Presentation Authors: Geolani W. Dy*, Ian Nolan, Matthew Katz, Adam Jacoby, Rachel Bluebond-Langner, Lee Zhao, New York, NY
Introduction: Penile inversion vaginoplasty (PIV) is the most common technique for primary feminizing genital reconstruction in transwomen, which requires regular lifelong dilation to maintain adequate canal depth and width. Vaginal stenosis is a common complication of PIV and canal reconstruction is a challenge due to paucity of tissue, requiring extragenital skin grafts or use of enteric segments. We present an alternative approach to canal reconstruction using robotic assisted peritoneal flap mobilization.
Methods: Between September 2017 and September 2018, we identified 8 transgender female patients who underwent peritoneal flap revision vaginoplasty. Two peritoneal flaps measuring approximately 8 cm wide by 10 cm long are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder. The two peritoneal flaps are advanced distally to serve as an attachment for inverted penile skin from previously a created, stenosed vaginal cavity. The proximal edges of the flap form the neovaginal apex. Patient demographics, medical comorbidities, surgical indications, intra-operative details are described. Post-revision neovaginal dimensions and complications served as outcome measures.
Results: Patients had a mean age of 37 years (range 28-58) at time of revision. All underwent primary penile inversion vaginoplasty, undergoing revision at a median of 13.5 months (range 6-240) since primary vaginoplasty. Seven of 8 patients underwent initial PIV at an outside institution. Three patients had undergone previous revision vaginoplasty. Surgical indications included short or stenotic vagina or absent vaginal canal in all 8 patients._x000D_
Average procedure length was 5 hours and average length of stay 5 days. Mean follow up was 120 days (18-362) days. At most recent follow up, mean vaginal depth and width were 14.5cm (range 14.5) and 3.7cm (range 3.5-3.8), respectively. There were no complications related to peritoneal flap harvest; one patient had post-operative bleeding from a prostatic pedicle requiring suture ligation under anesthesia.
Conclusions: We describe a safe, minimally invasive approach to revision vaginoplasty for vaginal stenosis after primary and failed revision PIV. Peritoneal flaps provide a well-vascularized canal without additional donor site morbidity.