The standard procedure for vaginoplasty involves creating a cutaneous neovagina with inverted penis and scrotum skin. The goal is to make the genital complex as female as possible from an anatomical, aesthetic and functional point of view.
The reconstructed vagina’s size will vary depending upon three characteristics of the transsexual patient: the size of their penis, the elasticity of their skin and their height (which determines the size of the cavity to house the new vagina). Furthermore, Dr. Mañero and his team use the skin of the scrotum to increase the depth of the vagina, so the amount and type thereof are also important in establishing this depth.
It will be the surgeon, together with his or her medical team, who will decide upon the most appropriate technique, although patients are provided with all the information to be able to take part in the final decision on the technique to be chosen.
Generally speaking, for any transsexual patient who, after meeting attendance requirements, decides to undergo a vaginoplasty, this will be the first technique to be considered. To be able to undergo penile inversion vaginoplasty, transsexual patients must have a minimum penis size (more than 12 centimetres, stretching the penis skin, from the penis-pubis angle to the tip of the prepuce) and good-quality penis skin. In any case, it will always be the surgeon who must weigh up both the patient’s medical history and the suitability of the technique to be employed.
Patients must stop hormone therapy some four weeks prior to the operation, since oestrogens (female hormones) in the bloodstream increase the risk of deep vein thrombosis (blood clots inside the veins) with all the associated risks and problems. This process should be gradual: in other words, patients should reduce their intake of oestrogens little by little. For the four weeks prior to the procedure, patients should completely refrain from taking any type of hormone.
The effects of stopping hormone therapy will be clear to patients. Although they vary from one person to another, the symptoms range from sharp mood swings, dizziness and nausea to the appearance of clearly masculine traits (facial hair, involuntary erections, etc.). The situation will soon stabilize and the discomfort may well disappear. The more gradual the cut in hormones, the more bearable the change.
Patients are admitted the day before the procedure. Over the course of the day, the relevant tests are carried out and the colon (large intestine) cleaned out with the taking of laxatives and antibiotics, since during surgery it is exposed to injury. It is thus preferable that it be clean and as free from bacteria as possible.
Penile inversion vaginoplasty requires at least a week in hospital, so that the medical team can better monitor patients’ progress.
The operation generally lasts between five and six hours, plus pre-anaesthesia and patient preparation time and recovery immediately after surgery. It is always carried out under general anaesthetic, except for the odd exceptional case when performed under spinal anaesthesia.
It begins by cutting open the penis down the middle to reveal the corpora cavernosa and the blood and nerve supplies. Part of the glans will be used to form the clitoris, whilst the majority of the penis skin is moved to form the vaginal walls. The remaining parts of the penis, including the corpora cavernosa (whose function is erection) and part of the penile urethra are eliminated.
The urethra is shortened and redirected to emerge at the normal point for a woman, i.e. just in front of the new vaginal opening. Excess erectile tissue around the urethra is eliminated to prevent it from increasing in size during sexual stimulation and thereby interfering with the proper opening of the vagina. Where possible, Dr. Mañero uses a large part of the urethra to form the labia minora and internal walls of the vaginal vulva, thereby giving pink, mucous appearance similar to the female vulva.
The spermatic chords are cut and the testicles eliminated, although the skin of the scrotum surrounding them and that of the adjacent areas will be used to form the labia majora and minora. The scrotum left over after reconstructing the labia majora is used to form a tube of skin that is added to the final part of the penis to increase the depth of the vagina by a few centimetres.
The space in the body in which the vagina will be built is located between the bladder and the rectum (the end of the large intestine). This is the most technically-complex part of the procedure, as there is a risk of perforating the intestine.
Once the space in which the vagina is to be located has been created, the inverted penis skin will be put in place there, forming the vaginal walls. The depth of the vagina will depend on the individual patient: the factors affecting this include the amount of penis skin available (which will be based on the length of the penis and the amount of scrotal skin for grafting) and the anatomical arrangement of the internal organs. However, the depth should not be less than 15 centimetres. Once the vagina is fixed in place, a special surgical packing is used to keep the skin inverted within the vaginal cavity until it heals.
The next stage of surgery involves reconstructing the clitoris with the portion of the glans that has been retained together with its nerves and blood vessels for the purpose of ensuring sensitivity and the ability to enjoy full sexual satisfaction. The clitoris will be placed above the urethral meatus and a hood will be made to cover it. This latter step may be carried out during the procedure or subsequently.
Surgery is concluded after constructing the vaginal labia. Part of the skin of the scrotum is made into the labia majora and, it there is skin left over, two additional folds can be made to simulate the labia minora, as can a hood for the clitoris. Usually, all this surgery can be performed at once but, in certain special cases, the aesthetic vaginal surgery may be postponed for a second operation.
Then compression bandages are put in place, as are two drainage catheters which are kept for the following 48 hours. The vaginal packing put in place during the procedure is removed in two stages. The urinary catheter is left in place until day 10, so patients leave hospital with it still in.
Around a week after admission, a member of the medical team will release the patient and instruct her on dilatation and washing techniques. For this, two dilators of different sizes are provided.
Once back home, patients should contact the doctor who oversees their hormone therapy to restart it (after around three weeks) and adjust the dosage. Under no circumstances should patients themselves adjust their hormone therapy dosage, as this could cause health problems.
After vaginoplasty and recovery, patients will have a functional, anatomic vagina aesthetically similar to that of a biological woman. This new vagina will be suitable for a normal and satisfactory sex life, free from painful scarring and with enough sensitivity to provide pleasurable erogenous stimulation during sexual relations.
Possible post-operative complications that may appear immediately subsequent to the procedure include wound infection, hematomas and/or urine retention.
In later post-op, the following could occur: introitus or vaginal stenosis, urethral and meatum stenosis, recto-vaginal fistula and/or deep vein thrombosis and pulmonary embolism.
A member of the medical team will tell patients how to prevent these possible complications and how to act should they appear.