Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4312–4320

Functional, aesthetic, and sensory

postoperative complications of female
genital gender affirmation surgery:
A prospective study
Ivan Mañero Vazquez a,b,∗, Trinidad Labanca a, Anna I Arno a,c,∗
a
Institute of Plastic Surgery, Carrer de Victor Hugo 24, Sant Cugat del Vallès, Barcelona 08174, Spain
b
University of Barcelona, Barcelona, Spain
c
Universitat Autònoma de Barcelona, Spain

Received 16 July 2020; accepted 16 August 2022

KEYWORDS Summary Background: Female genital gender affirmation surgeries have increased in recent
Vaginoplasty; years. Prospective studies with homogeneous standardized techniques and outcomes assess-
Complications; ment are scarce in the current literature.
Clavien-Dindo; This study aims to: 1) report the functional, aesthetic, and sensory postoperative complications
Female genital gender (POCs) of primary genital gender confirmation surgeries performed on transgender women and
affirmation surgery 2) compare functional and aesthetic POCs amongst three vaginoplasty techniques: inverted
penile skin, penoscrotal skin graft, and pedicled intestinal flap vaginoplasty.
Methods: All (n = 84) consecutive transfemale individuals who underwent primary genital gen-
der confirmation surgery from January 2015 to December 2016 at IMCLINIC were prospectively
followed. Functional, aesthetic, and sensory POCs were registered according to the Clavien-
Dindo POC classification.
Results: Functional POC rates after vaginoplasty at our centre were 19%, 12%, 13%, and 1% at
short (one month), mid-early (three months), mid-late (six months), and long-term (one year)
follow-up visits, respectively. None of them were severe complications (grades IV-V), 25% were
grade III, and less than 20% were low-grade complications (grades I-II).
Overall, aesthetic satisfaction was high (90%). The total number of secondary surgeries needed
to satisfy the cosmetic outcome was 20 (aesthetic POC grade IIIb). No differences regarding
functional or aesthetic complication rates amongst vaginoplasty techniques were encountered.
Twelve months after surgery, 81% of patients had initiated sexual intercourse, and 96% reported
clitoral sensitivity.

∗ Correspondingauthors.
E-mail addresses: dr.ivanmanero@ivanmanero.com (I. Mañero Vazquez), anna_arno@yahoo.com (A.I. Arno).

https://doi.org/10.1016/j.bjps.2022.08.032
1748-6815/© 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4312–4320

Conclusions: In our experience, female genital gender affirmation surgery is a feasible, low-
complication surgery that offers high satisfaction in the long term. Further multicentric well-
designed research is mandatory to improve outcomes.
© 2022 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Pub-
lished by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/)

