Genital Reconstructive Surgery in Male to Female Transgender Patients: A Systematic Review of Primary Surgical Techniques, Complication Profiles, and Functional Outcomes from 1950 to Present Day.

ABSTRACT

CONTEXT Genital reconstructive surgery (GRS) is a necessary part of transitioning for many transwomen, and there is evidence of positive effects on a person's well-being and sexual function. Surgical techniques have evolved, from pursuing aesthetic outcome to now functional outcome with natal females as the standard. OBJECTIVE: To systematically review the evidence, identifying the surgical techniques used in primary GRS, their complications, functional outcomes, and the tools used to assess them. EVIDENCE ACQUISITION The clinical question was designed using the standard PICOS format. The search complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 statement and was performed by two independent reviewers. EVIDENCE SYNTHESIS: Europe, USA, and Thailand favour the penoscrotal technique for vaginoplasty, whereas in the UK, the penile inversion (PI) technique predominates. Primary vaginoplasty using a segment of bowel is less common, and all three techniques have comparable rates of intraoperative rectal injury. The incidence of rectovaginal fistula is reportedly higher in the PI technique. Wound haematoma and vaginal prolapse rates are comparable. Higher rates of clitoral necrosis, urethral meatal stenosis, and wound infection are reported in PI. However, the ability to orgasm, ability to have penetrative sexual intercourse, and satisfaction with aesthetic result are better with PI. CONCLUSIONS: The evidence for GRS complications and functional outcomes is of low level. Standardised nomenclature reporting of adverse events and robust patient-reported outcome measures (PROMs) are lacking. PROMs are a powerful assessment tool, and standardised definitions of adverse events and functional outcomes should be a priority of future research. PATIENT SUMMARY: We looked at all studies published on genital reconstructive surgery from 1950 to the present day. We assessed each surgical technique and their associated complication rates, sexual and urinary function outcomes, and how they were reported. We found the evidence to be low and weak. We suggest more robust ways of reporting complications, and the impact on patients' quality of life should be investigated.