General Information
What is gender-affirming bottom surgery?
Some patients with gender dysphoria desire removal of male genitalia (penis, testes, scrotum) and construction of female genitalia (clitoris, labia, vagina).
Goals of this surgery include gender affirmation, maintenance or enhancement of sexual and urinary function, increased comfort and safety in public settings, and receptive vaginal intercourse.
Types of bottom surgery include:
Orchiectomy +/- scrotectomy - removal of the testicles with or without removal of the scrotum.
Undergoing orchiectomy DOES NOT affect future vaginoplasty/vulvoplasty options, however removal of the scrotum does limit options for vaginal canal creation.
Minimal depth vaginoplasty / vulvoplasty - creation of external female genitalia without creation of a vaginal canal.
Robotic peritoneal flap vaginoplasty (RPFV) - creation of external female genitalia with a full depth vaginal canal that is augmented by peritoneum.
Penile inversion vaginoplasty - creation of external female genitalia and use of the penile skin alone to create a vaginal canal.
Colon vaginoplasty - creation of external female genitalia and creation of a vaginal canal with colon.
Personalized surgery (ie: phallus-preserving vaginoplasty) - offered on a case-by-case basis. Discuss with your surgeon.
What is robotic peritoneal flap vaginoplasty (RPFV)?
RPFV is a procedure done to create a vulva and a full depth vaginal canal.
It is a combined robotic/traditional surgery and often done with two surgeons working at the same time.
Internal:
A 2cm incision is made over the belly button to allow access for the surgical robot (DaVinci SP).
An additional 1cm incision is made over the right hip for an assistant instrument.
The robot is used to create a space for the vaginal canal in the plane between the prostate and the rectum.
The peritoneum is the lining of the abdominal cavity. It is mobilized to create the top half of the vagina.
External:
The clitoris is created out of the glans (head) of the penis.
The erectile bodies within the penile shaft are removed.
The penile skin is used to create labia minora.
The urethra is shortened to the level of the skin so you will urinate sitting down.
The testicles are removed. Please let us know if you are interested in fertility preservation, as removal of the testicles will make you infertile.
The scrotum is used to create the labia majora as well as the first half of the vaginal canal. Hair removal needs to be performed on the front of the scrotum prior to surgery.
The vaginal canal is created under the urethra and met up with robotic surgeon on the inside.
Am I a good candidate for RPFV?
We mostly follow WPATH SOC8 guidelines:
On hormones and socially transitioned for at least 6 months.
2 letters of support - 1 from your mental health providers, 1 from your hormone provider (endocrinologist or PCP).
SOC8 states that only 1 letter is needed but most insurances still require 2.
Any other medical or psychiatric conditions are well controlled.
You must be a non-smoker.
Active nicotine use impairs healing. You must stop all nicotine products at least 3 months before surgery.
If you are a diabetic, your A1c needs to be less than 6.5%.
Your BMI should be under 35.
Obesity increases risk of surgical complications and makes the surgery itself technically more difficult.
If your BMI is higher than 35 at time of consult, we will discuss healthy ways to lose weight and refer you for weight loss assistance, if applicable.
No history of rectal surgery, prostatectomy, or pelvic radiation.
If you have this history, consider a minimal depth vaginoplasty as creating a canal has an excessively high risk of rectal injury and is not recommended.
Understand and be willing to commit to lifelong dilation.
What are potential complications of RPFV?
As with any surgery, there is a risk of bleeding, infection, and injury to surrounding structures.
External complications:
Loss of definition of the labia minora
Decreased sensation of the clitoris due to scar tissue
Introital stenosis
Urethral stenosis
Internal complications:
Loss of vaginal depth
Granulation tissue
Preparing for Surgery
What must be done or ready prior to my surgery?
Most insurances require two letters of support - one from your hormone provider (endocrinologist or PCP) and one from your mental health provider.
These letters must be dated within 1 year of your surgery date.
