Repairing stress urinary incontinence and dehiscence after masculinizing genital gender affirmation surgery: A staged approach

Abstract

Background

Stress Urinary incontinence (SUI) is an infrequently reported complication following masculinizing genital gender affirming surgery (gGAS). Thus far there are no reports to describe the management of this post-operative complication.

Objective

Here, we show de novo SUI following vaginectomy and metoidioplasty can be safely surgically corrected. These were treated with a staged approach. Stage 1 included placement of an autologous fascial retropubic sling, and a first stage urethroplasty with buccal mucosa graft (BMG) and stage 2 involved tubularization of the neourethra.

Methods

We present a 22 year old transgender male who developed severe SUI, constant leakage, and ventral dehiscence following vaginectomy and metoidioplasty. He was referred for treatment of SUI and correction of ventral shaft dehiscence. Prior to surgical repair he completed three months of pelvic therapy, which improved his incontinence.

The procedure was done in dorsal lithotomy position. Perineum (site of prior vaginectomy) and previously created pars fixa were opened ventrally. Using the balloon of the Foley at the bladder neck as a palpable landmark, the native urethra and the bladder neck were dissected to the inferior aspect of the pubic symphysis. A 1.5 × 8 cm segment of rectus fascia was harvested for the autologous sling. Full length 2–0 polypropylene suture was secured to either end of the fascial sling and delivered retropubically to the abdominal incision from the perineal incision using a fine tonsil clamp. The sling was appropriately tensioned and secured. Ventral penile chordee was released sharply and a stage 1 urethroplasty was performed with dorsal BMG inlay. Six months later the patient did not show any signs of recurrence of SUI or retention, and the second stage urethroplasty was completed.

Results

At one year follow up he continues to have a normal voiding pattern, low residuals and no longer needs pads. Patient's office uroflow and post void residual results are: flow rate = 27 ml/s, voided volume = 536 mL, residual = 0 mL. He reports marked improvement in his overall symptoms, leakage, urinary frequency, and quality of life.

Conclusion

SUI is a real and devastating complication following masculinizing gGAS. Here we show it can safely be treated using an established pelvic floor reconstructive techniques with durable results. More report is required to determine the true incidence of this complication following masculinizing surgery and further studies are needed to assess the efficacy of this approach.