Last updated July 30, 2025 > [!important] This report was produced by Gemini Deep Research. It is for educational purposes only and should not be considered medical advice. - [[#Introduction]] - [[#Surgical Techniques of Phallus Preserving Vaginoplasty]] - [[#Benefits of Phallus Preserving Vaginoplasty]] - [[#Risks and Complications of Phallus Preserving Vaginoplasty]] - [[#Comparison with Other Vaginoplasty Techniques]] - [[#Penile Inversion Vaginoplasty (PIV)]] - [[#Peritoneal Pull-Through Vaginoplasty (PPT)]] - [[#Colo-vaginoplasty]] - [[#Comparative Table: Benefits, Costs, and Risks]] - [[#Conclusion]] - [[#References]] ## Introduction Phallus-preserving vaginoplasty represents a specialized and increasingly recognized approach within the spectrum of gender-affirming surgical procedures for individuals assigned male at birth. This surgical option, also known as penile preserving vaginoplasty or Salmacian surgery, distinguishes itself by creating a functional neovagina while intentionally retaining the individual's existing penis. This preservation stands in contrast to more traditional vaginoplasty techniques, which typically involve penectomy (removal of the penis) as a fundamental step in constructing the neovagina and vulva. The emergence and increasing interest in phallus-preserving vaginoplasty underscore a growing understanding of the diverse needs and goals of individuals seeking gender affirmation, particularly those who identify as non-binary or who wish to maintain their penis for reasons of sexual function, personal identity, or other deeply personal considerations. This approach aims to provide a more tailored and personalized gender affirmation journey, acknowledging that the desire for genital alteration can manifest in various ways. The rising interest in this specific procedure highlights the increasing importance of offering inclusive and personalized care within the field of gender-affirming procedures. The primary objectives of phallus-preserving vaginoplasty are multifaceted. Firstly, the procedure aims to construct a functional neovagina, allowing for the creation of a vaginal canal. Secondly, a key goal is the preservation of the existing penile structure, which is intended to maintain sexual function and sensitivity. Thirdly, surgeons strive to form external genitalia that are not only functional but also aesthetically congruent with the individual's gender identity. Furthermore, the procedure aims to enable receptive intercourse and, if desired by the patient, to retain some degree of erectile function. Ultimately, phallus-preserving vaginoplasty seeks to align the individual's physical characteristics more closely with their internal sense of gender identity, offering a more personalized outcome that enhances both physical comfort and overall satisfaction. The core principle behind this approach recognizes that gender affirmation does not necessarily require the removal of the phallus for all individuals and instead emphasizes the "and" rather than "either/or" nature of genital surgery for many. This allows individuals to maintain certain aspects of their original anatomy while still achieving a significant degree of feminization. ## **Surgical Techniques of Phallus Preserving Vaginoplasty** The surgical techniques employed in phallus-preserving vaginoplasty involve sophisticated methods utilizing various tissues to achieve the desired outcome. Construction of the neovaginal canal typically requires complex flaps and grafts. Surgeons often utilize scrotal tissue and skin grafts harvested from the hips to create the vaginal canal. In some approaches, skin from the penis itself is repurposed to form the inner lining of the new vagina, with scrotal tissue providing additional structural support. The skin used for the vaginal canal is typically sourced from the base of the penis and the scrotal area. For individuals who desire both a vulva and a vaginal canal while preserving the phallus, the surgical plan might involve using scrotal skin or a skin graft taken from another part of the body to construct the external vulvar structures. One specific technique employed in phallus-preserving vaginoplasty is the Peritoneal Pull-Through (PPT) method. In this variation, penile tissue is not used for lining the vaginal canal. Instead, the surgeon creates an incision in the perineum and dissects a space for the vaginal cavity between the rectum and the prostate gland. The lining of this newly formed cavity is then created using peritoneal tissue, which is the membrane lining the abdominal cavity. The specifics of the surgical procedure can be tailored to meet individual needs and preferences. Patients have the option to retain their scrotum and testicles if they choose. Furthermore, the procedure can be adapted to either preserve or prevent the ability to ejaculate. Some surgeons may recommend or require hair removal on the external genital area as part of the preparation for surgery. The desired depth of the neovaginal canal is another aspect that can be discussed and planned in consultation with the surgeon. These customizable aspects underscore the patient-centered nature of phallus-preserving vaginoplasty, allowing