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Peritoneal Flap

The peritoneum is an underappreciated but increasingly used reconstructive resource for the robotic-era urologist. Its value comes from three properties: it is harvested through the same access already used for the index operation (no separate incision), it functions as a multipotent matrix that supports urothelial regeneration, and it is essentially zero donor-site morbidity. The trade-off is structural — peritoneum is thin, shrinks over time, and lacks the bulk of muscle-based flaps — so it fills specific reconstructive niches rather than replacing VRAM, gracilis, or omentum in high-stakes cases.

The four indications that matter most for the reconstructive urologist: vesicovaginal fistula repair, peritoneal vaginoplasty (Davydov technique), renal pelvis / upper tract coverage, and experimental ureteral tubularization.

See the overview article: Flaps in GU Reconstruction.

Anatomy and Vascular Supply​

The parietal peritoneum receives rich perfusion from multiple sources, most prominently the deep inferior epigastric artery (DIEA) — the same pedicle that supplies the VRAM flap.[1]

DIEA-Based Anatomy​

  • 70% of cadavers show a constant pattern of three branches from the DIEA directly supplying the peritoneum, with additional small branches arising from the main stem.[1]
  • Can be raised as a pedicled flap for local reach or as a free microvascular flap for distant reconstruction (rare urologic indication).
  • For in-pelvis reconstruction (robotic VVF repair, vaginoplasty, ureteral wrap), perfusion is typically maintained through broad segmental attachment to the underlying mesentery and peritoneal perforators — the flap does not need a single named pedicle.

Peritoneum as a Multipotent Matrix​

This is the biological case for using peritoneum in the urinary tract:

  • Peritoneal mesenchymal cells can differentiate into urothelium and myofibroblasts.[2][3]
  • Peritoneum placed against a urinary-tract defect promotes urothelial ingrowth and re-epithelialization.
  • This is why peritoneal patches work as covers for renal-pelvis defects and why peritoneal vaginoplasty produces a lubricated neovaginal canal rather than requiring an epithelial graft.

Harvest Technique​

Robotic / Laparoscopic Harvest​

  • Patient supine or in low lithotomy depending on the index operation.
  • Peritoneum incised sharply (or monopolar scissors) along the planned margin.
  • Developed as a pedicled flap based on the intended axis of rotation — anterior for bladder-to-vaginal interposition, posterior (cul-de-sac) for anterior vaginal wall lining, lateral parietal for ureteral wrap.
  • Typical flap dimensions: as long as required; widths up to 5–8 cm practical without compromising closure.
  • The abdomen is closed primarily in most cases; large defects may be left open (the peritoneum is not a major structural layer).

Open Harvest​

Identical principle — in open cystectomy or radical hysterectomy, parietal peritoneum is incised and raised before it is needed, leaving the pedicle intact.

Key Technical Points​

  • Broad base preservation is the safest approach to maintain vascularity.
  • Avoid diathermy along the margins of the planned flap where perforators lie.
  • Tension-free inset — peritoneum cannot tolerate stretch.

GU Reconstructive Applications​

Vesicovaginal Fistula Repair​

The most widely practiced urologic peritoneal-flap indication.

Transvaginal approach (Raz technique):[4]

  • Peritoneum is developed from the cul-de-sac (pouch of Douglas) through the vaginal vault, mobilized, and interposed between the bladder and vaginal repair layers.
  • Particularly suited to proximal (high-lying) fistulas where the peritoneum is easily reached via the vaginal apex.
  • 82–96% cure rate in published series.[4][5]

Eilber / Raz 10-year series of 207 VVF repairs:[5]

  • Peritoneal flaps used in 83 patients (40%)
  • 96% cure rate after initial repair
  • Zero intraoperative complications
  • Comparable to Martius flap (97%) with significantly less morbidity

Flap-transfer coverage series (Wang 2023):[6]

  • 91.9% primary complete healing (34/37 patients)
  • 3 recurrences successfully treated with secondary repair
  • Lateral free flaps can preserve vaginal length
  • Key technical principle: transfer the fistula away from the incision suture line

Transabdominal robotic approach: peritoneal flaps are routinely interposed during robotic VVF repair; see Robotic Applications for comparative outcomes.

