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Page 2 of 16 Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11

numerous benefits, including high-definition 3D visualization, wristed articulation with markedly increased
range of instrument motion compared to straight-stick laparoscopy and the ability to eliminate hand
tremors. These features collectively enhance surgical precision, dexterity, and the ability to maneuver within
deep, narrow spaces with less tissue trauma. Furthermore, surgeon control of a fourth arm improves
efficiency by facilitating instantaneous instrument change without the need for manual exchange through
ports.

As a result, robotic surgery is widely used across many surgical specialties, contributing to reduced operative
[2]
time, postoperative pain, length of postoperative stay, and complications, as well as quicker recovery .
In the field of gender affirmation surgery (GAS), robotic surgery has numerous applications in both primary
and revision surgery. While various robotic surgical systems exist, most published data on robotic-assisted
surgery in GAS involve the use of the da Vinci Si, Xi, or single port (SP) Surgical Systems (Intuitive Surgical,
Sunnyvale, CA). The standard Da Vinci Xi system has four robotic arms, which are used to access the
peritoneal cavity through 4-5 separate ports, depending on patient positioning and instrument
requirements. The more recent Da Vinci SP system enables the control of three multi-jointed surgical
instruments and an articulating endoscope through a SP. Typically, two access ports are required with this
system: one for the robotic trocar and another for a laparoscopic assistant port .
[3]

Here we will appraise the different robotic techniques applied to GAS and their published outcomes to date.

ROBOTICS IN LOWER FEMINIZING SURGERY
Robotic gender-affirming vaginoplasty
Penile inversion vaginoplasty (PIV) remains widely regarded as the gold-standard technique for full-depth
vaginoplasty. However, it is not suitable for all patients - particularly those who have previously undergone
circumcision, those with a micropenis, or those with peno-scrotal hypoplasia. In such patients, as well as
those with neovaginal stenosis following ‘standard’ vaginoplasty techniques, robotic technology can become
a valuable tool in the surgeon’s armamentarium.

Primary robotic-assisted gender-affirming peritoneal vaginoplasty
The most frequently reported robotic-assisted technique for gender-affirming vaginoplasty is the peritoneal
flap vaginoplasty. This procedure has been adapted from Davydov’s original technique described in 1969,
[4,5]
which was employed in cis female patients for dyspareunia . Our literature search revealed nine studies
reporting outcomes of primary robotic-assisted gender-affirming peritoneal vaginoplasty (pRA-GPV)
[Table 1].

In 2019, Jacoby et al. reported outcomes of pRA-GPV in 41 transfeminine patients. Their widely published
[5]
technique involves simultaneous perineal and robotic approaches [3,5,6] . The perineal surgeon performs the
perineal dissection, bilateral orchidectomy, and penectomy alongside neoclitoris, labia minora, and labia
majora formation. Concurrently, the robotic pelvic surgeon raises 12 cm × 12 cm anterior and posterior
peritoneal flaps from the posterior aspect of the bladder and the anterior border of the rectum, respectively.
The ureters mark the lateral borders of the flaps. Externally, the scrotal skin graft is tubularized around a 38
mm dilator and inset with the inverted penile skin tube. This penoscrotal skin tube is then passed through
the neovaginal canal to the robotic surgeon, who insets it with the peritoneal flaps using a barbed 3-0
absorbable suture. The anterior and posterior peritoneal flaps are sewn together at the apex of the neovagina
and the flap donor sites are closed. In their study, the average operative time was 262 min and the average
inpatient stay was 5 days. At the most recent follow-up (average 114 ± 79 days), neovaginal depth and width