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Revision & Salvage GAS

Primary procedures, particularly genital reconstruction, have substantial complication rates, and more patients present with functional and aesthetic concerns that need secondary intervention. For primary techniques, see Feminizing and Masculinizing procedures.

Revision After Vaginoplasty (Transfeminine)​

Up to one-third of patients have been reported to undergo secondary surgical revision after penile inversion vaginoplasty (PIV) for functional or aesthetic concerns.1 A 240-patient institutional series reported 7.9% reoperation or revision, principally for cosmesis (3.8%) and stenosis (2.1%), but median follow-up was only 87 days. This short-term estimate is not directly comparable with longer-term revision rates.2

External genital (vulvar) revisions are the most frequently performed secondary procedures. In a series of 35 patients undergoing vulvar revision, the majority required concurrent corrections in multiple categories:3

  • Labial concerns (77.1%): excess tissue, asymmetry, or insufficient labia minora / majora.
  • Clitoral concerns (57.1%): buried clitoris, excess hooding, or inadequate sensation.
  • Urologic concerns (48.6%): meatal stenosis, spraying urine stream, or urethral redundancy.
  • Introital concerns (34.3%): posterior introital webbing limiting penetration, or canal stenosis.

Common revision techniques include posterior introital web release, revision labiaplasty, clitoral unhooding / repositioning, and meatoplasty.13 Patients who developed minor postoperative complications after primary PIV (granulation tissue, intravaginal scarring) were significantly more likely to require revision. Among survey respondents after revision labiaplasty or clitoroplasty in a single-surgeon PIV cohort, 82.4% reported satisfaction and 76.5% reported resolution of genital dysphoria.4

Salvage for Neovaginal Stenosis​

Neovaginal stenosis is a long-term complication. Across 59 studies of 7,338 primary vaginoplasties with variable follow-up and stenosis definitions, canal stenosis occurred in 428/7,338 (5.83%; range 0–34.2%) overall and 412/7,223 (5.70%) after PIV; introital stenosis after PIV occurred in 226/7,223 (3.13%).5 Assess scar, pain, tissue healing and pelvic-floor or access difficulties as well as dilation; avoid assuming every narrowing is caused by inadequate adherence.6 Salvage options include:

  • Robotic peritoneal flap revision. In 24 patients with stenotic or absent canals after PIV, robotic peritoneal flap mobilization achieved a mean vaginal depth of 13.6 cm and width 3.6 cm at mean follow-up of 410 days, with no rectal injuries; one patient required reoperation for postoperative bleeding.7 In a separate 45-patient retrospective comparison after PIV, long-term recurrent vaginal stenosis was reported in 7/21 peritoneal-flap revisions versus none of 24 intestinal revisions (p = 0.003).8 The intestinal group had long-term introital stenosis in 3/24 and short-term ileus in 2/24; small, nonrandomized groups limit causal comparison.8
  • Robot-assisted sigmoid vaginoplasty (RSV). A 36-patient cohort included 11 primary and 25 revision operations. The revision subgroup had a mean preoperative depth of 3.4 cm; final mean depth of 17.6 cm was reported for the whole cohort. Four of the 25 revision patients also had a prostato-vaginal fistula before surgery; none developed a new fistula after revision, and two sigmoid-skin anastomotic strictures required intervention.9
  • Laparoscopic intestinal vaginoplasty. In a retrospective revision cohort of 50 transgender and three cisgender women (median follow-up 3.2 years), intestinal versus perineal full-thickness skin graft vaginoplasty yielded mean depth of 15.9 versus 12.5 cm (p < 0.01), successful reconstruction in 19/21 versus 26/32, and intraoperative rectal perforation in 2/21 versus 6/32.10
  • Right colon vaginoplasty. In a 22-patient salvage cohort, four patients had complications within 30 days (three ileus or small-bowel obstruction and one intraabdominal hemorrhage); six had 14 later complications, including five prolapses, four stenoses (two introital and two from extrinsic rectovaginal compression), one late small-bowel obstruction and three episodes of diversion neovaginitis. All reported satisfaction with neovaginal function and appearance; discuss bowel-specific morbidity during counseling.11

