Life-Threatening Bleeding Following Penile Inversion Vaginoplasty: Case Analysis and Practice Improvement

Gender-affirming surgery is a medically necessary treatment for transgender and gender-diverse patients experiencing dysphoria caused by the discordance between an individual’s sex assigned at birth and their gender identity. These surgeries include mastectomy or breast augmentation (“top” surgery), metoidioplasty, phalloplasty, and vaginoplasty (“bottom” surgery). Other gender-affirming interventions include social transitioning and medical therapy with hormones. Surgical care for transgender and gender-diverse patients must be individually tailored because not all patients desire or have access to these surgeries. Furthermore, the ideal aesthetic and functional outcomes vary among patients and the extent of their dysphoria. Nearly 25% of over 27,000 respondents in the 2015 US Transgender Survey had undergone at least 1 gender-affirming surgery.¹ Preliminary data demonstrate an association between gender-affirming surgery and improved mental health outcomes.²

Penile inversion vaginoplasty is the most frequently performed feminizing bottom surgery in transwomen.³ Local flaps from the penis and scrotum are used to create the labia majora and minora, and scrotal skin can be used to epithelize a full-depth vaginal canal to provide the ability for future penetrative intercourse. The urethra is shortened by spatulation and repositioned, and the clitoris is fashioned using the glans of the penis. The neovagina is packed at the end of the procedure using vaginal packing with an anticipated first dressing change in 5 to 7 days. Other surgical approaches to feminizing bottom surgery include nongenital skin flap vaginoplasty, intestinal vaginoplasty, and peritoneal vaginoplasty. These approaches are used in cases where patients lack enough penile and scrotal skin to construct the neovaginal lining or as a salvage procedure following loss of the scrotal skin graft. Alternatively, some patients may not desire a full-depth neovagina or have multiple surgical risk factors; in these cases, a shallow-depth vaginoplasty or vulvoplasty may be preferred. Vulvoplasty can be performed without hair removal and is associated with high patient satisfaction, low decision regret, and the absence of dilation-related postoperative complications.⁴ Bottom surgery can be performed individually or collaboratively by gynecologic, urologic, and plastic surgeons. Postoperative care and recovery involves an interprofessional team that includes surgeons, clinicians, pharmacists, and nurses.

Adverse events related to feminizing bottom surgery include rectoneovaginal fistula, neovaginal canal stenosis and strictures, lower urinary tract injuries, prolapse, tissue necrosis, and a number of minor complications that do not require operative intervention, such as dehiscence and exposed granulation tissue.⁵ The aggregate major complication rate across all approaches to feminizing bottom surgery is estimated to be 15% with a reoperation and takeback rate of up to 5%.⁶ However, these studies are limited by a small sample size and lack of follow-up. Accordingly, there is a need to characterize the breadth of potential complications associated with gender-affirming vaginoplasty to refine surgical techniques and postoperative care. Herein, we present a life-threatening complication that occurred in a transgender woman during routine vaginal packing removal after penile inversion vaginoplasty.

A 37-year-old woman, assigned male at birth, underwent gender-affirming orchiectomy, penile inversion vaginoplasty, and vulvar reconstruction in December 2021. Previously healthy, her medical history was notable for uncomplicated breast augmentation with autologous fat grafting, laser hair removal, and 5 years of hormone therapy on estradiol and spironolactone. The patient preoperatively met criteria recommended by the World Professional Association for Transgender Health. Her surgical goals were a full-depth neovagina with penetrative capacity and seated micturition.

Penile inversion vaginoplasty was completed without intraoperative complications. Two Penrose drains and a Foley catheter were inserted, and the neovagina was packed with 3 vaginal packing strips that were sutured together, soaked in mafenide solution, and liberally lubricated. An incisional wound vacuum dressing was placed on the vulva to reduce swelling and improve wound healing. The patient was extubated and taken to the recovery room in stable condition. The bladder was intermittently drained, and no hematuria was noted. A urinary catheter was placed for a period of 2 weeks following surgery.

On postoperative day 1, the patient’s pain was well controlled. She was afebrile and hemodynamically stable. The Foley catheter was draining clear fluid, and her wound vacuum dressing was draining minimal serosanguinous fluid. The rest of her physical examination was unremarkable.

The patient’s wound vacuum and Penrose drains were removed as scheduled on postoperative day 5. On inspection of the neovaginal canal, the vaginal packing was noted to be dry and adherent to the canal wall, so the dressing was soaked in saline. During vaginal packing removal, there was an abrupt onset of bright red blood coming out of the neovagina. Manual pressure was applied, and the patient was taken back to the operating room for exploration under anesthesia.

After induction of anesthesia and securing access for blood transfusion, the lower edges of the labia majora were deconstructed allowing the neovaginal flap to be delivered out of the cavity. A 300‑µL clot was evacuated out of the cavity, and a single bleeding artery measuring 2 mm in diameter was identified on the left sidewall of the neovaginal canal. The artery was clipped with small vessel clips and ligated with 0-Vicryl polyglactin 910 suture (Ethicon Inc). Hemostasis was achieved. Two Penrose drains were replaced, and a dilator was used to place the neovaginal flap back in the cavity. The lower edge of the labia majora was again repaired, and the neovagina was packed and dressed before the patient was extubated and transferred to the postanesthesia care unit in stable condition.

