Lee C. Zhao, MD

For referring physicians

Revision after vaginoplasty: how I choose the operation

Stenosis, loss of the canal, inadequate depth, fistula, granulation and pain after a vaginoplasty of any technique, done here or elsewhere. What decides rescue versus revision, which revision, and what governs the whole decision.

Can she get a dilator in?

That is the line between rescue and revision, and it is a test in clinic rather than a measurement. If a dilator goes in, intensive dilation is still credible. If she cannot get a dilator in at all, dilation is pointless and the canal needs an operation. A canal that closes is not an operation I perform: it is what happens when a patient stops dilating, and there is no procedure and no consent for it.

Which revision

My revision is a robotic peritoneal flap canal, dissected between the bladder and the rectum to the stenosed cavity, with flaps from the posterior bladder and the pararectal fossa advanced to line it. In the first 24 women, all after penile inversion elsewhere, depth at a year was 13.6 cm with no rectal injury. When the peritoneal flap will not cover the whole canal, tubularized AlloDerm bridges the remnant lining to the flap; in the pilot cohort it added a median 9.7 cm of depth with no intraoperative complication.

There is no residual-depth threshold that sends a patient to a bowel segment. Where the peritoneum will not reach, AlloDerm bridges the gap. And a prior peritoneal flap vaginoplasty does not close the door on a second one. The peritoneum can be reused, and a viable harvest site is findable after prior surgery.

Fistula, and the canal that came from bowel

A fistula into the neovagina from the bladder or the urethra is repaired robotically, with the ureter reimplanted in the same sitting when it is involved; the neovesicovaginal video shows both. A canal built from intestine brings its own complications, stenosis, false passage and diversion colitis among them, and each of the four women we revised was dilating to at least 15 cm afterward.

What governs the decision

Patient compliance and expectations, not anatomy. The anatomy tells me what to bring into the operating room. It does not decide whether to operate. A woman who will dilate and whose expectations match what a revision can deliver gets one; the operation fails on arrival without those two things, however good the tissue. Distance from home support belongs in the same conversation.

Videos by operation

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Robotic peritoneal flap revision

Fistula into the canal

Intestinal vaginoplasty and its revision

Videos are being edited for the library.

Papers

  1. Dy GW, Blasdel G, Shakir NA, et al. Robotic peritoneal flap revision of gender affirming vaginoplasty: a novel technique for treating neovaginal stenosis. Urology. 2021. PubMed 33823174
  2. Parker A, Brydges H, Blasdel G, et al. Mending the gap: AlloDerm as a safe and effective option for vaginal canal lining in revision robotic assisted gender affirming peritoneal flap vaginoplasty. Urology. 2023. PubMed 36642117
  3. Parker A, Blasdel G, Bluebond-Langner R, et al. Vaginoplasty complications and revisions. Clin Plast Surg. 2025. PubMed 41093465
  4. Robinson IS, Cripps CN, Bluebond-Langner R, et al. Operative management of complications following intestinal vaginoplasty: a case series and systematic review. Urology. 2023. PubMed 37479146
  5. Robinson IS, Blasdel G, Bluebond-Langner R, et al. The management of intra-abdominal complications following peritoneal flap vaginoplasty. Urology. 2022. PubMed 35150666
  6. Dy GW, Salibian AA, Blasdel G, et al. External genital revisions after gender-affirming penile inversion vaginoplasty: surgical assessment, techniques, and outcomes. Plast Reconstr Surg. 2022. PubMed 35426889
  7. Blasdel G, Hemal K, Dubach-Reinhold C, et al. Gender-affirming vaginoplasty using robotic peritoneal flap method: long-term outcomes of 500 cases. Ann Surg. 2025. PubMed 39781707
  8. Jacoby A, Maliha S, Granieri MA, et al. Robotic Davydov peritoneal flap vaginoplasty for augmentation of vaginal depth in feminizing vaginoplasty. J Urol. 2019. PubMed 30707129
  9. Blasdel G, Kloer C, Zarchen N, et al. The greatest challenges after gender-affirming vaginoplasty: a qualitative analysis. Transgend Health. 2024. PubMed 42445340
  10. Lee J, Oh C, Brucker B, et al. Impact of gender affirming vaginoplasty on lower urinary tract function: a single-center prospective cohort study. Neurourol Urodyn. 2024. PubMed 39718157
  11. Schardein JN, Zhao LC, Nikolavsky D. Management of vaginoplasty and phalloplasty complications. Urol Clin North Am. 2019. PubMed 31582033

All my gender-affirming surgery papers

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