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A Rectoprostatic Fascia Reinforcement Flap for Rectal Injury and Rectoneovaginal Fistula in Gender-Affirmation Surgery

Background: Intraoperative rectal injuries and rectoneovaginal fistulas are rare complications in gender-affirmation surgery for trans women. Primary repair with an improper method may result in recurrence. The procedures required for the surgical treatment of these problems are rare. In this article, the authors describe the surgical technique using a rectoprostatic fascia reinforcement flap for intraoperative rectal injury and rectoneovaginal fistula correction in gender-affirmation surgery for trans women. Methods: Retrospective data were collected on the female transgender patients who underwent surgical treatment of intraoperative rectal injury and rectovaginal fistula with the prostaticovesicular fascia reinforcement flap. Patient demographics, follow-up, and intraoperative details were collected and analyzed. Results: From January of 2006 to December of 2018, 14 female transgender patients presented with intraoperative rectal injuries and five cases of rectovaginal fistulas from a total of 2059 patients who underwent neovaginoplasty. Two patients with rectovaginal fistulas had their neovaginoplasty performed elsewhere. The mean location of intraoperative rectal injury was 5.2 cm (range, 2 to 6.5 cm), and the rectoneovaginal fistula was 5.4 cm (range, 3.5 to 6.5 cm) from the vaginal introitus. The mean size of intraoperative rectal injury and rectoneovaginal fistula was 2.5 cm (range, 1 to 3.5 cm) and 2.3 cm (range, 0.2 to 3.2 cm) in diameter, respectively. No recurrence of rectovaginal fistulas was reported after 1-year follow-up. Conclusion: A rectoprostatic fascia reinforcement flap is an alternative technique to repair intraoperative rectal injury and rectoneovaginal fistulas incorporating the neovaginal lining with a skin graft or sigmoid colon in gender-affirmation surgery for trans women. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.