Penile inversion vaginoplasty (PIV) involves an approximately 15-cm dissection in the rectoprostatic interval for neovaginal canal creation. 1 This dissection carries a risk of rectal injury, with rates up to 6. 8%. 2 Intra-operative identification and repair of rectal injuries are imperative to prevent the formation of rectovaginal fistulae (RVFs) or rectocutaneous fistulae. Occurring in 0. 3%–1. 7% of patients, RVFs are perhaps the most devastating complication of PIV due to the risk of associated vaginal canal loss, as well as the need for further pelvic or intra-abdominal procedures, including a diverting ostomy. 2 Primary rectal injuries in PIV typically result from blunt, thermal, or ischemic injury at a depth greater than 4 cm proximal to the anal verge and are generally less than 2 cm in diameter. 3 As direct visualization is limited, identification of full-thickness injury often requires a povidone-iodine enema with observation for egress into the vaginal canal; however, this is less effective in identifying partial-thickness injuries or microperforations. When a primary rectal injury is identified intraoperatively, current management algorithms recommend general surgery consultation for primary layered repair of the bowel wall. In some cases, conversion to minimal-depth PIV (eg, vulvoplasty) or colonic diversion may be necessary. 2 Existing literature also supports the utility of local muscle flaps to reinforce primarily repaired rectal injuries incurred during PIV. 2 The bulbospongiosus muscle, which is routinely excised in PIV, is an ideal adjunct for distal rectal injury repair due to its robust vascular supply and negligible donor-site morbidity. To date, however, this technique has not been described in the literature for use during PIV. We present the case of a 48-year-old transfeminine individual, assigned male at birth, with gender dysphoria, who desired genital surgery and met the World Professional Association for Transgender Health Standards of Care (Version 8). The patient had no relevant previous medical or surgical history, including no prior abdominal or pelvic surgery and no active tobacco or nicotine use. Per our protocol, estradiol was held for 2 weeks preoperatively, a 2-day bowel preparation was undertaken, and a subcutaneous heparin injection was administered on the day of surgery. We proceeded with PIV in our standard fashion, including uncomplicated scrotal skin graft harvest, bilateral orchiectomy, and exposure of the urogenital diaphragm. Vaginal canal dissection was subsequently undertaken. The rectoprostatic interval was identified between the levator ani and transverse perineal muscles, just lateral to the perineal body. This interval was then dissected. During this portion of the procedure, a 2-cm full-thickness left-sided intersphincteric anorectal injury was noted. The enterotomy was identified via manual palpation and confirmed with direct visualization. The general surgery team performed a multilayer closure intraoperatively, repairing the mucosa via a transanal approach and the seromuscular wall via a transperineal approach. The decision was then made to reinforce the repair with a pedicled bulbospongiosus muscle turnover flap. The bulbospongiosus was selected based on its proximity to the distal anorectal injury. In natal males, the bulbospongiosus consists of 2 paired muscles that encircle the penile bulb and form an ejaculatory unit with the ischiocavernosus muscles. The bulbospongiosus muscles are routinely excised during PIV; therefore, their harvest yields little donor-site morbidity. Our practice is to delay excision of the bulbospongiosus until the vaginal canal dissection and a povidone-iodine enema have been completed without evidence of rectal injury. Owing to the location of the defect, we designed a left-sided bulbospongiosus muscle flap based posterolaterally on the bulbar and urethral arteries. The flap was raised off the underlying corpora cavernosa and spongiosum using electrocautery and dividing the right border of the bulbospongiosus. Once sufficiently mobilized to reach the rectal injury, flap perfusion was confirmed using indocyanine green angiography. The bulbospongiosus was then turned over and inset over the primary rectal defect repair with an interrupted 3-0 polyglactin suture. (See Video online, which displays the use of a bulbospongiosus muscle flap for reinforced primary repair of a rectal injury encountered during PIV. We provide stepwise instruction and include anatomical and clinical considerations for the general use of this flap. ) "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1. ", "caption": "This video outlines the specific use of bulbospongiosus muscle flap for reinforced primary repair of a rectal injury encountered during a penile inversion vaginoplasty. We provide stepwise instruction and include anatomical and clinical considerations for general use of this flap. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ᵤce0ym2x", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Due to the injury, further canal dissection was aborted, and the procedure was converted to a vulvoplasty, with plans for further canal deepening with robotic-assisted peritoneal vaginoplasty in the future. The remainder of the operation proceeded without complication. Postoperatively, the patient was placed in a bolster dressing and admitted for 5 days of strict bed rest. She underwent uneventful bolster takedown on postoperative day 6, and after urinating and defecating without issue, was discharged home. She was seen in clinic on postoperative day 30. At this time, she was healing well with full return of bowel and urinary function and no apparent postoperative complications, including rectal fistula. She is now more than 1 year postoperative and is planning canal deepening with robotic-assisted peritoneal flaps. Although not yet described in PIV, the bulbospongiosus flap has been used for the secondary repair of vesicovaginal and low RVFs in cisgender women. 4 Further, in cisgender men, it has been shown to be nearly 95% successful for the repair of rectourethral fistula. 5 Proponents believe that the flap prevents rectal fistula formation or recurrence owing to its sheer bulk and robust vascular inflow. However, no large-scale studies have been conducted to validate this clinical observation. The bulbospongiosus flap offers advantages over a traditional layered closure but may not be the ideal choice in all circumstances. Decisions regarding repair modality should account for the location, layers involved, and extent of injury. Primary closure may be used for partial-thickness injuries; however, for full-thickness injuries, additional blood supply and muscle bulk are often warranted. Owing to its pedicle location, the bulbospongiosus muscle is most valuable for repairs of the distal rectum, whereas more proximal rectal injuries may benefit from the use of other muscle flaps, such as the gracilis flap. 2 In PIV, timely and robust management of rectal injuries is crucial to avoid potentially devastating sequelae. The bulbospongiosus muscle flap offers a valuable adjunct for primarily repaired distal anorectal injuries. In PIV, the benefits of this flap include expeditious harvest, a versatile bipedicled vascular supply, proximity to the distal rectum, and negligible donor-site morbidity. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENT The authors acknowledge Alyson Brinkman, MD, and Danielle J. Eble, MD, for their assistance with the illustrations included in the video associated with this article. ETHICAL APPROVAL The data included in this article were collected under appropriate institutional review board approval.
Brydges et al. (Wed,) studied this question.