There are different types of vaginoplasty depending on the technique used to perform the neovagina. When a transgender woman requests genital affirmation surgery or transgender vaginoplasty (also widely referred to as feminising genital surgery), it is essential for the medical team to plan the procedure meticulously, considering her unique needs, medical history, personal characteristics and circumstances. The surgeon will recommend penile inversion vaginoplasty, grafting or colovaginoplasty, depending on the aforementioned factors.
Penile inversion vaginoplasty
Penile inversion vaginoplasty is a surgical technique that creates a vagina using only the skin of the penis. This method is employed when the characteristics of the penis—including size, thickness, length and skin quality—are deemed suitable for creating an adequate and sufficiently deep vaginal tunnel that allows for satisfactory penetrative intercourse.
Once the vaginal space is formed, the inverted penile skin is placed to form the vaginal walls. The resulting depth of the vagina varies from patient to patient, primarily depending on the amount of available penile skin and the person’s anatomical arrangement of internal organs. Typically, the goal is to achieve a vaginal depth of at least 15 centimetres.
Penile elements like the corpora cavernosa are discarded. The urethra is then shortened and repositioned to open just above the new vaginal opening. The clitoris is reconstructed using the preserved portion of the glans, along with its nerves and blood vessels, to preserve sensitivity and the ability to experience full sexual satisfaction.
Aesthetic aspects of the vagina are also carefully constructed in penile inversion vaginoplasty, specifically the vaginal labia. The labia majora are formed using skin from the scrotum, while extra skin may be used to craft additional folds, simulating the labia minora and a clitoral hood
Postoperatively, compression bandages are applied, and a bladder catheter is typically required for about two weeks to aid in the healing process.
The surgery generally lasts between 3 and 5 hours and is performed under general anaesthesia. It usually requires a minimum hospital stay of one week for adequate monitoring of recovery.
Vaginoplasty with grafting
Vaginoplasty with grafting is often performed when the penile inversion technique alone does not provide sufficient vaginal depth for a transgender woman to have a satisfactory penetrative sex life. In this procedure, scrotal skin, left over after creating the labia majora, is prepared as a graft to enhance the vaginal depth and cavity.
This scrotal skin is prepared as a graft, ranging in size from 3 to 6 centimetres deep. Hair follicles must be removed to prevent hair regeneration. This procedure largely follows the steps of penile inversion vaginoplasty, but here, the skin graft is inserted into the vaginal cavity before it is closed.
Before deciding on this technique, it is essential to consider that the grafted skin may have limitations in terms of attachment and resistance, and it is particularly vulnerable to chafing during sexual intercourse. Therefore, the medical team must conduct a thorough assessment to determine if this technique is suitable for the individual patient.
Colovaginoplasty
Colovaginoplasty is often performed in cases where the size of the penis is insufficient for the penile inversion technique. Colovaginoplasty may also be considered if there has been significant circumcision before vaginoplasty that affects the amount of tissue available or if there is an underdevelopment of the penis resulting from hormonal inhibitors during puberty and adolescence. The penile inversion technique is not recommended in these cases. Relying exclusively on limited penile skin for the creation of a new vagina could result in inadequate vaginal depth, which may not support a satisfactory penetrative sex life for a transgender woman.
The colovaginoplasty procedure involves first creating a vaginal tunnel between the perineum and the peritoneum, and then, making an abdominal incision to remove a section of the sigmoid colon along with its vascular pedicle. This specific section of the colon is then transposed into the perineal area to form the new vagina, whereas the remaining parts of the colon are reconnected to continue normal gastrointestinal function. The rest of the colovaginoplasty follows the same procedural steps as penile inversion vaginoplasty.
Colovaginoplasty, also known as pedicled rectosigmoid flap vaginoplasty, is conducted under general anaesthesia and typically lasts 5 to 6 hours. Postoperatively, patients require a minimum hospital stay of 7 days.
How do you choose the most appropriate technique for your case?
Several factors influence the choice of one technique or another. One of them is the quantity and quality of the penile skin available and the woman’s target vaginal depth. Due to the personalised nature of the surgery, a prior assessment by the medical team is crucial for an accurate diagnosis and design of a customised vaginoplasty plan.
All types of vaginoplasty require specific postoperative care, which will be diligently provided by the medical team along with a vaginal dilatations process, which will also be clearly explained with some guidelines before being discharged.
While 15 to 20 years ago, the most commonly performed transgender vaginoplasty technique was penile inversion vaginoplasty, today, more than half of all vaginoplasties are performed using the colovaginoplasty technique. This is because transgender people receive care at an earlier stage.
If you have more questions about the types of vaginoplasty, book an appointment with the IM GENDER team and we will inform you.
