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Robotic / Laparoscopic Peritoneal Pull-Through Vaginoplasty (Davydov Augmentation of PIV)

Robotic or laparoscopic peritoneal pull-through vaginoplasty — most commonly performed as robotic Davydov peritoneal-flap augmentation of PIV (RPGAV) — is an emerging full-depth feminizing GAS technique that uses pedicled pelvic peritoneal flaps harvested abdominally to augment (or replace) the inverted-penile-skin neovaginal lining, adding approximately 5 cm of additional depth to deliver consistent neovaginal depths of ~14 cm regardless of available natal genital tissue.[1][2][3] Pioneered by Zhao and Bluebond-Langner at NYU Langone in 2017, RPGAV is now the largest-volume robotic GAS vaginoplasty technique worldwide, with 500 consecutive cases quantified from a single centre.[1][4] The Belgrade group (Bizic / Djordjevic) independently developed a laparoscopy-assisted variant beginning in 2016.[10]

This is the dedicated atlas page. For the cohort-level decision framework, see Feminizing Gender-Affirming Surgery. For the skin-lined gold standard, see Penile Inversion Vaginoplasty. For the canal-not-desired alternative, see Zero-Depth Vulvoplasty.

Historical Origins​

The technique is adapted from the Davydov procedure (1969), originally developed for cisgender women with vaginal agenesis (Mayer–Rokitansky–Küster–Hauser [MRKH] syndrome).[5] In MRKH patients, the laparoscopic Davydov achieves functional depths of 8–10 cm with 95–97% functional success and peritoneal-to-squamous metaplasia within 6–12 months.[6][7][8]

Jacoby, Zhao, and colleagues first reported the GAS adaptation in 2019 (n = 41), combining robotic peritoneal-flap harvest with standard PIV.[1] The key conceptual innovation was using peritoneal flaps not as the sole canal lining (as in MRKH) but as an augmentation of the inverted penile skin tube ± scrotal graft, specifically to address insufficient genital tissue for adequate canal depth.[1]

Indications​

IndicationRationaleAnchor
Penoscrotal hypoplasia from puberty suppression (GnRH agonists)Tanner-2/3-blocked patients have insufficient penile + scrotal skin for standard PIVDy 2023[9]; Castanon 2022[10]
Radical circumcisionLoss of preputial / distal-shaft skin (16/52 in Belgrade)Castanon 2022[10]
Prior orchiectomy3× greater odds of needing extragenital tissue due to scrotal atrophySineath 2022[11]
Scrotal skin insufficiency / lichen sclerosusAtrophic donor bedCastanon 2022[10]
Patient preferenceHairless canal, possible lubrication — 13/52 (25%) of Belgrade cohort chose it over PIV despite adequate skinCastanon 2022[10]
Revision / salvage of failed PIVRefractory canal stenosis or depth loss; minimal donor-site morbidity vs sigmoid salvageDy 2021[12]; Celis 2026[13]

The Blasdel 2023 case-control study (n = 43 with genital hypoplasia vs non-hypoplastic controls) found equivalent neovaginal depth outcomes after RPGAV — median depth 14.5 cm with no depth-revision surgeries in the hypoplastic group — establishing the technique's role as the reconstructive answer to penoscrotal hypoplasia.[3]

Surgical Technique — Step by Step​

A. Robotic Davydov Augmentation of PIV (Zhao / NYU)​

Single-stage combined perineal–abdominal operation, performed with simultaneous (Single Port) or sequential (Xi) two-team workflow:[1][2][14][15]

Perineal phase (standard PIV components):

  1. Orchiectomy with cord ligation through scrotal incision.
  2. Penile disassembly — degloving of penile skin tube; dorsal NVB preserved on a pedicle with the glans for clitoroplasty; corpora cavernosa excised; corpus spongiosum dissected from the urethra.
  3. Penile skin tube preparation — inverted tube (± scrotal FTSG anastomosed to extend length) forms the distal canal lining.
  4. Urethral shortening and repositioning.
  5. Clitoroplasty — glans reduced to a sensate neoclitoris.
  6. Vulvar construction — clitoral hood, labia minora (preputial or distal-shaft skin), labia majora (scrotal-skin flaps).

