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Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11 Page 5 of 16

In 2025, Johnston et al. reported outcomes of robotic-assisted tubularized peritoneal vaginoplasty in a
[10]
mixed cohort of 33 patients undergoing primary or revision surgery . By tubularizing a single anterior
peritoneal flap instead of two flaps, the authors theorized that this may reduce the risk of internal herniation
along suture lines. Furthermore, they postulated that by leaving the peritoneum overlying the rectum intact,
the risk of rectal injury and recto-neovaginal fistula may be reduced. The anterior peritoneal flap was raised
off the bladder wall, tubularized and anastomosed either directly to the introital skin (original technique) or
to inverted penile skin (newer technique). Neovaginal stenosis occurred in one-third of patients and was
thought to be related to difficulty dilating in patients who had had the original anastomotic technique, with
stenosis occurring in only 1 out of 10 undergoing the newer technique. Revision vaginoplasty was
performed for stenosis in 3 cases, with buccal vaginoplasty offered for introital stenosis and sigmoid
vaginoplasty for canal stenosis. Acute postoperative complications occurred in one-third of patients, which
were all Clavien-Dindo grade ≤ 2 [Table 1].

Single-port robotic systems have become increasingly popular in recent years. In 2020, a small study by
Acar et al. used the Xi system in 2 patients and the SP system in 9 patients . The study included a mixed
[11]
population, including primary lower feminizing surgery (LFS), revision for neovaginal stenosis after prior
LFS, and vaginal hypoplasia secondary to disorders of sexual development in cisgender women. The mean
procedure length was 267 min and the initial postoperative mean neovaginal depth was 13.9 ± 0.5 cm. Major
complications included 1 case of urethral injury in a patient with extensive scar tissue and distorted
anatomy from prior PIV, which was repaired intraoperatively, but resulted in a subsequent urethra-
neovaginal fistula managed with a robotic intestinal vaginoplasty.

In 2021, Dy et al. compared the da Vinci Xi and SP systems in 145 transgender patients undergoing pRA-
[12]
GPV . Average procedure times were longer using the Xi versus the SP system at 252 min vs. 222 min,
respectively (P < 0.001). At mean follow-up of 11.9 months, the average neovaginal depth was greater with
the SP system at 14.1 cm (range 9.7-14.5) vs. the Xi system at 13.6 cm (range 9.7-14.5 cm) (P = 0.07).
However, the average neovaginal width was comparable [Table 1]. There were no reported differences in
complication rates between the two approaches.

A major advantage of pRA-GPV is that it offers an alternative tissue to line the neovaginal canal in patients
with insufficient penoscrotal skin for PIV. In 2023, Blasdel et al. published a retrospective case-control
[13]
analysis comparing 43 patients with genital hypoplasia undergoing pRA-GPV vs. 49 controls without . At
a median follow-up of 12 months, there was no difference in neovaginal dimensions between the two
groups (median depth 14.5 cm, diameter 3.8 cm), with 89% of all patients obtaining a neovaginal depth ≥
12.1 cm. Neovaginal stenosis was reported in 10 patients (11%), but no revisions were required. There was
no statistically significant rate of external revision between the two groups (7% in the hypoplasia group vs.
14% in the control group).

Comparison of pRA-GPV with PIV and other vaginoplasty techniques is limited by a lack of randomized
control trials and the fact that most published studies have small sample sizes. Larger studies in our review
of pRA-GPV with over 100 patients report a neovaginal stenosis rate of up to 7% and a recto-neovaginal
fistula rate of up to 1.1% [8,12] . These rates are comparable with that of primary PIV published in a systematic
review by Dunford et al., which found rates of 7.2% and 1.5%, respectively . In this review, the average
[14]
neovaginal depth with pRA-GPV was 13.1-15.7 cm, which is greater than in PIV and comparable to
intestinal vaginoplasty in a meta-analysis of vaginoplasty outcomes by Bustos et al. . In 2022, Huang et al.
[15]
reported a small retrospective case review of 19 patients undergoing pRA-GPV, including 14 primary and 5
revision cases with neovaginal stenosis post-PIV . Outcomes were compared with 28 patients who
[16]