MTF Vaginoplasty is a male to female 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.
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.
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.
Hair removal prior to surgery may or may not be necessary, depending on your surgeon’s technique.
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.
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.