Gender-affirming vaginoplasty was historically a two-stage procedure with secondary labiaplasty after the initial vaginoplasty. Techniques have evolved into what is now generally a single stage procedure, however some patients may still require revision surgery for cosmetic or functional reasons. Additionally, as with any urethral procedure, patients may develop issues with their urinary stream requiring repeat surgery.

The patient is a 51-year-old transgender woman. She underwent robotic-assisted peritoneal flap vaginoplasty in the summer of 2020. Her post-operative course was complicated by recurrent infections. Once the infections had settled and the surgical site was well healed, she had persistent complaints of flat labia majora, overly exposed clitoris causing hypersensitivity, as well as spraying of her urinary stream. We aimed to demonstrate that minor revisions with urethroplasty to relocate the urethral meatus inferiorly as well as securing the clitoris in a more inferior position and bringing the labia together in the midline can provide coverage for the clitoris, more aesthetic appearance of the vulva, and an excellent functional outcome. 

We first performed the urethroplasty. We began with cystoscopy to identify the level of the external sphincter which was marked externally on the skin. We then incised the skin in the midline starting at the level of the current urethral meatus and extending inferiorly for approximately 2cm. Skin flaps were mobilized off of the urethra bilaterally. The urethra was spatulated ventrally for approximately 1.5cm. The edges were oversewn with 3-0 Vicryl for hemostasis. The superior part of the spatulated urethra was sutured to the surrounding skin to form the lower edge of the vestibulum and provide further definition to the labia minora. The lower edge of the spatulation was sutured to the surrounding skin to become the new urethral meatus. 

We then turned our attention to the clitoroplasty and labiaplasty. The patient’s clitoris was sitting high, over-exposed, and somewhat prolapsed after her initial vaginoplasty and post-operative infections. We started by making a circumferential degloving incision at the level of the glans clitoris. The skin was then carefully mobilized off of the clitoris. A midline incision was made inferior to the clitoris and the clitoris was secured to the vestibulum. A double Z-plasty was performed, in order to bring the labia majora together in the midline to provide better coverage for the clitoris.

The procedure lasted 4 hours. There was minimal bleeding and no intra- / post-operative complications were encountered. She was discharged home on post-operative day one in good condition. The Foley catheter was left in place until post-operative day five. One month post-operatively, the patient reported resolution of urinary spraying, improved cosmesis, and better coverage for the clitoris.

Patients may not be satisfied with the cosmetic and functional results following gender-affirming vaginoplasty even if the vaginal canal itself is of adequate dimensions. Minor revisions can provide significant rewards in terms of improvements to the cosmetic appearance of vulva and lower urinary tract symptoms.

Continence 2S2 (2022) 100306
DOI: 10.1016/j.cont.2022.100306