Chapters Transcript Video Advances in Vaginoplasty - Techniques, Outcomes, and What’s Next Laura M. Douglass, MD Um, good morning, everyone. I'm excited to welcome Doctor Laura Douglas, um, here from Temple, speaking to us this morning about gender affirming surgery. She's an associate professor of urology at the Lewis Ketz School of Medicine at Temple and the co-director of the Gender Affirming Surgical Program. Doctor Douglas completed a trauma and reconstructive fellowship with Dr. Michael Metro at Temple, um, and she focuses on her practice in adult gender affirming surgery. She has been recognized for her dedication to health equity and compassionate patient care. Earning awards such as the Patient Experience Award in 2025 and the Health Equity Leadership and Social Justice Award in 2022, as well as the 2025 Women in Medicine and Science Rising Star Award. Doctor Douglas, thank you for joining us. I'll let you get started. Perfect. Well, thank you, Doctor Horoitsky for inviting me to speak with you all. Um, we trained Doctor Horoitsky here for her reconstructive virology fellowship. So thank you all for training her so well, and we were happy to Send her back to you all. Um, she was a great fellow and she's someone that I call myself, uh, now, and I have questions about urethroplasty, and so, uh, we're very proud of Doctor Hoitsky. So, um, as, um, as Doctor Hoitsky mentioned, I'm Laura Douglas, and I will be talking to you all about advances in vaginalplasty techniques, outcomes, and what's next. So I don't have any disclosures. The objectives for this morning's talk is to review the current techniques and outcomes in vaginalplasty. Specifically, we'll review penile inversion vaginalplasty, robotic peritoneal flat vaginalplasty, and intestinal vaginalplasty. And then we'll discuss some exciting future directions. We'll talk about revision vaginal plasty, the feasibility of staged vaginalplasty, and some other potential future direction. So just to give you all just a crash course on vaginalplasty, I'm just gonna review the procedure itself and then we'll delve into each of the different techniques a little bit more. So, what is vaginalplasty? So, vaginalplasty is the creation of the external female genitalia or the vulva and a vaginal canal. So, the creation of the vaginal canal is specific to The term vaginalplasty. But when we say vaginalplasty, we're typically talking about all the procedures that are rolled into one here. So, of course, if the patients haven't already had bilateral orchiectomy, we're doing orchiectomy, we're creating the vaginal canal, and then we have to line that vaginal canal with epithelialized tissue so that that space doesn't just seal back up. So there's a variety of different tissues that we can use to line the canal. You can use a combination of penile skin, scrotal skin graft, additional skin grafts from the lower abdomen, groin or thigh. You can use peritoneal flaps, and you can also use intestinal segments. Vaginalplasty also includes the penile disassembly. Um, you have the preservation of the dorsal neurovascular bundle, which is important for clitoral sensation and ability to orgasm. We're also removing the erectile tissue. We're creating a clitoris using the gland's penis. Uh, we are shortening the urethra during erythroplasty, and then, of course, creating the labia minora and labia majora. Some of the surgical step highlights. So I think this is a great teaching case. I love this case for teaching uh with the residents because it's a combination of many known neurologic surgeries and you're seeing the anatomy in a way that you'll never see um in any other case. So, of course, we're doing orchiectomy. The perineal dissection is the exact same dissection as you would for urethroplasty or for um an artificial urinary sphincter. The canal dissection is similar to perineal prostatectomy, which of course isn't done. As often anymore, um, but we borrow a lot from the perineal prostatectomy literature for this portion of the surgery, the urethroplasty and the penile disassembly, um, is akin to a traditional panectomy, but also, um, one of the ways we can. And preserve the dorsal neurovascular bundle, is elevating it within bucks fascia of the corporal bodies just like we do for plaque incision grafting. So it's really great to see, um, a lot of, um, a lot of different neurologic cases. And also, um, when you do the corpootomies in the penile disassembly, it's really great teaching for penile prostheses that you're seeing the entire corpora from tip. Um, to coral dissection. So, um, really great for just understanding the anatomy. So some of the surgical step highlights. So first is the skin incision planning. So, um I've learned a lot from my plastic surgery colleague in terms of flap skin flap design. Uh, the scrotal skin graft is then defatted and de-epilated on the back table. So most vaginal plasty techniques have some amount of skin within the vaginal canal, and because of concerns regarding hair growth within the vaginal canal, most surgeons require some amount of permanent hair removal plus or minus intraoperative follicle scraping or cautery to minimize hair growth. Because if hair does grow in the vaginal canal postoperatively, it can cause issues like odor and drainage and getting concretions. It's really, really difficult to remove this hair postoperatively. So, for the canal dissection, um, the perineal dissection, you're going to be releasing the central tendon, um, uh, releasing the central tendon from the vulva urethra and dissecting towards the apex of the prostate. And this is where the rectum is most tethered, and the risk for injury to the rectum is the highest here. So, the goal is to then get in between the anterior and posterior leaflets of the novia, but this can be very challenging from the perineal approach. And as I mentioned earlier, many will often refer to the perineal prostatectomy literature. There's actually um a chapter in Glen's neurology uh that talks about the surgical technique, uh, when we're discussing this dissection. There's a great video on YouTube um through AUA University. Um, uh, let me see if I'm gonna try to share this with you all. Um, so this is from the OHSU group and just gonna show you some highlights here just to kind of understand the space and, and what it looks like when you're in the vaginal canal. So this, this is straight off of YouTube through AUA University. So I'm just gonna play just um some