A 64-year-old transgender woman with recurrent rectoneovaginal fistula (RnVF) presents for care following penile skin inversion neovaginoplasty at an outside institution. The index surgery was complicated by an intraoperative rectal injury, which was repaired in two layers. One week following the neovaginoplasty, the patient was allowed to dilate her neovagina. She developed an RnVF, which was initially managed with a diverting loop ileostomy. When the ileostomy was reversed three months later, the RnVF symptoms returned immediately.
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Fistula confirmed on preoperative flexible sigmoidoscopy
An uncommon complication
Transgender women with RnVF present with a set of symptoms that are clinically similar to neovaginal fistula in natal women, namely drainage of feces and or passage of flatus from the neovagina. RnVF is an uncommon but morbid complication following neovaginoplasty. Despite of its relative rarity, neovaginal fistula is a known complication of each of the five steps in male-to-female gender affirmation surgery: orchiectomy, disassembly of the penis, creation of a neovaginal cavity, urethral meatus construction, neoclitoris construction and creation of labia. The most significant risk factor is intraoperative rectal perforation, which occurred in this patient’s index surgery.
A multidisciplinary team, including colorectal surgery, reconstructive urology and urogynecology, proceeded with laparoscopic diverting loop ileostomy and rectoneovaginal exam under anesthesia. The exam revealed a 2- to 3-cm fistula at the cephalad nevoagnial, roughly 6 cm proximal to the anorectal ring. The providers developed a surgical plan and took the patient into surgery for fistula repair using a buccal mucosa graft (BMG) three months later.
Options for repair include fistulectomy with primary closure, local advancement flaps, pedicled flaps and/or free flaps. The surgical team chose to use an autologous BMG because, similar to native vaginal tissue, oral mucosa is tick, nonkeratinized stratified squamous avascular epithelium, lending stability to the graft while the thin submucosa permits early revascularization. Additionally, the team has a history of success with the use of BMG in urethroplasty.
“To our knowledge, this is the first reported use of BMG in RnVF repair,” says Cecile Ferrando, MD, MPH, Director of Cleveland Clinic’s Female Pelvic Medicine & Reconstructive Surgery Fellowship program and Director of Cleveland Clinic’s Transgender Surgery & Medicine program.
“We were pleased when the patient reported good sensation in her neovagina, and no leakage of stool or gas from the vagina at her three-month follow-up appointment,” says Molly DeWitt-Foy, MD, a resident in the Glickman Urological & Kidney Institute’s Department of Urology.
Fluoroscopic images of a radio-opaque enema showed that there was no connection between the neovagina and the rectum. Exam and proctoscopy in the operating room confirmed adequate repair of the fistula and the patient’s ileostomy was reversed.
Negative postoperative barium enema
Six months later, the patient reported good urinary, bowel and vaginal function with no symptoms of RnVF recurrence. At this point, the patient was permitted to begin vaginal dilation up to three times daily.
Penile inversion neovaginoplasty
Gender affirming surgery, such as neovaginoplasty, may complement hormone therapy in order to reduce gender dysphoria and improve quality of life for transgender women. The penile inversion neovaginoplasty technique involves use of the penile skin and a scrotal graft to create a functional neovaginal tube, which is inset in the vesicorectal space, a potential space that is created through a transperineal dissection. The external genitalia are created using penile skin, a portion of the urethral mucosa and the penile structures including the glans penis.
Postoperatively, the reconstructed anatomy is functional and sensate. Surgical risks include bleeding and need for transfusion; postoperative hematoma, seroma and infection; and intraoperative rectal, bladder and urethral injury, with risk for postoperative fistula formation between these organs and the neovagina.
“Following surgery, our patients are admitted to the hospital for three nights and remain on bedrest, allowing their flaps to heal properly,” Dr. Ferrando explains. “Most of our patients are from out-of-state, and require extended recovery time before returning home. Following discharge on postoperative day three, patients go to an on-campus hotel, where they are observed for four to 10 nights. We ensure that our patients are healing properly and get the wound care they need for favorable outcomes.”
Comprehensive care for transgender patients
Comprehensive care for transgender patients involves a wide spectrum of services, ranging from routine medical visits to the physical transition process. Few hospitals are equipped to provide such care. Even fewer hospitals offer surgical care for patients wishing to undergo gender affirmation surgery. Over the last several years, Cleveland Clinic has actively expanded the services it offers to gender and sex-minority patients.
The team follows the World Professional Association for Transgender Health guidelines to ensure patients are appropriate surgical candidates. It requires that patients live full time as their self-affirmed gender for more than one year, that they have undergone cross-sex hormone therapy for at least one year, and that they have letters of support for surgical transition from two mental health professionals who are well-versed in transgender patient care. Patients who have met these criteria are deemed appropriate surgical candidates. They cannot be smokers or be excessively overweight, and they must be medically optimized for surgery if they have medical comorbidities.