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Peritoneal Flap

Peritoneal flaps provide thin, locally available tissue for selected fistula repairs and vaginal reconstruction. They can often be harvested through the operative access already in use. They have limited bulk, and intra-abdominal dissection adds risks including bowel injury, adhesions and internal herniation. A vascularized flap, a free peritoneal graft and a peritoneum-covered fat flap are different constructs; their outcomes should not be treated as interchangeable.[1][2][15][26]

See Flaps in GU Reconstruction, Omental Flap, Gracilis and VRAM for other tissue options.

Anatomy and Harvest Principles​

Peritoneal perfusion depends on the harvest site and preserved attachments. Winters studied the deep inferior epigastric artery territory of anterior parietal peritoneum in 30 embalmed and 15 fresh cadavers. Three named branches were identified in 70% of the embalmed specimens, but additional small branches also contributed. This does not establish the DIEA as the principal pedicle for every pelvic peritoneal flap.[1]

  • Plan the flap around the actual defect, available peritoneum and route of transfer. Prior surgery, adhesions, radiation and inadequate reach may limit availability.
  • Preserve a broad, viable attachment for a local flap; avoid excessive thinning, thermal damage, twisting and tension. Do not assume a universal safe width or length.
  • Mobilize under direct vision, protecting bladder, ureters, rectum and bowel. Check both perfusion and reach before inset.
  • Manage the donor defect and final closure to avoid bowel entrapment or a narrow internal-herniation aperture. Releasing peritoneum does not make abdominal-wall or visceral injury inconsequential.[16][25][26]

Experimental urinary-tract studies demonstrate urothelial coverage of some peritoneal constructs. This finding does not establish durable human ureteral replacement, normal bladder function or physiologic vaginal lubrication. Free grafts require integration with their recipient bed; they do not bring an intact vascular pedicle.[2][3][27]

Vesicovaginal Fistula Repair​

Peritoneal interposition is an option for selected proximal vaginal repairs and abdominal or robotic repairs when healthy tissue can reach between the closed bladder and vagina. Flap choice depends on defect location, tissue quality, prior repairs, vaginal access and the need for additional bulk. Peritoneum is not restricted to small, uncomplicated fistulas, and its routine use in every robotic repair has not been established.[4][5][16]

EvidenceFinding and interpretation
Raz 1993Transvaginal peritoneal interposition closed 9/11 difficult fistulas. One patient developed a bladder diverticulum containing a stone. Small initial technique series.[4]
Eilber/Raz 2003Among 207 vaginal repairs, 83 used peritoneum and 34 used Martius; reported initial cure was 96% and 97%, respectively. Interposition was selected for complex or previously failed repairs, and flap choice depended on proximal versus distal location. These were not randomized comparison groups and do not prove lower morbidity or equivalence.[5]
Yang 2025All 15 selected robotic repairs using a posterior-bladder “rainbow-shaped” peritoneal flap closed at reported mean follow-up of 7.8 months. Seven had prior failed repair. This small, uncontrolled series supports feasibility rather than superiority or a guaranteed outcome.[16]

Tissue identification matters: Wang's 37-patient flap-transfer series used mobilized vaginal flaps, not peritoneal interposition. Its 34/37 initial closures must not be counted as a peritoneal-flap success series.[6]

The 2026 Cochrane VVF publication is a review protocol, without completed comparative results.[17] Use the VVF pathway and vaginal fistula flap selection for repair planning. Martius, peritoneum and omentum are selected according to anatomy and tissue needs; no single flap is preferred for all recurrent or irradiated defects.

Peritoneal Vaginoplasty​

Distinguish the reconstruction​

The Davydov family of procedures uses pelvic peritoneum for neovaginal reconstruction. MRKH reconstruction and gender-affirming peritoneal-flap augmentation have different anatomy and technique. In common robotic gender-affirming approaches, peritoneal flaps form the proximal canal/apex and are joined to inverted penile skin, sometimes with a scrotal graft. They do not necessarily provide an entirely peritoneal or hairless canal.[22][24]

For MRKH, patient-directed vaginal dilation is generally the initial treatment. Surgery is an option after unsuccessful dilation or informed preference, with appropriate expertise and readiness for postoperative care. Surgery does not remove the need to maintain the canal.[40]

