Experts discuss initial outcomes in gender-affirming vaginoplasty and vulvoplasty

In this interview, Kayla Blickensderfer and Jim Hotaling, MD, highlight the study, “Gender-affirming vaginoplasty and vulvoplasty: an initial experience,”¹ for which they served as the lead and senior authors, respectively. Blickensderfer is a third-year medical student at the University of Utah School of Medicine, and Hotaling is an associate professor of urology at the University of Utah in Salt Lake City.

"We wanted to look and see what our outcomes were and what predictors were of different complications," says Jim Hotaling, MD.

Could you describe the background for this study?

Hotaling: We started our gender affirming surgery program for bottom surgery from the urology side in roughly 2018. We wanted to look and see what our outcomes were and what predictors were of different complications.

Blickensderfer: We wanted to understand the patient characteristics of those coming to the program for gender affirming surgery, specifically with a vaginoplasty and vulvoplasty, and to get an understanding of the complications that arise and how our complication rates compared [with] some of the others in this population.

What were some of the notable findings from this study?

Blickensderfer: One of the notable things was the complications are frequent—which is something that was previously known about these surgeries—but they're minor. I thought it was interesting that some of the complications were things that you'd expect in people born with female internal genitalia, like yeast infections. I also thought it was interesting that the complication rates overall were similar between vaginoplasty and vulvoplasty, because those are pretty different surgeries.

It was surprising that we did find rectal injury in [2 of] the vulvoplasty patients, which was something that hadn't been previously noted. Then also, we did look at preoperative risk factors [and] health conditions, including cardiovascular and metabolic factors, and those didn't seem to have any outcome or any correlation with the complications.

Hotaling: We had 2 rectal injuries in our series of patients, which is similar to what you see in the literature. It's hard to look at predictors of that, because it's a rare event. Almost all of these patients have some minor wound issues with some skin healing, and scabbing over, and a little bit of tissue sloughing. I think it's helpful to know, and I think it's been helpful to counsel patients that this is normal. Most of those don't require going back to the OR. But I think [around] 17% of the patients who have these surgeries required some minor revision.

Blickensderfer: Yes, it was a pretty big number. Then if you look at the total revisions, including any aesthetic, any urinary stream diversion correction, [it was approximately] 48%. So, revisions are pretty common.

Hotaling: The other thing is that these data didn't support [a] BMI cutoff or other things as a huge predictor of complications, which I think is also helpful for counseling patients.

What are some implications of these findings for both patients and urologists?

Blickensderfer: Dr. Hotaling already mentioned that it's helpful in giving patients a good understanding of what the procedure is like, complications to expect, and also including some anticipatory guidance, with aftercare and potential need for future surgeries. I think that's one of the big takeaways.

Hotaling: I would agree. I think it's helpful to counsel patients. We worry a lot about these devastating complications, like a rectal injury, which are very rare, but hugely impactful. Counseling them that it's common to have minor surgery, and setting some realistic expectations about that is really helpful.

Is there any further research on this topic planned? If so, what might that focus on?

Blickensderfer: One thing that we wanted to include but were unable to was some more information on the patients' satisfaction with the aesthetic, sexual function, [and] general happiness with the outcome. I think it'd be an interesting addition to see if these complication rates in any way were a significant drawback, or if patients found overall that the surgeries had improved their quality of life, regardless of the complications. The other thing is that our information only shows the length of the neovaginal canal when the operation was performed. I think it'd be interesting to see what the final depth ends up being for most of our patients and how the dilation protocols might factor into that.

I think the other thing with this particular study is these data were the first initial part of the program, so it'd be interesting to see what it looks like factoring in learning curves. There have been other studies that have looked at that and seen how complication rates or outcomes changed with time.

Hotaling: We [have] some partnerships with other high-volume centers around the country looking at this with some grant funding in a more prospective fashion. Because the other big component is you want validated questionnaires and patient survey data, [but] it's a heavy lift to get that, especially for long-term follow up, because a lot of these patients live far away, so their follow-up can be variable.

Reference

1. Blickensderfer K, McCormick B, Myers J, et al. Gender-affirming vaginoplasty and vulvoplasty: an initial experience. Urology. Published online March 16, 2023. Accessed June 2, 2023. doi:10.1016/j.urology.2023.03.002