little The white Mhm We can't hear the video like audio, but if you wanna just kind of describe what they're seeing, that'd be great. Yeah, so, um, what you're seeing is the ventral rectal fascia right here they're getting in between the leaflets of the, uh, anterior posterior leaflets of the noviase, and this is the prostate here. And then I'm just gonna show you one other. Portion here. So, um, here you're looking at the anatomy of the canal after the canal dissection is complete. And so this is the ventral rectal fascia here, and this is the labator anni, the pelvic floor muscles that typically you have to release to widen the canal, um, and potentially make dilations a bit easier. And so this is a great view of the anatomy here. This is the bladder. This is the prostate here, and this is the bulbar urethra. Um, that's a really nice dissection. I'll admit that, uh, I typically have not seen the anatomy so beautifully, um, outlined here. Um, this is, uh, Dan Doogie at OHSU here. So that, that's a great video, um, to refer to when you kind of want to understand the, the canal. So, uh, moving on after canal dissection, um, we have the penile disassembly where the urethra is dissected off the corporal bodies. Then we perform the bilateral ventral corparotomies and you're opening up the corpora from the tip all the way down to the corral dissection. And then we're removing that erectile tissue. We use a periosteal elevator to kind of scrape this erectile tissue, um, Off the inside of the tuica of the corpora, and then, uh, of course, preserving the dorsal neurovascular bundle within the tuica. So this particular technique, um, we're really staying away from the dorsal aspect of, um, the dorsal neovascular bundle to decrease the chance of having any sort of injury. As I mentioned, the other technique you can use is more of a traditional panectomy and elevating the dorsal neurovascular bundle, um, with bucks off of the corpora, but I find that it just, it takes longer. Um, I think there's a higher risk of injury to the dorsal vascular bundle with this technique. And as we know from our Pironi's data that there's definitely, you know, some neuropraxia that can happen just with manipulation of the dorston avascular bundle so directly. So, um, not my preferred technique. And then there's creation of the clitoris, the clitooplasty, there are various shapes and techniques, um, that have been reported. The propecial collars used to make a clitoral hood, and the clitoris is typically affixed with the level of the insertion of the abductor longus. You don't really want the clitoris to be above the abductors, because when the patient's legs are closed, you want the clitoris to be concealed, and you don't want it to be kind of protruding anteriorly like a phallus. And then moving on to the urethroplasty, we're satulating the urethra ventrally and we're taking that all the way down into the bulb, and you want to take it down enough so that the urine stream is kind of coming out straight, so that when the patient is sitting, the stream should be going directly into the toilet bowl. The spongiosum is the bolt, and then, of course, you do have to oversew these edges um for hemostasis. And then the penile skin and the scrotal skin graft, um, are then inverted into the vaginal canal, and you have to make an incision in the penile skin to expose the clitoral urethral complex. Then all these skin edges have to be matured to the clitoris and the urethral plate. And then, of course, you have the labiaplasty, which is creating the labia majora using the remaining scrotal skin and the, the scrotal subcutaneous tissues and fat, and creating the labia menora. And we're gonna talk a little bit more now about the various techniques, uh, that really, the techniques differ in the tissues that are lining the vaginal canal. So, first, we'll talk about penile inversion vaginalplasty. The canal is lined with a combination of penile skin, scrotal skin graft, plus or minus any extragenital skin grafts if needed. So the entire canal here is lined with skin. This is the most common technique and it's a good, a good technique for patients who are otherwise not good candidates for abdominal surgery. This is a completely pelvic surgery. So for anyone that might have uh a hostile abdomen or have had Uh, various prior abdominal surgeries. This is potentially a good technique for that person. It's more accessible. There are more surgeons that are familiar with this technique. It's lower cost than, say, robotic, which we'll talk about robotics in just a moment. But some of the drawbacks here is that you really are limited by the available skin. As I mentioned, the entire canal is lined with skin. So for people who have smaller anatomy, who have less skin, you're likely going to need to take extra genital skin grafts having additional morbidity of another donor, a donor skin site. And because the entire canal is lined with skin, there potentially are more issues with hair growth. So hair removal is much more important with this technique, and hair removal for a lot of folks is, uh, is a barrier. It's expensive, it's multiple treatments. Um, so this can be, this can be an, uh, a major barrier for some folks. And it also takes time. It can take months to go through multiple rounds of the hair removal. So, um, that's definitely something to consider. Now, in terms of outcomes of penile inversion vaginalplasty, there's, um, you know, quite a few studies out there because this is the most established technique. So this is one of the largest, um, one of the largest papers. This was the retrospective single institution analysis. And you can see here that in terms of short-term complications, um, a relatively low rectal injury rate, but, you know, definitely not zero. Um, you can see here one of the most common issues, those minor necrosis, having some wound healing issues which, um, you know, by far is the most common issue that we see postoperatively. And then, as well as urinary retention, um, after surgery, we're requiring recatheterization. In terms of long-term complications, we can see some nasal stenosis. Um, we can see stenosis of the vaginal canal, um, and that we can see here that up to a third of patients underwent uh minor cosmetic revisions. This is one of the largest meta-analysis done. They looked at 46 different studies, and across all these studies, the average vaginal depth was 10.7 centimeters. You can see here in terms of um