For a stenosis repair using skin or buccal mucosa grafts, a pack fashioned from a medium negative-pressure wound sponge, about 12 cm wide and cut to the canal length plus 1–2 cm, has been described for graft fixation: suction compresses the pack for insertion, and once it is positioned, releasing suction lets it expand and gently compress the grafts against the wound bed; the pack is secured externally with nylon retention sutures and re-compressed with suction for removal. This is an attributed technical option, not a proven advantage over other packing methods.12

Neovaginal Prolapse​

Neovaginal prolapse is uncommon. A systematic review of 24 studies totaling 3,166 patients found an overall rate of 2.7% (2.5% after penile-inversion vaginoplasty, 3.5% after intestinal vaginoplasty); elevated BMI was the only identified risk factor, and sacrospinous ligament fixation combined with vaginal packing was the most commonly reported intraoperative prevention measure.13 After penile-inversion vaginoplasty, pessary use, vaginal repair and sacrospinous ligament fixation have been described.14 Published surgical treatment includes case reports of open or laparoscopic sacrocolpopexy; a 2023 case report documents recurrence after vaginal repair without mesh, followed by robotic sacrocolpopexy using an autologous medial umbilical ligament graft.15 Chapter authors caution that sacrocolpopexy in this setting carries a risk of bladder or rectal injury because a distinct rectovaginal septum may be absent.14

Rectoneovaginal Fistula​

In a retrospective series of 1,082 patients, rectoneovaginal fistula occurred after 0.8% of primary and 6.3% of revision vaginoplasties (OR 8.6).16 There were 25 neovaginal fistulas in total: 13 rectoneovaginal, 11 urethroneovaginal and one pouch-neovaginal fistula. Management approaches include:161718

  • Intraoperative rectal injury. Prompt assessment and repair, with colorectal input when needed. One institutional series reported 10 rectal injuries in 146 PIV procedures, all repaired immediately in two or three layers; two patients later required temporary fecal diversion and two required muscle flaps. A separate small series used rectoprostatic-fascia reinforcement for 14 rectal injuries and five fistulas, with no rectovaginal fistula recurrence reported after one year; neither series establishes a universally required repair configuration or guarantees success.1718
  • Postoperative rectoneovaginal fistula. For a recent small fistula, initial conservative measures can include a low-residue diet, a temporary pause in dilation and sexual activity, and antibiotics when infection is present; in a 17-study review, 9/12 conservatively managed patients had closure.19 Individualize local repair and tissue interposition for persistent fistula according to defect, infection and tissue quality.16 Fecal diversion is selective rather than mandatory for every fistula; four patients in the 25-fistula cohort underwent diversion.16 In most patients, surgical repair was successful without impairment of neovaginal function.16
  • Urethroneovaginal fistula. In a 25-patient fistula series, 6/11 urethroneovaginal fistulas followed another complication, including meatal stenosis. Two patients received temporary suprapubic diversion; fistulectomy with primary closure or a local advancement flap was usually sufficient across fistula types.16
  • Vesiconeovaginal fistula. Evaluation has been described using examination under anesthesia, cystoscopy and vaginoscopy, with a guidewire passed through the tract; repair uses an abdominal approach to the proximal fistula, two-layer absorbable bladder closure, and omental or peritoneal interposition when recurrence is a concern. Described postoperative practice uses a vaginal pack for 1–7 days, a urinary catheter for 7–10 days, and dilation resumed one size below the caliber measured at repair; these are the cited authors' practice preferences rather than a tested protocol.20

Revision After Phalloplasty (Transmasculine)​

Urethral lengthening can entail substantial revision burden. In a 63-patient cohort combining 55 phalloplasties and eight metoidioplasties, 46 patients (73%) required urethral revision; this is not a phalloplasty-only population estimate.21 A separate online survey of 129 patients after penile reconstruction reported 281 complications and 142 revisions, with the limitations of self-selected respondents.22

