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Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes

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Abstract

Introduction

Various methods have been described to create a functional neovagina with feminizing (male-to-female) gender affirming surgery. Intestinal vaginoplasty using ileal or colon segments confers natural mucus production and greater canal depth with primary vaginoplasty. In this work we describe an alternative approach to primary and salvage vaginoplasty using right colon. We focus on relative advantages compared to use of other bowel segments, and we review patient outcomes.

Methods

Transgender women who had previously undergone primary vaginoplasty underwent laparoscopic right colon vaginoplasty at our center between 12/2017 and 7/2019. Demographic, medical, outcome, and satisfaction data was collected and retrospectively reviewed.

Results

Twenty-two consecutive transgender women patients underwent laparoscopic right colon vaginoplasty. Mean age was 39.3 years. There were two intraoperative complications:1 injury of the ileocolic pedicle, and 1 minor bladder injury. Four of 22 patients (18.2%) had short-term complications (< 30 days): 3 had postoperative ileus/small bowel obstruction and 1 had intra-abdominal hemorrhage. All were managed conservatively. Six of 22 patients (27.3%) experienced a total of 14 long-term complications (> 30 days): 1 developed Crohn’s (not involving the neovagina); 1 developed late small bowel obstruction (SBO) (managed conservatively); 5 developed neovagina prolapse; 4 developed stenosis (2 at the vaginal introitus, and 2 had extrinsic obstruction at the recto-vaginal junction (all underwent successful laparoscopic surgical correction); and 3 were diagnosed with diversion neovaginitis (all treated conservatively). All complications were successfully treated with conservative and/or surgical intervention. All (100%) patients reported satisfaction with neovagina function and appearance.

Conclusion

This is the only outcomes series of transgender women patients who have undergone right colon vaginoplasty, to date. Our study finding suggests that laparoscopic right colon for primary or salvage vaginoplasty has several important advantages over use of Sigmoid colon or Ileum, and is a reliable technique whose complications can be managed successfully, with favorable, satisfactory long-term outcomes.

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References

  1. Zaliznyak M, Bresee C, Garcia MM (2020) Age at first experience of gender dysphoria among transgender adults seeking gender-affirming surgery. JAMA Netw Open 3(3):201236

    Article  Google Scholar 

  2. Coleman E, Bockting W, Botzer M et al (2012) Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Intl J Transgend 13(4):165–232

    Article  Google Scholar 

  3. Salim A, Poh M (2018) Gender-affirming penile inversion vaginoplasty. Clin Plast Surg 45(3):343–350

    Article  Google Scholar 

  4. Horbach SE, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG (2015) Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med 12(6):1499–1512

    Article  Google Scholar 

  5. Meerwijk EL, Sevelius JM (2017) Transgender population size in the united states: a meta-regression of population-based probability samples. Am J Public Health 107(2):e1–e8

    Article  Google Scholar 

  6. Garcia MCN, Thomas P, Ralph D (2017) Genital gender affirming surgery for transgender patients. American Urologic Association. AUA Update Series 2017

  7. Pariser JJ, Kim N (2019) Transgender vaginoplasty: techniques and outcomes. Transl Androl Urol 8(3):241–247

    Article  Google Scholar 

  8. Karim RB, Hage JJ, Mulder JW (1996) Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg 37(6):669–675

    Article  CAS  Google Scholar 

  9. Shoureshi P, Dugi D 3rd (2019) Penile inversion vaginoplasty technique. Urol Clin N Am 46(4):511–525

    Article  Google Scholar 

  10. van der Sluis WB, Pavan N, Liguori G et al (2018) Ileal vaginoplasty as vaginal reconstruction in transgender women and patients with disorders of sex development: an international, multicentre, retrospective study on surgical characteristics and outcomes. BJU Int 121(6):952–958

    Article  Google Scholar 

  11. Georgas K, Belgrano V, Andreasson M, Elander A, Selvaggi G (2018) Bowel vaginoplasty: a systematic review. J Plast Surg Hand Surg 52(5):265–273

    Article  Google Scholar 

  12. Bouman MB, van Zeijl MC, Buncamper ME, Meijerink WJ, van Bodegraven AA, Mullender MG (2014) Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function. J Sex Med 11(7):1835–1847

    Article  Google Scholar 

  13. Bouman MB, van der Sluis WB, van Woudenberg Hamstra LE et al (2016) Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. J Sex Med 13(9):1438–1444

