Vaginal Lengthening Procedures for Noncongenital Indications.

Each of these cases was able to maintain vaginal patency through dilation after surgery, with a TVL range of 7–10 cm. The goal is to maintain vaginal patency with a TVL of greater than 6 cm [ 11 ]. Although there is to our knowledge no standard dilation protocol in the literature, there is a risk of recurrent shortened vaginal length or vaginal obliteration with discontinuation of dilation and/or regular intercourse [ 11 ]. For nongraft vaginal cases, patients should dilate daily, starting at postoperative day 3 and continuing daily for at least 3 months, followed by three times a week until resuming regular intercourse. McIndoe/biologic graft approaches require continuous mold wearing for 3 months, followed by 3–6 months nightly, then three times a week for 6–9 months, followed by regular intercourse. Patients are counseled to use their dilator as a measure and to increase the frequency of dilation if they notice loss of vaginal length.

From October 2022 to March 2024, three patients with shortened vaginal length due to noncongenital indications underwent vaginal lengthening procedures. Informed consent was obtained from all patients, and they were counseled on the risks and benefits of surgical technique, in addition to requisite dilation therapy. The first case was a patient approximately 50 years old with vaginal shortening due to graft-versus-host disease. She was treated with a nongraft-based approach owing to patient preference, defect size, and presence of native tissue for coverage of the internal surface of the vagina. Initially, medical management with first-line agents were attempted. These included topical steroids, estrogen cream, and biologic creams (tacrolimus) paired with dilator therapy. Given only modest improvement and desire for more vaginal length, the decision was made to pursue a surgical approach. A lysis of adhesions was performed from a combined vaginal and laparoscopic approach. First, a laparoscopic hysterectomy was performed to allow concurrent proximal and distal lysis of adhesions. After colpotomy, a laparoscopic lysis of vaginal adhesions was performed while a vaginal finger provided tactile feedback. Lysis of adhesions was then performed vaginally to restore vaginal anatomy and length. The vaginal cuff was closed laparoscopically. Nongraft augmented repairs with an underlying medical condition, such as this case, require long-term management with medical therapy and dilation. This patient achieved a TVL of 9 cm. Lysis of adhesions is considered the gold standard for vaginal shortening due to agglutination. Some of the risks for lysis of adhesions include re-agglutination and need for further procedures. A retrospective study of 34 patients with lichen planus who underwent lysis of adhesions observed a 6% (2 out of 34) re-agglutination rate [ 8 ]. Optimization of medical conditions (i.e., lichen planus, graft-versus-host disease) is necessary prior to performing adhesiolysis [ 8 ]. In cases of patients who have received pelvic radiation, lysis of adhesions may not be possible owing to obliteration of surgical planes; grafting may be needed instead. The second case was a patient approximately 40 years old status post-hysterectomy with a TVL of 3 cm. The patient was a suitable candidate for a modified McIndoe procedure, a vaginal surgical approach with a graft, given that she was amenable to a graft donor site scar and there was a lack of native tissue for adequate vaginal length. It is important to assess potential graft harvest sites, and existing vaginal length and caliber before offering this treatment. When assessing a possible graft harvest site, evaluate for tissue integrity, the presence of hair and tattoos, dermatoses, and moles concerning for malignancy. Patients with hair in the planned harvest site should undergo laser removal or electrolysis, as hair growth in the neovaginal tissue is a risk. A split-thickness skin graft (STSG) was performed, which can be harvested with a dermatome from the buttocks or the thigh ( Fig. 1 ). When creating a STSG, include an additional 2–3 cm of tissue length to make sure the graft is not too small and to account for mild shrinkage. The dermatome has a 10-cm blade that cuts to a depth of 5–6 mm. The graft harvest site should be prepped with betadine and mineral oil, which helps the dermatome to glide, preventing skipping. The graft harvest site re-epithelialized by 6 weeks and faded to a shade near the patient’s base skin color within 6 months. It is important to consider morbidity associated with STSGs. A systematic review of STSG donor sites found that re-epithelialization commonly occurs within the first 2–4 weeks, and that there is associated postoperative pain during that period. Additionally, there are long-term risks, such as scarring, pruritus, and hypertrophic scar formation [ 9 ]. Surgically, a modified McIndoe procedure yielded a TVL of 10 cm for this patient. In the vaginal agenesis literature, the McIndoe vaginoplasty is notable for long-term sexual activity and satisfaction [ 10 ]. In a long-term prospective study of patients with vaginal agenesis who underwent a McIndoe neovagina procedure, participants had a mean follow-up period of 23 years and 91% of patients were sexually active, with 75% reporting the ability to orgasm [ 10 ]. These data can be extrapolated to vaginoplasty for noncongenital indications. The third case was a patient approximately 35 years old with a history of a complex genitourinary sinus after multiple repairs with upper vaginal obliteration and endometriosis, who did not desire a graft harvest scar. The patient had good intraperitoneal access, so a robotics-assisted approach with a 7 × 10 cm acellular porcine biologic graft was an appropriate approach. Acellular porcine biologic grafts are a newer material with limited but growing data on perioperative management, long-term outcomes, and complications. In neovaginal creation, key benefits to acellular porcine biologic grafts include elimination of autologous donor site morbidity and the ability of endogenous vaginal mucosa and glandular cells to populate the neovagina [ 11 ]. Biologic grafts can be processed differently, so know the instructions for use. Some limitations include pork restrictions or allergy, in addition to the expense of this material, and limited standard-size selection. There is also a risk of graft shrinkage; when determining graft size anticipate shrinkage of 15–20% during healing. This robotics-assisted approach required a biologic graft with cystoscopy, bilateral ureteral stents, and opening of the patient’s vaginal cuff to dissect cephalad tissues and elongate the patient’s vagina. To achieve this, an end-to-end anastomosis (EEA) sizer was inserted into the vagina to delineate where the vagina was relative to the peritoneum. A transverse incision was made along the EEA sizer to open the vagina. The biologic graft was 7 × 10 cm and was inserted into the abdominal cavity through the vagina, taking care not to damage the graft. The posterior graft edge was then sutured with interrupted suture of 2–0 polyglactin 910 to the posterior vaginal edge. The 9-cm vaginal mold (Allura; PMT Corporation, Chanhassen, MN, USA) was placed in the vaginal opening. The graft was folded over the mold, and the anterior graft was sutured with interrupted sutures of 2–0 polyglactin 910 to the anterior vaginal edge. The sides of the graft were trimmed and tubularized with bilateral running, unlocked sutures of 2–0 polyglactin 910. This patient maintained a TVL of 7 cm. A retrospective study of 13 patients who underwent vaginoplasty with acellular porcine grafts obtained a mean vaginal length of 8.96 cm (IQR 8–10), with one patient achieving a TVL of < 7 cm [ 11 ]. Additionally, all patients had successful engraftment without extrusion or reactions [ 11 ].