Introduction consent and following Helsinki Declaration principles and

Gender dysphoria (GD) is a condition that many gender di-
verse people experience throughout their lives, and it refers
to the discomfort or distress caused by the discrepancy be-
tween their gender identity and sex assigned at birth. Gen-
ital gender confirmation surgery (genital GCS) is one of the
treatment options proposed for individuals seeking care for
GD, and its demand has dramatically increased in recent
years. It is estimated that 1:30,000 adults assigned male
at birth and 1:100,000 adults assigned female at birth seek
gender confirmation surgery in Europe.1
For transgender women, genital GCS consists of the elim-
ination of the male sexual organs (bilateral orchiectomy
and penile disassembly) and the creation of a neovagina, a
glans-derived sensate clitoris, labia majora and minora, and
repositioning of urethral meatus at the female anatomical
site. Several genital GCS techniques performed on transgen-
der women have been described in literature.2-4 However,
there is a lack of homogeneity in terms of surgical tech-
niques and outcome measurements regarding functional and
aesthetic results.5 , 6 As the number of performed genital
GCS have increased in recent years, a peak of incidence of
postoperative complications (POCs) might be expected. For
valuable quality assessment, outcome data should be ob-
tained in a standardized, objective, and reproducible man-
ner to allow comparison amongst different centers, differ-
ent therapies, and within a centre over time.7
Our study aims to prospectively analyse the POC rate of
all primary genital GCS performed on transgender women
at our centre from January 2015 to December 2016, us-
ing the Clavien-Dindo8 , 9 classification measurement tool, at
short (0–1 month), mid-early (1–3 months), mid-late (3–6
months), and long-term (6–12 months) periods. We divided
POCs into three categories: functional (nonsensory) com-
plications, aesthetic complications, and sensory complica-
tions. Since the primary genital GCS performed on trans-
gender women was either inverted penile skin vaginoplasty,
penoscrotal skin graft vaginoplasty, or pedicled intestinal
flap vaginoplasty, our secondary objective was to compare
the functional and aesthetic POC rates amongst the differ-
ent aforementioned vaginoplasty techniques.
Materials/ patients and methods
Study design and surgical technique
We performed a prospective observational study in which
all (n = 84) consecutive transfemale individuals who un-
derwent primary genital GCS from January 2015 to Decem-
ber 2016 at IMCLINIC were included, after signing informed
STROBE guidelines. The research protocol was approved by
the local Ethical Committee with the reference number
CEEAH 5689. Exclusion criteria were transfemale individu-
als younger than 18 years old. The Standards of Care of
the World Professional Association for Transgender Health
(WPATH) (version 7) were followed as a preoperative proto-
col. Transfemale individuals were prospectively followed at
our Gender Unit, and every deviation from the normal post-
operative course was registered and graded according to the
Clavien-Dindo POC classification, during hospital admission
(first week after surgery), and at short (one month), mid-
early (three months), mid-late (six months), and long-term
(one year) follow-up outpatient visits.
We registered and defined “functional complication” as
every complication related to the new organ’s functional-
ity, besides sensorial function. Considering that one of the
most important outcomes after genital GCS is the female
appearance, we defined aesthetic complication as the sur-
gical need for further cosmetic refinement. Moreover, we
considered a sensory or sensitive complication the lack of
clitoral sensitivity at any of the follow-up visits.
Transwomen were seen at our outpatient clinic, where a
full physical examination and medical history including ba-
sic demographics were recorded at the preoperative visit,
and they were advised to discontinue hormonal treatment
three weeks prior to surgery. The indication of a specific
vaginoplasty technique depended mainly on penis and per-
ineal lengths. If the surgeon considered that penile skin
would be sufficient to cover the entire neovagina, inverted
skin vaginoplasty was considered as a primary surgery. Oth-
erwise, they were offered a colovaginoplasty. Peno-scrotal
skin grafts were used only if, during the initial surgery with
the inverted penile skin technique, more skin was needed
in order to achieve adequate vaginal depth. More in detail,
to determine if bowel would be used, the following mea-
surements and/or facts were considered: Skin elasticity af-
ter penectomy (intrasurgical measurement), the presence
of circumcision scar, the amount of skin (redundancy) of
balanopreputial sulcus, perineal dimensions/ raphe length,
scrotal skin availability, and penis length and width.
Transfemale individuals were admitted to the hospi-
tal the day before surgery and completed a low-residue
diet and bowel preparation using an oral laxative solution
(phospho-soda oral solution, Casen Recordati SL, Zaragoza,
Spain). On the day of surgery, and prior to any skin incision,
antibiotic prophylaxis (2 g cefazolin) was administered. Pa-
tients were placed in lithotomy position, and intermittent
pneumatic compression was used to prevent deep venous
thrombosis.
All surgeries were performed using the same surgical
technique as described in the literature,4 with very few

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 I. Mañero Vazquez, T. Labanca and A.I. Arno

Figure 1 Vaginoplasty technique. 1a: A neurovascular bundle flap is dissected from the tip of the penis and elevated off the
tunica, keeping the glans and preputial skin for clitoral and labia minora recreation. Afterwards, glans skin and prepuce are shaped
to become neoclitoris and labia minora, respectively, following Preecha’s described letter “M” pattern technique4 (using the “v"
part to recreate the clitoris and anchoring the letter "M" legs -preputial skin- at both sides of the urethral anterior flap to recreate
the labia minora). 1b: The proximal 4–5 cm of urethra are used as an anteriorly-based flap attached to the pubis, which not only
minimizes meatal stenosis but also creates the illusion of vulvar vestibule due to its mucosal origin. The bulbospongiosus muscle is
completely removed along with the bulbous part of the urethra to prevent bulbous swelling during sexual arousal.