Urethral Complications — The Dominant Driver of Revision​

  • Urethrocutaneous fistula is reported in roughly 15–60% of phalloplasty patients across series (27% of the 55 phalloplasties in one cohort).621 In a systematic review, 19–54% of urethral fistulae resolved spontaneously without surgical intervention.23 For persistent fistulae, repair options include fistulectomy with primary closure, local flap coverage, or buccal mucosa graft urethroplasty.2425 One chapter's authors distinguish a small fistula (under 5 mm), usually an epithelialized tract where the ventral urethral and skin suture lines fused, treated with excision and multilayer closure, from a larger defect (over 5 mm) that more often represents dehiscence of the neourethral plate; a fully open plate can be managed as a second-stage Johanson urethroplasty, or, when it is too narrow for tension-free closure, with a cutaneous graft allowed to mature for about six months before tubularization. These size categories and the staged pathway are the cited authors' practice framework rather than a validated cutoff, and they advise ruling out or treating a distal stricture first; their usual urethral or suprapubic drainage is about 21 days, with urethrography before removal.26
  • Urethral stricture. Risk varies with reconstruction, urethral segments and follow-up. Define the location and length before selecting endoscopic treatment, local repair or staged urethroplasty. A 14-study review of retrospective series (595 patients; 76% after phalloplasty) reported 0–25% recurrence after staged urethroplasty, used particularly for long pendulous strictures.27 A frequently quoted comparison of 82% versus 43% three-year recurrence-free outcomes for open versus endoscopic treatment comes from a 96-patient metoidioplasty cohort, not a phalloplasty trial; small technique-specific subgroups do not establish 100% success rates.62125 Acute urinary retention after phalloplasty warrants urgent evaluation. The 2026 EAU guideline identifies suprapubic drainage as first-line for early retention and strongly recommends against endoscopic incision or urethroplasty within six months after neophalloplasty. After healing, it strongly recommends no more than two endoscopic incisions unless treatment is palliative, weakly recommends staged urethroplasty when open repair of a neophallic urethral stricture is indicated, and offers definitive perineostomy for refractory disease or patients who decline complex reconstruction.28 When transurethral management is chosen for acute urinary retention after phalloplasty, Santucci and Briles describe an operating-room approach under direct vision: flexible cystoscopy, a wire passed across the stricture, gentle dilation only enough to pass the scope into the bladder, redeployment of the wire in the bladder, and further dilation to 20 or up to 24 Fr; the authors favor a lubriciously coated S-shaped dilator.29 Many such strictures are short and located in the upper scrotum.29
  • Colpectomy (vaginectomy). In a retrospective cohort of 294 transgender men undergoing genital surgery with single-stage urethral lengthening, fistula occurred in 111/232 (48%) without primary colpectomy and 13/62 (21%) with it. For selected recurrent fistulas at the proximal urethral anastomosis or fixed neourethra, secondary colpectomy achieved closure in 17/17 patients; discuss both urethral and vaginal goals during planning.30
  • Persistent vaginal remnant. A symptomatic remnant may contribute to pooling, infection or fistula and require treatment. An incidental remnant does not automatically require excision.24 A remnant that communicates with the neourethra and requires repair can be completely excised and obliterated through a robotic transabdominal or open perineal approach; subepithelial injection of lidocaine with epinephrine has been described to hydrodissect the cavity lining and reduce bleeding, and placing bilateral ureteral stents plus a urethral catheter before dissection helps identify and avoid ureteral injury. In one center's selected experience with 15 re-excision and re-obliteration cases, every specimen showed vaginal epithelium on histology; this reflects a treated case series, not how often remnants occur.31

In the 63-patient mixed reconstruction cohort, 44 patients (70%) ultimately voided from the phallic tip. Measured symptom scores and flow did not differ meaningfully from preoperative values, but this does not establish normal function or equivalent outcomes for every reconstruction.21

Flap Failure and Redo Phalloplasty​

Flap failure represents the most challenging salvage scenario. In a Dutch series of 18 patients who underwent secondary reconstruction after primary flap failure:32

  • Reconstruction involved a new shaft flap (n = 7), new urethral flap (n = 4), or both (n = 7).
  • There were no redo flap failures.
  • 13 of 16 patients with urethral lengthening (81%) achieved standing micturition.
  • Among 11 questionnaire respondents, 72% were satisfied or very satisfied with penile appearance and all would undergo surgery again.

An algorithmic framework from two high-volume centers (Johns Hopkins / Harvard and GU Recon / Buncke Clinic) guides the decision between salvaging the existing neophallus versus complete redo phalloplasty:33

  • Preserve the original flap when feasible. Partial tissue loss can often be addressed with local flaps or skin grafts.
  • Additional free flaps may be required for significant tissue deficiency.
  • Complete redo phalloplasty is reserved for severe cases (total flap loss, multiple concomitant complications).
  • Multidisciplinary collaboration (plastic surgery, urology, microsurgery) is required.

