Abstract
Introduction
To describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20 cm in length and 3.5 cm in diameter) in a case of male-to-female transsexual.
Presentation of the case
The patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70 min.
Discussion
Up to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator.
Conclusion
Laparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.
Keywords: Sigmoid neovagina, Male-to-female transsexual, Laparoscopy
1. Introduction
Male-to-female transsexual surgeries are well defined and have achieved perfect cosmetics and excellent functional results. These techniques include reduction penoplasty/clitroplasty allowing for clitorial orgasm, orchietectotmy, creation of a normal and adequate vagina, an introitus, and vaginoplasty for a normal sexual intercourse.1 Although the surgical techniques of male-to-female transsexual are standardized, the post-operative complications of these surgeries remain challenging. Complications include wound infection, necrosis of the glans, vaginal stenosis, bowel obstruction, rectovaginal fistulas and neovaginal shrinking.2
For preventing shrinkage and stenosis of the neovagina, long-term intravaginal stenting is prohibited;3 instead, patients are encouraged to have daily intravaginal dilation by applying a large vaginal dilator for 15 min daily.4 The complications with the application of such dilators in male-to-female transsexual patients have not yet been reported. We present a case of vaginal dilator migration to the abdominal cavity through the intravaginal dilation in a male-to-female transsexual patient who had undergone sigmoid vaginoplasty. The patient was managed laparoscopically to reduce the associated morbidity of an open procedure and to avoid any further large abdominal surgical scar.
2. Case report
A 24-year-old male-to-female transsexual patient, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She was afebrile and had no problem in defecation and micturition. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month and breast augmentation 6 month before admission. The technique used for gender reassignment was sigmoid colpopoiesis approach that involved orchidectomy, neourethrostomy, clitoroplasty, creation of neovagina by using sigmoid colon. Briefly, through a Pfannenstiel abdominal incision, about 20 cm segment of sigmoid colon on its vascular pedicle had been harvested. The proximal end of the sigmoid segment had been closed. The flap had been passed through a rectovesical tunnel and its distal end had been sutured to the perineum. The operation was successful.
She was not sexually active and used a large vaginal metallic dilator (length 20 cm, diameter 3.5 cm) 15 min twice daily for prevention of vaginal shrinkage.
Attempts for transvaginal extraction of the foreign body failed because of upward migration of the dilator toward the abdomen. The tight pubic arch did not permit for caudal movement of the dilator. The patient was scheduled for abdominopelvic laparoscopic exploration.
A written informed consent was obtained from the patient for any need of conversion to open surgery in case of difficulties during the laparoscopy.
The patient had been offered abdominal laparotomy in many centers before referring to our department. But she insisted on avoiding any major open operation with a potentially lengthy postoperative recovery and large abdominal scar.
3. Methods
The patient was admitted 3 days before surgery. The urinary tract was evaluated with abdominopelvic sonography, intravenous urography and voiding cystogram to ensure its integrity. No rectal injury was detected in rectal examination. Preoperative care included complete bowel preparation, rectal enema and intravenous administration of Ceftriaxone and Metronidazole.
3.1. Surgical technique
With the patient under general anesthesia in lithotomy position with 30° head down position, three port transperitoneal laparoscopy was done with a 10-mm camera port at the umbilicus, a 10- and a 5-mm ports along the left lateral border of rectus muscle at the level of umbilicus and at left lower quadrant area at the midpoint between the umbilicus and anterior superior iliac spine; respectively.
Laparoscopic exploration of pelvic cavity showed that the neovagina remained intact containing the large dilator (Fig. 1A). Through a transverse incision over the sigmoid vagina the dilator was extracted (Fig. 1B), snared in an endobag and put in the abdominal cavity. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques with polyglycolic acid 2–0 stitches in two layers. After ensuring the integrity of the repair by intraoperative vaginal examination, the dilator was removed by extending the site of umbilical port (Fig. 1C). A Hemovac was put as an external drainage in the pelvic cavity and the trocar sites were closed.
Fig. 1.
Laparoscopic view of the intact sigmoid neovagina containing the large metallic dilator (A) which was extracted through a transverse incision (B). The dilator was removed by extending the site of umbilical port (C).
4. Results
Operative time was 70 min. Diagnosis and removal of the dilator was successfully accomplished in a minimally invasive milieu. Estimated blood loss was minimal and no blood transfusion or open conversion was required.
Oral intake was started on the first postoperative day when bowel sounds resumed, and was gradually advanced. The hospital stay lasted 3 days and the Hemovac drain was removed on the discharge day. Two weeks after surgery, daily vaginal dilation was instructed.
5. Discussion
Male-to-female transsexual surgeries are well established with excellent reported results. Various methods have been described for neovaginoplasty in these patients. The type of procedure depends on the patients particular circumstances. Rectosigmoid segments have been widely used in intersex and transsexual patients.5 This procedure has several advantages over its counterparts including: normal tactile feeling, sensibility, excellent arterial support, natural lubrication, no need to skin grafts.6 Although this procedure is partly standardized, the surgery remains challenging due to the possible complications. The previously reported complications of this technique were including wound infection, pelvic abscess, vaginal stricture and bowel obstruction.1,2
Daily vaginal dilators are frequently used after male-to-female transsexual surgery to prevent vaginal shrinkage and to prevent long-term continuous intravaginal stenting. The most important cause of vaginal shrinkage is postoperative infection that interferes with wound healing process.
Most investigators have noted that 15 min daily vaginal dilation prevents the neovaginal depth and introital width lose.3,4,7
To the best of our knowledge, this is the first reported case of upward dilator migration to the bowel segment after rectosigmoid colpopoiesis in male-to-female transsexuals. As the sigmoidal portion was used for vaginal construction, we approached the migrated dilator as a rectal foreign body.
The extraction and management of rectosigmoidal foreign bodies is quite complicated especially when the foreign body has a smooth, metallic surface or a circular shape as in our case.8
Most of the problems that are encountered during the approach to rectisigmoidal and vaginal foreign bodies include diagnostic difficulties and the selection of the most appropriate therapeutic modality.9 Many of rectosigmoidal or vaginal foreign bodies, approximately 60% of reported cases, can be extracted transanally or transvaginally with adequate sedation.10
Several equipments and procedures have been introduced for nonsurgical removal of rectosigmoidal and vaginal foreign bodies: a Foley catheter that is placed proximal to the foreign body, and use of a flexible endoscope equipped with a snare or basket.11
When surgical exploration is indicated, a longitudinal laparotomy is performed to extract the foreign body.12 To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metallic dilator. We believe that laparoscopy offers a minimally invasive approach and to the best of our knowledge has not yet been reported for the removal of foreign bodies from the rectosigmoid, vagina and uterine.
6. Conclusion
The practicing urologist is likely to encounter a male-to-female transsexual patient. This case demonstrates that when approaching the vaginal metallic dilator migration to the sigmoidal vault used for vaginal reconstruction in a person who has undergone male-to-female gender reassignment, the laparoscopic approach is a viable salvage alternative for exploration of the possible perforations and removal of the foreign body to avoid any further open surgeries after transsexual surgeries.
Conflict of interest
None.
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for the publication of this case and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.
Authors’ contributions
A. Aminsharifi supervised the study, F. Afsar and A. Tourchi were involved in the drafting of the article, and M. Jafari did the data collection.
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