Robotically Harvested Peritoneal Flaps As a Well-Vascularized Adjunct to Penile Inversion Vaginoplasty

Purpose:

Penile inversion vaginoplasty (PIV) is the standard operation for genital reconstruction in transwomen.  Despite usually providing an excellent aesthetic result, the technique can be complicated by vaginal stenosis and inadequate depth, particularly in transwomen with limited penile and scrotal tissue.  Vascularized peritoneal flaps have been used to augment vaginal depth in neovaginal creation in patients with congenital vaginal agenesis.  Here, we review our experience with the novel application of peritoneal flaps in penile inversion vaginoplasty in transwomen, to augment the neovaginal apex with well-vascularized tissue.

 

Materials and Methods:

Between 2017 and 2018, 20 male-to-female patients were identified who underwent a robotically assisted PIV using peritoneal flaps. In brief, approximately 5cm by 5cm peritoneal flaps are raised from the anterior rectum and posterior bladder to create the apex of the neovagina and serve as an attachment for inverted penile skin and scrotal skin graft.  Patient demographics, medical comorbidities, intra-operative details, peri-operative complications, and neovagina measurements served as primary outcome measures.

 

Results:

In our cohort of 20 patients, average age at time of surgery was 33.5 +/- 11.2 years. Average length of procedure was 319.3 +/-41.6 minutes and the average inpatient stay was 5 days. Average length of follow up was 54.6 +/- 42.1 days and at most recent follow up, vaginal depth and width were measured to be 12.83 +/- 1.1 cm and 2.85 +/- .3 cm respectively. The peritoneal flap added an additional 5 cm of depth.   There were no complications related to peritoneal flap harvest.

 

Conclusion:

Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Neovaginal depth can be limited by available donor tissue. With increased use of puberty blockade, we believe that there will be an increase in women presenting with limited natal tissue. While intestinal flaps or extragenital skin grafts have been used when there is inadequate penile and scrotal skin, there can be considerable donor site morbidity.  Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex without additional donor morbidity.