Vaginal lengthening for noncongenital indications can be achieved using nonsurgical and surgical techniques, all requiring regular vaginal dilation. When considering operative management, candidate tissue integrity and medical history are key factors in determining the appropriate surgical approach. As vaginal and minimally invasive surgeons, urogynecologists can employ these techniques in their practice or perform joint cases with other specialties, such as plastic surgery, to offer vaginal lengthening to patients.

Vaginal lengthening procedures are often considered in cases of congenital differences, iatrogenic vaginal shortening, and medical conditions that cause loss of vaginal patency. Iatrogenic shortened total vaginal length (TVL) may be seen with pelvic radiation, radical hysterectomy, prolapse repairs, and multiple cervical procedures [ 1 , 2 ]. Medical conditions may also obliterate vulvovaginal architecture, such as post-menopausal changes, vulvovaginal dermatoses such as lichen sclerosus, and graft-versus-host disease. For all vaginal lengthening indications, dilator therapy is the first line and an essential part of postoperative care [ 2 , 3 ]. Surgical approaches to vaginal lengthening can be accomplished with or without autologous grafts, flaps or biologic grafts via vaginal and/or minimally invasive intra-abdominal approaches. Among the various grafting options for surgical vaginal lengthening, a commonly used graft in reconstructive urology is a buccal graft. This graft is easy to harvest and leaves no visible scar. It is important to mark Stenson’s duct, adjacent to the second upper molar, to avoid postoperative xerostomia. As a precaution, electrocautery should not be used near the patient’s airway during graft harvesting [ 4 ]. A case series of 87 buccal grafts found that there were no intraoperative or major postoperative complications such as hemorrhage, infection, or nerve injury. However, all patients had diminished ability to eat and drink within the first 24–48 h, and they observed minor complications that resolved by the 3-month postoperative visit such as mild discomfort, temporary numbness, cheek swelling, and restrictive oral movement [ 4 ]. Li et al. performed vaginoplasty in 38 patients with autologous buccal micromucosa and found that oral mucosa healed within 5–7 days and the average time for mucosal epithelialization over the neovaginal tissue was 13 days [ 5 ]. The average neovaginal length was 8.5 ± 0.66 cm and in the long term, sexually active patients reported satisfactory sexual function [ 5 ]. Of note, buccal grafts can be unilateral or bilateral but are relatively small, even with meshing; applications are limited to smaller defects. The pudendal thigh fasciocutaneous flap, also known as the Singapore flap, is another option for vaginal lengthening. This flap is sensate with the same innervation as the perineum and upper thigh. It offers coverage and bulking in reconstructing a large vaginal defect and the primary closure leaves a well-hidden scar in the groin [ 6 ]. The Singapore flap has a robust blood supply from the internal pudendal artery and has low donor-site morbidity [ 6 ]. A surgical drain may be placed to prevent fluid accumulation and can be removed when there is appropriately low output within 48 to 72 h. A case series that included 7 patients who underwent neovaginal creation with a pudendal thigh flap observed 6 patients with a TVL of 10 cm or more and 1 patient with a TVL 6–10 cm. There were no donor site infections, rectal or urethral injuries [ 7 ]. Surgical techniques traditionally utilized for congenital and gender-affirming cases can also be utilized for medical and iatrogenic vaginal lengthening indications. This includes the modified McIndoe technique, which is a two-stage vaginal approach, the Davydov technique, which uses laparoscopic access and peritoneal flap mobilization, and sigmoid colovaginoplasty, which uses a sigmoid colon segment as an autograft. The objectives of this video are to provide an overview of autologous grafts, tissue flaps, and biologic grafts used in vaginal lengthening procedures for noncongenital indications, to discuss management of three patient cases with shortened TVL, and to provide dilation therapy tips.

The online version contains supplementary material available at https://doi.org/10.1007/s00192-026-06551-5