Counseling and operative scope​

Peritoneal tissue avoids a bowel segment and can provide additional lining when genital skin is insufficient. These advantages must be balanced against abdominal access, dissection near the rectum and urinary tract, and the risk of stenosis, fistula, bleeding, infection or internal hernia. Do not promise self-lubrication, a fixed depth, freedom from dilation or superiority to penile inversion. Serous secretion is not the same as arousal-related lubrication; even the full-length flap report advised lubricant for intercourse.[22][24][25][26]

The common robotic approach combines abdominal and perineal creation of the canal, harvests peritoneum from the posterior bladder and adjacent rectal/pararectal region, and joins it to the distal lining to form a closed apex. Flap design, apical closure and support vary. Use the dedicated peritoneal vaginoplasty page for technique-specific planning; MRKH steps should not simply be transferred to a patient with a prostate.[22][24]

Outcomes that inform counseling​

Population / studyMain findingLimits
MRKH: Zhou 2010, 182 patientsReported long-term sexual-function results after transvestibular peritoneal vaginoplasty; one rectovaginal fistula and 34 cases of vault granulationObservational; not all anatomical measurements represent 15-year assessment.[18]
MRKH: Zhao 2015, 83 patientsAnatomical success reported in all patients; 95.3% functional success at 12 monthsFunctional assessment involved sexually active participants; no randomized technique comparison.[19]
MRKH: Willemsen 2015, 68 surgical patientsFunctional depth averaged 7.8 cm; granulation 23%, tendency to obliteration 12%Historical cohort with variable follow-up.[20]
MRKH: Uncu 2018, 27 patientsMean length 7.9 cm at one yearBladder injury, rectovaginal fistula and complete introital closure were each reported in individual patients.[21]
Gender-affirming: Dy 2021, 100 with ≥6-month follow-up out of 145 operatedMean depth 13.6 cm (Xi) and 14.1 cm (SP); vaginal stenosis 7%, transfusion 6%, bowel obstruction 2%, RVF 1%Retrospective platform comparison; selection and follow-up affect estimates.[22]
Gender-affirming: Castanon 2022, 52 patientsMean six-month depth 14.7 cm; approximately 96% reported satisfactionUncontrolled laparoscopic series; patient reports do not demonstrate physiologic lubrication.[23]
Gender-affirming: Blasdel 2026 (online 2025), 500 consecutive cases425/500 had ≥1-year follow-up; 4% had a complication requiring procedural intervention and 12% elective revision. Median self-reported one-year depth 14.5 cmSingle-center retrospective cohort; elective revision and complication intervention are distinct outcomes. No concurrent penile-inversion control group.[39]

A full-length anterior turnover flap is a distinct, early technique. Ratanalert/Pobpan reported ten patients, with comparable immediate-to-three-month depth in eight; one needed partial scrotal grafting because of limited reach and one developed closure after stopping dilation. Short follow-up and incomplete baseline urinary assessment prevent conclusions about long-term functional or bladder safety.[25]

In a separate 274-patient robotic series, six patients (2.2%) developed intra-abdominal complications requiring readmission and/or operative assessment. These included hematoma, abscess, bowel obstruction and internal hernias at the closure or donor site. These symptoms require prompt assessment; “minimal donor morbidity” does not mean no abdominal risk.[26]

Bladder Augmentation and Upper-Tract Reconstruction​

Autoaugmentation​

Peritoneal coverage of detrusor myectomy has produced limited functional improvement. In Oge's 13-patient series, capacity increased by a mean 18.6%, six achieved continence and four required subsequent enteric augmentation. The authors did not find that adding peritoneum clearly improved capacity/compliance over classical autoaugmentation. The observation that failures had small initial capacities does not validate a universal “above 30% of expected capacity” selection rule.[7]

Muscle-backed peritoneum has also been explored in animals and small historical exstrophy series. These constructs differ from a thin local peritoneal flap and do not establish an equivalent substitute for established augmentation.[8][9][10] See augmentation principles.

