Vaginoplasty

Vaginoplasty is the surgical construction or reconstruction of the vagina. The vagina is a part of the female reproductive system. It is divided into two parts

1. External genitalia (the part which is visible externally on the body): It consists of the vulva, clitoris, glands and vaginal opening.
2. Internal genitalia (the part which is present inside the body): From outside to inwards the internal structures are the vagina, then uterus, then fallopian tubes and lastly, ovaries.

The function of the vagina is for the passage of menstrual blood, sexual intercourse and for passage of the foetus (unborn baby) during labour.

There are many reasons for recommending the surgery

• Absence of vagina/malformation present from birth: symptoms include no history of menstrual bleeding post-onset puberty, difficulty or pain in sexual intercourse.
• Injuries sustained during childbirth: symptoms include loose vagina, feeling of mass in vagina due compression from urinary bladder or rectum, which can cause issues in urination and passing stool, respectively.
• The vagina itself is protruding from its opening (condition is also known as vaginal prolapse).
• Tumours: symptoms include bleeding and foul-smelling discharge.
• Sexual Assault/ Trauma.
• Gender affirming surgeries (also known as Sex Reassignment Surgeries) as requested by a transgender person.

Surgery is not advised to people with the following conditions

• Other illnesses which are not under control/treatment
• Pre-existing infection in the vagina
• If the tumour has spread to other parts of the pelvis or abdomen making surgery riskier, thereby reducing life expectancy.

This is a major procedure, and hence requires consultations from many specialities, the three mainly being:

• Obstetrics and Gynaecology: Routine blood tests followed by ultrasound, CT scan and MRI of the pelvis and abdomen are the investigations done. Depending on the indication of the surgery, the procedure of how the surgery is performed will be explained to the patient along with risks and intended outcomes.
• Plastic surgery: Cosmetic and functional needs of the patient are discussed.
• Psychiatry: Counselling of the patient is very important and spans from before the surgery to post-surgery.

In each speciality consultation, the doctor will take a detailed medical history, medication history and menstrual history. In addition, in cases of gender-affirming surgeries, the required documents for surgical clearance are required as outlined by The World Professional Association for Transgender Health.

Before the date of the surgery, the primary doctor may stop certain medications/replace such as anticoagulants (blood thinners), hormones (in people who are on hormone replacement therapy), heart medications, diabetes medications.

The patient is admitted usually a day or two before the date of the surgery with all the necessary reports and documents. Post admission, the patient changes into the hospital gown and is visited by the doctors of the concerned teams. 

A final assessment of the patient is done by the doctors to clear the patient as medically fit for surgery and the patient is again counselled about the procedure, duration of the surgery and possible risks, complications and outcome.

Preoperative instructions

Preoperative instructions include:

• Continuing any medications as prescribed by the doctor for any pre-existing illness. Since the procedure is a major one, blood is already arranged and kept ready in case of major blood loss during the surgery.
• Taking consent for surgery from the patient and relatives while explaining the risks and outcomes. 
• Preparing the site of surgery, that is shaving off the hair around the pelvis, abdomen and legs and taking a bath. 
• Switching the diet from solid to liquids to finally intravenous fluids so that the patient is fasting for around 8-10hrs before surgery.
• Giving the patient a laxative to cleanse the bowels of faecal matter.
• Due to anxiety before the surgery, the patient can be given a mild sedative prescribed by the doctor so that the patient has a restful sleep before the procedure.

On the day of the surgery

On the day of the surgery the patient is shifted into the operation theatre (OT). The patient is placed into the lithotomy position (position where the patient is lying on their back and the legs of the patient are spread wide when giving birth).

Machines are attached to the patient that monitors the patient’s vitals (heart rate, blood pressure, oxygen saturation, breathing etc). Antibiotics are given through the IV cannula to prevent infection. A catheter is placed to allow drainage of urine during the surgery. The patient is given general anaesthesia so that she sleeps throughout the surgery.

