Pedicled rectosigmoid flap vaginoplasty

What does the rectosigmoid pedicled flap technique or colovaginoplasty consist of?

The vaginoplasty with a pedicled rectosigmoid flap is a surgical procedure that consists of using a section of the lower large intestine (sigmoid colon) to create a neovagina.

Who can undergo a colovaginoplasty?

It will be the surgeon along with their medical team who will decide upon the most suitable technique for each patient, after examining each patient’s physical characteristics and medical history.

The pedicled rectosigmoid flap technique tends to be performed in cases where the penile inversion procedure is not viable. This often occurs when the stretched penile skin measures less than 12 centimetres, when the patient has been circumcised or when the patient was operated on previously for sex reassignment but did not gain sufficient vaginal depth.

The preparations

Stopping hormone treatment

The patient must cease hormone treatment around four weeks before the operation. Oestrogens (female hormones) in the bloodstream increase the risk of deep vein thrombosis (blood clots within the veins) with all their associated risks and problems. The process of hormonal reduction should be gradual, so patients are advised to begin reducing the dosage one week before beginning the four, hormone-free weeks.

The effects of stopping hormone treatment will be apparent to patients. Although they vary from one person to another, symptoms range from sharp mood swings, dizziness and nausea to the appearance of clearly masculine traits (facial hair, involuntary erections, etc.). Shortly, the situation will stabilise and any discomfort will disappear. The more gradual the hormonal reduction, the more bearable the change.

Admission

A few days before the procedure, the medical team will stipulate a diet to aid colonic cleansing. The patient must follow it scrupulously to ensure the operation is a success.

The patient is admitted to hospital the day before the procedure. On that day, the relevant control procedures and cleansing of the colon (large intestine) is performed to ensure it is clean and as free from bacteria as possible.

The aim of cleansing is to reduce the risk of infection stemming from handling the colon, a viscera that is habitually colonised by a wide variety of bacteria.

The operation

The colovaginoplasty requires at least seven days’ admission so the medical team can better monitor patients’ progress.

The operation generally lasts from five to six hours, plus pre-anaesthesia and patient preparation time, as well as post-operative recovery. It is always performed under general anaesthesia.

Vaginal stage: The surgeon will construct a tunnel from the perineum to the peritoneum, where the vagina will be formed. This is, in its anatomical location, between the rectum and the bladder.

Abdominal stage: Afterwards, a left para-Pfannenstiel incision is made in the abdomen (the same as used in a caesarean, but further left), allowing the surgeon access to the abdominal cavity. Eighteen to 20 centimetres of sigmoid colon are separated and sectioned, complete with a vascular pedicle, and displaced towards the area of the perineum, where the vaginal tunnel was created. The rest of the sectioned colon is spliced so that it can continue to fulfil its function once the operation is complete (end-to-end anastomosis).

The remainder of the operation (removing the testicles, shortening the urethra and vaginal aesthetics) develops in the same fashion as the penile inversion technique.

Admission to the hospital centre

The patient will remain admitted for seven days post-operative, to be evaluated daily by medical team at IM CLINIC Gender Unit and to ensure the patient’s peace and comfort after such a complicated process.

During the post-operative visits, a supervision protocol will be followed in all possible cases, monitoring vital signs, overseeing progressive dietary increase, rotation of analgesics and antibiotics orally, monitoring early mobility and managing pain.

In the case of a colovaginoplasty, it is preferable that the intestine does not recover its motility until a few days post-operative have passed, when food intake can begin orally.

During the hospital admission, the patient will receive subcutaneous enoxaparin to avoid thrombi growth.

On the last day of admission, a doctor from the Gender Unit will conduct the first dilatation of the neovagina under a standardised protocol and will instruct the patient so that she can perform the recommended dilatations at home.

As well as correct post-operative monitoring, the medical team will at all times assess each patient’s social support and vulnerability individually.

Hospital discharge

The urinary catheter will remain in place until the tenth day or until periurethral inflammation is minimal, so the patient is discharged with the catheter in place.

The patient undertakes to perform the dilatations indicated by the physician, following the technique taught including the bathing protocol and to take the recommended analgesic treatment and antibiotic therapy.

Once at home, the patient should contact the endocrinologist who supervises their hormone treatment to restart it (after around four weeks) and readjust the dosage. Under no circumstances should the patient readjust the hormone treatment dosage themselves as this could cause health problems.

Possible complications

Any procedure entails a risk of complications. The most common in this procedure are infection, bleeding or haematoma and urine retention. In the late post-operative phase, vaginal introitus stenosis, urethral or meatal stenosis, recto-vaginal fistulae, clitoris pain, venous thrombosis or blood clots may appear.

Furthermore, the possibility of a failure in the colonic suture should be considered, requiring a timely diagnosis and early intervention. This situation involves a serious risk for the patient, who would have to remain admitted for a prudential period of time so as to correctly evaluate the evolution of the intestinal transit.

The new vagina may also become necrotised from lack of blood circulation through the vascular pedicle.

A member of the medical team will instruct the patient on how to avoid these possible complications and what to do if they appear. If the patient has any doubt or anomaly after the operation, she should consult her doctor, so that they can diagnose her and provide a solution.

Post-operative visits

It is very important not to miss any of the post-operative consultations with any member of the medical team. Only they can evaluate the evolution of recovery from the colovaginoplasty.

As a general rule, after the hospital (but not medical) discharge, an appointment will be made for the patient’s next visit, more or less three weeks after the hospital discharge (one month after the operation). During this time, the patient will have access to a phone number for post-operative support at all times, to resolve any doubts that may arise.

The following medical visits will be at approximately three months, six months and one year after the operation.