Renal pelvis and ureter​

Thüroff's historical series reported good or excellent urographic results in 25/31 operations using free peritoneal patches for selected renal-pelvis/UPJ defects or wrapping. A free patch is not a vascularized flap, and these heterogeneous older results do not establish a preferred modern reconstruction.[2]

Peritoneum can provide coverage around a repaired ureter in selected circumstances. The WSES urinary-injury guidance discusses tissue coverage as an adjunct to a viable, tension-free, appropriately drained repair; it does not validate replacing a missing ureter with a peritoneal tube.[28]

Animal results illustrate that distinction. A canine mucosal-avulsion model using free grafts showed epithelialized lumens, whereas a six-pig tubularized-flap study showed shrinkage, collecting-system dilation and deteriorating renal function despite maintained vascularity and focal urothelial lining. Tubularized peritoneal ureteral replacement remains investigational.[3][27] Choose established repairs according to stricture length, location, tissue quality and renal function; see the upper-tract reconstruction atlas. Reported onlay graft/flap results come from selected series rather than interchangeable success rates.[11][12]

Other Pelvic Applications​

Pelvic peritoneal closure after ELAPE​

The bladder-peritoneum flap (BLAPER) was described for selected patients with a rigid irradiated pelvis in whom primary peritoneal closure was not possible. A three-patient initial report and a subsequent 27-patient prospective stage-II study support feasibility. The latter completed reconstruction in 26/27 patients and reported no small-bowel obstruction or perineal hernia during its reported observation. These uncontrolled findings do not prove prevention of those outcomes or replace structural pelvic-floor reconstruction when required.[13][29]

Sacrocolpopexy mesh coverage​

Covering mesh from the bowel and inserting tissue between mesh and the vaginal cuff are different interventions. Peritonealization over mesh is commonly used to separate it from abdominal viscera. Small nonrandomized studies do not establish its comparative effect on adhesions, bowel obstruction or mesh complications, and should not be used as evidence that it routinely causes pain or dyspareunia.[31][32]

Yagur's video report describes a pedicled uterovesical-peritoneum barrier at the cuff together with altered colpotomy, cuff closure and mesh placement. One illustrated case plus ten additional patients had no reported exposure at the reported follow-up. This multicomponent technique report cannot isolate the flap's effect or demonstrate a reduction in mesh exposure.[30]

Perivesical fat flap​

Perivesical fat with overlying peritoneum can be rotated on a broad attachment when local anatomy permits. Hwang's three illustrative cases support a possible alternative when omentum is unavailable; they do not establish equivalence or reliable protection of every irradiated repair.[15]

Lymphocele Prevention After RARP and PLND​

The evidence no longer supports the blanket instruction to avoid peritoneal flaps. Several randomized trials support fewer lymphoceles, although results differ by study and technique. This evidence chiefly concerns transperitoneal robot-assisted radical prostatectomy with pelvic lymph-node dissection; it should not automatically be transferred to other operations or approaches.[33][34][35][37]

StudyRelevant findings
PIANOFORTE 2020, 232 patientsNo statistically significant reduction at 90 days. The often-quoted 9.1% was the overall symptomatic-lymphocele frequency, not an identical rate in each arm.[14]
ProLy 2022, 530 randomized / 475 analyzedAny lymphocele: 22% with flap versus 33% without; symptomatic: 3.3% versus 8.1%; requiring intervention: 1.3% versus 6.8%. Follow-up was 90 days; attrition and locally selected intervention thresholds limit interpretation.[33]
PELYCAN 2024 (online 2023), 551 randomizedSymptomatic lymphocele: 3.7% versus 9.1% at six months; operative time was 11 minutes longer. Survey-based follow-up is a limitation.[34]
Pose/Michl 2025, 1,080 randomizedLymphocele requiring intervention: 7.2% versus 8.8%, without a significant difference; no observed difference in continence or other complications at one year.[35]
PIANOFORTE long-term follow-up 2024176/232 assessed at median 43 months; no significant flap benefit. Late lymphoceles occurred, and loss to follow-up limits certainty.[36]
Baumann 2026, six-RCT analysis with individual data from fiveOverall synthesis favored flaps for lymphoceles requiring intervention. Technique, follow-up and reporting differed; it does not establish one optimal flap design or universal benefit in every subgroup.[37]

Current EAU guidance discusses both the positive trials and the larger negative Michl trial. Consider a studied flap technique when performing transperitoneal RARP with PLND, with attention to the operative anatomy and local expertise. The flap does not eliminate lymphocele risk, justify PLND by itself or establish a benefit for extraperitoneal/Retzius-sparing approaches.[37][38]

Practical Selection​

NeedRole of peritoneum
Thin interposition at a proximal VVF repairOption if viable peritoneum reaches; select against Martius/omentum according to access and tissue needs
Additional neovaginal liningEstablished specialist applications, with technique-specific counseling and ongoing canal maintenance
Large dead space or a skin-bearing perineal defectPeritoneum alone usually lacks the bulk or skin required
Bladder capacity or a long missing ureteral segmentExperimental or limited historical constructs do not replace established reconstruction
Lymphocele prophylaxis during transperitoneal RARP with PLNDSupported by pooled randomized evidence, with differing individual-trial results