Figure 2 Sigmoid intestinal Vaginoplasty postoperative results. 2 a: Mid-term (six month) postoperative aspect of colon mucosa
recreating the neovaginal canal after sigmoid intestinal vaginoplasty. 2 b: Long-term (one year) functional and aesthetic postoper-
ative sigmoid intestinal vaginoplasty results.

surgical changes (Figure 1). In colovaginoplasty cases, the
abdomen was entered through a left para-Pfannenstiel la-
parotomy incision. Next, a vascular pedicle of 18–25 cm
large bowel segment (generally, sigmoid) was identified
and harvested in an antimesenteric direction through the
vagina. The proximal portion of the pedicled bowel seg-
ment was closed using interrupted vicryl 2/0 stitches, which
became the neovagina’s cuff. Next, intestinal continuity
was restored by end-to-end anastomosis. The length of the
colon segment depended on patient’s anatomical variabil-
ity, height, weight, and adipose tissue, and on the length of
the meso’s vascular supply that should be harvested, fixed
to the promontory, and derived to the external end of the
neovagina.
Postoperative period and follow-up
After surgery, a compressive dressing was placed in order
to prevent bleeding. A Foley catheter was left in place for
seven days. During this period, transwomen received an-
tibiotic prophylaxis with ciprofloxacin 500 mg/day po and
tolterodine tartrate 2 mg/day po and anticoagulants with
enoxaparin 40 mg/day throughout admission. On day seven

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4312–4320

a b c

d e f

Figure 3 Penile inversion vaginoplasty postoperative results. 3a: Case 1: Long-term (one-year) functional and aesthetic postop-
erative penile inversion vaginoplasty results. 3b, 3c, and 3d: Case 2: Long-term (one-year) functional and aesthetic postoperative
penile inversion vaginoplasty results. 3e: Case 3: Long-term (one-year) functional and aesthetic postoperative penile inversion
vaginoplasty results. 3f: Case 4: Long-term (one-year) functional and aesthetic postoperative penile inversion vaginoplasty results.

after surgery, dilation protocol was started. Transwomen
were given detailed instructions about the correct tech-
nique and frequency for self-dilations, performing the first
dilation before being discharged. According to our clinic’s
protocol, transwomen were encouraged to perform dilations
by themselves, at home three times a day for the first post-
operative month, twice a day from the second to the sixth
postoperative months, and once a day afterwards (unless
engaging in frequent penetrative sex, when they may re-
duce or even stop dilations).
Follow-up visits were scheduled on the first, third, and
sixth postoperative months, and after that, on an annual
basis. At these appointments, the surgeon assessed if any
complications were encountered and recorded them ac-
cording to the Clavien-Dindo POC classification. The surgeon
checked to exclude vaginal stenosis and asked about cli-
toral sensitivity, the initiation and frequency of sexual inter-
course or use of sex toys, and aesthetic satisfaction. Regard-
ing neoclitoral sensitivity and orgasm achievement, tactile
sensitivity was evaluated by Semmes-Weinstein monofila-
ment test10 in the glans clitoris. Erogenous sensitivity was
evaluated by questioning the patient about the presence or
absence of orgasms during any sexual practice. If any trans-
female individual could not attend the follow-up visit, the
surgeon either rescheduled for another date or performed
a telematic follow-up visit. We evaluated the overall POC
rates, emphasizing high-grade complications (Grades ≥ III)
as they represent higher transfemale individual risks and
higher costs.
Statistical analysis
The SPSS programme, version 2.0, for database and statis-
tical analysis was used. The median and percentile 25/75
were used to describe quantitative variables. The differ-
ence between the qualitative variables was compared using
the Fisher test. The quantitative variables were analysed
using a nonparametric test (paired samples Wilcoxon test).
All statistical tests were two-tailed. A p-value below 0.05
was considered statistically significant.
Results
Transwomen sample
From January 2015 to December 2016, 84 transgender
women underwent primary genital GCS at Ivan Mañero In-
stitute of Plastic Surgery (IMCLINIC).

