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Robot-assisted Vaginoplasty: A Multidisciplinary Technique For Gender Affirmation
Haripriya S. Ayyala, MD1, Alexandra Naides, BFA2, Jerette J. Schultz, MD2, Kathryn Doshi, PA-C3, Nitin Patel, MD4, Jonathan D. Keith, MD, FACS2,3.
1Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA, 2Division of Plastic and Reconstructive Surgery, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA, 3East Coast Advanced Plastic Surgery, Livingston, NJ, USA, 4Division of Urology, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA.

Background: Gender affirming trans female bottom surgery is critical in treating gender dysphoria but can result in complications such as stricture/stenosis development, neovaginal prolapse, and rectal injury. The authors describe a multidisciplinary robot-assisted technique incorporating a free peritoneal graft to alleviate these complications.
Methods: Patients who met the World Professional Association for Transgender Health (WPATH) criteria for bottom surgery, underwent robotic-assisted penile inversion vaginoplasty with senior author (J.D.K), and had at least three months of follow-up were included in the study. Patients undergoing zero-depth vaginoplasty or revision vaginoplasty were excluded. The free peritoneal graft is harvested robotically and used as a strip of mucosal-like tissue for a more anatomic neovagina and sutured to scrotal skin grafts over a vaginal conformer. The construct is sutured to the remaining penile shaft skin and then then inverted and passed through the perineal body into the robotically-created space. The apex of the neovaginal lining created by the skin graft-peritoneal graft construct is then sutured to the peritoneal reflection with barbed suture in two layers intra-corporally via the robot.
Results: Thirty-eight patients were included in our study. Average age at the time of initial consult was 31 years. All patients were on hormone therapy and 42% of patients had previously undergone top surgery. The average length of follow-up was 230 days. The most common complication was stricture/stenosis secondary to non-compliance with post-operative dilation protocol. Eight patients (21%) experienced stricture, four of which were managed with aggressive dilation. Three patients required surgical revision and one patient did not require any intervention. Seven patients (18%) experienced wound dehiscence with four patients requiring operative repair. Four patients (11%) developed labial banding/webbing that required revision. Other complications included one hematoma, one infection, and two episodes of post-operative bleeding. Eleven patients (29%) developed symptomatic granulation tissue during the healing process that was treated with silver nitrate application and resolved with time. Lastly, two patients (5%) had labial asymmetry that did not interfere with function, but who desired revision for cosmesis. Eighty-four percent of patients used Soul Source vaginal dilators (Sour Source Therapeutic, North Hollywood, CA) post-operatively and of those patients 53% could dilate with the orange dilator (the largest, 1 1/2 inch diameter), 13% with teal (1 3/8 inch diameter), 16% with blue (1 inch diameter) and 19% with purple (1 1/8 inch diameter). All dilators are 9 inches in length. Patients are cleared for sexual intercourse three months after surgery. Many patients had return of sensation to light touch of the neo-clitoris and were able to achieve organism through direct neo-clitoral stimulation.
Conclusion: With experience and an interdisciplinary team, robotic-assisted vaginoplasty with free peritoneal grafting is safe and effective with a low complication rate and high neo-vaginal patency rate. Many patients report successful penetrative intercourse and the ability to achieve orgasm post-operatively.


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