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Peritoneal Flap Vaginoplasty

Robotic or laparoscopic peritoneal flap vaginoplasty uses vascularized pelvic peritoneum to supplement the neovaginal lining. The commonly reported operation is a hybrid: penile skin, sometimes with a scrotal graft, lines the distal canal; peritoneal flaps form its proximal portion and apex. This can extend the available lining when genital skin is limited or a previous canal requires revision. It does not guarantee a particular depth, eliminate the need for dilation or make the entire canal hairless.[1][2][32]

For overall selection, see Feminizing Gender-Affirming Surgery, Penile Inversion Vaginoplasty and Zero-Depth Vulvoplasty. The peritoneal flap principles page covers other reconstructive uses.

Selection and counseling​

Selection depends on the patient's goals, usable genital skin, previous operations, abdominal access and available surgical expertise. Assess the intended distal lining and vulvar construction separately from the tissue needed for canal depth.[9][15][20][32]

SituationPractical interpretation
Limited genital skin, including after puberty suppressionPeritoneum can provide additional canal lining, but the introitus and external vulva still need careful skin allocation. Puberty-suppression history alone does not determine the operation.[3][9]
Circumcision, skin disease or previous genital surgeryMeasure available healthy tissue; these factors may limit the skin available for inversion or grafting.[10][11]
Previous orchiectomyA prospective 235-patient PIV cohort found approximately threefold greater odds of needing additional skin grafts. This informs planning; it is not an automatic indication for peritoneal vaginoplasty.[11]
Canal stenosis or inadequate functional depth after previous vaginoplastyEstablish the location and cause of narrowing, remaining lining and dilation difficulties before choosing revision tissue.[12][32]
Adequate skin but preference for peritoneal augmentationDiscuss abdominal surgery, port scars, the center's outcomes and alternatives. Comparative evidence does not establish routine superiority over PIV.[20][29][37]

Hair removal planning applies to any hair-bearing skin that will line the canal, even when the apex is peritoneal. Peritoneal moisture is not a reliable substitute for lubricant during dilation or penetration. Discuss postoperative access to follow-up, pain management, pelvic-floor support and the ability to maintain the agreed dilation regimen.[9][25][32]

Historical context: MRKH is a different population​

The Davydov approach originated in reconstruction for vaginal agenesis. MRKH studies describe squamous epithelialization and useful functional outcomes, but differ in anatomy, hormonal environment, starting vaginal tissue and canal construction. They should not be used to promise equivalent outcomes after gender-affirming surgery. Long-term MRKH experience also includes granulation and canal obliteration, rather than universal success.[5][6][7][8][21]

Operative principles​

The following outlines the commonly described two-flap hybrid operation. Flap geometry, port placement, skin allocation and postoperative schedules vary by anatomy and center; the original operative reports provide the technique-specific detail.[1][2][15][32]

  1. Plan the skin-lined distal canal and vulva. Preserve tissue needed for the clitoris, hood, labia and introitus. Perform orchiectomy if still required. Protect the neurovascular supply during penile disassembly and clitoral reconstruction; coordinate urethral reconstruction with the perineal work.
  2. Obtain abdominal access and establish the dissection plane. The abdominal and perineal teams connect a canal between the urinary structures and rectum. Direct visualization helps identify these structures, but comparative reduction in rectal injury has not been established.
  3. Mobilize vascularized peritoneal flaps. In the original description, flaps approximately 6 × 8 cm were raised from peritoneum over the posterior bladder and the anterior rectal/rectosigmoid region. Dimensions are a reported technique, not a universal prescription. Avoid injury to the underlying organs and preserve a viable tissue base.
  4. Join peritoneum to the distal lining. Advance the flaps to meet the inverted penile skin, with or without additional graft. Create a tension-free circumferential junction with adequate caliber and close the proximal flap edges to form the apex.
  5. Inspect the reconstruction and abdominal defects. Check hemostasis, tissue viability and potential spaces that could entrap bowel. Internal hernias have occurred at both flap-closure and donor sites; prevention requires attention to the actual defect geometry.[16]
  6. Place the planned packing or conformer and arrange follow-up. Packing, catheter removal and dilation timing follow the operating team's protocol; a schedule from one series is not a universal standard.