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

4. Raz S, Bregg KJ, Nitti VW, Sussman E. "Transvaginal Repair of Vesicovaginal Fistula Using a Peritoneal Flap." J Urol. 1993;150(1):56–9. doi:10.1016/s0022-5347(17)35396-x

5. Eilber KS, Kavaler E, Rodríguez LV, Rosenblum N, Raz S. "Ten-Year Experience With Transvaginal Vesicovaginal Fistula Repair Using Tissue Interposition." J Urol. 2003;169(3):1033–6. doi:10.1097/01.ju.0000049723.57485.e7

6. Wang X, Gao Z, Li L, et al. "Clinical Efficacy of Flap Transfer Coverage in the Treatment of Vesicovaginal Fistula." Int Urogynecol J. 2023;34(8):1797–1802. doi:10.1007/s00192-023-05465-w

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8. Weingarten JL, Cromie WJ, Paty RJ. "Augmentation Myoperitoneocystoplasty." J Urol. 1990;144(1):156–8. doi:10.1016/s0022-5347(17)39400-4

9. Büyükünal SN. "Interim Report in Humans of a Previously Described Technique in an Animal Model — Closure of Bladder Exstrophy With Rectus Abdominis Muscle Flap-II." J Urol. 1994;152(2 Pt 2):706–9. doi:10.1016/s0022-5347(17)32686-1

10. Carr MC, Docimo SG, Mitchell ME. "Bladder Augmentation With Urothelial Preservation." J Urol. 1999;162(3 Pt 2):1133–6. doi:10.1016/S0022-5347(01)68097-2

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13. Yang T, Wei M, Deng X, Meng W, Wang Z. "A Novel Laparoscopic Technique With a Bladder Peritoneum Flap Closure for Pelvic Cavity for Patients With Rigid Pelvic Peritoneum After Neoadjuvant Radiotherapy in Laparoscopic Extralevator APE." Dis Colon Rectum. 2019;62(9):1136–1140. doi:10.1097/DCR.0000000000001435

14. Bründl J, Lenart S, Stojanoski G, et al. "Peritoneal Flap in Robot-Assisted Radical Prostatectomy." Dtsch Arztebl Int. 2020;117(14):243–250. doi:10.3238/arztebl.2020.0243

15. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A Novel Perivesical Fat Rotational Flap as an Alternative to Omental Interposition in Challenging Urological Reconstruction." Urology. 2023;182:e262–e263. doi:10.1016/j.urology.2023.08.023

16. Yang Y, Chenchen H, Shiliang W, Yuke C, Cheng S. "Robot-Assisted Vesicovaginal Fistula Repair With 'Rainbow-Shaped' Peritoneal Flap: A Single-Center Experience." Arch Gynecol Obstet. 2025;311(6):1697–1703. doi:10.1007/s00404-024-07919-y

17. Okada Y, Matsushita T, Hasegawa T, et al. "Surgical Interventions for Treating Vesicovaginal Fistula in Women." Review protocol. Cochrane Database Syst Rev. 2026;1:CD015413. doi:10.1002/14651858.CD015413

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

19. Zhao XW, Ma JY, Wang YX, et al. "Laparoscopic Vaginoplasty Using a Single Peritoneal Flap: 10 Years of Experience in the Creation of a Neovagina in Patients With Mayer-Rokitansky-Küster-Hauser Syndrome." Fertil Steril. 2015;104(1):241–247. doi:10.1016/j.fertnstert.2015.04.014

20. Willemsen WN, Kluivers KB. "Long-Term Results of Vaginal Construction With the Use of Frank Dilation and a Peritoneal Graft (Davydov Procedure) in Patients With Mayer-Rokitansky-Küster Syndrome." Fertil Steril. 2015;103(1):220–227.e1. doi:10.1016/j.fertnstert.2014.10.014

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

22. Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. "Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems." Eur Urol. 2021;79(5):676–683. doi:10.1016/j.eururo.2020.06.040

23. Castanon CDG, Matic S, Bizic M, et al. "Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women." Urology. 2022;166:301–302. doi:10.1016/j.urology.2022.05.001

