Introduction: Recently, in gender confirmation surgery, the peritoneal pull through option for male to female vaginoplasty procedures has arisen as a new exciting procedure. Traditionally, there is the more common option of the penile inversion technique (the McIndoe Procedure is the gynecologic equivalent) and then there is the more complex sigmoid colon vaginal construction procedure usually reserved for salvage or reconstruction. Peritoneal pull through has the theoretical benefit over the penile inversion technique of having lubrication, needing less dilation, less douching, less maintenance, and more depth. This option may be less risky than sigmoid colon vaginas; not having the risk of anastomosis breakdown, having less risk of prolapse, not having odorous mucus discharge, no need for monitoring colon pathology. Due to these benefits, patients are interested and asking more about the peritoneal pull through option. So, do we adopt this procedure as the best option for our patients born without vaginas?

Definition: What is the peritoneal pull through procedure? The medical name for the gynecological version of this procedure is the Davydov Procedure. It is a combination perineal and abdominal approach procedure developed to help women who had congenital absence of their vaginal canal. A vaginal opening was created or further developed on the perineum. Then an abdominal procedure opened and connected the lower developed portion of the vagina to the upper peritoneal/abdominal cavity. Obtaining, dragging the abdominal (peritoneal) lining down, and then sewing the peritoneum to the existing lining or graft from the perineal approach is performed. The top of the opening is then closed to separate the vagina from the peritoneal/abdominal cavity.

Background: Peritoneal pull through procedure was developed by pelvic surgeons to help women with a congenital absence of their vaginal canal. The syndrome associated with an absence of the vaginal canal and other Mullerian associated anomalies is Myer-Rokitansky-Kuster-Hauser Syndrome (MRKH Syndrome).

Incidence: MRKH syndrome affects approximately 1 in 5000 (range 1 per 4000 to 10,000 females). [1,2]

Some surgical procedures offered to MRKH patients are similar to the male to female vaginoplasty procedures:

MRKH MTF Vaginoplasty 1a) McIndoe Procedure 1b) Penile Inversion Technique 2a) Sigmoid Vaginoplasty 2b) Sigmoid Vaginoplasty 3a) Davydov Procedure 3b) Peritoneal Pull Through Procedure

1a) McIndoe procedure – The McIndoe procedure, which is often used by gynecologists, utilizes a split-thickness skin graft from the buttocks [3,4]. This graft is placed over a form with the dermal side facing the vaginal space/form. This form is kept in place for approximately a week. Postoperative dilation of vaginal lining required. Risks including graft failure, hematoma and fistula are in the range of 5-10%. [5,6,7]

1b) Penile inversion procedure – Also uses split-thickness skin graft from scrotum, groin or lower abdomen for upper portion of vagina, applied in same fashion around a form. The distal opening of the vagina is a full thickness graft of penile skin sewn to the additional split-thickness graft. Dressing and vaginal packing kept in place for 5-10 days, then lifetime dilation, addition of lubrication, douching required. Risks include graft failure, hematoma, fistula, stenosis, stricture, pain, persistent gender dysphoria, wound separation, further surgery. Surgical risks range from 4-60%.

2a & 2b) Sigmoid vaginoplasty – A segment of transected sigmoid is pulled down to the introitus to form a neovagina, and the other end is closed to create a blind pouch. An end-to-end reanastomosis is performed to recreate a patent gastrointestinal tract. The advantage of this procedure over the McIndoe is that maintenance with dilation, adding lube, and douching may not be required. Risks include infection, sepsis, anastomosis breakdown, stenosis at the anastomotic sites, prolapse of the graft, chronic mucus discharge with a foul odour, risks of colonic pathology occurring in graft lining. [8,9,10].

3a) Davydov Procedure – The Davydov technique can be performed open, laparoscopically, robot assisted laparoscopically. Dissection of the rectovaginal space, releasing peritoneum and pulling the lining down to the existing vaginal lining, then sewing both linings together. The proximal/abdominal portion of the vaginal lining is closed with a purse string suture. [11,12,13].

3b) Peritoneal Pull Through Procedure – Just as in the Davydov Procedure, an abdominal approach to obtain peritoneum and develop Denonvilliers fascia between the rectum and prostate to create a space for the neo-vagina or vaginal reconstruction. Risks include all the risks involved in a penile inversion technique if being done concurrently, as well as: stricture, stenosis, graft failure, lack of lubrication, and risks of abdominal procedure of damage to bowel, bladder, prostate, muscles, nerves, and vessels. Another risk is the lack of literature and long term data on this procedure.

Literature: There is very little information on long term outcomes for MRKH and MTF vaginoplasty procedures.

Conclusion: Surgeons are striving for a vaginoplasty procedure which creates the desired features of a natal vagina. Goals for vaginoplasty procedures: to create a vagina which is natural in appearance, has self-lubrication, minimal upkeep (minimal to no dilation, minimal to no douching), functions for sexual experiences, has erogenous sensation, and has acceptable surgical risk. The peritoneal pull through technique is promising for most of the above features, and offers more possible features than either the penile inversion technique or the sigmoid vaginoplasty.

However, there is a paucity of long-term data for MRKH patients with peritoneal pull through procedures and even less information for the peritoneal pull through procedure for MTF vaginoplasty procedures. Caution in performing the peritoneal pull through procedure until more information is available seems prudent.

At this point, this option may be an option for patients who need salvage vaginal reconstruction whose only option is colon procedure or patients who need more grafting than is available by traditional penile inversion technique: gender non-conforming procedures (ie penile preservation vaginoplasty) or patients with atrophic anatomy (congenital, acquired, women who have been exposed to puberty blockers).

We need to have transparency of follow up for these patients in the interest of future informed consent for our patients.

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Dr. Heidi Wittenberg is an experienced Urogynecologist based in San Francisco who offers transgender bottom surgery procedures, including Orchiectomy, Penectomy, Vulvoplasty and Vaginoplasty. Dr. Wittenberg works exclusively with trans patients. To speak with Dr. Wittenberg about gender affirming genital surgery, please contact her office to arrange a consultation.