Other reported configurations​

ConfigurationEvidence and limits
Laparoscopy-assisted two-flap pull-throughCastanon/Bizic's 52-patient series used posterior-bladder and anterior rectosigmoid peritoneum joined to penile skin. This is another hybrid operation; its roughly 96% self-reported satisfaction is an uncontrolled series result.[10]
Single posterior-bladder flapMorelli described a pedicled flap turned over to complete the dome in eight patients. No complications were reported in that small series; this does not establish superiority or negligible risk.[17]
Anterior turnover flap intended to line the full canalRatanalert/Pobpan's 10-patient report had only three-month follow-up. One patient needed a partial scrotal graft and one developed canal closure after stopping dilation. Eight maintained initial depth. The report therefore does not establish universally skin-free reconstruction, durable lubrication or freedom from stenosis.[18]
AlloDerm bridge in revisionNine patients received an acellular dermal matrix bridge when available peritoneum could not cover the gap. Median final depth was 12.1 cm at median 368 days; two required office excision of excess matrix. This remains limited pilot evidence.[19]

Outcomes: keep the cohorts separate​

StudyPopulation and follow-upWhat it establishes
Jacoby 2019[1]41 primary hybrid operations; mean follow-up 114 daysMean depth 14.2 cm; peritoneum added about 5 cm beyond skin in this series. Neither number is a guaranteed individual result.
Dy 2021 platform comparison[2]100 of 145 patients had ≥6 months follow-up; mean 11.9 monthsMean depth 13.6 cm with Xi and 14.1 cm with SP; operative times 4.2 and 3.7 hours. Retrospective platform comparison, not a randomized trial.
Blasdel hypoplasia study[3]43 patients with genital length <7 cm and 49 controls; median one yearSimilar measured dilation outcomes; overall median depth 14.5 cm. No depth revisions observed; 10 external revisions across the 92 patients. This supports feasibility in selected patients with limited skin.
Acar early mixed-indication series[14]11 patients, including primary, revision and developmental indicationsMean blood loss 131.8 mL and return of bowel function 1.7 days; two readmissions and one revision. These figures must not be attributed to the hypoplasia cohort.
Blasdel 500-case cohort, published online 2025 and in print 2026[36]Consecutive single-center operations, 2017–2023; 425/500 had ≥1 year follow-upTwenty patients (4%) had complications requiring a procedure; 61 (12%) underwent elective revision. These are distinct outcomes, not the rate of all complications. Median self-reported depth at one year was 14.5 cm. There was no concurrent PIV control group.

The 500-case report materially expands the available experience, but self-reported dimensions, follow-up loss and center-specific practice limit prediction for an individual patient. Reports from the same center and overlapping dates may include the same patients and should not be added as independent cohorts.[1][2][3][4][36]

Platform and learning curve​

The SP platform can facilitate simultaneous abdominal and perineal work. The reported shorter operating time does not mean dual-team work is impossible with Xi. In Hemal's retrospective 500-case learning analysis, the overall median operative time was 125 minutes; operative-time stabilization occurred at approximately 300 cases, and SP use was associated with 34 fewer minutes after adjustment. These are findings from one evolving program, not a universal training threshold or a guaranteed time saving.[2][4]

Comparative evidence​

Zucchi's retrospective comparison included only eight peritoneal and 11 PIV patients, assessed with a custom questionnaire. More peritoneal patients reported improvement in intercourse quality and overall satisfaction, but the small sample cannot establish superior sexual function or equivalent safety; one severe complication occurred in the peritoneal group.[29]

The June 2026 systematic review and single-arm meta-analysis reported ten studies and 974 patients, with a search through May 2026. It supports feasibility but explicitly does not establish superiority over other techniques. Its overall-complication endpoint should not be compared directly with the 500-case cohort's procedure-requiring endpoint. Older systematic reviews likewise emphasize low-level evidence, inconsistent outcome reporting and short follow-up.[30][31][37]

Complications and postoperative problems​

Complication estimates depend on definitions and follow-up. In the 100-patient Dy platform cohort, reported events included stenosis (7%), transfusion (6%), bowel obstruction (2%), rectovaginal fistula (1%) and pelvic abscess (1%). These figures describe that cohort and should not be combined with other series into a synthetic “overall” risk.[2]

Abdominal pain or obstruction after peritoneal flap surgery

Persistent or severe abdominal pain, vomiting, distension or systemic illness warrants urgent surgical assessment. A published 274-patient series identified two incarcerated internal hernias requiring operative reduction. “Bowel rest” is not an adequate blanket recommendation for obstruction after this operation.[16]

Robinson's series recorded six intra-abdominal complications among 274 patients: one hematoma needing evacuation, two abscesses needing drainage, one patient with recurrent obstruction managed with bowel rest, and the two incarcerated internal hernias. These complications reflect the added abdominal component; they are not unique diseases that occur only with peritoneal vaginoplasty.[16]

For narrowing or difficult dilation, assess the introitus, skin–peritoneal junction and deeper canal; evaluate pain, pelvic-floor dysfunction, granulation and scar rather than assuming nonadherence. Persistent loss of functional depth or caliber may require revision. Peritoneal lining does not remove the need for postoperative dilation and follow-up.[20][32][35]