Robotic abdominal phase:

  1. Robot docking and ports — da Vinci Xi (multiport) or Single Port (SP) (single umbilical incision). SP enables the dual-surgeon approach — the SP robot occupies only the umbilicus, leaving the perineum fully accessible for a second surgeon to work simultaneously, reducing operative time by ~34 min after adjusting for the learning curve.[2][4]
  2. Peritoneal-flap harvest — two ~6 × 8 cm flaps:[1]
    • Anterior flap: posterior bladder (vesicovaginal peritoneum).
    • Posterior flap: anterior rectum / sigmoid (pararectal-fossa peritoneum).
  3. Transabdominal canal-space dissection — rectovesical space dissected from above under direct robotic vision, meeting the perineal dissection. Superior visualisation of the bladder–rectum plane may reduce rectal-injury risk vs blind perineal dissection.[2]
  4. Flap-to-skin anastomosis — inverted penile skin tube (± scrotal graft) sutured to the peritoneal flaps; flaps form the proximal apex, adding ~5 cm of depth.[1]
  5. Apex closure (cul-de-sac creation) — proximal flap edges approximated to create a closed neovaginal dome mimicking the posterior fornix.[1]
  6. Donor-site closure — peritoneal defects closed primarily. Incomplete closure creates potential internal-hernia sites at both the flap closure and donor sites — see Complications.[16]
  7. Vaginal stent / conformer placement within the completed canal.

B. Laparoscopy-Assisted Peritoneal Pull-Through (Belgrade)​

Two peritoneal flaps from posterior bladder and anterior rectosigmoid are harvested by standard laparoscopy, then maximally mobilised and pulled through to join the inverted penile skin; flaps are joined laterally to create the canal; vaginal packing for 7 days postoperatively.[10]

C. Single Pedicled Peritoneal Flap (Morelli / Zucchi modification)​

A single posterior-bladder peritoneal flap, pedicled on the neovaginal dome and overturned circumferentially to the skin cylinder to create a cul-de-sac. Simplifies the abdominal phase. n = 8: no complications; OR time 6 ± 1.5 h; LOS 6 d.[17]

D. Full-Length Peritoneal-Flap Vaginoplasty (Ratanalert 2025)​

Anteriorly based peritoneal turnover flap creates a full-length peritoneal lining with no skin lining. n = 10: no major complications; 80% maintained depth at 3 mo; mucosal surface with self-lubrication on internal exam.[18]

E. AlloDerm Bridge for Revision Cases (Parker 2023)​

When peritoneal flap alone is insufficient for full canal coverage during revision, tubularised AlloDerm (acellular dermal matrix) bridges the gap between remnant vaginal lining and peritoneal flaps. n = 9 revisions: median depth 12.1 cm, width 3.5 cm at median 1-yr follow-up; no intraoperative complications.[19]

Robotic Platform: da Vinci Xi vs Single Port​

The first direct platform comparison (NYU; n = 100 with ≥ 6-mo follow-up):[2]

Parameterda Vinci Xi (n = 47)da Vinci SP (n = 53)p
Operative time4.2 h3.7 h< 0.001
Neovaginal depth13.6 cm (9.7–14.5)14.1 cm (9.7–14.5)0.07
Neovaginal width3.7 cm (2.9–3.8)3.7 cm (3.5–3.8)0.04
Complication ratesNo differenceNo differenceNS
Dual-surgeon approachNot feasibleFeasible—

SP's structural advantage — a single umbilical incision leaving the perineum fully accessible — enables a simultaneous two-team workflow that reduces OR time by ~34 min after adjusting for the learning curve.[4]

Operative Parameters (Aggregate)​

ParameterValueSource
OR time (initial 41-pt series)262 ± 35 minJacoby 2019[1]
OR time (expert phase, > 300 cases)Median 125 min (IQR 105–181)Hemal 2025[4]
Length of stay5 daysJacoby 2019[1]; Blasdel 2023[3]
Estimated blood loss132 ± 93 mLBlasdel 2023[3]
Return of bowel function1.7 ± 0.9 dBlasdel 2023[3]
Neovaginal depth (follow-up)13.6–14.5 cmJacoby; Dy; Blasdel[1][2][3]
Neovaginal width (follow-up)3.6–3.8 cmSame
Peritoneal-flap depth contribution~5 cm beyond skin graftJacoby 2019[1]
Mean follow-up11.9 mo (range 6–25.4)Hemal 2025[4]

