Peritoneal Vaginoplasty Methods and Surgeons

Peritoneal vaginoplasty creates a vaginal canal with a tissue, the peritoneum, that lines the abdomen and organs. The abdominal space it lines is called the “peritoneal space” and so peritoneal (or “peritoneal pull through”) describes this method. See “Why Use Peritoneum?” at the bottom of this page for more general info.

This is a newer technique in gender affirming surgery, but dates back to 1930’s (1960’s first shows up in literature) Russia, and indeed there is a Russian patent on the method in cisgender and intersex women born without vaginas. Below I try to describe versions of this surgery, as techniques are not the same everywhere.

*BIAS DISCLOSURE: I work at the NYU program which performs the robotic peritoneal flap method. I do outcomes research there. My opinions/views do not represent the institution. I see zero financial benefit from you getting surgery there or anywhere. I have presented all surgical options and peer-reviewed literature that I am aware of below.*

Robotic Peritoneal Flap Vaginoplasty
A peritoneal flap means that the tissue used to line the canal, the peritoneum, comes with its own blood supply. In this case, the blood supply is a “pedicle” or an attachment to the original location. This is where the phrase “pull through” comes from: it is describing that part of the peritoneum was moved to a new location (pulled through to the vaginal canal) remaining attached to the old location.

The robot assistance is like driving a remote controlled car, but with surgery instruments. This picture shows an operating room where a surgeon at the far right operates at a control panel and surgical assistants help from next to the patient. This gives better ability to see, range of motion, and control of the instruments. Surgery to remove the prostate, which involves similar challenges and risks as vaginoplasty, is frequently done with robotic assistance due to better safety outcomes.

Media:
This is the only method of peritoneal vaginoplasty (as a gender affirming surgery) where outcome studies, which look at a group of patients and how they did after surgery, have been published in peer reviewed journals (ALL LINKS HAVE BLOODY SURGERY PICTURES): #1 (41 patients), #2 (100 patients) and video version of paper, #3 (11 patients), and #4 (8 revision vaginoplasty patients)
-This is a video that shows peritoneal revision vaginoplasty from the surgeons viewpoint using the robot: video
-In this video, Dr. Bluebond-Langner discusses her techniques and the use of the robot and specific information about lubrication and the peritoneal flaps. This is another video where she discusses these techniques: video.
-An interview with Dr. Min Jun on this method: interview
-Dr. Wittenberg discusses her techniques in this video.

Laparoscopic Peritoneal Flap Vaginoplasty
This has only been described in case reports (writing up a single patient) in peer reviewed journals and informal materials surgeons have put out for patients. The procedure also uses a “flap” of peritoneum. Instead of a robotic assistant, this procedure is done with special tools (“laparoscopy”) which extend the surgeon’s hands into the body like a set of very fancy, very clean reacher-grabber sticks with different attachments on the end. The surgeon remains next to the person, holding the sticks and looking at a screen that shows what cameras at the end of the sticks see.

Media:
These are peer reviewed case report on this method: #1, #2


Peritoneal Graft Vaginoplasty
A graft is when you take the tissue (peritoneum), separate it completely from the body, and put it back in a new location There are no peer reviewed case reports or outcome studies on peritoneal graft vaginoplasty. In general, grafts have a more difficult time healing than flaps, as they have to establish a new blood supply in the new location. There are reports on the internet that Mount Sinai’s surgery program is currently using peritoneum grafts from the tunica vaginalis (a slightly different kind of peritoneum which lines the testicle). If this is the case, I look forward to them releasing more information on this surgery in the peer reviewed literature.

Media:
None that I know of

Why use peritoneum?
1) It can help to provide more depth to the new vagina, especially in people without much genital skin.
2) It can also be used as a second procedure if the vagina is too small after the first surgery.
3) POSSIBLE MYTH: Some people think peritoneum in the vagina may help with lubrication, as it makes some fluid. However this fluid is not made in response to arousal, and is not as thick as the “pre-cum” fluid that all bodies potentially make.
4) DEFINITE MYTH: Some people think that you will need to dilate less. While more long term outcome studies are needed, it is my opinion that with any method where a vaginal canal is created you need to plan for some dilation throughout your life, if you want to be able to receive penetration throughout your life. The ring of scar tissue around the entrance of the vagina (you have to connect to the skin somewhere) can tighten if you don’t dilate, especially in the first year after surgery. Peritoneum and colon, two tissues that are used in vaginoplasty, and are sometimes said to need less dilation, have a unique potential problem because they produce fluid. There have been rare cases where the entrance to the vagina has closed, even when the rest of the canal remained open and producing fluid, causing health problems requiring further surgery. Dr. Wittenberg discusses this in the video linked above as occurring in a cisgender woman who had a peritoneum technique a decade prior. The goal of dilating is not only to stretch the lining of the vagina, but also to teach your muscles how to relax and not feel pain during penetration.