Yang 2025 — "rainbow-shaped" peritoneal flap for robotic VVF repair in 15 patients (7 with prior failed repairs): 100% success rate, mean operative time 137 min, blood loss 14 mL, mean LOS 4.9 days, no complications at 7.8-month follow-up.[16]

2026 Cochrane review on VVF lists peritoneum among the standard interposition flaps for both transvaginal and transabdominal repair.[17]

When to choose peritoneum vs Martius vs omentum:

  • Peritoneum — small-to-moderate fistula, healthy non-irradiated tissue, accessible transvaginally or laparoscopically/robotically
  • Martius flap — complex, recurrent, irradiated — vascularized adipofascial interposition, standard for urogenital fistula in many centers
  • Omentum — large defect, irradiated bed, multi-quadrant exposure; see Omental Flap

Peritoneal Vaginoplasty (Davydov Technique)​

A major contemporary indication — particularly for gender-affirming vaginoplasty in transgender women and vaginal reconstruction in MRKH or androgen insensitivity syndrome.

History and evolution:

  • Originally described by Davydov (1969) for MRKH.
  • Robotic Davydov vaginoplasty has become a standard GAS technique at many centers, with lower morbidity than open.

Robotic Davydov technique:

  1. Incise peritoneum over the rectovesical pouch.
  2. Dissect along Denonvilliers' fascia, meticulously protecting the rectum.
  3. Simultaneous perineal dissection to define the distal neovaginal space.
  4. Abdominal and perineal dissections meet.
  5. Peritoneal flaps (anterior + posterior) are raised and passed distally to line the neovaginal canal.
  6. Suture lines closed; peritoneum closed from within the neovaginal canal.
  7. Apex of the neovagina pexed to the peritoneal incision to reduce prolapse risk.
  8. Peritoneal abdominal closure robotically.

Advantages over skin-graft (McIndoe) and bowel (sigmoid) vaginoplasty:

  • Hairless neovaginal lining (vs STSG with hair follicles)
  • Lubricated (peritoneum produces fluid; STSG is dry)
  • No bowel resection with its metabolic / dietary sequelae
  • Robotic approach decreases morbidity

Indications:

  • Gender-affirming surgery (transgender women)
  • MRKH / vaginal agenesis
  • Androgen insensitivity syndrome
  • Revision after neovaginal stenosis in a previously reconstructed patient

Major MRKH series​

StudynTechniqueOutcome
Zhou 2010[18]182Transvestibular vaginoplasty with pelvic peritoneumMean neovaginal length 9 cm; 80% cumulative sexual satisfaction at 15 yr; 1 rectovaginal fistula
Zhao 2015[19]83Laparoscopic single peritoneal flap (SPF)100% anatomical / 95.3% functional success at 12 mo; FSFI comparable to controls
Willemsen & Kluivers 2015[20]68Davydov procedure with peritoneal graftMean functional vaginal depth 7.8 cm at 90 mo; granulation tissue 23%; obliteration 12%
Uncu 2018[21]27Double-layer peritoneal pull-down with paramesonephric remnant supportMean depth 7.9 cm at 1 yr; satisfaction 8.65/10

Gender-affirming vaginoplasty — robotic and laparoscopic series​

StudynApproachOutcome
Dy 2021[22]100 (≥ 6-mo follow-up)Robotic peritoneal flap (Da Vinci Xi vs Single Port)Mean depth 13.6–14.1 cm; vaginal stenosis 7%, bowel obstruction 2%, RVF 1%, pelvic abscess 1%; SP shorter OR time (3.7 vs 4.2 h)
Castanon 2022[23]52Laparoscopic peritoneal pull-throughMean depth 14.7 cm, width 3.4 cm; 96% patient satisfaction; complications 13.5%, none requiring reoperation
Jacoby 2019[24]41Robotic Davydov peritoneal flap augmenting penile inversionAdds ~5 cm of additional depth beyond the penile-skin graft; mean depth 14.2 cm
Ratanalert & Pobpan 2025[25]10Full-length anteriorly based peritoneal turnover flapFull-length mucosal lining with self-lubrication and high elasticity; 80% maintained depth at 3 mo

