Hello my name is Gladys Ng. I'm a
reconstructive urologist here at the
David Geffen School of Medicine at UCLA
and today we're going to talk about
genital gender affirming surgery
specifically vaginoplasty
transition from male to female
some considerations before and after
surgery as well as the surgery itself so
some of some of the items we're going to
talk about today or are its what what is
going back to the basics what is gender
genital gender affirming vaginoplasty
criteria for vaginoplasty as well as
preparing for a vaginoplasty the
surgical overview and some relative
anatomy and terminology and some
post-operative care so go back to the
basics what is gender affirming
vaginoplasty it is a trans feminizing
male to female procedure using the natal
male genitalia to create a functional
and/or aesthetic vagina there's kind of
two options a vaginoplasty with a canal
for penetrance intercourse and then a
vaginoplasty without a canal or vulva
plasti form or for the appearance we'll
focus a little bit more about the full
vaginoplasty with the canal today's talk
what are the goals of an Adreno plasti
it's basically to attain an appearance
of indistinguishable from from other
women and although there is no real
uniformity of appearance and in the
vagina the vuelven insists woman it's
also to create functional goals
retaining erotic sensation as well as a
canal if desired for for penetrative
intercourse and the benefits are that
after surgery you can have decreased
secondary benefits are decreased hormone
requirements because the testicles are
removed leading to no production of
testosterone so you don't need blockers
anymore after surgery and it just helps
with better aligning your your gender
identity with your body to make you feel
more comfortable and you can feel a lot
a lot of patients feel a lot of very
much comfortable after this procedure
for that reason okay so some of the
criteria for for doing surgery kind of
falls from the world professional
association for transgender health this
is the International Organization or so
Association for health professionals it
was first founded in in the United
Kingdom under the Harry Benjamin
foundation he was one of the first
physicians and inner chronologist that
treated patients with gender dysphoria
and soon this organization organization
grew internationally into a big
Association were there they committed to
ethical as well as safe treatment
healthcare treatment for transgender
patients so some of the criteria
specifically for gender genital surgery
is that there's their needs there's
documented documentation of gender
dysphoria and keep in mind these
criteria are not to serve as barriers or
our diagnostic tools in any way it's
it's just that the surgery itself is
just it's it's irreversible
so none other another criteria is to
have capacity to make informed consent
for treatment you have to be of a legal
adult age as and then some kind of real
life experience with 12 continuous
months of hormone therapy as well as 12
continued tanja continuous months of
living in the gender role and then some
supportive letters of assessment from
some of your health care professionals
that have been revolved in your care
relate to you know support your progress
in in the the hormones and them and how
the transition has been and then also
making sure that there's no other
medical major medical conditions that
would that would lead to bad outcomes
from from surgery itself so making a
decision for for vaginoplasty it genders
genital surgery can be complex and
really before coming to the surgeon you
wanna you want to essentially ask
yourself as you all know
is this surgery essential to you to
becoming feeling as a whole and
integrated person and talking to a
surgeon in the consultation as I do with
my patients won't help you make that
decision but certainly we can talk about
the procedure and the surgery itself the
risk and what it involves the procedure
how much time involves you know the
whole process itself the risk and
benefits and and possible complications
to any kind of surgery that kind of help
you make that decision as well okay so
getting to to know your surgeon is very
important and that's why intern meeting
patients I like to like to get to know
them on a more personal basis understand
their medical and social conditions as
well and helping them make this
transition and also talk talking about
them what their concerns about the
functional and also aesthetic concerns
about the whole reconstructive surgery
in and of itself so this is all very
important and very important prior to
the date of surgery to meet meet your
surgeon and have have these have these
conversations I also like to discuss
because it does it's infertility is a
result of the surgery itself discuss
reproductive options at that time you
know some some patients may have already
have children have their own children
but for those that have not there are
options out there such as banking sperm
or if further technologies are needed I
have health care other providers that
are specialist in fertility that that
I'm happy to send my patients to that
can discuss options of it if you do
choose to do any kind of sperm banking
sometimes the the requirements for the
hormones may be less or may need to be
decreased in order for production but
this is also when we can discuss during
the consultation itself the other thing
to consider in choosing a vaginoplasty
is the timing of things it does
we do require it is about a four to five
hour surgery on average we do need some
preoperative workup before we'll discuss
it later on the prison
tation in usually in the hospital for
like five to seven days and recovery
takes about eight weeks and during this
time period you're in the hospital we
take care of everything we kind of show
you how to take care of yourself
afterwards but when you go home there's
a little bit of a dilation scheduled
we'll talk about that in a little bit
but you also want to have the support of
family and and your partner as well and
helping you take care of things and
we'll also talk about a list of items to
to get to have on hand prior to coming
into the hospital before surgery once