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 I. Mañero Vazquez, T. Labanca and A.I. Arno

Table 1 Transwomen’s characteristics, surgery details, and intraoperative complications.

Patient data Median (P25/ P75) n (%)
Age (years) 24 (21/31)
Past medical history 6 (7%)
Hepatitis C 2 (2%)
HIVa 3 (4%)
Arterial hypertension 1 (1%)
Hormone treatment 77 (92%)
Smoking 21 (25%)
Surgical procedures (trans) 42 (50%)

Primary surgery Median (P25/ P75) n (%)

b
PIV 50 (60%)
PIV with graft 13 (15%)
Colovaginoplasty 21 (25%)
Surgical times (minutes) 240 (201/280)
PIV 230 (200/260)
PIV with graft 250 (225/300)
Colovaginoplasty 300 (270/309)
Intraoperative complications 11 (13%)
Rectal injury 3 (4%)
Severe bleeding 2 (2%)
Prostate injury 4 (5%)
Inguinal hernia 2 (2%)
a HIV = Human Immunodeficiency Virus
b PIV = Penile Inversion Vaginoplasty.

These transwomen’s medical history, surgical, and epi-
demiological characteristics are described in Table 1. The
median age was 24 years (IQR 21–31). Prior to surgery, most
transfemale individuals were noted to have a negative blood
panel for infectious diseases. However, 2% were incidentally
found to be positive for Hepatitis C and 4% for HIV. Ninety-
two percent (77/84) had received hormonal treatment in
the last one year (most of them with oestradiol valerate
4 mg/day and cyproterone acetate 50 mg/day). Transfemale
individuals who were not under recent hormone treatment
had discontinued it because of severe side effects or had de-
cided to interrupt their hormone therapy. Twenty-five per-
cent were smokers (21/84), and 50% of the cohort (42/84)
had at least one aesthetic plastic surgery operation in the
past. amongst them, augmentation mammaplasty and facial
feminization were the most common performed procedures
(32 and 10 patients, respectively).
Surgical procedure and intraoperative
complications (Table 1)
Fifty transwomen underwent vaginoplasty by inverted pe-
nile skin (60%), 13 transwomen peno-scrotal skin graft
vaginoplasty (15%), and 21 patients pedicled intestinal flap
vaginoplasty or colovaginoplasty (25%).
Median surgical time was 240 min (IQR 201–280). Eleven
(13%) intraoperative complications were reported (Table 1).
All of them were treated during the first surgical procedure,
and none of them increased the transwomen’s hospital stay.
Postoperative complications (Tables 2-6)
Short-Term (One-Month) follow-up
Functional outcomes. During the first 30 postoperative
days, 16 functional POCs (19% rate) were recorded: amongst
them, eight were grade II complications, one was grade
IIIa, and seven were grade IIIb. amongst high-grade com-
plications (grades III and above), one (1%) suffered post-
operative ileus and needed a nasogastric tube (grade IIIa),
four transwomen (5%) had haematoma requiring surgical
drainage under anaesthesia (grade IIIb), one patient (1%)
had a rectovaginal fistula (which was repaired in another
surgery, requiring an ileostomy on discharge: complication
grade IIIb “d”), and two (2%) suffered from neovaginal flap
necrosis and underwent a secondary surgery with pedicled
intestinal flap vaginoplasty (grade IIIb) (Table 2).
Aesthetic outcomes. In the short-term follow-up period,
we did not record the transwomen’s aesthetic perception
due to normal postoperative inflammation.
Sensory function and sexual satisfaction. A total of 74 out
of 84 transwomen (88%) had clitoral sensitivity at the short-
term follow-up visit (Table 6).
All included transwomen denied having started sexual in-
tercourse along the first postoperative month, following sur-
geons’ recommendations.
Mid-Term follow-up
Mid-Early term (Three-Month) follow-up
Functional outcomes. At the third-month follow-up visit,
10 functional POCs were recorded (12%), corresponding to

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Table 2 Description of POCsa at short, mid, and long-term follow-up.

