No Increase in Complications With IV TXA Use in Vaginoplasty

Abstract and Introduction

Abstract

Background: Across surgical specialties, tranexamic acid (TXA) is applied to reduce intraoperative and postoperative bleeding. Within plastic surgery, both topical and intravenous routes are used. The application of TXA has yet to be examined in vaginoplasties.

Methods: The authors performed a retrospective chart review of Mayo Clinic patients receiving penile inversion vaginoplasty from January 2017 through July 2021. Incidence of hematoma formation was assessed as the primary outcome. Secondary outcomes included perioperative hemoglobin, vaginoplasty complications, and possible TXA complications. These outcomes were compared across topical only (t-TXA), any intravenous (IV-TXA), and no TXA groups.

Results: Of the 124 vaginoplasties, 21 patients received t-TXA only and 43 received any IV-TXA. Only 4 patients developed a hematoma; 2 were from the no TXA group and 2 were from the any IV-TXA group. There was no significant change in perioperative hemoglobin across groups. Analysis showed lower incidence of divergent urine stream (odds ratio [OR], 0.499 [95% confidence interval (CI)], 0.316–0.789], P = .003) and neovaginal stenosis (OR, 0.435 [95% CI, 0.259–0.731], P = .002) within the any IV-TXA group and no increased incidence of other complications.

Conclusions: The use of either t-TXA or IV-TXA in vaginoplasty cases did not result in an increased rate of complications. There was no significant reduction in hematoma formation or postoperative hemoglobin decrease across groups.

Introduction

As part of gender-affirming care, some transwomen may choose to pursue vaginoplasty. The mainstay of this procedure includes orchiectomy, labioplasty, urethroplasty, and clitoroplasty.^[1] Some patients may also desire creation of a vaginal canal. One approach is penile inversion to create the introitus and proximal canal, with possible grafting from donor sites, such as the scrotal skin or medial thigh, to achieve sufficient depth.^[2] The creation of the canal is in a nonanatomic plane, and there are risks of hematoma formation. In addition, shearing and moisture in the perineal region make the surgery prone to graft failure.^[3,4]

Effective intraoperative hemostasis is important in reducing ongoing blood loss. In addition to technical steps, another recent tool empirically applied to limit intraoperative and postoperative bleeding is tranexamic acid (TXA). TXA is an antifibrinolytic, which only carries formal US Food and Drug Administration approval for procedural prophylaxis in hemophilia patients and treatment of menorrhagia.^[5] Its use has been extrapolated to many surgical applications. Studies have shown the effective use of the intravenous-TXA (IV-TXA) formulations in reducing transfusion requirements and drain output in total joint arthroplasties.^[6,7] Outside of orthopedics, TXA's usage has been examined within trauma,^[8,9] neurosurgery,^[10] and obstetrics practice,^[11] among others with results suggesting or demonstrating the treatment's efficacy.

Within the plastic surgery domain, TXA is also often administered topically. Among survey respondents within the American Society of Plastic Surgeons, around 18% used TXA routinely in their practice; of these surgeons, nearly half gave TXA either topically alone or in combination with an IV bolus.^[12] Topical-TXA (t-TXA) in randomized controlled trials has been found to reduce operative blood loss as well as the need for blood transfusion when compared with placebo or no TXA use.^[13] Within reconstruction applications, t-TXA has demonstrated efficacy in reducing drain output in mastectomy^[14] and reduction mammoplasty.^[15] For those utilizing the liposuction technique in mammoplasty reduction, the addition of t-TXA, as a component of Klein's solution, with IV-TXA administration decreased liposuction decanted volume and dermal bleeding during de-epithelialization when compared with those procedures that did not employ this local component.^[16] Moreover, both single and dual-route administration of this agent have reduced intraoperative and postoperative blood loss or drainage in various aesthetic surgeries, although the clinical significance of this reduction remains unclear.

Although TXA's application has been extended to vaginoplasties from the other specialty and plastic surgery reconstructive procedures, the authors are unaware of studies examining the efficacy of either route or of combined administration in vaginoplasties. Thus, a retrospective review of vaginoplasty cases was performed at their institution to characterize the route of TXA administration and to compare outcomes for these routes.