Gender-affirming surgery leads to improved mental health, quality of life, and high patient satisfaction.^1,2 Among trans women and nonbinary individuals assigned male at birth, 10% have undergone genital gender-affirming surgeries such as vaginoplasty (creation of vulvar anatomy and a vaginal canal) and/or labiaplasty, and 45% report wanting to pursue genital gender-affirming surgery in the future.³ Those who undergo vaginoplasty must commit to a strict vaginal dilation schedule both in the early postoperative period and long term. Nonadherence to dilation schedules, inadequate dilation, and other complications can result in vaginal stenosis, insufficient depth, and trapped fluid collections within the remnant vagina.⁴

Multiple operative approaches exist for primary gender-affirming vaginoplasty. Penile-inversion vaginoplasty is the most commonly performed technique,⁵ though robotic-assisted peritoneal flap gender-affirming vaginoplasty is being increasingly utilized. Surgical management of vaginal stenosis holds further challenges given difficult surgical access from the perineum, paucity of adequate soft tissue for flap creation in reoperative fields, and obliterated tissue planes near critical organs (eg, rectum, bladder, urethra). Here, we review the benefits of the robotic platform for performing revision vaginoplasty operations, with a focus on the single-port (SP) robotic approach.

Robotic-Assisted Peritoneal Flap Gender-Affirming Vaginoplasty

Use of peritoneal flaps to line the neovaginal canal was initially reported in 1933 and was popularized by Davydov in 1969 for the treatment of vaginal agenesis in cisgender females,⁶ in order to avoid grafting from other areas. Utilizing peritoneal flaps results in the ability to construct the canal, while eliminating additional donor site morbidity from skin grafting or the increased risks associated with harvesting a pedicled intestinal/colonic segment (bowel obstruction, anastomotic leak, etc). The robotic platform has allowed for minimally invasive adaptation of the originally described peritoneal vaginoplasty, achieving a more facile peritoneal flap elevation, decreasing the risk of injury to nearby critical structures, and allowing for creation of anterior and posterior flaps up to 12 × 12 cm in size.^4,7 In-depth technical details of this operation are outlined elsewhere.^8,9 This concept has now been implemented for primary gender-affirming vaginoplasty, and is especially useful in cases where patients’ natal genital tissue alone is inadequate for coverage of the entire vaginal canal. In these cases, the peritoneal flaps are sutured to the inverted penile tissue to create a vascularized neovaginal canal apex. Suturing the inverted penile/scrotal tissue to the peritoneal flaps essentially eliminates neovaginal prolapse.⁹ The efficacy and safety of this approach has been demonstrated, and its implementation has expanded.^7,9 Postoperative dilation is still required to prevent stenosis.

SP vs Multiport

While SP and multiport (Xi) robotic approaches are described with similar long-term outcomes,⁸ the SP approach offers several advantages. The SP robotic arm allows for the transabdominal and perineal portions of the operation to occur simultaneously, which significantly decreases operative times.⁸ In addition, the SP approach leads to improved cosmetics, as the single 27-mm robotic port can be concealed at the umbilicus with only 1 additional 5-mm assistant port. In contrast, the Xi approach requires the placement of four 8-mm ports. The SP robot also provides narrower access, facilitating deep dissection of the vaginal cavity to the level of the pelvic floor musculature while minimizing clashing with the pelvic side walls.

Robotics in Revision Vaginoplasty

The robotic platform truly distinguishes itself during neovaginal canal reconstruction operations. Loss of vaginal canal depth is one of the most common issues after all types of vaginoplasty.⁵ Revision surgery is often technically challenging due to adherence of the stenosed canal to the adjacent rectum, bladder, prostate and proximal bulbar urethra, which puts these structures at risk of injury. Tissue options for canal revisions typically include skin grafting, peritoneum, or colon. The use of peritoneum involves less morbidity than harvesting skin graft or colonic tissue,⁴ and in cases where the primary vaginoplasty was performed by the perineal penile-inversion vaginoplasty technique, the superior visualization of the robotic platform during antegrade dissection renders the robotic approach ideal for revision surgery.¹⁰ Furthermore, as robotic prostatectomy predominates in the current era and trainees are exposed to less and less perineal prostatectomy, urologists will become increasingly comfortable with this approach.

Both SP and Xi robotic approaches have been shown to be safe and effective modalities for revision vaginoplasty,¹⁰ though the SP robotic approach offers the combined benefits of robotic revision and the SP approach—that is, faster operative times, minimal donor morbidity, fewer abdominal incisions, a more facile dissection in previously unviolated planes, a vascularized apex of tissue to prevent canal restenosis, and a deeper canal than skin graft–based revision operations.¹⁰ Surgeons performing gender-affirming vaginoplasty should be familiar with this approach.