156 Fresh Human Cadaver Vaginoplasty Surgical Prosections to Guide Surgical Technique, Post-Operative Care, and the Design of a Novel Neovaginal Dilator and Douching Device

Abstract

they complete masculinizing and feminizing surgery e specific care needs and the rationale for each, and common-practice care regimens. We conclude by offering practical approaches to providing the needed care we describe within the prison environment. Methods: Review of Federal and State prison legal and procedural policies governing the housing and care of transgender people. Review of common care practices related to transgender care in general and pre and post-genital gender affirming surgery, and interviews with prison administrators. Results: Currently, in the U.S., there is no formal policy governing the assignment of trans people to gender congruent prisons. Trans people are assigned to prisons based on the presence or absence of a penis (specifically). Active use of gender congruent hormones, and past history of other gender surgeries such as orchiectomy, vaginectomy, and chest surgery have no bearing on assignment to a prison of a specific gender. We found that there is no formal policy at all governing their care with respect to pre and post-genital surgery needs. The primary barrier appears to simply be lack of education and teaching about the transgender population as a whole, and trans people's specific needs. Conclusions: Within the U.S., and presumably a majority of other countries, there is no provision for assignment of inmates to a gender congruent prison. We conclude that the most fruitful starting point to address such complex and challenging questions is education and dialogue between administrators of the prison system and people expert in transgender healthcare, health policy and human rights law. Objectives: Gender affirming vaginoplasty surgical techniques vary, and their description is often limited to "how to", but less often "why"-or "why not". Answers to the latter can be especially enriching for surgeons. We highlight here several observations about genetic male pelvic anatomy as it relates to vaginoplasty for MtF transgender women, and describe how studies using anatomic dissection and histology support specific techniques and care guidelines. Methods: 1. We review the anatomic basis for a sharp peri-prostatic surgical approach for creation of the neovaginal cavity, compared to the traditional sub-bulbar approach; 2. We describe anatomic dissection findings using 15 fresh cadavers on which we performed vaginoplasty surgery (penile inversion), imaging, and sagittal sectioning; 3. We describe anatomic findings using fresh cadavers after vaginoplasty surgery to highlight challenges associated with common douching techniques. Results: Anatomic dissection and immunohistochemistry results showed that the sharp dissection we describe is associated with incision through significantly fewer blood vessels and sensory-motor nerves as compared to the traditional surgical approach. Imaging studies in living trans women and fresh cadavers after vaginoplasty suggest that the shape of the neovaginal cavity is S-shaped. We describe a novel dilator-douche design we have developed (U.S. Patents Pending). Findings also suggest that it is less likely that the apex of the vaginal vault is effectively irrigated with douching using conventional douche devices and techniques. Conclusions: Our anatomic findings suggest that a sharp surgical approach upon the apex of the prostate gains access to a surgical plane anterior to DVF as distally as possible, poses less risk to immediate or delayed injury to the rectum, and injures fewer collateral nerves (many of which are likely sensory) during direction of the neovaginal space. The neovagina in a transgender woman is S-shaped, and reflects the shape of the dilator design we introduce. Our findings also suggest that the deepest part of the neovagina is unlikely to be irrigated with douching. Poor hygiene of the vault may contribute to general poor hygeine of the neovagina, and gran-ulation tissue The novel dilator-douche device design we describe addresses this, as it allows douching to occur through the dilator. Disclosure: Work supported by industry: no. The presenter or any of the authors act as a consultant, employee (part time or full time) or shareholder of an industry. 157 COMMON AND UNCOMMON COMPLICATIONS AFTER M TO F GENDER AFFIRMING GENITAL SURGERY WITH VAGINOPLASTY Garcia, M. Cedars-Sinai Medical Center, USA Objectives: Transgender people today represent approximately 0.6% of the adult population (1.4 million people). Genital gender affirming surgery (vaginoplasty) for transgender women has been a covered benefit by MediCare, MediCal, and in an increasing number of U.S. states, commercial health insurance plans due to state laws that bar exclusion of provision by insurance plans. There is not yet an accepted "gold standard" vaginoplasty technique, or, approach to preventing or managing complications. Because many patients present to general urolo-gists for management of short and long-term complications after surgery, how to manage such complications is relevant to general urologists and reconstructive urologists not specialized in gender affirming surgery. We present here a review of common and uncommon complications after surgery, and how we propose such complications arise. We review management approaches.