Strategies to prevent and mitigate common complications in gender affirming penile inversion vaginoplasty

INTRODUCTION

Much has changed in the overall surgical landscape over the past few years, with the incorporation of more gender-affirming programs throughout the world. Although this long-needed change means faster access to surgical care by transgender and gender non-conforming individuals, it also brings an uptake in post-surgical complications, which have been reported to range from 15%^[1] to 70%^[2].

Adequate training should be pursued by all practitioners willing to dedicate a large portion of their careers to gender-affirming procedures. Amongst those procedures, genital surgeries are rightfully often seen as more demanding and requiring more expertise than so-called top surgeries.

This paper aims to review some of the most common complications encountered in gender-affirming vaginoplasty and provide some strategies to mitigate them based on our experience of a large-volume center.

We present our opinion on how to decrease or treat some of the most serious or most encountered complications based on preliminary reports of 1004 vaginoplasties performed by a single operator over five years from 2010 to 2014 inclusively. Specifically, poor cosmesis, soft tissues related complications, rectal and urethral injury, neovaginal stenosis, as well as intraoperative and postoperative bleeding will be discussed.

PATIENT SELECTION, TIMING OF SURGERY AND MANAGEMENT OF EXPECTATIONS

The preparation leading to surgery should not be overlooked as some postoperative complications could be easily prevented by better patient education and, in some cases postponing of intervention until certain criteria are met. The WPATH standards of care in the version currently in use (version 7)^[3] have been useful in making sure that some of the criteria were met prior to surgery but are not always enough to predict good outcomes of vaginoplasty. Strict adhesion to a dilation protocol is of paramount importance to achieve long-term function and satisfaction^[4]. The resulting loss of depth encountered in non-compliant patients can be devastating and will often require additional morbid procedures for a secondary deepening of the neovaginal cavity. To avoid such situations, the surgical team needs to be aware of patient-related situations (lack of support in the workplace, lack of family support, poor logistical feasibility of a demanding dilation protocol both at home and at work, financial issues preventing good postoperative hygiene, etc.) that would ultimately lead to non-compliance and work with the patient ahead of the surgical procedure. We believe that this is best achieved with a multidisciplinary approach, and we do have a dedicated preoperative team composed of nurses and social workers.

During the preoperative planning, it is important to recognize the lack of available local genital tissue (genital hypoplasia caused by early puberty blockers, shortened penile skin tube after aggressive circumcision, or other anatomical factors), and have an informed discussion with the patient as far as possible technical difficulties, need for additional techniques, or perhaps simply the limitation of depth when the patient refuses any additional procedures [Figure 1]. Gender-affirming vaginoplasty is not merely a reconstruction of a function, but rather a construction of a new function^[5,6]. Tissues are remodeled as per the native anatomy, but the function is newly created with a diversity of postoperative outcomes from excellent to less favorable. A lot of postoperative frustrations can be avoided by reviewing patients’ expectations and ensuring that the surgeon can meet those or discuss any reasonable alternatives. A true informed consent is then achieved by both the surgeon and the patient’s collaborative path and might be the best way for patients to reappraise their care^[7].

Figure 1. Penoscrotal hypoplasia.

COSMESIS AND THE IMPORTANCE OF SYMMETRY

Surgical markings need to be made as symmetrical as possible as the cosmesis of the vulva is a very important outcome of the procedure. The surgeon needs to keep in mind that patients will not only spend a significant amount of time with a mirror to perform dilations but also to get familiar with their new anatomy and experiment with newer sexual sensations. During this time, any significant symmetry issue will be noticed, and could cause the patient to feel dissatisfied, anxious, or even dysphoric.