Common non-urethral complications requiring revision include excess bulk or lymphedema, phalloplasty malposition, hypertrophic or keloidal scarring, and donor-site issues.3334

Reversal of Prior Genital Surgery (Phallic Reconstruction)​

A three-stage approach has been described by one specialist center for select transfeminine patients who request reversal of prior genital surgery with phallic reconstruction: removal of the neovagina and other internal genital structures with reconstruction of the proximal urethra and scrotum, free musculocutaneous latissimus dorsi flap phalloplasty, and then staged buccal-mucosa urethral lengthening and penile-prosthesis placement. In that center's small, selected series, patients had favorable appearance, standing voiding and erectile function, along with limited tactile neophallic sensation and urethral complications (fistula, stricture) managed with minor revision; independent psychiatric evaluation preceded surgery in every case. This is a historical, author-attributed option from one center, not a general protocol or evidence that this sequence suits every person seeking reversal.35

Penile Prosthesis Revision (Transmasculine)​

Published post-phalloplasty cohorts report substantial prosthesis complication and revision burdens. The neophallus lacks native corporal bodies; one described infrapubic malleable-implant technique anchors the device to the pubic symphysis.3637 Flap sensation depends on reconstruction and nerve coaptation.

  • In a Dutch ZSI cohort (50 patients; 66 hydraulic and 19 malleable implantations, including 35 secondary procedures), 3-year explantation-free survival was 39% versus 31% (p = 0.64).36
  • In a separate retrospective cohort of 694 first-time three-piece inflatable implants after phalloplasty, the 15-year cumulative incidence of revision for mechanical failure was 30.6%, and the estimated incidence of revision for any cause was 65.1%. Mechanical failure was identified only when revision surgery was requested; these outcomes differ from explantation-free survival.38
  • Secondary (redo) implantations were associated with higher complication odds in the separate Dutch ZSI cohort of 50 patients (85 implantations) (OR 3.5, p = 0.03); urethral lengthening was associated with late complications (HR 2.6, p = 0.01). These are observational estimates, and an odds ratio is not a risk ratio.36
  • In an infrapubic series, 40 patients received implants and 30 maintained follow-up for a mean of 34.9 months; 12/30 required surgical revision. The most common complications were device detachment (7/30), malposition (3/30), and infection (1/30). No neophallus erosions or flap losses occurred.37
  • A nine-study meta-analysis estimated overall complication rates of 38% for inflatable and 37% for malleable implants, and any-cause explantation rates of 19% versus 13%; neither between-type difference was statistically significant.39
  • Another retrospective series of 32 patients reported that 21 of 45 implanted prostheses, including revision procedures, were surgically replaced or removed, illustrating the need to discuss repeat operations and device-specific follow-up.40
  • A 2026 Delphi project recruited 21 experts; 17 completed round one and 16 round two, producing 53 consensus items for implant care. This is a practice-consensus protocol, not evidence that adopting it has already reduced complications.41
  • An 80-patient implant cohort found infection probability decreased with case number. This observational association is consistent with a possible learning effect but does not establish causality or a validated minimum center volume.42

Revision After Chest Surgery​

Masculinizing Top Surgery​

Reported revision estimates depend on technique, follow-up and whether minor contour touch-ups are counted:

  • A 73-patient series (146 breasts; mean follow-up 7.9 months) reported revision in 8/146 breasts (5.4%), whereas a separate 104-patient series reported surgical revision in 25.6% of patients.4344 In another series, 38% of patients who underwent revision had a periareolar incision versus 13% of those who did not undergo revision (p = 0.03); the authors found no incision-type difference for unplanned revisions, whereas another series found no significant difference between techniques.4544
  • Most common indications: residual breast tissue, nipple-areola complex malposition, contour irregularity, and dog-ear deformity.4546
  • Concomitant liposuction was associated with fewer revisions in one cohort (p = 0.026); this was not a randomized comparison.43
  • In a 560-patient series, touch-up procedures were performed in 9% of patients.46
  • Cohorts reported hematoma rates of 10.8–14%, and one reported an association with testosterone use.454446 These findings do not show that holding testosterone prevents bleeding: a separate 490-patient cohort found hematoma rates of 2.9%, 2.8% and 2.9% when testosterone was held, continued or never used, respectively.47

