Tubularized augmented peritoneal cap (TAPCap) with intact fish skin xenograft for primary gender-affirming vaginoplasty: early experience and surgical results

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.