once you just pop the side upon the
surgery itself so the preparation for
surgery and these I mentioned these
specific items because it takes a little
bit time to set in it's not something
that you kind of choose the day before
the night before surgery and so it's
good to speak about it because typically
we ask patients to stop estrogen izing
hormones about six weeks prior to
surgery and this is for the reason of
decreasing the risk of deep venous
thrombosis or blood clots forming in
your in your in your veins that could be
potentially fatal if they progressed to
the lungs and so we want to decrease the
risk of all of that so we have the
patient stop hormones at that time the
Estrin izing hormones at that time six
weeks prior to surgery itself once the
date has been obtained and you know you
can be started up about two weeks after
surgery once you're a little bit more
mobile but you know you also have to
keep in mind that there could be hormone
because the hormone changes there could
also be mood swings that can be
associated with being off these hormones
if you are smoker
you prefer that you stop smoking
altogether but but definitely eight
weeks before surgery then the reason is
that this can also increase your risk
for the blood clots that I just
mentioned but also when we're using the
skin tissue to create the canal the
blood supply is very important and
smoking is is something that can affect
the the health or the outcome of the of
the vaginal canal in terms of using the
skin to to to reconstruct it
and then the body mass index of 30
meaning that it typically means obese if
you're 30 and above and it's just more
tissue to heal more more chances for
infection and it's also in the groin
area or in the area in between the legs
where the surgery is being performed it
can also affect the ability to bring the
tissues together to for the more
cosmetic part of things but if it's if
you know if there's too much tissue
meaning subcutaneous tissue or you know
a fatty tissue then it may be a little
bit harder to do reconstruction but you
know that's something that can be
assessed during the consultation itself
with a surgeon sometimes it depends on
where the fat is also distributed but
typically 30 and below is what we'd like
to go by in terms of criteria and then
it's good to understand that after the
surgery you're you're there's going to
be a lifelong commitment to dilation of
the vaginal canal because we're using
skin tissue or bits of skin tissue to
create that cavity but to put it you
know initially after surgery is going to
be a little more intense it's almost you
know almost three times and we'll talk a
little bit more about detail about that
a little bit but you know to put in
perspective in about a year's time it's
about two or three times a week and if
if you're having penetrative intercourse
then that can switch them for dilation
schedule so it's not it's not that
cumbersome but it is something that
you'd have to continue on for the rest
of your life to keep the vaginal canal
open and then the hair removal since we
do use squirtle scrotal versus penile
skin or some around there or a
combination of both do you three the
canal hair removal either by laser
electrolysis takes some time to be done
part of the date of surgery we usually
give patients on average about you know
four to six months so that's something
to keep in mind then in planning
so this is just a list of items that I I
asked patients to purchase prior to
coming in for their surgery so that
after your surgery when you're when
you're discharged home you're not on a
scavenger hunt to to find all these
items with a fresh room and just fresh
wound and feeling kind of under the
effects of you know just having a major
surgery performed so usually like papers
patients do have on hand some
water-based lubrication and initially
when you're dilating three times a day
it's good to have as much lubrication as
you need to kind of to to ease the
dilator in and get a sense of things as
you get more proficient you may not need
to use that much Lube but just to have
on hand it's better to map have more
than not enough initially also some
disposable under pads because it could
get messy as you dilate and then also
douche to clean the canal dilators we
ask that that the patients purchase them
before the surgery itself I will show
you a picture of them there's various
sizes and various types we have
particular ones that we we suggest also
a douche as well and that helps clean
the cap helps to clean the cavity some
paper towels a good stock of paper
towels some strong absorbent kind some
bacitracin antibiotic ointment to put on
the suture area some feminine pads and
the best is the ones that are cotton
lines just because the sutures are still
fresh and it'd be just more comfortable
and then also some throwaway large loose
Underpants because they could get soiled
during this time period as you heal and
then some and then a handheld mirror
because this will help you kind of
understand your anatomy as you get used
to your Anatomy will teach you all this
but this takes some time to kind of
settle in after surgery when you're on
your own after discharge from the
hospital so kind of what are that what
are the main components of a
vaginoplasty now we're going to talk
about the surgery itself there's really
six main components one is the penectomy
or or what that means is removal of the
penis penis shaft the erectile bodies
the orchiectomy
which we do on both sides which is
removal of both testicles this is where
the testosterone was produced and this
is this is where after it's pretty
removed there's no more no needful for
testosterone blocking hormones because
of that the vaginoplasty portion which
we're just talking about creating the
vaginal canal using either skin or
scrotal skin the clitoral plasti which
is create using the portion of the head
of the penis as well as the nerves to
the head of the penis to create the
clitoris I'll show you a picture of all
this it's kind of hard to imagine and
then the original plastic portion which
is where we shortened the urethra and
reposition it so that you'd have to sit
down and urinate from here on out after
