Rectal Injury during Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management

Abstract

Background: Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. Methods: Adult patients who underwent PIV at the authors’ institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. Results: Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. Conclusion: The authors’ algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Considerations for the Treatment of Sexual and Gender Minority Individuals in Colon and Rectal Surgery

“…56 The most common cause of RNVF fistula is rectal injury during vaginoplasty. 57 In the largest published series of RNVF to date, 17.4% of known rectal injuries progressed to RNVF. 56 It is likely that several cases are due to occult rectal injury or local ischemia, as the majority of cases present in the immediate postoperative period.…”

“…56 It is likely that several cases are due to occult rectal injury or local ischemia, as the majority of cases present in the immediate postoperative period. [56][57][58] Other reported causes of RNVF include dilation injury, tissue necrosis, and cancer; however, these causes are significantly less common. 56,59,60…”

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today

“…Within the Section of Plastic Surgery, physicians affiliated with the UMCGSP have published extensively on key topics in gender-affirming surgery, including gender-affirming vaginoplasty, [31][32][33][34] facial gender-affirming surgery, 35 genderaffirming chest surgery, [36][37][38] gender-affirming phalloplasty and metoidioplasty, 39,40 and care models in gender-affirming surgery. 41 In the Department of Obstetrics and Gynecology, research projects on the impacts of hormone therapy on fertility 42 and on care models for gender-affirming care provision 43,44 have been conducted.…”