24. Jacoby A, Maliha S, Granieri MA, et al. "Robotic Davydov Peritoneal Flap Vaginoplasty for Augmentation of Vaginal Depth in Feminizing Vaginoplasty." J Urol. 2019;201(6):1171–1176. doi:10.1097/JU.0000000000000107

25. Ratanalert W, Pobpan P. "Full-Length Peritoneal Flap Vaginoplasty: A Feasible Approach for Hairless Neovaginal Reconstruction in Gender-Affirming Surgery." Plast Reconstr Surg. 2026;157(3):566–569. Published online 2025. doi:10.1097/PRS.0000000000012265

26. Robinson IS, Blasdel G, Bluebond-Langner R, Zhao LC. "The Management of Intra-Abdominal Complications Following Peritoneal Flap Vaginoplasty." Urology. 2022;164:278–285. doi:10.1016/j.urology.2022.01.036

27. Yifeng J, Shujie X, Hongbin S, et al. "Use of Free Peritoneal and Bladder Mucosal Grafts as Ureteral Mucosa Substitutes for Management of Avulsion of the Ureteral Mucosa in a Dog Model." J Endourol. 2008;22(4):729–734. doi:10.1089/end.2007.0136

28. de'Angelis N, Schena CA, Marchegiani F, et al. "2023 WSES Guidelines for the Prevention, Detection, and Management of Iatrogenic Urinary Tract Injuries (IUTIs) During Emergency Digestive Surgery." World J Emerg Surg. 2023;18(1):45. doi:10.1186/s13017-023-00513-8

29. Shen Y, Yang TH, Deng X, et al. "Closure of Pelvic Peritoneum With Bladder Peritoneum Flap Reconstruction After Laparoscopic Extralevator Abdominoperineal Excision: A Prospective Stage II Study." J Surg Oncol. 2023;128(5):851–859. doi:10.1002/jso.27382

30. Yagur Y, Kalantan A, Bukhari M, et al. "Intrafascial Colpotomy, Edge-to-Edge Closure, and Peritoneal Graft Technique for Minimizing Mesh Erosion in Concurrent Robotic Hysterectomy and Sacrocolpopexy." Int Urogynecol J. 2025;36(4):923–927. doi:10.1007/s00192-024-06012-x

31. Kulhan M, Kulhan NG, Ata N, et al. "Should the Visceral Peritoneum Be Closed Over Mesh in Abdominal Sacrocolpopexy?" Eur J Obstet Gynecol Reprod Biol. 2018;222:142–145. doi:10.1016/j.ejogrb.2018.01.027

32. 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

33. Gloger S, Ubrig B, Boy A, et al. Bilateral peritoneal flaps reduce incidence and complications of lymphoceles after robotic radical prostatectomy with pelvic lymph node dissection: the prospective randomized multicenter ProLy trial. J Urol. 2022;208:333–340. doi:10.1097/JU.0000000000002693.

34. Neuberger M, Kowalewski KF, Simon V, et al. Peritoneal flap for lymphocele prophylaxis following robotic-assisted radical prostatectomy with lymph node dissection: the randomised controlled phase 3 PELYCAN trial. Eur Urol Oncol. 2024;7:53–62. doi:10.1016/j.euo.2023.07.009.

35. Pose RM, Knipper S, Beyer B, et al. Impact of peritoneal bladder flap in robot-assisted radical prostatectomy patients on lymphoceles: a prospective randomised trial. World J Urol. 2025;43:148. doi:10.1007/s00345-025-05518-3.

36. Goßler C, May M, Weikert S, et al. Long-term follow-up of peritoneal interposition flap in symptomatic lymphocele reduction following robot-assisted radical prostatectomy: insights from the PIANOFORTE trial. Cancers. 2024;16:1932. doi:10.3390/cancers16101932.

37. Baumann G, Haney-Aubert CM, Wieland VLS, et al. Peritoneal flaps for the prevention of lymphoceles after robot-assisted radical prostatectomy: a systematic review and IPD-meta-analysis of randomized controlled trials. World J Urol. 2026;44:193. doi:10.1007/s00345-026-06254-y.

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39. Blasdel G, Hemal K, Dubach-Reinhold C, et al. Gender-affirming vaginoplasty using robotic peritoneal flap method: long-term outcomes of 500 cases. Ann Surg. 2026;283:1068–1074. Published online 2025. doi:10.1097/SLA.0000000000006621.

40. ACOG Committee Opinion No. 728. Müllerian agenesis: diagnosis, management, and treatment. 2018. ACOG guidance.