POC 1st month n = 16/84 (19%) Treatment POC grade (Clavien-Dindo) POC grade n (%)
Urethral bleeding 1 Compressive bandage II II = 8
Abscess 3 Antibiotic and wound care II (10%)
Wound dehiscence 3 Antibiotic and wound care II
Psychiatric crisis 1 Anxiolytics and Psychiatric evaluation II
postoperative ileus 1 nasogastric tube iiia iiia = 1 (1%)
haematoma 4 surgical drainage under anaesthesia iiib iiib = 7
Rectovaginal fistula 1 Fistula correction and ileostomy IIIb (d) (8%)
Neovaginal necrosis 2 Colovaginoplasty IIIb

POC 3rd month n = 10/84 (12%) Treatment POC grade POC grade n (%)

Urinary infection 4 Antibiotics II II = 4 (5%)

Clitoral necrosis 1 Surgical repair IIIb IIIb = 6
Vaginal stenosis 4 Surgical dilation IIIb (7%)
Ileostomy 1 End-to-end anastomosis IIIb

POC 6th month n = 11/84 (13%) Treatment POC grade POC grade n (%)

Vulvar HPVb 1 Imiquimod 2% cream II II = 4

Recurrent UTIc 3 Antibiotic + Urodynamic study II (5%)
Vaginal stenosis 7 Surgical dilation IIIb IIIb = 7 (8%)
POC 12th month n = 1/84 (1%) Treatment POC grade POC grade n (%)
Vaginal stenosis 1 Colovaginoplasty IIIb IIIb = 1 (1%)
a POC = Postoperative Complication.
b HPV = Human Papilloma Virus.
c UTI = Urinary Tract Infection.

Table 3 Functional and aesthetic POCa rates at short, mid, and long-term follow-up.
Follow-up FUNCTIONALb POC AESTHETICc POC
30 days 19% -d
3 months 12% 10%
6 months 13% 13%
12 months 1% 1%
aPOC = Postoperative Complication.
bTypes of functional POCs have been described in detail in Table 2.
c Aesthetic POCs referred to the surgical necessity of revision cosmetic surgery. They were all ambulatory minor surgeries—20 surgeries;

mainly labiaplasties (16 surgeries), followed by clitoroplasties (4 surgeries)—with positive outcomes.

d - = Not measured.

four grade II complications (5%), and six grade IIIb compli-
cations (7%) (Table 2).
Aesthetic outcomes. In the mid-term follow-up period, a
total of eight transwomen (10%) reported aesthetic com-
plaints, requiring another surgical intervention (Table 3).
Sensory function and sexual satisfaction. Results are de-
scribed in Table 6.
Mid-Late term (Six-Month) follow-up
Functional outcomes. At the six-month follow-up, we
recorded 11 functional POCs (13%): four of them (5%) were
grade II complications, and seven (8%) were grade IIIb com-
plications. All these IIIb (high-grade) complications were
vaginal stenosis that required surgical dilation (Table 2).
All affected transwomen failed to accomplish the recom-
mended regular preventive dilation regimen.
Aesthetic outcomes. At the six-month follow-up, 11
transwomen underwent an aesthetic refinement surgical
procedure (13%) (Table 3).
Sensory function and sexual satisfaction. Results are de-
tailed in Table 6.
Long-Term (12-Month) follow-up
Functional outcomes. At the 12-month follow-up, one
functional IIIb POC (1%) was recorded, corresponding to
vaginal stenosis that required colovaginoplasty for its cor-
rection (Table 2). It is important to mention that she had un-
dergone a surgical dilation at the sixth postoperative month
and was still not complying with our recommended ambula-
tory self-dilation protocol.
Aesthetic outcomes (Figures 2 and 3). At the 12-month
follow-up, one transfemale individual required aesthetic
surgical correction of the labia (1%) (Table 3).
Sensory function and sexual satisfaction. At the 12th post-
operative month, 96% of transwomen (81/84) reported hav-
ing clitoral sensitivity, while 81% (68/84) admitted to having
initiated sexual intercourse (Table 6).

