We read with great interest the article by Manrique and colleagues entitled, “Gender-Confirmation Surgery Using the Pedicle Transverse Colon Flap for Vaginal Reconstruction: A Clinical Outcome and Sexual Function Evaluation Study.”1 The authors should be complimented on the description of a novel technique for laparoscopic intestinal vaginoplasty, with a low complication rate and good postoperative sexual function and genital self-image. As stated in their study, bowel conduits for vaginoplasty are increasingly popular, because young transgender women treated with puberty-suppressing hormones develop penoscrotal hypoplasia, making standard penile inversion vaginoplasty not feasible.1
However, we encourage the authors to substantiate their choice to use a pedicle transverse colon flap instead of another part of the bowel such as the more-often-described sigmoid or ileal segments.2 In our clinic, we perform over 10 laparoscopic sigmoid vaginoplasties per year, with good functional outcomes and low complication rates.3,4 After reading the article by Manrique et al., it remains unclear what the benefits are of the transverse colon. Are there technical advantages regarding anastomosis or length of pedicle? We have concerns about the possible limitations to reach the pelvic floor without torsion or tension. Can you please inform us about the mobilization of the ascending and descending colon that was performed to make a continuity restoration possible? It seems necessary to fully mobilize the hepatic and splenic flexure, which can be demanding. Which pedicle is used for the transverse flap? Do the authors use the marginal artery supplied by the middle colic artery, or is the Drummond artery used? In the literature, an anastomosis near the splenic flexure (Griffiths point) is associated with an increased leakage rate because of ischemia. The mean operating time of 10.2 hours suggests a difficult dissection, compared with the average operating time of under 4 hours for a laparoscopic sigmoid vaginoplasty in our hands, as recently published.4
In the Discussion, disadvantages of using a sigmoid segment for this procedure are mentioned: excessive discharge, mucous stasis, and in some cases malodor. Does this also apply to the transverse colon interposition? One patient had an introitus stenosis, the most common complication in intestinal vaginoplasty, mostly caused by relative ischemia (mean, 5 percent; range, 1 to 6 percent).2 Did the authors take special measures in this series to prevent stenosis by, for example, using an exaggerated interdigitating anastomosis at the perineum? What was the intervention to solve the problem? Another known complication after sigmoid vaginoplasty is diversion neovaginitis.5 Is the chance of developing diversion neovaginitis lower when using the transverse colon? Finally, we believe the study results require some scrutiny. The authors have provided averages of the Female Sexual Function Index, measurements of the neovagina, and the follow-up duration. However, no ranges or standard deviations are provided. Furthermore, little information is given regarding the demographics of the included patients, such as preoperative penile skin length. The conclusions of the article would have been more powerful and valid with the above-mentioned additions. Nevertheless, we appreciate this work and presentation of a novel technique. We look forward to the authors’ response to our questions.
The authors have no financial disclosures to declare. There was no funding obtained for the production of this communication.
Claire V. A. van Hövell tot Westerflier, M.D.Department of Plastic, Reconstructive and Hand SurgeryVU University Medical CenterAmsterdam, The Netherlands
Wilhelmus J. H. J. Meijerink, M.D., Ph.D.Department of Operation RoomsRadboud UniversityNijmegen, The NetherlandsGender Surgery AmsterdamAmsterdam, The Netherlands
Jurriaan B. Tuynman, M.D., Ph.D.Department of Colorectal SurgeryVU University Medical CenterAmsterdam, The Netherlands
Wouter B. van der Sluis, M.D., Ph.D.Department of Plastic, Reconstructive and Hand SurgeryVU University Medical CenterAmsterdam, The Netherlands
Mark-Bram Bouman, M.D., Ph.D.Department of Plastic, Reconstructive and Hand SurgeryVU University Medical CenterAmsterdam Public Health Research InstituteGender Surgery AmsterdamAmsterdam, The Netherlands
1. Manrique OJ, Sabbagh MD, Ciudad P, et al. Gender-confirmation surgery using the pedicle transverse colon flap for vaginal reconstruction: A clinical outcome and sexual function evaluation study. Plast Reconstr Surg. 2018;141:767771.
2. Horbach SE, Bouman MB, Smit JM, Özer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12:14991512.
3. Bouman MB, van der Sluis WB, van Woudenberg Hamstra LE, et al. Patient-reported esthetic and functional outcomes of primary total laparoscopic intestinal vaginoplasty in transgender women with penoscrotal hypoplasia. J Sex Med. 2016;13:14381444.
4. Bouman MB, van der Sluis WB, Buncamper ME, Özer M, Mullender MG, Meijerink WJ. Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: A prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg. 2016;138:614e623e.
5. van der Sluis WB, Bouman MB, Meijerink WJHJ, et al. Diversion neovaginitis after sigmoid vaginoplasty: Endoscopic and clinical characteristics. Fertil Steril. 2016;105:834839.e1.