Abstract
Background
Primary gender-affirming vaginoplasty (GAV) may be limited by insufficient natal genital skin and the burdensome requirement for preoperative hair removal in transfeminine individuals. To address these challenges, we introduce the robotic-assisted “tubularized augmented peritoneal cap (TAPCap)” technique, incorporating decellularized fish skin xenografts (FSXs) for primary full-depth GAV.
Methods
Thirty-two consecutive transfeminine individuals who underwent primary TAPCap vaginoplasty using FSX between July 2023 and April 2025 were retrospectively chart reviewed. Collected data included baseline medical and surgical history, intraoperative data, and postoperative results. The robotic surgical technique involved using a peritoneal cap to line the proximal neovagina, tubularized FSX for the mid-vaginal segment, and penile skin to form the introitus.
Results
All 32 patients underwent robotic TAPCap vaginoplasty with FSX without intraoperative complications. The 30-day postoperative complication rate greater than Clavien-Dindo grade II was 6.2%, with a 3.1% readmission rate. At the conclusion of surgery, median vaginal depth was 16 cm. At a median follow-up of 147 days, 93.8% of patients remained adherent to dilation, and final median depth and width of the neovaginal canal were 14.25 cm and 3.18 cm, respectively. Vaginal stenosis occurred in 15.6% of patients, and 9.4% underwent revision of the neovaginal canal.
Conclusions
TAPCap vaginoplasty with FSX is a practical approach that may reduce reliance on genital skin and eliminate the need for preoperative hair removal. Early outcomes suggest adequate neovaginal dimensions and low revision rates. Further studies are required to evaluate the long-term viability of graft integration and its cost-effectiveness.
Keywords: Gender-affirming surgery, vaginoplasty, genitourinary reconstruction, robotic surgery, xenograft
Highlight box.
Key findings
• Primary tubularized augmented peritoneal cap (TAPCap) vaginoplasty with fish skin xenografts (FSXs) was performed in 32 transfeminine patients without intraoperative complications.
• Early outcomes showed low neovaginal canal revision (9.4%) rates, with maintained vaginal depth and width.
What is known and what is new?
• Primary gender-affirming vaginoplasty (GAV) often requires hair removal and depends on limited genital skin.
• The TAPCap technique with FSXs reduces the need for genital skin and eliminates preoperative hair removal, with encouraging early results.
What is the implication, and what should change now?
• The TAPCap approach may expand surgical options for patients with limited skin or those avoiding hair removal.
• Longer-term studies may help better understand the applicability of FSXs in primary GAV.
Introduction
A lack of adequate or high-quality tissue for lining the neovagina can present a technical challenge for surgeons performing primary full-depth gender-affirming vaginoplasty (GAV). Transfeminine individuals seeking GAV often undergo months to years of gender affirming hormonal therapy prior to seeking surgical transition (1,2). Some patients experience genital skin hypoplasia on hormonal treatment, which may limit future primary vaginoplasty options (3). The most widely used method for primary full-depth neovaginal GAV, perineal-only penile inversion vaginoplasty (PIV), is significantly reliant on genital skin for constructing the neovagina. Reports have indicated a minimum of 12 cm of preoperative penile skin length is required to construct the neovagina solely with penile skin (4). In practice, scrotal skin and other tissue lining options are typically used to further augment the neovaginal canal (5).
Given the reliance on genital skin, many surgeons advise patients to seek hair removal prior to surgical intervention. Neovaginal construction using hair-bearing skin may lead to both cosmetic and infectious concerns (6).
Newer surgical techniques have been introduced to overcome common issues associated with inadequate natal genital skin. The primary robotic-assisted vaginoplasty (“robotic GAV”) uses peritoneal flaps to create the proximal neovaginal cap in combination with genital skin to augment the canal. Dy et al. demonstrated a robotic GAV method in which scrotal skin was grafted, tubularized, and then sutured to inverted penile skin where penile skin was insufficient (7). As a result, hair removal may still be required as the distal neovagina is still composed of hair-bearing genital skin (8). Common pre-surgical hair removal techniques may impose an additional burden on patients (9). Permanent hair removal methods, including electrolysis and thermolysis (diathermy), are carried out by destroying individual hair follicles by inserting needles into the skin. These methods are painful and have variable success rates based on operator skill and timing of the hair growth phase. Hair regrowth rates with electrolysis are as high as 40% which in some cases requires multiple sessions weekly over a year to achieve acceptable outcomes (10,11). Laser hair removal, on the other hand, requires a more personalized approach based on skin and hair color specifications and requires spaced repetition for maximal efficacy (12). Hair removal before undergoing GAV may discourage some patients from proceeding with surgery due to the associated time and financial burdens. The TAPCap technique enables patients with insufficient natal skin and those who do not choose hair removal to pursue GAV.