    Article  Google Scholar 

  14. Kim SK, Park JW, Lim KR, Lee KC (2017) Is rectosigmoid vaginoplasty still useful? Arch Plast Surg 44(1):48–52

    Article  Google Scholar 

  15. Garcia MM (2018) Sexual function after shallow and full-depth vaginoplasty: challenges, clinical findings, and treatment strategies- urologic perspectives. Clin Plast Surg 45(3):437–446

    Article  Google Scholar 

  16. Garcia MM, Harmon D, Topp K (2017) The anatomy of gender affirming genital surgery. Gray's Anatomy.

  17. Kwun Kim S, Hoon Park J, Cheol Lee K, Min Park J, Tae Kim J, Chan KM (2003) Long-term results in patients after rectosig-moid vaginoplasty. Plast Reconstr Surg 112:143–151

    Article  Google Scholar 

  18. van der Sluis WB, Bouman MB, de Boer NK et al (2016) Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med 13(4):702–710

    Article  Google Scholar 

  19. Alsabilah J, Kim WR, Kim NK (2017) Vascular structures of the right colon: incidence and variations with their clinical implications. Scand J Surg 106(2):107–115

    Article  CAS  Google Scholar 

  20. Kuzu MA, Ismail E, Çelik S et al (2017) Variations in the vascular anatomy of the right colon and implications for right-sided colon surgery. Dis Colon Rectum 60(3):290–298

    Article  Google Scholar 

  21. Haywood M, Molyneux C, Mahadevan V, Srinivasaiah N (2017) Right colic artery anatomy: a systematic review of cadaveric studies. Tech Coloproctol 21(12):937–943

    Article  CAS  Google Scholar 

  22. Phillips M, Patel A, Meredith P, Will O, Brassett C (2015) Segmental colonic length and mobility. Ann R Coll Surg Engl 97(6):439–444

    Article  CAS  Google Scholar 

  23. Goulder F (2012) Bowel anastomoses: the theory, the practice and the evidence base. World J Gastrointest Surg 4(9):208–213

    Article  Google Scholar 

  24. Stamos M, Brady M (2018) Anastomotic leak: are we closer to eliminating its occurrence? Ann Laparosc Endosc Surg 3(8):66

    Google Scholar 

  25. Bouman MB, van der Sluis WB, Buncamper ME, Özer M, Mullender MG, Meijerink WJ (2016) Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg. 138:614

    Article  Google Scholar 

  26. Morrison SD, Satterwhite T, Grant DW, Kirby J, Laub DR Sr, VanMaasdam J (2015) Long-term outcomes of rectosigmoid neocolporrhaphy in male-to-female gender reassignment surgery. Plast Reconstr Surg 136(2):386–394. https://doi.org/10.1097/PRS.0000000000001459

    Article  CAS  PubMed  Google Scholar 

  27. Jacoby A, Maliha S, Granieri MA et al (2019) Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J Urol 201(6):1171–1176

    Article  Google Scholar 

  28. Wu J, Guo R, Chu D et al (2016) Comparison of two techniques of laparoscopy-assisted peritoneal vaginoplasty. J Minim Invasive Gynecol 23(3):346–351

    Article  Google Scholar 

  29. Yao F, Zhao W, Chen G et al (2014) Comparison of laparoscopic peritoneal vaginoplasty and sigmoid colon vaginoplasty performed during radical surgery for primary vaginal carcinoma. World J Surg Oncol 12:302

    Article  Google Scholar 

  30. Wessells H, Lue TF, McAninch JW (1996) Penile length in the flaccid and erect states: guidelines for penile augmentation. J Urol 156(3):995–997

    Article  CAS  Google Scholar 

  31. Hyman N, Manchester TL, Osler T, Burns B, Cataldo PA (2007) Anastomotic leaks after intestinal anastomosis: it's later than you think. Ann Surg 245(2):254–258. https://doi.org/10.1097/01.sla.0000225083.27182.85

    Article  PubMed  PubMed Central  Google Scholar 

  32. Saur NM, Paulson EC (2019) Operative management of anastomotic leaks after colorectal surgery. Clin Colon Rectal Surg 32(3):190–195. https://doi.org/10.1055/s-0038-1677025

