1
Condous et al, 2005
Male to female transsexualism: Laparoscopic pelvic floor repair of prolapsed neovagina
George Condous1 MRCOG, Robert Jones2 FRANZCOG and Alan M Lam1 FRANZCOG
Centre for Advanced Reproductive Endosurgery and Royal North Shore Hospital, Sydney
Gynaecologist, Memorial Medical Centre, North Adelaide, Adelaide, South Australia, SA 5006
Running title – Transsexualism and laparoscopic pelvic prolapse repair
Key words – laparoscopy, transsexualism, neovaginal prolapse, pelvic floor repair
Correspondence
Dr George Condous
Centre for Advanced Laparoscopic Surgery (CARE)
Suite 408 4th Floor
69 Christie Street
St Leonards
Sydney 2065
New South Wales
Australia
Telephone: +61299669121
Fax: +61299669126
Email:
Precis
We present the first case of laparoscopic total pelvic floor repair in a male-
to- female transsexual.
Abstract
The incidence of prolapse of the neovagina after male-to-female gender]
reassignment surgery is unknown. We present the first case of laparoscopic total pelvic floor repair in a male-to-female transsexual. This surgical procedure combined an understanding of the anatomy of the male pelvis with the principles of laparoscopic pelvic floor repair in the female karyotype.
Case Report
A 40-year-old male-to-female transsexual presented to her family physician with a three month history of increasing dyspareunia, anorgasmia, a vaginal bulge, and difficulty with defecation requiring digital assistance for complete bowel evacuation. She was referred to a gynecologist (RJ) and was confirmed to have eversion of the neovagina. A defecating proctogram demonstrated the presence of a large enterocele and mucosal prolapse (See Figure 1).
She had had the diagnosis of transsexualism confirmed in her late teenage years. She underwent breast augmentation as a 20-year-old, and gender reassignment as a 24-year-old. The technique used was a peno-scrotal procedure which involved orchidectomy, neo-urethrostomy, clitoroplasty, creation of neo-vagina by infibulation and inversion of the penile skin, and creation of neovulva using scrotal skin. The penile glans was used to create the neo-cervix. The operation was successful.
The women married another male and enjoyed a normal sexual relationship with full penetration and vaginal orgasms. She was placed on estrogen replacement therapy, initially ethinyl estradiol 20 mcg daily, which later was changed to menorest 37.5 mcg patches twice weekly.
She had been offered abdominal sacrocolpopexy for the neovaginal prolapse, but was keen to avoid major open surgery with a potentially lengthy post-operative recovery. She was therefore recommended to another Gynecologist (AL) for assessment of her suitability for a laparoscopic repair.
The patient was determined to avoid open surgery at all costs. After thorough pre-operative discussion with the patient about the unproven role of a laparoscopic approach compared to the proven abdominal sacrocolpopexy for vaginal prolapse, the possibility of surgical failure, the chance of conversion to laparotomy, the risks of bowel and genito-urinary tract injuries, the patient consented to laparoscopic surgery.
Examination under anesthesia demonstrated protrusion of the vaginal vault 3 - 4cm outside the introitus, i.e. stage IV apical prolapse of the vaginal vault (See Figure 2). The anterior and posterior lateral vaginal walls were unsupported resulting in the formation of cystocele and rectocele-enterocele. The prostate, the bulbus penis and membranous urethra were palpable by rectal examination. The perineum was intact.
At laparoscopy, the appearance of the pelvis differed from that of a hysterectomized female in that there was the presence of the ductus deferens and the absence of any residual female organs, i.e. fallopian tubes, ovaries, round and uterosacral ligaments. The prostate was not visualized as it was located below the bladder and atrophied from long term estrogen treatment.
Laparoscopic repair of the rectocele-enterocele followed the same principles as previously described in the female1, with however the difference being no midline dissection in order to avoid injury to the prostate. Two 0-Ethibond sutures were used to suture the lateral aspect of the neo-vaginal vault to the iliococcygeus fascia on each side. This effectively suspended the posterior lateral angles of the neovagina. The incised pelvic peritoneum was closed. Attention was now directed at the correction of the paravaginal cystocele via the cave of Retzius. The principles of laparoscopic colposuspension, as previously described in the female2, were followed in order to correct this defect. Two 0-Ethibond sutures were placed through the paravaginal tissue and then the iliopectineal ligament. These were then tied to effectively approximate the lateral vaginal angles to the obturator fascia. This resulted in correction of the paravaginal cystocele. Figure 3 represents the appearance of the introitus and vagina immediately post- operatively.
The procedure was uncomplicated as was the post-operative recovery with the patient being discharged on day 1 post-operative. A post- operative defecating proctogram was performed and demonstrated the absence of any enterocele and mucosal prolapse (See Figure 4).
She has been followed up for 6 years with no recurrence to date.
Discussion
To our knowledge based upon a MEDLINE search from 1966 to 2005, this is the first reported case of a male-to-female transsexual undergoing laparoscopic total pelvic floor repair for prolapsed neovagina. The term “transsexual” was coined by Cauldwell in 1949 and since then an unknown number of people worldwide have undergone sexual reassignment surgery.3 “The transsexual believes him/herself to be a female/male in the body of a male/female.”4 The prevalence of transsexualism is approximately one in 20000 in the general population4, however in the United States it may be as high as 1:2500. Despite this, most clinicians will not meet a transsexual during their clinical practice.
