Peritoneal Flap Vaginoplasty

5 Must-Knows About Peritoneal Flap Vaginoplasty

Dr. Min Jun, DO, Crane Center

What is peritoneal flap vaginoplasty?

Peritoneal flap vaginoplasty has several names: Davydov vaginoplasty and peritoneal pull through are the best-known alternative terms. The peritoneum is the inside lining of the abdomen. Through several small incisions on the abdomen, robotic-assisted laparoscopy is performed to rearrange the peritoneum in the pelvis.  This will create the inside half of the vaginal canal. The remainder of the vaginoplasty is a standard penile inversion vaginoplasty. 

Is there a difference between peritoneal flap versus graft?

Absolutely! In fact, this is a very important distinction. A flap has a defined blood supply whereas a graft is tissue that is removed from its blood supply and moved from one place to another. A graft’s survival depends on growing a new blood supply from its surroundings. Flaps have much better blood supply and thrive much more robustly. Thus, they are more resistant to scarring. 

What’s the history of peritoneal flap vaginoplasty?

In 1933, M.I. Ksido, a Russian gynecologist, performed the first peritoneal flap vaginoplasty in cis-women born without a fully developed vagina in a condition known as Mayer-Rokitansky-Kuster-Hauser syndrome. This technique was further developed and more widely published by another Russian gynecologist, S.N. Davydov, in the 1960s and 1970s. In 2019, Dr. Lee Zhao, a reconstructive urologist at NYU, adapted the principles of the Davydov procedure and published the first series of peritoneal flap feminizing vaginoplasty in transgender women. 

So it’s been around for 90 years? Why is it just becoming mainstream now?

Because feminizing vaginoplasty is performed on women born with male anatomy, urologic surgeons are uniquely qualified to operate there due to (1) the many pelvic surgeries they perform, (2) their familiarity with the cis-male pelvis, in addition to (3) the many urologic procedures they do in cis-women, and (4) their expertise in robotic surgery.  In contrast, gynecologists, while well acquainted with the cis-female pelvis, are not trained in cis-male pelvic surgery. More urologists are finding themselves in a position to innovate in the fast-growing field of feminizing surgery, and it comes as no surprise that a reconstructive urologist pioneered the feminizing peritoneal flap vaginoplasty. 

What are the advantages?

• The peritoneum does secrete fluid, but not enough to be considered “self-lubricating” as commonly believed. The peritoneum is, however, tissue that is used to being “wet” as opposed to skin, which is what the vaginal canal solely consists of in standard vaginoplasty.

• Maximum vaginal depth can be achieved since surgery is performed internally. 

• A potential for less hair removal on a case-by-case basis. 

• More tissue available to create the vulva.

• Improved outcomes in cases of limited genital skin, as is sometimes the case in girls who underwent puberty blockade. 

• Minimized risk of prolapse.

• Excellent technique for revision vaginoplasty for loss of depth / vaginal stenosis.

Dr. Min Jun is a genital gender-affirming surgeon who trained at four different academic centers. He completed his residency training in urology at Detroit Medical Center under Dr. Richard Santucci.

During that time, he travelled to Serbia for additional transgender-focused training with Dr. Miroslav Djordjevic. Dr. Jun then completed a reconstructive and traumatic urology Fellowship at Temple University with Dr. Michael Metro. To further focus on gender-affirming surgery, Dr. Jun completed a Fellowship in gender affirming genital and robotic surgery at New York University with Dr. Lee Zhao and Dr. Rachel Bluebond-Langner.

Dr. Jun offers robotic peritoneal flap vaginoplasty in both primary and re-do (e.g. vaginal stenosis) cases, and care for urethral complications.

Dr. Jun practices exclusively with the Crane Center for Transgender Surgery in Greenbrae, California. Dr. Jun is a member of WPATH.