Double check your insurance requirements here or directly with your insurance carrier.
Plans differ in terms of letter and hormone requirements. Make sure you follow their guidelines in order to avoid delays with scheduling surgery
Hair removal of the scrotum with either electrolysis or laser.
BMI <35.
Not actively smoking tobacco products.
You do not need to stop your hormones.
General readiness and preparation
Appropriate expectations regarding external appearance and dilation schedule.
Financially ready to take at least 6 weeks off work. 8-12 weeks is preferable, if possible. Check with your employer about short-term disability or medical leave.
Consistent and scheduled access to mental health care.
Housing stability and sufficient social support.
What will my hospital stay be like?
This surgery requires at least 5 days in the hospital.
Days 0-4 are focused on ambulation and pain control.
On day 4, the catheter will be removed from the bladder and the dressing will come off the vulva.
On day 5, you will be taught how to dilate.
Discharge usually occurs on day 5.
Letters of Support
As per the guidelines set forth by the World Professional Association for Transgender Health (WPATH) in the Standards of Care (SOC) version 8, you will require 1-2 letters of support prior to your gender affirmation surgery. Your first letter must be from your mental health provider. If you are undergoing vaginoplasty, vulvoplasty, or phalloplasty, you also need an additional letter from your hormone provider (endocrinologist or PCP).
WPATH's SOC 8 serves as a comprehensive resource for healthcare professionals, ensuring that transgender and gender nonconforming individuals receive competent and compassionate care. In line with these guidelines, your readiness for gender affirmation surgery is typically assessed through the evaluation of referral letters from qualified mental health professionals as well as your hormone provider (if necessary). These letters should come from professionals who are knowledgeable about gender identity and experienced in providing mental health support to transgender individuals.
Surgery cannot be scheduled until all letters have been received and meet the requirements outlined in this document. Letters that do not follow the format below will be returned for completion. Please show this document to the provider(s) writing your referral.
RECOMMENDED CONTENT FOR MENTAL HEALTH LETTERS:
1. Description of the provider’s qualifications as well as the duration of their relationship with the patient. Include types of evaluation and therapy to date.
2. The patient’s general identifying characteristics.
3. Results of a psychosocial assessment, including all psychiatric diagnoses and accompanying psychiatric medications.
4. An explanation that the criteria for surgery have been met, and a brief description of the clinical rationale for supporting the patient’s request for surgery. Criteria include:
Confirmation of the patient's persistent gender dysphoria diagnosis.
Documentation of the patient’s capacity to provide informed consent.
If significant mental health concerns are present, they must be well-controlled.
5. Assessment of the patient’s understanding of the potential benefits and risks of gender-affirming surgery.
6. Evaluation of the patient’s overall mental health and ability to cope with the surgery and recovery process.
FOR HORMONE PROVIDERS:
1. Description of the provider’s qualifications as well as their duration of their relationship with the patient.
2. Duration and dosage of current hormone medications.
3. Confirmation that the patient has been on hormones for at least 6 months.
OTHER HELPFUL TIPS FOR LETTER WRITERS:
Each letter needs to specifically state the type of surgery that the patient is requesting (ie: vaginoplasty or orchiectomy).
Letters must be dated within 12 months of surgery date.
The letter must be signed. Insurance companies will not accept electronic signatures.
Each provider needs to submit a separate letter. One letter signed by multiple providers will only count as one letter.
Send your letters via MyChart so they can be uploaded into your chart.
Hair Removal Template
Hair removal is required for full depth vaginoplasty. It is not required for orchiectomy or minimal depth vaginoplasty.
Remove all hair in the yellow outlined area, from the base of the shaft to the anus and between each groin crease. This will include scrotal and perineal skin which will be used to line a portion of your vaginal canal. You may also perform hair removal of the top and sides of the scrotum if you would like, although this is not required.
Either electrolysis or laser hair removal can be done. Consult with a hair removal technician to learn more about what may work best for your skin and hair type.
