Patients undergoing gender-affirming vaginoplasty have the option of either full-depth vaginoplasty (FDV) or minimal-depth vaginoplasty (MDV, also known as vulvoplasty). While hopefully uncommon, patients with prior MDV may request a conversion to FDV. One challenge during such conversion is the lack of genital skin after prior MDV. Our objective was to describe an operative technique of converting MDV to FDV utilizing peritoneal flaps for the apex of the canal and full-thickness abdominal skin grafts. Peritoneal flaps are hairless, can be readily harvested using robotic assistance, and obviate the need for bowel harvest. Abdominal skin grafts are taken from hairless redundant groin or lower abdominal skin, and the donor site can be closed primarily. We describe such a technique in a 43-year-old transgender female who had previously undergone MDV and had a canal depth of 1 cm.

The patient was placed in the lithotomy position. We harvested full-thickness bilateral groin grafts measuring 15 × 4 cm bilaterally. These were closed primarily in layers, thinned on the back table, and sewn over a dilator to form a cylinder. We then began perineal dissection. The apex of the existing short canal was incised transversely, and we dissected under the central tendon at the midline. Laterally, we developed spaces just below the inferior pubic ramus bilaterally to the pelvic floor. Next, a da Vinci Xi was docked with 4 robotic 8-mm ports and 1 assistant port. We incised the peritoneum in the rectovesical pouch just underneath the expected level of the vas deferens. The location of this incision is important as these peritoneal edges will later be advanced and sewn to the skin graft. Dissection for the canal is continued distally just below Denonvilliers’ fascia, which is a relatively virgin plane adjacent to the prostatic capsule. Once the rectal attachments were identified at the midline, we focused our dissection laterally. To more clearly delineate the rectum, an assistant can place a finger to demonstrate its location. Eventually the pelvic floor musculature was identified lateral to the rectum. This muscular sheet of pelvic floor offers a safe location to connect the dissection between the robotic and perineal surgeons. Careful transection of the muscle revealed the pelvic surgeon’s instrument (just inferior to inferior pubic ramus on each side). Once these 2 connections were made, the assistant placed a clamp through the hole so that aperture in the muscle could be widened. We perform lateral pelvic floor musculature incision to facilitate future dilation. Completion of the midline dissection may be performed robotically or perineally, and we often favor the latter. Once the canal space was created, we inserted a wide vaginal silicone dilator (41 mm diameter) to ensure adequate width. With the cylindrical skin tube on the dilator, we sutured it to the edges of the introitus with interrupted absorbable suture. The tube can was then pushed into the canal with a dilator.

Robotically, we identified the templated outline for our peritoneal flaps (part A of Figure). The lateral borders are the medial umbilical ligaments anteriorly and the ureters posteriorly. Anteriorly, a transverse incision over the peritoneum was made ∼20 cm from the initial incision. Posteriorly, the peritoneal flap continued to the level of the sacral promontory, sparing the midline over the rectum itself. At times, adjustments of the template are made due to the patient’s anatomy. Using barbed suture, the circumferential skin tube was sewn to the anterior peritoneal flap in running fashion, starting in the midline with 1 suture running each way laterally to the lateral edge of the skin tube. This process was repeated for the posterior flap to complete the circumferential anastomosis. A silicone dilator was inserted to assure that width was not lost in this anastomosis (part B of Figure). The anterior and posterior edges were then anastomosed laterally. To close the apex, we sometimes need to close the anterior flap to itself in the midline or partially drop the bladder. Lowering the pneumoperitoneum can assist in the finalization of the closure. The anastomosis was continued until the vaginal canal was excluded from the abdomen. A small gap was left to prevent bowel obstruction. An inflatable vaginal stent was placed into the vaginal canal. We also placed an abdominal drain and a Foley catheter. The patient was admitted for 5 days, after which the stent, Foley, and drain were removed, and the patient immediately started dilating 3 times daily. In follow-up, the patient was able to dilate to a depth greater than 14 cm without difficulty.

Figure. A, Once the canal is established, peritoneal flaps are harvested by incising the peritoneum on the dotted line. B, With a dilator in the canal, the skin grafts are sewn to the peritoneal flaps.

Conversion of MDV to FDV is safe and effective but requires extragenital tissue. The robotic approach facilitates dissection of the canal through a virgin plane and allows for harvest of peritoneal flaps. Full-thickness skin grafts from the groin or abdomen have minimal morbidity and excellent cosmesis.

Conflicts of Interest: The Authors have no conflicts of interest to disclose.