VAGINECTOMY
(Removal of the vaginal lining also known as mucosa)

I perform a vaginectomy for multiple reasons:
• Desire to have the vagina removed.
• Desire to eliminate the secretions produced by the vaginal mucosa.
• When a urethral lengthening or scrotoplasty is being performed.
• Eliminates the need for necessary and potentially embarrassing speculum exams or the yearly Pap Test.

Not all doctors recommend performing a vaginectomy when one of these procedures is being done.
A normal complication rate when it is not done is roughly 40-45%. In the hands of our transgender group, and in particular Dr. Meltzer, the complication rate when a vaginectomy is performed with these procedures is less than 3%.

Benefits to having a vaginectomy performed at the same time as a urethral lengthening, hysterectomy or other genital reconstruction procedures:
• Fewer trips to the operating room
• Reduced costs by combining procedures
• Less time off from work
• Less travel and lodging expenses
• Fewer complications

Advantages seen by my vaginectomy patients:
• I was trained by Dr. Desmond Johnson who initially developed his technique to reduce bleeding and surgical time. I have refined and improved his technique. This, combined with a state-of-the art specialty hospital with the most modern equipment, allows advanced surgery with great success and then permits patients to recover and rest in a modern comfortable room where there is excellent nursing care. My patient satisfaction is extremely high. Our success with the vaginectomy has virtually eliminated the need for blood donation and intensive care unit hospital stays. Complications are possible and will be discussed with you at a pre-operative visit. Our patients are able to recover in a beautiful and tranquil facility that allows for overnight care, private rooms, private bathrooms, and wireless internet access. We encourage significant others to stay overnight with patients.

• I work with a transgender team which carefully coordinates combined procedures and any future needs as well as getting to and from the facility and doctor's offices. We try and offer complete service for your convenience.

What do I need prior to surgery?
• Your individual situation, primary procedures being done and current medical condition will determine what is needed prior to surgery.
• A complete medical history.
• All the appropriate/pertinent surgical forms will need to be filled out and signed.

What can I expect when I come to Scottsdale for my procedure?
• You will meet with me for a pre-operative appointment - generally the day before the procedure. I usually do not perform a physical exam unless there is a specific question or concern. If you are combining vaginectomy with other procedures, you probably will have an appointment to meet with Dr. Meltzer at his office. If you are from out-of- town, you will most likely be staying in a hotel which is near the facility where your surgery will be performed. If you are in town just for either a hysterectomy or vaginectomy my office will help you coordinate transportation and your hotel stay.
• You will be given the opportunity to ask questions and have them answered at your pre-operative appointment.
• We will discuss the procedure, risks and complications.
• A bowel preparation is required and you will be given instructions. Please note: a clear liquid diet is required the day of your bowel prep, so please plan accordingly. You will not be permitted to eat or drink 10 hours before your procedure.
• Your family, friends and/or significant others are more than welcome to attend any appointments, and be present during post-operative discussions.

What can I expect the morning of surgery?
• Arrive at the hospital two hours before your surgical time for registration, lab work and preparation for surgery. Please bring only your identification with you. Leave your valuables with whoever came with you.
• A caring hospital staff member will start your IV and administer antibiotics and answer any questions you may have.
• You will meet your anesthesiologists who will talk with you and review your medical history and identify any potential surgical problems.
• I will visit with you and answer any last minute questions you may have.
• You will be transferred to the operating room where you will be administered sedation and gently go to sleep.
• I will then position you, perform an examination and shave the surgical area before starting the surgery.

How is the procedure performed?
• I usually start with a horizontal incision just underneath the urethra inside the vagina. This can vary depending on your future surgical plans or needs. I then undermine the vaginal mucosa staying as superficial as possible to minimize bleeding. This technique allows for faster healing, faster recovery and less post-operative pain. In addition, I use a special laser to dissect the mucosa. This further minimizes bleeding. I separate the top and bottom part of the mucosa from the underlying and overlying tissues. I do the same on the sides. I then work my way up the vagina towards the top of the vagina, or the apex. Once I have removed all the vaginal mucosa I very carefully inspect for any remaining tissue or any bleeding areas. The way that I perform the procedure minimizes injury to both the bladder and the rectum. In addition, it also supports both of them so you are less likely to have problems in the future from these two areas. A careful examination is performed when I am done to ensure that any bleeding is stopped. This area is irrigated with antibiotic solution to decrease the risk of infection. I place sutures to bring the sides of the vagina together to obliterate the space, provide better support for the remnants of the vagina and rectum, to prevent the bladder from falling down, reduce pain, and improve healing.

Can I have other procedures performed at the same time?
• For a vaginectomy, recovery is 36-48 hours.
• If other procedures are performed your stay may be slightly longer. A hysterectomy does not lengthen your stay.
• A major exception to this is if a vaginectomy is combined with a urethral lengthening using buccal mucosa. Then a stay of six nights is required (this is necessary if one has already had a metoidioplasty).
• For the most part, the pain diminishes significantly within two weeks. However, we have had patients that have had discomfort up to six months after surgery (this is rare). There tends to be more discomfort when riding a bicycle, swimming, riding motorcycles, and horseback riding.
• You may return to work in as soon as two weeks; some patients may require as much as eight weeks of recovery time, especially if combining procedures. This, of course, may depend also on the type of work that someone does.


