IM GENDER develops an algorithm to select the best vaginoplasty technique

What does the algorithm measure?

To establish an objective basis for choosing the trans vaginoplasty technique, a series of anatomical measurements are taken in the operating room. These measurements allow us to estimate how much genital skin is available, the distance that needs to be covered to achieve an adequate neovaginal length, and which surgical technique will be the safest and most effective according to these dimensions.

What exactly is measured?

• • The length of penile skin at maximum extension (before separating the penile shaft from its skin).
  • The distance between the pubis and the urethral meatus.
  • The distance between the urethral meatus and the perineal body.
  • The distance between the perineal body and the recto-vaginal fossa.

How does the technique selection process work?

Once the medical team has these measurements, they calculate a ratio between the “distance to be covered” and the available penile skin length. Based on that ratio – along with other anatomical factors such as skin elasticity, genital volume, history of puberty blockers, or scars (e.g., from circumcision) – it is decided whether the most appropriate technique will be:

• • Penile inversion: if the penile skin is sufficient to cover the distance between the pubis and the vaginal fossa, good depth can be achieved without the need for more invasive techniques.
  • Colovaginoplasty (using intestine, usually sigmoid): when there is not enough genital skin, or the anatomy suggests that achieving adequate depth with inversion may not be sufficient or safe for optimal results.
  • Peritoneal technique: when penile skin is insufficient, the peritoneum offers interesting properties. This option is considered in specific cases where anatomy allows it and the patient prefers it.

Other factors considered in the choice of technique

The algorithm takes into account more than just numbers. Other important factors include:

• • Patient preferences: for example, whether the patient wishes to have penetrative sex, prioritizes faster recovery, or seeks lower morbidity.
  • General health status: comorbidities, ability to undergo major surgery, recovery capacity.
  • Hormonal history: length of hormone therapy, use of puberty blockers, etc.
  • Quality and elasticity of genital skin, and the presence of scars.

How does this algorithm contribute to medical decision-making when choosing the most suitable vaginoplasty technique? It provides several key benefits:

• • Shared and realistic decision-making
    With objective measurements shown to the patient, it is possible to explain what vaginal depth can be expected with each technique, what risks exist, and what trade-offs (e.g., dilation, recovery, possible complications) may be involved. This allows tailoring vaginoplasty to the patient’s wishes, not just technical feasibility.
  • Optimization of available tissue
    Considering penile skin length, elasticity, and anatomical distances ensures that, when sufficient genital tissue exists, more invasive techniques (such as intestinal use) are avoided unnecessarily. This can shorten surgery time, reduce complications, and improve recovery.
  • Better functional, aesthetic, and satisfaction outcomes
    This method favors achieving sufficient vaginal depth for each woman’s personal goals, an aesthetically pleasing neovagina, improved sensitivity, and fewer corrective procedures.
  • More realistic patient expectations
    When patients understand the variables —what their body allows, what the technique can achieve— they develop more realistic expectations, experience less frustration, and feel greater emotional satisfaction.

This algorithm reinforces the idea that there is no “one ideal technique” for everyone. Instead, the surgical approach must be personalized and adapted to each trans woman’s anatomy and wishes when considering vaginoplasty as part of her transition.

This algorithm provides more tools for trans women to choose their vaginoplasty. They should not settle for a team that offers only one technique under the claim of “we only perform the best technique” or “this is the only technique we do”, since studies show that personal characteristics determine which technique is best in each case.

Therefore, patients should ask and understand why a specific vaginoplasty technique is recommended over another. They should also realize that a more novel or “exotic” technique is not necessarily better —each technique is a real option for a specific case.

Most importantly, good outcomes do not depend solely on surgery but also on clinical support before, during, and after, as well as the mutual commitment between patient and team. Trans women should actively participate in choosing their vaginoplasty technique to ensure it is the best option for them.

The algorithm presented by Dr. Labanca in Hamburg perfectly summarizes IM GENDER’s philosophy: every trans woman deserves a surgery designed specifically for her. Based on intraoperative anatomical measurements, her body, her tissues, her preferences, her goals, and her lifestyle, the result is realistic and aligned with expectations in depth, functionality, and aesthetics, as well as emotional satisfaction after surgery.