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JU INSIGHT: Genital Hypoplasia in Gender-affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning
By: R. Craig Sineath, MD, MPH; Christi Butler, MD; Geolani W. Dy, MD; Daniel Dugi III, MD, FACS | Posted on: 01 Dec 2022
Sineath RC, Butler C, Dy GW, Dugi D III. Genital hypoplasia in gender-affirming vaginoplasty: prior orchiectomy, penile length, and other factors to guide surgical planning. J Urol. 2022;208(6):1276-1287.
Study Need and Importance
Urologists are called upon increasingly often to perform or guide gender-affirming surgery because of our understanding of urogenital anatomy and function. Gender-affirming vaginoplasty requires such knowledge as well as understanding of skin grafting and harvesting, as most patients will need a skin graft to complete construction of the neovaginal canal. Understanding when there is enough genital skin present and recognizing genital hypoplasia, when other sources of tissue will be necessary, are critical for patient counseling and surgical planning.
What We Found
About 15% of our patients needed extragenital skin grafts. Genital skin available for neovaginal construction and the need for extragenital skin graft are highly associated with penile length (see Figure). This is the first report to our knowledge to document scrotal surface area and its association with penile length. Orchiectomy prior to vaginoplasty is associated with significantly less scrotal skin and 3 times greater odds of needing extragenital skin grafting.
Limitations
How much skin surface area is needed for neovaginal construction will vary based on surgical technique, which is far from standardized at this time, and the utility of the associations we encountered will therefore vary by surgical technique. We do not fully understand the impact of androgen blockade on scrotal skin as we did not measure this prior to patients starting hormone therapy.
Interpretation for Patient Care
A simple measurement of stretched penile skin length done quickly and discreetly against the examiner’s premeasured finger in the office may be helpful to recognize genital hypoplasia prior to surgery and guide counseling and surgical planning. While orchiectomy predicts less scrotal skin available, we do not discourage pre-vaginoplasty orchiectomy as it may be an important step to treating the patient’s gender dysphoria while they consider or prepare for later vaginoplasty.
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