(016) SALVAGE VAGINOPLASTY WITH SINGLE-PORT ROBOT ASSISTED TUBULARIZED URACHUS PERITONEAL HINGE FLAP: TECHNIQUE HIGHLIGHTS, OUTCOMES, AND AN EVIDENCE-BASED PROPOSAL FOR HOW AND WHEN TO USE (AND NOT USE!) PERITONEUM WITH VAGINOPLASTY

Abstract

Abstract Introduction Vaginoplasty is a commonly performed genital gender affirming surgery. Currently there are two published techniques that describe using peritoneal tissue to contribute to the necessary tissue to line the neovaginal canal: The modified Davydov technique, first described in 2019 by Zhao et al, and the Tubularized Urachus-Peritoneal Hinge Flap, described by Garcia et al in 2022. Today many providers use the Davydov technique at time of primary vaginoplasty, while other providers argue that use of peritoneum is not necessary at the time of primary vaginoplasty. We use the urachus flap only for salvage surgery. Objective Herein, we report our technical innovations related to the urachus hinge flap, and our clinical outcomes at 1.5 years post-op. We also review the literature to determine whether there is evidence to support using peritoneum at time of primary vaginoplasty. Methods We review our single-port robot assisted urachus hinge flap technique to augment neovaginal depth after primary vaginoplasty complicated by loss of vaginal depth. We also review technical innovations to maximize neovaginal depth with primary vaginoplasty using only penile and scrotal skin. We present our literature review, and posit a theory that explains why, regardless of PV technique, mean neovaginal depth is 11-13 cm in all series. Results Our mean neovaginal depth after our salvage urachus hinge flap technique is 12.5 cm (range 11-14.2) at 409 days post-op. This is comparable to the Davydov PV technique. With primary vaginoplasty using only penile and scrotal skin, our mean depth is 12.5 cm, which is > other series using only penile/scrotal skn, and comparable to series that also use peritoneum. We use video to show how, with the Davydov technique, rectum and bowel are pulled deep into the pelvis post-op, which increases risk of bowel injury at time of salvage surgery with intestine. Conclusions By the techniques described herein, in our hands, with primary vaginoplasty using only penile and scrotal skin we achieve vaginal depth comparable to techniques that augment with peritoneum. We suggest that peritoneum is rarely to never necessary at primary vaginoplasty, and should be reserved for use as a salvage surgery if and when it is needed. We also suggest that the urachus flap is a safer alternative to the Davydov technique if and when PV fails and salvage intestinal vaginoplasty must be undertaken. Disclosure No.