Epidural infusions for trans-women undergoing neo-vaginoplasty: a case for central sensitization

Abstract

INTRODUCTION: Neovaginoplasty, is a gender affirming surgery provides a way for transfeminine persons to remove masculine appearing genitalia and replace with a more gender congruent appearance. As of 2019 “bottom” surgery was reported in transgender and non-binary persons at a rate of 4-13% with prevalence increasing rapidly (Nolan et al., 2019). The benefits of combined general and epidural anesthesia for neovaginoplasty has been well described (Salgado et al., 2019). In this study we examined dosing strategies for epidural infusions at our institution for patients undergoing neovaginoplasty. METHODS: This study was approved by the Institutional Review Board at our institution. Non-experimental retrospective chart reviews were conducted and all trans-gender patients who underwent neovaginoplasty procedures between 2014-2019 and were over the age of 18 at the time of chart review were included. Patient demographics including age, ethnicity, BMI were collected as well as comorbidities, history of hormone use, DVT, and nausea. Lumbar Epidurals were placed preoperatively and dosed after incision. Epidural start and stop times were collected along with pain scores measured on a visual analogue scale, and blood loss was recorded. RESULTS: The final cohort consisted of 154 cases that matched the eligibility criteria of this study. About half of these patients, 49.3%, spent 2-4 hours in the PACU after their procedures. The most common ASA status was 2. As expected, an overwhelming number of patients, 141 of 154 (91.6%) reported using hormone therapy. Epidural infusion duration prior to first pain score assessment was 0 to 701 minutes. Median epidural infusion duration was 285 minutes. Patients whose epidural was begun early had an average pain score of 5.06/10 (+2.11). Epidurals which were started late had an average pain score of 5.16/10 (+3.04). Maximum EBL noted for all cases was 450 mls. CONCLUSION: Overall, pain score was not significantly impacted by epidural start time post incision. Average initial pain scores were high in both cohorts, despite good pain relief on postoperative day 1. Observed EBL for these procedures was low at our institution, with no patients requiring blood transfusion. Central sensitization may play a large role in the initial pain scores and PACU length of stays for neovaginoplasty patients. Our future protocols will move towards dosing epidurals prior to incision for these procedures