Intestinal Neovagina Using Small Bowel Grafts: A South African First

Neovaginal reconstruction is one of the most complex and life-changing procedures in urological and reconstructive surgery. It provides patients — whether born with congenital absence of the vagina, those requiring reconstruction after cancer surgery, or transgender women undergoing gender-affirming surgery — the opportunity for both functional and psychological restoration.

In South Africa, Dr MC Conradie has pioneered a new milestone: performing the first neovaginal reconstruction using small bowel (ileum or jejunum) grafts. Not only was this the first use of the small bowel, but it was also performed laparoscopically — a minimally invasive approach that reduces recovery time. While traditional methods often relied on the sigmoid colon, using the small bowel introduces distinct advantages for both surgical success and long-term patient satisfaction.

Indications and Patient Selection

Candidates for intestinal neovagina may include:

• Patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome or other congenital vaginal agenesis.
• Women requiring reconstruction following oncological resection of the vagina.
• Transgender women seeking gender-affirming vaginoplasty, particularly when penile inversion alone is not feasible or insufficient.
• Revision cases where prior reconstructions have failed or complications occurred.

Because this is major surgery involving both urology/gynaecology and colorectal expertise, patient selection is individualised. Factors such as prior abdominal operations, bowel health, fertility goals, psychosexual needs, and long-term compliance with follow-up all play important roles.

Why Use Small Bowel?

The small bowel (ileum or jejunum) offers unique qualities that make it particularly suited for neovaginal creation:

• Natural lubrication: Small bowel mucosa produces mucus, which helps maintain comfort and reduces the need for ongoing dilation.
• Vascular reliability: Strong blood supply increases graft survival and reduces ischemic complications.
• Appropriate length and diameter: Segments can be tailored to patient needs, ensuring functional outcomes.
• Reduced faecal contamination risk compared with colon segments.

These factors make small bowel a compelling alternative to the traditionally used sigmoid colon.

Small Bowel vs Colon – How Do They Compare?

Historically, the sigmoid colon has been the most commonly used intestinal graft for neovagina due to its size, vascular pedicle, and ease of mobilisation. However, it also brings challenges:

• Excessive mucous production may cause discharge and odour.
• Faecal bacterial load increases the risk of infection.
• Heavier tissue bulk may create long-term discomfort.

In contrast, small bowel grafts:

• Produce less problematic discharge than colon, although still lubricating.
• Have fewer issues with odour and bacterial contamination.
• Offer lighter, more flexible tissue, which can feel more natural for patients.

While both options remain viable, small bowel grafts may improve patient comfort and long-term satisfaction — particularly in complex or revision cases.

Surgical Technique Overview

The procedure involves harvesting a carefully selected small bowel segment (ileum or jejunum) with its vascular pedicle intact. This graft is then mobilised and fashioned into a neovaginal canal, which is anchored into the perineum. For transgender women, the graft may be used alone or in combination with penile and scrotal skin flaps depending on available tissue.

The surgery is performed using meticulous dissection techniques to preserve blood supply and ensure correct positioning, creating both a functional and aesthetic vaginal substitute.

Perioperative Care & Donor Site Considerations

Harvesting from the small bowel requires careful planning to minimise risks at the donor site. Patients are monitored closely for potential bowel obstruction, leaks, or strictures. Bowel continuity is restored immediately during the same operation, and enhanced recovery protocols are followed to promote healing.

Functional Outcomes

When successful, patients experience:

• Durable neovaginal depth and width.
• Satisfactory sexual function with natural lubrication.
• Reduced need for lifelong dilation compared with non-intestinal methods.
• Improved psychological well-being and quality of life.

For transgender women, the use of small bowel provides additional depth and lubrication compared with penile inversion alone, offering a closer approximation to female anatomy.

Short and Long-Term Complications

Like any major reconstruction, complications may occur:

• Short-term: infection, bleeding, bowel leaks, graft ischemia.
• Long-term: mucorrhea (excess discharge), stenosis, neovaginal prolapse, or bowel-related complications.

Complication rates are influenced by surgical expertise, patient comorbidities, and post-operative care.

Postoperative Management

Patients require close follow-up to monitor healing, maintain neovaginal patency, and manage mucus discharge. Dilation protocols may still be advised, though often less intensive than with skin graft techniques. Long-term follow-up is essential to ensure both functional and psychosocial success.

Alternatives to Small Bowel Neovagina

Other reconstructive options include:

• Penile inversion vaginoplasty (in transgender women).
• Split-thickness skin grafts (McIndoe technique).
• Peritoneal vaginoplasty (minimally invasive laparoscopic approach).
• Sigmoid colon grafts (traditional intestinal method).

Each option has benefits and limitations, and the choice depends on anatomy, patient goals, and surgical expertise.

Why Dr MC Conradie?

Dr MC Conradie is the first surgeon in South Africa to successfully perform small bowel graft neovagina. With advanced training in urological reconstruction, laparoscopic and robotic-assisted surgery, and a focus on patient-centred outcomes, she offers a unique level of expertise not previously available in the country.

For patients and referring doctors, this represents access to cutting-edge surgical options previously unavailable in South Africa, delivered with international-level precision and care.

The creation of a neovagina using small bowel grafts is more than a surgical procedure — it is an opportunity for patients to regain identity, intimacy, and self-confidence. Whether for congenital absence, cancer reconstruction, or gender-affirming surgery, this technique offers renewed possibilities where traditional methods fall short. With Dr Conradie’s pioneering expertise, patients in South Africa now have access to one of the most advanced forms of neovaginal reconstruction — restoring both anatomy and quality of life with compassion and precision.