Gender-affirming vaginoplasty is a procedure of several steps that need to be performed precisely to achieve a good outcome. Most of the procedure is a “midline” surgery, meaning that it is very important to stay centered to get a good symmetry and avoid unnecessary bleeding. For this reason, we believe that spending enough time in setting the surgical field can help avoid complications. In our hands, it is often easier to rely on automatic retraction that does provide the same pull on either side or to use the fingers of the non-dominant hand of the operator rather than asking assistance from an additional person [Figure 2]. Either way, the choice of retractors, as well as the overall set-up, will help the surgeon to become safer and more efficient in most situations. Figure 3 depicts our set-up.

Figure 2. Dissection facilitated by automatic retraction in order to stay midline.

Figure 3. Set-up for vaginoplasty with the patient in gynecologic position.

SOFT TISSUES COMPLICATIONS (NECROSIS, WOUND DEHISCENCE AND HYPERGRANULATION)

Wound healing issues are very common after penile inversion vaginoplasty. They can range from minor wound healing delay, dehiscence, small and larger necrosis, and resulting in hypergranulation.

In the penile inversion vaginoplasty, the penile skin is a flap of variable length which is set under some tension. Adequate tension allows for a natural and cosmetic outcome of the labia, while any additional tension will cause early dehiscence, usually at the posterior fourchette. To try and limit this very common problem, we design a triangular perineal flap to break the incision line and limit subsequent contraction. We also place separate Vicryl stitches on the posterior fourchette to give the strength needed against the dilation motion. If dehiscence still happens, it could be of various severity degrees, ranging from a loose stitch to a complete dehiscence [Figure 4]. It is of paramount importance to counsel patients to avoid any cessation of dilation and to treat pain adequately. We found that wet-to-dry dressings using the normal saline solution will always result in complete healing after a few days to a few weeks.

Figure 4. Complete posterior dehiscence at the posterior fourchette and partial loss of skin graft.

Interestingly, there is a wide range of reporting of these complications in the literature, from 7%^[2] to 33%^[8]. In our experience, about 75% of patients will experience some level of wound breakdown at the posterior fourchette. A combination of tension, moisture, and the need to perform dilations several times a day while tissues are healing certainly explains the high incidence of this complication. Even though the occurrence is high with wounds sometimes initially impressive, a simple wound dressing protocol (with saline wet-to-dry dressing changes twice a day) and sitz bath will result in complete healing.

Necrosis of the labia can also be encountered as the result of impaired blood flow of the penile skin, either by design, by technical difficulties in the dissection, or by a dressing that was applied too tight. Upon removal of the external bolster dressing at day 4, the skin will typically start presenting a discoloration that can evolve in a complete partial or full-thickness necrosis [Figure 5]. Wound dressing changes will often again be the mainstay of treatment, but the distortion caused by secondary contraction could lead to a poor cosmetic outcome [Figure 6]. We therefore advise for early intervention in cases of large necrotic areas that would need to be debrided until healthy tissues are encountered and subsequently covered by a split-thickness skin graft [Figure 7A, B and C].

Figure 5. Necrosis of left labia majora.

Figure 6. Cosmetic deformity of vaginoplasty outcome, with left labia majora loss and scar contracture.

Figure 7. A: Necrosis of the right labia majora; B: after debridement; C: after healing of split-thickness skin graft.

Hypergranulation is another very common finding after vaginoplasty and will occur in locations where wound healing is achieved by secondary intention, hence directly correlated to soft tissues complications described above. Although reported to range from 7% to 26% of cases^[2,9], most surgeons performing gender-affirming vaginoplasties, including at our center, agree that almost every patient will have some degree of granulation^[10]. When located in the neovaginal cavity, hypergranulation will be associated with foul smelling, blood spotting, discharges, and pain. The mainstay of treatment is the application of silver nitrate aggressively every week to two weeks. Vaginal douching with a saline solution will also help between sessions of silver nitrate. We found that setting up a hypergranulation clinic with dedicated nurses was very useful for patients to be seen on a regular basis until fully healed.

Bleeding

Bleeding is the most common acute complication of gender-affirming vaginoplasty^[10]. There are a few anatomical locations that need to be addressed with caution to reduce the incidence of postoperative bleeding:

(1) Perineal arteries: during the initial dissection, staying midline and under bulbospongiosus muscle investing fascia as well as Buck’s fascia is critical to avoid the perineal arteries.

