Robotic Davydov Peritoneal Flap Vaginoplasty for Augmentation of Vaginal Depth in Feminizing Vaginoplasty

Purpose: Penile inversion vaginoplasty is the most common procedure for genital reconstruction in transwomen. While penile inversion vaginoplasty usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. We describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. Materials and Methods: Between 2017 and 2018 we identified 41 transwomen who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6 cm wide by 8 cm long peritoneal flaps were raised from the anterior aspect of the rectum and the sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. Results: Average +/- SD age of the 41 patients was 34 +/- 14 years. Average procedure duration was 262 +/- 35 minutes and average length of stay was 5 days. Average followup was 114 +/- 79 days. At the most recent followup vaginal depth and width were measured to be 14.2 +/- 0.7 and 3.6 +/- 0.2 cm, respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. Conclusions: Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well vascularized apex with acceptable anticipated complications.