Rectal Injury during Penile Inversion Vaginoplasty: An Algorithmic Approach to Prevention and Management

Background:Penile inversion vaginoplasty (PIV) is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris and a natural-appearing vulva. Creation of the neovagina requires opening of the prerectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3% to 5%. Methods:Adult patients who underwent PIV at the authors' institution were identified retrospectively. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. Results:Ten of 146 patients (6.8%) experienced a rectal injury. All patients underwent an immediate repair (two-layer repair in eight patients, and three-layer repair in two), with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified 18 relevant publications, with scarce in-depth analysis of management of initial rectal injuries. Conclusion:The authors' algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care.