Reconstructive surgery of difficult urethrocutaneous fistula following gender-affirming surgery

Abstract

Introduction: In Japan, transgender individuals have historically had limited therapeutic options, prompting many to seek gender-affirming surgeries in private or foreign clinics because of restricted access to public hospitals. This has led to challenges for patients undergoing surgery.

Case presentation: A transgender man underwent surgery at a private clinic and experienced recurrent complications. Subsequent examination at another clinic and our hospital revealed limited medical records, complicating our understanding of this case. After a detailed investigation, the urethrocutaneous and urethrovaginal fistulas were identified and addressed by joint urologists and plastic surgeons, resulting in no recurrence after 1 year.

Conclusion: This case underscores the importance of thorough preoperative assessment with a flexible mindset, emphasizing the need to avoid being misled by inadequate records or appearances in complication management of gender-affirming surgery. Collaborative efforts among healthcare professionals based on comprehensive evaluations lead to safer complication treatments.

Keywords: gender‐affirming surgery; pedicle flap; reconstructive surgery; transgender man; urethrocutaneous fistula.

Fig. 1

Pubic appearance at visit.

Fig. 2

(a) Removed urethrocutaneous and urethrovaginal fistulas, vertically incised ALT flap. Inserted Foley catheter intraoperatively as a marker in the naive vagina. (b) Closed urethra, covered with surrounding tissue. (c) Rotated a bilobed flap to patch the urethral closure site, in addition, the flap was placed over a partial circumferential vaginal orifice, further rotated second flap from inner thigh to relieve tension at the bilobed flap donor site. Carefully positioned flap to maintain blood flow. (d) After fistula closure, intentionally preserved untrimmed dog‐ear at the site of harvested inner thigh skin flap, resembling a minor labial pouch.

Fig. 3

(a) Tubular formation of the anterior vaginal wall flap, performing urethral lengthening procedure. (b) The thigh skin is tubularized to form urethra and wrap skin around urethra (role‐in‐role procedure) for phallus construction. Pass the phallus under thigh skin. (c) Urethral extension within the phallus from (b), anastomosed to the lengthened urethra with the anterior vaginal wall flap covering the vaginal orifice (estimated). Subsequently, indicating the sites where urethrocutaneous fistula and urethrovaginal fistula were formed.

Fig. 4

(a) Postoperative urethrogram at 2 weeks. Detected minor leak, no contrast extravasation into the skin. (b) Urethrogram postgauze compression of the leaking area (4 weeks postoperative). No contrast leakage from the urethra.