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 I. Mañero Vazquez, T. Labanca and A.I. Arno

Table 4 Functional POCsa at short, mid, and long-term follow-up: Comparison amongst vaginoplasty techniques.
FUNCTIONAL POCa (n,%)
Follow-up PIVb (n = 50) PIV with graft (n = 13) Colovaginoplasty (n = 21) p value

30 days 9 (18%) 2 (15%) 5 (24%) 0.858

3 months 4 (8%) 2 (15%) 4 (19%) 0.321
6 months 6 (12%) 2 (15%) 3 (14%) 0.907
12 months 0 1 (7%) 0 0.133
a POC = Postoperative Complication.
b PIV = Penile Inversion Vaginoplasty.

Table 5 Aesthetic POCsa at short, mid, and long-term follow-up: Comparison amongst vaginoplasty techniques.
AESTHETIC POCa (n,%)
Follow-up PIVb (n = 50) PIV with graft (n = 13) Colovaginoplasty (n = 21) p value

3 months 3 (18%) 3 (23%) 2 (9.5%) 0.118

6 months 6 (12%) 3 (23%) 2 (9.5%) 0.531
12 months 0 0 1 (4%) 0.467
a POC = Postoperative Complication.
b PIV = Penile Inversion Vaginoplasty.

Table 6 Sensory POCsa at short, mid, and long-term follow-up. Clitoral sensitivity and initiation of sexual intercourse (n = 84).
CLITORAL SENSITIVITY∗ SENSORY Initiation of sexual
Follow-up YES (n) (%) NO (n) POC (%) intercourse n (%)

1 month 74 10 12% 0
3 months 78 (92%) 6 8% 53 (63%)
6 months 80 (95%) 4 5% 62 (74%)
12 months 81 (96%) 3 4% 68 (81%)
∗ Meaning erogenous sensation as patient-reported experienced orgasm.
a POC = Postoperative Complication.

Most of the transwomen reported satisfactory sexual in-
tercourse. However, few colovaginoplasty transwomen oc-
casionally referred to sexual intercourse-associated spas-
tic neovaginal contractions or spasms, which are under
study.
Comparison amongst different surgical techniques
No significant differences were found regarding functional
and aesthetic POCs amongst the three different genital
GCS performed techniques at any of the different follow-up
time-points of the study (Tables 4 and 5).
Discussion
At our single institution, we found less than 20% of func-
tional POCs after female genital gender affirmation surgery.
Severe life-threatening complications (Grades IV and V in
the Clavien-Dindo classification) were not encountered in
our cohort. However, female genital gender affirmation
surgery is a complex surgery. A recent review by Claes
K.E.Y. et al.3 describes severe complications such as necro-
tizing fasciitis, intestinal necrosis, bilateral lower extremity
compartment syndrome, intraluminal abscess, and neopla-
sia after pedicled intestinal vaginoplasty. In our study, we
did not find any urethral meatal stenosis, which is consid-
ered the most frequent complication after penile inversion
vaginoplasty in a meta-analysis by Dreher PC et al11 . The
majority of female genital GCS POCs that were found in
our cohort were labelled as grade III in the Clavien-Dindo
classification and required additional repair surgery. Neo-
vagina stenosis, one of the most prevalent complications
after vaginoplasty,12 was also found in some of our trans-
female individuals (all of them corresponding to penile in-
version vaginoplasties) after the third month of surgery; all
cases were resolved by surgical dilation, but one had recur-
rence, and colovaginoplasty was performed as a secondary
procedure. All neovagina stenosis complications found in
our study after female genital GCS were associated with
noncompliance to the self-dilation protocol regimen. In our
experience, strict adherence to this protocol is mandatory
for proper maintenance of neovagina diameter and length
and is recommended lifelong if the transfemale individual
does not have frequent penetrative sex with an anatomi-
cal phallus or other instruments/sex toys. Similar to other
studies, functional nonsensory complications were the most
frequent complications after female genital GCS in our co-
hort, followed by aesthetic complications.13

