LAUSR

OBJECTIVE This study reports outcomes in 146 patients that underwent PIV. The results, in conjunction with a systematic review of the literature, were used to develop a treatment algorithm for the prevention, surgical management and postoperative considerations of iatrogenic rectal injuries. BACKGROUND PIV is a common procedure for transfeminine patients, with the goal of creating a functional vaginal canal and clitoris, as well as a natural-appearing vulva. Creation of the neovagina requires opening of the pre-rectal space, most commonly from a perineal approach, and the reported rates of rectal perforation during this dissection range from 3 to 5%. METHODS Adult patients who underwent PIV at our institution were retrospectively identified. Demographics, operative information, and postoperative clinical outcomes were extracted from the electronic medical record. RESULTS Ten of 146 patients experienced a rectal injury (6.8%). All patients underwent an immediate repair (2-layer in 8, 3-layer in 2) with two patients subsequently requiring temporary fecal diversion and two requiring muscle flaps (1.4% each). Literature review identified eighteen relevant publications, with scarce in-depth analysis of management of initial rectal injuries. CONCLUSIONS This algorithmic approach to rectal injury during PIV is designed to facilitate decision-making based on preoperative preparation, consistent intraoperative monitoring, feasibility of primary repair of the rectum, and a multidisciplinary approach to longitudinal postoperative care.