal behaviour and the high rates of suicide attempts in patients of this group.

The only way to achieve adequate psychosocial adaptation of patients with an established diagnosis of transsexualism is a set of medical measures including medico-psychological assistance, balanced replacement hormone therapy, and surgical treatment.

Transformations of the "male-to-female" type occupy a significant place in this problem. The key and fundamental stage of gender correction in male transsexualism is neovaginoplasty, that is, the creation from the organs of the male perineum of a genital apparatus analogous to the female one, both in terms of functional result and aesthetic outcome. It is important to note that the functional and aesthetic aspects are equally significant for patients of this group.

At present, there are various approaches to solving this problem. The main options for creating a neovagina in male-to-female transformation are: a) the use of a colon segment; b) techniques using rotation of local flaps (scrotal skin, etc.); c) modifications of penile inversion. From our point of view, the most acceptable in practice is the use of the penile inversion method, both from the standpoint of the impact of the volume of the operative procedure on the patient's body and the achievement of the final functional and aesthetic result (Milanov N.O., Adamyan R.T., Kozlov G.I. 1999). However, the classical modifications of the penile inversion method, along with advantages, have a number of shortcomings, such as: insufficient erogenous sensitivity in the postoperative period, insufficient blood supply to the skin sleeve, in some cases resulting in necrosis of the skin of the formed neovaginal sleeve in the early and late postoperative period and leading to significant shortening of the neovagina.

At the same time, the problem of neovestibuloplasty remains incompletely resolved. To achieve the optimal aesthetic result when creating the vestibule of the neovagina, which in appearance and texture would be as close as possible to that of an anatomically normal woman, various technical methods are used. One of the solutions to this problem is neovestibuloplasty with the creation of a mucosal lining. Urethral mucosa is widely used to create the labia minora and to line the vestibule of the neovagina in the surgical treatment of transsexualism in male-to-female transformation and allows a good aesthetic result to be achieved. However, existing methods of neovestibuloplasty using full-thickness tissue of the distal urethra have a number of shortcomings, such as: a high risk of urethral bleeding, both in the early and late postoperative period. Thus, the development of an alternative method for creating the vestibule of the neovagina with an epithelial mucosal lining represented by urothelium is a topical problem and requires further study.

This work is devoted to a new method of neovaginoplasty with simultaneous creation of the vestibule of the neovagina, represented by a urethral mucosal lining. The proposed methods, based on the well-known technique of penile inversion, have been patented by the Department of Reconstructive Microsurgery of the RSCS RAMS and have found successful application in clinical practice.

AIM OF THE WORK: to develop a new method of neovaginoplasty with simultaneous vestibuloplasty of the neovagina.

To achieve this aim, the following tasks were set:

1. To develop a new technique of neovaginoplasty with simultaneous vestibuloplasty of the neovagina, differing from the previous one by the simplicity of tissue dissection, excluding traumatisation of the main vascular and nerve structures of the penis and allowing the creation of a functional genital apparatus.

2. To study the possibilities of practical application of a free urethral flap for neovestibuloplasty.

3. To develop an alternative method for forming the vestibule of the neovagina and the labia minora, and to determine indications for its use.

4. To study the immediate and long-term aesthetic and functional results of the new method of neovaginoplasty with simultaneous neovestibuloplasty in the transformation of the male perineum in patients with the male form of transsexualism.

5. Based on the obtained results, to evaluate the proposed method in comparison with other methods already in use.

Scientific novelty.

For the first time, a method of neovaginoplasty by the modified penile inversion with corporotomy and simultaneous neovestibuloplasty using a free split-thickness urethral flap has been developed, allowing the achievement of an optimal aesthetic result and the creation of a functional neovagina with preservation of all types of sensitivity, while the structures of the dorsal neurovascular bundle remain intact throughout all stages of tissue dissection; on representative material, an evaluation of the results has been performed in comparison with the currently known methods of male-to-female transformation in patients with the established diagnosis of "Transsexualism, core type".

For the first time, a comparison of the results of alternative vestibuloplasty of the neovagina using the mucosa of the distal urethra with already applied methods has been carried out, indications for its use have been determined, and the principles of tactics for the management of patients in the postoperative period have been developed.

Practical significance.

Based on the analysis of the technique and long-term postoperative results, the advantages of the new method of modified penile inversion with corporotomy have been shown.

Based on the analysis of the technique and long-term postoperative results, the possibility of transplanting a free split-thickness urethral autograft and its use as a plastic material for creating the vestibule of the neovagina with an epithelial mucosal lining has been demonstrated.

The developed methods of transformation of the male perineum in performing the main stage of gender correction in patients with the diagnosis "Transsexualism, core type" — vaginoplasty with simultaneous vestibuloplasty of the neovagina — allow them to achieve maximum social and psychological adaptation and improve the quality of life.

Implementation of the results of the work.

The main provisions and recommendations of the work are implemented in the practical activities of the Department of Reconstructive Microsurgery of the RSCS RAMS.

Approbation of the work.

The work was approbated at the scientific conference of the Department of Reconstructive Microsurgery (15.06.2006).

The materials of the dissertation were reported at:

The 10th International Congress of the European Society of Plastic, Reconstructive and Aesthetic Surgeons, Vienna, Austria, August 2005.

The International Congress on Plastic, Reconstructive and Aesthetic Surgery, Yerevan, Armenia, April 2006.

Publications.

On the topic of the dissertation, 10 works have been published.

Volume and structure of the work.

The dissertation is set out on 125 pages of typewritten text, consists of an introduction, 4 chapters, a conclusion, findings, and practical recommendations. The bibliography contains 125 sources. The work is illustrated with 68 figures and 8 tables.