Introduction: Stress urinary incontinence (SUI) is an infrequently reported complication following transmasculine genital gender affirming surgery (gGAS), thus far there are no reports to help with management of severe SUI post gGAS. In this video, we demonstrate a case of de novo SUI following vaginectomy and metoidioplasty. These were treated with autologous fascial sling and staged urethral repair. Methods: Patient is a 22 year old transgender male who underwent vaginectomy and metoidioplasty and developed severe SUI. Three months of pelvic therapy improved incontinence to 168g daily. He was referred for treatment of SUI and correction of ventral shaft dehiscence. Stage-1 included placement of an autologous fascial retropubic sling, and stage 1 urethroplasty with buccal mucosa graft (BMG). In the time interval before the Stage 2, the patient was monitored for evidence of recurrent SUI or urinary retention. Stage 2 involved tubularization of the neourethra. The procedure was done in dorsal lithotomy position. Perineum (site of prior vaginectomy) and previously created pars fixa were opened ventrally. Using the balloon of the Foley at the bladder neck as a palpable landmark, the native urethra and the bladder neck were dissected to the inferior aspect of the pubic symphysis. A 1.5x8cm segment of rectus fascia was harvested for the autologous sling. Full length 2-0 polypropylene suture was secured to either end of the fascial sling and delivered retropubicly to the abdominal incision from the perineal incision using a fine tonsil clamp. The sling was appropriately tensioned and secured. Ventral penile chordee was released sharply and a stage 1 urethroplasty was performed with dorsal BMG inlay. After a 6-month delay the patient did not show any signs of recurrence of SUI or retention and the Stage 2 urethroplasty was performed. The patient's urethral plate was augmented with an additional BMG to achieve 3cm width. The neourethra was tubularized and the neophallus was closed in multiple layers with non-overlapping suture lines. Results: The procedure resulted in the successful repair of the patient’s SUI and metoidioplasty shaft dehiscence. The patient achieved durable social continence (completely dry) with normal voiding patterns and low residuals after placement of autologous retropubic sling. Conclusions: SUI is a real and devastating complication following masculinizing gGAS. Here we show it can be safely and effectively treated using an established pelvic floor reconstructive technique for a new indication. SOURCE OF Funding: none
