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Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11 Page 7 of 16

segment harvest. The first part of the procedure involved performing a standard PIV augmented with a
scrotal graft. Peritoneal flaps were then elevated from the posterior bladder wall via a robotic trans-
abdominal approach and reflected down into the neovaginal canal. A 15-20 cm segment of jejunum was
harvested as a free flap along with its vascular supply from mesenteric branches of the superior mesenteric
artery. The great saphenous vein was harvested to create an arteriovenous loop between the flap vessels and
the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal free flap
was then passed intra-abdominally through the groin incision and then transperitoneally into the
neovaginal canal, where it was inset to the proximal peritoneal flaps and the inverted penoscrotal skin of the
neovaginal introitus. The mean operating duration was 263 min (range 236-296 min). At mean follow-up of
8 months (range 1-14 months), mean neovaginal dimensions were 1.78 cm depth and 3.3 cm diameter.
Major complications (Clavien-Dindo ≥ 3) occurred in 4 of the 6 patients [Table 1].

Robotic intestinal segment vaginoplasty may be utilized in the management of recto-neovaginal fistula post-
gender-affirming vaginoplasty. Fouche et al. published a video vignette demonstrating their technique for
robotic sigmoid colon vaginoplasty in a case of recto-neovaginal fistula after previous PIV . A left
[20]
colostomy had previously been performed as an initial step along with a rectal advancement flap via trans-
anal approach. During the robotic sigmoid colon vaginoplasty, meticulous dissection between the anterior
surface of the rectum and the neovaginal canal was performed until the fistula site was identified. A metal
dilator was then introduced via the neovagina to widen its orifice to accommodate the sigmoid segment.
The old colostomy site was resected, bowel continuity restored, and sigmoid vaginoplasty performed.
Successful treatment of the fistula was confirmed on MRI and digital examination at 2 months
postoperatively.

ROBOTICS IN LOWER MASCULINISING SURGERY
Robotic gender-affirming vaginectomy
Transmasculine patients may wish to undergo removal of the vagina for several reasons, including gender
dysphoria related to the vagina, vaginal secretions, or the need for screening for gynaecological
malignancy [21,22] . Vaginectomy in this population comes with its own specific challenges. Gender-affirming
hormone therapy with testosterone can result in a narrow, atrophied vagina with friable mucosa prone to
[23]
bleeding . This may be compounded by the majority of this population being nulliparous and not
engaging in receptive vaginal intercourse . The resulting narrow vagina impacts surgical access, exposure,
[24]
and visualization, making a purely perineal approach particularly challenging. This may increase the risk of
injury to surrounding structures, including the bladder, ureters, and rectum, along with potential for
[23]
incomplete removal of the vaginal epithelium .
While terminology regarding vaginectomy varies across the literature, there are two broad techniques: total
[12]
vaginectomy and ablative colpocleisis . Total vaginectomy (also referred to as colpectomy) involves full-
thickness resection of the vagina whereas colpocleisis involves destruction of the vaginal epithelium with
high power electro-ablation. In both techniques, the vaginal canal and perineum are closed. Part of the
anterior vaginal wall may be preserved in patients wishing to undergo phalloplasty or metoidioplasty with
urethral lengthening and hook-up to the phallic urethra. At present, there are no studies directly comparing
the two techniques, nor evidence to determine the superiority of one technique over the other.
Traditionally, vaginectomy has been performed via a completely perineal approach. However, many
surgeons now favor a laparoscopic or robotic transabdominal approach, leaving distal vaginal closure to be
performed via a perineal approach .
[22]