(296) 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 Introduction Currently, only two published gender-affirming vaginoplasty techniques describe using peritoneal tissue to contribute to the neovaginal canal: The modified Davydov technique, first described by Zhao et al (2019), and the Tubularized Urachus-Peritoneal Hinge Flap, described by Garcia et al (2022). Today, many providers use the Davydov technique at the time of primary vaginoplasty, while other providers argue that use of peritoneum is not necessary at the time of primary vaginoplasty. We use peritoneum (urachus-flap) only for salvage surgery. Objective We report urachus hinge-flap technical innovations, and clinical outcomes at 1.5-years postoperatively. 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 following primary vaginoplasty. 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 salvage urachus hinge flap technique is 12.5 cm (range 11-14.2) at 409 days post-op, comparable to the Davydov technique. With primary vaginoplasty using only penile and scrotal skin, our mean depth is 12.5 cm, which is comparable to other series (Fig. 1). 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 (URL: https://youtu.be/z3pQrNY-A5I). Conclusions By the techniques described herein, we are able to achieve comparable vaginal depth as other groups that use the “pull-through” technique. We suggest that peritoneum is only rarely necessary at primary vaginoplasty, and should be reserved for use as a salvage surgery if needed. 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.