The use of xenografts for primary robotic GAV overcomes both the limitations posed by inadequate genital skin and the necessity for preoperative hair removal. However, there is scarce data on xenograft and acellular matrix application for primary GAV in the transfeminine population (13). The Kerecis© decellularized fish skin xenograft (FSX) (Kerecis Inc., Isafjordur, Iceland) has been used in other settings, such as managing necrotizing fasciitis (14) and burn injuries (15). We have previously reported acceptable outcomes using FSX for revision GAV cases with inadequate natal genital skin (16). These patients developed well-epithelialized canals without the need for additional skin grafting, and we hypothesized that using FSX in primary robotic-assisted GAV would obviate the need for hair removal and minimize the dependence on genital tissue. This would also avoid exhausting available peritoneum and retain this tissue for potential revision procedures (Figure 1). Herein, we introduce a novel primary GAV technique referred to as “tubularized augmented peritoneal cap (TAPCap)” vaginoplasty augmented with FSX and present short-term clinical outcomes. We present this article in accordance with the STROBE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-714/rc).
Figure 1.
Sagittal view of neovagina constructed using the TAPCap method. Proximal portion (pink) demonstrates peritoneal cap. Middle portion (yellow) shows tubularized xenograft portion. Distal segment (white) shows introitus constructed using inverted penile skin. TAPCap, tubularized augmented peritoneal cap.
Methods
Patient selection
A total of 32 consecutive transfeminine individuals underwent primary TAPCap vaginoplasty with FSX between July 2023 and April 2025 and were the first patients to receive this procedure in a primary setting. This study was approved by the University Hospitals Cleveland Medical Center Institutional Review Board (No. 20210504) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from all patients, noting the novel nature of FSX use in this setting while explaining its established use in other wounds. After shared decision making, all patients agreed to the use of xenograft within the neovaginal canal. Patients were required to cease all nicotine products 3 months prior to surgery. This was confirmed with a negative cotinine test at 6 weeks preoperatively. We did not advise patients to stop hormone replacement therapy before surgery. Patients were deemed eligible for the procedure with a body mass index (BMI) <40 kg/m2 at the time of surgery. Two surgeons performed all procedures.
Surgical technique
After induction of general anesthesia and infusion of prophylactic antibiotics, the patient is placed in dorsal lithotomy. A two-surgeon team works together at the perineum to perform scrotectomy, simple orchiectomy (if applicable), and penile degloving. At this point, the robot team begins to establish access utilizing the DaVinci Xi robotic platform (Intuitive Surgical; Sunnyvale, CA, USA), while the perineal team starts the neovaginal canal dissection by incising the central tendon and establishing the plane between the bulbar urethra/prostate and peri-rectal fat.
Intraperitoneal insufflation is accomplished using a Veress needle. The camera port is placed approximately 2 cm cephalad to the umbilicus in the midline, and three additional robotic ports are placed in line with the inferior edge of the umbilicus—one on the patient’s left and two on the right. In addition, an 8 mm AirSeal assistant port is placed on the patient’s left in line with the robotic ports. The robot is docked, and sigmoid colon adhesions are taken down in order to retract redundant sigmoid colon out of the pelvis. The vasa deferentia are identified bilaterally, and the peritoneum is incised. Both vasa deferentia are tracked distally until the seminal vesicles are seen, which are kept anteriorly with the prostate. The dissection is carried towards the floor of the pelvis until meeting the previously dissected canal from the perineum and the canal is adequately widened to accommodate the largest dilator (3.81 cm diameter). At this point, a 10 cm × 10 cm anterior peritoneal flap is harvested after measurement with a paper ruler passed in through the assistant port. In addition, two individual lateral posterior flaps (7 cm × 5 cm) are harvested, paying careful attention to the ureters.
