AOSA Episode 5

Hello, everyone, and welcome back to Behind the Knife. I'm Dan Schiest, one of the Surgical Education Fellows here at BTK, and I'm thrilled to bring you the fifth episode of our collaboration with the Association of Out Surgeons and Allies. Today, we're continuing the conversation on gender affirming surgery and care, a topic we first explored in our June 6th episode.

In this episode today, we'll delve into critical management strategies that general surgeons should consider when evaluating complications or performing surgeries on other organs in gender diverse patients. We're fortunate to have Dr. Andrew Schlossel again with us who will introduce the rest of our esteemed guests.

Thank you again, Dan. And again, to the Behind the Knife team, I really appreciate you all having us back and the great welcome and enthusiasm from our guests on the last episode. So again, tonight we have Dr. Megan Lane. She's a plastic surgery resident at University of Michigan. We have Dr.

Amy Swanable, who's a colorectal surgeon at the University of Michigan and Dr. Monica Yarofarula, who

is a plastic surgeon at OHSU. So tonight I thought we would Delve a little deeper into some of the technical aspects of gender affirming surgery and specifically about what those who don't do this on a regular basis should be looking for in regards to general patient management and complications.

And I thought a good way to approach this would be to start with some clinical scenarios and With that, maybe you can help us manage these scenarios and then step us back a little bit to explain how we would have gotten to this through these the technical parts of these operations. So, scenario number one.

You are on a vas you are on a vascular location and have a transmasculine patient who has an aortic aneurysm requiring an open repair. The patient had a free radial forearm phalloplasty with urethral reconstruction five years ago. After the patient is induced, the circulating nurse asks you to place the

Foley because of the patient's previous surgeries.

What should you do? So, phalloplasty, there's multiple different types. The most common, so there's a few different options, and this kind of goes along with like general plastic surgery. Depending on what the patient wants, there's kind of like two, a few different decision points. So, I should mention, so the two kind of main things we're thinking about is how we're going to create kind of the soft tissue of the phallus, and then how do we create the urethra if the patient wants one?

In terms of the soft tissue of the phallus or like the phallus itself there's a few different options. There's some local options including an abdominally based flap. Some people also use a pedicled ALT flap. that's coming from the thigh. The most common procedure that's performed is free radial florem flaps.

So that's using tissue from the arm based upon the radial artery. And then in terms of the urethra you basically want to have something lined usually with epithelial tissue. So for a radial forearm flap. There's actually some really nice

photos online, but essentially it's kind of a rectangle kind of design that we will create a tube within a tube.

So you end up with skin on the inside creating a tube that becomes the urethra and then skin on the outside that is kind of the skin of the phallus. The hookup and kind of the staging of this depends on the center. So a lot of places have transitioned to doing a two stage approach where essentially the native urethra, some people do things at the native urethra at the time of the free flap, but essentially the first surgery is focusing on the free flap or kind of getting the phallus into the perineal area making sure that it's viable.

And then on the second stage going and connecting up the urethra that's in the phallus to the native urethra. Monica, do you have anything to chime in about general for phalloplasty steps? No. So I think that that was pretty comprehensive. And what the only thing that I would add right is kind of you alluded to a little bit, but just for those who are

not the difference between what we call a pedicle than a free radial forearm flap or a free flap in general.

Is that right? There is no micro vascular re anastomosis. So, for example, right from a consideration in this scenario where you're going to have someone who's going to have an open laparotomy for you know, a triple a essentially Then you have to be very wary of where the connection is. If this phalloplasty is an ALT phalloplasty, then, and especially so if it's pedicled, then the vasculature for the phalloplasty is not as much of a consideration from a surgical incision planning as it would be for a free flap, whether it's ALT or a free radial forearm flap.

Because both of those flaps are basing their blood supply on the inferior epigastric system, which resides behind the rectus muscle and essentially right when you're creating a laparotomy, although you're certainly trying to stay within the linea alba and away from your rectus space, the concern is that right with manipulation with placement of your book Walter or self

retaining retractor that you can actually cause an avulsion of that pedicle thus basically eliminating the blood supply to the actual phallus.

So that's really important then for any laboratory or even any minimally invasive procedure, since the trocars could be coming in direct contact with where the epigastric could be. Oh, absolutely. And to that effect, right, for, like Dr. Lane was saying when we plan these, depending on the center, You know, but the majority by and large do a staging approach or a big band approach.

So the first stage is focused on the creation of the phallus. The second stage is on the urethral lengthening or other adjunct procedures that may include perineal masculinization, vaginectomy, glansplasty, scrotoplasty. And then at a third stage is essentially the implantation of a penile device for penetrative intercourse and or testicular devices.