for a surgical approach that aligns with the unique goals and anatomical considerations of each individual. ## **Benefits of Phallus Preserving Vaginoplasty** Phallus-preserving vaginoplasty offers numerous psychological and emotional benefits for individuals seeking gender affirmation. A significant advantage is that it allows individuals to affirm their gender identity while retaining part of their original genitalia, which can be crucial for their sense of self and body image. This often leads to a more positive body perception and reduced gender dysphoria. Many individuals report feeling more authentic after undergoing this procedure, which significantly boosts self-esteem and overall confidence. This enhanced sense of well-being contributes to a happier outlook on life and fosters a stronger connection with one's body. Furthermore, individuals frequently experience greater ease and satisfaction in intimate relationships as they feel more aligned with their gender identity. Regarding functional benefits, phallus-preserving vaginoplasty creates a neovagina capable of receptive intercourse while maintaining some degree of erectile function. The procedure utilizes existing genital tissues to preserve sensitivity, ensuring both the neovagina and retained penile structures remain sensitive and functional. The retention of penile tissue and sensation represents a significant functional advantage for those choosing this option. Additionally, the newly created vagina typically develops pressure sensitivity, contributing to sexual pleasure. Beyond psychological and functional aspects, phallus-preserving vaginoplasty—particularly when utilizing the Peritoneal Pull-Through (PPT) technique—offers additional advantages. In some cases, the PPT method eliminates the need for skin grafts for vaginal lining. The peritoneal tissue used in PPT provides natural self-lubrication. This technique also enables the creation of a deeper vaginal canal, and since peritoneal tissue is used, there is no risk of hair growth within the neovagina—addressing common concerns associated with other vaginoplasty techniques. ## **Risks and Complications of Phallus Preserving Vaginoplasty** As with any surgical intervention, phallus-preserving vaginoplasty carries a range of potential risks and complications. These can be broadly categorized into general surgical risks common to many procedures and specific risks more pertinent to phallus preservation or vaginoplasty in general. General risks include those associated with anesthesia, as well as the potential for blood clots such as deep vein thrombosis or pulmonary embolism. Other general concerns involve fluid collection at the surgical site (seroma, hematoma, abscess), delayed wound healing or wound separation (sometimes referred to as skin splitting), and changes in sensation such as numbness, hypoesthesia, or dysesthesia. The possibility of needing additional surgery or revisions is also a common consideration. Specific risks related to preserving the phallus during vaginoplasty include potential alterations in urination patterns, as well as possible changes in the sensation of bladder fullness and urinary urgency. Furthermore, individuals may experience significant changes in arousal, erotic sensation, and orgasm. Potential long-term complications associated with phallus-preserving vaginoplasty can include neovaginal stenosis (narrowing of the vaginal canal). Fistula formation, an abnormal connection between the new vagina and nearby organs such as the rectum or bladder, represents another potential risk. Changes in sexual sensation can persist long-term, and urinary tract infections (UTIs) may occur. In rare cases, clitoral necrosis (tissue death) may occur. ## **Comparison with Other Vaginoplasty Techniques** To provide a comprehensive understanding, it is essential to compare phallus-preserving vaginoplasty with other common vaginoplasty techniques: Penile Inversion Vaginoplasty (PIV), Peritoneal Pull-Through Vaginoplasty (PPT), and Colo-vaginoplasty. ### **Penile Inversion Vaginoplasty (PIV)** Penile Inversion Vaginoplasty (PIV) is the most frequently performed and extensively studied technique for vaginoplasty. A key benefit of PIV is its utilization of penile skin, which contributes to the preservation of erogenous sensation and creates a more natural aesthetic appearance of the neovagina. The procedure typically allows for the creation of a satisfactory vaginal depth, generally ranging between 12 and 16 centimeters. Patient satisfaction rates following PIV are generally high, with many individuals reporting positive feelings about their genitals and expressing a willingness to undergo the surgery again. PIV also enables penetrative intercourse and the ability to achieve orgasm through stimulation of the clitoris, which is typically constructed from the glans of the penis. Advancements in surgical techniques have led to the development of robotic-assisted PIV, which may offer the benefits of shorter operating times and a potential reduction in complications. The surgical time for PIV can vary, typically ranging from 2 to 6 hours, with robotic-assisted procedures potentially taking around 3.7 