Is Rectosigmoid Vaginoplasty Still Useful? Seok-Kwun Kim, Ji-Woen Park, Kwang-Ryeol Lim, Keun-Cheol Lee Department of Plastic and Reconstructive Surgery, Dong-A University School of Medicine, Busan, Korea Original Article Background The ideal vaginoplasty must be successful functionally as well as have a natural Correspondence: Seok-Kwun Kim appearance, and also must retain its functionality and appearance over the long term. Department of Plastic and Reconstructive Surgery, Dong-A Conventional vaginoplasty techniques have functional limitations and are associated with University School of Medicine, 26 recurrent complications, but rectosigmoid vaginoplasty is known to have a high satisfaction Daesingongwon-ro, Seo-gu, Busan rate due to its functional similarity with the vagina. We conducted the present study to 49201, Korea assess the usability of rectosigmoid vaginoplasty over the course of long-term follow-up. Tel: +82-51-240-2807 Fax: +82-51-243-5416 Methods From March 1992 to February 2014, 84 patients were treated with rectosigmoid E-mail: [email protected] vaginoplasty; 44 had gender identity disorder, 29 had vaginal agenesis, 8 had female pseudohermaphroditism, and 3 had gynecologic malignancies after radical pelvic surgery. This retrospective study was based on a review of the patients’ records, clinical examinations, complications, and questionnaires about appearance, function, and sexual intercourse. Results All patients who underwent rectosigmoid vaginoplasty were discharged within 2 weeks without surgical flap loss. The early complications were partial flap necrosis, difficulty in defecation, mucous hypersecretion, and postoperative ileus. The late complications were vaginal introitus contracture, vaginal prolapse, and difficulty in urination. The mean length and diameter of the neovagina 3.4 years after rectosigmoid vaginoplasty were 13.2 cm and 3.8 cm, respectively. On questionnaires about satisfaction, 70% of patients reported excellent satisfaction, 11% good, 12% fair, and 7% poor. Conclusions Rectosigmoid vaginoplasty is useful, safe, and well-accepted operative method This study was supported by research with good functional and cosmetic results, such as natural lubrication and adequate vaginal funds from Dong-A University. length and width obtained without requiring the use of a dilator. No potential conflict of interest relevant Keywords Gender identity / Vagina / Surgical flap to this article was reported. Received: 6 Sep 2016 • Revised: 19 Oct 2016 • Accepted: 20 Oct 2016 pISSN: 2234-6163 • eISSN: 2234-6171 • https://doi.org/10.5999/aps.2017.44.1.48 • Arch Plast Surg 2017;44:48-52 INTRODUCTION treatment using vaginal expanders and surgical treatments, such as full-thickness skin grafts, split-thickness skin grafts, local flaps For many years, reconstruction of the female genitalia has been such as labial flaps, and penoscrotal vaginoplasty, which is used performed. Diverse methods are used for patients with vaginal for gender identity disorder patients. Special materials are also agenesis, also known as Mayer-Rokitansky-Küster-Hauser syn- used, such as peritoneum, bladder mucosa, amnion, and oxi- drome; male pseudohermaphroditism; gender identity disor- dized regenerated cellulose fabric. However, these surgical der; and for patients whose vagina has been removed due to a methods require the use of expanders or stents to prevent canal gynecologic neoplasm. obstruction, and other complications, such as stenosis, contrac- The methods of vaginal reconstruction include non-surgical ture, and unpleasant odor may arise [1,2]. Copyright © 2017 The Korean Society of Plastic and Reconstructive Surgeons This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-aps.org 48 Vol. 44 / No. 1 / January 2017 On the contrary, vaginal reconstruction using the rectosig- tery. The resected colon was descended to the vaginal canal, and moid colon does not require expanders, since the use of the en- the upper part was sutured and the lower part was anastomosed tire layer of the colon minimizes the chances of contracture. The to the perineal or penile flap. Physical examinations, including reconstructed vaginal length and width are compatible with sex- measurements of the length and width of the newly reconstruct- ual intercourse. The texture is also similar to the normal vagina, ed vagina, were performed during follow-up visits 1, 6, and 12 and the natural lubrication gives satisfaction to patients with re- months after the procedure. Subsequently, annual physical exam- spect to the functional and aesthetic results [3]. inations were conducted. The definition of vaginal width was the