And so For patients that are interested

in pursuing FOP plasty, if the goal is essentially to have a VA ectomy, urethral lengthening and that kind of thing, then a hysterectomy is a prerequisite. And so we try to encourage every patient who is un gonna undergo a fall plasty to have their hysterectomy before the FOP plasty to avoid iatrogenic injury to the pedicle with trocar placement.

Why do you have to do the hysterectomy before everything? Just because of anticipated surgeries in the future or because you are unable to screen for potential uterine cancer in the future? Well, it's a twofold scenario. So essentially if the patient is interested in standing micturition or standing to pee, then certainly, at least at OHSU, a majority of the centers will not proceed with doing urethral lengthening without a vaginectomy.

So in that setting, you have to have a hysterectomy. But even if you weren't going to have a vaginectomy for whatever reason If you are

interested in essentially negating the risk of uterine malignancy and or not having to deal with menstrual cycle, then certainly it is a consideration to just have a hysterectomy, and if that is what's going to be ultimately pursued, then we recommend having it before rather than later to avoid the risk of injury to the pedicle.

Do you ever feel so there are definitely some instances and I think some centers that, after free flaps at, you know, four weeks, you're like, oh yeah, things have started to heal in, new blood supply beyond the pedicle itself has formed. Do you, I guess, Monica at OHSU, do you, worry a little bit less if it's been, a year or two about the pedicle, even if, someone's going back and getting a prosthetic, or is that something you guys still worry about?

It's something that we counsel all patients in, at that point in time things scarred down a little bit. little bit, but certainly it is a known risk factor. And while the there is

angiogenesis that happens as in with every flap or graft there are certainly, I would say that that's more of an axial pattern or just a random pattern blood supply.

That is certainly, I wouldn't put, you know, rest my head saying that it's going to be. provide enough blood supply for sustenance, especially when it's a tube within a tube, right? Yeah. It's rather girthy, large surface area. And so certainly while there is some supplemental blood flow that happens to the flap, I don't think it will be sufficient to sustain it.

I think the other big thing in this scenario is okay, a folio placement following phalloplasty. And doctor, I think Mike, who isn't able to be here tonight he wrote a paper recently and talked about just the rates of fistula and structures in patients who've undergone phalloplasty.

I'm wondering If you have any thoughts on, how to approach fully placement following a foul plaster, if there's anything you recommend to, patients that are

going back home and may need surgeries in the future. Yeah. So certainly right in the traumatized patient or someone who is not basically able to communicate, that's certainly a consideration that you may not know what's going on for the most part, patients who have complications from urethral lengthening, that being.

either stenosis or fistula formation are going to be very well aware of those situations and they're going to be very forthcoming to let you know that they have A, B, or C sort of complications. You know, there's a complication, right? These complications aren't something that is just kind of brushed off.

They're either physically apparent as within, a fistula. Or at least they verbalize it because they have likely undergone mold. You know, at least one or two procedures to fix the problem. Equally, if they're stenotic, which may not always be sort of appreciable. Or rarely is it appreciable clinically.

They will let you know that they have issues with that, right? And so certainly.

Depending on the time frame if it's a phalloplasty that has happened, you know, in months preceding or at least about a year preceding, then it's very likely that everything is kind of scarred in. So what I would say is I would try for a coudé, go with the smallest French possible, and try to Feed even like a pediatric foley to get past the stricture if the issue is a fistula, right?

Depending on whether or not it's been repaired and how long it's been since that then it's the consideration about You know going through it or not I would always encourage if that if there is any hesitancy or any question Especially with a surgery being fairly acute or recent then I would call the urologic urologic, Folks to get them to help out a little bit and then the other consideration too is right Especially with urethral lengthening which is the only case where this is a little bit of a concern and I'll talk a little bit About shaft only in a second That's certainly the other option is that these patients have had a suprapubic catheter for several weeks at least four

weeks while they were healing from the urethral lengthening so certainly right to a certain degree that bladder is pexied.

Because of the having the two previously. So putting a suprapubic catheter in again is probably a fairly easy endeavor to do if necessary. And there's other complications going on. And so that is one consideration from a urethral lengthening standpoint. And I think the most important part, too, is to ask the patient how they void, right?

Not every patient that has a phallus void standing up. Some of them either have had perineal masculinization, in which case there's, there is the meatus in the usual location, but it must, it will have some epithelium around it, so it's not going to be quite, mucosa at the sort of orifice or they haven't had any kind of masculinization procedures, right?

And so it's really important, right, to start off with the basic and ask them how they urinate. Do they urinate via the phallus or not? Because if they don't, right, You can find yourself trying to put a Foley through

a blank pouch, because when we do a shaft only, for example, we essentially create a Fo me atus, and so it's essentially a two centimeter blank patch that doesn't go anywhere, but if you push a Foley hard enough, especially in the acute period, you will literally leave.

put that fully into the flap itself. , so foregoing that kind of awkward moment and just asking them is, I think it's going to be the first step because even in those patients who have had, right, let's suppose that you have a patient with an issue in between stage one and stage two. So they have a phallus, but nothing has been connected from a urologic standpoint.

