Robot-assisted peritoneal pull-through vaginoplasty (PPTV) is the technique our practice has been performing for over a year for primary genital gender affirming surgery in transgender women. This technique is preferred over penile inversion vaginoplasty (PIV) for several reasons, including good functional depth which may be limited in PIV due to puberty blockade or scrotal skin insufficiency. The aim of this study was to evaluate the short-term outcomes of transgender women who underwent robot-assisted peritoneal pull-through vaginoplasty (PPTV) for gender affirmation.

In this case series, clinical information from 20 transgender women who underwent robotic peritoneal pull-through vaginoplasty between May 2021 to November 2022 was analyzed to assess surgical short-term outcomes. A retrospective chart analysis was conducted on March 15th, 2023 to assess early complications and functional outcomes, and comorbid conditions were documented using the Charleston comorbidity index. Data were analyzed descriptively as percentages, and no statistical tests were performed due to the study's descriptive nature and small cohort.

The follow-up period ranged from 1 to 14.5 months (mean 6.5 months), and the average age of the patients at the time of operation was 35 years (range 28-56 years). The majority of patients had a prior diagnosis of anxiety (80%; n=16) or depression (65%; n=13). The mean BMI of the patients was 26.6 kg/m2 (range 21.1-51.8 kg/m2), and 55% underwent orchiectomy prior to vaginoplasty. The average operative time was 9.08 hours, and the postoperative hospitalization was a minimum of 5 days with an average length of stay of 5.35 days. Acute hospital complications occurred in 10% of patients (n=2) and were mild (i.e. anemia and wound leakage). After hospital discourse, 25% of patients (n=5) had ER visits averaging 35.25 days after surgery for dehiscence, vaginal discharge, and infection. Postoperative complication data is presented in table 1. As of March 15th, 2023, 35% (n=7) of patients had revision surgeries with an average time of 161.8 days post-op.

Robot-assisted PPTV was found to be a promising technique for primary vaginoplasty in transgender women, with favorable outcomes in this series of patients. Although postoperative complications occurred, the majority were minor and did not require revision surgery. However, a larger cohort is needed to evaluate the significance of complication rates and assess associations between patient characteristics and complication type, and severity.

In conclusion, this case series suggests that robot-assisted peritoneal pull-through vaginoplasty is a promising technique for primary gender affirming surgery in transgender women. Short-term complications did occur but were mostly minor and the majority of patients didn’t require revision surgeries. PPTV may be of particular interest to the increasing population of transgender women who have undergone puberty blockade and thus have limited donor tissue for PIV.  Further studies with larger cohorts and longer follow-up periods are necessary to confirm these findings and evaluate the significance of complication rates and patient characteristics. Additionally, future work should aim to compare aesthetic, sensory, and functional outcomes between peritoneal pull-through and penile inversion techniques.

Continence 7S1 (2023) 101030
DOI: 10.1016/j.cont.2023.101030