A mould is made which has dimensions similar to the desired vaginal length and girth. The mould is responsible for maintaining the shape and size of the vagina during and after surgery till the surrounding tissues and supports are healed and strong enough. The techniques of the surgery are different based on the indications of surgery. 

• In patients with loose vagina (because of  injury due to childbirth/assault/trauma) 
  • The deformed tissue is removed.
  • The vaginal canal is made tighter using stitches.
  • The vagina opening is reduced.
  • Injuries to other areas are repaired and support of other organs such as the bladder and rectum are strengthened.
• In patients with absent/narrow vaginal canal
  • A functional tract is made between the urinary tract and the rectum.
  • The graft tissue is placed to form the lining of the vagina.
  • Excess tissue is removed.
  • For cosmetic appearance, tissue grafting is done.
• In Gender Affirming Surgery
  • The male external genitalia is partially removed and reconfigured to form the female external genitalia.
  • A functional tract is made between the urinary tract and the rectum.
  • The graft tissue is placed to form the lining of the vagina.
  • Nerve endings are preserved and reconfigured so as to maintain the sensation for sexual pleasure.

The skin used for grafting is taken from the patient usually from the thighs or buttocks. Newer types of grafts involve skin flaps, amniotic membranes (the covering in which the developing baby is present) or buccal mucosa (skin from the inner lining of the cheek)

The duration of vaginoplasty varies depending on the cosmetic and functional requirement of the patient.

Once the surgery is complete, drains are placed in the pelvis to prevent the pooling of blood around the surgery site. All incisions are sutured and the patient is shifted to the post-op area.

These can include

• Complications related to anaesthesia
• Excessive bleeding
• Injury to surrounding arteries or nerves
• Injury to the bladder
• Injury to bowel
• Aggravation of pre-existing medical conditions such as heart conditions, stroke, or seizures

Since this is a major surgery, the patient is kept in the ICU for overnight observation and vitals are monitored. Once stable, the patient is shifted to the ward. 

Postoperative care is important and needs to be taken seriously to prevent complications. It involves:

• Proper hygiene of the surgical site to reduce chances of graft rejection.
• Postoperative pain is severe but is managed through pain medications.
• Antibiotics are administered timely so as to prevent infection.
• Problems in passing stool and urine may arise which are noted and managed accordingly.
• Events such as excessive bleeding /discharge/ fever are looked out for and managed.
• Counselling is given postoperatively to reduce the anxiety associated with pain and difficulty in daily activities.

The patient can perform light activities by the end of one week and resume daily activities by the end of six weeks.

Discharge is usually done once the patient is able to perform light activities, there is minimal fluid present in the drains and all vitals are stable.

The patient is discharged with a list of medications for pain and antibiotics which should be followed strictly. Advice on wound care is given to prevent infection and reduce swelling. Physiotherapy exercises are prescribed to strengthen the supports around the vagina. 

Serial follow-ups are done with the primary physician and counsellor. After 6 weeks when the patient visits the doctor, the mould is removed from the newly constructed vagina. 

Thereafter the patient is given vaginal dilators to maintain the shape and size of the vagina. However, the complete surgical healing takes time and varies from 12-18 months.

When to contact the doctor after discharge from the hospital:

• Excessive bleeding from the wound
• Foul-smelling discharge from the wound
• Excessive pain not controlled by medication
• Persisting fever

Outcome risks after surgery:

• The vaginal opening is too tight.
• Inadequate length of the vagina.
• Vaginal stenosis - narrowing of the vagina due to fibrosis.
• Painful intercourse.
• Vesicovaginal fistula - an abnormal connection between the urinary bladder and vagina.
• Rectovaginal fistula - an abnormal connection between the rectum and the vagina.
• Loss of sensation around the area due to nerve injury.
• Poor cosmetic outcome.

In conclusion, vaginoplasty is considered a major surgery with significant risks and involves a long period of recovery. Functional and cosmetic needs should be properly discussed with the surgeon doing the procedure. Adequate thought and time should be taken by the patient before considering going through with the surgery. Pre and post-operative counselling sessions are important for the patient.