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Vaginoplasty: Peritoneal Pull-Through

By Heidi Wittenberg, MD

Vaginoplasty is considered a good option for healthy patients who want gender affirming genital surgery.  

*Because of the unknown long-term outcomes, Dr Wittenberg currently offers Peritoneal Pull Through Vaginoplasty (PPTV) for those patients that need vaginal depth revision, who do not have enough skin for grafting, whose hair follicles have been resistant to hair removal treatments, and patients who are willing to be followed for results and outcomes of this procedure.

 

PREOP REQUIREMENTS for peritoneal pull-through vaginoplasty include:

  • Three letters (2 from mental health professionals, 1 from a hormone provider or primary care doctor).

  • Overall good health.

  • No smoking, nicotine, or any other inhalational products (including second hand smoke) around 3 months before and after surgery. This can cause about a 5-fold increase in complications. Patients who smoke within this 3 month window before surgery may be rescheduled for a later time when then they have reliably stopped smoking.

  • Perioperative assistance (friends, family, hired help).

  • Surgical technique, anatomy, and genetics dictate most of the individualized aesthetic results.

  • Hair removal (same guide for a vaginoplasty procedure).

  • No prior abdominal mesh surgery.

  • No prior exploratory laparotomy for trauma.

  • No prior history of pelvic radiation.

  • No prior history of inflammatory bowel disease.

    • No Crohn's disease, ulcerative colitis, or diverticulitis.

 

PROCEDURE BACKGROUND:

 

  1. Penile inversion technique: the most common, well-known and least invasive option. It uses tissue that would be discarded and does not intentionally enter the abdominal cavity.

  2. Colon technique: higher risk procedure with higher rates of major complications. The colon-derived vaginal lining has the benefit of self-lubrication and some elasticity. 

  3. Peritoneal pull-through technique: the peritoneum (an abundant, moist inner lining of the abdominal wall) is pulled down into the potential space between the rectum and the urethra/prostate to serve as the future vaginal lining. This is a new procedure for gender affirmation but has been done before in patients with vaginal agenesis. 

PROCEDURE DETAILS:​

During surgery, a laparoscope and several instruments are inserted through small 5-8 mm incisions on the abdomen. These instruments allow dissection of the potential space between the lower urinary tract (urethra, prostatic urethra, and bladder) and rectum. This space will become the future vagina. Peritoneum flaps can be pulled through to the area between the urethra and the rectum to line a portion of the vaginal canal. The top of the vagina is separated from the abdominal contents by closing the peritoneal lining approximately 15 cm from the vaginal opening. The remainder of the vaginoplasty procedures (labiaplasty, clitoroplasty, penectomy, orchiectomy, partial urethrectomy, and other associated procedures) are similar to that of the penile inversion technique.


Potential benefits of this option:

  • Self-lubricating lining with some elasticity

  • Less need for dilation (compared to that of the penile inversion technique)

  • Less need for douching

  • Less preop hair removal

  • More vaginal depth

  • Lower risk than colonic vaginoplasty

Risks of peritoneal pull-through procedure:

  • All the risks of the penile inversion vaginoplasty

  • Additional risk of an abdominal laparoscopic procedure, including intra-abdominal organ injury, ileus, herniation, and others

  • Flap failure and stenosis

  • Unknown long-term outcomes*

 

*Because of the unknown long-term outcomes, Dr Wittenberg currently offers Peritoneal Pull Through Vaginoplasty (PPTV) for those patients that need vaginal depth revision, who do not have enough skin for grafting, whose hair follicles have been resistant to hair removal treatments, and patients who are willing to be followed for results and outcomes of this procedure.

 

Note:

  • PPTV does not preclude the colon option if it fails to create a reliable vagina.

  • Patients requesting this as an initial vaginoplasty are warned that this carries potentially higher risk than penile inversion vaginoplasty with unknown long-term results.