The supporting mechanisms of a normal vagina consist of the muscular and endopelvic system. Of which the levator ani is believed to be the more important component. It is believed that in the presence of a strong pelvic floor muscle prolapse is unlikely. Though prolapse is known to occur in patients who have unusually weak connective tissues. The most important common etiological factor for pelvic floor prolapse is believed to be due to the denervation injury related to parturition tough fascial injuries are also sustained during parturition. Though the injury are sustained during the process of parturition during their reproductive age the prolapse often only manifest in later years when the age related wear and tear and menopausal status further weakens the support. The resultant prolapse depends on the fascial injury or defects present in individual patient. Thus in patients who have a midline defect in the pubocervical fascia will most likely present with a midline cystocoele and patients with paravaginal detachments will present with paravaginal defects.
The support of the peno-scrotal neovagina is also likely to involve 2 system likely involving a combination of levator ani and the adhesion formed between the inverted penal-scrotal skin and surrounding tissue. In contrast to the normal vagina neovagina do not have a well-organised endopelvic support system involving rectovaginal fascia, pubocervical fascia, cardinal ligaments and uterosacral ligaments. People who have experience in creating neovagina both in patient with vaginal agenesis and male-female gender reassignment surgery reported that the levator ani were better developed in male-female transsexuals. This is expected due to the male phenotype and having no previous childbirth insult. Therefore the likelihood of weakening of support is unlikely to be pelvic floor muscle. This strong levator muscle may be a contributing factor to the low incidence of neovaginal prolapse despite of the absence of well organised endopelvic fascia. We postulated therefore the prolapse in our case may be largely due to a possible weakness in the adhesion formed between the inverted peno-scrotal skin and the surrounding tissues. It made good sense to us that the support of the neo-vagina where there is a good levator ani to be complemented by creating the effect of endopelvic fascia by providing lateral support. The improved alignment by placing the upper vagina in a horizontal plane over the levator ani is recognised to be an important component to improve the supporting effect of the levator ani. In addition, in the absence of parturition and aberrant sexual behaviour the penoscrol tissue was not likely to develop thining or weakening. Therefore it made no sense in repairing the anterior prolapse with a midline plication technique. Particularly in view of the common tendency of the neo-vaginas to contract.
The incidence of prolapse of the neovagina in male-to-female transsexualism is unknown. There are only three papers in the published literature in which prolapse of the neovagina in male-to-female transsexualism has been described.5-7
Transvaginal sacrospinous colpopexy or abdominal sacrocolpopexy have been described to restore the neovagina, without compromising its function.5,6 To reduce the associated morbidity of an open procedure, laparoscopically assisted and even a total laparoscopic rectosigmoid colpocleisis have been performed when inversion of the combined penile and scrotal skin flaps occurs.7
A laparoscopic approach to vaginal vault prolapse in the female karyotype is well described in the literature.8-10 This is the first case in the published literature in which a male-to-female transsexual, who presented with neovaginal prolapse, underwent laparoscopic total pelvic floor repair.
Similar principles in the approach to the pelvic floor were applied to the male pelvis in this case. Compartmentalizing the defect, i.e. evaluating the anterior, posterior and lateral supports of the pelvic floor at laparoscopy, meant that the prolapse could be repaired in the same way one would repair pelvic floor defects in female karyotypes. Identifying the levator ani muscles and appreciating that the lateral fascia of the pelvic floor had separated from the arcus tendineous enabled the surgeon to restore the anatomical support of the neovaginal vault.
The practising gynaecologist is more likely to encounter a male-to-female transsexual patient than most other specialists. Transsexuals should be treated to the extent possible like any other female gynaecological patient.
When approaching prolapse in such women, the laparoscopic surgeon should not only be skilled in pelvic floor repair, but also have an extensive understanding of the anatomy of the male pelvis with its ligamentous and soft tissue supports.
References
1. Thornton MJ, Lam A, King DW. Laparoscopic or transanal repair of rectocele? A retrospective matched cohort study. Dis Colon Rectum. 2005,48:792-8.
2. Lam AM, Jenkins GJ, Hyslop RS. Laparoscopic Burch colposuspension for stress incontinence: preliminary results. Med J Aust. 1995,162:18-21.
3. Hertoft P, Sorensen T. Transsexuality: some remarks based on clinical experience. Ciba Found Symp. 1978,14-16:165-81.
4. Imber H. The management of transsexualism. Med J Aust. 1976,2:676-8.
5. Freundt I, Toolenaar TA, Jeekel H, Drogendijk AC, Huikeshoven FJ. Prolapse of the sigmoid neovagina: report of three cases. Obstet Gynecol. 1994,83:876-9.
6. Loverro G, Bettocchi C, Battaglia M, Cormio G, Selvaggi G, Di Tonno P, Selvaggi FP. Repair of vaginal prolapse following penoscrotal flap vaginoplasty in a male-to-female transsexual. Gynecol Obstet Invest. 2002,53:234-6.
7. Maas SM, Eijsbouts QA, Hage JJ, Cuesta MA. Laparoscopic rectosigmoid colpopoiesis: does it benefit our transsexual patients?
Plast Reconstr Surg. 1999,103:518-24.
8. Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol. 1994,84:885-8.
9. Dorsey JH, Sharp HT. Laparoscopic sacral colpopexy and other procedures for prolapse. Baillieres Clin Obstet Gynaecol. 1995,9:749-56
10. Rozet F, Mandron E, Arroyo C, Andrews H, Cathelineau X, Mombet A, Cathala N, Vallancien G. Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases. Eur Urol. 2005,47:230-6
Figure 1. Pre-operative defecating proctogram demonstrating the degree of rectocele
Figure 2. Neovaginal prolapse demonstrated under anesthesia.
Figure 3. Post-operative appearance.
Figure 4. Post-operative defecating proctogram demonstrating the absence of rectocele