NOTES Robotic-Assisted Transanal Repair of Recto Neovaginal Fistula

INTRODUCTION: Treatment of recto neovaginal fistuale is challenging due to the altered perineal anatomy in patients undergoing gender-affirming vaginoplasty. We present a case of a successful repair using a robotic-assisted transanal NOTES approach. OBJECTIVE: The objective of this video is to illustrate a unique approach to repairing a recto neovaginal fistula using a robotic-assisted transanal approach. This video also demonstrates the use of an acellular dermal matrix graft to aid in fistula repair. METHODS: This intervention was performed at a large academic institution as a joint case with the urogynecology and colorectal services. We present the case of a 19-year-old trans female with past surgical history significant for a penile inversion vaginoplasty followed by a transvaginal vaginoplasty revision for a vaginal stricture who initially presented to our hospital for new evaluation of passage of gas from her neovagina. The patient was noted to have a 0.5-cm dimple along the posterior vagina consistent with a recto neovaginal fistula seen on initial pelvic exam. Prior to the current presented case, the patient underwent an attempted repair using a robotic-assisted peritoneal flap pull-through vaginoplasty approach. The patient continued to report passage of gas from her neovagina at her initial post-op visit. A persistent small recto neovaginal fistula was confirmed during in-office flexible sigmoidoscopy, approximately 6 cm from the anal verge. RESULTS: This approach demonstrates various key points that led to successful repair including (1) prone positioning to better visualize the fistulous tract, (2) creation of a rectal mucosal advancement flap, and (3) application of an acellular dermal matrix graft. CONCLUSIONS: Recto neovaginal fistulae can be safely and effectively repaired using a transanal NOTES approach. Providers may also consider the use of an acellular dermal matrix graft to aid in repair.