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Page 6 of 16 Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11

underwent primary PIV at their institution. Average intraoperative neovaginal depth with pRA-GPV was
comparable to PIV, at 13.1 ± 3.0 cm vs. 12.7 ± 1.5 cm, respectively.

Revision robotic-assisted gender-affirming peritoneal vaginoplasty
A robotic-assisted approach may be applied to revision vaginoplasty for neovaginal stenosis, prolapse, or
canal malposition. Traditional perineal approaches in revision vaginoplasty can be technically difficult due
to limited visibility from the perineum into the pelvis (‘a deep dark hole’), with extensive scar tissue and the
adherence of the stenosed neovagina to the bladder and rectum. The robotic approach offers better access to
the narrow, deep pelvis and phenomenal visibility. An additional advantage is access to a concealed donor
site, the peritoneum, for lining the revised neovaginal canal . Neovaginal canal revisions can be
[17]
successfully performed using peritoneal flaps, harvested in a similar fashion to the primary vaginoplasty
[17]
technique and sutured to the remnant existing canal once the stenosis has been incised and released . Our
literature search revealed two studies reporting outcomes of revision robotic-assisted gender-affirming
peritoneal vaginoplasty (rRA-GPV).

In addition to their large case series on primary RA-GPV, Dy et al. have reported on salvage neovaginal
reconstruction with robotic peritoneal flap vaginoplasty in 24 patients. In most cases, the indication was
neovaginal stenosis or a short neovagina . While the technique is similar to that described for primary
[17]
cases, the canal dissection between the bladder and rectum is toward the stenosed neovaginal cavity, which
is subsequently incised and widened. The proximal peritoneal flap edges are approximated to form the
neovaginal apex. The average procedure length was 300 min. The average neovaginal depth and width were
13.6 cm and 3.6 cm, respectively, at a median follow-up of 13.2 months. Despite the more scarred plane
between the bladder and rectum, no patients experienced rectal injury. Complications included 1 case of
postoperative canal bleeding requiring surgical re-intervention and 1 case of hypocontractile bladder
secondary to inferior hypogastric plexus injury.

Smith et al. have described an alternate robotic technique for management of neovaginal stenosis post-PIV
in 10 patients using a single-pedicled urachus-peritoneal hinge flap . The mean preoperative neovaginal
[18]
depth was 9.2 cm (SD 1.5 cm), which was increased to 15.1 cm (SD 2.2 cm) immediately post-revision
surgery, with a subsequent reduction to 12.5 cm (SD 2.1 cm) at mean follow-up (13.1 months). Anastomotic
narrowing occurred in 1 patient at 6 weeks postoperatively, managed with dilation under anesthesia.
Satisfactory neovaginal receptive intercourse with male partners was reported by 5 patients (50%). Orgasmic
function was maintained in the 8 patients able to achieve orgasm after primary PIV, with orgasm quality
improved in 75% of patients following rRA-GPV. While the majority of patients (70%) reported being
bothered by the appearance of their abdominal port scars, 80% reported that if given the opportunity to go
back in time, they would still choose to undergo rRA-GPV for neovaginal stenosis.

Robotic intestinal segment vaginoplasty
Intestinal segment vaginoplasty can provide a self-lubricating neovagina secondary to intestinal mucus
production. It is less commonly performed than PIV due to associated complications of using bowel
segments, such as anastomotic leak, diversion colitis and mucus hyperproduction. While this is mostly
performed via a laparoscopic approach, some surgeons are now exploring robotic-assisted approaches. Our
literature search revealed two papers reporting a robotic-assisted intestinal segment vaginoplasty.

In 2024, Del Corral et al. described their technique and outcomes using a robotic-assisted jejunal free flap
harvest in combination with PIV in 6 transfeminine patients . Jejunum was selected over other bowel
[19]
segments due to reduced mucus secretion and lower risk of functional bowel problems arising from short-