Sex Reassignment Surgery in HIV positive Transsexuals

by A. Neal Wilson, M.B., B.S., F.R.C.S.
Clinical Assistant Professor of Surgery, Plastic Surgery
Wayne State University, Detroit, Michigan

Citation: Wilson A.N.  (1999) Sex Reassignment Surgery in HIV positive Transsexuals. IJT 3,1+2, http://www.symposion.com/ijt/hiv_risk/wilson.htm

Correspondence and requests for materials to:
A. Neal Wilson, M. D. 3011 W. Grand Blvd. Suite 571-5 Detroit, MI 48202

• Summary
• Introduction
• Review of Literature
• Findings
• Conclusion
• References

Summary
It can be said that in the absence of frank AIDS (CD4 Lymphocyte count of 200 or less) the HIV infected transsexual can undergo reassignment surgery with little more likelihood of adverse results than their uninfected peers. Providing universal precautions are undertaken and everybody in the operating team and postoperative care team understand the situation there should be no needle sticks or infected blood spillage. This report focuses on the author's experience with performing sex reassignment surgery for 10 male-to-female transsexuals.
  

Introduction
The decision to operative on HIV positive patients was not made by me or my urological colleague; it was made by the ethics committees of the two Detroit Medical Center Hospitals in which we undertake these surgeries. The first case in 1988 turned up with positive serology the day of surgery. Surgery was canceled. The Western Blot was positive three days later. The case was presented to the Ethics Committee at the Harper Hospital in the Detroit Medical Center and this august body deemed it unethical to withhold surgery. Since this time, the number of HIV positive transsexual or transgendered individuals presenting to myself with a request for sex reassignment surgery numbers eleven. Of these eleven, ten were reassigned. The patient who was not reassigned presented at the age of 37 years, having been in and out of local gender programs for 10 years or so, requesting reassignment to "get out of the gay life style." This patient never seriously tried to fulfill the requirements of the Harry Benjamin standards of care. She was diagnosed as HIV positive two years after she first presented to this author. She had many ups and downs and was eventually treated with Protease inhibitors. She died of AIDS encephalopathy at the age of 42. The other ten patients are much more typical.
  

Review of Literature
A computerized Medline search was conducted from 1966 through the present and turned up only 10 papers concerning HIV positivity and surgery, none of them being in transgendered or transsexual individuals. In 1997, Flum and Wallack (1) conducted a literature search concerning the impact of the human immunodeficiency virus infection and syndrome have had on the practice of surgery. They concluded that the incidence of human immunodeficiency virus infection ranges from 1.3% of patients hospitalized at sentinel hospitals to 1.5/1,000 patients in lower risk environments. The rate of percutaneous injury during an operation is 5% to 6% and human immunodeficiency virus transmission after percutaneous injury with a needle contaminated with the human immunodeficiency virus is .3%. Furthermore, Lowenfels, Mehta, Levi, Montecalvo, Savino and Wormser (2) reported in 1993 on the incidents of percutaneous injuries in surgeons. They reported that there was a decrease in the frequency of reported percutaneous injuries over the period 1988 to 1993. The number of yearly injuries per surgeon decreased from 5.5 to 2.1. As Flum and Wallack (1) reported, the transmission of human immunodeficiency virus after percutaneous injury with a needle contaminated with HIV is .3%. It would therefore seem not particularly dangerous to the individual surgeon, providing universal precautions are undertaken, to undertake surgery on HIV positive patients. From the first case in 1988 until mid 1995, our index of severity of HIV infection was the CD4 Lymphocyte count. After this time the viral load has been used and this is measured as viral RNA. Before 1995, measurement of viral load was unavailable to us. Currently, I think patients without any history of opportunistic infection, without frank AIDS, with a CD4 Lymphocyte count above 200, and with viral replicas less than 600 meet what seems to be the most reasonable parameters for surgery. All these patients present themselves to me thoroughly evaluated by their own doctors at home or locally. If they have not been evaluated and no doctor is taking responsibility for their HIV status, then suitable specialists are found for them either as outpatients and certainly as inpatients during their reassignment surgery. Consultation is undertaken with the patient's primary care doctor, either by telephone or hopefully by means of written reports.
  

Findings
The salient features of the series of eleven are as follows (see Fig. 1). The age at presentation seeking reassignment surgery varied from 19 years to 45 years of age with a median in the late 20's. Of these eleven most waited one to two years after presentation before reassignment surgery. The number of years of history of HIV positive at presentation varied from 0, (the patient who turned up positive the morning of surgery which was then postponed) to 9 years with a median of 3 years.

The surgery of the first patient when eventually she was rescheduled and the operation was undertaken was a "Wilson" type procedure involving a corpora cavernosa neurovascular island glans flap, and a skin graft later (see Fig. 2). This was very difficult in this patient and she sustained a blood loss of 4,500 cc's necessitating 15 units of packed red cells. Postoperatively she suffered from Myglobinemia and Renal Insufficiency and Femoral Neuropathy. This was probably due to the type of operative position in which she was placed. However, she eventually recovered from this and has lived well for the last 10 years. Her CD4 count at the time of surgery was 584. No viral load was done on this patient.