to 4.2 hours. The hospital stay following PIV usually lasts between 4 and 8 days. The overall recovery period can extend from several weeks to months, with restrictions on physical activity and sexual intercourse often advised for 3 months or longer. A significant aspect of PIV is the necessity for lifelong vaginal dilation to maintain the depth and prevent the narrowing of the neovaginal canal. Additionally, preoperative electrolysis or laser hair removal from the scrotal sac is often recommended to prevent unwanted hair growth inside the neovagina. PIV is associated with various potential risks, including tissue healing or wound-related complications such as scarring and neovaginal stenosis, as well as wound breakdown with necrosis. Patients may experience prolonged pain and swelling, excessive scarring and strictures, and surgical site infections. Other risks include bleeding and hematoma, fistula formation (rectovaginal, urethrovaginal, vesicovaginal), and urinary complications such as poor or splayed stream, meatal stenosis, irritative symptoms, urinary retention, incontinence, urethral stricture, and urinary tract infections. Other potential complications include neovaginal prolapse, rare instances of rectal injury, and nerve damage. ### **Peritoneal Pull-Through Vaginoplasty (PPT)** Peritoneal Pull-Through (PPT) vaginoplasty represents a newer approach to gender-affirming surgery, drawing upon techniques initially developed for cisgender women born without a vaginal canal. One of the primary benefits of PPT is its ability to achieve a full vaginal depth, even in individuals who have limited genital skin available, with typical depths reaching 12-14 cm or more. With the aid of robotic surgery, PPT may also offer the advantage of shorter operating times, potentially under 2 hours in some cases. A significant benefit for many is the potential for self-lubrication due to the use of peritoneal tissue, which naturally produces moisture. As peritoneal tissue is utilized for the vaginal lining, there is no risk of hair growth within the neovagina, eliminating the need for extensive preoperative hair removal in that area. Some individuals may also find that PPT requires less frequent dilation compared to Penile Inversion Vaginoplasty. Furthermore, PPT can be a valuable option for revision surgery in patients who have experienced complications or unsatisfactory outcomes following a traditional vaginoplasty. The surgical time for PPT can be around 3.7 hours when using a single-port robotic system, while primary surgeries may take approximately 5 hours. The hospital stay following PPT can range from 2 to 7 days. The recovery period is generally similar to other types of bottom surgery, often requiring around 4 to 6 weeks away from work. While PPT may necessitate less dilation than PIV, some level of dilation may still be recommended to maintain the desired depth and width of the neovagina. Preoperative hair removal is still typically required for the external genital structures. While PPT offers several advantages, it also carries potential risks. These include all the risks associated with penile inversion vaginoplasty, as well as additional risks stemming from the laparoscopic nature of the abdominal part of the procedure. These additional risks can include injury to intra-abdominal organs, ileus (a temporary lack of intestinal movement), and herniation. There is also a potential risk of flap failure and stenosis. As PPT is a newer procedure in the context of gender affirmation surgery, the long-term outcomes are still being studied. Some patients may find the amount of vaginal discharge produced by the peritoneal lining to be bothersome. Additionally, there is a risk of peritonitis if there is leakage of bowel contents during the procedure. ### **Colo-vaginoplasty** Colo-vaginoplasty, also known as rectosigmoid vaginoplasty, involves using a segment of the sigmoid colon to create the lining of the neovagina. One of the significant benefits of this technique is the ability to achieve a greater vaginal depth compared to PIV, potentially reaching 14 to 19 centimeters. Colo-vaginoplasty also provides natural self-lubrication due to the mucus-producing intestinal lining. The texture and elasticity of the intestinal lining closely resemble that of a biologically female vagina. Some studies suggest that colo-vaginoplasty may be associated with higher rates of orgasm compared to PIV. The neovagina created with this technique tends to exhibit greater long-term stability in terms of depth and width, and it may require less long-term dilation. Colo-vaginoplasty can also be a suitable option for individuals who have insufficient penile skin available for PIV. The procedure of colo-vaginoplasty is more complex than PIV as it involves the use of a bowel segment. It necessitates bowel preparation prior to surgery, and the recovery period can be longer compared to PIV. In some instances, a temporary colostomy may be required. Colo-vaginoplasty carries a higher risk of complications compared to penile inversion vaginoplasty. Potential risks include perforation of the rectum and bladder during the surgery, nerve compression during the