A Kerecis graft is soaked in saline for 30 seconds in preparation for use. Depending on institutional availability, either Kerecis SurgiClose© or Kerecis SurgiBind© (each measuring 7 cm × 10 cm) is used. SurgiClose is more expandable, enabling canal lining with a single graft in most cases, whereas SurgiBind consistently required two grafts sutured in tandem for adequate coverage. No other chemical or material properties differed between the two graft types. The graft(s) is then tubularized around the largest dilator using running chromic suture on the planned distal half and interrupted chromic suture on the planned proximal half (Figure 2A). This allows for trimming of the graft robotically should this be required. This Kerecis graft tube is then sutured to the penile skin tube with running chromic suture. The 6 o’clock position of the proximal end of the Kerecis graft is then tagged with a Stratafix suture (Figure 2).
Figure 2.
Depiction of key surgical steps in TAPCap GAV. The xenograft (Kerecis Surgibind) is tubularized around a large orange SoulSource vaginal dilator (A). The anterior peritoneal flap is shown (B). Right and left posterolateral peritoneal flaps (C,D). Antegrade view of inverted xenograft prior to suturing to peritoneal cap (E). These representative images are extracted from an intraoperative video provided in the supplementary materials to illustrate key surgical steps. GAV, gender-affirming vaginoplasty; TAPCap, tubularized augmented peritoneal cap.
The penile skin and attached graft are passed into the abdomen, and the pre-placed 3-0 Stratafix suture is used to secure the 6 o’clock edge of the graft to the peritoneal incision and run laterally. In addition, three additional 3-0 Stratafix sutures are utilized to create a running closure of the four quadrants of the neovagina. Subsequently, a 3-0 double arm suture is used to close the apex of the peritoneal augment in a running fashion, which excludes the colon. The robot is undocked, and Tisseel fibrin sealant (Baxter International Inc., Westlake Village, CA, USA) is sprayed in the surgical bed under laparoscopic guidance. Similarities to established peritoneal techniques for vaginoplasty with straightforward modifications make this approach easy to learn for experienced surgeons with a minimal learning curve.
While the robotic portion is taking place, the perineal surgeon is concurrently completing the penectomy, urethrectomy, clitoroplasty, labiaplasty, and urethral advancement. The penile skin tube is divided ventrally and sutured to the distal edge of the peritoneal flaps. A Foley is placed, a wound vac sponge is rolled to serve as the vaginal stent, and a negative pressure dressing is applied (Video 1). Representative video snippets are included in Figure 2 to illustrate the tubularization and placement of the xenograft.
Video 1.
Demonstration of the primary robotic tubularized augmented peritoneal cap gender-affirming vaginoplasty technique with fish skin xenograft application.
Follow-up
Patients are admitted for 1 week with a Foley, and the wound vac is removed on the day of discharge. Patients are then seen at 2 weeks, 4 weeks, 8 weeks, 12 weeks, 4 months, 6 months, and 1 year postoperatively in the outpatient setting, with a pelvic exam performed at each visit (Figure 3). The patients are then followed up annually and visited between routine postoperative visits, as needed. All patients are instructed to dilate twice daily starting from discharge day (~ postoperative day 5) using Soul Source dilators (Soul Source Therapeutic Devices Inc., North Hollywood, CA, USA), with each dilation session lasting 40 minutes (10 minutes each with the small purple and small orange dilator and 20 minutes with the large purple dilator). Dilators are upsized, if appropriate, at the 6-week time point.
Figure 3.
Intra-neovaginal canal image obtained 3 months after primary TAPCap vaginoplasty, demonstrating a distinct transition from the distal segment lined with inverted penile skin to the region lined with xenograft. TAPCap, tubularized augmented peritoneal cap.
Data collection
Demographic, intraoperative, and postoperative data were retrospectively collected for all individuals undergoing TAPCap vaginoplasty at our institution. All data were obtained from electronic medical records (EMR). Intraoperative data included the American Society of Anesthesiologists (ASA) score, the number and type of Kerecis graft sheets used, estimated blood loss, operative time, vaginal depth achieved intraoperatively, and any intraoperative complications. Postoperative variables included duration of follow-up, days with catheter, length of hospital stay, complications within 30 days classified by Clavien-Dindo grade, emergency room (ER) visits, readmissions, genitourinary infections, revision vaginoplasty rate, vaginal depth and width (diameter) at most recent follow-up, and adherence to the dilation regimen. Neovaginal canal width and depth were calculated according to the largest tolerated vaginal dilator at the last follow-up visit. While no standardized definition of vaginal stenosis exists in the literature, for the purposes of this study, stenosis was defined as either complete obliteration of the neovaginal canal or inability to tolerate dilation due to compromised depth or width diagnosed during follow-up visits. Vaginal dilation regimen adherence was assessed based on patient self-report during follow-up visits recorded in the EMR.
