Vaginoplasty for gender dysphoria and Mayer–Rokitansky–Küster–Hauser syndrome: a systematic review

Objective

Vaginoplasty is performed on approximately 20% of Dutch patients with male-to-female Gender Dysphoria (GD) and Mayer–Rokitansky–Küster–Hauser Syndrome (MRKHS). Various procedures are available, but comparisons of technique outcomes are lacking. The investigators aim to aid well-informed decision making by highlighting information gaps, weaknesses, and strengths.

Evidence Review

A systematic search in PubMed, EMBASE, Web of Science, and Scopus until October 7, 2022, by Population, Intervention, Comparator, Outcomes method and prospectively registered systematic reviews registration. Original retrospective studies on complete neovaginal creation were included. Inclusion criteria were original, peer-reviewed articles, ≥10 adult patients with MRKHS or transfeminine, ≥6 months postvaginoplasty, and report at least one outcome (anatomy, complications, complaints, satisfaction, sexual function, or quality of life [QoL]) with 5 patients with MRKHS or transfeminine needed as isolated patient population. Exclusion criteria were merged results of patient types (with control groups) and/or vaginoplasty techniques, unspecified vaginoplasty techniques, combined treatments, or vaginoplasty as secondary procedures. Methodological quality and potential bias were assessed by the Newcastle–Ottawa Scale and the National Institutes of Health Quality Assessment Tool. Outcome assessed anatomy, QoL, satisfaction, sexual function, complications, or complaints.

Results

Our search yielded 52 studies with 9 different vaginoplasty techniques. In total, 35 GD and 17 MRKHS studies were eligible. Mean vagina length was 8.3–16.2 cm and 7.6–16.4 cm, respectively. In patients with GD, hemorrhage (mean 0%–43.9%), necrosis (mean 0%–25.7%), prolapse (mean 0%–7.7%), stenosis (mean 0%–73.8%), gastrointestinal complications (mean 0%–8.3%), revisions (mean 3.2%–63.2%), pain (mean 3.1%–13.6%), discharge (mean 3.2%–6.7%), regret (mean 0%–6.5%), and fecal- (mean 3.2%–17.3%) and urinary issues (mean 1.3%–46.2%) were reported. Patients with MRKHS reported necrotic (mean 0%–16.7%) and stenotic complications (mean 0%–13.0%), discharge (mean 0%–100%), and prolapse (mean 0%–3.7%). Both patients with GD and MRKHS showed a high variation of Sexual activity (mean GD = 31.1%–86.7% and MRKHS = 21.2%–100%) and Dyspareunia (mean GD = 1.6%–50% and MRKHS = 0%–41.7%). Patients with MRKHS were more satisfied with anatomy (mean GD = 72.2%–100% and MRKHS = 100%).

Conclusion

For patients with GD and MRKHS, multiple vaginoplasty techniques improve QoL and self-image with low rates of complications/complaints and high satisfaction. However, the heterogenicity of outcome-measuring methods reflects the need for standardized validation tools. Direct technique comparisons per patient cohort and exploration of tissue-engineering methods are critical for future surgical advancements and well-informed decision making. This first systematic review on 9 vaginoplasty techniques in patients with MRKHS and GD provides useful insight for patients and physicians and might aid well-informed decisions and manage realistic surgical expectations.