Urethral stricture after gender-affirming masculinizing genital reconstruction (GAMGR) is a common complication, which can lead to proximal fistula formation through increased intraluminal pressure. This phenomenon can lead to persistence of vaginal cavity after GAMGR which in turn increases the risk of secondary infection and worsening urinary complaints. Surgical treatment of these patients should address the urethral pathologies and vaginal persistence simultaneously which warrants a combo procedure involving perineal and abdominal approaches. We present an interesting combination surgical approach for management of a patient with urethral stricture and urethra-vaginal fistula into his vaginal remnant.

This is a 30-year-old trans male who underwent single stage GAMGR with radial forearm free flap elsewhere 2 months before presenting to us. He reported progressive voiding difficulty. Endoscopic evaluation demonstrated stricture involving the anastomosis between pars pendulans and pars fixa. Urethrogram confirmed the presence of a large vaginal cavity with a wide ostium situated proximal to the stricture. Bladder was unremarkable. Shared decision was to proceed with urethral reconstruction and excision of vaginal remnant. Urethral stricture was less than 2 cm in length and was treated with excision and primary anastomosis. Vaginectomy and closure of its urethral ostium was accomplished using Single Port robotic assistance. Ostium closure was reinforced with peritoneal flap.

Operative time was 245 minutes and estimated blood loss was 160 mL. Patient was discharged home on POD3 after an uneventful postoperative course. Urethrogram on POD21 showed patent urethra with no sign of extravasation. Urethral catheter was removed. Suprapubic tube was removed a month later during which patient reported stable improvement in urinary stream and voiding symptoms.

Urethral complications following GAMGR is a rule rather than an exception. Strictures can be further complicated with fistulization and persistence of vaginal cavity. In our view, Single Port robotic assistance greatly facilitates complete vaginectomy and water-tight closure of its urethral ostium. Treatment of urethral stricture follows general principles and can be accomplished in a single stage fashion with excision and primary anastomosis if tension-free correction seems amenable.

Continence 7S1 (2023) 100800
DOI: 10.1016/j.cont.2023.100800