The repair of a colonic neovagina using a biological graft in a transgender patient. The authors declare no relevant conflicts of interest. One in 2,900 genotypical males report gender dysphoria. In 2016, 390 out of 100,000 adults were estimated to be transgender. Genital stenosis is the most common complication in both penile-scrotal skin inversion and bowel vaginoplasty. Grafts using porcine extracellular matrix have been used in vaginal reconstruction with evidence that porcine bladder matrix acts as a scaffolding for smooth muscle tissue and matrix regeneration. In this image of normal male anatomy, note the location of the testes, the prostate, the urethra, and the seminal vesicles. After a rectosigmoid vaginoplasty, note the location of the colonic neovagina and labia majora. The location of the prostate and seminal vesicle is unchanged. This case presents a 32-year-old with a history of rectosigmoid vaginoplasty for gender confirmation who presents to the office with genital adhesions and levator inis spasms. The patient underwent excision of the vaginal granulation tissue and lysis of scar at vaginal introitus. However, she developed a recurrence of the granulation tissue and underwent a second surgery for revision of introitus within five months. The granulation tissue then reformed within six months of her second surgery, and she once again presented with vaginal bleeding and stenosis of her introitus. The vaginal opening was obliterated by granulation tissue with adhesions across the midline. It did not allow entry of a finger, but only permitted a two-millimeter sound. The vaginal length was measured to be 12 centimeters. A Foley catheter was placed. The vasopressin, 20 units in 100 ml of normal saline, was injected around the vaginal opening. The granulation tissue was lysed in the midline up to four centimeters anterior to the vaginal opening. A combination of blunt dissection and electrocortis were used. Manipulation of the Foley catheter helped us avoid injuries to the urinary tract. Once again, dilute vasopressin was injected, and a medial lateral episiotomy was cut in the four and seven o'clock positions. The distal two centimeters of the levator plate was also lysed with frequent rectal examinations to ensure that there was no injury to the rectum. The vaginal introitus was opened to the point where healthy colonic tissue was reached. In this animation, notice how developing granulation tissue causes stenosis of the vaginal opening. The wound bed extended from the introitus to six centimeters inside where the colonic tissue began. The width of the introitus measured four centimeters. The porcine urinary bladder matrix is available in different sizes. We used the seven by 10 centimeter size. We cut a four centimeter square with an approximately six centimeter diagonal. The rough surface of the graft faces the defect while the smooth surface faces upwards. The biological graft was then sutured over the wound bed using 2-O-Vicryl. Interrupted mattress sutures were used to tack the graft to the underlying tissue. Multiple pieces of the graft were fashioned and sutured in place using 2-O-Vicryl. This was repeated until the entire wound bed was covered with the biological graft. You can see the excision of the granulation tissue to reestablish the vaginal introitus with the location of the biological graft. Note the relationship of the graft with the rectum posteriorly and the urethra and prostate anteriorly. All the graft edges are sutured to the edges of the wound bed. Cystoscopy at the end of the procedure was negative for any injuries and the patient was discharged home on postoperative day number one.

colonic neovagina repair

biological graft

transgender patient

genital stenosis

porcine extracellular matrix grafts