Narrow neovaginal width in a trans person due to short interramic distance

One of the goals for vaginoplasty for trans people is to provide a functional neovagina. Regardless of the method used to line the neovagina, the cavity is created in between the pubic rami posterior to the pubic symphysis,... [ view full abstract ]

One of the goals for vaginoplasty for trans people is to provide a functional neovagina.
Regardless of the method used to line the neovagina, the cavity is created in between the pubic rami posterior to the pubic symphysis, and between the prostate and the rectum.
Two different methods can be used to form the cavity: blunt dissection (for example using a finger); sharp dissection, from the apex of the prostate anterior to Denonvillier’s fascia.
A finger or a stent can be inserted in the rectum to facilitate the plane exposure. A urethral sound or retractor can be inserted through the urethra into the bladder, and used to push the prostate anteriorly into the perineum.
The interramic distance (ID) constitutes an important limiting factor for the width of the neovagina. The mean ID, 3 cm below the lower border of bony structure of the symphysis pubis, is reported to be significantly shorter in biological males than in biological females, being 3.95 (± 0.25) cm and 5.2 (± 0.36) cm respectively in Taiwanese males and females.

To report a case of a trans person, in which an exceptionally short ID caused difficulties in cavity dissection and required a smaller-than-usual stent at dilation. [ view full abstract ]

To report a case of a trans person, in which an exceptionally short ID caused difficulties in cavity dissection and required a smaller-than-usual stent at dilation.

A 32-year-old trans person underwent vaginoplasty by penile skin inversion at the Department of Plastic Surgery at Sahlgrenska University Hospital (Gothenburg, Sweden) in April 2016. The patient had previously gone through... [ view full abstract ]

A 32-year-old trans person underwent vaginoplasty by penile skin inversion at the Department of Plastic Surgery at Sahlgrenska University Hospital (Gothenburg, Sweden) in April 2016. The patient had previously gone through psychological assessment and hormonal treatment as according to WPATH Standards of Care.
At preoperative examination the penile skin amount was judged as adequate: no skin graft or scrotal flap was required. Patient’s height was 158 cm.
At surgery the cavity dissection was performed by sharp dissection to the plane of Denonvillier at the apex of the prostate. This dissection was noted to be more difficult than usual, due to a short ID.

Both surgery and the post-operative period were uneventful. However, when starting the dilation regimen, the insertion of the usual stent was impossible. In fact, the standard stents (2.5 cm, 3.0 cm) used after vaginoplasty... [ view full abstract ]

Both surgery and the post-operative period were uneventful. However, when starting the dilation regimen, the insertion of the usual stent was impossible. In fact, the standard stents (2.5 cm, 3.0 cm) used after vaginoplasty could not be inserted in the neovaginal cavity. In spite of sufficient depth of the cavity (11.5 cm) the width was restricted ventrolaterally by the pubic rami.
A CT scan of the pelvis was performed to measure pubis symphysis proportions.

Although the proportions of the pelvis were normal for a biological male; the angle between the inferior pubic rami at the most caudal level was 51°; the ID, at 3.0 cm below the lower border of bony structure of the symphysis... [ view full abstract ]

Although the proportions of the pelvis were normal for a biological male; the angle between the inferior pubic rami at the most caudal level was 51°; the ID, at 3.0 cm below the lower border of bony structure of the symphysis pubis, was only 3.2 cm, which is shorter than the average reported in the literature. The patient could successfully perform dilation using a stent with a diameter of 2.0 cm.

A short ID can cause a restriction of width of the neovagina after vaginoplasty in trans persons. If a biological male patient presents with a short stature, a short ID may be anticipated. Radiological imaging can be... [ view full abstract ]

A short ID can cause a restriction of width of the neovagina after vaginoplasty in trans persons. If a biological male patient presents with a short stature, a short ID may be anticipated. Radiological imaging can be considered to measure the ID preoperatively. It is important to inform the patient of this possible limitation in the creation of the neovagina, and to be equipped with appropriately sized stents.