VA102 - Robotic-assisted transanal repair of recurrent rectal-neovaginal fistula

Purpose/Background: Rectal-neovaginal fistula is a surgically-complex problem after gender-affirming penile inversion vaginoplasty with incidence rates between 2-3%. Many approaches for fistula repair have been described with variable success rates though data is limited. These range from conservative management with or without fecal diversion, to reconstructions with advancement or transposition flaps.

Methods/Interventions: We present a technique using a robotic platform to repair a rectal-neovaginal fistula transanally in a 42-year-old trans female patient status post penile inversion vaginoplasty. The patient first developed pain and discharge from the neovagina after noting stool on the dilator during serial neovaginal dilation as per protocol. A rectal-neovaginal fistula was confirmed on video anoscopy 10 cm from the anal verge. In the operating room, a TAMIS Gelport was used and the robot was docked. Proximal and distal submucosal flaps were raised and the defect repaired with 2 layers of V-loc suture. Fibrin glue was applied over the repair and the flaps closed with 2 layers of V-loc suture. Laparoscopic diverting loop ileostomy was then created. On follow up flexible sigmoidoscopy, a persistent defect was seen and water leaked through the vagina when it was irrigated. A subsequent robotic repair was performed. Submucosal flaps were newly raised and the repair closed primarily with V-loc. Alloderm Select was used to reinforce the repair before closing the flaps with V-loc.

Results/Outcomes: 6 weeks after repair with Alloderm interposition, flexible sigmoidoscopy showed well-healed flaps with no persistent defects. Ileostomy reversal was performed and the patient has been doing well since.

Conclusion/Discussion: Repair of rectal-neovaginal fistula remains a complex surgical challenge, in part because the anatomical planes have been altered and tissue quality may be compromised by fibrosis. While outcomes data after repair is scarce, there are reports of recurrence rates of approximately 15%. In comparison, recurrence rates after rectovaginal fistula repair in cis women are reported as high as 30-60%. While additional research is needed to determine best practices, robotic-assisted transanal repairs should be considered for rectal-neovaginal fistulas, as the robotic platform provides improved visualization and dexterity. Protocols after vaginoplasty generally include serial vaginal dilation. Since dilator trauma is a common cause for fistula, additional education on safe use of these may decrease rectal-neovaginal fistula rates.