Robotic-Assisted Microsurgery in Gender-Affirming Phalloplasty

Genital gender-affirming masculinization surgeries require handling of small vessels and nerves handling in deep planes. Since the introduction of the Symani Surgical System for robotic-assisted microsurgery in clinical practice, its value in handling small and deep vessels via additional distal motion axes, motion scaling, and tremor elimination has been demonstrated. We combined the Symani with the robotic exoscope RoboticScope to achieve maximum flexibility and ergonomics for the microsurgeon. Here, we present the initial application of robotic-assisted microsurgery for gender-affirming phalloplasty. The Symani and the RoboticScope were used to perform the end-to-side nerve coaptation of the lateral antebrachial cutaneous nerve to the dorsal nerve of the clitoris with five epineural 9.0 Ethilon sutures. Arterial anastomosis to the deep inferior epigastric artery (DIEA) was completed in an end-to-end fashion with six 8.0 Ethilon sutures. Cephalic vein anastomosis to the great saphenous vein was performed manually in an end-to-end fashion using a 3.5-mm coupler. The time for nerve coaptation was 17 minutes; for arterial anastomosis, 26 minutes; and for vein anastomosis, 6 minutes. Time for flap ischemia was 157 minutes. Incision to closure was performed in 401 minutes. Symani's tremor elimination and motion scaling support precise arterial anastomosis and nerve coaptation. The additional degrees of freedom distal to the tips of the instruments enable flexible operation in deep planes, such as the periclitoral space. Combining Symani with a robotic exoscope enables a comfortable remote positioning for the surgeon. The presented case demonstrates feasibility and encourages further exploration to elucidate the potential benefits of this robotic-assisted technique.