Robotic-assisted laparoscopic approach has revolutionized the applicability of minimal invasiveness to various types of urological pelvic surgery. The novel Da Vinci Single Port (SP) technology, which seems to be a big step forward considering the technological advancements it offers, has recently been approved by the FDA for the urological procedures that are appropriate for a single port approach. Herein, we aim to present a gender-affirming vaginoplasty with the combination of penile skin inversion technique and Davydov procedure using the SP robotic platform.

A 29-year-old transgender female presented to our clinic due to her interest in gender confirming vaginoplasty. Her past medical and surgical histories were unremarkable. She met the World Professional Association for Transgender Health (WPATH) criteria for genital reconstruction. She was circumcised and the testicles had not been removed. She desired penetrative vaginal intercourse. A combined robotic and perineal approach was selected to assist in the creation of a full-depth neovagina by harvesting peritoneal flaps to augment the inverted penile skin flap without requiring tissue grafts. Furthermore, the single port platform offers both a flexible camera particularly suited to deep pelvic surgery and a single abdominal incision for improved cosmesis.

The patient was placed in lithotomy and 45° Trendelenburg position. The perineal and robotic parts of the surgery began concurrently. We began penile degloving with circumcision. Penile skin flap was created by liberating the penile skin from the shaft. The bulbospongiosus muscle was excised. Lateral attachments between the prostate and levator sidewall were released with the mini-ligasure device. We then developed the plane between the prostate and the rectum. We incised Denonvillier’s fascia and extended the rectoprostatic dissection proximally towards the bladder. Simultaneous to the peritoneal dissection, the single port robot was used to harvest anterior and posterior peritoneal flaps. The development of peritoneal flaps was guided by external pressure at the perineum. A communicating window was created between the perineal and pelvic dissection planes. This fenestration was enlarged and lateral incisions were made along the levator side walls in order to widen the neovaginal canal. Penile skin flap was transposed into the peritoneal cavity. Anterior and posterior peritoneal flaps were sutured to the respective lips of the penile skin flap. Lateral peritoneal defects were closed. Intraoperative neovaginal depth was measured as 14cm. No anti-prolapse fixation stitches were placed. The dilator was inserted through the penile skin flap and maintained at its maximal depth while a purse-string suture was placed to define the neovaginal apex. The robot was undocked and the SP site was closed. 
Dorsal half of the glans penis was dissected proximally on its neurovascular pedicle and then it was reconfigured into neoclitoris. Penis was disassembled, corpora cavernosa were excised. The urethra was shortened and spatulated. Urethral mucosa was sutured to the perineal skin, which also served to define labia minora. 
Duration of the surgery was 420 minutes with an estimated blood loss amount of 250 ml. Drains were removed on postoperative days (POD) 1 and 2, respectively. Vaginal packing was removed on POD 5. Foley catheter was removed on POD 6. She was discharged home after an uneventful course on POD 7. Neovaginal self-dilation protocol was initiated on POD 15.

This case represents the first successful use of the Da Vinci SP robotic platform in gender affirming vaginoplasty whereby robotically-harvested peritoneal flaps were used to augment the skin flap created by penile inversion. This combined approach demonstrates both feasibility and efficacy in creating a neovagina with optimal dimensions and minimizes the risk of devascularization and prolapse. The SP platform, with its flexible camera, appears well-suited to pelvic reconstructive surgery.