Impact of vaginectomy technique on the outcomes of transmasculine gender affirming surgery.

Abstract

Background: The optimal approach for vaginectomy in transmasculinizing surgery is not well-defined, with options for sharp excision of vaginal epithelium or electrocautery fulguration of the vaginal mucosa.

Aim: This study compares the outcomes of excisional and fulguration vaginectomy approaches.

Methods: A retrospective review of patients who underwent transmasculine surgery from 2021 to 2023 at a single institution was performed. All patients had vaginectomy with metoidioplasty.

Outcomes: Post-operative complications, estimated blood loss (EBL), and operating room (OR) time were compared between excision and fulguration techniques.

Results: Of 70 patients, 50 (71%) had epithelial excision and 20 (29%) had fulguration. Both groups had identical rates of post-operative vagino-cutaneous fistulae (10%). Vaginal remnant recurrence occurred in four patients (8%) in the excision group and one patient (5%) in the fulguration group (P = 0.67). Repeat vaginectomy was required in 2% of the excision group and 5% of the fulguration group (P = 0.50). In patients without hysterectomy, mean EBL was 254 mL in the excision group vs. 88 mL in the fulguration group (P < 0.01). Mean OR time was 290 minutes for excision compared to 183 minutes for fulguration (P < 0.01).

Clinical implications: This study identifies a safe and effective approach to vaginectomy technique that is not standardized in transmasculine surgery.

Strengths and limitations: A strength of our study is that it directly compares outcomes of the excisional approach and fulguration approach to vaginectomy. Limitations include its retrospective nature and that surgical technique was determined by surgeon preference.

Conclusion: Our data suggest that a complete fulguration approach, when compared to an epithelial excision approach, reduces blood loss and OR time without compromising rates of vagino-cutaneous fistulae or vaginal remnants requiring re-operation.