Introduction: Congenital anomalies of the vagina including vaginal agenesis and hypoplasia can pose a reconstructive challenge. Vaginoplasty techniques using skin grafts, flaps, intestine and peritoneum have been described. Most recently, vaginoplasty techniques have been applied to gender-affirming surgery. In cases where revision is warranted, peritoneal flaps have proven to be efficacious for augmenting the neovaginal canal. Our reconstructive technique, outlined here, is a laparoscopic robotically-assisted adaptation of the techniques we apply in our gender-affirming surgeries. Methods: We show the procedure on a 36 year old female with mixed gonadal dysgenesis (46 XY/XO) and vaginal agenesis who presents with vaginal stenosis after ileal vaginoplasty in 2010. After exam under anesthesia and genitogram to delineate the patient’s anatomy, the plan was to create a continuous opening between the patient's vaginal remnant and the ileal vagina to relieve the vaginal stenosis. In the setting of significant adhesions from prior pelvic surgeries, the da Vinci Single Port (SP)® dissection was facilitated externally through the use of vaginoscopy, vaginal dilators and a second surgeon to perform the distal most aspect of the anastomosis at the genital hiatus. Colpopexy was performed to fix the neovagina into the proper position between the bladder and rectum. Closure of the neovaginal vault was achieved through the use of peritoneal flaps. Results: This procedure has been performed in 4 cisgender patients to date, 2 of whom had prior failed vaginoplasty attempt(s). The other 2 patients underwent robotic vaginoplasty with placement of biologic implant (AlloDermTM) in addition to the use of peritoneal flaps. All 4 patients were patent at last followup. None have required further procedures. Conclusions: Peritoneal flap vaginoplasty is an established gender-affirming surgery technique. Here we demonstrate that it is also a good surgical option for cisgender women with congenital vaginal agenesis, many of whom may have failed prior vaginoplasty attempts. The result is a well-vascularized neovagina without the morbidity of intestinal harvest or the need for skin flaps or grafts. Our technique using the robotic SP platform facilitates low morbidity, excellent cosmesis and expedient recovery. SOURCE OF Funding: None.