Three days later, the patient’s dressings were changed, and the neovagina was examined under anesthesia. The vaginal packing was removed without bleeding. A vaginal speculum was inserted into the canal. There was no evidence of bleeding or hematoma. The vaginal canal was again packed with vaginal packing soaked in mafenide solution and lubricant. Another uncomplicated dressing change was performed 5 days later, and the patient was subsequently discharged. On outpatient follow-up, patient was found to have partial loss of her canal skin lining. After discussion with the patient, the decision was made to proceed with robot-assisted elevation of peritoneal flaps to reconstruct the lining of the distal canal where the scrotal skin graft was partially lost. The patient tolerated the procedure well and had a full recovery with a functional and aesthetic neovaginal canal. 

As more transgender and gender diverse individuals seek out gender-affirming surgeries, it is critical that all health care professionals who interact with these patients be made aware of the scope of potential complications and their management. Postoperative bleeding and hematoma after vaginoplasty are common complications, affecting approximately 12.5% of patients.⁷ However, most reported cases are of slower, venous bleeds that may require transfusion but not emergent operative intervention. The most common reported site of bleeding is from the cut edge of the corpus spongiosum surrounding the bulbar urethra (Figure 1).⁷ Because the vulva and outer canal are constructed using penile skin flaps, their arterial supply is provided by paired axial arteries arising from the external pudendal artery. These paired arteries start from the base of the phallic shaft and extend to the prepuce.⁸ The rest of the blood supply to the penile shaft and glans is provided by the dorsal arteries and vein, which are branches of the common penile vessels originating from the internal pudendal vessels. 

Dissection of the neovaginal canal is often the most difficult step of gender-affirming vaginoplasty due to the complex vasculature and surrounding structures.⁹ The ideal plane of dissection is between the ventral rectal fascia and Denonvillier’s fascia, which covers the dorsal surface of the prostate (Figure 2).¹⁰ In this area, the anterior rectal wall is supplied by the middle and inferior rectal arteries, which run posteroinferiorly between levator fascia and the fascia proper of the rectum. Neurovascular bundles supplying the prostate pass laterally in anterior (nerves, anterolateral pedicle of the prostatic artery, and veins) and posterior (deep artery, poster-lateral pedicle of the prostatic artery, and rectal arteries) divisions before joining the pudendal neurovascular bundle near the penile hilum. The distribution of vessels and nerves creates a safe area on the prostate’s dorsal surface. Understanding the vascular anatomy of this plane of dissection is critical. Damage to these vessels is responsible for major arterial bleeds and graft loss. Robotic assistance may improve visualization of these structures and allow for a more precise dissection. While robot assistance has been used in peritoneal flap vaginoplasty, its superiority in traditional penile inversion vaginoplasty for patients with adequate genital skin and tissue has not yet been evaluated. Advantages may include risk reduction of major complications and preserved sensory function; however, these must be weighed against the potential for additional time under anesthesia and the surgeon’s training.

This case describes a life-threatening but preventable complication of gender-affirming vaginoplasty. Several practices can be implemented intraoperatively and postoperatively to minimize the risk of arterial bleeding during vaginal packing removal. First, the neovaginal canal should be inspected carefully with a speculum after upsized dilators are used intraoperatively to widen the canal; the canal walls should be inspected for any exposed vessels that should be individually cauterized or suture ligated. While these exposed vessels may be intact and hemostatic intraoperatively, they are susceptible to mechanical trauma during packing removal postoperatively and throughout dilation sessions afterwards. 

Second, the neovagina should be packed with soaked, liberally lubricated vaginal packing to prevent desiccation. The vaginal packing strips are sutured together instead of being tied to prevent the creation of packing nodules that could adhere to the skin graft lining the canal upon unpacking. In addition to retarding wound healing, desiccation can cause unwanted mechanical trauma to the skin graft when packing is removed.¹¹ Vaginal packing should be rehydrated and removed with gentle traction. If the packing is adherent, the dressing change should be aborted and resumed in the operating room under anesthesia to prevent excess shearing forces that could result in potential bleeding and loss of the skin graft. 

Third, ensure that supplies are accessible before dressing takedown. If there is a substantial bleed at the time of packing removal, place the largest dilator in the neovaginal canal to tamponade any bleeding vessels while the patient is transported to the operating room. Because many health care professionals may be involved in the patient’s postoperative care, the surgeon must counsel all team members about this potential complication and its management. 

Finally, the attending surgeons should be available and preferably present in the facility when the unpacking takes place to respond rapidly to a potential adverse event. For all these reasons, the removal of the vaginal packing should be done in a hospital setting. 

Postoperative complications following penile inversion vaginoplasty are not uncommon. Surgeons and other health care professionals of the care team must be aware of potential life-threatening complications associated with these procedures. However, there is a paucity of high-quality evidence reported in the literature about the management and breadth of complications regarding feminizing bottom surgery. 

Health care professionals should be prepared and exercise caution throughout the perioperative period of vaginoplasty patients. This case highlights the importance of an interprofessional approach to the care of postoperative gender-affirming vaginoplasty patients, including several important practice improvement strategies to decrease the risk of life-threatening complications associated with this procedure.