Skin Management During Robotic Peritoneal Flap Vaginoplasty for Penoscrotal Hypoplasia Secondary to Pubertal Suppression

Objective: To demonstrate an approach to skin management in cases of gender-affirming vaginoplasty in the setting of penoscrotal hypoplasia. Gender-affirming penile inversion vaginoplasty is a procedure that has traditionally relied upon the use of local genital tissues to both construct the vulva and line the neovaginal canal. Improved and earlier access to pubertal suppression has resulted in an increasing number of individuals presenting for vaginoplasty with penoscrotal hypoplasia and significantly less skin available to accomplish the goals of vaginoplasty. Robotic-assisted gender-affirming peritoneal flap vaginoplasty is one solution that has emerged to help address the challenge of limited skin and provide an alternative source of neovaginal lining. Although this technique provides valuable peritoneal tissue that is used to line a large portion of the neovaginal canal, external vulvar construction remains a challenge. Amid a growing number of cases of penoscrotal hypoplasia secondary to pubertal suppression, there is a need for resources that illustrate strategies to deal with these challenging scenarios. In this video the authors demonstrate their approach to vulvar construction in the setting of penoscrotal hypoplasia secondary to pubertal suppression. Methods: This video demonstrates an approach to skin management during robotic peritoneal flap vaginoplasty in the setting of limited genital skin secondary to pubertal suppression at Tanner stage 2. Results: Penile inversion vaginoplasty typically relies upon the penile skin tube reaching and reconstructing the introitus, and forming the distal aspect of the neovaginal canal. However, in most cases of penoscrotal hypoplasia secondary to pubertal suppression, there will not be enough length of penile skin to reach or construct the introitus. In these cases, the inverted penile skin tube is also often also too narrow in caliber to accommodate passage of a dilator for neovaginal dilation. These clinical scenarios are challenging and often require construction of the introitus with skin graft, complete splitting of the ventral penile skin tube and optimization of remaining skin to form other critical vulvar structures (labia minora and clitoral hood). Conclusion: As individuals with penoscrotal hypoplasia continue to present for gender-affirming vaginoplasty procedures, it is important to adjust traditional approaches to vulvar construction and optimize strategies to manage cases with limited genital skin. In this video the authors present their approach to skin management and vulvar construction in gender-affirming vaginoplasty with penoscrotal hypoplasia secondary to pubertal suppression.