Graft nonadherence can complicate the postoperative course of gender-affirming vaginoplasty with penile skin inversion. Some of the patients might be amenable to management with neovaginal packing. However, those with nonadherence involving the whole canal that persists despite prolonged packing would benefit from a corrective surgery. Herein, we report a case with poor graft take after penile inversion vaginoplasty (PIV) who was salvaged with a redo procedure using a full-thickness abdominal skin graft to resurface the neovaginal cavity

This is a 53-year-old trans female who underwent PIV. Her postoperative course was complicated with complete graft nonadherence and neovaginal prolapse which persisted despite numerous packing/depacking sessions. Additionally, she developed urethro-neovaginal fistula due to packing-induced pressure necrosis. Urethral fistula was repaired primarily over a Foley catheter. At the last packing exchange session, her cavity was found to be patent with preserved dimensions. However, poor graft take did not resolve with conservative measures. The shared decision was to proceed with a redo procedure using abdominal skin to line the vaginal cavity.

Vaginal packing and the previous skin graft were removed at the beginning of the procedure. Vaginal canal was copiously irrigated with 3 liters of saline. Cystoscopy confirmed urethral patency. There were no signs of fistula or stricture. Foley catheter was exchanged. 
A full-thickness skin graft, measuring 16 cm in length and 14 cm in diameter, was harvested from the abdomen. Graft was defatted and tubularized around a dilator (17/16 inch width, 5½ inch length). The abdominal skin was elevated and midline was plicated with 2 sutures placed lateral to the umblicus. Abdomen was closed in a layered fashion over 2 15 Fr. drains.
The skin graft was sutured to the apex of the vaginal canal as well as the side walls and introitus. Vault was suture fixated (with Prolene) to the levator side wall via anchoring device (Anchorsure system, Neomedic International). Graft was then quilted to the side walls by way of interrupted 2/0 Vicryl stitches, starting at the apex advancing towards introitus.
A 15 Fr. drain was placed in the vaginal cavity beneath the skin graft and brought out through a seperate incision. Cavity was packed with vaginal pack soaked in Sulfamylon and lubricating gel. Procedure lasted 3 hours with an estimated blood loss amount of 250 ml. Packing was exchanged on day 7 and removed on day 14. She did well in the long run with no further problems with graft take and no recurrence of neovaginal prolapse. She was put on anticholinergics due to de-novo OAB symptoms.

Graft nonadherence after PIV can be initially managed with neovaginal packing. In patients with complete graft nonadherence refractory to packing and preserved neovaginal patency and dimensions, resurfacing the cavity with full-thickness abdominal skin graft can be considered as a viable salvage option. Fixating the apical part of the cavity to the levator side walls with an anchoring device will aid in preventing recurrence of neovaginal prolapse.

Continence 2S2 (2022) 100307
DOI: 10.1016/j.cont.2022.100307