Gender-affirming surgery can be a psychologically relieving operation for patients with gender dysphoria, and penile inversion vaginoplasty is the most common form of feminizing gender-affirming genital surgery. Although an uncommon postoperative complication, urethro-neovaginal fistulas can arise from intraoperative injury during vaginoplasty. There is no standardized surgical procedure for urethro-neovaginal fistula repair, as the approach depends on the size and location of the fistula and individual anatomic factors. urethro-neovaginal fistulas originating at the prostatic urethra are particularly difficult to address due to their deep location within the pelvis and proximity to sphincteric structures. We present a novel approach to address a recurrent prostatic urethro-neovaginal fistula using the Da Vinci single-port robotic platform.

The patient is a 41-year-old transgender female with a history of prostatic urethra injury during revision vaginoplasty 6 years prior, leading to a prostatic urethro-neovaginal fistula. An attempt at repair was made with a robot-assisted trans-vesical approach using buccal mucosal graft. The patient initially did well, but over the next two years, the postoperative course was complicated by refractory overactive bladder symptoms requiring intra-detrusor Botox® injections. They subsequently required intermittent catheterization due to high post-void residuals. They then presented with continuous incontinence concerning for a recurrent fistula that was confirmed on endoscopic and radiographic evaluation and surgical repair was planned with robot-assisted prostatectomy. A wire was placed through the fistula cystoscopically for guidance during the operation. Intraperitoneal access was obtained with the Da Vinci single-port robotic platform. Careful posterior dissection was performed until the wire in the fistula tract could be identified between the prostatic urethra and neovagina. Once the posterior plane was sufficiently developed, the peritoneum overlying the bladder was incised, the bladder was dropped and the atrophic prostate was dissected off in a similar fashion to a radical prostatectomy. The prostatic urethro-neovaginal fistula was readily identified and the fistulous tract was excised in its entirety, together with the prostate. The neovaginal opening was closed with a 3-0 Vicryl™ suture and a tension-free bladder neck-urethral anastomosis was completed using a 3-0 Stratafix™ suture ensuring no overlapping suture lines to avoid recurrence. The patient left the operating room with a suprapubic and foley catheter, as well as a pelvic drain.

The patient had an unremarkable early postoperative course. The drain was removed on postoperative day two and the patient was discharged home. Her recovery was complicated by an episode of clot retention requiring cystoscopy with clot evacuation and fulguration of the bladder neck. One month later, a cystogram showed no extravasation and the urethral catheter was removed. At the two-month follow-up appointment, the patient admitted to mixed urinary incontinence, but no continuous urinary leakage from the neovagina. They are to complete pelvic floor physical therapy, continue anticholinergic medication, and follow behavioral modifications.

Prostatic urethro-neovaginal fistula is a rare complication following gender-affirming vaginoplasty and can be difficult to address given the deep pelvic location and proximity to the external urethral sphincter. Complete excision of the fistula tract and bringing healthier edges together might require prostatectomy, especially in redo cases, which can be accomplished with the Da Vinci single-port robot-assisted approach.