What urologists need to know about male to female genital confirmation surgery (vaginoplasty): techniques, complications and how to deal with them.

Vaginoplasty is the most commonly performed genital surgery for gender affirmation. Male-to-female (MTF) patients are roughly four times more likely to undergo genital surgery than female-to-male (FTM) patients. Penile inversion vaginoplasty is the most common technique used today, although there are also lesser used alternative methods including visceral interposition and pelvic peritoneal vaginoplasty. In general, outcomes are excellent, and many of the complications are self-limited. Most surgeons performing genital surgery for gender dysphoria adhere to the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. Currently, there are no absolute contraindications to vaginoplasty in a patient who is of the age of majority in their country, only relative contraindications which include active smoking and morbid obesity. Important complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in excellent surgical candidates by skilled surgeons, vaginoplasty can be a rewarding surgical endeavor for the patient and surgeon.