Salvage Vaginoplasty With Single-Port Robot Assisted Tubularized Urachus Peritoneal Hinge Flap: Technique Highlights, Outcomes, and an Evidence-Based Proposal for How and When to Use (and Not Use!) Peritoneum With Vaginoplasty

M. Garcia, A. Talamas, S. Mallavarapu, S. Sandhu, E. Dadashian

Vaginoplasty, Salvage, Urachus

Introduction: Two gender-affirming vaginoplasty techniques currently describe the use of peritoneal tissue: the modified Davydov technique and the Tubularized Urachus-Peritoneal Hinge Flap. While the Davydov method is often used during primary vaginoplasty, some argue peritoneum is unnecessary at this stage. Our approach reserves the urachus-based peritoneal flap for salvage cases.

Objectives: Here, we present technical innovations in the hinge-flap technique, report 1.5-year postoperative outcomes, and review existing literature to assess the role of peritoneum in primary vaginoplasty.

Methods: We review our single-port robot-assisted urachus hinge flap technique to augment neovaginal depth following primary vaginoplasty. We also review technical innovations to maximize neovaginal depth with primary vaginoplasty using only penile and scrotal skin. We present our literature review, and posit a theory that explains why, regardless of PV technique, mean neovaginal depth is 11-13cm in all series.

Results: Our mean neovaginal depth after salvage urachus hinge flap technique is 12.5cm (range 11-14.2) at 409 days post-op, comparable to the Davydov technique. With primary vaginoplasty using only penile and scrotal skin, our mean depth is 12.5cm, which is comparable to other series (Figure 1). We use video to show how, with the Davydov technique, rectum and bowel are pulled deep into the pelvis post-op, which increases risk of bowel injury at time of salvage surgery with intestine

Conclusions: By the techniques described herein, we are able to achieve comparable vaginal depth as other groups that use the “pull-through” technique. We suggest that peritoneum is only rarely necessary at primary vaginoplasty, and should be reserved for use as a salvage surgery if needed. As a salvage technique, the urachus flap is a safer alternative to the Davydov technique, because the urachus flap does not involve bowel or yield adhesions that complicate “post-peritoneal vaginoplasty salvage intestinal vaginoplasty”.

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