Lining, lubrication and microbiome​

Histology does not establish lubrication or a screening schedule​

MRKH studies document a change from peritoneal mesothelium toward squamous epithelium. A later gender-affirming study examined five selected patients undergoing vulvar revision at least 12 months after surgery; all five biopsies contained squamous epithelium without residual mesothelium. Patients with stenosis or extensive granulation were excluded. This supports metaplasia in those sampled patients, not a precise timetable or measured longitudinal loss of lubrication.[6][24][25]

Three of the five samples had changes mimicking low-grade condylomatous dysplasia, interpreted as likely reactive changes. This is not a 60% incidence of dysplasia or cancer. The study does not establish a routine cytology or biopsy schedule. Symptoms or suspicious lesions warrant clinical evaluation, with the original lining tissue and operation communicated to pathology.[25]

Counsel that baseline moisture, peritoneal secretion and bowel mucus differ from arousal-related lubrication. Histologic appearance alone does not demonstrate adequate lubrication for dilation or intercourse; lubricant may still be needed.[25][32]

Microbiome findings are exploratory and population-specific​

The 54-patient Qin study and 39-patient longitudinal Chen study involved congenital vaginal absence/MRKH, not transfeminine hybrid vaginoplasty. Chen followed microbiome assembly for up to two to four years and found a community increasingly resembling the preoperative vaginal dimple; only 27 of 39 participants were available at the final recall. Its authors explicitly caution against generalization to transgender women.[26][27]

These studies do not establish that a polymicrobial or BV-like profile alone represents symptomatic infection, nor do they validate routine antibiotics or probiotics to “normalize” an asymptomatic neovagina. The neovaginal microbiome systematic review also found heterogeneous tissue types and limited evidence on hormones, dilation, sexual practices and douching.[26][27][28]

Revision and salvage​

Assess the previous operation, retained lining, location of stenosis, symptoms, desired function and modifiable barriers to dilation before selecting another reconstruction. Both the vulva and canal may need attention; in a selected 35-patient external-revision series, 12 also underwent peritoneal canal revision. That is not a revision rate among all vaginoplasty patients.[12][32][33]

In Dy's 24-patient revision series after PIV, peritoneal flaps were advanced to the opened, widened remnant cavity and closed proximally into an apex. Mean final depth was 13.6 cm at mean 410 days. No rectal injuries were observed, but one patient returned to the operating room for canal bleeding. Zero events in 24 patients does not establish zero injury risk.[12]

Celis's 2026 video report provides another revision example, with three-hour operating time and 20 mL reported blood loss. Its short accompanying article does not establish a comparative improvement in operating time or guarantee that previously harvested peritoneum can be reused. Detailed feasibility depends on remaining tissue and scarring.[13]

Peritoneum versus intestine in revision​

The choice depends on remaining peritoneum, prior abdominal surgery, the extent of obliteration, bowel considerations and patient preference. Peritoneal reconstruction generally avoids planned bowel resection and anastomosis, but still carries abdominal and bowel-injury risks. Intestinal vaginoplasty supplies another lining option, with bowel-anastomosis, mucus, prolapse and inflammatory complications to consider.[22][23][32]

The Dy peritoneal series and Sljivich sigmoid series are separate studies, not a head-to-head comparison. Sljivich reported 36 patients, including 11 primary and 25 revision operations; its mean depth of 17.6 cm was reported for the study cohort. Comparing it directly with Dy's 13.6 cm does not establish superior depth or lower morbidity for either revision method. Intestinal or other salvage may be required when usable peritoneum is insufficient, particularly after previous peritoneal reconstruction.[12][32][34]

A 237-patient retrospective study associated obesity with stenosis and revision, and associated robotic approaches with less delayed wound healing. Selection bias and mixed techniques prevent using this as proof that a robotic approach is preferable solely because of BMI. Individual assessment and support for postoperative recovery remain necessary.[35]

Evidence limits​

The most useful evidence is the larger contemporary cohort and systematic synthesis, interpreted alongside the specific operative reports. Most studies remain retrospective; outcome definitions, follow-up and patient-reported measures vary. Avoid promises of universal depth, absent donor morbidity, hair-free hybrid lining, spontaneous lubrication or freedom from dilation. Large prospective comparisons with standardized functional and patient-reported outcomes remain needed.[20][30][31][32][36][37]

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;37(7):2191–2192. 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. 2026;157(3):566–569. Published online 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. 2026;207:239–244. Published online 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. 2026;38(8):611–620. Published online 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;204:227–233. 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

36. 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(6):1068–1074. Published online January 9, 2025. doi:10.1097/SLA.0000000000006621

37. Jiang JL, Zhang L, Chen XZ. Robot-assisted peritoneal flap vaginoplasty in gender-affirming genital reconstruction: a systematic review and single-arm meta-analysis. J Robot Surg. 2026;20:604. doi:10.1007/s11701-026-03572-6