(2) The penile stump: it is common to place a circumferential ligation at the base of the penis prior to performing the penectomy. Even if this ligation can be most times efficient in controlling any bleeding from the stump, we advise the placement of selective ligations of the two deep penile arteries, which provides an additional layer of safety.

(3) Bulb of the penis and bulbospongiosus tissue: extra time needs to be taken to cautiously remove all the spongy corporal tissue from the under aspect of tunica albuginea. Injection of epinephrine in the bilateral crus of the corpus cavernosum will significantly reduce the bleeding during this step [Figure 8]. Spongy corporal tissue should be excised with scissors in a gentle peeling motion. We also advise cauterization of any residual tissue, as well as on the lateral aspects of Buck’s fascia after having safely identified the neoclitoris pedicle [Figures 9 and 10].

Figure 8. Injection of epinephrine solution in the crus of corpus cavernosum.

Figure 9. Peeling of residual spongy corporal tissue beneath tunica albuginea.

Figure 10. Cauterization of the lateral aspect of Buck’s fascia after dissection of the neoclitoris pedicle.

(4) Urethral edges are oversewn with a running 4-0 Vicryl stitch on a taper needle.

(5) Prostate venous plexus and anterior artery: while approaching the prostate during the dissection cavity, controlling of any bleeding around the prostate.

(6) Neovagina sidewalls: after the initial dissection of the neovagina cavity, both the depth and the width are assessed. The extent of the depth is limited by the peritoneum reflection. The width, however, can be slightly increased by selectively dividing the levator ani muscles. During this maneuver, adjacent internal pudendal artery and vein can be injured and sometimes hard to control because of their location. We advise a cautious dissection and the use of a figure of eight stitches (of Vicryl, for example) to control any bleeding that would occur.

Because of the major bleeding risk in the early postoperative period, a large bolster dressing is applied to the perineal area, with an extra emphasis on a proper bolstering of the spatulated urethra, and after a neovaginal mold has been placed. The dressing is usually tightened from one groin to the other. It needs to be applied with enough pressure to prevent postoperative bleeding with keeping in mind the tissue necrosis that could result from overtightening. Thrombo-embolic prophylaxis is not used, and patients are asked to ambulate a few hours after surgery.

In the postoperative setting, most bleedings will be venous and coming from the urethral edges or the bulb of the penis. These bleedings cause the dressing to be progressively soaked, hence, not acting as a good bolster on the operative site anymore. A return to the operating room is needed in about 1.9% of cases. In our opinion, early recognition of the problem and dressing change under short anesthesia will avoid trying unnecessary bedside measures.

Any increasing pain felt while there is bleeding should raise the surgeon’s awareness that there might be active arterial bleeding, slowly dissecting the tissues or that an outside blood clot is getting larger and causes increased pressure between the dressing and the wound [Figure 11]. Patients will typically complain of pain becoming progressively more intense and a sensation of the need to defecate. In those cases, patients need to be taken emergently back to the operating room for evacuation of any hematoma and exploration of the site in search of any active bleeding.

Figure 11. Dissecting hematoma of the neovaginal posterior vault.

While most patients are able to recover from an episode of postoperative bleeding, transfusion was needed in about 2.8% of patients.

CONCLUSION

In conclusion, gender-affirming vaginoplasty is a procedure that can be associated with a wide range of complications. Although it can be daunting to think of a surgery that could lead to many adverse situations, most complications will be minor and treated only with wound care and patience. We have shared our experience regarding some well-known complications following vaginoplasty, which we believe could be limited by incorporating a few strategies. It is, however, important to recognize that multiple vaginoplasty techniques have been described, and that what applies to our technique is not necessarily true for others. Nonetheless, we still believe that a few general guiding principles could help mitigate commonly encountered adverse situations.