(Video Poster 30) Revision Vaginoplasty with Urethrovaginal Fistula Repair

Objectives: To illustrate the surgical approach for a revision vaginoplasty after five prior revisions with concomitant urethrovaginal fistula repair, discussing preoperative planning, surgical techniques, and patient education to optimize both functional and aesthetic outcomes.

Methods: A 66-year-old patient with a history of male to female gender affirming surgery and five subsequent revision vaginoplasties presented with vaginal stenosis and scarring precluding sexual activity. She was using vaginal dilators without success. After deliberation, a revision vaginoplasty with full thickness skin graft was planned. On initial evaluation in the operating room, the patient had an unexpected four-centimeter urethrovaginal fistula. The surgical procedure involved correction of the fistula and revision vaginoplasty using bilateral full thickness pudendal/thigh skin grafts. The video details essential patient education, anatomical considerations, and reconstructive strategies.

Clinical Relevance: With increasing numbers of gender affirming surgeries and complex pelvic reconstructive procedures, it is inevitable that more urogynecologists will be challenged with the complications of these surgeries, even if they did not perform the initial surgery. This requires familiarity with graft options and skin flap techniques. This video provides an educational resource for urogynecologists by outlining one approach to revision vaginoplasty with concomitant fistula repair. Emphasis on preoperative and postoperative patient education, in line with patient-centered goals, helps to optimize patient outcomes.