Although reconstruction of the female genitalia using the rec- greatest distance between the two endpoints of the vaginal ori- tosigmoid colon is effective because it has many advantages, No fice. The vaginal length was defined as the distance from the vagi- studies have reported the complications and viability of recto- nal orifice to the reconstructed vaginal vault. sigmoid vaginoplasty over the long term. Therefore, the authors We surveyed the operative method and complications using of this paper analyzed the records of 84 patients who underwent patient records, and interviewed the patients directly to inquire rectosigmoid vaginoplasty over the course of 23 years to identify about any recent medical conditions. The patients were sur- complications and characterize the long-term outcomes. veyed about their functional or aesthetic satisfaction with the newly reconstructed vagina, the presence of any complications, METHODS and orgasm or pain associated with sexual intercourse. We analyzed and retrospectively collected the medical records of RESULTS patients who underwent rectosigmoid vaginoplasty in our medi- cal center between March 1992 and February 2014. A total of 84 All patients were discharged from the hospital within 2 weeks patients were included in this study, and the sample was com- without severe complications. During the follow-up period, no posed of 44 gender identity disorder patients, 29 patients with flaps showed total necrosis. A variety of complications occurred vaginal agenesis, 8 female pseudohermaphroditism patients, and in 30 cases. Eleven cases only required a simple surgical inter- 3 patients with cervical cancer who had undergone radical hyster- vention. The others required additional treatment. ectomy (Fig. 1). The patients ranged in age from 23 to 47 years, Seven patients (23%) experienced difficulty in defecation, 5 with a mean age of 28 years. The observation period ranged from (17%) experienced excessive mucous secretion, 3 (10%) expe- 0.5 years to 20 years, with a mean observation period of 3.4 years. rienced transient ileus, and 2 (7%) experienced partial necrosis The surgeon resected the part of the rectosigmoid colon where of the rectosigmoid flap. The late complications included 5 cases blood is supplied from the branch of the inferior mesenteric ar- of vaginal prolapse (17%), 4 cases of introitus contracture (13%), and 4 cases of micturition difficulty (13%) related to Fig. 1. Characteristics of the study group ureteral contracture (Fig. 2). According to the survey, constipa- tion, frequent defecation, and urgent defecation occurred within The study group consisted of patients with gender identity disorder (male to female), vaginal agenesis, female pseudohermaphroditism, 3 months of the surgery, and these symptoms all improved with and cervical cancer. time. Excessive mucous secretion, which is a common compli- Cervical cancer cation of rectosigmoid vaginoplasty, improved within 3 months. 4% This symptom lasted longer in a few patients, but showed a clear Female pseudohermaphroditism decrease by approximately a year after surgery. Postoperative ile- 9% us was a common complication, but conservative care brought spontaneous relief. Four patients showed contracture of the vag- inal introitus, and correction was performed with a multiple Z- Gender identity disorder plasty and local flap. In 4 of the 5 vaginal prolapse patients, the (Male to female) problem was resolved by excising the prolapsed mucosa and fix- Vaginal agenesis 52% 35% ating it to the vaginal wall. One patient with severe vaginal pro- lapse had to undergo a second abdominal operation to ascend the rectosigmoid flap. Four patients suffered from voiding diffi- culty due to partial stenosis of the urethral orifice. Symptoms did not subside in 2 of these 4 patients, and they underwent ex- cision and suture of the stricture site. 49 Kim SK et al. Rectosigmoid vaginoplasty Fig. 2. Complications after rectosigmoid vaginoplasty Fig. 4. Patient satisfaction after rectosigmoid vaginoplasty (%) Partial flap Bad necrosis 7% 7% Defecation difficulty Fair Vaginal prolapse 23% 12% 17% Good Urination difficulty Mucous 11% 13% hypersecretion Excellent 17% 70% Postoperative Vaginal ileus introitus 10% contracture 13% Fig. 3. Size of the rectosigmoid flap and neovagina Neovagina 3.8 (after 12 mo) 13.2 Rectosigmoid flap 4 (intraoperative) 14 3.2 Normal vagina 9.4 Diameter (cm) Length (cm) 3.4 Erect penis 12 0 2 4 6 8 10 12 14 (cm) At a long-term (12-month) follow-up, the length of the vagina over 80% of patients reported being satisfied with the outcomes ranged from 11.3 to 15 cm, with a mean of 13.2 cm, which