Transfeminine Breast Augmentation Revision​

  • Among 99/159 questionnaire respondents at a median four years after augmentation, 5% underwent reoperation for surgical complications and 3% had Baker III–IV capsular contracture; all-cause reoperation was 14%, primarily for replacement of PIP/Rofil implants.48
  • In a 30-year Amsterdam cohort of 527 patients (median follow-up 11.2 years), long-term reoperations included implant rupture (5.7%), capsular contracture (4.9%), and aesthetic concerns (3.8%).49
  • In a meta-analysis of 1,864 transfeminine patients, the pooled capsular contracture rate was 3.62%, not statistically different from cisgender women (p = 0.41).50
  • Capsular contracture revision options include capsulectomy, implant exchange and plane change; acellular dermal matrix may reduce recurrence, though long-term data are limited.51
  • New delayed swelling or seroma prompts ultrasound and image-guided fluid aspiration for cytology, immunohistochemistry and flow cytometry to evaluate implant-associated malignancy; biopsy a suspicious mass before elective implant exchange.52
  • In a meta-analysis of 14 transfeminine studies (n = 1,864), implant asymmetry or malposition (3.89%) and hematoma or seroma (0.63%) exceeded historical cisgender augmentation rates.50 In a separate single-center comparison (153 transfeminine and 250 cisgender patients), transfeminine patients had wider breast bases and larger implants (median 500 versus 350 mL) and more surgical-site infections (3.9% versus 0.4%), although overall reoperation rates were similar.53

Revision Facial Feminization Surgery​

Secondary FFS is increasingly common as primary FFS volume grows. In a series of 161 FFS patients, 25.5% underwent secondary surgery, consisting of additional procedures on previously unoperated areas (n = 32) and/or revision of previously operated areas (n = 30).54

  • Most commonly revised areas. Nose (36.6%), forehead / brow (26.8%), cheeks (17.1%), chin (17.1%), lips (12.5%).54
  • Dominant indication. The main indication for revision was undercorrection to feminine ideals across all facial units.5455
  • Feminizing rhinoplasty revision rate. In a 102-patient series, 17/102 (16.7%) underwent revision; among 22 stated reasons, dorsal hump reduction (8/22, 36.4%) and tip revision (8/22, 36.4%) were most common. No patient characteristics were significantly associated with revision.56
  • Revision rates for gender-affirming rhinoplasty are comparable to those reported for cosmetic rhinoplasty in the general population.57
  • Causes of poor outcomes after FFS include inadequate bone reduction, asymmetric contouring, visible hardware, and soft-tissue complications (alopecia at coronal incision, temporal hollowing).55

Overarching Principles for Revision & Salvage GAS​

  1. Multidisciplinary teams are needed. Revision cases often involve concurrent urologic, plastic surgical, and colorectal issues that require coordinated planning.2433
  2. Experienced multidisciplinary services can coordinate complex salvage and repeated follow-up. Existing small cohorts and learning-curve associations do not guarantee superior outcomes for every center or establish a volume threshold.3242
  3. Patient counseling. Preoperative counseling covers that revision is common. Some cohorts report high satisfaction despite complications and after revision, but respondent selection and incomplete follow-up limit generalization.432
  4. Pelvic floor symptoms merit assessment and individualized rehabilitation. The often quoted 94.1% dysfunction estimate came from a 68-person testosterone-treated online sample that excluded previous urogynecologic surgery; it is not a postoperative incidence estimate.58 Consider pelvic floor physical therapy for appropriate symptoms.6 In the FLOWER randomized trial, 37 vaginoplasty patients had 12-week data; therapy at weeks 3 and 6 did not improve ease or pain of dilation, vaginal length or pelvic-floor symptoms versus no therapy.59
  5. Standardized outcome reporting is improving: the 2025 GenderCOS core set for feminizing genital surgery and the 2026 implant consensus provide useful starting points. Core outcomes and expert consensus do not replace validated measures and comparative follow-up for each reconstruction.4160

Footnotes​

  1. Morris MP, Wang CW, Lane M, Morrison SD, Kuzon WM. "Common Revisions After Penile Inversion Vaginoplasty: Techniques and Clinical Outcomes." Plast Reconstr Surg. 2022;149(6):1198e–1201e. doi:10.1097/PRS.0000000000009159 ↩ ↩2

