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Oliver et al. Plast Aesthet Res. 2025;12:19 https://dx.doi.org/10.20517/2347-9264.2025.11 Page 13 of 16

robotic-assisted microvascular anastomosis is feasible, effective, and safe, with comparable rates of
[42]
anastomotic patency and leak incidence to conventional techniques, but with longer anastomotic times .
The review emphasized the need for robust comparative studies to validate the advantages of robotic-
assisted microsurgery over traditional methods.

The first application of robotic-assisted microsurgery in a gender-affirming phalloplasty was only recently
described in a case report by Wellenbrock et al. using the Symani Surgical System. This procedure utilized
the robot for end-to-side nerve coaptation and arterial anastomosis of a RFFF, demonstrating its
[43]
feasibility . The time for nerve coaptation was 17 min and the arterial anastomosis time was 26 min, with a
total surgical time of 401 min, comparable to conventional phalloplasty. No complications occurred within
the 8-week follow-up period. The authors highlighted advantages such as tremor elimination, motion
scaling, and enhanced precision for deep-plane procedures, including movements in the peri-clitoral space
beneath the suspensory ligament. These features suggest that robotic assistance could enhance precision and
flexibility during gender-affirming phalloplasty.

Robotic-assisted flap harvesting
[44]
In 2012, Patel and Pedersen reported the first robotic-assisted flap harvest . Since then, robotic
applications for flap harvesting have expanded. A systematic review pooling data from 262 patients across
25 studies found that robotic flap reconstruction is feasible and safe, with shorter hospital stays compared
with conventional flap harvest . However, as with robotic microsurgery, longer operative times were seen
[45]
compared to conventional techniques. The advantages of robotic-assistance described in the same review
were: lower complication rates and quicker recovery, particularly for commonly used flaps like the LD and
RFFF.

In 2023, robotic-assisted RFFF harvesting was described by Shin et al. . Although the cases were not
[46]
performed as GAS procedures, their experience with eleven patients using the Da Vinci Si robot
demonstrated statistically significant longer harvesting times compared to conventional methods. However,
a decreasing trend in harvesting time was observed as surgeons gained experience, suggesting that robotic
harvesting times could eventually match those of conventional techniques.

LIMITATIONS
The main limitations of this review include the small number of studies published in this field, the small
sample sizes in the majority of studies, and the lack of randomized control trials or direct comparisons to
traditional surgical techniques in GAS. This reflects the relatively recent introduction of robotic surgery to
the specialty, and as experience increases, we hope to see larger, controlled studies to strengthen the
evidence base and guide practice. The evidence for robotic-assisted phalloplasty in our review was limited,
with only 1 case review, reflecting limited experience in this area, which remains under research. This
review is also limited to genital surgery within GAS, with robotic surgery in other areas of GAS in relative
infancy.

CONCLUSION
This paper outlines robotic-assisted techniques for genital gender-affirming surgery. It highlights the clear
benefits of robotic techniques in pelvic surgery. These include improved visualization and working space in
a narrow surgical field compared to traditional surgical approaches, improved postoperative recovery, and,
in some cases, decreased complications. While costs and surgical learning curve are potential downsides, as
the use of robotic surgery becomes more widespread across more surgical specialties, these factors may be
offset.