Then that means that you're going to find yourself with At the introitus, you're going to have your meatus, you're going to have your vaginal canal opening, and then you're also going to have the proximal inset of that phallic urethra, which is eventually going to be connected. So, it's important to make yourself very familiarized with the anatomy of that particular patient, and make sure that you're going for the right part.

And that's inferior, if you're at that, that stage where you've

just created a phallus, we have not. Perform the urethral insert. So when we insert the proximal urethra, what we essentially do is we excise one of the labia minora, and the reason for that is to create a flat mucosal surface that will eventually become the pars fixa or the connection between the native or congenital urethral meatus and the phallic urethra.

And so essentially, We're going to see the inset of that proximal urethra when it's not connected after stage one, just superior to that labia minora on that side. Are those steps pretty standard across the country, or does each program do some of that a little bit differently? I would probably say in the U.

S., the majority of centers do stage it. Again, because the sequela and the possible complications from a urologic standpoint increase significantly. The, not, not so much the

morbidity overall, specifically, but essentially, the risk of having a flap complication as a result of the urologic complication. So as a way of sort of avoiding compounding those risk factors or that risk, then essentially, we focus basically only on the microvascular flap portion and then on the urologic sequelae so that if there is an issue with the urologic portion, then hopefully there, it doesn't translate to issues with perfusion of the flap.

That being said, right? Individuals who have had a metoidioplasty, meaning basically where the erogenous the erogenous tissue or the clitoris is essentially enlarged. But the removal of the suspensory ligaments with or without urethral lengthening to that elongated clitoris, then essentially in those instances, it is not done often as a stage procedure.

We actually go straight for the urethral lengthening because of the way that the tissue has already been manipulated previous, but in an individual who hasn't gone any procedures,

by and large, what we're doing is we're staging them. Is there anything else about that operation, as a general surgeon doing an emergency operation, anything else we should be very mindful of once we're inside the abdominal cavity past the epigastric or the skin level?

I think it's important to note, right? And again we typically try to stay outside of sort of the rectus space unless you're going in for, a hernia repair. But it's important to know that we are sacrificing the deep inferior pegastric system. So certainly there's a confluence and you still have the super, the superiors.

system as long as they haven't had any kind of heart bypass. So it's really important to know that that rectus muscle is now relying on one major pedicle as opposed to two, right? So that muscle may not tolerate as much as it would have otherwise. I think that that's really important, especially as you're closing the tissue and you know, avoiding further trauma to the muscle itself.

I think that that's one consideration. The other consideration comes into, and this is not as much on a sort of an acute sort of situation, but more so planning. For example, if you're planning on doing a TEP or even a TAP, for an inguinal hernia repair. It's really important, right? Because now you're crossing.

And so, for example, we connect the flap to the ilioinguinal nerve. And while we don't go into the inguinal canal or anything of the sort, certainly sometimes we use even a little bit less. external ring to bring our pedicle through it. So it's really important as you're planning on doing an inguinal hernia repair that you're very cognizant that there might be some structures there.

And in those patients depending, it might be even better to do an open approach as to a tap or a tap due to the risk. Just something else that I thought of that's really important semantics. So, for example, if we harvest a left radial forearm flap, then the pedicle to which we connect our flap is on the

right side.

And vice versa. And so essentially the pedicle that we utilize and where our vessels are going to lay, it's going to be on parallel with where the urethral inset is so at, you know, even if you're just looking at the sort of the vault, the anatomy, the genital anatomy where you see the urethra is by and large, the side on which we harvested the vessel.

So that's important right from a planning standpoint. Sounds like if we're gonna do a hernia repair, we should reach out to a fellow plasty surgery colleagues. Probably so. Just to change it up just a little bit here. Next portion of the scenario looking to treat a trans feminine patient with vaginoplasty.

Primary team is trying to place the Foley catheter. Anything different for those type of operations, that type of Foley placement? Same scenario, laparotomy for abdominal aorta. So I can, I guess for

us in terms of, I've seen this as a consult. So, at our center we primarily do penile and virgin vaginoplasties.

And so differently than radial forms or phalloplasties, you know, we're, we are doing things to the urethra during these operations, but we're not doing any type of anastomosis. I should say in like the first The first scenario, I think like one important takeaway is you really have to understand not only the pedicle anatomy, but also the fact that there is a large amount of urethra reconstruction.