Learning Curve​

Hemal 2025 (500 consecutive RPGAV cases, the largest single-centre cohort):[4]

  • 300 cases required to plateau operative time — reflecting substantial combined perineal–abdominal complexity.
  • After adjusting for the curve, each 1-point increase in BMI added 1.4 min (p < 0.05).
  • Expert-phase median OR time 125 min (IQR 105–181).
  • Raises generalisability concerns for lower-volume centres.

Complications​

ComplicationIncidenceManagement
Vaginal stenosis~7%Dilation; revision if refractory
Blood transfusion~6%Supportive
Intra-abdominal (total)2.2% (6/274)See below[16]
Small-bowel obstruction~2%Bowel rest
Incarcerated internal hernia0.7% (2/274)Diagnostic laparoscopy + reduction
Intra-abdominal abscess0.7% (2/274)Laparoscopic drainage
Postoperative hematoma0.4% (1/274)Return to OR for evacuation
Rectovaginal fistula~1%Operative repair
Pelvic abscess~1%Laparoscopic drainage
30-day readmission (early series)18% (11 patients)Variable

Intra-abdominal complications are unique to the peritoneal-flap technique and warrant deliberate recognition:[16]

  • Internal hernias occurred at two distinct sites — the flap closure site and the flap donor site — both presenting with small-bowel incarceration and requiring diagnostic laparoscopy + reduction. Underscores meticulous peritoneal closure during the abdominal phase.
  • Intra-abdominal abscesses (n = 2) required laparoscopic drainage.
  • The overall 2.2% intra-abdominal rate is low but clinically significant — these are life-threatening if missed.

Histology and the Self-Lubrication Question​

A central claim of peritoneal vaginoplasty is self-lubrication. Histologic evidence has significantly nuanced this claim:

MRKH (cisgender) priors:

  • Peritoneal lining undergoes metaplasia from mesothelium to stratified squamous epithelium within 6–12 months.[6][24]
  • Vaginoscopy: homogeneous smooth pink mucosa; Schiller test iodine positivity (glycogen) from 3 mo, near-complete by 6–12 mo.[6][8]
  • Light microscopy: adequate thickness and differentiation with glycogen storage; SEM ultrastructure close to normal vaginal mucosa.[6]
  • In the Davydov MRKH series, no specimens retained mesothelial elements — all squamatised completely.[24]

Transfeminine RPGAV (Dhami 2025; n = 5 biopsies ≥ 12 mo post-op):

  • All 5 biopsies showed complete metaplasia to stratified squamous epithelium with no residual mesothelial cells.[25]
  • Peritoneal neovagina may produce fluid initially when mesothelium is still present, but this capacity is unlikely to be maintained long-term.
  • 60% of biopsies showed features mimicking low-grade condylomatous dysplasia — likely chronic reactive change. One case required p16 immunostaining to exclude moderate-to-high-grade dysplasia.
  • Diffuse strong superficial hypergranulosis identified as a key histologic feature distinguishing reactive change from true condyloma.
  • Implications for cancer screening and tailored surveillance remain undefined.

Neovaginal Microbiome​

Characterised across several cohorts:[26][27][28]

  • Early postoperative period — stochastic colonisation with bloom of Enterococcus faecalis and genital Mycoplasma species.[27]
  • 6–12 months — community resembling bacterial-vaginosis-like structure, with some vaginal species present.[27]
  • 2–4 years — further evolution toward a structure resembling pre-surgical dimple microbiota.[27]
  • Vaginal pH: ~57.4% of patients achieve pH ≤ 4.5 after laparoscopic peritoneal vaginoplasty.[26]
  • Dysbiosis common early (64.5% within 2 yr); gradually normalises (39.1% > 2 yr).[26]
  • Lactobacillus colonisation detected (L. crispatus strains traceable to pre-surgical dimple), but dominance remains rare.[27][28]

Direct Comparison vs Standard PIV​

Zucchi 2025 (n = 19: 11 PIV, 8 RPGAV) — the first direct head-to-head comparison:[29]

  • Quality of sexual intercourse: 87.5% vs 27.3% improvement (p = 0.04).
  • Overall sexual satisfaction: 87.5% vs 27.3% improvement (p = 0.04).
  • No significant difference in orgasm quality, speed, or erogenous sensitivity.
  • Similar complication rates; 1 Clavien–Dindo ≥ IIIb in RPGAV.

