I haven't seen a lot of GCS consult write-ups, and I might (?) have a couple more of these - including meeting with Dr. Wittenberg's junior partner next week - so I was thinking I'd write up my notes, and see if there's anything others thing I might want to ask next time. My apologies if my terminology is not 100%; I'm not a medical professional, and took more notes than at anytime since college.

Stop HRT 2 weeks before. Will get medication for nerve pain, that also helps with the menopausal symptoms.

Has done 300 PI and 30 PPT surgeries.

Must be in San Francisco a month in total; bring enough meds for 6+ weeks

• Arrive 1 week before for an in-office visit
• Bowel prep one day before
• PI takes 4-5 hours, PPT 6-7
• 3 nights in hospital after; you'll feel like you need to pee/poop constantly; try to walk around a bit, can resume meds when you can walk up and down the hall 3 times. Walking is important, especially with PPT, for pain reduction due to gas buildup.
• 3 follow-up visits, one each week, while in SF. Bladder "test drive" at the first, and also get materials and instructions for dilating
• Week 2 you'll have lots of swelling. Use ice. Walk no more than 2 blocks. For half of patients some of the incisions will separate and need to be addressed.
• Recommend 3 months off work:

1. Dilation schedule is intense
2. Sitting upright for long periods of time can be difficult
3. Post-surgery depression/fatigue is common/expected, since the body is using resources to heal
4. Can try to work around this if you work from home etc.

• Month 3/6/9 follow-ups preferred to be in person, though it is possible to have a local provider (endo or gyno, likely) do this; Dr. W is available to answer any questions
• 80% of swelling goes away within 3 months, the rest within a year; nerves can take longer.
• For PPT would like to do additional follow-ups. Still working with the first cohort.

Dilating - 3/day for 3 months, 1/day for months 3-6, 1/48 hours for months 6-12, and 2/week after.

Complications/revisions

• one year out, 4% of patients ask for a revision; note that it may be slightly assymetric
• 90% of women get granulation scabbing.
• Erectovaginal fistula - worst complication. 4 in her first 100 patients, 2 in the next 100, 0 after that. PI vs. PPT doesn't affect this. Stop dilation if this happens.
• 1 patient had a bladder injury, repaired on its own
• Can have pelvic and other pain - maybe talk to a pelvic PT in advance

Effects

• Bladder infections will be more common
• Pee can be a bit more of a spray, especially at first
• Orgasms are different, and it can take over a year for nerves to heal. Only one patient of hers was completely unable to orgasm.

Depth - try to get ~13cm from PI, but no elasticity. PPT gets 12-16 in the OR, but post-op this tends to shrink a bit to ~12-13; this is similar to cis women.

PPT will have a bit of lubrication, but will still need lube for penetration and dilation. Don't need to douche as much as PI, and slightly more elastic. But will be thinner than PI.

PPT is more risky vs. the similar procedure for cis women. Cis women already have somewhat of a vaginal cavity, and have less muscle in the area in general. Same risk for PI though.

Electrolysis/LHR is preferred but less crucial for PPT. Requied for PI. The diagrams are slightly different.

Tunica vaginalis tissue is not used for the vaginal canal; it's under the labia. The canal is all peritoneal tissue.

The external parts are the same for PI vs. PPT.

Robotics are used for 100% of the surgery.

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DEEP BREATH

I'm sure I'll think of questions over the next week, to ask when I meet her junior partner, Dr. Bonnington. Any questions others have I could also include.

If you have reasons why I should not consider Dr. Wittenberg and/or PPT, I'd appreciate hearing those as well.

Thanks for reading!

/u/2d4d_data

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Edit a few days later:

I talked to the Physician Assistant at Dr. W's office, and she answered the remaining questions I had:

1. What are the major concerns for possible long-term possible negative outcomes specifically for PPT?

None, the major concerns would be sepsis or other complications soon after surgery. But there's no long-term data, unlike PI.

2. How long after surgery can I start exercising (i.e., running) again?

No sooner than 3 months. Pain or discomfort may limit this though. Can start walking soon after surgery (a day or two), and increase the distance over time. Would need to ramp up running distance over time, too, starting at 3 months. Swimming might be a better option to start.

3. Dr. Wittenberg mentioned that, for PPT, the vaginal walls are thinner and/or more prone to injury, compared to PI? Could you elaborate on that?

This is more of an issue during surgery, not really afterwards.

4. What should be done if/when I have granulation scabbing?

GS is proliferation of blood vessels in the vagina. This is benign, but can cause (painless) bleeding, such as blood on the dilator. Dr. W's office can cauterize at follow-up visits, or a local ObGyn can do this too. Usually gone by 1 year.

5. How often will I need to douche? Especially long-term? I’ve often heard that douching is not actually needed/healthy for cis women. Why is it needed/recommended post-GCS?

The cis vagina is slightly acidic, and so does not need to be douched. Trans vaginas don't have the acidity, so you need to douche to change the pH. Once/day immediately after surgery, eventually down to once/week for life.

6. What are the advantages/disadvantages of PPT vs. a hybrid peritoneal method?

Advantage: the whole vaginal linine is the same feeling/texture; hybrid can also create a bit of a constriction point in the middle of the vagina. Also, any hair regrowth from laser/electrolysis will be right at the entrance to the vagina, so accessible, though probably not comfortable to remove.

No particular disadvantages for PPT vs. hybrid.

7. What happens to the “extra” material that would be used for vaginal lining in PI that is no longer needed for that in PPT?

It is discarded.

8. For injections, what does “2 weeks without HRT” look like? Two weeks since the most recent injection, or 2 weeks since the end of the last injection cycle? My injection cycle is biweekly, so the latter option would mean 4 weeks since my last injection.

The last injection would be no fewer than 28 days before surgery.