Urethral fistulas following gender affirming phalloplasty are not uncommon at the proximal and distal urethral anastomosis sites, as these connection sites are under high pressure due to directional changes in urinary flow. Colpocleisis is generally the primary choice of treatment for fistula post-phalloplasty unless the patient desires vaginal stimulation. Our patient was a 27-year-old who presented with recurrent urethrovaginal fistula (UVF), 18 months after initial phalloplasty, and after prior urethroplasty for stricture and failed fistula repair. Retrograde urethrogram revealed a UVF at the proximal urethral anastomosis site. As he desired the ability for vaginal sexual function, a primary vaginal approach was planned.

The patient was placed in dorsal lithotomy with a foley catheter, and bladder filled with methylene blue solution. The foley was used to milk the dye into the urethra and identify the fistula. A midline incision was made on the vaginal epithelium over the tract. 

Fibromuscular tissue flaps were developed bilaterally for the entire length of native urethra and the fistula tract was further visualized. A suture was initially placed at the site of the fistula for easy identification. Mobilization of the surrounding tissue continued circumferentially around the fistula tract continued in order to ensure tissue mobility and the ability to conduct a tension free closure. 

Generally, we do not remove the entire urethrovaginal fistulous tract. However; we chose to remove the tract due to the recurrent nature, inflammation, and the possibility for mucous producing cells associated with the prior buccal graft site which could propagate recurrence. 

After removal of the tract, the defect in the urothelium was closed with interrupted 4-0 Polyglecaprone 25 sutures. A second layer was closed over the initial layer with 2-0 polyglactin 910 in an interrupted manner.  For further reinforcement, the most proximal aspect of tract was closed with an additional layer created by mobilization of more proximal anterior vaginal fibromuscular tissue.  Watertight closure was confirmed by bringing the foley just distal to repair and pushing methylene blue solution through the foley.  Cystoscopy demonstrated the integrity of our repair.

The genital skin and vaginal epithelial layer were then closed over the defect, completing the repair.

A Foley catheter remained in place for three weeks. He was then seen in office when an active voiding trial with methylene blue solution was conducted. Retrograde voiding urethrogram was performed on post-op week 8, demonstrating resolution of the fistula, and the patient was asymptomatic. The patient was very pleased with the outcome at his 8-month follow-up visit with no signs of recurrence.

For patients with urethrovaginal fistula post phalloplasty in individuals desiring future vaginal penetrative sexual stimulation, primary vaginal repair with vaginal wall fibromuscular layer advancement flaps is an appropriate technique for fistula closure and maintenance of sexual function.

Continence 7S1 (2023) 100799
DOI: 10.1016/j.cont.2023.100799