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Robotic tubularized peritoneal flap vaginoplasty
Joshua Roth, MD, PhD, Ramzy T. Burns, MD, Ashley W. Johnston, MD, Michael O. Koch, MD.
Riley Hospital for Children, Indiana University, INDIANAPOLIS, IN, USA.

BACKGROUND:For trans-feminine patients desiring penetrative intercourse, several surgical reconstructive options exist including: penile inversion vaginoplasty, sigmoid vaginoplasty, and peritoneal vaginoplasty. Penile inversion vaginoplasty requires preoperative laser hair removal which can be time-consuming and costly. Sigmoid vaginoplasty requires bowel harvest and some patients are bothered by excess mucus secretion and odor. Peritoneal vaginoplasty, though without known long-term outcomes, foregoes the need for preoperative laser hair removal and bowel reconstruction. It provides an excellent option for transgender patients desiring penetrative intercourse. We present the first video of a robotic tubularized peritoneal flap vaginoplasty with penile skin inversion.
METHODS:Our patient was a 21-year-old transgender female who desired a gender affirming vaginoplasty that would allow for penetrative intercourse. She had been on hormones and living in her experienced gender for 2 years. She had no significant past medical or surgical history. She met all WPATH criteria to proceed with surgery, and elected for a robotic-assisted peritoneal vaginoplasty, penectomy, clitoroplasty, labiaplasty, orchiectomy, scrotectomy, and urethroplasty.
RESULTS:Robotic-assisted peritoneal vaginoplasty, penectomy, clitoroplasty, labiaplasty, orchiectomy, scrotectomy, and urethroplasty were performed successfully. The surgery was performed simultaneously by two surgical teams; one surgeon was on the robotic console creating the tubularized flap while the other surgeon was operating on the perineum performing a modified Ghent penile inversion vaginoplasty. The tubularized peritoneal flap was anastomosed robotically to the inverted, non-hair bearing penile shaft skin. The completed neovagina easily accommodated a 1.5 inch vaginal dilator. Total operative time was 7 hours which included 4.5 hours of robotic console time.
The patient was discharged home on postoperative day 6 after removal of vaginal stent and foley catheter. Vaginal dilation was immediately initiated and performed twice daily for 30 min each session. The patient was also instructed to perform vaginal flushing daily. Penetrative sexual activity was allowed after 8 weeks. At 3 month follow-up, the patient was achieving orgasm and comfortably dilating with the largest caliber dilator (1.5 inch diameter, 8 inch length).
CONCLUSION:This video shows that a robotic-assisted peritoneal vaginoplasty is a feasible option for transgender females desiring penetrative intercourse. It negates the need for the time-consuming and costly preoperative hair removal required for penile inversion vaginoplasty, and avoids the morbidity of bowel reconstruction with a sigmoid vaginoplasty.


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