Partial neovaginal prolapse. In this picture, the prolapse of the posterior vault is evident
Total neovaginal prolapse
Several authors have reported their casuistics after SRS, but all of them involved a low number of patients, though the real incidence of neovaginal prolapse is not well known.
Perovic SV et al. in 89 consecutive transsexual M to F patients using penile skin and urethral flap had no reported cases of neovaginal prolapse .
Moreover, Krege S et al. reported two cases in 66 patients who had undergone male-to-female SRS by penoscrotal flap vaginoplasty. However, the authors did not specify if prolapse were partial or total .
Finally, Djordjevic et al.  reported a series of 86 consecutive rectosigmoid vaginoplasties; in their experience seven cases (8.1 %) of partial vaginal prolapse had been observed. However, this series comprise transsexual patients as well as females affected by vaginal agenesia or who had undergone vaginectomy for genital trauma. All vaginal prolapse were repaired by minor surgery.
We herein report the incidence in our experience of total and partial neovaginal prolapse, how we prevent it, and what’s the optimal way to correct it.
We have retrospectively analyzed the prevalence of partial and total neovaginal prolapse after androgynoid sexual reassignment surgery between December 1994 and January 2012 in our institute, performed using a single surgical equipment. Our procedure includes bilateral orchiectomy, removal of corpora cavernosa, creation of the urethrostomy, neovaginoplasty, creation of neoclitoris with preservation of neurovascular bundles, and neovulvoplasty. Since the end of 2010, we had adopted an original technique, which consists of creating a neoclitoris embedded in the urethral mucosa using a urethral flap . In the refinement the urethra is carefully dissected from the corpora cavernosa within Buck’s fascia and shortened approximately 7 cm distally from the bulbs. It is then spatulated on its ventral side all down to the bulbs where a neomeatus is then created at the level of the female-type urethra. Urethral bulbs are removed carefully and entirely, because their remnants may cause painful penetration and bulky sensations during erection . At this point, the urethral plate is further incised on the distal end following the median line to form a bifurcation, which surrounds the neoclitoris.
To create the neovagina, a penile and scrotal skin inversion technique has been adopted. We prefer to not close the apex of the neovaginal cylinder; in this way, the penile and scrotal skin covers spontaneously the cavity where the cylinder is located, ensuring a deeper neovagina.
During the years, two different techniques were adopted with the aim of fixing the neovaginal cylinders:
In the first, two absorbable stitches (Vicryl 3-0, which requires 35 days to be absorbed) are positioned at the top of the penoscrotal cylinder with the aim of fixing it to the prerectal fascia (old technique) (Fig. 20.3). In the second technique, we decided to fix the neovagina using four sutures: two absorbable stitches were fixed from the top of the penoscrotal cylinder to the Denonvilliers fascia and the other two from the midpart of the scrotal flap (which will constitute the posterior neovaginal wall) to the prerectal fascia (new technique) (Fig. 20.4).
Penile and scrotal skin flaps are sutured to each other forming a skin tube, two absorbable stitches are fixed from the top of the penoscrotal cylinder to the Denonvilliers fascia and the cylinder is inverted
Two additional stitches are fixed from the midpart of the cylinder to the prerectal fascia. In our opinion, this fixation reduces the risk of prolapse of the posterior vault
When the suture is passed through the Denonvilliers fascia, we often decide to incorporate in the suture even some prostatic tissue or seminal vesicles, with the aim of strengthening the suture.
At the end of procedure, an inflatable silicon vaginal tutor is introduced in the neovaginal cavity and maintained for 3 days and during nighttime for 3 months. This guarantees that the penoscrotal flap well adheres to the cavity, facilitating recovery. Four days after the procedure, patients have been educated by a specialized nurse to self-dilate the neovagina with progressive larger dilators. Neovaginal self-dilatation is a fundamental step for a good long-term result – first, a deep neovagina and second, prevention of vaginal prolapse. Patients must well learn how to perform it without straightening the penoscrotal flap.
After surgery, patients had been evaluated 6 and 12 months after the procedure.
We included in our casuistic 282 consecutive male transsexuals who had undergone to male-to-female SRS.
Sixty-five (23.04 %) of 282 were treated with our old technique and the remaining 217 (76.96) with the new technique.
Furthermore, since we had started sexual reassignment procedure, inverted penile skin vaginoplasty was used for the first nine patients, while in the remaining cases penile and scrotal skin inversion technique was adopted.
In the old technique casuistic, on 65 patients, 8 patients presented a neovaginal prolapse (12.30 %). One case (1.53 %) of total prolapse and seven cases (10.76 %) of partial prolapse had been observed, while in the next 217 patients treated with the new technique, only nine cases of partial prolapse were observed (4.14 %) and no cases of total prolapse. Considering partial prolapse, ten occurred in the posterior vault and six in the lateral vault. All prolapse occurred within 6 months after the procedure. Results are shown in Table 20.1; differences between two groups were statistically significant.
Incidence of partial and total neovaginal prolapse in our casuistic. A lower incidence in the new technique group was observed
65 (23.04 %)
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