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 75 (2022) 4312–4320
One of the limitations of this study was that all genital
GCS were performed by a single experienced surgeon. This
might be interpreted as a bias, considering that there was
no surgeon variability, leading to a theoretical lower per-
centage of functional POCs, which could be attributed to
the surgeon’s experience and not to the procedure itself.
On the other hand, this fact implied a homogeneous sam-
ple and methodology to ensure consistent measurements in
a prospective manner, which constituted a major strength
in this study. Indeed, the prospective design and objec-
tive classification outcomes tool used in this research were
both advantageous, as most of the published reports on
this topic are retrospective,13-15 with heterogeneous tech-
niques and nonstandardized or even subjective outcome re-
porting tools, and overall with scarce scientific evidence
and therefore limited quality. However, proper consensus
on outcomes measurement after genital GCS is still required
and might be the focus of future research.
Another limitation of our prospective study might be the
short follow-up period, which was one year.16 Although the
most severe complications appeared during the first post-
operative months and there were only 1% of functional and
aesthetic complications at the end of the first year after
surgery, we plan to increase the follow-up study period in
order to detect long-term complications, aiming to achieve
a new analysis with this cohort of transfemale individuals
in subsequent years. The short follow-up period in combi-
nation with not a large enough population size could ex-
plain why we found no statistically significant differences
amongst the three vaginoplasty techniques at any of the
different follow-up time points of the study. According to
other authors15 , 17-19 and to our 20 year long experience, in-
testinal vaginoplasty (especially sigmoid colovaginoplasty,
which is the intestinal vaginoplasty we usually perform at
our clinic) may arise as the gold standard vaginoplasty tech-
nique, but further research is necessary to shed more light
on this controversial arena in the literature.
As another limitation of our study, all our pedicled in-
testinal vaginoplasties were performed as open surgeries
and not by laparoscopy or even robotic surgery; compar-
ing open and laparoscopic colovaginoplasties would also be
of great interest. It has been reported that total laparo-
scopic sigmoid vaginoplasty has lower mortality rates than
open vaginoplasty,3 but more research on that topic is also
required.
In comparison with other published reports, to our knowl-
edge, this is the first study to use the Clavien-Dindo classifi-
cation objective tool to prospectively report female genital
GCS POC rates. Other strengths of our study were the high
number of surgeries performed in two consecutive years and
the postoperative serial outcomes measurements at differ-
ent time points of the study period, which provided informa-
tion about the time-related frequency of POCs after genital
GCS.
We consider that consensus regarding the correct clas-
sification of POCs in a field that lacks standardized surgi-
cal and postoperative protocols is mandatory for quality
healthcare. Furthermore, it may facilitate the evaluation
and comparison of surgical outcomes amongst different sur-
geons, centers, and techniques, and for one single centre or
surgeon throughout time. Moreover, it could also be useful
for teaching and educational purposes.
4319
Conclusion
At our single institution, we found less than 20% of func-
tional POCs after female genital GCS at short, mid, and
long-term follow-up periods. Aesthetic complications were
reported in less than 15% of the cases. At 12 months postop,
only 1% of the transwomen reported functional or aesthetic
complications, with initiation of satisfactory sexual inter-
course in most transwomen and restored clitoral sensory
function in 96% of them. In our prospective cohort, we did
not find any differences in functional or aesthetic POC rates
between the three offered female genital GCS; that is, pe-
nile skin vaginoplasty, penoscrotal skin graft vaginoplasty,
and pedicled intestinal flap vaginoplasty. In our experience,
female genital GCS is a feasible, low-complication surgery
that offers high transwoman satisfaction in the long-term.
Establishing a standardized validated tool for measuring
postoperative POCs after genital GCS may increase scientific
evidence to compare and standardize surgical procedures
and outcomes worldwide in genital GCS, limiting healthcare
costs and improving medical care. Further well-designed re-
search is strongly required to provide new updated efficient
evidence-based clinical guidelines to improve the quality of
life of transgender and gender diverse people.
Declaration of Competing Interest
None declared.
Funding
None.
Ethical approval
The research protocol was approved by the local Ethical
Committee with the reference number CEEAH 5689.
Research informed consent and Photo Patient Consent
was obtained.
Acknowledgements
The authors acknowledge all professionals at IMCLINIC and
especially all transwomen who participated in this research,
as well as their families for their continuing support.
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