Repair of rectal neovaginal fistula with the interposition of Singapore posteriorly based fascia cutaneous axial flap on male to female transsexual. Presented by Woojin Jung at Mount Sinai Medical Center in New York. Others are listed here. There are no disclosures. According to the American Society of Plastic Surgeons, a total of 3,256 transmasculine and transfeminine surgeries were performed in 2016 with 19% increase over the past year. Complications after male to female gender reassignment surgery include deep infection, rectal vaginal fistula, pulmonary embolism, and bleeding. Rectal vaginal fistula are rare conditions. The most common cause of rectal vaginal fistula in females is OB trauma with the traumatic devascularization of the perineal region resulting in the development of the fistula. However, since a male to female gender reassignment surgery has become popular, rectal neovaginal fistula is one of the major complications from the gender reassignment. Incidence was noted to be 1%. Treatment of rectal neovaginal fistula requires a multidisciplinary approach involving colorectal plastic surgeons, urologists, and gynecologists. Depending on the localization, size, and etiology of the rectal neovaginal fistula, various approaches can be utilized, such as a sewing on anal fistula plug or a patch of biologic tissue into the fistula using a tissue graft, repairing the anal sphincter muscles, or performing a colostomy before repairing the fistula in complex or recurrent cases. This table shows the reported outcomes of various rectal vaginal fistula repairs, including advestment flap, transperineal sphincteroplasty, gracilis muscle flap, plugs, transabdominal ligation, repair with mesh, and Martius flap. Closure of the fistula within the position of a pedicle to tissue flap is a useful surgical approach to reconstruct the perineal space in providing neovascularization. Martius flap, muscle flap, and Singapore flap are the examples of pedicle to tissue flap. Singapore flap is first described by Wee and Joseph, then later modified by Woods and his coworkers. As seen in these pictures, the inferior edge of the flap is not divided. Instead, the labia are released and retract anteriorly. Singapore flap is a pedicle to pudendal fasciocutaneous flap from the thigh centered on the labia crural fold. With a base at the perineal body, this flap is sensate as the cutaneous innovation is spared. In order to prevent disruption of this vessel network, the deep fascia overlying the adductor muscles must be carefully elevated. The Singapore flap is used for vaginal reconstruction in case of vaginal agenesis, perineal wound closure, rectal vaginal fistula repair, and disorders of sexual differentiation. The objectives of this video presentation are to present a case of rectal neovascular fistula on a male to female transsexual and to describe vaginal reconstruction with interposition of unilateral Singapore posteriorly based fasciocutaneous axial flap. A 37-year-old male to female transsexual presents with a large rectal neovascular fistula. She reports leakage of stool coming from the vagina one week after penile inversion vaginoplasty. Plasty history is notable for HIV infection and gender reassignment surgeries. On bimanual exam, the entire anterior wall of the rectum was absent for the length of seven to eight centimeters. Vaginal intrudus was wide open and leased directly to the rectum. Multidisciplinary surgical planning was made. After informed consent with risks, benefits, and alternatives, Singapore flap was chosen for this patient to repair rectal neovascular fistula. Patients was taken to OR for eczema anesthesia, laparoscopic loop ileostomy creation, repair of rectal mucosa transvaginally, repair of rectal neovascular fistula with interposition of Singapore posteriorly based fasciocutaneous axial flap. Revision vaginoplasty with correction of structure. Eczema anesthesia revealed that there was a communication between rectum and the posterior vagina. The surgeon's index finger in the rectum comes out of the vagina. Polyvalume once inserted into the rectum, the backfill of water was coming out from the vagina. The temporary loop ileostomy was created laparoscopically. Osteomy bag was placed. Repair of rectal mucosa was carried out transvaginally upon exposure of the posterior neovascular area, healthy rectal mucosa as is well noted. Using bovie electrocautery, the neovaginal tissues were carefully dissected off from the rectal mucosa. After mobilization of rectal mucosa from the neovaginal tissue, the edges of rectal mucosa were re-approximated using two observable sutures in layered fashion. Bubble test was done to confirm for watertight repair of rectal mucosa. The rectal exam revealed a complete closure of rectal defect. Now, I would like to briefly talk about how we repair rectoneovascular with interposition of unilateral Singapore posterior-based fasciocutaneous axial flap. Although both males and females' perineal areas share the same embryologic origins, they are different phenotypically. Patients who underwent gender reassignment surgery carry unique anatomy. The blood supply to the perineal structures is derived from the branches of internal pudendal artery. In males, the internal pudendal arteries supply the perineal regions as well. The area of cell perineum can be divided into six different regions as shown here. We decided to utilize the left upper portion of the perineum for the flap. The flap was created three centimeter in width by nine centimeter in length. Pedicle to pudendal fasciocutaneous flap was marked with a marking pen on the left upper perineum and thigh centered on the labial crawl folds with the base at the perineal body. See the red colored line on the diagram. In order to prevent disruption of the blood vessel network, careful dissection was performed to elevate the deep fascia overlying the adductor muscle. The skin of the neovaginal intruders proximal to the beginning of the fistula was then split just off the midline in the perimedian axillary incision. The skin edges were dissected free for approximately three centimeters wide enough to allow the Singapore flap to be inset. This flap was rotated and advanced into the neovaginal and the edges of the flap were sewn initially to the edges of split vaginal intruders epithelium using observable sutures. The apex of Singapore flap was brought into the neovaginal defect and suture secured at the apex of the neovaginal. Please note that the point big A is sewn to point small A and the point big B is to point small B. The rest of Singapore flap was then sutured in layers to the cut edges of vaginal epithelium to the cut edges of vaginal epithelium. This provides vascularization and multi-layer reinforcement of the primary repair of the rectal mucosa and also it enlarges the width of the vaginal intruders in the first seven or eight centimeters of the vagina by approximately three centimeter to correct the vaginal stricture in this region. The donor site for the Singapore flap was repaired in layers using observable sutures. The vagina was then packed loosely with metronidazole-fused vaginal packing and secured it with stitches at the intruders. The patients tolerate the procedure well. The right picture shows the final presentation. Total vaginal length at this time was noted to be five to six centimeters. Patients was discharged home on post-op day four. The loopy leostomy was functioning well and the surgical scar in the perineum was healing well without any signs of infection. These are taken in post-op day seven. In conclusion, it is predicted that we at PMRS Surgeons will encounter more patients with rectal neovaginal fistula as there will be an increasing number of gender reassignment surgeries performed in the future. It is important to treat such a patient with multidisciplinary approach. Vaginal reconstruction with vasocutaneous Singapore flap is a good option for male to female transsexual patients with a complex rectal neovascular fistula as it provides excellent neovascular adhesion with sensate flap. These are our references. Thank you for comments and questions. Email at www.oojin.gmail.com.

rectal neovaginal fistula

gender reassignment surgeries

complications

multidisciplinary approach

Singapore posteriorly based fasciocutaneous axial flap