Intra-abdominal complications after robotic peritoneal flap vaginoplasty are rare (2.2% in 274 patients) but include hematoma, abscess, small-bowel obstruction, and internal hernia at the peritoneal-flap closure or donor site — a unique complication requiring prompt recognition.[26]

Bladder Augmentation and Autoaugmentation​

A limited-efficacy indication — the evidence does not support peritoneal flap as a primary augmentation strategy.

Technique: detrusor myectomy (preserving urothelium) followed by covering the exposed mucosa with a peritoneal flap.[7]

Outcomes (13-patient series, mean age 11.9 y):[7]

  • Capacity increase: only 18.6%
  • Compliance: 3.4 → 5.8 cmH₂O/mL
  • Continence achieved in 6/13 (46%)
  • 31% required re-augmentation with intestinal segments
  • All failures had initial capacity <30% of expected for age

Practical stance: reserve for bladders with relatively good baseline capacity (>30% expected); use to avoid initial bowel use, with informed consent about a one-in-three chance of requiring enterocystoplasty later. For small, poorly compliant bladders, intestinal augmentation remains superior.[7][10]

Experimental variants:

  • Myoperitoneocystoplasty (skeletal muscle–backed peritoneum) — 67% capacity increase in animals, urothelial regeneration.[8]
  • Rectus abdominis island flap with peritoneum used for bladder exstrophy closure (6 children) — transitional epithelium over peritoneum at follow-up, no mucus, no metabolic abnormalities.[9]

Renal Pelvis and Upper Urinary Tract​

An older but durable indication.

Thüroff 1981 series — 31 operations on renal pelvis and ureter:[2]

  • Excellent or good results in 81% (25/31)
  • Free peritoneal patch used for:
    • Pelvic / UPJ defects after stone or tumor surgery
    • Intrarenal pyelocalicotomy when primary suture impossible
    • Envelope for the pelvis/ureter in extensive perihilar inflammation
    • Prevention of pyeloureteral junction stenosis from scarring
  • Animal data confirm urothelial ingrowth when peritoneum covers urinary collecting-system defects

Current use: niche but effective when a vascularized cover is needed in a defect that will epithelialize spontaneously.

Ureteral Reconstruction — Experimental​

Not yet a standard clinical technique.

Yifeng / Shujie 2008 dog model — tubularized peritoneal grafts successfully reconstructed avulsed ureteral mucosa with complete transitional-epithelium lining and no stenosis on follow-up imaging, comparable to bladder mucosal grafts.[27]

The 2023 WSES guidelines on iatrogenic urinary-tract injuries recommend covering ureteral anastomoses with peritoneum or other tissue when possible to support healing.[28]

Brandao porcine study (6 animals, 6–9 wk follow-up):[3]

  • Robot-assisted tubularized peritoneal flap — median OR time 223 min
  • Technical feasibility confirmed with abundant vascular supply
  • BUT: significant shrinkage in length and width; dilation and tortuosity of proximal ureter; elevated creatinine at end of follow-up (P=0.003)
  • Functional obstruction is the principal failure mode
  • Histology: focal urothelial lining — peritoneal mesenchymal cells do differentiate into urothelium, but the composite is not durable as a tubular conduit

Clinical status: no human series published; remains investigational.