operation, bleeding complications, and infections. There is also a risk of partial or complete skin necrosis of the vagina, scarring disorders, difficulties with urinary weaning after catheter removal, and the formation of vesico- or urethro-vaginal fistulas. Peritonitis, a serious inflammation of the abdominal cavity, is another potential complication, as are intestinal canalization problems. Patients may experience excessive mucus production, sometimes requiring the constant use of sanitary pads. Although with a low incidence, there have been reports of diversion colitis and adenocarcinoma of the neovagina. Functional dissatisfaction, such as difficulty urinating, incontinence, or pain during defecation, can also occur, albeit rarely. In very rare cases, fatal events have been reported in the literature, with mortality rates cited as up to 3-4%. ## **Comparative Table: Benefits, Costs, and Risks** | | | | | | |---|---|---|---|---| |**Feature**|**Phallus-Preserving Vaginoplasty**|**Penile Inversion Vaginoplasty (PIV)**|**Peritoneal Pull-Through Vaginoplasty (PPT)**|**Colo-vaginoplasty**| |**Benefits**|Retains penis, functional neovagina, potential for erectile function, receptive intercourse, personalized gender affirmation, may have self-lubrication (PPT), deeper vagina (PPT), no hair growth in neovagina (PPT)|Most common technique, utilizes penile skin for natural appearance and sensation, satisfactory vaginal depth, high patient satisfaction, enables penetrative intercourse and orgasm, robotic option available|Can achieve full vaginal depth even with limited skin, potential for self-lubrication, no hair growth in neovagina, may require less dilation, robotic option available|Greater vaginal depth, natural self-lubrication, texture similar to biological vagina, potentially higher orgasm rates, greater long-term depth stability| |**Costs (Surgical Time)**|Several hours|2-6 hours (robotic: ~3.7-4.2 hours)|~5 hours (robotic: ~3.7 hours)|More complex, longer| |**Costs (Hospital Stay)**|1-2 days initially|4-8 days|2-7 days|Longer| |**Costs (Recovery)**|Several weeks|Several weeks to months|4-6 weeks off work|Longer| |**Costs (Dilation)**|Some may be required|Lifelong, regular dilation|May require less dilation|May require less long-term dilation| |**Costs (Hair Removal)**|May be required for external genitalia|Often recommended preoperatively|Required for external genitalia|Bowel prep preoperatively| |**Risks**|General surgical risks, changes in urination and sexual function, neovaginal stenosis, fistula, changes in sensation, UTI, clitoral necrosis (rare)|General surgical risks, tissue healing complications, wound breakdown, prolonged pain/swelling, excessive scarring, infection, bleeding, fistula, urinary complications, prolapse, rectal injury (rare), nerve damage|All PIV risks, intra-abdominal organ injury, ileus, herniation, flap failure, stenosis, excessive discharge, unknown long-term outcomes, peritonitis risk|Higher risk of complications, rectum/bladder perforation, nerve compression, bleeding, infection, skin necrosis, scarring, urinary difficulties, fistula, peritonitis, intestinal problems, excessive mucus, diversion colitis (rare), adenocarcinoma (rare), functional dissatisfaction, potential for mortality| ## **Conclusion** Gender-affirming genital surgery offers several distinct options, each with its own set of benefits, costs, and risks. Phallus-preserving vaginoplasty occupies a unique position within this spectrum, providing a surgical pathway for individuals who desire a functional neovagina while retaining their penis. This approach serves a specific subset of the transgender and non-binary community whose gender identity and personal goals align with preserving their existing phallic structure. Among the options, penile inversion vaginoplasty remains the most established and widely practiced technique. It offers reliable results in terms of vaginal depth and functionality, though it requires lifelong dilation and carries a range of well-documented complications. Peritoneal pull-through vaginoplasty, a newer alternative, may provide advantages such as enhanced vaginal depth, potential self-lubrication, and reduced need for hair removal within the neovagina. However, it introduces risks associated with abdominal surgery and lacks extensive long-term data. Colo-vaginoplasty can achieve excellent depth and self-lubrication but carries a higher risk profile due to bowel involvement and is typically reserved for specific clinical scenarios. Ultimately, choosing the most suitable vaginoplasty technique is a highly personal decision. It depends on multiple factors, including the individual's gender identity, desired surgical outcomes for functionality and aesthetics, anatomical characteristics, risk tolerance, and commitment to postoperative care. It is essential for individuals considering any form of vaginoplasty to engage in thorough consultations with experienced surgeons who can provide detailed information about each procedure, assess individual needs, and guide them toward an informed decision that best aligns with their gender affirmation journey. ### References 1. 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