Robotic peritoneal vaginoplasty has been described with both the multi-port and single-port DaVinci robotic platforms. Prior to peritoneal vaginoplasty, prophylactic antibiotics are commonly administered. Common protocols include piperacillin-tazobactam, vancomycin, cefepime, and/or metronidazole given at the time of induction and maintained for 24–48 h post operatively. Many preoperative protocols included providing prophylactic heparin or enoxaparin. Surgical sterile preparation is done from the xiphoid to the proximal thighs to facilitate both abdominal and perineal approach. The patient is positioned in dorsal lithotomy and secured to the operating table for positioning in 45-degree steep Trendelenburg. There are concurrent perineal and robotic surgical teams to begin the penile inversion technique and the abdominal approach for peritoneal flap creation, respectively.

The purpose of the peritoneal approach is to anastomose the penile inversion skin flap to allow for greater depth. Robotic peritoneal vaginoplasty can also be performed in the revision setting after primary penile inversion vaginoplasty [5••, 7•].

The robotic approach begins with gaining intrabdominal access to create peritoneal flaps. Any bowel adhesions are released laterally from the pelvic sidewalls to expose the rectovesical space. The peritoneal flaps are dissected from the pelvic side walls to the posterior surface of the bladder and the pararectal fossa [5••]. A horizontal incision is made at the level of rectovesical junction over the seminal vesicles, similar to a posterior approach to a robotic-assisted laparoscopic prostatectomy. The dissection is widened beneath the vas deferens bilaterally [6]. Care must be taken from this approach to avoid ureteral and vascular pedicle injuries when creating peritoneal flaps. If the prostatic pedicle is injured in this dissection, suture ligation is the preferred hemostatic approach. Both the posterior and anterior peritoneum are dissected, ensuring more of the posterior peritoneum is spared.

The peritoneal dissection is being done simultaneously with the perineal dissection. Penile inversion vaginoplasty has been described in detail but involves a separate team performing the dissection between the rectum and prostate/bladder plane to develop the distal neovaginal canal. This is initiated by creating a rhomboid perineal flap between the ischial tuberosities and the perineal-scrotal junction. The flap is elevated to the level of the bulbar urethra. The perineal dissection continues laterally and posteriorly to achieve adequate depth and width. The scrotal skin previously removed is thinned to create a full thickness skin graft to bridge introitus to peritoneum. The vaginal canal dissection is carried posteriorly to Denonvilliers’ (rectoprostatic) fascia. The neovaginal canal depth and width can be limited by narrow pelvic dimensions or difficulty in dissecting the vaginal space [8•].

The peritoneal dissection is dependent on the dimensions achieved in the neovaginal canal and the amount of tissue available to line the neovagina. Ideally, a 12 cm by 12 cm anterior peritoneal flap from the posterior aspect of the bladder is raised with medial umbilical ligaments as lateral borders. The extent of the posterior peritoneal flap includes the rectum, medial aspect of the ureters, and the sacral promontory. Other reports have been able to safely augment neovaginal canal with 6 cm by 8 cm peritoneal flaps from the anterior and posterior aspects to meet in the midline and form the neovaginal apex [9]. Additional peritoneal flap harvest is performed to ensure tension free anastomosis to avoid peritoneal flap devascularization and dehiscence. If there is limited mobility of the peritoneal flaps, then the penoscrotal tube is lengthened with potential additional skin grafts to avoid an anastomosis on tension [5••, 7•].

A window is developed between the perineal and pelvic dissection planes. If there is tension between the peritoneal flap and the neovagina, lateral incisions can be made along the peritoneal incisions to facilitate greater length. These flaps are then sutured anteriorly and posteriorly to the penile/scrotal skin or tubularized full thickness skin grafts that create the neovaginal canal. The posterior flap is sutured to the inferior ventral penoscrotal skin and the anterior flap is sutured to the dorsal aspect. The neovaginal apex is created using a purse string suture is performed with 2–0 or 3–0 V-lock suture in purse string fashion from the peritoneum to the skin flaps or grafts. The anterior, posterior and lateral peritoneal defects are closed with running 2–0 or 3–0 V-lock suture (Fig. 1) [5••, 7•].

Peritoneal flaps sutured using running locking V-lock suture to create the vaginal apex and the anatomic relation to the neighboring bladder, ureters and rectum

A modified single pedicled robotic peritoneal flap to augment the neovaginal canal performed with penile inversion vaginoplasty is also described as an alternative to anterior and posterior peritoneal flaps harvest. This flap is harvested only from the posterior bladder surface. This peritoneal reflection is incised and dissected to reach the neovaginal apex. The flap is reflected and sutured circumferentially to the neovaginal apex. The sides are adapted to the cul de sac posteriorly. For a single pedicled flap, a wider base must be harvested. Care must be taken to avoid suturing the superior side of the neovaginal canal which is pushed into the abdominal cavity through perineal access to avoid compromising the anastomosis and potential depth of the canal [10]. Otherwise, the remaining steps are similar for robotic peritoneal vaginoplasty.

There have also been descriptions utilizing tubularized urachus-peritoneal hinge flaps in the setting of revision vaginoplasty. In this method, the bladder is filled to demarcate the bladder margins. Urachus is thought to be more durable than only peritoneum as it has more fibrous vascularized tissue. The free end of the anterior flap by the bladder is dissected and the free end is flipped posteriorly and sutured to the posterior edge of the open canal remnant, creating a peritoneal pouch. The lateral edges of the pouch are sutured together. The anterior edge of the canal remnant is also sutured to create a watertight anastomosis. This approach is limited to patients who have at least 7 cm of primary or revision neovaginal canal. This is an alternative in the setting of limited ability to harvest the posterior peritoneal flap and to avoid potential intrabdominal rectal injury [11].

In patients who have undergone primary penile inversion vaginoplasty or vulvoplasty without canal creation, revision for insufficient neovaginal canal, neovaginal stenosis or desire for neovaginal canal can be necessary. The median time to revision for creation or revision of a neovaginal canal was 35 months. Peritoneal vaginoplasty in this setting can also provide additional depth with minimal donor site morbidity. This technique can be performed both as a primary approach to vaginoplasty and as a technique to be used in patients undergoing revision surgery [12].

There are variations in wound dressing approach following incisional closure. Some authors have used: sulfamylon/mafenide acetate and lubricant over kerlix or similar packing placed inside the neovaginal canal, a vaginal packing with mupirocin and bacitracin, or silvadene with lubricant placed prior to closure of the neovaginal apex from the abdomen with a negative pressure wound vacuum dressing over the introitus, and a foley catheter was kept in place. Additional dressings with kerlix are placed over a dressing with elastic tape to maintain the dressing [5••, 7•, 11].