complications, you know, Relatively low, um, about a 10% rate of stenosis, um, of the vaginal canal. But what I really wanted to highlight here, highlight here is the patient reported outcomes that people are quite satisfied after vaginalplasty. There's um a very high overall satisfaction rate, satisfaction with function, the aesthetics, um, about 75% were uh able to orgasm postoperatively. You can see here a 2% rate of regret. Um, so, regret after gender-forming surgery in general is quite low. And, um, and when there is surgical regret, it's not due, typically not due to like the transition. It's typically due to The reason why most of our patients might regret having surgery, the outcomes weren't as expected or there are complications, so people regret having surgery. And just to make things as relative, uh, the regret, the regret for joint replacement surgery, um, in the ortho literature is about 15%. So, um, you know, we see here that vaginalplasty has, um, relatively lower regret. So now we'll talk about robotic peritoneal flat vaginalplasty. The, with robotic peritoneal flat vaginal plasty, the canal is lined with a combination of penile skin. A scrotal skin graft and peritoneal flaps. So this is a great technique for patients who have less skin, who have smaller current anatomy, who have less scrotal skin, penile skin available, because we need less skin to line the vaginal canal. The depth is a bit more reliable here with the robotic technique. We have now entered the abdominal space, so we can kind of control. How deep we want the vaginal canal to be, whereas penile inversion vaginalplasty, we're really limited by the pelvic anatomy and you're taking that canal up to the peritoneal reflection. um, and you don't, you don't want to end up in the abdominal cavity for penile inversion vaginalplasty. So for, uh, our robotic patients typically getting more reliable depth and on the higher range of depth. Um, you know, we're talking, you know, more like 5 inches, um, or more with the robotic technique. It is a newer technique. Um, it was really innovated, um, by Liza at NYU, uh, you know, taking off of a known technique, the baby Dove technique that was developed for vaginal atresia, uh, and cis women, and, um, you know, some of the considerations here is that you need a robotic surgeon, so typically this is a two surgeon procedure and the increased costs associated with the robotic technique. So, um, this is just showing the anatomy of um the uh the peritoneal flaps here. So you have your vas deference and your ureters are the border here of the posterior flap and the anterior flap. Gonna show you hopefully um a great video here um coming from the NYU team here just so you get a better idea of um what's going on during the um peritoneal flap. Can you hear the narration of the video? No, can't hear, hear the narration, but I can see it well. Yeah, so this is um coming under the boar urethra here, um, and They're about to come through. The your genital diaphragm into the abdominal cavity here. So you can see some of that light coming here from the robotic surgeon and then they're coming through and you can see the view from inside, um, from the robotic view. So these are landmarks that I had kind of mentioned that um you have your ureters here bordering the vas deference um in terms of the flap harvest. So this is gonna be your posterior flap and this is gonna be your anterior flap. So the vaginal canal dissection here is just the same as a resus-bearing prostatectomy. Um, so it's a posterior approach, um, and it is very similar. So, in a lot of institutions, the robotic surgeon isn't necessarily a gender surgeon. It's usually their one of their robotic surgeons who learns the technique and has been, um, you know, um, is more of a technician and not necessarily, um, you know, completely, uh, involved with the gender affirming surgery team. Right. And then this is a clip um that's just gonna show kind of the actual peritoneal flaps. So here, um the perineal surgeon is passing the, um, the penile skin and scrotal skin graft, and they're gonna anastomose it to the um to the peritoneal flap. So you can see here is the, the skin graft and um the robotic surgeon is gonna bring these peritoneal flaps down to the skin here. So, in terms of the robotic peritoneal flat vaginalplasty outcomes, so, NYU does have the largest cohort here at this point, um about 500 patients and um this is one of their uh most recent papers kind of going over. For their um outcomes here. So self-reported vaginal death, um, is about 14.5 centimeters and 3.8 centimeters width. There's a low rectal injury rate here. There's a 4% lain bio 3A or greater complication rate. With about half of the patients having granulation tissue within the vaginal canal requiring silver nitrate. And that's one of another very common issue that we see after all vaginal plastic techniques is this granulation tissue, but potentially higher in this, uh, with this robotic technique. I was interested in about some of the urinary symptoms, and the urinary issues. Um, there has been some suggestion, um, you know, some of the data is showing potentially that the robotic technique. May cause some more voiding dysfunction and lower urinary tract symptoms and um one of the groups was actually theorizing that potentially the anterior peritoneal flap harves off of the posterior bladder wall that perhaps were disrupting some of the innervation of the bladder and um potentially causing more um voiding dysfunction after robotic technique. Um, pretty low rate of revision for vaginal death. What I, what I thought was interesting was this 8% of patients were no longer dilating greater than 1 year post-op. And we'll talk a little bit about this more when, when we talk about, um, revisions. And then also coming out of the NYU group, they did in terms of innovation here, originally, they had started off using the multi-port, um, the XI da Vinci. And um in 2018, they switched over to single port, and so they basically went through their data, comparing the, the two different cohorts. And overall, um, the single port had decreased operative time. I think the biggest reason is that the single port allows for both surgical teams to be operating at the same time. With the XI, which is what we currently have at Temple, when you dock the XI, the arms are like right in the face of the perineal surgeon, and so it is pretty difficult to be trying to operate at the same time. And