Doctors Share What They Have Learned After Performing 185 Peritoneal Pull Through Vaginoplasties!

It has been three years since my last blog post Risks and Benefits of Peritoneal Pull Through Vaginoplasty where I sat down with Dr. Heidi Wittenberg to explore the risks and benefits of the procedure.

In 2019, Dr. Wittenberg started offering peritoneal pull through vaginoplasty (PPT) to all patients who qualify, not just individuals unable to undergo the most common penile inversion technique.

Since, her private practice at MoZaic Care, specializing in gender related genitourinary and pelvic reconstructive surgeries, has expanded with the addition of Dr. Adam Bonnington. Adam, an amazing gender affirming surgeon, is just the right person to team up with Heidi to meet the increasing demand of individual’s desiring PPT vaginoplasty.

Together, they have performed 185 peritoneal pull through vaginoplasites to date!

I was thrilled to reach out to both of them for an opportunity to sit down and probe deeper into their knowledge, expertise, and especially follow up of semi-long term patients in regard to PPT and its benefits.

What they both shared inspired and renewed my hopes for continued advancement in transgender medicine, especially when it comes to complicated procedures such as vaginoplasty. Here is what they both had to say in response to my questions in an extensive interview we had.

DR Z: Heidi, Adam, thank you for sitting down with me. Please share approximately how many PPT procedures you have done up to date?

Dr. Wittenberg/Dr. Bonnington: Our clinic has performed a total of 185 peritoneal procedures to date, which includes primary vaginoplasty, vaginoplasty revision, and penile-preservation vaginoplasty.

DR Z: In my 2019 article I outlined some of the main benefits of PPT:

• Self-lubricating lining with some elasticity

• Less need for dilation (compared to that of the penile inversion technique)

• Less need for douching

• Less prep hair removal

• More vaginal depth

• Lower risk than colonic vaginoplasty

Do these benefits remain the same or have you noticed any additional benefits to PPT procedure over the course of your experience?

Dr. Wittenberg/Dr. Bonnington: Most of these benefits are still the same.  There is a natural discharge for most patients but it usually is not enough to replace the need to add synthetic lube for dilation or receptive play.  This little bit of discharge maybe does have a bit of a self-cleaning property as many of our peritoneal patients report back that they need to douche less often than the 1-2 times per week that we recommend. 

There is a little bit of elasticity, maybe at most 1cm of stretch at the top of the vagina.  And total depth is maybe 1-2cm more for some peritoneal patients compared to penile inversion. 

Dilation requirements are actually the same as the penile inversion technique.  There are rumors out there that you need to dilate less often with PPT but we have no long term data to corroborate that rumor, and have actually seen patients lose depth because they are not dilating.  And lastly yes, lower risk than colon vaginoplasty.

DR Z: That’s important to know that the dilation requirement are actually the same and not less than penile inversion! In regards to the risks, do these remain the same as listed in 2019 below?

• The same risks as penile inversion vaginoplasty

• Additional risks of an abdominal laparoscopic procedure, including intra-abdominal organ injury, ileus, herniation, and others

• Flap failure and stenosis

• Unknown long-term outcomes

Dr. Wittenberg/Dr. Bonnington: Most of these risks are still the same.  We have not had any flap failures with PPT, but we do sometimes see patients with vaginal stenosis, though not necessarily at a higher rate than penile inversion. The risk of stenosis and loss of vaginal depth are the same as PIV in our experience.

DR Z: By now you have performed over a hundred of PPT procedures, what have you observed from following up with semi-long patients post PPT?

Dr. Wittenberg/Dr. Bonnington: As we perform more surgeries, it seems like the differences between these methods are minimal.  So when patients are trying to decide between the options, it’s helpful for them to think about their comfort with risk and uncertainty. 

Some patients are very risk adverse and want to go with the option that has the most long-term data so they lean toward PIV.  Others are excited to be a part of a new and promising surgical technique and are okay without having that long-term data. 

Also, if either of these surgeries are unsuccessful the first time around, it’s important to think about what backup options exist.  If a PIV vagina scars closed for some reason, PPT can usually be performed a second time as a salvage procedure to recreate the vagina. 

If a PPT fails, there are less back-up options.  We cannot go back and do PIV, and at this point we don’t think a second peritoneal procedure is possible, so if PPT fails we only have colon or large skin grafting from other areas of the body as the backup options.  And the risk of losing the vagina for some reason is about 5% for either of these procedures.  So this also can help patients make decisions if they are undecided based on how they feel about that potential risk.

DR Z: While the 5% risk sounds minimal, I am glad we are having this discussion to help trans women make a better informed decision in regards to this surgery. Let’s compare and contrast a bit here. Based on your observations, are there benefits to PPT vs penile inversion PIV?

Dr. Wittenberg/Dr. Bonnington: The main difference/benefit that draws most patients to the PPT method is the natural lubrication, even though it’s not enough to replace adding synthetic lube. 

Also, sometimes patients are very worried about hair growth inside the vagina so they like the idea of a procedure with no chance of that.

Another potential benefit for full depth peritoneal flap vaginoplasty is that we have additional skin (from the penile shaft) to create labia minora flaps because that skin is not being used for the vaginal canal, unlike hybrid techniques.

The initial idea of utilizing this otherwise discarded tissue was that there might be longer term definition of the labia minora compared to the technique for creating labia minora with PIV which can result in softening or lack of definition over time.

