Robot-assisted peritoneal flap vaginoplasty in gender-affirming genital reconstruction: a systematic review and single-arm meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not reported in abstract

• Effect Size: Pooled neovaginal depth: 13.41 cm; pooled neovaginal width: 3.61 cm; pooled operative time: 305.37 minutes; pooled length of hospital stay: 5.80 days

• Primary Outcome: Pooled overall postoperative complication rate: approximately 30.1% across 10 studies (974 patients)

• Nnt Or Sensitivity: Not applicable for this single-arm descriptive meta-analysis; complication rate of 30.1% implies approximately 1 in 3 patients experiences a postoperative complication, though severity grading (Clavien-Dindo classification) is not specified in the abstract

• Confidence Interval: Neovaginal depth: 95% CI 12.86–13.96 cm; neovaginal width: 95% CI 3.55–3.67 cm; operative time: 95% CI 244.62–366.12 min; hospital stay: 95% CI 4.72–6.87 days

Clinical Application

Robot-assisted peritoneal flap vaginoplasty appears technically feasible based on pooled data, achieving neovaginal dimensions (depth ~13.4 cm, width ~3.6 cm) broadly comparable to reported benchmarks for other full-depth techniques. However, operative time (~305 minutes) and hospital stay (~5.8 days) reflect resource-intensive care. The 30.1% complication rate requires careful patient counselling and comparison with institutional outcomes for alternative techniques before adoption. In Australia, gender-affirming genital surgery is performed at a small number of specialist centres, with access influenced by state-based funding, Medicare rebate availability, and waitlist constraints. The TGA does not regulate surgical techniques directly, but robotic surgical platforms (da Vinci system) require institutional credentialing and significant capital investment. RACGP and ANZPATH guidelines emphasise multidisciplinary care and informed consent processes for gender-affirming surgery. The 30.1% complication rate and absence of patient-reported outcome data are particularly relevant for Australian clinicians navigating shared decision-making with patients. PBS does not cover surgical procedures directly, but associated medications (e.g., hormone therapy) are PBS-listed. Australian practitioners should note that this evidence base does not yet support preferential recommendation of robot-assisted over conventional peritoneal or penile inversion vaginoplasty techniques. Transfeminine and gender-diverse individuals seeking gender-affirming vaginoplasty at centres with robotic surgical capability and specialist gender surgery expertise. Results are most applicable to patients at high-volume academic centres where the included studies were likely conducted.

Abstract

Robot-assisted peritoneal flap vaginoplasty has emerged as an evolving reconstructive option in gender-affirming genital surgery. This systematic review and single-arm meta-analysis aimed to synthesize the available evidence regarding its perioperative, functional canal, and postoperative safety outcomes. This study was conducted according to PRISMA guidelines and prospectively registered in PROSPERO. PubMed, Cochrane Library, Embase, and Web of Science were searched from database inception to May 2026. Eligible studies included transfeminine or gender-diverse individuals undergoing robot-assisted peritoneal flap-based vaginoplasty with extractable clinical outcomes. Continuous outcomes were synthesized as weighted mean estimates with 95% confidence intervals (CIs), and overall postoperative complications were pooled using Stata version 18.0. Heterogeneity was assessed using the I² statistic, and leave-one-out sensitivity analyses were performed. Ten studies involving 974 patients were included. The pooled mean operative time was 305.37 min (95% CI 244.62, 366.12), and the pooled length of hospital stay was 5.80 days (95% CI 4.72, 6.87). At the last available follow-up, pooled neovaginal depth was 13.41 cm (95% CI 12.86, 13.96), and pooled neovaginal width was 3.61 cm (95% CI 3.55, 3.67). The pooled overall postoperative complication rate was approximately 30.1%. Sensitivity analyses suggested that the pooled estimates were not driven by any single study. Robot-assisted peritoneal flap vaginoplasty appears feasible and may achieve neovaginal dimensions broadly comparable to those reported for other full-depth vaginoplasty approaches. However, predominantly retrospective single-arm evidence precludes conclusions regarding superiority and highlights the need for standardized prospective studies with longer follow-up and patient-reported outcomes.

References

1. 1.Jiang, J.-L., Zhang, L., & Chen, X.-Z. (2026). Robot-assisted peritoneal flap vaginoplasty in gender-affirming genital reconstruction: a systematic review and single-arm meta-analysis. Journal of Robotic Surgery. https://doi.org/10.1177/17562872251336639