    Article  PubMed  PubMed Central  Google Scholar 

  33. Veyrie N, Ata T, Muscari F et al (2007) Anastomotic leakage after elective right versus left colectomy for cancer: prevalence and independent risk factors. J Am Coll Surg 205(6):785–793. https://doi.org/10.1016/j.jamcollsurg.2007.06.284

    Article  PubMed  Google Scholar 

  34. Bouman MB, van der Sluis WB, Buncamper ME, Özer M, Mullender MG, Meijerink WJ (2016) Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg 138(4):614e–e623. https://doi.org/10.1097/PRS.0000000000002549

    Article  CAS  PubMed  Google Scholar 

  35. Djordjevic ML, Stanojevic DS, Bizic MR (2011) Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases. J Sex Med 8(12):3487–3494. https://doi.org/10.1111/j.1743-6109.2011.02494.x

    Article  PubMed  Google Scholar 

  36. Claes KEY, Pattyn P, D'Arpa S, Robbens C, Monstrey SJ (2018) Male-to-female gender confirmation surgery: intestinal vaginoplasty. Clin Plast Surg 45(3):351–360. https://doi.org/10.1016/j.cps.2018.03.006

    Article  PubMed  Google Scholar 

  37. Salgado CJ, Nugent A, Kuhn J, Janette M, Bahna H (2018) Primary sigmoid vaginoplasty in transwomen: technique and outcomes. Biomed Res Int. https://doi.org/10.1155/2018/4907208

    Article  PubMed  PubMed Central  Google Scholar 

  38. Manrique OJ, Sabbagh MD, Ciudad P et al (2018) Gender-confirmation surgery using the pedicle transverse colon flap for vaginal reconstruction: a clinical outcome and sexual function evaluation study. Plast Reconstr Surg 141(3):767–771. https://doi.org/10.1097/PRS.0000000000004122

    Article  CAS  PubMed  Google Scholar 

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Funding

Grant/non-financial support from NIH/NCI R01 Grant #: 1R01CA12430728 (P.I. Garcia).

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Authors and Affiliations

  1. Cedars-Sinai Transgender Surgery and Health Program, Division of Urology, Cedars-Sinai Medical Center, 8635 W. Third Street, Suite 1070W, Los Angeles, CA, 90036, USA

    Maurice M. Garcia

  2. Department of Urology & Department of Anatomy, University of California San Francisco, San Francisco, CA, USA

    Maurice M. Garcia

  3. Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Maurice M. Garcia, Michael Zaliznyak, Moshe Barnajian, Jason Cohen & Yosef Nasseri

  4. Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Michael Zaliznyak

  5. Surgery Group Los Angeles, Los Angeles, CA, USA

    Wesley Shen, Rachel Zhu, Isabella Stettler, Moshe Barnajian, Jason Cohen & Yosef Nasseri

  6. Division of Colorectal Surgery, University of California San Francisco, San Francisco, CA, USA

    Ankit Sarin

Authors
  1. Maurice M. Garcia
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  2. Wesley Shen
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  9. Yosef Nasseri
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Corresponding author

Correspondence to Maurice M. Garcia.

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Disclosures

Dr. Maurice Garcia is the Principal Investigator for NIH/NCI R01 Grant #1R01CA201709-01. Dr. Garcia’s research is also supported by a private research endowment. Dr. Garcia is also an educator for the World Professional Association for Transgender Health’s (WPATH) Global Educational Initiative (GEI) and receives honoraria for educational lectures. Dr. Garcia is Chief Medical Officer & Co-founder for Safe Medical Designs, LLC, and, founder of MLM Medicus, LLC, and has issued and pending U.S. Patents. Dr. Yosef Nasseri is a consultant for Surgical Intuitive. Dr. Moshe Barnajian, Dr. Jason Cohen, Dr. Ankit Sarin, Mr. Wesley Shen, Ms. Rachel Zhu, Ms. Isabella Stettler, and Mr. Michael Zaliznyak have no conflicts of interest or financial ties to disclose.

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Garcia, M.M., Shen, W., Zhu, R. et al. Use of right colon vaginoplasty in gender affirming surgery: proposed advantages, review of technique, and outcomes. Surg Endosc 35, 5643–5654 (2021). https://doi.org/10.1007/s00464-020-08078-2

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  • DOI: https://doi.org/10.1007/s00464-020-08078-2

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