Statistical analysis
Descriptive statistics were used to summarize variables. Medians with ranges were used to describe continuous variables, whereas categorical variables are demonstrated as counts and percentages. Statistical analysis was conducted using Microsoft Excel (version 16.0; Microsoft Corporation, Redmond, WA, USA; 2024). Kaplan-Meier survival analysis was used to estimate 1-year vaginal canal revision-free survival following primary TAPCap vaginoplasty. Analyses were performed in RStudio (version 2025.05.1-513; Posit, Boston, MA, USA).
Results
Preoperative and surgical characteristics
Thirty-two consecutive individuals underwent primary TAPCap GAV. Median age at the time of procedure was 30 (range, 21–69) years. Median BMI on surgery day was 26.78 (range, 19.3–38.08) kg/m2. Patients had undergone social and hormonal transition prior to primary TAPCap GAV for a median of 4 (range, 1–26) and 3.5 (range, 1–21) years, respectively. One patient (3.1%) had undergone orchiectomy prior to primary TAPCap GAV with FSX. Demographic information and baseline medical and surgical characteristics are summarized in Table 1.
Table 1. Demographic and preoperative characteristics of transfeminine patients undergoing TAPCap vaginoplasty.
| Demographics and preoperative characteristics | Data (n=32) |
|---|---|
| Age (years) | 30 [21–69] |
| Race | |
| White | 29 (90.6) |
| African American | 1 (3.1) |
| Asian | 1 (3.1) |
| Prefer not to answer | 1 (3.1) |
| BMI (kg/m2) | 26.78 [19.3–38.08] |
| Diabetes status | |
| None | 29 (90.6) |
| Type I/II DM | 3 (9.4) |
| Nicotine product use | |
| Never user | 21 (65.6) |
| Former user | 11 (34.4) |
| Abdominopelvic irradiation history | 0 (0.0) |
| Prior dermatologic condition | |
| No | 31 (96.9) |
| Keloid formation | 1 (3.1) |
| Prior orchiectomy? | |
| No | 31 (96.9) |
| Yes | 1 (3.1) |
| Time lapsed between social transition and TAPCap (years) | 4 [1–26] |
| Time lapsed between hormonal transition and TAPCap (years) | 3.5 [1–21] |
Data are presented as median [range] or n (%). BMI, body mass index; DM, diabetes mellitus; TAPCap, tubularized augmented peritoneal cap.
During the surgical procedure, the number of FSX sheets was determined according to the patients’ requirements for augmenting the middle portion of the neovagina. Twenty-four patients (75.0%) required a single sheet, and 8 patients (25.0%) required two FSX sheets. A total of 27 patients (84.4%) underwent TAPCap with the Kerecis Surgiclose® FSX, while 5 patients (15.6%) had Kerecis Surgibind®. The median depth achieved intraoperatively at the conclusion of the procedure was 16 (range, 16–17.5) cm. Operations were carried out over a median of 3.4 (range, 2.7–5.5) hours. No intraoperative complications occurred during any procedure.
Postoperative characteristics
The patients were followed up for a median of 147 (range, 30–646) days following primary TAPCap GAV. Within the first 30 days postoperatively, 2 patients (6.2%) presented with complications greater than Clavien-Dindo grade II. One patient required operating room take-back for perineal hematoma evacuation on the same day as TAPCap surgery. Another patient presented to the ER and was admitted due to neovaginal bleeding and down-trending hemoglobin, which required surgical exploration on postoperative day (POD) 13. One other ER visit was reported during the first 30 days postoperatively for neovaginal bleeding on POD 16, which was managed conservatively without admission. Four patients (12.5%) required surgical intervention for hypergranulation tissue, though the observation of granulation tissue not requiring intervention was higher in our cohort. Given the variable nature of granulation tissue description, a clinically relevant rate of granulation tissue presence was not estimable. Postoperative characteristics are summarized in Table 2.
