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well-vascularized canal, natural lubrication from the intestinal mucosa, and plentiful donor tissue without
[4]
the need for extragenital skin grafting . The sigmoid colon is the most common intestinal segment utilized
[35]
due to its large lumen, thick walls, and proximity to the pelvis . However, with any type of intestinal
vaginoplasty, there are unique risks related to bowel harvest and anastomosis, diversion colitis,
inflammatory bowel disease, and the need for long-term surveillance of gastrointestinal malignancy within
[2]
the neovaginal segment . Additional disadvantages include the production of malodorous discharge and
mucus. As such, intestinal flaps are less commonly offered for primary gender-affirming vaginoplasty; some
[7]
authors consider it a favorable option for revision cases when facing a severe lack of suitable donor tissue .
OUR EXPERIENCE AND TECHNICAL CONSIDERATIONS FOR CANAL CREATION
Our institutional approach for primary and revision vaginoplasties reflects these considerations. We use the
robotic platform to facilitate and standardize pelvic dissection and canal creation. For full-depth
vaginoplasty, we primarily offer penile inversion vaginoplasty with scrotal skin grafts. For revision
vaginoplasty, we utilize peritoneal flaps with or without extragenital FTSGs; the need for grafts depends on
the depth of the remnant neovaginal canal.

Minimal-depth vaginoplasty
In some circumstances, patients pursue vaginoplasty without creation of a functional vaginal canal, termed
minimal-depth vaginoplasty, zero-depth vaginoplasty, or vulvoplasty. This is a unique aspect of our
institutional practice in that it comprises roughly 50% of our total vaginoplasty volume.

Patients seen in our clinic for gender-affirming genital feminization are counseled extensively regarding
surgical options (minimal versus full-depth) and associated perioperative risks, long-term care, and
implications for intimacy and intercourse. We elicit patients’ particular aesthetic and functional preferences.
We also strive to entertain niche requests (e.g., penile-preserving vaginoplasty) so long as they are surgically
feasible and in concordance with patients’ goals of care.

Patients in our practice who elect for minimal-depth vaginoplasty may prefer its relative “simplicity” over
the demands of routine long-term dilation, which we stress as critical to the success of full-depth
vaginoplasty. Some have cited the cost and time commitment of preoperative depilation as deterrents to
electing full-depth vaginoplasty. Lastly, the high proportion of minimal-depth vaginoplasty in our practice
may simply reflect regional variations in patient preference and sexual practices; put simply, such patients
seek out the “low maintenance” option. We have similarly noted a high proportion of patients who seek
gender-affirming orchiectomy only, with no plans for future vaginoplasty.

Minimal-depth vaginoplasty precludes penetrative vaginal intercourse, albeit with several advantages: (1)
shortening operative times and minimizing perioperative morbidity, (2) avoiding the potentially hazardous
rectoprostatic dissection, and (3) obviating the need for preoperative hair removal and long-term
[36]
neovaginal canal douching and dilation . Patients should consider this a relatively permanent decision,
given that healthy scrotal skin is discarded. However, we and others have described techniques for the
conversion of minimal-depth to full-depth neovaginas .
[37]

Though there is no true neovaginal canal created during minimal-depth vaginoplasty, we have noted several
nuances critical for success. After taking down the perineal body, the neovagina is set at the level of the
membranous urethra. After inverting the penile skin tube, the ventral skin (oriented posteriorly after
inversion) is incised longitudinally to meet the perineal skin flap posteriorly; the perineal skin is similarly
incised for tension-free apposition. These incisions determine the angle of the minimal-depth canal, which