Hypothesis-generating only — small, retrospective, single-centre.

Patient Satisfaction​

SeriesCohortKey outcome
Dy 2021 SP-vs-Xi[2]n = 100 RPGAVDepth 13.6–14.1 cm, width 3.7 cm at mean 11.9 mo
Blasdel 2023 hypoplasia[3]n = 43 hypoplasticEquivalent dilation outcomes; median depth 14.5 cm; no depth revisions; 11% external-only revision
Castanon 2022 (Belgrade laparoscopic)[10]n = 52~96% satisfaction at mean 29 mo
Zucchi 2025[29]n = 8 RPGAV87.5% improved quality of intercourse / overall satisfaction

Revision / Salvage Use​

RPGAV is a valuable salvage technique for refractory canal stenosis or depth loss after failed PIV, with minimal donor-site morbidity vs sigmoid salvage and a 0% rectal-injury signal across the index NYU revision experience.[12][13][19]

Patient demographics and timing​

From the Dy 2021 NYU index revision series (n = 24):[12]

  • Mean age at revision 39 yr (range 27–58); all patients had previously undergone PIV.
  • Median time from primary vaginoplasty to revision 35.3 mo (range 6–252 mo) — heterogeneity reflects the spectrum from early postoperative contracture to late progressive depth loss over decades.
  • Indications: short / stenotic vagina or absent canal.
  • 34.3% (12/35) of NYU vulvar-revision patients had concurrent canal stenosis requiring robotic peritoneal-flap revision — vulvar and canal pathology frequently co-occur.[33]

Step-by-step revision technique (Celis 2026)​

The revision differs from primary RPGAV in that the rectoprostatic / rectovesical space is scarred from prior surgery:[12][13]

Perineal phase:

  1. Identify the stenosed neovaginal cavity (if any) and enter from the perineum.
  2. Re-enter the rectovesical space, extending dissection toward the peritoneal cavity.
  3. Incise and widen the stenosed cavity — scar tissue incised to re-establish the canal space.
  4. Connect the perineal dissection to the robotic abdominal dissection, creating a continuous channel.

Robotic abdominal phase:

  1. Peritoneal-flap harvest from posterior bladder + pararectal-fossa donor sites (same anatomy as primary technique).
  2. Flaps advanced distally and sutured to the edges of the stenosed neovaginal cavity (the technical hallmark of revision).
  3. Proximal flap edges approximated to form the new cul-de-sac.
  4. Donor-site closure (incomplete closure → internal-hernia risk).[14]

Operative parameters: total OR time 3 h in the Celis technique paper (reduced from ~5 h in the original Dy 2021 series); EBL 20 mL; discharge within the first week; serial postoperative vaginoscopies for healing and patency.[13]

Revision-specific outcomes​

ParameterDy 2021 NYU (n = 24)[12]Celis 2026[13]AlloDerm augmentation (n = 9)[19]
Mean depth13.6 cm (range 10.9–14.5)—12.1 cm median
Mean width3.6 cm (range 2.9–3.8)—3.5 cm median
Median depth gain——9.7 cm
OR time5 h3 h—
EBL—20 mL—
Intraoperative complications0NoneNone
Rectal injury0%0%0%
Return to OR4.2% (1/24, canal bleeding)—0%
Follow-up410 d (range 179–683)—368 d median (range 186–550)

AlloDerm bridge for insufficient peritoneal coverage (Parker 2023)​

When the peritoneal flap is insufficient for full canal coverage — particularly with extensive prior scarring or very short remnant canals — tubularised AlloDerm (acellular dermal matrix) is used as an off-the-shelf scaffold bridging the remnant lining to the peritoneal flap. n = 9: median depth 12.1 cm, width 3.5 cm, depth gain 9.7 cm at median 1 yr; 0 intraoperative complications; 2 patients had focal excess AlloDerm requiring in-office excision without compromising canal caliber or depth.[19]

