Outcome and refinements of gender confirming surgery

Introduction: Gender dysphoria is a state in which the individual shows strong and persistent identification with the opposite sex. After thorough diagnostic assessment, the treatment includes gender confirming surgery (GCS). The efficacy and benefit of GCS has been advocated to effectively resolve the patient’s gender dysphoria as well as improve quality of life and psychosocial functioning. The aim of the studies described here was to assess surgical techniques, complications, quality of life and functional outcomes of GCS.

Patients and Methods: Study I is a retrospective study of surgical outcomes for patients who underwent male-to female (MtF) GCS over a 14-year period (n=205). Study II describes a prospective study (n=80) of vaginal depth after vaginoplasty performed using solely penile skin for intra vaginal lining. Factors predicted to correlate with poor outcomes were analyzed using a multivariate regression model. Study III is a prospective study (n=193) examining patient-reported outcomes on health-related quality of life. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1,3 and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population. Study IV is a cohort study (n=22) of the sensitivity of the neoclitoris and its patient-reported functionality. Tactile and vibratory sensitivity was measured with the Semmes-Weinstein monofilaments and the Bio The siometer vibratory measurement device, respectively. A body image questionnaire was provided to patients and the patients were asked about orgasm, pain and general satisfaction with the surgery.

Results: In study I, the most common short-term complications were bleeding (11%) and infection (10%). Other complications, such as wound dehiscence (2%), rectovaginal fistula (2%), pulmonary embolus (2%) and deep vein thrombosis (0%), were rare. In study II, the average neovaginal depth was 10.2 cm (range 1-16 cm). Noncompliance with dilation protocol (p<0.001) and postoperative complications (p=0.01) were associated with decreased vaginal depth. Neither circumcision nor age affected the outcome of vaginal depth. In study III, transgender women reported significantly lower quality of life in most dimensions when compared to the general population. One year postoperatively, there was a trend towards higher scores compared to the preoperative measurement point; however, these scores then declined. In study IV, the average pressure threshold for the neoclitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. The vast majority of the study participants could reach orgasm (86%), and reported satisfaction with having undergone GCS (86%).

Conclusions: MtF GCS can be performed with a low rate of major complications. Using solely penile skin is sufficient to create the vaginal lining, although adhering to a dilation protocol is crucial to attaining sustained vaginal depth. Quality of life among MtF patients compared to the general population is improved one year after GCS, but then declines. The sensate neoclitoris has a protective tactile sensation, gives the patient erogenous sensitivity and the ability to reach orgasm in the majority of patients. Over all, the vast majority of patients who undergo MtF GCS are satisfied.

List of scientific papers

I. Hannes Sigurjónsson, Johan Rinder, Caroline Möllermark, Filip Farnebo, T. Kalle Lundgren. Male to female gender reassignment surgery: Surgical outcomes of consecutive patients during 14 years. Journal of Plastic and Reconstructive Surgery Open. 2015, 69-73.
https://doi.org/10.1016/j.jpra.2015.09.003

II. Hannes Sigurjónsson, Johan Rinder, Ebba K. Lindqvist, Filip Farnebo, T. Kalle Lundgren. Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery. Plastic and Reconstructive Surgery Global Open. 2016;4:e767.
https://doi.org/10.1097/GOX.0000000000000761

III. Ebba K. Lindqvist, Hannes Sigurjónsson, Caroline Möllermark, Johan Rinder, Filip Farnebo, T. Kalle Lundgren. Quality of Life Improves Early after Gender Reassignment Surgery in Transgender Women. European Journal of Plastic Surgery. 29th of October 2016.
https://doi.org/10.1007/s00238-016-1252-0

IV. Hannes Sigurjónsson, Caroline Möllermark, Johan Rinder, Filip Farnebo, T. Kalle Lundgren. Long-term sensitivity and patient reported functionality of the neoclitoris after gender confirming surgery. [Manuscript]