  2. Levy JA, Edwards DC, Cutruzzula-Dreher P, et al. "Male-to-Female Gender Reassignment Surgery: An Institutional Analysis of Outcomes, Short-Term Complications, and Risk Factors for 240 Patients Undergoing Penile-Inversion Vaginoplasty." Urology. 2019;131:228–233. doi:10.1016/j.urology.2019.03.043 ↩

  3. Dy GW, Salibian AA, Blasdel G, Zhao LC, Bluebond-Langner R. "External Genital Revisions After Gender-Affirming Penile Inversion Vaginoplasty: Surgical Assessment, Techniques, and Outcomes." Plast Reconstr Surg. 2022;149(6):1429–1438. doi:10.1097/PRS.0000000000009165 ↩ ↩2

  4. Boas SR, Ascha M, Morrison SD, et al. "Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty After Gender-Affirming Genital Surgery." Plast Reconstr Surg. 2019;144(6):1451–1461. doi:10.1097/PRS.0000000000006282 ↩ ↩2

  5. De Rosa P, Kent M, Regan M, Purohit RS. "Vaginal Stenosis After Gender-affirming Vaginoplasty: A Systematic Review." Urology. 2024;186:69–74. doi:10.1016/j.urology.2024.02.005 ↩

  6. Motiwala ZY, Misra S, Desai A, et al. "Postoperative Urogynecologic Complications After Gender-Affirming Surgery: A Narrative Review." Int Urogynecol J. 2026;37(4):805–822. doi:10.1007/s00192-025-06405-6 ↩ ↩2 ↩3 ↩4

  7. Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. "Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: A Novel Technique for Treating Neovaginal Stenosis." Urology. 2021;154:308–314. doi:10.1016/j.urology.2021.03.024 ↩

  8. Lava CX, Berger LE, Li KR, et al. "A comparative analysis of peritoneal flap and intestinal vaginoplasty for management of vaginal stenosis." J Plast Reconstr Aesthet Surg. 2024;98:55–63. doi:10.1016/j.bjps.2024.08.047 ↩ ↩2

  9. Sljivich M, Torres C, Chen D, et al. "Feasibility and Outcomes After Robot-Assisted Sigmoid Vaginoplasty for Gender Dysphoria." Urology. 2025. doi:10.1016/j.urology.2025.06.003 ↩

  10. Van der Sluis WB, Bouman MB, Buncamper ME, Mullender MG, Meijerink WJ. "Revision Vaginoplasty: A Comparison of Surgical Outcomes of Laparoscopic Intestinal Versus Perineal Full-Thickness Skin Graft Vaginoplasty." Plast Reconstr Surg. 2016;138(4):793–800. doi:10.1097/PRS.0000000000002598 ↩

  11. Garcia MM, Shen W, Zhu R, et al. "Use of Right Colon Vaginoplasty in Gender Affirming Surgery: Proposed Advantages, Review of Technique, and Outcomes." Surg Endosc. 2021;35(10):5643–5654. doi:10.1007/s00464-020-08078-2 ↩

  12. Nikolavsky D, Dugi DD III. Complications of Gender-Affirmation Surgery. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:850–862. ↩

  13. Tran S, Guillot-Tantay C, Sabbagh P, et al. "Systematic Review of Neovaginal Prolapse After Vaginoplasty in Trans Women." Eur Urol Open Sci. 2024;66:101-111. doi:10.1016/j.euros.2024.06.013 ↩

  14. Mishra K, Ferrando CA. Urogynecologic Care and Management for Transgender Women and Men. In: Garcia M, ed. Genital Gender Affirming Surgery: An Illustrated Guide and Video Atlas. Springer; 2024:101–109. doi:10.1007/978-3-031-69997-9_10 ↩ ↩2

  15. Egbe A, Issa R, Walker R, Tay A, Seth J, Rashid T. "Robotic sacrocolpopexy with medial umbilical ligament autologous graft to treat neovaginal prolapse in a transgender woman." Urol Case Rep. 2023;51:102580. doi:10.1016/j.eucr.2023.102580 ↩

  16. van der Sluis WB, Bouman MB, Buncamper ME, et al. "Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women." Obstet Gynecol. 2016;127(6):1118–1126. doi:10.1097/AOG.0000000000001421 ↩ ↩2 ↩3 ↩4 ↩5 ↩6

