title: Non-grafted Vaginal Depth Augmentation for Transgender Atresia, Our Experience and Survey of Related Procedures.
abstract: BACKGROUND
  Neovaginal atresia especially following male-to-female transgender vaginoplasty is a distressing concern. A pelvic space must be re-created. Traditionally, an epithelial or mucosal lining is employed to cover the space. However, in our series of 18 patients, a non-grafted approach has been equally efficacious, as previously described by others.
  
  
  OBJECTIVE
  To follow the outcome of male-to-female transsexuals undergoing secondary depth enhancement without use of graft or flap.
  
  
  METHODS
  Patient selection included two operated on elsewhere, one of whom had a lower abdominal skin graft, and the remainder done here using an inverted penile skin flap supplemented by a scrotal graft extension as needed. The time lag from primary to revision surgery varied from 5 months to 23 years, average 3.7 years. The fascial plane of Denonvilliers was reopened and packed for 7 days to facilitate maintenance of a pelvic space. Patients are requested to perform serial self-dilations with a stent set indefinitely to maintain patency and procure additional depth. Immuno-histochemistry staining was performed to demonstrate estrogen receptor (ER) presence in male genital skin. Estrogen cream may be utilized to facilitate wound healing. Main outcome measures were post-operative depth results and Female Sexual Function Index (FSFI) scores. Several attempts were made to contact all patients for completion of a FSFI. Ten out of 18 responded.
  
  
  RESULTS
  Following revision of the pelvic space, static depths increased two-fold on average, from 2.4 in. (6.2 cm) to 5.0 in. (12.7 cm). The FSFI domain scores (of desire, arousal, lubrication, orgasm, satisfaction, and pain) were all mid-range or above. Full scale FSFI scores (compilation score) averaged 23.4 (range limits 2-36). Histologic staining showed the presence of ER in genital skin of all genetic males tested regardless of estrogen usage and perceived gender.
  
  
  CONCLUSIONS
  Given adequate development of the rectal-vesical space and preservation of that space with self-dilation, epithelialization will ensue providing sexual gratification for patient and partner (as per patient).
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors.affiliation: Division of Urology, Columbia University at Mount Sinai Medical Center, Miami Beach, FL, USA, Reed@srsMiami.com.
authors.forename: Harold M
authors.initials: HM
authors.lastname: Reed
authors.forename: Rafael E
authors.initials: RE
authors.lastname: Yanes
authors.forename: Joan C
authors.initials: JC
authors.lastname: Delto
authors.forename: Yumna
authors.initials: Y
authors.lastname: Omarzai
authors.forename: Kailee
authors.initials: K
authors.lastname: Imperatore
mesh_terms: D000328:Adult; D015331:Cohort Studies; D019317:Evidence-Based Medicine; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000503:physiopathology / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000379:methods*; D012086:Reoperation / Q000379:methods; D012189:Retrospective Studies; D018570:Risk Assessment; D057829:Gender-Affirming Procedures / Q000009:adverse effects* / Q000379:methods; D015626:Tissue Expansion / Q000295:instrumentation / Q000379:methods*; D015625:Tissue Expansion Devices; D014189:Transsexualism / Q000601:surgery*; D016896:Treatment Outcome; D014621:Vagina / Q000503:physiopathology / Q000601:surgery*