so we try to do as um as much of the perineal work um as we can before, um before we dock the robot because it's just a lot harder to operate, um, at the same time. So the SP platform allows both teams to be operating at the same time, um. The arms are not in your face and so it's a lot easier. And reported improved visualization and mobility within the very narrow pelvic space that you that you're using the SP platform here. And there was no difference in vaginal debt or complication rate. So, um, you know, definitely an area for innovation here, um, going from um XI to SP. So I want to talk about sigmoid colon vaginalplasty for, so for sigmoid colon vaginalplasty, the canal is lined with a combination of penile skin, plus or minus the scrotal skin graft plus the sigmoid colon. The sigmoid colon is the most commonly used intestinal segment, but people have used other um other intestinal segments. It's not a very common primary technique here in the United States. Um, it's really been reserved more for revisions, and we'll talk about that a little bit more when we talk about revision vaginalplasty. And typically exclusion criteria for sigmoid colon vaginalplasty, um, inflammatory bowel disease, a history of any sort of intestinal cancer, any sort of genetic predis predisposition to colon cancer. Some of the benefits of sigmoid colon vaginal plasty, it's good vaginal depth, um, similar to the robotic technique, we're now in the abdomen. And depending on the length of the colon segment that you take, you can establish, you know, pretty good vaginal depth. Um, reportedly a less tendency to atrophy or stenosis because the, um, the sigmoid colon is very well vascularized, uh, with less chance for it to atrophy over time compared to skin or peritoneum. Um, and possibly because of this lower tendency to atrophy, potentially. A lower requirement for dilations, potentially. Um, the sigmoid, um, mucosa is similar to vaginal epithelium and it is self-lubricating, so that might be something that's really important to a patient. But of course, some of the drawbacks here and why I think it never really took off as a common primary technique in the United States are the bowel implications. There's a there's, it's a bowel surgery, there's a bowel and anastomosis, um, it can be malodorous. There can be excessive mucus production, that's typically within the first year or so. Um, and that typically does slow down after that first year. Um, and the, the lubrication and this mucus production is, uh, not related to sexual arousal, so it's just kind of a continuous vaginal discharge. And of course, risk for adenocarcinoma. So, um, this segment does need to be surveyed, um, for colon cancer. These are some photos here, um, of the sigmoid colon vaginalplasty technique externally, you know, the external, um, the vulvoplasty portion is the same. Um, you can see here is the sigmoid colon being brought out um to the perineum. And then here um is the colon, um, has been satulated and is being matured uh to the perineal tissues here. So in terms of the outcomes, this was a retrospective single institution where they looked at both primary and secondary or revision sigmoid colon vaginalplasty. The mean vaginald was 13.2 centimeters, so similar to our robotic peritoneal flap, vaginalplasty cohorts, um, you can see here that there is, you know, um, a relatively High rate of short-term complications here, uh, most commonly um related to bowel, um, uh, bowel complications, and then we see here a 24.4% long-term complication rate here. So, um, and particularly a higher risk for prolapse at 11.8%, which is higher than Any of the other vaginalplasty techniques. But interestingly, there was no significant difference and complications between the primary versus secondary vaginalplasty groups. This is a nice table um in um coming out of the OHSU group where they're just going over the advantages and disadvantages of the different tissues. We talked about skin. It's widely available, but, um, you know, depending on if there's peno scrotal hypoplasia, people with uh less available skin. Um, that can be one of the drawbacks here, the need for hair removal. We talked about, um, peritoneum. Um, it's nice because it's well vascular tissues. It's staying on his pedicles, so, um, they're well vascularized, um, that you don't need as much skin to line the canal, but of course, you've now turned this into an intraabdominal surgery and requires two surgeons and the costs of robotic surgery and of course, um, we just want more bowel here, um. And then again, has some of the benefits of um depth and lubrication, but you can see a lot of these risks here just related to the fact that it is now a valve surgery. So, the key takeaways um here are that there are multiple vaginalplasty techniques, there's no single best technique, and it's hard to compare apples to oranges, and these are all Retrospective, um, in uh retrospective and typically single institution studies. So take everything with a grain of salt here. Um, of course, these techniques should be individualized to the patient, what their goals are, what their history is, um, and their current anatomy. And I think it's really neat to see, um, the innovation in this space here, um, but also considering some of the older techniques like the sigmoid, uh, colon vaginalplasty, which, you know, Um, people hadn't really considered, but it's now kind of making a comeback right now, and we'll talk about that, um, shortly. So, for revision vaginalplasty. So, if a patient loses their vaginal canal for whatever reason, and they decide that they want to have a revision vaginalplasty and have this canal revised to either increase the depth or regain the entire vaginal canal. I think a big question you have to ask is, you know, why did the initial canals know? And for many patients, the cause is multifactorial. It might be related to a lack of understanding. There may have been difficulty tolerating dilations. They can be painful, um, lack of postoperative support, and other psychosocial barriers. So I think it's really important to fully understand the underlying reason for the initial loss of the canal. Before even offering a revision vaginalplasty because otherwise we risk recreating the same problem. And, you know, the next major challenge with revisions is the limited tissue availability. So, by the time patients present for revision, The original penile scrotal skin has already been used or it's