Surgical Therapy after Failed Feminizing Genitoplasty in Young Adults with Disorders of Sex Development: Retrospective Analysis and Review of the Literature.

Background: Secondary vaginal stenosis may occur after reconstruction of genital malformations in childhood or after failed vaginal aplasia repair in adults. Aim: This study focusses on the results of the surgical treatment of these patients in our multidisciplinary transi-tional disorders/differences of sex development team of pediatric surgeons and gynecologists. Methods: A retrospective analysis was carried out on adult and female identified disorders/differences of sex develop-ment patients with vaginal stenoses treated between 2015 and 2018 in a single center with revision vaginoplasty. The underlying type of malformation, the number and surgical techniques of vaginoplasties in infancy, techniques of revi-sion of the stenotic vagina, vaginal length and caliber, possibility of sexual intercourse, and temporary vaginal dilatation. A review of literature with regard to recommended surgical techniques of revision vaginoplasties was accomplished. Outcomes: To describe the surgical technique, the main outcome measures of this study are vaginal calipers after revision vaginoplasty as well as ability for sexual intercourse. Results: Thirteen patients presented with vaginal stenosis with a median age of 19 years (range 16-31). All patients had one or more different types of vaginoplasties in their medical history, with a median age at first vaginoplasty of 15 months (0-233). Underlying anatomical conditions were urogenital sinus (n = 8), vaginal agenesis (n = 2), persis-tent cloacae (n = 2), and cloacal exstrophy (n = 1). The main symptoms were disability of sexual intercourse in 13 patients due to stenotic vaginal tissue. The most frequently performed surgical technique was partial urogenital mobilization with a perineal or lateral flaps (n = 10), followed by bowel vaginoplasty (n = 2), in 1 patient a revision vaginoplasty failed due to special anatomical conditions. In a median follow-up of 11 months, all but one patient presented with physiological vaginal length and width, and normal sexual intercourse in those with a partnership. Clinical Implications: Perineal flap with partial urogenital mobilization should be considered as a treatment of choice in severe cases of distal vaginal stenosis and after multiple failed former vaginoplasties, while bowel vagino-plasty should be reserved only for cases of complete cicatrization or high located stenosis of the vagina. Strengths & Limitations: The strength of this study is the detailed description of several cases while the retro-spective character is a limitation. Conclusion: In patients after feminizing genital repair, perineal flap with partial urogenital mobilization provides a normal anatomical outcome and allows unproblematic sexual intercourse. Copyright (C) 2021, International Society of Sexual Medicine. Published by Elsevier Inc. All rights reserved.