Use of a Split Pedicled Gracilis Muscle Flap in Robotic-Assisted Vaginectomy and Urethral Lengthening for Phalloplasty: A Novel Technique for Female-to-Male Genital Reconstruction.

BACKGROUND: We describe the technique of robotic vaginectomy, anterior vaginal flap urethroplasty, and use of a longitudinally split pedicled gracilis muscle flap to recreate the bulbar urethra and help fill the vaginal defect in female-to-male gender affirming phalloplasty. METHODS: Vaginectomy is performed via robotic assisted laparoscopic transabdominal approach. Concurrently, gracilis muscle is harvested and passed through a tunnel between the groin and vaginal cavity. It is then split longitudinally and the inferior half is passed into the vaginal cavity, where it is inset into the vaginal cavity. Following urethroplasty, the superior half of the gracilis flap is placed around the vaginal flap to buttress this suture line with well-vascularized tissue. RESULTS: From May 2016 to March 2018, 16 patients underwent this procedure, of average age 35.1 +/- 8.8 years, BMI 31.4 +/- 5.5, and ASA class 1.8 +/- 0.6. The average length of operation was 423.6 +/- 84.6 minutes, with an estimated blood loss of 246.9 +/- 84.9 mL. Patients were generally out of bed on post-operative day 1, ambulating on post-operative day 2, and discharged home on post-operative day 3 (average day of discharge 3.4 +/- 1.4 days). At mean follow-up time of 361.1 +/- 175.5 days, no patients developed urinary fistula at the urethroplasty site. CONCLUSIONS: Our use of the longitudinally split gracilis muscle in first stage phalloplasty represents a novel approach to providing well-vascularized tissue to achieve both urethral support and closure of intra-pelvic dead space, with a single flap, in a safe, efficient, and reproducible manner.