Since the FDA approved the use of Da Vinci Single Port (SP) robotic platform, its applicability has revolutionized the field of Urology, especially in lower urinary tract & pelvic reconstruction as it facilitates complex procedures in difficult-to-access anatomical locations with its flexible camera and floating dock feature. Herein, we demonstrate a SP robotic-assisted vesicovaginal fistula repair using buccal mucosa graft (BMG) in a transgender woman.

This is a 38-year-old transgender female with no apparent medical history, presenting a status post-vaginoplasty penile inversion. Due to a shortened vaginal canal, she underwent a robotic SP revision with a peritoneal flap (Davydov technique). The Prostatic urethra was injured during this procedure, and a multi-layer primary repair was used intraoperatively. The postoperative course was complicated by a urethro-neovaginal fistula that was not healed by urinary diversion. Cystoscopy with retrograde urethrography confirmed a 2 cm fistula between the prostatic urethra and the neovaginal cavity. Stenosis of the vaginal canal was found on examination under anesthesia. CT angiography documented adequate vascular supply in the affected area. Joint decision to proceed with another SP robotic reconstruction procedure, this time transvesical and tissue insertion using BMG.

Patient was placed in lithotomy and 45° Trendelenburg positions. Flexible cystoscope was introduced, and bladder was distended with CO2. A vertical 4-cm infrapubic skin incision was made. Following cystotomy, SP access port was placed into the bladder. A 5-mm assistant port was placed juxtavesically under digital guidance. Robot was docked. Dissection line was marked circumferentially at the level of bladder neck. Atrophic prostate tissue was enucleated. Dissection plane was developed circumferentially, fistulous tract was identified at the posteromedial aspect of the prostatic urethra. Following complete excision of the fistula, peripheral part of the prostate was approximated in midline as an interpositional layer between the neovagina and the urethra. BMG was sutured distal to the bladder neck. A 16 Fr. Foley catheter was placed into the bladder. Robot was undocked and cystotomy was closed. Patient was discharged home on postoperative day 1. Retrograde cystourethrogram demonstrated absence of extravasation on postoperative day 29 and catheter was removed.

Treatment of urinary fistulas after gender-affirming feminized genital reconstruction often requires additional procedures. The SP robotic platform is an important asset in urological equipment and can be used in both primary and revision settings for reconstructive purposes. The transvesical approach, with its flexible camera and floating dock features, In addition to BMG insertion, can be successfully used for lower urinary tract fistulas after vaginoplasty.

Continence 2S2 (2022) 100394
DOI: 10.1016/j.cont.2022.100394