The number of sessions required for complete hair removal will vary amongst individuals. Discuss this with your hair removal technician.
Plan ahead. Hair removal can take as long as 6 months to a year.
Hair removal needs to be completed at least 2 weeks prior to your surgery date.
Post-Operative Instructions
***DISCLAIMER***
The below instructions are provided to Dr Alford’s patients. If you are undergoing a procedure with a different surgeon, please follow the discharge instructions that were given to you at discharge.
Wound Care
Shower using a mild foaming cleanser or gentle soap. Wash between all folds and creases. Gently pat incisions dry.
No baths or submersion in other bodies of water until all incisions are completely healed, usually around 4-6 weeks.
Douche daily as directed with normal saline. When you have used all of the normal saline that you were sent home with, continue douching with a mixture of half tap water and half white distilled vinegar. It is easiest to douche when in the shower.
Dilate 4 times/day as directed.
Remember to wipe from front to back after urinating or defecating.
Medications
Take Tylenol (acetaminophen) every 6 hours.
Take Motrin (ibuprofen) every 6 hours.
Tylenol and Motrin should alternate:
For example: Tylenol 12MN/6AM/12noon/6PM and Motrin 3AM/9AM/3PM/9PM.
Take Neurontin (gabapentin) every 8 hours - this also helps with pain and is not a narcotic.
Only use the narcotic medication (oxycodone) for pain NOT relieved by the Tylenol, Motrin and Neurontin. An occasional sharp pain does not qualify as severe pain.
It is important not to become constipated.
Use gentle laxatives (Sennakot, Dulcolax or Miralax) as prescribed. You should hold the medications if stool is loose.
Constipation/straining can cause vaginal bleeding.
Do NOT use suppositories or enemas.
You may continue your estrogen at the same dose you were taking prior to surgery. Please see or speak with your hormone provider regarding resuming the hormone blockers (Aldactone).
Resume your home medications unless specifically advised otherwise.
Vaginal Medications
Metrogel - apply to tip of dilator for FIRST dilation of the day. Apply lubricant just below the Metrogel. Use this for 4-6 weeks or until you run out.
Santyl - apply to tip of dilator for the LAST (FOURTH) dilation of the day. Apply lubricant just below the Santyl. Use this for 4-6 weeks or until you run out.
Regenecare - lubrication with lidocaine in it, okay to use in addition to or instead of lube/lidocaine jelly. OK to use long-term. This is purchased over-the-counter or online.
Lidocaine jelly - can be used to help with stinging pain with dilation. Apply a small amount to the opening of your vaginal canal, 15-30 minutes prior to dilating. You may not need to use this at all.
Activity
Walking is good for you. Walk around every hour while you are awake. Balance activity with rest.
No more than one flight of stairs at a time. Take stairs slowly and carefully.
No lifting more than 10lbs for 6 weeks.
Avoid pushing, pulling or straining for 6 weeks.
No gym or strenuous physical activity for 6 weeks.
No sexual intercourse (VAGINAL OR ANAL) until cleared to do so after follow up appointment. This will usually be at your 3 month visit.
Diet
Resume pre-op diet.
Eat more fiber to prevent constipation. Foods like fruits, vegetables and whole grains have a lot of fiber.
Drink lots of water - aim for 2L a day.
Avoid excessive alcohol intake.
If You Are Sent Home with a Urinary Catheter
Empty the urinary drainage bag frequently during the day. Please keep the leg bag attached to your leg. Do NOT allow the bag to hang freely, as this will pull down on the catheter and cause pain.
Change to bedside drainage bag (larger bag) at night. The night bag holds more urine, and allows you to sleep through the night without having to get up to empty the bag.
Wash hands before and after manipulating the catheter.
You can shower with your catheter and drainage bag.
Increasing your activity may cause your urine to turn intermittently pink or bloody, which is normal.
Patients who have catheters often have the sensation of needing to urinate, even though the urine is draining through the catheter. This sensation is known as bladder spasms. If this sensation is especially painful for you, please contact the office and we can prescribe an additional medication.
