Surgical Problems Following MtF Gender Reassignment Surgery

Mr. Philip Thomas

Consultant Surgeon Hove Nuffield Hospital

Summary by Alice Purnell RGN, BSc, PGDC

Gendys Conference, 2002

 
Mr Thomas began by observing that patients often fail to listen to what could go wrong, because they are excited by the prospect of at last getting the operation they want. It is vital that patients understand the issues prior to signing a consent to what is elective surgery, and that she is prepared for any adverse reactions as well as for her role in post op' care, thereby reality reduces anxiety. All surgery is subject to possible complications. Fortunately there have been no fatalities in the UK and at most no more than 20% have any problems and these are generally easily rectified.

During surgery bleeding is rarely a problem, none have needed transfusions. The blood supply to the scrotal skin flaps and the neo-clitoris is vulnerable since very small blood vessels are involved. The proximity of the rectum to the inverted skin tube needs to he carefully avoided and is easily rectified if nicked. This has not occurred in Brighton, but in such a case a colostomy might be required in the worst case scenario. Urethral bleeding could occur from the stump, but this is easily cauterised. Occasionally labial bruising or haematoma may occur.

Any infections should be managed by the GP, providing antibiotics. Recurrent cystitis or pyelonephritis has occurred in some cases and should be dealt with on a case by case basis. Inability to micturate can be addressed by re-catheterisation or the use of stents. After 3 months generally things have settled down, swelling should have reduced and healing completed. In perhaps five percent of cases there may be problems arising from scarring or narrowing of the urethral opening, which can be alleviated, as a day case, by dilation of the meatus.

In the early stages proper use of the vaginal dilator is vital, and proper training in this procedure is very important. Those who do not dilate end up with a narrow vagina. Sometimes there is scarring and some narrowing of the vagina post op'. Several patients experience bulging of the back wall of the vagina (three per cent), and a few may prolapse. This can be repaired, by stitching and pulling up the vagina. Depth is not lost this way. If too much tissue is retained in the neo-clitoris erectile tissue around the urethra may cause a prominence which can be troublesome, so it is important to take away enough tissue, whilst hopefully allowing this to retain sensitivity, further surgery may offer a solution to this. Hair in the vagina and discharges tend to go together, so perhaps clearing the scrotal skin of hair will be useful in hirsute cases. It is hard to predict sensation, realistically a patient may have to face a life without orgasm, but this is unusual and so far nobody has opted not to go ahead on this basis alone. A realistic concept of depth is important, four inches is normal and adequate.

Good nursing care is very important, nurses need to be able to teach the patient dilation and aftercare. Good advice optimises a good outcome. Removal of the pack is important and generally should be supervised by the surgeon or a fully experienced nurse. Confidence is important and over enthusiastic dilation is not a good idea.

Smoking and obesity do reduce the safety of surgery (DVT, haematomas and prolapse), also fat around the area of surgery makes it hard to get good depth. HIV and sickle cell anaemia will increase the likelihood of infections and complications and will need special care. At Charing Cross they do not operate on the obese or smokers. Risk of a poor outcome is increased with age and in the case of diabetics.

A single stage operation is the norm in the UK, however follow-up revisional surgery does generally resolve most problems. Careful consideration is needed with the colo-vaginoplasty, since it is more radical than the scrotal skin flap vaginoplasty. Four out of five have no surgical problems, but it is important that a full informed consent be understood and given.