Post Vaginoplasty Sacrocolpopexy for Neovaginal Prolapse

Objectives: The aim of this surgical video is to show the utilization of robotic-assisted mesh sacrocolpopexy for the treatment of neovaginal prolapse, a rare delayed complication of gender affirming vaginoplasty.

Methods: This surgical video presents the case of a 71-year-old transgender female status post penile inversion vaginoplasty and subsequent revision vaginoplasty. She presented with bulge symptoms and incomplete bladder emptying for one year. She reported needing to splint in order void and to defecate. On physical exam she was noted have stage 3 pelvic organ prolapse and a negative cough stress test. She was initially offered a ring pessary, which failed. She ultimately opted for definitive surgical management with robotic-assisted sacrocolpopexy using polpyproylene mesh. With her permission, exam under anesthesia was documented as well as the robotic-assisted procedure itself and the postoperative exam. An educational video highlighting this case was produced using adobe premiere pro software.

Clinical Relevance: Penile inversion vaginoplasty is the most commonly performed technique for primary male-to-female transgender vaginoplasty. Though complications are rare they include wound dehiscence, neovaginal stenosis, hematoma, abscess, genital pain, rectovaginal fistula, neovaginal prolapse among others. Neovaginal prolapse (3%) can be treated similarly to pelvic organ prolapse in the cisgender population, though data regarding this treatment modality in transgender patients is limited. Our case highlights the use of a well documented reconstructive surgical technique, mesh sacrocolpopexy, to treat neovaginal prolapse in a transgender patient. To limit the potential for mesh erosion through the scrotal neovagina, we opted for primarily apical dissection with minimal anterior and posterior dissection during the procedure. Additionally we attempted to minimize the number of permanent sutures placed into the neovagina. We employed well-established aspects of robotic-assisted sacrocolpopexy throughout the procedure. Future study is needed to look at long term outcomes regarding synthetic mesh and the transfeminine neovagina. Regardless of whether or not one is doing primary gender affirming procedures, as urogynecologists, we can be prepared to manage complications with well established pelvic reconstructive surgical techniques.