Dilation Schedule
Weeks / Months After Surgery:
5 days to 6 weeks: 4x/day
6 weeks to 12 weeks: 3x/day
12 weeks (3m) to 4 months: 2x/day
4 months to 6 months: 1x/day
6 months to 8 months: 3x/week
8 months to 12 months: 2x/week
12 months on: 1x/week
Tips for Dilating:
Upsize as you feel comfortable. Focus on width/girth at the beginning and depth after you feel comfortable with your routine.
Establish care with a pelvic floor physical therapist by 6-8 weeks post-op to help with dilating.
Continue dilating even when/if you start having receptive intercourse.
Lifelong dilation is recommended at 1x/week.
Literature Review
Robotic peritoneal flap vs perineal penile inversion techniques for gender-affirming vaginoplasty. Peters et al, 2022.
Discussion of standard penile inversion vaginoplasty (PIV) compared to robotic peritoneal flap.
Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. Jacoby et al, 2019.
Results (average follow-up of 119 days):
Average vaginal depth 14.2 cm.
Average vaginal width 3.6 cm.
20% of patients experienced granulation tissue and/or delayed healing at introitus, all resolved with supportive cares.
Excellent accompanying video and technique description (Jun et al, 2021).
Outcomes of gender-affirming peritoneal flap vaginoplasty using the Da Vinci single port vs Xi robotic systems. Dy et al, 2020.
Comparison of the Xi vs SP robotic platforms for RPFV.
SP is significantly faster, no difference in complications.
Results (average follow-up of about 12 months):
Average vaginal depth with SP: 14.1 cm (range 9.7-14.5 cm).
Average vaginal width with SP: 3.7 cm (3.5-3.8 cm).
Complications (SP):
Blood transfusion 2%
Vaginal stenosis 2%
Acute urinary retention 9%
Rectovaginal fistula 2%
External revision 11%
Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis. Dy et al, 2021.
Assesses the use of RPFV in patients who have had prior penile inversion vaginoplasty and experienced canal stenosis.
At average follow-up of 410 days (range 179-683):
Average vaginal depth 13.6 cm (range 10.9-14.5 cm).
Average vaginal width 3.6 cm (range 2.9-3.8 cm).
No intra-operative rectal injuries.
Genital hypoplasia before gender-affirming vaginoplasty: does the robotic peritoneal flap method create equivalent vaginal canal outcomes? Blasdel et al, 2022.
Compared patients with pre-op penis length less than 7cm and greater than 7cm.
No significant differences in vaginal depth after RPFV based on pre-operative penis size.
Mending the gap: AlloDerm as a safe and effective option for vaginal canal lining in revision robotic-assisted gender-affirming peritoneal flap vaginoplasty. Parker et al, 2023.
Patients undergoing revision vaginoplasty no longer have scrotal skin available to line the first half of the vaginal canal.
AlloDerm is an acellular dermal matrix that allows for additional coverage between the introitus and the peritoneal flap.
At median follow-up of 368 days:
Median vaginal depth 12.1 cm
Median vaginal width 3.5 cm
The management of intra-abdominal complications following peritoneal flap vaginoplasty. Robinson et al, 2022.
Over three years, 2.2% of patients developed intra-abdominal complications that required another surgery.
Postop hematoma (1), intra-abdominal abscess (2), small bowel obstruction (1), incarcerated internal hernia (2).
Sexual health after vaginoplasty: a systemic review. Kloer et al, 2021.
17.4% - 100% (median 79.7%) of patients are able to orgasm post-operatively, regardless of operative technique.
64% - 98% (median 81%) of patients are happy with their general sexual satisfaction.
Coming soon: ability to orgasm after gender-affirming vaginoplasty. Blasdel et al, 2022.
Median time to orgasm after RPFV is 180 days.
At 12 months post-op, 86% of patients experience orgasms.