Direct comparison with robotic sigmoid revision (Sljivich 2025)​

The first head-to-head context for revision RPGAV vs robot-assisted sigmoid vaginoplasty (RSV) as revision techniques:[34]

ParameterRobotic peritoneal-flap revisionRobot-assisted sigmoid revision
Mean depth13.6 cm17.6 cm
OR time3–5 h272.9 min (~4.5 h)
LOS~1 wk3.7 d
Bowel anastomosisNoYes
Rectal injury0%0%
Vaginal strictureNot reported8% (2/25)
MucorrheaNoneResolved by 3 mo
Diversion colitisN/A0% on vaginoscopy
Self-lubricationTransient (mesothelial → squamous metaplasia)Yes (colonic mucosa)

Trade-off framework: RSV achieves greater depth (17.6 vs 13.6 cm) but requires bowel anastomosis with leak / stricture / ileus risk. Peritoneal-flap revision avoids bowel surgery entirely but loses self-lubrication capacity over time as the mesothelium squamatises (see the Histology section). RSV may be preferred for complete canal obliteration or after failed peritoneal-flap revision; peritoneal-flap revision may be the lower-morbidity first-line revision in most settings.[12][34]

Re-harvest after prior peritoneal-flap surgery​

Patients who underwent primary peritoneal-flap vaginoplasty and develop stenosis present a unique challenge — peritoneum has already been harvested. The Celis 2026 technique paper specifically addresses this, noting that finding a viable harvesting site after prior perineal-flap surgery is feasible though available peritoneal surface area may be reduced.[13]

Obesity and revision-context outcomes​

Berger 2024 (n = 237) — obesity is a significant risk factor for vaginal stenosis after primary vaginoplasty: class I obesity OR 7.1 (p = 0.003); class II/III OR 3.4 (p = 0.018) for developing stenosis. However, undergoing robotic peritoneal or robotic intestinal vaginoplasty was associated with lower odds of delayed wound healing (OR 0.2, p < 0.05) — an argument for the robotic approach in higher-BMI patients who are also at higher stenosis risk and therefore more likely to need revision.[35]

Concurrent vulvar revision​

NYU vulvar-revision series — 34.3% of patients undergoing external genital revision had concurrent canal stenosis warranting robotic peritoneal-flap revision; comprehensive assessment of both vulvar and canal dimensions is appropriate at revision counselling.[33]

Advantages and Disadvantages​

AdvantagesDisadvantages
Consistent ~14 cm depth regardless of donor skin[1][3]Robotic / laparoscopic expertise + equipment required
Hairless canal — no intravaginal electrolysis[18]300-case learning curve before OR-time plateau[4]
Potential early self-lubricationLubrication likely transient — mesothelial → squamous metaplasia[25]
Robust flap vascularityUnique intra-abdominal complications (internal hernia, SBO, abscess) — 2.2%[16]
Transabdominal canal vision may reduce rectal injury[2]Reactive atypia mimicking dysplasia — surveillance undefined[25]
Minimal donor-site morbidity (no external scars)[17]Higher cost (robotic equipment, longer OR during learning)
Equivalent outcomes in genital hypoplasia[3]Limited long-term data (most series < 2 yr)
Viable salvage option for failed PIV[12]Only one small head-to-head vs PIV[29]

Comparison vs Intestinal (Sigmoid) Vaginoplasty​

FeaturePeritonealSigmoid (Intestinal)
Depth~14 cm12–15 cm
Self-lubricationTransient (squamatises)Persistent (mucus-secreting mucosa)
Donor-site morbidityMinimalSignificant (bowel anastomosis)
Surgical complexityModerate (robotic / laparoscopic)High (laparotomy / laparoscopy + bowel)
Excessive dischargeNoCommon (mucus overproduction)
OdorMinimalCan be significant
Stenosis risk~7%Lower (De Rosa SR: 0.20%)
Diversion-colitis-like riskNoYes
Primary vs revisionBothPrimarily revision / salvage

Anchors: Jacoby[1], Castanon[10], Morrison 2023 review[20], Bene 2024 tissue-options review[32].

