V04-03: Robotic Peritoneal Flap Technique for Revision Vaginoplasty in Transgender Women
Penile inversion vaginoplasty (PIV) is the most common technique utilized for feminizing genital reconstruction in transgender women. After surgery, patients must perform regular vaginal dilation to maintain vaginal canal depth and width. Vaginal stenosis is a common complication after initial surgery and can be challenging to manage. Revision vaginoplasty for increased depth is difficult due to lack of available tissue and scar formation from previous dissection, as well as limited visualization using a perineal approach. This video presents a novel technique for revision vaginal reconstruction using robotic assisted peritoneal flap mobilization.
We identified 8 transgender women who underwent peritoneal flap revision vaginoplasty for vaginal stenosis after prior PIV between September 2017 and September 2018. The revision vaginoplasty is performed by developing two peritoneal flaps measuring approximately 8 cm wide by 10 cm long. The retrovesical pouch is opened, and dissection proceeds between the prostate and rectum to the stenotic vaginal canal. The canal is opened laterally. The flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder. The flaps are sutured to the inverted penile skin to create the apex of the neovagina. Outcomes were reported using descriptive statistics on intra-operative details and peri-operative complications/results.
Robotic peritoneal flap revision vaginoplasty was successfully performed in all 8 patients. Patients had a mean age of 37 and underwent revision vaginoplasty at a median of 13.5 months (range 6-240) after initial PIV. Some (7/8) 88% of patients underwent initial PIV at an outside institution. Surgical indication for revision surgery was short or stenotic vagina (n=7) or absent vaginal canal (n=1). There were no intraoperative complications. Mean estimated blood loss was 162.5 mL, operative time 295 minutes, and length of stay 5.1 days. At mean follow up of 120 days, the mean vaginal depth and width were 14.5cm and 3.7cm.
We present a novel technique for revision vaginoplasty using a robotic approach with peritoneal flaps. This procedure can be safely performed with low morbidity for transgender female patients with vaginal stenosis to improve vaginal canal depth and width.