Gracilis flap intervention for recurrent recto-neovaginal fistula post-sex-reassignment surgery

Abstract

Rectoneovaginal fistulas, occurring in 0.8–17% of cases postsex-reassignment surgery, stand as the most prevalent type of fistula [1]. Managing these fistulas involves various approaches, from conservative measures to primary closure or musculocutaneous flap preparations. Yet, managing recurrences remains a formidable challenge, necessitating a multidisciplinary approach [2].

We present the case of a 23-year-old patient, who underwent male-to-female sex reassignment surgery via the penile inversion technique in 2020. Six months postsurgery, the patient had fecaloid spotting through the neovagina, and a rectovaginal fistula was confirmed on a computed tomography (CT) scan. Despite two attempts of transvaginal and transanal primary suture, persistence of the fistulous orifice in the neovagina’s posterior aspect was noted in December 2021. In accordance with the patient’s preference to avoid a stoma, we opted to perform a gracilis muscle flap procedure without the creation of a stoma.

Upon positioning the patient in lithotomy, a 0.5 cm fistulous tract was identified 5 cm above the anal margin in the neovagina’s posterior aspect (Fig. 1). Incising the neovagina’s posterior aspect, dissection through the superficial fascia revealed the fistulous orifice. Figure 2 shows the resection of neovaginal skin followed by primary closure of the fistulous orifice through continuous suturing (Fig. 2). Concurrently, the plastic surgeons placed a gracilis muscle flap on the posterior neovaginal aspect, covered by a skin island (Fig. 3). Postoperatively, the patient had an uneventful recovery with no recurrence at the 1-year follow-up.