  17. Pansritum K, Thomrongdullaphak S, Suwajo P. "A Rectoprostatic Fascia Reinforcement Flap for Rectal Injury and Rectoneovaginal Fistula in Gender-Affirmation Surgery." Plast Reconstr Surg. 2022;150(4):909–913. doi:10.1097/PRS.0000000000009575 ↩ ↩2

  18. Morris MP, Wang CW, Holan C, et al. "Rectal Injury During Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management." Plast Reconstr Surg. 2023;152(2):326e–337e. doi:10.1097/PRS.0000000000010246 ↩ ↩2

  19. Lava CX, Huffman SS, Berger LE, et al. "Rectovaginal Fistula Repair Following Vaginoplasty in Transgender Females: A Systematic Review of Surgical Techniques." Plast Surg (Oakv). 2025;33(1):149–158. doi:10.1177/22925503231190923 ↩

  20. Jun MS, Odeluga N, Santucci RA. Neovagina Fistulas. In: Sotelo R, Polotti CF, Arriaga J, eds. Urinary Fistula. Springer; 2022:309–321. doi:10.1007/978-3-031-15317-4_22 ↩

  21. Veerman H, de Rooij FPW, Al-Tamimi M, et al. "Functional Outcomes and Urological Complications After Genital Gender Affirming Surgery With Urethral Lengthening in Transgender Men." J Urol. 2020;204(1):104–109. doi:10.1097/JU.0000000000000795 ↩ ↩2 ↩3 ↩4

  22. Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. "Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients." J Sex Med. 2021;18(4):800–811. doi:10.1016/j.jsxm.2021.01.183 ↩

  23. Nassiri N, Maas M, Basin M, Cacciamani GE, Doumanian LR. "Urethral Complications After Gender Reassignment Surgery: A Systematic Review." Int J Impot Res. 2020;33(8):793–800. doi:10.1038/s41443-020-0304-y ↩

  24. Elyaguov J, Isakov R, Nikolavsky D. "Evaluation and Management of Urologic Complications Following Transmasculine Genital Reconstructive Surgery." Neurourol Urodyn. 2023;42(5):979–989. doi:10.1002/nau.25100 ↩ ↩2 ↩3

  25. de Rooij FPW, Falcone M, Waterschoot M, et al. "Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men." J Sex Med. 2022;19(2):377–384. doi:10.1016/j.jsxm.2021.12.006 ↩ ↩2

  26. Briles BL, Santucci RA. Neopenis Fistulas. In: Sotelo R, Polotti CF, Arriaga J, eds. Urinary Fistula. Springer; 2022:323–332. ↩

  27. Neuville P, Madec FX, Vetterlein MW, et al. "Systematic review of the outcomes of urethroplasty following urethral lengthening in transgender men." Int J Impot Res. 2026;38:302–310. doi:10.1038/s41443-025-01132-4 ↩

  28. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Transgender Patients." 2026. Guideline chapter ↩

  29. Santucci RA, Briles BL. Principles of Gender-Affirming Genital Surgery. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:820–826. ↩ ↩2

  30. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. "Colpectomy Significantly Reduces the Risk of Urethral Fistula Formation After Urethral Lengthening in Transgender Men Undergoing Genital Gender Affirming Surgery." J Urol. 2018;200(6):1315–1322. doi:10.1016/j.juro.2018.07.037 ↩

  31. Schardein JN, Blakely SA, Nikolavsky D. Management of Urologic Complications Following Metoidioplasty and Phalloplasty. In: Nikolavsky D, Blakely SA, eds. Urological Care for the Transgender Patient: A Comprehensive Guide. Springer; 2021:141–164. ↩

  32. van der Sluis WB, Al-Tamimi M, Pigot GLS, et al. "Redo Phalloplasty and / or Urethraplasty After Previous Flap Failure in Phalloplasty in Transgender Men: Surgical Considerations and Outcomes." J Sex Med. 2024;21(11):1085–1093. doi:10.1093/jsxmed/qdae119 ↩ ↩2 ↩3

  33. Keller PR, Chen ML, Ovadia SA, et al. "Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage After Major Complications." Plast Reconstr Surg. 2024;154(2):362e–373e. doi:10.1097/PRS.0000000000010960 ↩ ↩2 ↩3

  34. Loughran A, Coon D. "Advanced Phalloplasty: Management of Complications and Techniques for Revision." Clin Plast Surg. 2025;52(4):507–514. doi:10.1016/j.cps.2025.06.007 ↩

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