Vaginoplasty surgery is performed for individuals born and assigned male at birth who affirm or identify as female. The most commonly performed surgery is the penile inversion technique, which involves orchiectomy, deconstruction of the penile structures, reconstruction, including creation of a vulva, labia, and clitoris, and creation of a neovagina with skin graft usually made from the scrotum. These two images show typical results of vaginoplasty surgery six months after surgery. Here, common complications associated with vaginoplasty surgery are listed. Formation of granulation tissue is the most commonly reported complication, followed by pain symptoms, wound separation, and poor cosmesis. The incidence of vaginal stenosis and abnormal urinary stream have been reported to be 3% and 1.8% respectively. In our experience, the incidence of these complications may be a little higher. In one cohort study, labiaplasty was the most common reason for revision surgery. Other revision surgeries include urethroplasty and repair of the vagina for stenosis or scarring. The objective of this video is to present a case of a patient who underwent revision surgery, including urethroplasty and entroidoplasty for an abnormal urinary stream and distal vaginal stenosis. We present a case of a 46-year-old transgender woman who underwent penile inversion vaginoplasty surgery six months prior to presentation. She complains of pain with insertion of her dilator despite conservative measures. She also reports urinary spraying and an abnormal urinary stream. On exam, her vaginal length is 13 centimeters and her caliber is appropriate. With the exception of the distal vagina and entroitis, which are tight and scarred and tender to touch. Her urethral meatus is partially obstructed by scarring and her urethral catheter is deviated upwards. A surgical plan is made with the patient and she is consented for entroidoplasty and urethroplasty. The patient is taken to the operating room and positioned in lithotomy. A Foley catheter is placed, clearly showing scarring over the urethral meatus as the catheter is angled upwards. Alice clamps are placed along the edges of the entroitis, revealing the scarring and narrowing of the opening. A plan is made to start with a posterior advancement flap and this area is marked. The marked area is infiltrated with a local anesthetic and dilute epinephrine to create a dissection plane and to achieve hemostasis. The area is incised with a scalpel and then deepithelialized. Alice clamps are placed on the epithelial edges and an advancement flap is created using careful sharp dissection. It is important to note that the planes of the entroitis in the transgender woman are different than in the natal woman. This is a reconstructed opening lined by a skin graft. As a result, there are no natural planes and care must be taken to not injure surrounding structures like the rectum. The advancement flap is created. This flap must be taken past the level of the scar in order to mobilize it, which is demonstrated here. A lateral releasing incision is then made at 9 o'clock in order to facilitate further tissue mobilization. Alice clamps are placed on the edges and a lateral flap is created. Anchoring sutures are then placed, which helps in determining how much further the scar needs to be mobilized on the contralateral side. Another lateral releasing incision is made over the scar at 3 o'clock. Another advancement flap is created using sharp dissection. Anchoring sutures are again placed. The posterior flap is advanced further. The dead space is then closed to avoid placing the flaps on tension. The edges of the flap are then trimmed. Additional sutures are placed to approximate the edges and to secure the flap off tension. The anchoring sutures are removed so that the edges of the mobilized tissues may be secured into place in a cosmetically appealing way. The remaining anchoring sutures are removed and excess epithelium is trimmed to avoid dog ears upon closure. The mattress sutures are again placed to re-approximate the suture line. The introidal caliber is confirmed to be adequate. Attention is then paid to the urethroplasty. The suburethral area is marked to create an advancement flap. The area is then infiltrated and then a scalpel is used to de-epithelialize the flap. The flap reaches the urethral mucosa and is advanced downwards. Additional sutures are then placed. At the end, the Foley catheter is pulled down to ensure that the angle is improved. The revision is performed as an outpatient procedure and the patient is discharged home with a Foley for three to seven days. She is seen at one week for a postoperative visit to ensure that the urethral revision is healing well and that there is no further need for catheterization. This is a picture of another patient three months following a urethroplasty. This patient's urinary stream is straight. With the open meatus with a clear path and no residual scarring. In summary, vaginal and introidal stenosis are known complications of vaginoplasty surgery. Periurethral scarring can lead to an abnormal urinary stream and spraying which is undesirable. FPMRS specialists should feel comfortable applying principles of reconstructive surgery to perform revision surgeries for postvaginoplasty patients. For more information visit www.FPMRSA.gov

vaginoplasty surgery

penile inversion

neovagina

complications

revision surgery