Hysterectomy with bilateral salpingo-oophorectomy is a part of gender reassignment surgery for the treatment of female-to-male transsexualism. Over the last years many efforts were made in order to reduce invasiveness of laparoscopic and robotic surgery such as the introduction of single-site approach. We report our preliminary experience on single-site robotic hysterectomy for cross-sex reassignment surgery. Our data suggest that single-site robotic hysterectomy is feasible and safe in female-to-male transsexualism with some benefits in terms of postoperative pain and aesthetic results.
Transsexualism is a condition in which a person lives a significant incongruence between gender identity and physical phenotype [
We conducted a retrospective analysis of perioperative data from ten consecutive patients who underwent robotic-assisted single-site laparoscopic hysterectomy (RSSH) for FMT at our institution from April to December 2013. Candidates for gender reassignment were referred to us for the operation from various centers. All patients had diagnosis of gender identity disorder assessed by mental health professional according to DSM-IV-TR criteria [
Data regarding baseline patients’ characteristics (age, BMI, previous surgery, comorbidities, smoke, hormonal therapy, parity, and sexual function) were collected as reported in Table
Patients’ characteristics.
Characteristics | Values |
---|---|
Age (years) | 28 ± 5.7 (M ± DS) |
BMI (kg/m2) | 22 ± 1.7 (M ± DS) |
Parity | — |
Previous abdominal surgery | 4 (40%) |
Mastectomy | 9 (90%) |
Comorbidities | 2 (20%) |
Smoke | 10 (100%) |
Androgen therapy (years) | 2.6 ± 1.2 (M ± DS) |
Virgin | 2 (20%) |
Visual Analogic Scale ranging from 0 = no pain to 10 = agonizing pain was used to evaluate postoperative pain, and VAS score was recorded every 3–6 hours for all patients from the end of surgery till discharge. According to our anesthesia protocol standard analgesic therapy with ketorolac 30 mg twice a day and acetaminophen 1000 mg every 8 hours was administered, while tramadol was used only on demand. At the end of surgery ropivacaine local infiltration was performed at the single-site port access.
All patients received venous thromboembolism and antibiotic prophylaxis according to institutions guidelines.
Every surgery was performed using a da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) by a team consisting of two experienced surgeons (Stefano Bogliolo and Luciana Babilonti) and one bedside assistant for uterine manipulation. The single-site system is a multichannel port device not reusable with space for 4 cannulae and an insufflation valve. The specific cannulae are as follows: two 250 mm in length curved cannulae for robotic instruments, one cannula for the high-definition three-dimensional endoscope, and one 5 or 10 mm assistant surgeon cannula.
Uterine manipulator device was placed, when possible, in order to improve uterine mobilization. A 2 cm incision was performed at the umbilical scar in correspondence with the physiological hernia (Figure
Single-site umbilical incision.
Pneumoperitoneum up to 12 mmHg of pressure was started and patient was placed in lithotomy position at the 30° Trendelenburg position. da Vinci Si robotic column was positioned between the patient’s legs and da Vinci Si 8.5 mm 30° endoscope was placed in umbilical trocar. After that, two 5 × 250 mm curved cannulae were introduced through the specific lumen, under constant visualisation and eventually the specific robotic instruments were placed (surgical forceps on Arm 2 and curved scissor on Arm 1). The assistant’s 5 or 10 mm cannula was also inserted allowing the use of classic bipolar instruments overcoming the absence of specific robotic one.
The technique used for robotic single-site hysterectomy and BSO was similar to that used in standard laparoscopy; uterus and adnexa were removed through the vagina and vaginal cuff was closed both vaginally and robotically depending on anatomic features.
A series of 10 patients underwent RSSH + BSO at our department during nine months. The clinic-pathological characteristics of these patients were reported in Table
Regarding surgical procedure in all cases a total hysterectomy with BSO was performed.
The mean operative time was
The vaginal cuff closure was performed in eight cases transvaginally; only in two cases of virgin patients the vaginal suture was performed with extracorporeal knots, with the aid of a push knot, as previously described [
Regarding perioperative outcomes, no laparoscopic or laparotomic conversion was needed during robotic surgical procedure.
Only in one case a minor postoperative complication occurred: vaginal bleeding required a partial vaginal suture for hymeneal ring laceration, due to important atrophy.
The median hospital stay was
Traditionally, in sex reassignment surgery, total laparoscopic hysterectomy with BSO is performed. Vaginal route, ideally “scarless” surgery, cannot routinely be offered to FMT patients because most transsexuals are nulliparous and virginal and have narrow and atrophic vaginal walls as a result of long term hormonal therapies [
At present there are no experiences describing robotic single-site technique in FMT; therefore a comparison between our preliminary data and perioperative outcome of similar reports is not possible.
Indeed the surgical technique of single-site hysterectomy is not different from that used in benign gynaecological disease and our FMT data are in line with those reported in literature for female patients [
Cross-sex surgery should be ideally offered to all transsexuals who do not desire fertility, for different reasons. First, according to literature, surgical reassignment allows amelioration of quality of life in several meaningful areas (socioprofessional, relationship, and psychological) and improves social and sexual functioning [
At present only few studies focused on surgical outcome and technique of hysterectomy with BSO for female-to-male transsexualism. In 1999 Ergeneli et al. first reported the feasibility and safety of laparoscopically assisted vaginal hysterectomy in FMT reassignment surgery in eight patients who subsequently underwent phallic construction. According to the author laparoscopy was useful allowing preservation of structures necessary for phallic reconstruction [
In 2007 O’Hanlan et al. reported the largest series in literature evaluating surgical outcome of 41 transsexual patients compared to normal female patients who underwent total laparoscopic hysterectomy and BSO [
Recently in 2013 Lazard et al. reported a series of ten patients who underwent single-point access laparoscopic hysterectomy for sex reassignment with no conversion to standard laparoscopy or laparotomy [
Similar to Lazard, in our peculiar series, robotic single-site approach allowed performing total hysterectomy and BSO with 100% success. The use of single intraumbilical incision made scar completely hidden; thus transsexual patients did not bear the “stigma” of standard laparoscopic gynecologic surgery [
Robotic single-site surgery in our experience achieved the goal of excellent postoperative pain control as already highlighted by other authors [
General satisfaction about surgery and aesthetic results are objective of an ongoing study at our institution. However preliminary data regarding the first five patients at 1–3 and 6 months reported a satisfaction VAS score >8 for both aspects.
Larger series and long term follow-up data are still lacking, but we consider single-site robotic surgery a valid choice in FMT reassignment surgery, with a low rate of complications, good pain control, and excellent aesthetic results. Indeed in our small series only a minor perioperative complication occurred and not directly related to single-site technique.
The authors declare that there is no conflict of interests regarding the publication of this paper.