Preferred ureteral reconstructive techniques instead:

  • Buccal mucosa graft ureteroplasty — 71–100% success[11]
  • Ileal or appendiceal flap ureteroplasty — 75–100% success[12]
  • Boari flap for distal defects
  • Psoas hitch with ureteroneocystostomy

Peritoneal Flap in Other Urologic Settings​

Bladder Peritoneum Flap (BLAPER) for Pelvic Cavity Closure After ELAPE​

A novel technique for closing the pelvic peritoneal floor after laparoscopic extralevator APR in patients with a rigid, fibrotic pelvis from neoadjuvant radiation where primary peritoneal closure is impossible:[13][29]

  • Arch-shaped flap from the bladder dome, base at the anterior pelvic cavity entrance
  • Height ≈ distance from bladder to sacral promontory
  • Rotated posteriorly to cover the pelvic inlet and sutured to the pelvic brim
  • Useful when standard peritoneal closure is impossible due to radiation fibrosis
  • Prevents small-bowel adhesion to the pelvic wall

Shen 2023 prospective Stage II study (27 patients) — success rate 96.3%, major pelvic wound complications in only 7.7%, no small-bowel obstruction, perineal hernia, or small-bowel descent into the retrourogenital space. Indocyanine green fluorescence imaging has been incorporated to confirm flap viability.[29]

Mesh Coverage in Sacrocolpopexy​

Peritoneal closure over mesh during sacrocolpopexy is standard practice to prevent visceral adhesions to the mesh.[30]

  • Yagur 2025 — pedicled peritoneal graft as a tissue barrier between mesh and the vaginal vault during concurrent robotic hysterectomy and sacrocolpopexy: no mesh erosion or exposure in 11 patients during follow-up.[31]
  • Kulhan 2018 — 34-patient retrospective: peritonealisation was associated with longer operative time, more blood loss, higher postoperative pain, and more de novo dyspareunia and urinary urgency, with no difference in mesh-related complications.[32]
  • van den Akker 2020 — 178 patients without peritoneal closure: only 3 serious complications were possibly related to non-peritonealisation, and > 70% reported improvement.[33]

The data are mixed: peritoneal closure is biologically reasonable to prevent visceral adhesions, but does not clearly reduce mesh-related complications and may increase short-term operative morbidity.

Peritoneal Flap After Robotic Pelvic Lymph Node Dissection (RARP) — Does NOT Prevent Lymphocele​

A 232-patient RCT evaluated peritoneal flap to prevent symptomatic lymphocele after robotic PLND:[14]

  • No benefit — symptomatic lymphocele 1.3% in-hospital, 9.1% at 90 days (same as control)
  • Do not use peritoneal flap for lymphocele prevention based on current evidence

Perivesical Fat Rotational Flap (Peritoneum-Covered Fat)​

A related — though not purely peritoneal — variant:[15]

  • Perivesical fat + overlying peritoneum rotated on a wide-based pedicle
  • Alternative to omentum when omentum is unavailable or inadequate
  • Reported in salvage prostatectomy after HIFU, recurrent VVF, colovesical fistula, rectourethral fistula
  • 3-patient series with no surgical complications and no recurrence at follow-up

Advantages and Limitations​

Advantages​

  • Minimal donor-site morbidity — no separate incision
  • No metabolic complications (unlike intestinal segments — no acid/base disturbance, no mucus, no B12 issues)
  • Multipotent matrix for urothelial regeneration
  • Well-vascularized when DIEA-based or broad-based
  • Easily accessed via the same approach as the index operation (robotic, laparoscopic, open)
  • Technically simple vs muscle-flap harvest

Limitations​

  • Limited structural bulk — cannot fill large pelvic dead space
  • Shrinkage over time — significant issue in tubularized reconstructions
  • Functional obstruction in tubularized ureteral use (experimental)
  • Limited capacity in bladder augmentation (only ~18% gain; 31% failure rate in small bladders)
  • No benefit for lymphocele prevention after PLND (RCT evidence)
  • Lacks durability for high-mechanical-load applications

