Repair of Rectal Vaginal Fistula in MTF

SavageGlow · #1 ● 05-09-2024, 06:51 PM

A 24-year-old male-to-female transgender adult with a body mass index of 25.8 kg/m2 who underwent gender reassignment surgery through penoscrotal flap vaginoplasty [6] in an external center was admitted to our clinic with the complaint of fecal incontinence through the vagina. Her medical history revealed no comorbidities or previous surgery, and she was using psychiatric drugs. After the initial surgery, neovaginal dilatation was performed using specifically designed dilators to prevent neovaginal stenosis, and fecal incontinence through the vagina occurred three months after the initial surgery. The patient was followed for a couple of months; however, no spontaneous closure of the fistula was noted. In our clinic, physical examination was performed in the lithotomy position under the supervision of a gynecologist, and methylene blue dye was given via the transanal route, which was fistulized to the vagina through the anterior wall. The fecal diversion was decided to prevent fecal contamination of the fistula tract and to provide secondary healing. Transverse end colostomy was performed. After three months of surgery, the patient was reexamined in the lithotomy position. However, the methylene blue dye, which was given via the transanal route was found to be fistulized to the vagina through the anterior wall. As a result, restorative perineal graciloplasty was planned. Written informed consent was obtained from the patient.

>>The gracilis muscle is a long and slender muscle located in the adductor compartment of the thigh. Its transposition is a viable option for repairing fistulas between the neovagina and rectum [7]. The operation was performed under general anesthesia in the lithotomy position (Figure 1).

>>Preoperatively prophylactic intravenous antibiotherapy was administered. The neovagina and rectum were cleaned with povidone-iodine, and a Foley bladder catheter was inserted for urine output monitoring. An anterior perineal incision was made between the neovagina and anus. The groove located between the rectum and neovagina was gently dissected, and the fistula was reached. The fistula tract was dissected and primarily repaired using tension-free Vicryl 3/0 sutures (Figure 2). After repair, hydrogen peroxide was injected into the fistula through the anus to ensure that there was no leak from the anterior wall.

>>A transverse incision from the proximal and an oblique incision from the distal left thigh was made, and the gracilis muscle was reached. Through the distal incision, the distal tendon of the gracilis muscle was cut, and the muscle was mobilized, preserving the proximal neurovascular pedicle (Figure 3).

>>A subcutaneous tunnel was created between the proximal thigh incision and perineal incision, and the gracilis muscle was retrieved to the perineum. The muscle was then fixed using the vicryl 3/0 sutures between the anterior rectal wall, which was repaired, and the neovagina (Figure 4).

>>Perineal and thigh wounds were primarily repaired, and aspiration drainage was placed to the surgical site (Figure 5).

>>The patient was hospitalized with bed rest in the ward for two days. No postoperative complications were observed, and she was discharged on day eight. During follow-up, neovaginal dilatation was recommended to prevent neovaginal stenosis. At three months of follow-up in the outpatient setting, an examination was carried out in the lithotomy position, and methylene blue dye was given via the transanal route. No vaginal leak was seen, and the fistula was found to be completely closed.

>>After three months, transverse end colostomy was successfully closed, and the patient was discharged from the hospital uneventfully on day five. At six months of follow-up, she was doing well with a healthy quality of life.