Combined General and Epidural Anesthesia is Associated With Decreased Opioid Consumption and Enhanced Pain Control After Penile Inversion Vaginoplasty in Transwomen.

BACKGROUND: Penile skin inversion vaginoplasty is a gender-affirming surgical procedure for transwomen with limited surgical analgesic protocol. This study compares the postoperative pain and opioid use in patients managed for surgery with general anesthesia (GA) with patients who were given combined epidural and general anesthesia (E/GA) with continuing postoperative epidural analgesia. METHODS: All patients who underwent penile inversion vaginoplasty between May of 2016 and May of 2018 under the care of single surgeon were identified retrospectively, 18 patients of which met the inclusion criteria. A retrospective chart review was conducted. Outcome measures were postoperative pain using visual analog scale, type and dosage of postoperatively administered intravenous or oral opioids (converted to morphine milligram equivalents, duration of inpatient admission, and time to ambulation. RESULTS: Patients who received combined E/GA reported significantly less pain and used less opioids during the first 4 postoperative days in comparison with patients who received GA alone. The reduction in mean pain associated with the use of an epidural was found to be statistically significant (P < 0.0005) as was the difference in opioid used in the 2 groups (P < 0.005) over the first 4 days postoperatively. Differences in day 5 pain suggest that postoperative pain is significantly lower even after the epidural has been removed (P < 0.005). There was no significant difference in length of hospital stay and time to ambulation (P > 0.05). CONCLUSIONS: Combined E/GA was associated with decreased inpatient opioid consumption after surgery and provided superior pain control than administration of GA alone. Based on these findings, combined E/GA should be strongly considered for patients undergoing penile inversion vaginoplasty.

Use of allograft fat for aesthetic and functional restoration of soft tissue contour deformities.

The authors report a case series of five patients with Leneva grafted into the nose, hand, genitalia and below-the-knee stump. Leneva is an allograft adipose matrix derived from aseptically processed human adipose tissue with retained matrix proteins, growth factors, cytokines and collagens. It is manufactured hydrated and is available in pre-loaded syringes. Five patients (3F, 2 M) with a mean age of 50.7 (range 31-77 years) injected with a mean volume of 4.2 cc (range 3-6 cc) of Leneva in various anatomic locations with an average follow up time of 4.25 months (range 0.5-12 months) experienced no allergic reactions, infection, fat necrosis or oil cysts. All patients were pleased with the restoration of fullness to the injected site. The authors believe that Leneva is a promising multi-use filler for restoring soft tissue defects following resection of tumours, to rejuvenate age-related atrophy, aesthetically enhance the genitals and provide padding for transtibial prostheses.