There has been an increased number of requests for gender affirmation treatment (GAT) worldwide in the last decade. Gender affirming treatment has a multidisciplinary approach and involves mental health support, hormonal treatment and surgical treatment, which together lower the level of dysphoria and distress for these individuals.

Transmasculine gender affirmation surgeries (TGAS) are still challenging, as the creation of the neophallus with functional urethra is the most demanding step in surgical treatment. There are 2 main surgical approaches in TGAS available today: metoidioplasty and phalloplasty. Metoidioplasty denotes the creation of the neophallus out of the hypertrophied clitoris, while phalloplasty presents the surgical creation of a larger neophallus using extragenital tissue in various forms of local pedicled or distant free flaps. Genital reconstruction can be performed as a 1-stage or multistage procedure.¹

Vaginectomy, one of the steps, is the removal of the female reproductive tract in order to reduce gender dysphoria and vaginal discharge and to create a male-like perineum. Vaginectomy before urethroplasty showed reduced rates of urethral fistulae in postoperative recovery according to literature data.² Due to prolonged use of testosterone, vaginal mucosa is mainly atrophic and of poor quality to be used in urethral reconstruction. In the majority of centers vaginectomy is performed by colpocleisis and direct closure of the vaginal vault.³ Some centers prefer to perform sharp excision, while others opt for robot-assisted laparoscopic colpectomy.^2,4 Vaginectomy performed by colpocleisis is considered a safe procedure, despite the possibility of severe complications such as severe blood loss, or vesicovaginal or rectovaginal fistula.²

Available literature suggests that patients undergoing TGAS with urethral reconstruction have a higher chance of developing some form of postoperative complications related to the neourethra because of the different anatomy and histology of this “man-made” urethra when compared to cisgenders. The most common complications after urethral reconstruction in TGAS are urethral fistula and urethral stricture, and complication rate varies from 10% to 78%.⁵ Urethral fistulae are mostly located at the junction of the native and “pars fixa” or “pars fixa” and neophallic urethra.⁶ The majority of urethral fistulae heal spontaneously, yet some require surgical repair. The real rate of vaginal remnants following transmasculine gender affirmation surgeries is still unknown because this complication is rarely reported. Some small internal urethral fistulae are associated with remnant of vaginal cavity and may present with various symptoms: prolonged dribbling of urine or recurrent urinary tract infections. The origin of vaginal mucosa regeneration lies in urine leakage between the suture lines and expanding the previously closed vaginal vault.⁶ Also, incomplete vaginal mucosa resection during TGAS can lead to mucocele or draining sinus formation, with bulging in the perineal area with mucous discharge. Several recent studies report the vaginal remnant to be present in 47% of their cases, and they were all associated with urethral fistula, urethral stricture or both.^7,8 Diagnosis of a vaginal remnant can be made using retrograde urethrogram and voiding cystourethrogram with the definition of vaginal remnant size (fig. 1).⁹

Figure 1. Preoperative voiding cystourethrogram showing urethral fistula and vaginal remnant.

The treatment of choice is complete excision of rejuvenated vaginal mucosa with subsequent urethroplasty by closing any fistulous tracts. Furthermore, there is no consensus on the best surgical technique for vaginal remnant management.⁷ The use of the perineal approach in combination with flexible endoscopy provides good visibility for the vaginal remnant to be completely excised and closed with final reconstruction of the perineum (figs. 2 and 3).¹ Different methods include the robotic transabdominal approach for performing the dissection between the bladder and rectum, with vaginal mucosa excision and closure.⁷ Recurrence of the repaired vaginal remnant is very rare–and has not been reported in the literature data so far–but may require repeated surgical repair.

Figure 2. Vaginal remnant dissection using perineal approach.

Figure 3. Vaginal remnant complete dissection and closure of the vaginal vault under direct vision.

There are a lack of literature data regarding vaginal remnant rates in transmen after colpectomy and TGAS. Causes may be different, from asymptomatic cases long after primary genital reconstructive surgery to cases presented to reconstructive urologists not primarily involved in these patients’ TGAS. Despite the increased need for TGAS worldwide, patients should also be provided with information regarding the possibility of local followup and possible treatment of urological complications as the most common in TGAS.