Of the remaining 9 patients, the operation performed in the succeeding three was a simple penile inversion on the grounds that this would provide less blood loss and therefore less exposure to the virus of the operating room team. Blood loss for these three averaged just over 700 cc's per operation. Blood loss for the more complex Wilson procedure, without including the 4,500 cc loss, averaged 800-850 cc's. Most hospitalizations were within the expected course, that is 8-10 days for the penile inversions and 15-18 days for the Wilson procedures. The Renal Insufficiency patient was kept in several days longer than the 18 days. All patients were placed in an intensive care unit postoperatively to carefully monitor fluid shifts and blood loss which in these cases tends to be unpredictable and often severe. The last patient in the series spent 6 days in the ICU with persistent ooze and requiring recurrent blood transfusions. There have been four late complications in the complete series. One was to repair labia majora which had split. The other three suffered from urethral stenosis which responded to dilatation and foley catherization. The rectum was injured in 2 cases but healed uneventfully (all patients had a complete bowel prep preop and "triple therapy" antibiotic postoperatively). CD4 Lymphocyte counts at the time of surgery ranged from 50 all the way up to 1827 with a median in the 400-450 range. One patient with a preoperative CD4 of 304 which decreased to 156 three days postoperatively was treated with intravenous AZT, particularly as she complained of night sweats and chills. This is the only case in the reassigned group of patients who have since died after having lived four years post surgery. Follow up, either in person or by telephone, indicated that all the patients except the one are alive and well anywhere between 10 years and 1 year after their surgery. Most hospital courses were normal except the renal insufficiency patient and one patient who complained of diarrhea which was negative for Clostridium Difficile. The maximum postoperative temperature of the whole series was no more than 102 degrees Fahrenheit. The maximum white blood counts for the hospital admissions varied from normal up and to 23,000/cubic cm. In the last two patients, CD4 Lymphocyte counts where undertaken but not relied on. Each patient had an undetectable viral load. The three penile inversions were undertaken, as noted above, on the grounds that less blood loss would expose the operative team to less risk of infection. However, it was pointed out to the author that the Americans with Disabilities Act said, in effect, that there was to be no difference in treatment between HIV positive patients and normal patients based on HIV positivity. Therefore, subsequently, we have always undertaken "Wilson" procedures (3). Normally the major reassignment is undertaken on one day; the raw area of the vaginal vault is split skin grafted seven days later; the skin graft is then looked at seven days after this (postoperative day 15) and the patient sent home within the next day or two or three if everything is fine. It is possible to split skin graft the vaginal vault at the same time as the original procedure thus possibly shortening the hospitalization to eight to ten days, but the reliability of skin graft take is much less. The author has received one or two requests so far for a Rectosigmoid Neocalphorrhapy in the HIV positive patient. After lengthy discussion with the general surgeons who undertake this surgery and the ethics committees, it was decided that this would not be justifiable at this time.
  

Conclusion
It seems there are no predictors concerning the patients who will do poorly after surgery. Night sweats are a fairly commonly described symptom and these were mentioned by four or five of our patients. It should be noted however that only the one who died noted this in detail "running rivers of ice over my back." The patient who's CD4 Lymphocyte count was only 51 at operation subsequently went on to an almost zero CD4 Lymphocyte count. This was managed with Protease inhibitors and the patient, on last speaking with her on the telephone, asserted that she was alive and doing well and her CD4 Lymphocyte count was in the 350 range. In conclusion, provided certain criteria are met, HIV positive transsexuals can undergo sex reassignment surgery.
  

References
1) Flum DR, Wallack MK. (1997). The surgeon's database for AIDS: a collective review. Journal of the American College of Surgeons. 184(4):403-12.

2) Lowenfels AB, Mehta V, Levi DA, Montecalvo MA, Savino JA, Wormer, GP. (1933) Reduced frequency of percutaneous injuries in surgeons. AIDS. 9(2):199-202.

3) The details of the "Wilson" procedure have been available on the Internet for sometime. The procedure itself has not been written up for the hard copy literature as it is still evolving. Basically, the perineum is opened with the posterior perineal skin flap and the vagina is constructed. Bilateral orchiectomies are undertaken; the scrotum and penile skin are split in the mid-line leaving a rectangular penile skin flap; the penis itself is taken to pieces leaving the urethra and spongiosis ventral and separate; one third of one corpus cavernosa is dissected out and left to carry the vascular supply and nerve supply to a small segment of the original glans. The reconstruction is begun by first suturing in the posterior perineal skin flap, then suturing in the penile skin flap to the prostatic fascia and at each side to the posterior perineal skin flap, then bring through the urethra and the glans of the clitoris, bringing down the labia scrotal elements and suturing them to the mid-line. The raw vaginal vault is skin grafted one week later. A first graft dressing change is undertaken one week after this. The main advantage is that there is enough penile skin left on the outside to undertake reconstruction of labia minora and clitoral hood. The bulb of the penis can be removed later and the urinary stream adjusted to suit the patient. The clitoral shaft and the glans apparatus comes from above downwards rather than below upwards as in the simple penile inversions with the residual urethra. Erotic sensation to the glans is preserved.@