Genital Hypoplasia before Gender-Affirming Vaginoplasty: Does the Robotic Peritoneal Flap Method Create Equivalent Vaginal Canal Outcomes?

Abstract

Background: Insufficient genital tissue has been reported as a barrier to achieving depth in gender-affirming vaginoplasty. The authors sought to characterize vaginal depth and revision outcomes in patients with genital hypoplasia undergoing robotic peritoneal flap vaginoplasty. Methods: Retrospective case-control analysis of patients undergoing robotic peritoneal vaginoplasty between September of 2017 and August of 2020 was used. All 43 patients identified as having genital hypoplasia (genital length <7 cm) were included with 49 random controls from the remaining patients with greater than 7 cm genital length. Baseline clinical characteristics and perioperative variables were recorded to identify potential confounders. Outcomes measured included vaginal size reported at last visit and undergoing revision surgery for depth or for vulvar appearance. Results: Patients were well matched other than median body mass index at the time of surgery, which was greater in the hypoplasia cohort by 3.6 kg/m2 (P < 0.0001). Patients had a median of 1-year of follow-up, with a minimum follow-up of 90 days. No significant differences in outcomes were observed, with a median vaginal depth of 14.5 cm (interquartile range, 13.3 to 14.5 cm), and a median width of dilator used of 3.8 cm (interquartile range, 3.8 to 3.8 cm). No depth revisions were observed, and an 11% (n = 10) rate of external revision occurred. Conclusions: Patients with genital hypoplasia had equivalent dilation outcomes in a case-control analysis with consistent follow-up past 90 days. The robotic peritoneal flap vaginoplasty technique provides vaginal depth of 14 cm or greater regardless of genital tissue before surgery. Further investigation with patient-reported outcome measures is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Robotics in Gender Affirming Surgery: Current Applications and Future Directions

“…4,9,11,13 At our center, the average vaginal canal depth is 14.5 cm in patients with a median follow-up of 1 year. 17 These data compare favorably to a recent meta-analysis of 39 studies encompassing more than 3,900 patients undergoing traditional penile inversion vaginoplasty, which reported an average vaginal depth of 9.4 cm. 18 In addition, we have found that using the robotic peritoneal flap approach, our vaginal depth outcomes are equivalent between patients with penoscrotal hypoplasia and those with greater genital tissue surface area.…”

“…18 In addition, we have found that using the robotic peritoneal flap approach, our vaginal depth outcomes are equivalent between patients with penoscrotal hypoplasia and those with greater genital tissue surface area. 17 Historically, patients with marked penoscrotal hypoplasia have been encouraged to pursue intestinal vaginoplasty. 19 20 The robotically assisted peritoneal flap vaginoplasty offers an alternative to colon vaginoplasty for these patients.…”

The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis

“…One case report described robotic nerve decompression [ 99 ]. Three articles described vaginoplasty/gender reassignment robotic techniques [ 100 – 102 ]. A total of 28 articles described ventral abdominal wall reconstruction and hernia repair [ 103 – 130 ].…”