Robotic-assisted vaginoplasty is a technically complex procedure and complications are not uncommon. Herein, we describe a case whose postoperative course was complicated by bleeding and necessitated additional procedures in order to correct neovaginal tissue loss, and urethral fistula.

A 43-year-old trans female presented due to her interest in gender-affirming genital reconstruction as the last step of her transitioning. Considering the limitations related to the quality of her genital skin, we decided to proceed with combined robotic and perineal approach, whereby peritoneal flaps would be used to augment the inverted penile skin flap and scrotal skin graft.

The procedure took 8 hours with an estimated blood loss of 250ml. Early postoperative course was unremarkable. She was discharged on postoperative day (POD) #6 after removing the Foley catheter and vaginal packing on POD #5. She did well until POD #13 at which time a sudden-onset profuse neovaginal bleeding occurred while she was resting at home. She was transferred to ER and was found to have an arterial bleeding originating from one of the distal branches of internal iliac artery. She received blood transfusions and underwent angiographic embolization by the Interventional Radiology team. Then, we did an examination under anesthesia (EUA) and confirmed the absence of ongoing bleeding. It was noted that the posterior lining of the distal neovagina was detached off the underlying surface due to the dissecting effect of pelvic hematoma. During this session, cavity was washed out, clots were partially evacuated and neovagina was packed. Two days later, EUA was repeated, the peeled-off, nonvital tissue lining the posterior neovagina was excised, skin edges were trimmed and the resultant defect was grafted with DermaPure (cadaveric dermal allograft). EUA and neovaginal packing exchanges were repeated several times in order to confirm proper graft take, monitor for recurrent bleeding, preserve neovaginal dimensions, and address additional wound-related problems. At the last EUA, that took place on POD #28, graft was in good apposition and integration with the underlying wall. However, a fistulous communication came to attention between the urethral lumen and neovaginal canal.  The defect was ventral and located distal to the verumontanum, measuring 1 cm in diameter. Foley catheter was renewed and the cavity was left unpacked. 3 weeks after this EUA (POD #49), urethral fistula was repaired primarily in a multi-layered fashion. Procedure was performed with the patient in prone position for a better exposure and digital endoscopic guidance was utilized in order to ensure precise suturing, and confirm complete closure. The Foley catheter was removed in 3 weeks and then neovaginal self-dilation protocol was initiated. At 3 months follow-up, she was emptying her bladder completely and did not report any voiding difficulties. She was not complaining of urinary leakage and there was no sign of recurrent fistula on physical examination.

Many things can go wrong during and/or after robotic-assisted gender-affirming vaginoplasty. As depicted in this case, one major complication may lead the way to the development of others. Involvement of related disciplines, staged approach to definitive repair, applying technical modifications, and utilizing technological advancements in a timely and rational way play a vital role for the effective management of these individually “difficult-to-treat” but essentially inter-related setbacks.