Commentary on: Vaginoplasty With Mesh Autologous Buccal Mucosa in Vaginal Agenesis: A Multidisciplinary Approach and Literature Review Free

The impact of creating genitals that align with one’s gender identity can have a substantial influence on a person’s quality of life.¹ Whether required because of congenital, acquired, or traumatic absence, or due to gender dysphoria, vaginoplasty can serve to feminize the genitalia. Techniques and approaches have advanced, but no method ideal for all populations has been described.^2,3 In treating those with vaginal agenesis who desire vaginoplasty, various flaps, grafts, and scaffolds have been used, all of which have drawbacks; ⁴ the paper by Wu et al⁵ expands on these treatment options by describing the use of buccal mucosal grafts.

Our practice has routinely been focused on gender-affirming vaginoplasty, which has associated sequelae when altering the external and internal genital appearance, including complications and the need for revisional surgery.^1,6 However, for patients with vaginal agenesis, the aim is to minimize external scarring while achieving adequate depth and aesthetics. Skin grafts, pedicled flaps, intestinal procedures, and use of peritoneal lining can come with external scarring, contraction of the vaginal canal, failure of reconstruction, or intra-abdominal complications. To minimize these issues, Wu et al⁵ used buccal mucosal grafts, which offer the added benefit of mucosalization of the vaginal canal. Others have shown similar results with buccal grafts, as Wu et al aptly discuss in their literature review. Although this study reports good data and patient outcomes, there are aspects that would have improved the results and conclusions.

Although the authors report that their patient population did not desire dilation without surgical intervention, it is nevertheless noted that dilation was needed for at least 8 months after surgery. Even with mucosal grafting, there is evidence of contraction with scarring. How did the authors account for this when establishing the depth of the vaginal canal? Did any patients experience loss of depth after the dilation phase ended? Should the patient desire penetrative intercourse, would the vaginal canal accommodate the average 12.9-cm erect length of a phallus?⁷ Although we, of course, understand that sexual satisfaction can be achieved without penetrative intercourse, it is a valid question for those who desire penetration. Moreover, although the population was mostly under the age of 18, the study would have been enhanced with the use of the Female Sexual Function Index or other validated genital satisfaction scale. Because patient-reported outcomes are extremely valuable in any genital reconstructive procedures, this would be important to assess in the future.⁸

Complications from vaginoplasty can be quite high depending on the patient population and procedures used.¹ In assessing the outcomes of their patients, further expansion on the complications and their impact on genital satisfaction or aesthetics would have strengthened the study. As Wu et al noted, some of these surgeries can last longer than 2 hours and bed rest is maintained for 7 days.⁵ This protocol can increase the risk of venous thromboembolism, and it would have been interesting to hear the authors’ practice on managing prophylaxis. We try to mobilize our patients on postoperative day 1 after penile inversion vaginoplasty to reduce such risks.¹ Future studies assessing outcomes and mobilization protocols will improve the standardization of techniques.

The role of physical therapy in reviewing and troubleshooting dilation protocols and pelvic floor therapy have been instrumental in certain vaginoplasty populations.⁹ The implementation of such programs could allow patients to discuss their concerns with dilation and assist them in the postoperative period. Although not all institutions can initiate such a program, for those that perform a significant amount of vaginoplasty, having a referral base for such therapists may improve patient compliance and satisfaction.

Lastly, determining the ideal approach to vaginoplasty in vaginal agenesis will require more substantial studies looking at long-term outcomes and comparing techniques. Augmentation of these studies with patient-reported outcomes will be important. Collaboration across institutions and specialties will be necessary to gather these data, but we owe it to the populations we serve to deliver the best care possible. Overall, this paper is a good discussion of the authors’ technique and initial outcomes, and we look forward to further studies that will continue to advance our understanding of vaginoplasty.

Disclosures

The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

REFERENCES

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