So you don't want to be trying to pass a fully blind. And you probably do want a urology consult in order to do that. For the second scenario when we are working on urethra we're essentially almost taking it down to the bulbous spongiosus muscle, and then we're basically spatulating it and setting it and shortening it.

So we're actually opening it up and as opposed to performing anastomosis reconstruction. So. There

isn't as much issue with stenosis of the urethra most, and there's not really any type of urethral structure or fistula that is normally encountered. Not to say that there aren't cases of fistulas involving the urethra for vaginal plasty, but they're much less common.

Same thing with structures. So, usually in this case we would. just come and place a Foley catheter. I should say too, in terms of the size of the Foley catheter most people are able to pass just a standard like 16 French catheter. You know, I, I don't know if you have any other thoughts.

I was going to say, is this, is it done in a staged fashion too, in similar to the not. So, essentially in penile version vaginoplasty you're taking many of the same anatomic parts of assigned male at birth genitalia and making them assigned female at birth genitalia or more feminine appearing.

So, you know, the glands of the penis becomes the clitoris. We take out the the vulva spongiosum and

And the urethra, the native urethra is the same urethra that you see. The scrotal tissue becomes usually the labia majora as well as some of the lining, depending on the center, some of the lining of the vagina.

The scrotal skin usually also is used as a skin graft. On the inside of the vagina. The skin of the shaft of the penis is used for some lining of the vagina as well. And that kind of varies based upon the center. But essentially we're taking the same and same anatomic parts and converting it from a more masculine appearing genitalia to more feminine appearing genitalia.

The only one consideration that I would say is especially more so with penile inversion vaginoplasty, although occasionally also with robotic, is that because of the tension from the actual inversion of the skin, sometimes it actually causes the urethra to be displaced a little bit anteriorly, right?

And so patients, and the reason why we know this, patients sometimes complain of spraying when they're urinating. And so it's important to note

that, you know, relative to where you would have otherwise. sort of found the urethral meatus, it might be displaced a little bit more anteriorly. Typically, if you start from the clitoral head and work your way posteriorly, you will always kind of fail safe find it.

And Amy, I know you, you do work with the, your class surgery colleagues with peritoneal flaps. Can you discuss a little bit of where that comes into play with this type of operation? Yeah, so outside of, Holy catheter placement, I assume. Yeah, yeah. In the reconstructive portion. Yeah, so my part of it is very minimal relative to what Megan and Monica are describing, I think.

My part of it is really just placing, because we do this robotically, we just place, you know, robotic ports facing the pelvis and Basically create peritoneal flaps peritoneal flaps using the anterior being the bladder flap and then the posterior flap being essentially

on top of the rectum and create essentially the apex of the vagina or the distal portion of the vagina and connect that to the the penile skin, the tube of the vagina.

So, so a circular anastomosis of the peritoneum to the scleral skin. Correct. And then you close off that at the top so it's not in direct communication with the Exactly. So that it is closed off off top so that it's not in direct communication with the intra abdominal cavity. And then what are the techniques to match up the bottom from the top as to the top?

The, as you're doing the surgery from the bottom and then they're, I'm assuming, handing you up the skin and then you have to, I'm assuming, size it in a way to make sure that this will be appropriate for intercourse. So, one thing to note is that not everyone uses this for sexual intercourse. So I think that's just an important thing to note that it's I think Megan you probably, Monica, you probably have a better idea about how to size this appropriately, but from my standpoint, it, when we were trying to approach the perineal flaps

and ensuring that there's not a lot of tension between the flap itself and the skin that's being delivered through the through the perineum.

That's how we think about it, how I think about it, at least from the top side of it. Or from the abdominal portion of it. So I actually I've seen some, or when I visit another institution in terms of the sizing, it's usually the skin graft is sewn over a dilator. I don't know Amy, what has been done at Michigan, but it's dilator that's formed and then it's passed through.

And if there isn't enough skin from the penis. The, there is always an opportunity for skin graft or if it's a redo, which is what we've been doing in Michigan now is we, there if there's not enough skin, other centers are using Alloderm. Do the majority of patients with your initial operation able to just use the penile skin or some other augmented, something like peritoneum or the grafts

used up front?

Okay. I think there is a few different criteria that different centers are using. Um, I think OHSU has a really nice pathway for patients and like some good patient education materials about when they choose one versus the other. Generally one of the biggest things is how much scrotal skin do they have?

So the scrotal skin usually is used as the skin graft harvest site for these operations. Especially if someone's like puberty suppressed and I should say also the shaft of the skin of the penis, but primarily like squirrel skin. So if they're puberty suppressed, they don't have a lot of general skin if, you know, they've had a previous vulvoplasty that would be another reason to potentially do a robotic approach.

