Artificial Urinary Sphincter-Sparing Vulvoplasty: A Case Report

Artificial urinary sphincters (AUSs) are a standard treatment for post-prostatectomy incontinence. The risk of AUS erosion after future urethral surgery could be seen as a contraindication to vulvoplasty in transgender patients. However, we describe a novel AUS capsule-sparing vulvoplasty technique that minimizes this risk. A 60-year-old transgender female with a history of bilateral orchiectomy, urethral sling excision, and AUS placement for post-prostatectomy incontinence sought vulvoplasty for gender-affirming care and wished to preserve her AUS. Risks, including erosion, infection, and AUS malfunction due to limited tissue coverage, were discussed. A combined plastic surgery and urology team performed the procedure. The AUS was deactivated, and a suprapubic tube was placed. Scrotal skin was excised, leaving the Dartos fascia over the pump intact. Dissection proceeded to the bulbospongiosus muscle, sparing the AUS capsule and tubing. A non-standard urethrectomy preserved urethral tissue, with the neomeatus created 2 cm distal to the capsule for protection. The AUS pump was repositioned beneath the left neolabia majora, constructed from perineal and scrotal flaps. After skin closure, the AUS was tested and reactivated. At follow-up, the patient was satisfied with vulvoplasty and AUS function. We present a novel AUS-sparing vulvoplasty technique for gender-affirming surgery (GAS) that preserves continence support in a complex post-prostatectomy patient.