Evidence Limitations​

The evidence base is dominated by retrospective single-centre case series, predominantly from the NYU group, with median follow-up < 2 years.[31] The only head-to-head with standard PIV included just 19 patients.[29] The Dhami 2025 histology challenges the long-claimed self-lubrication advantage and raises surveillance questions not yet operationalised.[25] The 300-case learning curve raises generalisability concerns.[4] Tay 2022 systematic review identified only level-4–5 evidence with healing times under-reported and complications captured by only half of publications.[30] Comparative priors include the Zhao 2015 MRKH 10-year laparoscopic single-flap series (n = 83; 95.3% functional success)[21], the van der Sluis intestinal-vaginoplasty review[22], and the di Summa 43-patient colic-based series[23]. Standardised PROMs and prospective comparative studies are needed.[31][32]

References​

1. 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

2. 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

3. Blasdel G, Kloer C, Parker A, et al. Genital hypoplasia before gender-affirming vaginoplasty: does the robotic peritoneal flap method create equivalent vaginal canal outcomes? Plast Reconstr Surg. 2023;151(4):867–874. doi:10.1097/PRS.0000000000010011

4. Hemal K, Blasdel G, Parker A, et al. Quantifying the learning curve in robotic peritoneal flap vaginoplasty. Ann Plast Surg. 2025;94(4S Suppl 2):S139–S144. doi:10.1097/SAP.0000000000004265

5. Slater MW, Vinaja X, Aly I, et al. Neovaginal construction with pelvic peritoneum: reviewing an old approach for a new application. Clin Anat. 2018;31(2):175–180. doi:10.1002/ca.23019

6. Origoni M, Fedele F, Parma M, et al. The peritoneal neovagina after Davydov's laparoscopic procedure in Mayer–Rokitansky–Küster–Hauser syndrome: morphology and ultrastructure investigation of the new epithelium. J Minim Invasive Gynecol. 2021;28(10):1795–1799. doi:10.1016/j.jmig.2021.04.002

7. 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

8. Fedele L, Frontino G, Restelli E, et al. Creation of a neovagina by Davydov's laparoscopic modified technique in patients with Rokitansky syndrome. Am J Obstet Gynecol. 2010;202(1):33.e1–33.e6. doi:10.1016/j.ajog.2009.08.035

9. Dy GW, Dugi DD, Peters BR. Skin management during robotic peritoneal flap vaginoplasty for penoscrotal hypoplasia secondary to pubertal suppression. Urology. 2023;173:226–227. doi:10.1016/j.urology.2022.12.020

10. 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

11. Sineath RC, Butler C, Dy GW, Dugi D. Genital hypoplasia in gender-affirming vaginoplasty: prior orchiectomy, penile length, and other factors to guide surgical planning. J Urol. 2022;208(6):1276–1287. doi:10.1097/JU.0000000000002900

12. Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. Robotic peritoneal flap revision of gender-affirming vaginoplasty: a novel technique for treating neovaginal stenosis. Urology. 2021;154:308–314. doi:10.1016/j.urology.2021.03.024

13. Celis V, Rodríguez VI, Fumero LK, et al. Robotic peritoneal flap revision vaginoplasty: step-by-step technique: tips & tricks. Int Urogynecol J. 2026. doi:10.1007/s00192-026-06617-4

14. Acar O, Sofer L, Dobbs RW, et al. Single port and multiport approaches for robotic vaginoplasty with the Davydov technique. Urology. 2020;138:166–173. doi:10.1016/j.urology.2019.11.043

15. Blackman C, Liang F, Jun MS. Vaginoplasty. Clin Plast Surg. 2025;52(4):463–484. doi:10.1016/j.cps.2025.06.004

16. 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

17. Morelli G, Zucchi A, Ralph D, et al. A single pedicled robotic peritoneal flap in penile inversion vaginoplasty augmentation. BJU Int. 2023;131(1):125–129. doi:10.1111/bju.15922

18. Ratanalert W, Pobpan P. Full-length peritoneal flap vaginoplasty: a feasible approach for hairless neovaginal reconstruction in gender-affirming surgery. Plast Reconstr Surg. 2025. doi:10.1097/PRS.0000000000012265

