Abstract Introduction When vaginoplasty includes creation of a vaginal canal (i.e. full-depth vaginoplasty, FDV), to create the typical 12-14 cm. long canal space, the desired surgical dissection plane is through the anterior portion of the central tendon (perineal body), and then along, just anterior to, Denonvillier’s Fascia (DVF), up to the peritoneal reflection at the Pouch of Douglas. The key complication with this dissection is injury to the rectum (incidence 1-4%, though likely under-reported), which often results in recto-vaginal fistula and canal loss. There is no published “gold standard” technique for this dissection. Many non-urologist surgeons also perform FDV (e.g. plastic and gynecologic surgeons), many of whom are not familiar with urologic anatomy and instruments. Objective Our aims are to highlight the anatomic basis for the technique, describe our clinical outcomes, suggested technical “pearls” and a new instrument that we designed based on this technique. Methods Intra-op video and illustration-based description of our surgical technique and standard and customized instruments. Clinical outcomes for all consecutive GAS vaginal canal dissections performed over a 6-year period are reported. Results A total of 224 consecutive neovaginal canal dissections were performed, including 65 salvage cases following prior canal dissection. All patients had follow-up exceeding four months. The overall rectal injury rate was low (0.4%), occurring in a patient with a history of pelvic fracture. No urinary tract injuries were observed (0%). Following the first 40 cases, preoperative bowel preparation was discontinued without adverse outcomes. A key technical innovation involved using a 16 Fr male urethral sound to safely displace the prostate, enabling precise incision of the Denonvilliers' fascia and safe blunt dissection of the neovaginal plane. Conclusions Our anatomy-based technique affords an exceedingly low complication rate, and is simple, safe, and obviates the need for lap/robotic approaches. Disclosure No
Garcia et al. (Mon,) studied this question.