been lost with the stenosis of the canal. So this limits the options and may require alternative donor sites for skin grafts or some of these other reconstructive techniques like peritoneal flap or sigmoid colon. Um, One of the limitations of primary peritoneal flat vaginalplasty, so using the robot and the peritoneal flaps for, for the initial vaginal plasty, is that the skin and peritoneum have already been used. Although some people see the peritoneum as a great bailout. You know, you do penile inversion vaginal plasty, they lose the canal, you still have the peritoneium available. Um, but if you're going straight to the robotic technique and you're using the peritoneum, if The canal stenosis, what tissues you have available. Um, some groups have published where they've actually gone back in and the peritoneum has, uh, re-epithelialized essentially and, you know, taking a secondary peritoneal, um, flap harvest, um, and, um, or considering sigmoid vaginalplasty, um, for patients who've had primary robotic. Um, peritoneal flat vaginal plasty. So that's, that's one of the criticisms of, um, of the peritoneal flat technique. Another major issue is the loss of normal surgical planes. So the previous operations, there's now fibrosis, the anatomy is distorted, which means when we're trying to get through this space again, that we're dissecting through d scar tissue rather than having these plants anymore. This definitely makes it more difficult and potentially increases the risk of injury. Um, to the urethra, the bladder, and the rectum. So all of these structures are potentially vulnerable as you're trying to get through, um, this scar tissue, and patients should be counseled on these potential increased risks when considering a revision vaginalplasty. And finally, even when the revision is technically successful in the operating room, these patients remain at elevated risk for secondary vaginal stenosis. There, there might be poor tissue quality, there's increased scarring and reduced elasticity of these tissues. We're trying to excise some of that scar tissue, um, and releasing as much of that scar tissue as possible without increasing the risk of injury. Um, something else, um, and the same underlying barriers to dilation, um, that contributes to the first failure may still be at play. So, all these factors highlight why careful patient selection and really working on preoperative optimization and especially working with pelvic floor physical therapists. I think most centers require their patients to go see pelvic floor physical therapists both before and after surgery to really help with the dilations, um, super important. To optimize these patients, and having really good postoperative support are really critical for getting patients the best outcomes. So, in terms of revision vaginalplasty, um, there's some um emerging data on the uh different potential techniques for revision vaginalplasty and these outcomes. So, one of the first papers, um, one of the first papers here is again coming out of the NYU group. Um, they, um, started doing robotic peritoneal vaginalplasty. So, um, this was their initial. Um, uh, their initial paper where they looked at 24 patients. Um, all these patients had previous penile inversion vaginalplasty with stenosis or absent canal. And the average procedure length is about 5 hours, and they are able to get 13.6 centimeters vaginal depth, which is great, which is typically, um, you know, which is one of the goals. There was no rectal injury and there was only one OR take back for canal, OK. And then trying to compare some of the different revision vaginalplasty techniques, so peritoneal flat versus sigmoid colon. So this is, you know, sigmoid colon has made a bit of a comeback here. Um, recently, um, because of, uh, the need for revision. So as, as we're doing more and more vaginalplasty, primary vaginalplasty here, um, we are seeing an increased demand for these revisions. And, um, and so sigmoid colon has seen a little bit of uh of a resurgence here. Um, so, Uh, this group, uh, it was a retrospective single institution. All these patients had primary penile aversion vaginalplasty and had stenosis, and they developed this, um, algorithm here, um. Using uh going off of the current vaginal depth, and they used 7 centimeters depth as a cutoff. So if the current vaginal canal was greater than 7 centimeters, then they were offered peritoneal flat vaginal plasty, and if they had less than 7 centimeters in intestinal segment, um, vaginal plasty or sigmoid colon vaginal plasty was offered. And You know, this, this kind of cutoff here is, is done because of some of the technical challenges of the peritoneal flap. So this is, it's a peritoneal flap, and um depending on how aggressive the mobilization of this flap is, the flaps can only reach so far. You may hear the term peritoneal pull through used and peritoneal pull-through is different from the peritoneal flap, vaginal plastic technique that I've described here. Peritoneal pull through their They're very aggressively mobilizing um the peritoneal flaps, and they're bringing them literally all the way to the entroitis. And so, um, the outcomes just aren't as good. They're devascularizing these flaps to uh mobilize them enough so that they'll reach all the way to the entroitus to the perineum. So, um, you'll see here in the United States, at least that the robotic peritoneal flat vaginalplasty is um more commonly used in the peritoneal pull through. Um, and so I think that's why you see here, um, I'm gonna present a a second study where they use a similar cutoff of 6 centimeters, um, in terms of, um, the current vaginal depth and, um, the techniques offered. So, um, with this group here, um, it was about 50/50 split between peritoneal flap and, um, sigmoid colon. And basically what their data showed was that the sigmoid colon was a shorter time in the OR. They had similar vaginal depth, but interestingly, the peritoneal flat group did have a higher rate of vaginal stenosis. And um this is their data here. So, um you can see here that um shorter time with sigmoid colon, they have similar rates of short-term complications, similar rates of long-term complications, but interestingly, uh, uh, a higher rate of vaginal stenosis here. So, this group concluded that potentially um sigmoid colon. Um, you know, uh, has lower rates of vaginal stenosis, uh, and maybe a preferred technique, especially in the setting of, um, when the