Skip to main content

Phallus-Preserving Vaginoplasty (PPV)

Phallus-preserving vaginoplasty (PPV) is an emerging individually customised gender-affirming genital procedure that creates a neovaginal canal while retaining the native penis and, in some cases, the testes — designed primarily for nonbinary and gender-diverse individuals who desire both a vaginal canal for receptive intercourse and preservation of penile function (erection, penetrative capability, voiding through the native urethra).[1] Published evidence remains extremely limited — the Ascha 2024 customised-procedures series (n = 16) is the central reference.[1]

This is the dedicated atlas page. For the broader variant-GGAS framework, see Non-Binary / Nullification Gender-Affirming Surgery. For canonical neovaginal-canal-lining options, see Peritoneal Pull-Through Vaginoplasty, Intestinal Vaginoplasty, and Skin Graft Vaginoplasty.

Concept and Indications​

Unlike standard penile inversion vaginoplasty (PIV) — which disassembles the penis and scrotum to construct vulva, clitoris, labia, and canal — PPV preserves the phallus intact.[2][3]

Key indications:

  • Nonbinary gender identity — patients who don't identify within a binary framework and desire both sets of genital anatomy.[1]
  • Desire to preserve penile sexual function — erection, ejaculation, penetrative capability.[1]
  • Desire for receptive vaginal intercourse — creation of a functional neovaginal canal.[1]

Because penile skin is not available for inversion (the standard PIV lining source), PPV requires alternative tissue sources for the neovaginal canal. The three principal lining options: peritoneum, skin grafts, intestinal segments.

Surgical Technique (Ascha 2024)​

The core steps:[1]

  1. Perineal dissection — neovaginal space created between rectum posteriorly and prostate / urethra anteriorly (same plane as standard vaginoplasty) without penile disassembly.
  2. Neovaginal canal lining — penile skin unavailable; canal lined with peritoneal flap / skin graft / intestinal segment (see below).
  3. Preservation of the penis — glans, corpora cavernosa, and dorsal NVB left intact. The urethra continues to traverse the penis.
  4. Orchiectomy — optional. If testes removed, scrotal skin may become available for grafting or labiaplasty; if preserved, alternative tissue sources are required.

Neovaginal Lining Options — Comparison​

The choice of lining tissue is the central differentiating factor in PPV (as in all vaginoplasty).[4]

FeaturePeritoneal flapSkin graftIntestinal (sigmoid)
Tissue sourcePelvic peritoneum (bladder, rectosigmoid)Scrotal / abdominal / thigh skinSigmoid colon segment
Surgical approachLaparoscopic / robotic + perinealPerineal (± laparoscopic)Laparoscopic / open abdominal + perineal
Self-lubricationYes (mucosal, transient)No (keratinised skin)Yes (mucus-secreting, persistent)
Neovaginal depth~14–15 cm~11–13 cm~12–16 cm
Dilation requirementRequired but potentially less intensiveIntensive, lifelongLess intensive; rare stenosis
Hair-growth riskNoneYes (if hair-bearing skin)None
Unique complicationsPeritoneal granulation; potential bladder effectsStenosis 1–12%; graft necrosis 0–23%Mucosal prolapse 12%; malodor 8%; mucorrhea 8%
Surgical complexityModerate (requires laparoscopy)LowerHighest (bowel resection / anastomosis)
Detailed atlas pagePeritoneal Pull-Through VaginoplastySkin Graft VaginoplastyIntestinal Vaginoplasty

Peritoneal flap — particularly well-suited for PPV​

Adapted from the Davydov procedure for MRKH vaginal agenesis.[5] Two peritoneal flaps from posterior bladder wall and anterior rectosigmoid, mobilised laparoscopically, pulled through the perineal dissection, sutured to form the canal.[6][7]

  • Castanon 2022 (Belgrade) n = 52 — neovaginal depth 14.7 cm, width 3.4 cm at 6 mo; complication rate 13.5% (all minor); 96% patient satisfaction.[6]
  • Ratanalert 2025 full-length peritoneal turnover flap — hairless, mucosal, self-lubricating lining; 80% maintained depth at 3 mo.[8]

Particularly well-suited for PPV because it does not require penile or scrotal tissue.