TOTAL HYSTERECTOMY:

How is the procedure performed?
• For my female-to-male patients, I prefer to perform the total hysterectomy (which includes removal of the uterus, the cervix, both ovaries and both fallopian tubes). I also remove the upper part of the vagina at this time. This makes a vaginectomy in the future more easily done.
• There are several different ways to perform a hysterectomy and each has its advantages and disadvantages:

Abdominal Hysterectomy – the most common approach, though not my preferred approach. This method has the advantage of having excellent exposure and makes it easy on the surgeon. Unfortunately, there is a relatively large incision in the lower abdomen. It is not only visible, but it can potentially interfere with future surgeries such as a pedicle groin flap. Furthermore, this method has a longer recovery time - typically 6 weeks.

Vaginal Hysterectomy – This method is performed entirely through the vagina. It leaves no visible scar and has a fast recovery. Unfortunately, removal of the ovaries is not always possible using this approach.

Laparoscopic Total Hysterectomy – My preferred approach. Only a trained and experienced laparoscopic surgeon should perform this technique. This is a new and technically more difficult procedure, yet it has many advantages: shorter operating time, smaller scars that should not interfere with future surgeries, relatively little pain and a fast recovery. I do not recommend the laparoscopic supracervical hysterectomy for transgender patients, only the laparoscopic total hysterectomy with a bilateral salpingo-oophorectomy.

How do I find the right surgeon and what questions should I ask?
• I believe finding a surgeon that is board certified, trained and experienced in performing laparoscopic surgery is very important.
• It is optimal to find a surgeon who is sensitive and aware of the specific needs of a female-to-male transgender. They should also be knowledgeable of other lower surgeries and preferably part of a transgender team.
• Are they affiliated with a credentialed hospital and able to provide overnight care?
• What type of post-operative care do they provide?

What do I need to do before surgery?
• Complete a medical health history questionnaire.
• All the appropriate/pertinent surgical forms will need to be filled out and signed.
• You will have a pre-operative appointment (usually the day before surgery) at which time the different surgical approaches will be discussed. The procedure along with the risks and complications will be explained. You will be given all the time you need to ask questions. Informed consent will be completed then. Your family, friends, significant other and/or caregiver are welcome to attend. I will be the one meeting with you.
• If you smoke, quit. Smoking significantly hinders your healing potential.
• Share all medications you are taking, as there are some you may need to stop. This information should be provided to us about 2-4 weeks prior to surgery.
• Arrange your travel and hotel needs in advance.
• You may not have anything to eat or drink 10 hours before surgery.

What will happen the morning of surgery?
• You need to arrive at the hospital two hours before surgery for registration and lab work.
• Arrange your travel and hotel needs in advance. You are welcome to bring your own music and earphones/headset. In the pre-operative area a trans-friendly staff nurse will greet you. A nurse will start your IV through which an antibiotic will be administered.
• Your anesthesiologist will come by and review your medical health history and answer all your questions and discuss any risk factors.
• I will be in to talk with you regarding any last minute questions or concerns.
• You will be transferred to the operating room where you will be administered sedation and gently go to sleep.
• After surgery you will be in the recovery room for 1 to 1 1/2 hours before being taken to your room.

How will the procedure be performed?
• As previously discussed, there are several different ways to perform a hysterectomy. Usually I will do it laparoscopically. I will make three small incisions - one in the umbilicus, and one by each hip bone. I will do my best to reduce the visibility of these incisions which are about 1 cm in length. The abdomen is then filled with CO2 gas. An instrument is passed through the cervix to assist with maneuvering the uterus and ovaries. Utilizing a laparoscope your anatomy is carefully visualized. Since everyone is not built the same way, it is important to visualize the key structures. Each ovary has its own blood supply. This is cauterized and cut. Next the blood supply to the uterus is cauterized. It is then cut. The bladder is then pushed out of the way to expose the top of the vagina. Utilizing a newly developed instrument, I remove as much of the top of the vagina as possible. This is done either in preparation for performing a vaginectomy next, or one is ever desired in the future. This is a special step that I take that reduces the risks of potential harm to the patient. Once the hysterectomy is done, the patient is transferred to a private room where they will generally stay 1-2 nights. Friends, family and /or significant others are welcome to visit. Visiting hours are liberal.
• If you are not having genital reconstruction or chest surgery, you are encouraged to stay in town for a few days and have a post-operative check. You can then return home. Certain additional procedures may require up to a two week stay.
• You are asked to call with any post-operative questions and / or concerns at (480) 222-3754

What if I have more questions or want more details?
• If you prefer to know more surgical details, we have a video available for viewing. Please note: If you are squeamish, it has not been edited.
• For other questions, you may call my office at 480-222-3754 or feel free to email me at burtwebb@cox.net .