Robot-Assisted Excision of Vaginal Remnant With Transperineal Cyst Removal Following Prior Vaginectomy and Metoidoplasty

INTRODUCTION: Vaginectomy is increasingly performed as part of gender-affirming surgery. A retrospective study of vaginectomy in transmasculinizing surgery reported vaginal remnant recurrence in 4/50 patients after epithelial excision and 1/20 after fulguration (P=.67), with one patient in each group requiring repeat vaginectomy. Robot-assisted excision of vaginal remnants after primary gender-affirming surgery may be technically challenging due to prior scarring and the difficulty of intraoperative identification. Cohen et al. described a robotic technique for excision of a vaginal remnant/urethral diverticulum in which cystoscopic light was used to assist with intraoperative localization of the remnant. OBJECTIVE: To present a case of robotic-assisted vaginal remnant excision with transperineal cyst removal in a transman with prior vaginectomy and metoidoplasty. METHODS: We present the case of a 29-year-old transmasculine patient with recurrent perineal cysts and perineal bulging. His surgical history included a robotic-assisted laparoscopic total hysterectomy with bilateral salpingo-oophorectomy (2021), followed by vaginectomy with fulguration, metoidioplasty with urethral lengthening, and scrotoplasty (2022). Postoperatively, he developed recurrent perineal swelling and cysts that enlarged with arousal or sexual activity. In 2023, he underwent two transperineal cyst excisions, with pathology revealing Bartholin gland hyperplasia. Preoperative MRI later demonstrated a proximal vaginal canal remnant with a fluid collection cephalad to the palpable cyst. The surgical video highlights a combined robotic-assisted vaginal remnant excision and transperineal cyst removal. RESULTS: The perineal incision healed well, with no recurrence at 9 months postoperatively. Pathology confirmed normal vaginal epithelium and a Bartholin duct cyst with features of prior rupture. The cyst etiology was attributed to mucus accumulation from the vaginal remnant. CONCLUSIONS: Robot-assisted excision of vaginal remnants is feasible but may be challenging in the setting of prior surgical scarring. Larger studies are needed before fulguration can be widely adopted for vaginal epithelium removal. A single-stage robot-assisted laparoscopic total hysterectomy, bilateral salpingo-oophorectomy with colpectomy has been reported with a low complication rate. Further research comparing single-stage, two-stage robot-assisted, and vaginal approaches in transmasculine gender-affirming surgery is warranted.