The reason to do a penile inversion vaginoplasty, one of them would be there's You know, given the technique and the positioning of robotic vaginal plasticity, there are BMI cutoffs at many places, just because you really need

steep Trendelenburg for these and it sounds like it's very difficult to do these peritoneal flaps at a certain point, a certain BMI.

Yeah, we haven't come across that yet at this point. Again, this is still, still very new. This is still a very new approach relative to the, This type of surgical care. So, I can't say there's absolutes for us. I mean, I think it's the same thing when Andrew, we do rectal cancer cases, right?

Like, sometimes when there is a more narrow pelvis, it's much more difficult to see into the pelvis, but we haven't come across that yet. And I don't, I I've heard of BMI cutoffs for just doing it, just not even the robotic approach, not even doing the peritoneal flaps, but not. Yeah. You know, for the robotic itself.

I'm not aware of any. Yeah, no, I think that, they're, again, like you were saying, there's just, it's just all so new, and where do, when do we employ each one, right? Certainly going straight to a robotic approach, it can have its downfall. And the fact that then we're left with zero

bailout, if there's any issue, right?

And specifically right and vaginal plastic, you really talk about the loss of depth. Especially, you know, It sounds like it wouldn't be as hard as it is, but taking three times a day to dilate when you're trying to sort of live your life, have a job, do all these other things, it's very hard, right? So as a result of that, and just sometimes just some healing factors, right?

We lose a lot of depth and if we've gone vaginoplasty from the beginning, then certainly you are left with very little recourse, right? Secondarily to that, which is one of the things that we always stress. Now, with more and more individuals who are pubertally suppressed, like Megan was saying, then certainly the issue is that you don't have enough genital skin to create that.

But, you know, to a certain degree at our institution, we are certainly counseling patients more and more, especially younger patients about doing a staged approach. And this kind of goes back, Andrew, to your question

while there is no actual staging for vaginoplasty for individuals, for example, who are having surgery in their early twenties who are in the middle of college or getting, you know, settled with their jobs or whatever it may be.

We found that those Patients have a much harder time sticking to the repeated sort of dilation protocols that are necessary to preserve that depth. And so, in view of that, we've been counseling patients more and more about going a vulvoplasty to vaginoplasty route. And so, essentially, we created a no depth vulvoplasty, or vaginoplasty, so to speak to sort of, Give the external genitalia alleviate the gender dysphoria, and then when that patient is sort of older in a more stable sort of situation that they're able to kind of fully commit to the dilations and that protocol, then we go in and then we create a canal on.

With peritoneal flaps. Certainly right. The consideration is

that at that point, you no longer have a skin graft from the scrotum or, you know, the penile shaft to use. So certainly we have to rely on harvesting other skin grafts, likely from the inguinal area, but certainly it has proved to be a really powerful sort of resource for patients that otherwise are very dysphoric, but for whom that dilation requirement would be, you know, would be precluded.

Every kind of patient is different, right? So occasionally we have someone who has a lot of shaft skin that we're able to sort of mitigate and use less of the skeletal skin. In theory, right, they've already had electrolysis, so the hair bearing is not as big of a concern, but certainly right. The type of epithelium from the scrotum that you can obtain is very different from that of the shaft.

And so if we can kind of mitigate and, minimize the amount of scrotal skin that's being used, and certainly that's a little bit of a plus side. It also means that there's one less suture line to

heal because then we're not going from penile skin to scrotal skin to peritoneum, for example. So I think that those would be the only considerations that I would add.

Oh, and you know, sorry, I apologize, because Monica and Megan, you guys are, you live in this space a lot more than the general surgeons, and so, just so you, so Andrew and Dan know, part of this is the electrolysis, so if you're using this skin as tube, you don't want it to be lined with hair, and so that's part of the preoperative planning of doing these operations.

And the other thing is that in the post operative planning, people have to do dilations to to keep it patent if they decide to do penile inversion vaginoplasty and not do just the no depth. And so, Part of that is a lot, there's a, still an in an in incidence of people getting vaginal stenosis, and that's where my role is that we aren't doing, so there's primary and secondary, you know, vaginal plasty or people who the primary vaginal plasty are, first time.

But then what we, what I've been involved in is when people develop vaginal stenosis and that's when, just like what Monica is describing is it can be

helpful as a backup plan if. There's, if there's vaginal stenosis and you need extra tissue, it's helpful from that standpoint. Does that make sense to you guys?

Is that, am I explaining this correctly? I'm just, I'm just like, I know, like we, we're getting into the weeds of this. And if you don't, if you don't know parts of those, like when I was starting to learn this, I needed to like really have Megan teach me, like outline the process of this because it's, there's a lot of different steps and it's very different than general surgery.

That's a very helpful explanation and seems like having all these different steps definitely can be a little bit confusing, but it's interesting to hear it all kind of be put together because for those who don't do it, we're going to see the finished product. Just knowing that there's all these different options helps us create whatever plan we need to do for that patient at that time.

