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Page 6 of 13 Chao et al. Plast Aesthet Res. 2025;12:29 https://dx.doi.org/10.20517/2347-9264.2025.18

bears several consequences. Too steep an angle results in a pit-like canal, which can collect debris and urine
despite its shallow depth. Insufficient angulation results in an unsightly straight-on appearance of the canal
apex, which resembles the umbilicus.

Full-depth vaginoplasty
For primary full-depth vaginoplasty, we offer a modified penile inversion vaginoplasty utilizing robotic
assistance for canal dissection. We prefer the combined perineal and robotic transperitoneal approach for
several reasons. Foremost is that it minimizes the risks of rectal and urethral injury, which in large series are
reported in 2.3%-2.6% and 1.1% of cases, respectively [38,39] . In our experience of 99 primary and 28 revision
full-depth vaginoplasties, we have encountered zero rectal injuries or rectovaginal fistulae. One urethral
injury (0.8%) occurred early in our learning curve and resolved with primary closure and prolonged Foley
catheter drainage. These and other complications are summarized in Table 1.

Second, the robotic platform standardizes neovaginal canal creation. The neovagina is pexied to the
peritoneal reflection, and in most cases, this yields a canal of sufficient depth without concern for later
prolapse. We do not routinely employ peritoneal flaps in primary full-depth cases, as we reliably gain
sufficient canal depth in this manner. This eschews the relatively rare but notable risks of small bowel
obstruction, internal herniation, and neurogenic lower urinary tract dysfunction associated with peritoneal
flap harvest [19,40] . In our technique, the peritonotomy is closed as the neovaginal apex is pexied, thereby
sequestering the canal from the intra-abdominal contents [Figure 1]. It is critical to note that each case is
individualized: for patients with penoscrotal hypoplasia or refractory genital hair growth, we do not hesitate
to proceed with peritoneal flap vaginoplasty to preserve sufficient skin for satisfactory vulvar definition.

After emptying the bladder, canal dissection begins via a perineal approach. We leave the bulbospongiosus
muscle attached posteriorly until canal dissection is complete, which maintains the correct plane of
dissection and, in the event of a rectal or urethral injury, serves as a well-vascularized flap for interposition.
The perineal body is taken down transversely and the dissection is continued along Denonvillier’s fascia to
develop the potential space between the rectum and prostatic apex. Laterally, dissection continues in the
fatty tissue just posterior to the inferior pubic ramus.

We then continue canal dissection via a robotic transperitoneal approach. In the steep Trendelenberg
position, pneumoperitoneum is established and robotic ports are placed; for a multi-port system, these are
configured in a manner similar to that for a robotic prostatectomy. It is prudent to minimize the distance
between ports (no greater than 8-9 mm), as the lateral-most ports will be restricted by the narrow inlet of
the “male” pelvis.

A peritonotomy is made in the rectovesical pouch and dissection continues caudad, posterior to the vas
deferens. This is akin to the dissection plane during a Retzius-sparing radical prostatectomy. Dissection can
be either in the intrafascial (between the leaflets of Denonvillier’s fascia) or infrafascial (posterior to both
leaflets) plane. We prefer the latter, as it leads rapidly to the pelvic floor musculature laterally and allows us
to “break through” (i.e., connect the perineal and abdominal surgical fields) off midline, minimizing the risk
of rectal injury. This space is easily found through blunt dissection by the perineal surgeon. The levator
musculature is incised over an assistant’s gloved finger or instrument just posterior to the inferior pubic
ramus. Once the bilateral spaces are widened sufficiently, a finger can be hooked around the remaining
rectourethralis midline attachments. These are taken down perineally over a finger, which allows for tactile
feedback to avoid urethral or rectal injury. Finally, the lateral pelvic floor musculature is further incised to
maximize vaginal width.