the surgery is performed but is
shortened also creates more of a pinkish
appearance more of a vulva appearance
that sits below the clitoris and then
finally the labia or the vulva which is
the outward external skin appearance of
the the vaginoplasty and this is the
creation of the lips of the vagina and
they the external appearance of the
vagina as I just mentioned and that's
using the skin so the the most standard
way of creating a vaginal canal just
just want to talk a little bit about
creating the bedroom can now itself is
using the penile skin the skin of the
penis but kind of inverted inwards like
a skin graft and that's why the whole
you know keeping healthy and no smoking
is important as because it's basically a
skin graft and in the area that we
create for the skin to to to take into
so the benefits is that the penile skin
is relatively elastic and and it's
hairless and less likely to contract on
itself and as Ana has really good pretty
good blood supply the thing is if that's
small or there's error or from being on
estrogens or if patients have are
circumsized which is non common then
there's just less skin to work with
there's then there's also a combination
and a penile and scrotal skin using the
skin of the penis as much as you can as
well as using the other side of the
scrotum or
flap of the graft of the scrotum on the
top side we can use that to augment the
canal itself and basically the benefits
is giving extra length and width to the
Badger to canal and then because it's
you're still using the the penile skin
there's less a tightening of the
entrance of the vagina disadvantage is
that because we're using scrotal skin
then you'd have to use hair hair removal
and sometimes depending on how that flap
is created for the scrotal skin you can
you you may be a little bit risk of
prolapse in terms of the canal itself
and these are all things that you want
to discuss for your surgeon during
consultation as they look at your
anatomy and look at the skin and see
what there is to to work with so this
picture is a picture of the female
anatomy itself it's this female and the
reason why I show it is just I want to
show we're relatives structures are and
how how they're similar to what we what
we do in the reconstruction itself so
you can see that the clitoris sits here
on the top the urethra is a little bit
below it the vaginal canal is here in
the city male and we reconstruction will
be in the in the in our reconstruction
will be a little bit lower here we don't
touch the anus part here so the labia
majora is here and this is what we also
kind of create and the labia minora is
the inner lips and sometimes that may be
more difficult to create depending on
the amount of skin that is present okay
now going to the male anatomy there's no
skin on this picture a skeletonized
picture so typically what we use is the
this part of the the head of the penis
this is what we use to create the
clitoris and the nerves that kind of
course along here and the rest of the
shaft is removed and then the urethra
that sits right below this is also
shortened so the clitoris sits right
here on the top on right at the base of
the pubic bone which is right here and
then the urethra is opened up up to that
area so it gives you more of that pink
vulva appear
and then this is the anus where we don't
touch again but in between the space
right here is where we create the
vaginal canal so given you another
perspective a cross-section picture you
can see that this is removed this is
where the blood and the prostate is and
this is the the the anal opening or the
were leads to the to the rectum of the
bowels and this is the space that we put
the the vaatrik rate for the vaginal
canal so in this picture you can see
this is the space right here where we
create the vaginal canal I'll give you a
better close-up picture in the next
slide so you can see that the space that
we create was the anal opening again
okay which we don't touch and then this
is the space between the back of the
bladder and the prostate and the rectum
top and front on the rectum and this is
the space that we create where we put
the skin into to create the vaginal
canal but you with either penile skin
itself there's enough or penis grow to
skin itself to create this this canal
I'll just I'll just put in a word about
intestinal vaginoplasty as well that's
not common and it's really not the first
resort to go to because there's a lot
more to do to to use to a lot more organ
spaces to go through it you use the bow
to bring it down but in select cases
which you can discuss with your surgeon
on your consultation you it can be it
may need to be used and and if there's
not enough skin at all okay but but
typically most common and standard is
using the penile skin and version
technique so then here is where the
clitoris has been made and this is the
urethral opening as I mentioned and and
this picture also shows in the creation
of this and performing the vaginal class
sees there's always a concern you know
for complications with as with any
surgery of you know lower and
surrounding organs and tissues and right
behind right next to the vaginal canal
is the rectum itself as well as the
prostate and the bladder it is also
worth noting that the prostate is not
moved in these vaginal classes so in
older patients if there's any concern
for prostate cancer prostate cancer
screening still needs to be done
especially in older patients and if
there's any urinary problems the
prostate could over grow within the
channel itself causing urinary symptoms
so those are things to think about
because the prostate is not not removed
okay all right so post-operative care as
I mentioned earlier that you being you'd
be in the hospital for five days and
it's really for that for that grafted
tissue that the skin to take and during
those five days we'll have packing in
the canal and it's just to allow the
blood vessels to realign from that skin
down to the cavity itself and then on
the fifth day we will remove the usually
I will remove the vaginal packing itself
and also teach the patient how to dilate
and Uche this is just one example of
diet of a dilator set and we would go up