19. Parker A, Brydges H, Blasdel G, Bluebond-Langner R, Zhao LC. Mending the gap: AlloDerm as a safe and effective option for vaginal canal lining in revision robotic-assisted gender-affirming peritoneal flap vaginoplasty. Urology. 2023;173:204–208. doi:10.1016/j.urology.2023.01.003

20. Morrison SD, Claes K, Morris MP, et al. Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol. 2023;20(5):308–322. doi:10.1038/s41585-022-00705-y

21. 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

22. van der Sluis WB, Tuynman JB, Meijerink WJHJ, Bouman MB. Laparoscopic intestinal vaginoplasty in transgender women: an update on surgical indications, operative technique, perioperative care, and short- and long-term postoperative issues. Urol Clin North Am. 2019;46(4):527–539. doi:10.1016/j.ucl.2019.07.007

23. di Summa PG, Watfa W, Krähenbühl S, et al. Colic-based transplant in sexual reassignment surgery: functional outcomes and complications in 43 consecutive patients. J Sex Med. 2019;16(12):2030–2037. doi:10.1016/j.jsxm.2019.09.007

24. Candiani M, Fedele F, Ruffolo AF, et al. Histological features of neovaginal epithelium after vaginoplasty in Mayer–Rokitansky–Küster–Hauser syndrome. J Pediatr Adolesc Gynecol. 2024;37(3):353–359. doi:10.1016/j.jpag.2024.01.002

25. Dhami JK, Bonapace-Potvin M, Ferrin PC, et al. The peritoneal neovagina after robotic-assisted peritoneal flap gender-affirming vaginoplasty: a morphologic and histologic investigation of the neovaginal lining. Urology. 2025. doi:10.1016/j.urology.2025.08.056

26. Qin C, Luo G, Luo X, et al. Analysis of the artificial vaginal microecology in patients after laparoscopic peritoneal vaginoplasty. Sci Rep. 2019;9(1):8482. doi:10.1038/s41598-019-44511-w

27. Chen N, Hao L, Zhang Z, et al. Insights into the assembly of the neovaginal microbiota in Mayer–Rokitansky–Küster–Hauser (MRKH) syndrome patients. Nat Commun. 2024;15(1):7808. doi:10.1038/s41467-024-52102-1

28. Mora RM, Mehta P, Ziltzer R, Samplaski MK. Systematic review: the neovaginal microbiome. Urology. 2022;167:3–12. doi:10.1016/j.urology.2022.02.021

29. Zucchi A, Maiolino G, Falcone M, et al. Comparing sexual outcomes and complications in male-to-female gender-affirming surgery: penile inversion vs robotic peritoneal vaginoplasty. Int J Impot Res. 2025. doi:10.1038/s41443-025-01157-9

30. Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: a systematic review. ANZ J Surg. 2022;92(3):373–378. doi:10.1111/ans.17147

31. Salibian AA, Schechter LS, Kuzon WM, et al. Vaginal canal reconstruction in penile inversion vaginoplasty with flaps, peritoneum, or skin grafts: where is the evidence? Plast Reconstr Surg. 2021;147(4):634e–643e. doi:10.1097/PRS.0000000000007779

32. Bene NC, Ferrin PC, Xu J, et al. Tissue options for construction of the neovaginal canal in gender-affirming vaginoplasty. J Clin Med. 2024;13(10):2760. doi:10.3390/jcm13102760

33. Dy GW, Salibian AA, Blasdel G, Zhao LC, Bluebond-Langner R. External genital revisions after gender-affirming penile inversion vaginoplasty: surgical assessment, techniques, and outcomes. Plast Reconstr Surg. 2022;149(6):1429–1438. doi:10.1097/PRS.0000000000009165

34. Sljivich M, Torres C, Chen D, et al. Feasibility and outcomes after robot-assisted sigmoid vaginoplasty for gender dysphoria. Urology. 2025. doi:10.1016/j.urology.2025.06.003

35. Berger LE, Lava CX, Spoer DL, et al. The effect of obesity on vaginoplasty outcomes. Ann Plast Surg. 2024;92(4):447–456. doi:10.1097/SAP.0000000000003808