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Page 8 of 16 Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11

Robotic gender-affirming total vaginectomy
Our literature search found three papers regarding total vaginectomy via a transabdominal robotic
approach [Table 2]. The perceived benefits of this approach were reducing the risk of leaving remnant
vaginal mucosa, which can lead to mucocele and urethral complications. However, this appears to be at the
cost of greater blood loss and the need for blood transfusion. Potential risk to adjacent organs from sharp
dissection is also a concern, although no cases were reported in these studies.

Robinson et al. reported their two-surgeon technique for total vaginectomy with urethral lengthening using
a split gracilis flap [3,25] . The perineal surgeon performs the distal vaginal excision from the introitus and the
preservation of the anterior vaginal epithelium for urethral lengthening, while the robotic surgeon
simultaneously establishes pneumoperitoneum and robotic access to the pelvis. The robotic surgeon
completes the proximal vaginal dissection and then receives the inferior portion of the split gracilis flap
created by the perineal surgeon, which is inset to the de-epithelialized vaginal wall to eradicate the dead
space following vaginectomy. Using this approach, the authors reported no cases of persistent vaginal
remnant. In their 24-patient retrospective review, they also had a significantly lower rate of urethral stricture
and fistula of the pars fixa of 8% each compared to 50%-80% in the literature [3,25] . This group published
outcomes using this technique in 16 patients with no complications related to vaginectomy .
[26]

In a separate paper from the same group, Jun et al. reported outcomes of robotic-assisted laparoscopic total
vaginectomy in 42 patients undergoing lower masculinising surgery (LMS): 37 phalloplasty [19 radial
forearm free flap (RFFF), 15 anterolateral thigh (ALT) flap, 1 abdominal phalloplasty], and 5
[27]
metoidioplasty . A gracilis flap technique, as described by Robinson et al., was used in 36 patients (86%)
[3,25] . At median follow-up (15.8 months), the authors reported 4 patients (9.5%) had complications related to
the vaginectomy. These were Clavien-Dindo grade 1-2 complications. There was also 1 case (2.4%) of a
rectovaginal fistula, which was concluded to be a result of previous hysterectomy and was repaired
intraoperatively. The authors reported that using a robotic approach to vaginectomy improved efficiency as
it can be performed concurrently with scrotoplasty and gracilis flap harvest.

In a prospective cohort study by Groenman et al., 36 transmasculine patients underwent robotic-assisted
total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (TLH-BSO) followed by robotic-
[21]
assisted laparoscopic total vaginectomy . Median blood loss was 75 mL (range 30-200 mL). Only 1 patient
(2.8%) experienced a major complication related to the vaginectomy (vaginal bleeding). This occurred 8
days postoperatively and required re-admission for a 2-unit blood transfusion for a Hemoglobin drop from
7.7 mmol/L to 4.7 mmol/L. There was a statistically significant reduction in median operative time (278 to
197 min, P = 0.00) and blood loss (175 to 30 mL, P = 0.01) after the first 18 cases, signifying a relatively short
learning curve. However, all cases were completed by a single gynecologist experienced in robotic surgery,
so a longer learning curve may be seen in surgeons with less robotic experience.

Approaches to reduce the risks of blood loss and local organ injury associated with robotic vaginal
[22]
dissection have been suggested by Coulter et al. . These include using a combined dissection and ablative
approach, limiting the amount of sharp dissection of the anterior vaginal wall. Alternatively, a combined
robotic and perineal approach may be utilized, as performed by Robinson and Jun [3,25,27] .

Robotic gender-affirming colpocleisis
There are currently no studies specific to colpocleisis using a robotic-assisted approach in the literature.
Colpocleisis via a perineal approach has been associated with a higher risk of vaginal remnant compared to
total vaginectomy [28,29] . This is likely secondary to incomplete electrocautery destruction, which may lead to