DR Z: When it comes to qualifying, are there patients who do not qualify for PPT? If so, why?

Dr. Wittenberg/Dr. Bonnington: If patients have had extensive intraabdominal surgery, we talk about the risk of intraabdominal scarring that may make it not possible to safely harvest the peritoneal flap. 

Patients who overall have significant medical comorbidities are sometimes encouraged to go with less invasive options like PIV as it is less time under anesthesia (about 1-2 hours). 

PPT also requires we place them in steep Trendelenburg position with their legs higher than their head while doing the robotic portion of the case, which puts strain on the cardiopulmonary systems.  Conditions that preclude patients from any full depth procedure (for example, history of prostate cancer with prostate removal) would be the same for any of our full depth procedures.

Note the opposite: that peritoneal option is available for patients who do not have enough donor skin for full depth PIV ie puberty blockers, trauma, congenital anatomy.

DR Z: Given your current knowledge and experience, in your opinion, what remains biggest surgical complication risk related to PPT?

Dr. Wittenberg/Dr. Bonnington: Overall, we say there is a 2-4% increased risk of some sort of complication with PPT compared to our procedures that don’t involve going inside the abdomen. 

It’s more time under anesthesia and associated anesthesia risk, there are five small abdominal incisions that could get infected, there’s a small risk of injury to intrabdominal organs by accident (bladder, bowel, ureters), etc.

DR Z: I noticed that the majority of gender affirming surgeons are not able to offer this procedure. Why do you think more surgeons are not offering and learning technique of PPT?

Dr. Wittenberg/Dr. Bonnington: PPT surgery requires an extra skill set of robotic surgery.  Plastic surgeons are still likely the most common type of physician to do gender-affirming surgeries and are not typically trained in robotic surgery or intraabdominal surgery in general. 

Sometimes plastic surgeons will work closely with a urologist or gynecologist to perform these surgeries in tandem, but the extra coordination and expense of having two surgeons perform a procedure is sometimes more complicated and burdensome.

DR Z: Do you think PPT specifically, is a procedure that offers the most similar resemblance in function to natal vagina?

Dr. Wittenberg/Dr. Bonnington: Some patients subjectively feel like the peritoneal lining is more natal-like than skin grafting procedures, though we are careful as providers to not necessarily make that comparison. 

While there are similarities between a peritoneal lining and natal lining like the natural discharge and color, we tell patients that both skin and peritoneal linings are different than natal linings. 

A lot of patients also ask about the pH of these different linings.  We tell them that natal linings are usually acidic (pH around 4), skin graft linings are usually basic (pH around 7), and the pH of peritoneal linings has not been studied, but the few patients whose lining we’ve tested in clinic have also had a more basic pH around 7 like skin.

DR Z: Let’s debunk inaccuracies. What is the biggest myth you hear from patients regarding PPT procedure?

Dr. Wittenberg/Dr. Bonnington: Patients sometimes come to us hearing that they don’t have to dilate after PPT and we are really clear in correcting this myth. 

It’s true that the peritoneal lining itself maybe has less tendency to constrict and scar than skin does, but the muscle and scar tissue around the vagina underneath the lining is primarily what dilation is working to keep open.  It may be that in the future with more data we are able to say that less dilation is needed for PPT, but for now we have nothing to prove that it is safe to dilate less.

DR Z: Is there a need for hair removal. I just read on the Crane Center website, who also offer this procedure, that hair removal is required because only half of the inside of the canal is created with peritoneal. My impression was that the entire vaginal canal is created out of peritoneal. Can you clarify?

Dr. Wittenberg/Dr. Bonnington: Some clinics perform a hybrid method where the canal is lined with skin and only the upper part/cap of the vagina is peritoneum.  

With our PPT surgery we don’t have the risk of hair inside the vagina because we use a full flap peritoneal lining co completely line the canal up to the opening/introitus.  For this reason, we previously told patients they didn’t need to worry about hair removal prior to a PPT procedure with us, but then we additionally evolved into a newer labia minor technique. We had some patients develop ingrown hairs in their vulva structures which proved difficult to manage after surgery. 

The full peritoneal lining technique also allows us to use more of the penile shaft skin for our newer labia minora technique with the hopes of additional long-term labial definition, though this technique requires us to sutures skin deep into folds, which a few patients complained of ingrown hairs. 

So now we also require 95% hair removal prior to PPT surgery.  There is less surface area that needs to be covered because most of the scrotal skin isn’t used and will be discarded, and we have diagrams on our website of the different areas that need to be covered for each or these procedures.

DR Z: This is an important distinction as I was under the impression that no hair removal is required.

Dr. Wittenberg and Dr. Bonnington, I want to thank you both for dedicating your time to sit down with me, and ultimately the trans community, to share, educate, and clarify in depth what you have learned given your extensive experience with PPT procedure. Thank you very much.

Dr. Wittenberg/Dr. Bonnington: Our pleasure. It is important to both of us to help people obtain accurate information to help them make informed decision in regards to surgery.

If you are interested and seriously considering PPT, I highly encourage all readers to visit the MoZaic Care resources page found HERE and watch the detailed videos Dr. Wittenberg and Dr. Bonnington have created to further elaborate and discuss PPT method as well as other procedures they perform.