So with that statement, I would like to ask. Other surgical procedures, either emergency or elective, what, what should we as general surgeons be mindful of if for a patient that's had a vaginoplasty? I would say

probably one of the big things that, that general surgeons may encounter is during the time of these penile inversion vaginoplasties there's a risk of rectal injury just because remember where the space, they're going, in front of the denon VAs.

And so the, There's not a lot of space there. And so, there is a risk of rectal injury during the operation, but also during the dilations, there can be injury to the neovagina and actually causing rectovaginal bistulas. And so that's a consideration and depending on when and where it's located and the size of it would depend on how you want to manage it.

But I would say, using the same principles of being safe, controlling sepsis would help determine how you want to manage those things. The other thing is that there is an approach in using a piece of the intestine as the new, as the neo vagina. And so that may be a place where a general surgeon may be called in to help with these operations.

Consideration to that. I think it's really important is when peritoneal flaps are used for

robotic vaginoplasty. And there's unfortunate incidents where there is, you know, a suture line failure, the patient will typically present with abdominal pain. They'll get a CT scan and they'll see free air in the abdomen.

And so that'll Immediately be the alarming call to the general surgeon that you have a patient who underwent robotic vaginoplasty and now has concerns for a perforated viscous or something because they have free air intra abdominally. And so it may be a suture line, you know, rupture. And again, this is all contingent upon what the timing is relative to the robotic procedure.

But I think it's really important to get the, you know, the gender surgeon involved and, or, Just be very weary that this may be a result of suture line failure as opposed to an actual hollow viscous injury.

Has there ever been any incidents of herniation through the suture line failures?

Yes. So, there, if you don't close

the space adequately, there's always a potential of having, you know, intestine fall through those. those areas. So yeah, that's certainly a risk. And then how about management of rectal cancer? That I asked on the colorectal side of things. If you've done one of these flaps and they need a single weight LAR, whichever it may be, I'm assuming you would Need to sacrifice that, that portion, or is there a way to preserve what you've already created?

It's a good question. My thought about this would be if this happened and there was a person with a low rectal cancer who needs, adjuvant chemoradiation. Obviously this would be an important thing to have decision making, a real important conversation with the patient about there's going to be radiation to the area if there's a, if there's a, if the cancer is, You know, high enough stage, but if you have to do in the operation.

You're going to have to take that down essentially, right? And so that

will come with it because the flat, the posterior flap is essentially the anterior wall of the rectum. I would venture to say, because you're violating right, you're right on the non VDAs fascia, and there's basically no real.

Right, that's going to become a scarred plane that when you're even with an LAR, especially with an APR, that that skin graft, which is thin in and of itself, is now going to be really adhering to that rectum. So it's either a consideration that a plastic surgeon would have to be involved to do a, Vertical rectus abdominal flap with a skin paddle to try to suture to that skin graft.

I don't know how fruitful that would be. There is literature about doing basically tubularizing a VRAM in order to create a vaginal canal in patients who have to have a near complete vaginectomy for other malignancies or just in general. And so certainly

that would be a consideration, but that has to be a very kind of.

Deliberate conversation with the patient because it's very unlikely that you will be able to get a tissue plane developed between that knee of a vagina and the rectum or the, well, the rectum or the sort of lower sigmoid because sometimes it even scars down especially if you've done peritoneal flaps, you're anchoring all that down enough so that you could spare the vaginal canal while removing what you need to remove.

Yeah, and there, I mean, you're right. There's no tissue plane. It's essentially skin, right? Adjacent to it, or, you know, within that space. And so it's, it would be really challenging to think about how you, that wouldn't be sacrificed, unfortunately. Yeah, I mean. Because even the skin graft, right, we're relying on those vascularized tissues from around, you know, the rectum and sidewalls and everything to

allow that skin graft to survive.

So, by definition, there is no dissectable plane, right? Right, right. Like, it's essentially adhered in order to survive. Right. And I guess my only, my point about, having the discussions is, of course, if somebody has cancer, as the as colorectal surgeons, you want to say, we got to treat your cancer, but to, you know, the, this is the patient's body.

And I fully believe that, they may say, I'd rather not, I'd rather not sacrifice this. So I think it's really, we can only offer our professional opinion on what we think the right thing to do is to treat a cancer, but they may not. And then we were seeing that right with how many people were going through watch and wait right now, and they're like, I'd rather not have an operation at this point, and they really are pursuing more watch and wait approaches for rectal cancer.

So, even to that point, it doesn't even have to be surgery, right? If you have someone with squamous cancer and you're counseling them on a Negro

protocol, right, how that may or may not affect their vaginal canal, I think is also a valid and important conversation. Yeah, absolutely. Absolutely. Is there any role for more frequent screening of the rectum for rectal cancer after they've had these procedures?

