An Alternative Option for Gender-affirming Revision Vaginoplasty: The Tubularized Urachus-peritoneal Hinge Flap

Abstract

INTRODUCTION: Peritoneal vaginoplasty has been reported for congenital and primary gender-affirming cases, but few have reported its use to treat postoperative neovaginal shortening after penile-inversion vaginoplasty. Recent adaptations of peritoneal vaginoplasty are modifications of the Davydov procedure, wherein peritoneum of the bladder, rectum, and Pouch of Douglas are incorporated to lengthen the vaginal canal. Here we describe our alternative technique using a single urachus-peritoneal hinge flap and discuss its proposed advantages. METHODS: We performed retrospective review of all trans-women with post-penile-inversion vaginoplasty vaginal canal shortening who underwent revision surgery with our technique. All cases were performed via combined trans-perineal and robotic-laparoscopic approaches. Preoperative and postoperative neovaginal circumference and depth were recorded. With a dilator in the canal, the peritoneum and terminal canal-end were incised and spatulated. The anterior canal-remnant epithelial edge was sutured to the anterior peritoneal edge. A midline, inferiorly based peritoneal flap (min.12-cm width) was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The flap’s free end was flipped posteriorly and sutured to the posterior edge of the open canal remnant, to create a peritoneum-lined pouch. The pouch’s lateral edges were sutured together. We confirmed water-tight closure. Patients resumed dilation on POD 8 and douching on POD 10. RESULTS: Five patients underwent peritoneal vaginoplasty with our technique from 5/2019 to 8/2020. Mean age was 32 years. Preoperative: mean canal girth was >12 cm, and depth was 8.6 (±1.8) cm. Immediate postoperative: mean girth was still >12 cm; depth was 16.8 (±1.2) cm (mean increase: 8.2 cm). At a mean follow-up of 1 year: mean girth was 11–12 cm, and depth was 13.5 (±1.8) cm (mean increase: 4.9 cm). There were no immediate complications. One patient developed anastomotic stenosis at 6 weeks postoperative, managed conservatively with dilation under anesthesia. All five patients endorse satisfactory sexual function; 3 of 5 report vaginal receptive intercourse. CONCLUSIONS: Early results suggest that our peritoneal vaginoplasty technique is a safe and effective option to treat neovaginal shortening. Advantages over existing techniques include: (1) No resting tension on peritoneal sutures, (2) Option for layered closure with omental interposition, and (3) Total exclusion of the rectum and Pouch of Douglas. Due to limited available peritoneum, we reserve this technique for cases where there is adequate residual canal girth and at least 6–7 cm of residual depth.