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MTF Surgery Procedures » MTF Vaginoplasty

MTF Vaginoplasty: What Patients Need To Know Before Choosing a Technique

MTF Vaginoplasty is a Gender Reassignment Surgery procedure that transforms natal male genitals into a functional, aesthetically pleasing vagina. With a qualified surgeon, patients can expect normal urination, sexual sensation, and minimal scarring.

The ultimate goal of MTF Vaginoplasty is a vagina that is secretory, flexible, hairless and pink, and approximately 4" in depth and about 1-1.5" in diameter. There are multiple MTF Vaginoplasty techniques used around the world to achieve this goal, but the two most common are Penile Inversion Vaginoplasty and Rectosigmoid Vaginoplasty. Understanding the basics of each technique will help you make a more informed decision about which one is right for you.

Penile Inversion Vaginoplasty

Referred to as the "gold standard" MTF Vaginoplasty technique, Penile Inversion is often performed as a one-stage procedure, incorporating Orchiectomy, partial Penectomy, penile dissection and creation of the vaginal cavity, Labiaplasty and Clitoroplasty. Some surgeons delay Labiaplasty and Clitoroplasty until stage 2, particularly in patients who have an insufficient amount of left over tissue to construct the inner labia and clitoral hood.

Uniklinikum Tübingen: Sex-Reassignment: Male to Female Surgery 2009 from Azraels-Art.

How Penile Inversion Vaginoplasty Is Performed

To create the vagina, the majority of skin from the shaft of the penis is inverted and used to line the vaginal cavity created in the perineum. If additional tissue is required to create a vagina of acceptable depth, skin grafts can be harvested from the abdomen or scrotum. Erectile tissue is removed so that sexual arousal doesn't cause narrowing of the vaginal opening or protrusion of the urethral opening and clitoris.

The urethra is shortened and the urethral meatus is relocated to the appropriate female position. A small, sensate clitoris is created from a small portion of the glans which is left attached to its nerve and blood supply. Labia minora and majora are constructed from prepuce or penile skin and scrotal skin.

The prostate gland, which is typically well-atrophied from hormone replacement therapy, is not touched. The vagina is created behind the prostate. Any future required examination of the prostate would thus occur via the vagina, not the rectum.

TIP: To estimate vaginal depth from Penile Inversion Vaginoplasty, subtract 1" from the length of the skin covering the penis.

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The surgery lasts between 2-4 hours.

Post-operative use of vaginal dilators for at least 6 months is required after surgery to maintain depth and diameter, though Penile Inversion Vaginoplasty has a lower risk of vaginal contraction versus techniques that employ non-genital, split-thickness skin grafts. (Bizic, 2014)

Hair removal prior to surgery may or may not be necessary, depending on your surgeon's technique.

Penile Inversion is the most commonly performed version of MTF Vaginoplasty in the United States today. It's also the most well researched. That said, the optimal surgical technique for MTF Vaginoplasty has not yet been identified, as outcomes of the different techniques have not been adequately compared in academic studies.

Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization. The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data.

Source: Outcome of Vaginoplasty in Male-to-Female Transgenders: A Systematic Review of Surgical Techniques. Horbach, Sophie E.R. et al. The Journal of Sexual Medicine , Volume 12 , Issue 6 , 1499 - 1512

Rectosigmoid Vaginoplasty

Rectosigmoid Vaginoplasty, aka Sigmoid Colon Vaginoplasty, uses a section of the Sigmoid colon to create the vaginal lining. First described in 1974, Rectosigmoid Vaginoplasty results in a well-proportioned, self-lubricating vagina, which does not require post-operative dilatation for extended periods of time. Furthermore, this segment of the colon is thick-walled and large in diameter, and thus carries a lower risk of bleeding after sexual intercourse. The technique is particularly suited to patients who have short penises, and is also used as a corrective surgery for patients with vaginal obstruction as the result of a previous Vaginoplasty, or in patients who have had Penectomy ("nullification.")