Skin graft (extragenital when penile / scrotal tissue unavailable)​

When peritoneal or intestinal approaches are not feasible, extragenital full-thickness skin grafts (abdomen, thigh, groin) can line the canal. Salibian 2021 SR: skin-graft stenosis 1.2–12%, necrosis 0–22.8%.[9] Skin-lined neovaginas do not self-lubricate and require lifelong dilation.[3] In PPV context, if orchiectomy is not performed, scrotal skin may not be available — necessitating extragenital donor sites with additional donor-site morbidity.

Intestinal (sigmoid colon)​

A sigmoid-colon segment is isolated on its vascular pedicle, closed at one end, and anastomosed to the perineum.[10] Provides self-lubricating, mucus-secreting lining that rarely stenoses and requires minimal dilation.[10][11]

  • Lava 2025 n = 119 — short-term complications 17.7%; long-term 24.4%; mucosal prolapse 11.8%, introital stenosis 9.2% as most common long-term.[12]
  • Disadvantages: bowel resection + anastomosis (ileus, anastomotic leak), potential malodor, mucorrhea in ~8%.[10][11]
  • Yinuo 2025 head-to-head MRKH found peritoneal had shorter OR, less abdominal discomfort, higher sexual satisfaction vs sigmoid.[13][14]

Outcomes and Complications Specific to PPV​

Published PPV-specific data are extremely limited — Ascha 2024 customised-procedures series (n = 16; combined PPV + vagina-preserving phalloplasty + nullification) reports complications but small sample limits generalisability.[1]

Considerations unique to PPV vs standard vaginoplasty:

  • Anatomical constraints — intact penis and urethra occupy space anteriorly, potentially limiting canal dimensions and increasing technical difficulty of perineal dissection.
  • Preserved erectile function — corpora cavernosa and NVB remain intact, the primary functional goal but adds surgical complexity.
  • Urethral considerations — urethra is not shortened or repositioned; voiding continues through the penile meatus.
  • Risk of rectovaginal or urethrovaginal fistula — same dissection plane as standard vaginoplasty; rectal injury occurs in ~ 1.6% and rectovaginal fistula is a recognised major complication.[15][2]
  • Neovaginal stenosis — remains the most common long-term complication across all lining types.[16]

Postoperative Care​

Postoperative management parallels standard vaginoplasty with modifications:

  • Dilation — required for all lining types but potentially less intensive with peritoneal / intestinal. Standard up to 3× daily initially, tapering over months to years. Non-compliance is the strongest predictor of complications and reoperation.[3][17]
  • Hygiene — skin-lined canals may accumulate sebum and dead skin; douching with dilute vinegar / betadine is reasonable. Intestinal-lined canals may produce excessive mucus.[18]
  • Sexual function — penile erection and ejaculation expected to be preserved; receptive vaginal intercourse should be possible once healing is complete.
  • Surveillance — periodic pelvic exam to monitor for stenosis, granulation tissue, or other complications.[18]

Evidence Gaps and Future Directions​

PPV is a novel procedure with very limited published evidence — primarily case series and technique descriptions.[1] Key unanswered questions:

  • Long-term neovaginal patency and depth maintenance with the phallus in situ.
  • Sexual function outcomes (both penetrative penile and receptive vaginal).
  • Optimal tissue lining choice specifically for PPV.
  • Psychological and QoL outcomes in nonbinary patients undergoing this specific procedure.
  • Comparative complication rates vs standard vaginoplasty.