Table 2. Operative and postoperative characteristics of 32 transfeminine patients undergoing TAPCap vaginoplasty.
| Operative and postoperative characteristics | Data (n=32) |
|---|---|
| ASA score | 2 [1–3] |
| Number of graft sheets used | |
| Single sheet | 24 (75.0) |
| Two full sheets | 8 (25.0) |
| Graft type | |
| Kerecis SurgiClose© | 27 (84.4) |
| Kerecis SurgiBind© | 5 (15.6) |
| Surgery duration (hours) | 3.4 [2.7–5.5] |
| Intraoperative vaginal depth (cm) | 16 [16–17.5] |
| Estimated blood loss (cc) | 400 [40–550] |
| Intraoperative complication | 0 (0.0) |
| Follow-up (days) | 147 [30–646] |
| Time with catheter (days) | 6 [5–6] |
| Length of hospital stay (days) | 6 [5–6] |
| 30-day postoperative complication > Clavien-Dindo grade II | |
| No | 29 (90.6) |
| Yes | 3 (9.4) |
| 30-day ER visit | 2 (6.2) |
| 30-day readmission | 1 (3.1) |
| GU infection during follow-up | 4 (12.5) |
| Undergone neovaginal canal revision after TAPCap? | |
| No | 29 (90.6) |
| Yes | 3 (9.4) |
| Time from TAPCap to first neovaginal canal revision procedure (days) | 532 [79–631] |
| Hypergranulation tissue requiring surgical correction? | |
| No | 28 (87.5) |
| Yes | 4 (12.5) |
| Vaginal depth at most recent follow-up (cm) | 14.25 [0–17.5] |
| Vaginal width at most recent follow-up (cm) | 3.18 [0–3.81] |
| Dilation regimen adherence at follow-up conclusion? | |
| Yes | 30 (93.8) |
| No | 2 (6.2) |
| Vaginal stenosis at any time during follow-up? | |
| No | 27 (84.4) |
| Yes | 5 (15.6) |
Data are presented as median [range] or n (%). ASA, American Society of Anesthesiologists; ER, emergency room; GU, genitourinary; TAPCap, tubularized augmented peritoneal cap.
At the most recent follow-up (median 147 days), the median depth of the neovaginal canal was 14.25 (range, 0–17.5) cm, and the median canal width (diameter) was recorded at 3.18 (range, 0–3.81) cm. Dilation regimen adherence was confirmed in 30 patients (93.8%) at follow-up conclusion.
A total of 5 patients (15.6%) developed stenosis of the neovaginal canal during the follow-up period. Among them, 2 patients (6.2%) were noted to have complete obliteration at their most recent follow-up due to non-adherence with the dilation regimen. One patient discontinued dilation on POD 21 due to surgical site pain and did not restart when pain was resolved, while the other demonstrated inconsistent dilation and was found to have canal obliteration on POD 83. Neither of these two patients had undergone surgical revision by the time of last follow-up.
The remaining 3 patients (9.4%) developed canal stenosis during follow-up and underwent elective surgical revision. The median time from primary TAPCap GAV to the first neovaginal canal revision procedure was 523 (range, 79–631) days. Two patients underwent perineal-approach canal revision with application of Kerecis FSX to the neovaginal lining. One patient underwent robotic-approach peritoneal revision vaginoplasty without the use of xenograft material. Notably, one of the patients who initially underwent perineal revision later required a subsequent robotic revision with Kerecis application approximately 10 months later due to recurrent canal obliteration. At final follow-up, all three patients were adherent to the dilation regimen. Additional details are provided in Figures 4,5.
Figure 4.
Neovaginal canal revision vaginoplasty outcomes following primary TAPCap vaginoplasty. *, days are calculated from the date of primary vaginoplasty. BMI, body mass index; F/U, follow-up; FSX, fish skin xenograft; POD, postoperative day; TAPCap, tubularized augmented peritoneal cap; w/, with; w/o, without.
Figure 5.
One-year vaginal canal revision-free survival following primary TAPCap vaginoplasty. Kaplan-Meier survival curve demonstrating the probability of remaining free from vaginal canal revision surgery within the first postoperative year. Tick marks indicate censored observations. The number at risk at each time interval is shown below the X-axis. Days are calculated from the date of primary vaginoplasty. This figure was generated using RStudio version 2025.05.1-513 (Posit; Boston, MA, USA). TAPCap, tubularized augmented peritoneal cap.
Discussion
The Kerecis graft was selected based on several advantageous properties. Biologically, it is enriched with omega-3 fatty acids, which are known to promote tissue regeneration and modulate inflammation, and it contains a high concentration of type I collagen, supporting wound healing and structural integrity (17,18). In vitro studies have also demonstrated that Kerecis FSX possesses antimicrobial properties, functioning as an effective bacterial barrier for up to 72 hours (19). Prior studies in complex wounds have shown host epithelialization under and throughout the Kerecis FSX, improving wound healing as the graft is slowly broken down by enzymatic processes (20).
