Neovaginoplasty using rectosigmoid colon on a superior rectal artery pedicle

Abstract

IndicationsMale-to-female gender reassignment and congenital absence of the vagina are the main indications for vaginal construction. Many different methods have been described. Operations from the perineum can involve the use of split skin grafts [1,2], amnion [3] peritoneum [4] or various pedicle grafts. In gender reassignment, inverted penile skin is suitable [5]. In each case an obturator is generally required to apply the graft to the tunnel between bladder and rectum. There are also advocates of the use of small bowel [6] caecum [7] or sigmoid colon [8]. Although these operations have the disadvantage of being major abdominal procedures, there is a lower reoperation rate in the long term and less risk of contracture.The caecum is usually vascularized by the ileocolic pedicle. In our experience, an insuf®cient length of this pedicle may not permit the graft to stretch to the introitus without tension. This can be avoided to some extent by using the entire right colon and swinging the hepatic exure down to the perineum. This creates a very long segment of bowel with the attendant problems of mucus retention. Rectosigmoid colon can be isolated on a branch of the inferior mesenteric artery but again the vessel length may be inadequate [8].We describe a new method using relatively short segments of rectosigmoid colon isolated on the superior rectal artery. Although we developed this method independently, it has also recently been described by Franz [9]. MethodThe procedure was developed of necessity, when it was found that neither caecum nor sigmoid colon vascularized from above would extend to the perineum in a patient with vaginal agenesis. A segment of rectosigmoid was prepared, vascularized from below by the superior rectal artery. This inverted segment reached the perineum with ease. The method has now been used in seven patients. The vascular anatomy is such that the inferior mesenteric artery anastomoses with the ascending superior rectal artery. The sigmoid branches of the inferior mesenteric artery supply the colon from a marginal vessel (Fig. 1a). A standard preoperative bowel preparation was used and the patient placed supine with their legs supported in Lloyd-Davis stirrups to allow perineal access.Step 1: an oval of skin is excised in the perineum or introitus and a tunnel between the bladder and rectum excavated. This is completed later from above. A Pfannenstiel incision is used for the abdominal part of the operation and the recto-sigmoid identi®ed.Step 2 (Fig. 1b): the recto-sigmoid is held to the left side of the patient and the base of the mesocolon incised at the sacral promontory, and extended caudad for < 10 cm and cephalad for < 5 cm.Step 3 (Fig. 1c): the colon is then swung to the right side and a comparable incision to the left side of the mesocolon made. Fingers can then be inserted between these incisions so that all the tissue anterior to the sacrum is mobilized forward. This posterior free edge will therefore contain the anastomosis between the inferior mesenteric artery and the sup...

Vaginal reconstruction with sigmoid colon in vaginal agenesis

“…Average operative time was 184 min (160-210). Average hospital stay was 11 days (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)(21)(22).…”

“…Some authors used the technique of isoperistaltic loop on a superior rectal artery pedicle with transaction of inferior mesenteric vessels, which provided immediate mobility with an adequate retrograde blood supply via the relevant sigmoid vessels [3,19]. On the other hand, Pratt stated that it makes no difference which end of the transplanted bowel is brought to introitus, the segment works equally well in either position [20].…”

Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery

“… 18 , 19 In comparison to surgical techniques using scrotal flaps or skin grafts, our postoperative dilatation protocol is not significantly different. 20 The use of pedicled intestinal tissue 7 , 21 may limit the need for postoperative dilatation but impose possible long-term risks of colitis 22 and a perceived increased morbidity by operating intraabdominally. Age at primary surgery was not correlated with vaginal depth, and the mean difference in centimeters between age groups was within 1.3 cm.…”

Experience With Neovaginal Construction Using the Full-Thickness Skin Graft in Vaginal Agenesis

“…1 Bowel flaps, however, bear the advantage of a mucosal lining. 1,4,9,16,17,18,21 However, the need for laparotomy, the morbidity of intestinal surgery, and the persistent, unpleasant secretion and odor with possible mucosal cracking at the time of intercourse are disadvantages. 1 Mucorrhea occurs with the use of all types of bowel except rectosigmoid.…”