Foreshortened vaginal canal, which is not an uncommon entity after gender affirming vaginoplasty, can lead to sexual dysfunction and impaired ability to perform self-dilation. In these cases, revision surgery may be necessary to reconfigure the neovagina. The Davydov procedure, which involves the utilization of peritoneal flaps, and is well suited for a minimally invasive surgical approach, represents a valid alternative to intestinal vaginoplasty in this setting.

A 24-year-old transgender female who had undergone gender affirming vaginoplasty in 2016 presented to our clinic with a chief concern regarding the insufficiency of her vaginal dimensions. The postoperative course after the primary vaginoplasty had been complicated by wound infection, necessitating prolonged hospitalization and serial incision & drainage procedures. Consequent post-inflammatory fibrotic reactions resulted in neovaginal stenosis and she reported having developed emptying phase lower urinary tract symptoms. She underwent revision surgery including clitoroplasty, urethroplasty, and labiaplasty in 2017. Afterwards, her urinary issues resolved. However, inadequate neovaginal depth and width continued to be a problem for her, precluding penetrative intercourse and making self-dilation almost impossible due to pain and resistance. Her past medical and surgical histories were otherwise unremarkable. Based on these findings; she was scheduled for another revision surgery in which a combination of peritoneal flaps (Davydov technique) and a full-thickness skin graft would be utilized in order to lengthen and widen her neovagina.

Patient was placed in lithotomy and 45° Trendelenburg positions. A total of 5 transperitoneal ports and an assistant port were introduced into the abdominal cavity after inducing pneumoperitoneum with the Veress needle. Da Vinci XI Robot was docked. In the meantime, the introitus and the vaginal canal were released. Peritoneal flaps were elevated from the anterior and posterior abdominal walls via robotic dissection. The skin graft lining the vaginal canal was released by lateral incisions. The posterior peritoneal flap was sutured with the posterior part of the vaginal wall robotically. The anterior counterpart of this connection was performed through the perineal approach. Peritoneal defects were closed with interrupted intracorporeal suturing. The apex of the neovagina was closed robotically with a V-lock purse-string suture. Great care was taken to avoid tension along the suture lines.
A full-thickness skin graft was harvested from the left lower abdomen measuring 10 cm in length x 6 cm in width. This was defatted and then sutured to the sidewall of the vaginal introitus at the 3 and 9 o'clock positions. The vagina was packed with packing soaked with lubricant gel. Packing and foley catheter was left in place for 5 days. She was discharged home on postoperative day 5 after an uneventful course. Neovaginal dilation protocol was initiated without any problems on postoperative day 10.

Davydov technique is a safe and effective way of compensating for the insufficiency of neovaginal depth and width after gender affirming vaginoplasty. The relative ease of harvest, deep pelvic transposition and suturing of the peritoneal flaps with the aid of robotic-assistance, decreased the likelihood of bowel-related complications and the resultant faster recovery process are the main advantages of this procedure. The combination of robotic-assisted laparoscopic and perineal approaches enables more precise suturing of the harvested peritoneal flaps and better optimization of the vaginal dimensions.