It offers ease of intraoperative handling, requiring only 30 to 60 seconds of hydration prior to use in the OR. In cases of extreme deficiency of penile skin, xenografts can be sutured together in tandem to achieve more neovaginal depth. We have also carried out perineal-only PIV using FSX, although the outcomes of this specific method fall outside the scope of this study.
Comparing TAPCap outcomes with published data from other GAV techniques provides a useful clinical context. Large-scale studies utilizing the perineal-only PIV techniques have shown 6.3% to 14.3% revision vaginoplasty rates following primary procedures (21,22). The neovaginal revision rate with TAPCap was 9.4%, which aligns closely with rates reported for perineal-only PIV techniques. While the stenosis rates were higher than revision rates in our study, the degree of stenosis is inadequately described in the literature. Revision rates, while imperfect measures of complications, are the most easily compared metric between techniques.
A further comparison could also be made between the TAPCap method and other published reports on robotic GAV outcomes. In a study by Sljivich et al., 41 patients undergoing primary robotic GAV had 30-day ER visit and readmission rates of 17.1% and 7.32%, respectively. In comparison, the TAPCap approach demonstrated lower 30-day ER visit and readmission rates of 6.2% and 3.1%, respectively. The neovaginal revision surgery rate reported by Sljivich et al. was 12.2% vs. the 9.4% rate with TAPCap (23). It is possible that the smaller peritoneal flaps harvested during the TAPCap technique contribute to these lower complication rates, though each study was at a single center, and so multiple factors may be contributing.
Unlike the TAPCap procedure, commonly described robotic GAV techniques often resemble conventional PIV, wherein scrotal skin is typically tubularized and sutured in tandem to the penile skin to augment neovaginal canal depth (24). In a study by Dy et al., outcomes of robotic-assisted peritoneal-PIV were assessed. However, there was no result stratification based on the use of additional scrotal grafts or lack thereof. Among Dy et al.’s cohort, the mean vaginal depth and diameter at 1-year follow-up were 13.6 cm and 3.7 cm, respectively. These outcomes are similar to those in our series, with a median neovaginal depth of 14.25 cm and diameter of 3.18 cm at a median follow-up of 147 days (7). When assessing vaginal dimensions alone, TAPCap appears to maintain functional depth and width.
Despite encouraging early outcomes, larger studies with long-term follow-up are needed to determine whether xenografts can reliably replace autologous grafts for neovaginal augmentation in primary robotic vaginoplasty. Additionally, this study could not assess erogenous sensation or sexual function due to incomplete patient-reported data. Long-term durability of the neovagina and graft-specific complications, such as contraction or resorption, remain unknown, and our revision rates could potentially be higher if our patients sought revision at another institution. The economic implications of xenograft use and robotic assistance were also not assessed, which may impact scalability and broader implementation. Evaluating the economic impact of this technique compared to other vaginoplasty methods was beyond the scope of this study. Future research could determine whether the higher upfront cost of grafts and robotic assistance is offset by reduced long-term expenses, such as fewer revisions or management of granulation tissue. This technique does not require preoperative hair removal, which may reduce preoperative costs for this patient population. In addition, our experience shows that the technique itself does not pose a limitation to its adoption by surgical teams. The operative workflow closely parallels other robotic vaginoplasty methods, thereby reducing the need for an extended learning period. The primary technical difference involves tubularizing the xenograft and attaching its ends to the inverted penile skin and peritoneal flap, a process comparable to other graft-based approaches used in robotic vaginoplasty.
Conclusions
TAPCap vaginoplasty with xenografts has similar surgical and functional outcomes to established robotic GAV techniques. In addition, FSX may be a possible solution to the limitations of other GAV techniques, including hair removal requirements and genital skin reliance. TAPCap does not have a significant additional learning curve for surgeons who are already accustomed to robotic peritoneal-PIV. This method is also applicable in the non-robotic, perineal-only PIV setting. Using commercially available FSX to augment the neovagina may demonstrate safety in the short term and obviate the need for using genital and extragenital skin grafts, ultimately enhancing the patient experience.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the University Hospitals Cleveland Medical Center Institutional Review Board (No. 20210504). Informed consent was obtained from all patients.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-714/rc
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-714/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-714/dss
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