How Rectosigmoid Vaginoplasty Is Performed

A sigmoid colon section approximately 3-4" in length is harvested as a pedicle flap, with the neurovascular bundle, through an abdominal incision or laparoscopy, then the rest of the colon is reconnected. The sigmoid colon section is connected to the perineum using genital skin flaps. Orchiectomy, Penectomy, Labiaplasty and Clitoroplasty are also performed as required.

The surgery lasts approximately 7 hours.

Disadvantages of Rectosigmoid Vaginoplasty

  • Additional abdominal surgery with intestinal anastomosis, which increases the risk of postoperative ileus.
  • Visible abdominal scar.
  • A longer surgery with added complexity and expense.
  • Rectosigmoid graft lining the vagina is unlikely to provide the quality of sensation that is possible with Penile Inversion.
  • The production of mucus from the colon graft can lead to excessive discharge, though this typically decreases significantly within 3–6 months. (Daily vaginal cleaning for 1 month can help.)
  • Colon grafts must be screened for colon cancer and should be monitored if the patient develops inflammatory bowel disease.

Rectosigmoid Vaginoplasty is performed regularly in Thailand, India, and Eastern Europe but rarely in the United States. However, satisfaction rates are positive and some surgeons in the U.S. believe that Rectosigmoid Vaginoplasty is safe and effective and should be offered to MTF patients for primary Vaginoplasty more often.

[Patients] were generally satisfied with life and scored 5.9 of 7 on a subjective happiness scale. Neovaginal functionality was rated as 7.3 and appearance as 7.4 of 10. Although surgical corrections were frequently necessary, women reported satisfaction with the surgical outcome and with life in general.

Source: Long-Term Follow-Up of Transgender Women After Secondary Intestinal Vaginoplasty. van der Sluis, Wouter B. et al. The Journal of Sexual Medicine, Volume 13, Issue 4, 702 - 710

Eighty-three patients were included over the course of 22 years, with an average clinical follow-up of 2.2 years (83 patients) and phone interview follow-up of 23 years (21 patients). Overall, the patients were healthy, with minimal comorbidities. Forty-eight patients (58 percent) had complications, but the majority (83.3 percent) were minor and consisted mainly of introital stricture or excessive protrusion of the corpus spongiosum. Smoking was associated with higher complication rates (p = 0.05), especially stricture formation. Excessive mucorrhea occurred in 28.6 percent but resolved after the first year. Overall patient satisfaction with appearance and sexual function was high. This study is one of the largest and longest reported series of rectosigmoid transfers for vaginoplasty in transsexual patients. Rectosigmoid neocolporrhaphies have many times been recommended for secondary or revision surgery when other techniques, such as penile inversion, have failed. However, the authors believe the rectosigmoid transfer is safe and efficacious, and it should be offered to male-to-female patients for primary vaginoplasty.

Source: Long-Term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery. Morrison SD, Satterwhite T, Grant DW, Kirby J, Laub DR Sr, VanMaasdam J. Plast Reconstr Surg. 2015 Aug;136(2):386-94.

Complications & Risks

Both the Penile Inversion and Rectosigmoid Colon techniques carry the risk of complications. A 2015 study concluded that the most common complication was narrowing of the vagina (12%-43% of patients, depending on technique). Changes in urine stream and heightened risk of urethral infection were also fairly common, affecting 33% of patients. Rare serious complications included tissue necrosis, rectal injuries, fistulas, deep vein thrombosis, and pulmonary embolism. With the Rectosigmoid Colon technique specifically, diversion colitis, adenocarcinoma of neovagina, introital stenosis, mucocele and constipation have been reported, although with a low incidence.

How to Choose?

The choice of which MTF Vaginoplasty technique to pursue is dependent upon a number of factors, including your surgeon's experience with a particular technique, your anatomy, and most importantly, your goals. Consider the advantages and disadvantages of the techniques, as well as what's most important to you with your surgery outcome, and bring your questions and concerns to your surgery consult. Together, you and your surgeon can make the final decision about the right MTF Vaginoplasty technique for you.

Surgeons who perform MTF Vaginoplasty:

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Last updated: 01/11/18