In the male-to-female transgendered patient, the creation of esthetic and functional external female genitalia with a functional neovagina represent the main objective. The most used M/F surgery is represented by penoscrotal inversion vaginoplasty, while other techniques are represented by colon-vaginoplasty or peritoneal flap vaginoplasty. This fascinating and challenging surgery is not without complications. The prevalence of complications is extimated to be about  32.5%. The most common complication is stenosis or stricture of the neo-meatus/ urethral complex and stenosis of the neovagina. Other relatively rare complications are represented by wound infection rectal injury, hematoma, tissue necrosis, rectovaginal fistula and transfusions. The prolapse of the neovagina is a relatively rare event and it is estimated to be approximately between 1.6- 7.5% . The pathophysiology of a neovaginal prolapse is still unclear. It is probably explainable with the missing integration into the pelvic floor in comparison to a natural vagina with its anterior and apical support to the pelvic side walls. Prolapse of the neovagina after vaginoplasty in M/F patients represent a poor aesthetic appearance as well can lead to possible difficulties with or obstacle to sexual intercourses. The management of vaginal prolapse after sex reassignment surgery represent a great challenge in the field of pelvic reconstructive surgery. To date there are no standardized techniques established to re-suspend the prolapse. Various surgical approaches ranging from vaginal mesh repair, to open or laparoscopic fixation of the neovagina with or without mesh inlay have been described.
The purpose of this video is to show a laparoscopic approach to repair a neovaginal prolapse in a male to female patient who underwent sex reassignment surgery and a neovagina creation with peno-scrotal inversion.

She was 42 years old. The preoperative evaluation including history, urogynaecological examination, urodynamic test.She reported bulging symptoms, pain during sexual intercourse enough to interrupt sexual relations with the partner.She had a vaginal vault prolapse III stage in according to POPQ, no urinary incontinence,and urinary symptoms. The surgery was performed by two experienced surgeons.Laparoscopic repair of the neovaginal prolapse followed the principles used for the native female patients with pelvic organs prolapse
The patient is positioned in a forced Trendelemburg position under general anaesthesia; the laparoscopic ports were placed in a standard position (10 mm optic port  above the umbilicus and other two  10 mm and 5 mm for the surgeon and another one on right side for the assistance). The first step is represented by a bluntly dissection of sacral promontory in order to get space enough to put a 2/0 not adsorbable suture in the periostium. Peritoneum is than prepared in the douglas space and the neo-vaginal dome is visualized; the neo-vaginal dome is than bluntly prepared using a retractor that pushes it into the abdominal cavity. A polypropylene mesh is positioned, shaping dimensions of the vagina and it is fixed on vaginal dome using three reabsorbable 3/0 sutures. Retro-peritoneum is than opened in the space between vagina and sacrum, in order to create a retroperitoneal passage of the mesh. The mesh is than fixed on the sacrum using previously apposed suture. Closure of retroperitoneum with a running suture.

The operation was completed successfully, without blood loss or complications and the patient was discharged on the 3 rd postoperative day. After one month from the surgical treatment, the patient presented the complete correction of the prolapse, the absence of vaginal exposure of the mesh, the absence of urinary symptoms. After 8 weeks she resumed sexual intercourse without reporting any discomfort either her or her partner

Our case showed that laparoscopic sacropexy could be used to treat a neovagina prolapse with a good anatomic outcome

Continence 2S2 (2022) 100308
DOI: 10.1016/j.cont.2022.100308