sequentially start with a certain size
for ten minutes and then you go up to
another size for fifteen minutes and
we'll start with that kind of moving
sequentially up to whatever's
comfortable for you there are other
dilators as well but this is just one
example of one and then the catheter
will also be removed on that fifth day
just because you'll be more mobile and
kind of and you can you know what we'll
make sure that you can urinate with no
difficulty so during that time we'll
teach you how to dilate and also how to
clean the canal ISM as well with it with
it with the addition device bulb and
then once you go home from the hospital
we'll set up what your post-operative
return to clinic schedule is at that
time so afterwards your hospital stays
is usually about sorry six to eight days
not weeks please excuse that error up
there and the recovery time I'd say
about eight weeks just because for the
first eight eight weeks
ask that patients do dialate three times
a day
and that's why I may be difficult if
you're you know and you don't want to be
running our going on the hustle-bustle
of going to work and stuff like that so
it's it's better to just take that time
off from surgery onwards to the eight
weeks afterwards just to take that in
consideration because I do ask the
patients to dilate three times a day
just to maintain the canal and then it
gets less intense after that and then we
usually see you after it and then we can
kind of go down maybe two times a day
and this is an example of a in enema
douche and it's made out of medical
grade silicone because it's soft you
don't want anything that's hardened and
you know it can have sharp edges so this
is soft and pliable but basically you
fill this up with mild soapy water and
you just after you dilate you you insert
the enema and and clean the canal and
that's just to maintain that the hygiene
in in this and the vaginal canal the
skin lined federal canal okay so with as
with any kind of major or any kind of
general to surgery or majors or a
complex surgery there are potential for
complications and some worse than others
but more common on the ones listed here
you can have one changes to the area
below just because it's also a dependent
area meaning sometimes you can have
collection of blood like a hematoma or
sometimes it may look the sutures may
come undone but everything heals up on
its own it just take it
taking it takes a matter of time and
some wound care and that's why we you
know we see you in the clinic and we ask
that you stay in within the vicinity and
each surgery may be different but I ask
that my patient stay within the vicinity
of Los Andres for at least four weeks
afterwards so I can make sure that
things are going well and I usually see
my patients with them one or two weeks
after surgery to make sure that dilation
is going well and the wounds are healing
well enough but revisions I'm sorry so
the wound changes can be common and it's
usually just wound care really need to
get back to the operating room to fix
those things
longer term if things are not you know
what you expect and then revisions can
can be done and they're usually not in
minor surgery minor genital surgery
and initially after surgery the urinary
stream when the catheter comes out could
countess play to a certain side or spray
all over but that's just because their
sutures and the urethra itself to kind
of tack things up and keep things open
so that was usually self resolved that
could be expected also because of the
the section four to create the clitoris
we dissect the nerves often off the
shaft of the of the the penis shaft
sometimes the nerves can be in a sense
shocked from that dissection and it
could be numb for up to 18 months
afterwards so it may take some time and
also has initially when the t-shirt of
the ball swollen think they're gonna are
you're not you may not have sensation as
you leave the hospital okay so it just
may take some time to get back to to
functioning again and then there could
be post-operative pain which will manage
with pain medications and pain control
and then also sometimes minor bleeding
and that's why I asked you you know for
you to purchase those cotton panty pads
or panty liners so that because some of
the wounds are still healing and and
depending on movement it could some of
those sutures could could you know still
be fresh and and and this gaps can come
off and cause a little bleeding and so
and and so but a lot of its just wound
care and we can certainly take care of
that in the clinic when we see you back
unless I wanted to show when I was I
wanted to show this picture because you
know it kind of gives you shows you the
variability of the vaginas out there and
this is created by an artist in in in
Brighton United Kingdom by the name of
Jamie McCartan McCartney he consented
woman and did a body casting of all the
vaginas and and it just shows the
variation in in in all the vaginas are
there out there there
one standard look and that's why you
know me also meaning the surgeon to kind
of talk speak about what do you expect
what you would like the external
appearance with and also with what's
your anatomy that you have is very
important but just to just to show there
isn't one standard conforming look to
the vagina to the vagina and and really
the vagina is the canal this is more the
vulva itself so lastly general de
surgery is is as likely life-changing
surgery but it's just one part in your
transitioning care and so I wanted to
say that I do work with a whole team of
physicians in in the UCLA gender health
program and every in not just physicians
itself there's all there's all other
supportive health care workers and
members and everybody's dedicated and
and fabulous in in in supporting care
for transitioning for transgender
patients and so here are some of the
services that our program offers other
specialty surgical services as well as
just hormone I mean hormone therapy and
also primary care as well and also case
management and care coordination and so
I want to thank you very much for your
attention today
um and we look forward to helping you we
want you to feel the most comfortable
being you thank you very much
