Then isolated sigmoid is brought down to the perineal canal without tension to create a tension-free coloperineal anastomosis. In order to prevent purse-string scarring, introital or perineal skin flaps are formed and approximated to the sigmoid vagina. In order to avoid prolapse, some authors perform a “U”-shaped incision posterior to the urethra and complete it with two lateral vascularized introital flaps. Vascularized flaps are completely mobilized to push the neo-introital opening as high as possible to prevent mucosal prolapse and to yield better aesthetic results with the anastomosis deeply hidden. Some other surgeons prefer to fix the proximal end of the neovagina to the sacral promontory.

Then the neovagina was packed with a compressive dressing for about 7 days, and a Foley catheter is placed and removed 4–5 days after surgery, in order to facilitate the fixation of the rectosigmoid graft to the surrounding tissues. Patients are instructed on how to perform self-dilation of the neovaginal introitus and irrigation of the neovagina for mucus removal, daily for 8 weeks and weekly thereafter.

The final result is showed in Figs. 18.6 and 18.7
[2–9].

The maintenance of hormonal therapy after surgery allows to aid the feminine aspect of external genitalia (hair and fat distribution) rectosigmoidal vaginoplasty.

As described more successfully for ileal vaginoplasty, some authors present the possibility of a combined laparoscopic and perineal approach for rectosigmoidal vaginoplasty. A three-port transperitoneal approach is used for the complete vaginal isolation and mobilization, for rectosigmoid segment isolation, and for vaginal anastomosis [10–11].

Furthermore, Kim et al. presented a case of a robot-assisted sigmoid vaginoplasty in a woman with vaginal agenesia. To date, this operation has never been performed for transsexual surgery [12].