MTF Surgery Procedures » MTF Vaginoplasty

Rectosigmoid Vaginoplasty

First described in 1974, Rectosigmoid Vaginoplasty, or Sigmoid Colon Vaginoplasty, uses a section of the sigmoid colon to create the vaginal lining, and the technique offers excellent depth as well as natural lubrication. It also carries a lower risk of bleeding after sexual intercourse because this segment of the colon is thick-walled and large in diameter. Furthermore, patients typically do not require post-operative dilatation for extended periods of time.

The technique is particularly suited to patients who have limited penile tissue, often the result of long term HRT, 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.

Dr. Christopher Salgado Rectosigmoid Vaginoplasty is performed regularly in Thailand, India and Eastern Europe but rarely in the United States. However, some surgeons in the U.S. believe that Rectosigmoid Vaginoplasty should be offered for primary Vaginoplasty more often. Dr. Christopher Salgado, an experienced gender surgeon and prolific researcher who has authored over 120 peer-reviewed studies, offers Rectosigmoid Vaginoplasty for some patients.

"It is our practice to have a careful, informed discussion about our patient's desires for penetrative sex, patient and partner anatomy, and expectations before considering sigmoid vaginoplasty," he wrote in a 2018 study. In our clinic, we tailor the planned vaginal depth to every individual rather than a preconceived ideal. We propose consideration of sigmoid vaginoplasty for patients with less than 4.5 inches or 11.4 centimeters of stretched penile length."

Additional studies have reported high satisfaction rates:

[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, April 2016.

Eighty-three patients were included over the course of 22 years, with an average clinical follow-up of 2.2 years (83 patients). 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. Excessive mucorrhea occurred in 28.6 percent but resolved after the first year. Overall patient satisfaction with appearance and sexual function was high. Rectosigmoid [Vaginoplasty] has 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.

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 Vaginoplasty.
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

All Vaginoplasty techniques carry the risk of complications. Narrowing of the vagina, changes in urine stream and heightened risk of urethral infection are common complications. Rare but serious complications include 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. Patients may also experience some degree of abdominal muscle weakness due to the incision used to access the abdominal cavity.

Contraindications to Vaginoplasty

In patients who have had any type of radical prostatectomy for prostate cancer it can be difficult to create the vaginal canal because critical tissues have been radiated. These patients can get a MRI to evaluate the area to see if Vaginoplasty remains an option and if not, can choose to proceed with Vulvoplasty instead.

Smoking increases the risk of poor wound healing significantly. Most surgeons require smoking cessation before surgery and some also order a pre-operative nicotine test to confirm cessation.

In general, obesity has been shown to be a risk factor for surgical complications, including delayed wound healing, infection and postoperative venous thromboembolic events (VTEs). Those who have a BMI of more than 35 or 40 may also have a harder time accessing the vaginal area for post-operative dilation. Both of these factors can lead to a less than satisfactory Vaginoplasty result. However, relying on BMI as a sole selection criteria for surgical candidacy is falling out of favor.

How to Choose?

There are many factors involved in choosing a Vaginoplasty technique and anyone considering this surgery is advised to weigh the pros and cons of each approach and to consult with multiple surgeons to determine the most appropriate surgical solution.

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