When to Choose Peritoneum vs Alternative​

Clinical scenarioPreferred
Small-to-moderate VVF, healthy tissue, transvaginal approachPeritoneum (cul-de-sac flap)
Complex / recurrent / irradiated VVFMartius (transvaginal) or omentum (transabdominal)
Robotic VVF repairPeritoneum (standard interposition) ± omentum for complex
Vaginoplasty (MRKH, AIS, transgender)Peritoneal (Davydov, robotic) — hairless, lubricated
Bladder augmentation in bladder with baseline capacity >30%Reasonable trial with peritoneal autoaugmentation
Small / poorly compliant bladderIntestinal augmentation
Renal pelvis / UPJ defect needing vascularized coverFree peritoneal patch (81% good results)
Ureteral reconstruction (long defect)BMG or ileal / appendiceal flap (peritoneum remains experimental)
Large pelvic floor / perineal defectVRAM / gracilis / IGAM (peritoneum insufficient)
Lymphocele prevention after PLNDNo flap (peritoneal flap unhelpful per RCT)

Key Takeaways​

  1. Peritoneum's unique strength is its accessibility — no separate incision, no significant donor morbidity.
  2. Multipotent matrix — peritoneum mesenchymal cells differentiate into urothelium, making it an effective cover for urinary-tract defects.
  3. VVF repair — peritoneal flap from the cul-de-sac achieves 82–96% cure transvaginally, 91–96% in large series. Comparable to Martius flap with less morbidity.
  4. Peritoneal vaginoplasty (robotic Davydov) is now a mainstream technique for MRKH, AIS, and gender-affirming surgery — hairless and lubricated advantages over skin grafts.
  5. Bladder autoaugmentation — only modest capacity improvement (~18%); reserve for baseline capacity >30% expected and counsel about 31% risk of later enterocystoplasty.
  6. Ureteral tubularization remains experimental — flap shrinkage and functional obstruction limit clinical translation. Use BMG, ileal, or appendiceal flaps instead.
  7. Renal pelvis / UPJ defect coverage is an underused but effective indication (81% good results).
  8. Do NOT use peritoneal flap to prevent lymphocele after PLND (negative RCT).
  9. For large pelvic-floor defects (exenteration, APR), choose VRAM, gracilis, or IGAM — peritoneum lacks the bulk.
  10. Perivesical fat rotational flap is a useful omentum-alternative for selected fistula and radiation cases.

References​

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2. Thüroff JW, Hutschenreiter G, Frohneberg D, Hohenfellner R. "Transplantation of a Free Peritoneal Patch in Surgery of the Renal Pelvis and Ureter." Eur Urol. 1981;7(5):304–11. doi:10.1159/000473246

3. Brandao LF, Laydner H, Akca O, et al. "Robot-Assisted Ureteral Reconstruction Using a Tubularized Peritoneal Flap — A Novel Technique in a Chronic Porcine Model." World J Urol. 2017;35(1):89–96. doi:10.1007/s00345-016-1840-4

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18. Zhou JH, Sun J, Yang CB, et al. "Long-Term Outcomes of Transvestibular Vaginoplasty With Pelvic Peritoneum in 182 Patients With Rokitansky's Syndrome." Fertil Steril. 2010;94(6):2281–2285. doi:10.1016/j.fertnstert.2010.02.010

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21. Uncu G, Özerkan K, Ata B, et al. "Anatomic and Functional Outcomes of Paramesonephric Remnant-Supported Laparoscopic Double-Layer Peritoneal Pull-Down Vaginoplasty Technique in Patients With Mayer-Rokitansky-Küster-Hauser Syndrome: Uncu Modification." J Minim Invasive Gynecol. 2018;25(3):498–506. doi:10.1016/j.jmig.2017.10.015

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33. van den Akker CM, Klerkx WM, Kluivers KB, et al. "Long-Term Safety, Objective and Subjective Outcomes of Laparoscopic Sacrocolpopexy Without Peritoneal Closure." Int Urogynecol J. 2020;31(8):1593–1600. doi:10.1007/s00192-019-04020-w