Technical considerations for neovaginal canal creation during primary and revision gender-affirming vaginoplasty

A critical component of gender-affirming vaginoplasty is the creation of a functional neovaginal canal capable of penetrative intercourse. Canal creation is inherently challenging due to the deep pelvic anatomy and risk of injury to the urethra, bladder, and rectum. These challenges are amplified in revision cases undertaken to correct neovaginal stenosis or convert minimal-depth to full-depth canals. With increasing interest in and access to gender-affirming surgery, myriad techniques for canal creation have arisen. These utilize a variety of donor tissues to line the canal, including genital and extragenital skin grafts, xenografts, allografts, peritoneum, and intestine. Moreover, the rectoprostatic dissection necessary for canal creation can be performed via a perineal approach or with robotic assistance. However, few comparative studies exist to inform the choice of surgical approach or donor tissue. In this article, we briefly review the donor tissue options available for neovaginal canal creation, discuss the associated advantages and disadvantages, and reference pertinent contemporary research. We additionally describe our institutional approach for canal creation in primary and revision vaginoplasties, highlighting technical nuances for success.