Not rectal cancer specifically, but I would say that certain patient populations are at higher risk for squamous cell. I think one of the biggest things is that patients do still have their Prostate after these exams after these operations. So especially patients that are getting vaginoplasty at an older age where they have been exposed to testosterone and have not been on testosterone blockers for a long period of time.

Patients definitely need to be advised that they do still have their prostate and they should follow up with their primary care physician in terms of working on screening I know that prostate cancer screening is very variable now and

people have very strong opinions depending urology, but making sure that patients and their primary care doctors still do know that they need prostate Screening when they do get to a older age is important.

And then for those who have sigmoid or, intestinal vaginoplasties. It's important to make sure that those are still screened for, regular colonoscopies in the same way. That's the only other thing I would add. I think the other important thing is for specifically like colorectal screening purposes is just to make sure that, just because someone, is trans doesn't necessarily mean that they have sexual intercourse in a certain way, or that they participate in higher risk activities.

I think that's a really important thing to bring up with this audience as well. And Amy, just going back real quick I was wondering if you could just take us through your algorithm for the management of the recto neovaginal fistulas. I know you touched on it a little bit. Oh yeah. So it's, I mean, it's generally the

same That we would think about, conservative measures first, right?

So fiber supplementation, control local sepsis, if it, if there is any especially if it's small. So if this happens in the operating room, it's, call, please call one of us to help assess. And generally these folks have a bowel prep so they can be primarily repaired to prevent a vector vaginal fistula from forming.

But then if it does happen where the person, there's You know, there's stool in some of the packing. That's generally how people present. And so, a way to think about how to manage it is, conservative measures first, right? It was just fiber and control local sepsis. And then if not, if surgery is necessary, it's does this person need a diversion?

Depending on how bad the official is, how big the official size is. Because again, this is, I mean, it's, If this is a penile inversion vaginoplasty, it's like paper thin. It's a paper thin skin graft next to the rectum. And so you're not going to be able to do a transvaginal approach. If anything, you would have to do some kind of

transrectal approach.

So like an endorectal advancement flap or some kind of VY flap would be recommended. And again, whether or not you decide you need to do diversion would depend on how symptomatic the patient is. I don't know, Monica, do you have any other thoughts about rectovaginal fistulas in patients? Or preventing them in the operating room or how you manage them in the operating room.

No, I mean, I think that you hit all the definitely really important points, right? And so You know, it's one thing to, and unfortunately, right, because of the dissection, you want to keep it as dry as possible because they can, you know, post op hemorrhage is one of the biggest complications or fear complications that we have certainly rectal injuries right there.

But my point is that if there's going to be a rectal injury, it's likely going to be thermal. And so that's the biggest concern, right, that there's going to be some thermal spread thereafter. And so certainly, Kind of assessing it right away and identifying is going to be the most important part right to mitigate and either if we can put a biologic in between something interpose or find some kind of tissue, right?

That's always ideal in that scenario. Not always feasible. Certainly. But it's, it's advantageous to actually catch it before it actually becomes a problem because as we were alluding to earlier, there is very. There's no space between that skin graft and the rectum, essentially, and the skin graft is not very robust, right, as a tissue per se and so certainly once that establishes, and again, because everything is going to be adhered, if you had a rectovaginal fistula in an individual who was assigned female at birth who has a vaginal canal congenitally, then certainly, You know, you can actually separate that area.

The rest of the vagina presumably is not well adhered to the rectum. And then you can put a gracilis muscle. You can put some kind of interposition, well vascularized tissue. That doesn't quite happen as well or as easily with a neovaginal, neovagina because essentially, right, everything is scarred down.

So essentially mitigating that situation, right. In an unfortunate circumstances where that, you know, where it was caught afterwards or whether it's very

symptomatic. And certainly right performing loop diversion to at least minimize the amount of flow through through that area to allow it to hopefully the heel would certainly be ideal.

It's just a very sort of difficult situation, which is why again, it is just one of those things that you really want to steer clear of. But occasionally, the dissection can be very limited in terms of its visualization from the perineum, which is one of the advantages of the robotic approach is that it helps meet halfway to the surgeon who is down and In the new vulva.

But certainly it's a difficult situation. Yeah. And I'll just add Monica. You did bring that up that important point too. So not just during if you recognize as an injury in trap and putting a piece of tissue between, the rectum and that new vagina that has no space. Otherwise if it is discovered later on, and you're at a point where you're thinking, do I need to divert?

There's probably an opportunity there might, you know, rather than just doing a transactional approach. Is there an opportunity to put a piece of tissue in there? In which case, then the plastic surgeons help and get either a piece of gracilis flap or something to try to

place in between that fissile or in that fissile space and then potentially needing to divert.