The broader vaginoplasty literature demonstrates significant QoL improvement post-surgery (PHQ-9, GAD-7, body image, sexual function); whether these benefits extend equally to PPV remains to be established.[19]

References​

1. Ascha M, Rigsby S, Shoham M, et al. Individually customized gender-affirming genital procedures: techniques and considerations. J Sex Med. 2024;21(9):827–834. doi:10.1093/jsxmed/qdae075

2. Morrison SD, Claes K, Morris MP, et al. Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol. 2023;20(5):308–322. doi:10.1038/s41585-022-00705-y

3. Committee on Gynecologic Practice and Committee on Health Care for Underserved Women. Health care for transgender and gender diverse individuals: ACOG Committee Opinion, Number 823. Obstet Gynecol. 2021;137(3):e75–e88. doi:10.1097/AOG.0000000000004294

4. Bene NC, Ferrin PC, Xu J, et al. Tissue options for construction of the neovaginal canal in gender-affirming vaginoplasty. J Clin Med. 2024;13(10):2760. doi:10.3390/jcm13102760

5. Slater MW, Vinaja X, Aly I, et al. Neovaginal construction with pelvic peritoneum: reviewing an old approach for a new application. Clin Anat. 2018;31(2):175–180. doi:10.1002/ca.23019

6. Castanon CDG, Matic S, Bizic M, et al. Laparoscopy-assisted peritoneal pull-through vaginoplasty in transgender women. Urology. 2022;166:301–302. doi:10.1016/j.urology.2022.05.001

7. Jacoby A, Maliha S, Granieri MA, et al. Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J Urol. 2019;201(6):1171–1176. doi:10.1097/JU.0000000000000107

8. Ratanalert W, Pobpan P. Full-length peritoneal flap vaginoplasty: a feasible approach for hairless neovaginal reconstruction in gender-affirming surgery. Plast Reconstr Surg. 2025. doi:10.1097/PRS.0000000000012265

9. Salibian AA, Schechter LS, Kuzon WM, et al. Vaginal canal reconstruction in penile inversion vaginoplasty with flaps, peritoneum, or skin grafts: where is the evidence? Plast Reconstr Surg. 2021;147(4):634e–643e. doi:10.1097/PRS.0000000000007779

10. Kwun Kim S, Hoon Park J, Cheol Lee K, et al. Long-term results in patients after rectosigmoid vaginoplasty. Plast Reconstr Surg. 2003;112(1):143–151. doi:10.1097/01.PRS.0000066169.78208.D4

11. Wylie K, Knudson G, Khan SI, et al. Serving transgender people: clinical care considerations and service delivery models in transgender health. Lancet. 2016;388(10042):401–411. doi:10.1016/S0140-6736(16)00682-6

12. Lava CX, Ferdousian S, Li KR, et al. Outcomes of gender-affirming sigmoid colon vaginoplasty: a retrospective study of 119 patients. J Plast Reconstr Aesthet Surg. 2025;106:310–318. doi:10.1016/j.bjps.2025.04.041

13. Yinuo L, Zihan L, Xiaorui L, et al. Comparative study of laparoscopic peritoneal vaginoplasty versus sigmoid colon vaginoplasty in the treatment of congenital absence of vagina. Surg Endosc. 2025. doi:10.1007/s00464-025-11868-1

14. Cao L, Wang Y, Li Y, Xu H. Prospective randomized comparison of laparoscopic peritoneal vaginoplasty with laparoscopic sigmoid vaginoplasty for treating congenital vaginal agenesis. Int Urogynecol J. 2013;24(7):1173–1179. doi:10.1007/s00192-012-1991-9

15. Opsomer D, Vyncke T, Mertens D, et al. Fifteen-year experience with the Ghent technique of penile inversion vaginoplasty. Plast Reconstr Surg. 2021;148(3):416e–424e. doi:10.1097/PRS.0000000000008300

16. Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med. 2015;12(6):1499–1512. doi:10.1111/jsm.12868

17. Levy JA, Edwards DC, Cutruzzula-Dreher P, et al. Male-to-female gender reassignment surgery: an institutional analysis of outcomes, short-term complications, and risk factors for 240 patients undergoing penile-inversion vaginoplasty. Urology. 2019;131:228–233. doi:10.1016/j.urology.2019.03.043

18. Jackson Q, Yedlinsky NT, Gray M. Lifelong care of patients after gender-affirming surgery. Am Fam Physician. 2024;109(6):560–565.

19. Haley C, Roblee CV, Blasdel G, et al. Gender-affirming vaginoplasty improves quality of life in transfeminine individuals: a single-centre prospective study. Ann Surg. 2025. doi:10.1097/SLA.0000000000006988