vaginal canal, current vaginal canal depth is less than 7 centimeters. So this is another group at Mount Sinai who um did something similar. They compared robotic sigmoid colon vaginalplasty versus robotic peristal flat vaginalplasty. And they had a little bit more of a mix of patients of what techniques um they had undergone previously. So, um, 34 uh for penile inversion vaginalplasty, 8 of them uh were peritoneal flap, and one of them was a minimal depth, um, or shallow depth or vulvoplasty, all describing the same surgery, which is essentially the No cre the vaginal canal. And um and they did revisions, um, 19 were peritoneal flap and 24 were sigmoid. And again, they used a similar algorithm, um they had a different cutoff, um, if it was a shorter canal or completely obliterated, they offered sigmoid colon, um, but if there was, um, decent vaginal debt, they offered, um, both peritoneal flap and sigmoid colon. So, looking at, um, looking at their data here that the uh sigmoid colon group did have greater vaginal depth gained even after adjustment. Um, of course, you know, the sigmoid vaginal plasty group did start with a, um, With a much, uh, with a much lower, uh, with a much shorter preoperative vaginal canal depth, but that was by design according to the surgical algorithm that people who had shorter baseline canals were only offered, um, sigmoid vaginalplasty. Um, but the postoperative depth gained was significantly greater in the sigmoid vaginalplasty group even after adjustment. So, um, both because these patients began with less step but also because the sigmoid segment. Inherently allows for more length. You can take whatever however long of a sigmoid segment that you wanna create um to create the vaginal canal that. Um, most of the complications were grade 1, and these occurred predominantly in the sigmoid vaginalplasty group. There were 7 patients in the sigmoid vaginal plasty group versus 1 patient in the peritoneal flat vaginal plasty group, but it was statistically significant. But most of these grade 1 complications were things like catheter discomfort or bladder spasms, postoperative fever or nausea, and MSS. There was one grade 2 complication, which was a UTI treated with antibiotics. And a grade 3 complication, which is a posterior vaginal wall to hisin, which is quite common with um any of the vaginal plastic techniques. So, the key takeaways here is that the demand for revision vaginal plasty is increasing, so I think it's important that we continue to innovate and study, um, study these different techniques and outcomes with revision vaginalplasty. These cases are uniquely challenging and complex, and to consider current vaginal death, um, when deciding what technique to offer and to consider the very real rates and possibilities of secondary vaginal stenosis. So, um, another, you know, exciting thing, um, that we're seeing here is staged vaginalplasty. So, um, I was really excited um to be able to talk, um, to the OHSU, OHSU group and Um, they allowed me to share some of, um, you know, some, some, some of their experience that is in the process, um, uh, of being published. So, a vaginal canal is a significant lifelong commitment, and several factors should be carefully evaluated before offering vaginalplasty. Patients must fully understand and agree to ongoing lifelong vaginal dilations to maintain the canal. So, um, you know, uh, the patients should be assessed for readiness to adhere to this regimen. But not all patients are prepared for lifelong dilation at the time they seek surgery, even though they might ultimately desire a vaginal canal. So, some of these barriers may include emotional or developmental immaturity, particularly as we see more young adults accessing gender-affirming surgery. So, um, these younger patients may be less consistent with their dilations. Um, they may be preparing to leave home for college. We had a patient who um had a complication, but she had to leave for college across the country and she wasn't able to get home. Um, to see us, we tried to find a reconstructive neurologist who could help kind of help her out there, but she ultimately ended up losing her canal. She stopped dilating her canal stenosis, um, because she had to, you know, get back to school, hadn't given herself enough time. Um, you know, with surgery and, and going back, back to school for the semester. There might be psychosocial factors can also pose challenges, so that these are issues like limited social support, unstable housing. Um, they might have housing but have a lack of a private space for dilation. They might have a roommate. Um, mental health instability or conditions like PTSD or autism spectrum disorder that can make dilation especially uncomfortable or distressing. So these are all considerations here. Um, as I mentioned previously, the NYU group noticed, uh, noted that approximately 8% of patients were no longer dilating at one year post-op. So these are individuals potentially experience the higher risks and complication profile associated with vaginalplasty rather than vulvoplasty, only to end up discontinuing their dilations and ultimately losing the canal. So I thought that was um uh interesting data from that study. But given that many of these temporaries might be temporary, They'll get older, they may become more mature, um, you know, housing may become more stable, they may work on getting social support. An important question to ask is, are there alternative surgical pathways that can provide gender affirmation now while preserving the option for future vaginal canal creation when the patient is ready for this? So, um, the OHSU genderforming surgery program, um, you know, has a staged approach to vaginalplasty, and this was designed specifically for patients who might not yet be ready to commit to the lifelong dilation. But still desire a future vaginal canal. So in their model, the first stage is to undergo vvoplasty, um, or shallow depth or minimal depth. Um, again, these are all, um, you know, different words to describe the surgery here, um, but essentially creating the external genitalia without a vaginal canal. So this approach provides patients additional time to mature developmentally, to stabilize any of the active psychosocial factors, and to build the support systems that are needed for successful long-term dilations and postoperative care. So, if and when the patient is ready, a second stage vaginalplasty can be performed. Um, at