The Challenge of Peritoneal Vaginoplasty in Transgender Women: Review Literature and Personal Perspectives

Search Strategy

A comprehensive literature search was conducted using PubMed, Scopus, and Web of Science from inception to 2025. Search terms included: “gender-affirming surgery”; “sex reassignment surgery”, “peritoneal vaginoplasty.”

Inclusion Criteria

• Studies describing peritoneal vaginoplasty in transgender women
• Primary surgical outcome data
• Clearly described operative techniques

Exclusion Criteria

• Duplicated studies
• Non-surgical studies
• MRKH reconstruction
• Review articles, book chapters
• Unclear techniques or mixed cohorts without trans- specific data

Data Extraction

• Eligible studies were reviewed for:
• Type of peritoneal flap
• Vascular supply
• Method of anastomosis
• Postoperative complications
• Short- and mid-term outcomes
• Year of publication Due to the limited number of studies, all eligible articles were included regardless of sample size.

Double-Flap (Pull-Through) Technique

The double-flap technique involves creating anterior and posterior peritoneal flaps. The anterior flap is harvested from the peritoneum overlying the posterior bladder and extended superiorly to the anterior abdominal wall, while the posterior flap is harvested from the pararectal peritoneum. The anterior flap is then folded downward and anastomosed to the posterior flap to create a tubular cavity. A perineal incision is made to develop the neovaginal canal. The peritoneum is opened into the abdominal cavity, after which the peritoneal tube is pulled through the canal and anastomosed to penile skin. In this method, part of the anterior rectal surface is included within the posterior flap. Both flaps are mobilized inferiorly into the neovaginal canal, hence the term “pull-through technique.” Several groups have employed this method, including Dy, et al. [5], Lava, et al. [6], Castañon, et al. [7], Blasdel, et al. [8] and Katz, et al. [9]. Among these, Lava, et al. [6] provided the most detailed outcome analysis, reporting hypergranulation tissue in 2 of 21 patients and complete vaginal stenosis in 7 of 21 patients at 30 days postoperatively. Dy, et al. [5] reported chronic granulation tissue in 2 of 24 patients. Robinson, et al. [10] described cases of internal herniation through peritoneal defects, resulting in acute abdominal pain that required reoperation.

Three-Flap Technique

Haile, et al. [11] described a robotic three-flap peritoneal vaginoplasty technique, harvesting peritoneal flaps from the pelvic sidewalls, posterior bladder surface, and the pararectal fossa. These were fashioned into a rhomboid configuration and anastomosed inferiorly to the penile skin flap. This approach represents a modification of the original Davydov procedure. However, the reported patient outcomes were unclear and limited in detail.

Pedicled Peritoneal Flap

Suwajo, et al. [12] and Sachan, et al. [13] described early experience with pedicled peritoneal flaps based on isolated peritoneal branches of the deep inferior epigastric artery (DIEA). These flaps were tubularized and their apex positioned into the neovaginal canal, followed by anastomosis to inverted penile skin. Although technically appealing due to their preserved vascularity, available series remain small and long-term outcomes are not well established.

Extended Posterior Bladder Flap

Smith, et al. [14] introduced a single posterior bladder peritoneal flap anastomosed to inverted penile skin. This wide-based flap provides robust vascularity and may be less invasive than double-flap techniques. Morelli, et al. [15] later described an extended posterior bladder–urachus hinge flap, reporting low intra-abdominal complication rates, procedural safety, effectiveness, and favorable patient satisfaction. Johnston, et al. [16] used a single anterior peritoneal flap secured with a “hitch stitch” to reduce anastomotic tension. Despite this innovation, 12 of 33 patients (36%) developed some degree of vaginal stenosis, and 13 of 33 (39%) reported difficulty with dilation, although no cases of hypergranulation tissue were observed. Ratanalert, et al. [17] reported vaginal stenosis in 1 of 10 patients at 3 months postoperatively .

Summary of Reported Outcomes

• Double-flap pull-through: High rates of vaginal stenosis, hypergranulation, and rare internal hernia (e.g: Dy, et al. [5], Lava, et al. [6] and Robinson, et al. [10]).
• Three-flap: Limited outcome data; technique feasible but poorly reported.
• Pedicled peritoneal flap: Small case series; maintains vascularity but limited follow-up.
• Extended posterior bladder flap: Lower anastomotic tension, fewer complications, and promising patient- reported satisfaction.

Personal Perspective

The peritoneum originates from mesoderm and is inherently more sensitive than skin, which is derived from ectoderm. This embryologic difference likely contributes to the discomfort and difficulty many patients experience during early postoperative dilation. In the original Davydov procedure, mesoderm-derived peritoneum was anastomosed to endoderm-derived vaginal mucosa, providing favorable epithelial compatibility. In transgender women, however, peritoneum must be anastomosed to penile skin- an ectodermal tissue-resulting in a less harmonious interface and potentially higher rates of long-term complications.

The pull-through technique is particularly prone to early

and late complications. The pararectal posterior flap exhibits significant “memory” or spring-back tension, leading to increased risks of internal herniation, hypergranulation tissue formation, and late stenosis. Although pedicled peritoneal flaps preserve vascular integrity, relatively few centers have adopted this technique, and outcomes remain limited. Due to its tissue characteristics, the peritoneal lining of the neovagina often remains hypersensitive for 3-6 months postoperatively. Patients with poor adherence to dilation regimens are therefore at increased risk of developing stenosis.

More recently, extended posterior bladder peritoneal flaps appear to offer more reliable outcomes, with lower anastomotic tension and fewer complications. Based on the author’s clinical observations, the anastomotic tension between peritoneum and penile skin is substantially lower compared with pull-through (double-flap) approaches, reducing the likelihood of hypergranulation tissue. A major limitation of the existing literature is the small number of published studies and the predominance of short-term follow-up.