Where within the anus and rectum is the actual rectal side of the fistula? Is this based on the dissection? Is this something that's above the dentate line? Is it pretty proximal in the standard place if they do happen? It's typically proximal right? Because right as, especially as you're arcing right, you're trying to protect your prostate and so you're really angling down.

But by then you've got Basically past really the dentate line. Right, because in the situation where you would have an injury kind of at the level of the dentate line, I would presume that your fistulas tract would be basically at your introitus, because it would It basically work itself out almost like a perianal abscess sort of situation.

The problem is when you're proximal, that's when it's going to fistulize into your neovaginal canal. Okay, that makes sense. I was trying to differentiate between how it may look with a cisgender

woman, female, vagina, standard perianal fistula. Which now, that makes a lot more sense on how difficult that could be to manage.

Is there anything, do you do anything intraoperatively before you leave the OR to test it? I guess if you're only doing a primary inversion vaginoplasty, you're not doing anything abdominally, so it's not like you can do a leak test or something at that point, but is there something else that you typically do?

So I think that this varies by center, so, At our center, we do do a bowel prep. Not every single center does. And one thing that we check with any dissection, and I should say to you know, at our center, we're primarily doing canal inversion vaginoplasty, so not robotic as Dr Swann, or as Amy was saying in terms of like, we're not doing like primary robotic cases currently, but we will actually do a beta dynamo after creating the canal.

So we. We'll put actually basically like

some like a towel inside of the vaginal canal. And then we'll do a beta enema to see if there is any bleak into the vaginal canal. And that's just regardless of, that's just like a primary, that's a portion of the vaginoplasty. And then if there is a rectal injury that is identified, we will do it again after repairing the The injury and they should say two in terms of developing a fistula.

If there's a right known rectal injury, there is a significant chance of a fistula forming. These don't happen. I mean, like the textbook incidence is one in a hundred, but they don't happen super often. So, there's not a ton of great data, but a large proportion of them have a known rectal injury at the time of their primary vaginal plasticity.

So that's how we look to see if there's one. Well, this was absolutely wonderful. I really appreciate all of this information. I wanted to give the three of you one more option to tell the surgical community

anything else that you feel that we should know about going into an operation for folks in this situation.

This may perchance not be as applicable to the general surgeon, but I think it's nonetheless very important. In situations where there's any concern in a prostate exam needs to be done and someone who has a vaginal canal or new vagina. It is ideal that you go. through the vaginal canal to do your digital test as opposed to your rectum.

It's something that sometimes kind of just is not really well thought of. But the truth of the matter is if that you do your digital exam via the rectum, you're going essentially through the anterior rectal wall, the posterior and anterior. vaginal canal in order to feel the prostate. And so I even had the experience of, you know, speaking with someone who had had a vaginoplasty and they went for a checkup and they went to do an exam and they were like, no, no, that's not where you need to actually check.

And so certainly I know that, you know,

behind the knife extends far beyond general surgery. So I thought it was just important to make note of that. I think for me, my last parting words would be, when, working with This patient population, it's important to create a an open and welcoming and non gender judgmental environment.

And so, recognizing that a lot of folks may not feel comfortable coming into. Our medical communities because they've been just they've been experiencing a bunch of discrimination in the past and making sure that we are doing the right thing and treating patients with respect and dignity is the most important thing to me.

And if that's making sure that we're using correct pronouns and being respectful of of how we examine the patients. And in speaking with them, I think that's, that's one of the most important things that I think we need to take away. I think the biggest thing too is just for the general surgery population is just planning.

So I think over the past two podcasts, one thing is that there is a lot

of nuance and there's a lot of differences. I think one great thing about This field is that it does kind of get to many ways the heart of plastic surgery, which is, you're kind of taking you have to, not every single procedure is standard.

So, if there are any questions reaching out to the surgical team or the subspecialties involved, such as plastic surgery, urology. That can give you a lot of these nuances, especially if you're planning an operation. So understanding where the pedicle is either ideally for that particular patient, but also just in general some of these big considerations that are actually like pretty standard.

Parts of plastic surgery, flat planning. What's a graph versus a flap, things like that. So, I would say the biggest thing is that if you are planning a procedure and obviously in general surgery, you guys deal a lot more with emergencies than we do, but reaching out to, the plastic surgery team or the urology team before doing anything would be great.

Well, thank you all again so much. And thank you, Dan. And behind the knife, this was a wonderful episode. I learned a lot

and I really appreciate you having us on here. Yes. And I echo what Andrew said. Thank you so much. I equally learned a ton from these past two episodes. So thank you all for joining and to our listeners dominate the day.