OHSU they're doing robotic peritoneal vaginalplasty. So this occurs only after a thorough reassessment of patient readiness, appropriate preparation, and optimization of factors that will support consistent dilations after surgery. So this stage strategy is offer, offering gender affirmation in the present while preserving the option for a canal in the future when the patient is prepared to maintain it. So the data from the stage approach cohort is still forthcoming, and I'm definitely interested to learn more about their experience. Things that I'm particularly curious about are the technical aspects of creating a vaginal canal after an initial vplasty, what tissues they're using. Are they using external, um, extragenital, um, Skin grafts to bridge um from the entroitis to the peritoneal flaps cause again, um, that, uh, typically we're not taking these flaps and bringing them all the way to the entroitis. So there needs to be a, a skin bridge there. So you need to take additional skin graft harvest. Um, one of the, one of the prior revision papers um from Mount Mount Sinai did, they did have one patient in the group who had undergone peritoneal vaginalplasty after a minimal vaginalplasty. Um, but I'm, you know, definitely interested in kind of the patient trajectories and the decision-making process for this, and I think it'll be important, you know, what I'm most curious about is, you know, what proportion of patients are satisfied after the first stage, after the Volvoplasty alone and choose never to pursue the second stage. And then, of the proportion who expressed a desire for a second stage vaginalplasty, so which, you know, who ends up wanting a second stage, but, um, specifically, the proportion of that group who ultimately ends up meeting eligibility criteria and proceeds with the second stage. So I'm really interested in seeing their numbers and learning a bit more about um Their experience. So, um, you know, this is uh pre-publication, so hopefully we'll be learning more about this experience. So, um, I think this will be really helpful so that we can understand this, um, you know, to try to figure out who would benefit most from this staged approach and how we can best counsel patients when considering this option. So, I think pretty, pretty neat um direction here. Some other future directions, um, you know, there's always talks about allographs and xenographs, and there was this big talk about tilapia fish skin, and um it didn't necessarily go viral, but I know that there was a lot of press about this. Um, really has never taken off here. Um, the first reported use of tilapia fish skins enograft was back in 2020. It was an end of one. And they demonstrated successful epithelialization by 30 days post-op, and there was no graft rejection or infection or major complications. Um, but, um, that's, that hasn't taken off despite, you know, this being established, you know, um, over 5 years ago. Um, there's also consideration of using Alloderm, um, uh, to augment the canal length again with the peritoneal flap, kind of bridging the inroitus to the peritoneal flaps. Um, the, the biggest issue with Alloderm, honestly, is the cost. It is just so expensive, um, to use Alloderm, but I don't think necessarily it is a sustainable option, um, you know, when you could simply take an extragenital skin graft from somewhere else on the body rather than using this, um, super expensive alloderm. Some other future directions that I'm interested in kind of um exploring in the future. Um, so managing puberty suppression and peo scrotal hypoplasia. We are seeing, um, we are seeing more patients um who have undergone puberty suppression and so we have less available tissues. And, you know, the, the robotic peritoneal. Flat group kind of offered this technique as a, as a great option for these folks who have less available tissues. So as we see more of these patients and learning how to create not only the, the external um vulva, um, the aesthetics with less available tissues, but as well as the vaginal canal. Um, something that's interesting, um, is the non-traditional surgery requests. So, um, there's really not a lot of that out here, but there are patients who have slightly different surgical goals outside of kind of, um, you know, I want, uh, vaginalplasty. Um, there have been some requests. I've had maybe one or two patients that have come in asking for penile preserving vaginalplasty. Um, so there have been some case reports, um, so that should be interesting as we, you know, experience gender, uh, more on a spectrum. Um, our surgeries are really offered on a binary and, um, so to have this kind of spectrum of surgeries. Available should be interesting as we see potentially more patients with, um, you know, uh, different requests for surgery. And I think one of the most important parts here and one of the most exciting future directions of gender affirming surgery in general are patient reported outcomes. So all of these studies are surgeon, uh, most of these studies are surgeon reported outcomes, um, and how happy the surgeons are after their surgeries. And, um, for years, there were no validated. Questionnaires, patient questionnaires, uh, for trans folks and specifically trans folks who are post-op. So, um, there are two recent studies that have come out, um, not studies, uh, questionnaires that have come out, um, that have been, uh, validated. The gender cue, um, the gender cu patient reported outcomes goes through um all the different, um, various aspects of gender affirming care and there are specific. Questionnaires uh related to surgery and all gender affirming surgeries from face to top and breast to genital surgeries, and, uh, this was a, uh, international, uh, multi-institutional efforts, um, to validate these questionnaires. Temple was one of those sites, so we're really excited and now we have access and use of these questionnaires to study more patient reported outcomes. And then the Affirm um questionnaire is also looking at urine, specifically urinary and sexual health. After, um, gender, genital gender affirming surgeries and that was also recently validated in um the transgender, uh, post-op, uh, patient population. So, I think that's a really exciting future direction, um, is having more patient, uh, focused and more patient reported outcomes. So that finishes up my talk. Um thank you so much um for inviting me to speak with you all. Um, please reach out to me with any other questions you have, and I'm happy to take any questions. Thank you. That was awesome. Um, it was a really comprehensive talk, and I think it really gave a great overview. Um, I just, for the residents who are on this, uh, the talk, I really wanna highlight something that Doctor Douglas went through with the complexity of, um, of these cases. I think, um, Sometimes you see the end result and you're like, wow, it's like magic. But there are just so many steps to, to getting the surgery done correctly. And as you mentioned, they really are great reconstructive cases. Um, I was wondering if you could talk a little bit more um about like canal length and, and patient perceptions for that. I think, you know, you, you really highlight. how the canal dissection and development is probably the hardest part of feminizing bottom surgery as compared to urethral lengthening for masculinizing surgery. Um, and so, you know, you, we're talking about like canal length, like, what do patients expect? Do patients come in asking for a certain size? Is this kind of like the, you know, the trans female equivalent of like, can I have a bigger penis? Like, you know, questions that we hear a lot in the office. Mhm. Yeah, absolutely. So, um, that's, that's a great question and a great point. Um, when I do patient counseling about vaginal canal deaths, um, I never guarantee a vaginal death, especially with penile inversion vaginalplasty, you really are limited by the pelvic anatomy. And, you know, when you get to that peritoneal reflection, like you should stop. Um, but I tell people, you know, I try to make it relative for them, for people born with a vagina, on average, um, 2.5 to 5 inches of, um, vaginal depth, and we're typically getting patients right within that range. Sometimes we get more, sometimes we get less. With the robotic techniques, both peritoneal flap and sigmoid colon, um, definitely on that higher range of the vaginal depth, you're seeing like 56 inches. And honestly, my personal opinion is that no one really needs a six-inch vagina, but certainly some patients come in and, um, you know, and they have certain goals about their vaginal depth. Um, and so, you know, I try to keep it realistic. I, you know, um, You know, I tell them that we'll try to create them, you know, the best canal that we can safely for them, but, you know, I'm pretty clear about what we don't guarantee a vaginal depth. But for folks who are more interested in depth is more important to them, I'll typically counsel them away from penile inversion vaginal plasty if Um, you know, if they're otherwise a good candidate for the other techniques, um, because if you saw from that meta meta-analysis that the average vaginal depth for penile inversion vaginalplasty is a bit on the, um, is less than what, what they're getting with the, with the robotic techniques. So, um, so yes, you know, certainly, you know, I don't think anyone needs, you know, an 89, 10-inch vaginal canal. And, and to be honest, Um, I think the limitation, um, are dilations, you know, the dilators, um, that we use. Um, you have to be able to dilate to reach the entire depth of vaginal canal. Um, and I know patients will get creative with things that they can put inside their vaginal canal, um, but, uh, typically, you know, that we're trying to keep vaginal canal depth within reason. Awesome. Thank you so much. Can you talk a little bit more about the dilation? So that's something, you know, like, what's the frequency? When do you start it? You mentioned um some techniques where patients might not, might not need to do it lifelong. Um, what does that usually look like postoperatively? So, yes, the dilation, um, what's very interesting is that there's actually no data. There's no data, there's no literature on what is the best dilation regimen and um, You know, and there is a, a wide variation in dilation regimens from surgeon to surgeon. And, um, in my opinion, the best dilation regimen is one that a patient will do every day. So, we typically tell our patients that they need to dilate for at least 60 to 90 minutes a day. And they can break that up however they want to. So, if they want to dilate for 1 hour to 1 hour and a half in one setting, go for it. If they want to split it in half, you know, in the morning before they go to work, and then before they go to bed, or if they want to dilate 3 times a day, I really leave that up to be. For what works best for them so that they'll actually do the dilation. Um, so that would, would be a potentially interesting area for research, you know, are there better dilation regimens than others? Um, you know, how much time is actually needed to maintain the canal? Um, so, um, so yes, the dilation regimens, you know, I, I counsel very vigorously during this part. Uh, the patient consult about the commitment to dilation and that this is the one tool that we have to counterbalance the natural healing process, which is to scar, to scar and contract that space. So, um, you know, so yes, definitely important dilation regs, but we don't really have great data there. Um, so yes, you know, the sigmoid colon, you know, some of these groups are reporting, you know, because it is not epithelium, it's mucosa, and it's very well vascularized, that it potentially has a lower rate of vaginal stenosis. And you saw from the, the one revision vaginalplasty study that the peritoneal flat vaginalplasty group um did have a higher rate of stenosis, um, whereas the sigmoid colon group had no steno. afterwards. Um, you know, from, from the review of the literature, uh, you know, I, I, I do see less canal stenosis, but one of the issues, um, that's been reported is actually, uh, entroidal stenosis, um, is bringing that colon to the entroitis to the skin, um, and satulating it and creating that entroitis in such a way that you don't have this just kind of like ring of contracture right at the right at the opening of the canal. Um, so that does seem like that's one of the issues with the sigmoid colon, even though the potential, the actual canal, you know, may be more stable. Awesome. Thank you. Uh, this is, uh, thinking about 60 to 90-minute time commitment, definitely get, shed some light on why patients may struggle for the, to do their dilation at home. So, um, anyone else have any questions? All right. We will go ahead and wrap it up here. Thank you so much and have a great day, everyone. Bye. Thanks, everyone. Bye. Published November 20, 2025 Created by
