Impact of Intraoperative Intravenous Tranexamic Acid Use on Postoperative Bleeding Events in Gender-Affirming Vaginoplasty

INTRODUCTION: One of the more common and disruptive complications of gender-affirming vaginoplasty is postoperative bleeding, typically presenting as a hematoma or hemorrhage. These complications often require readmission and reoperation. Interventions targeted at reducing the risk of postoperative bleeding include the use of hemostatic agents, such as intravenous tranexamic acid (IV-TXA), which has been found in multiple surgical disciplines to have some effect on postoperative bleeding events. The present study aims to evaluate the impact of intraoperative IV-TXA administration on postoperative bleeding events in a large sample of gender-affirming vaginoplasty patients. METHODS: Following approval from the Institutional Review Board at the Icahn School of Medicine, patients receiving gender-affirming vaginoplasty at the Mount Sinai Center for Transgender Medicine and Surgery between January 2018 and December 2021 were evaluated retrospectively. Demographics, comorbidities, intraoperative details, and postoperative outcomes were collected. Intraoperative details included hemostatic agents, estimated blood loss, anticoagulation, operative time, transfusion, and intraoperative complications. Preoperative and postoperative hemoglobin levels were also collected. Postoperative complications included minor hematomas, defined as hematomas requiring conservative treatment; major hematomas, defined as hematomas requiring intervention such as return to the operating room and readmission; postoperative hemorrhage; and readmission and reoperation related to bleeding. Non-plastic surgery patients, patients who did not receive heparin anticoagulation, and patients with bleeding disorders were excluded. Pearson’s Chi Square and Fischer’s Exact tests were used for categorical variables, and analysis of variance was used for continuous variables. Statistical significance was set at p<0.05. RESULTS: Three-hundred-forty-two (342) patients were included in the study, 189 of whom did not receive IV-TXA and 153 of whom received IV-TXA. Mean follow up time was 9.5 months. Surgeon preference alone dictated IV-TXA use. All patients received some form of local hemostatic agent, including topical thrombin and Gelfoam. Significantly fewer patients in the IV-TXA group had a minor hematoma (13.2% vs. 0.6%, p<0.001). Estimated blood loss was significantly less in the IV-TXA group (121±51 mL vs. 172±77 mL, p<0.001). Postoperative hemoglobin was higher in the IV-TXA group (10.5±2.3 g/dL vs. 9.75±1.6 g/dL, p=0.05). Major hematomas (3% vs. 2.6%, p=0.511), postoperative hemorrhage (7% vs. 4%, p=0.235), bleeding requiring reoperation (3.7% vs. 3.2%, p=0.828), and bleeding requiring readmission (3.7% vs. 1.9%, p=0.268) were not significantly different between the two groups. Venous thromboembolic events were not different between the two groups (0% vs. 1.3%, p=0.115). Subgroup analysis of readmissions and reoperations for major hematomas or postoperative hemorrhage in each group did not achieve statistical significance, although readmissions for major hematomas were 50% less in the IV-TXA cohort. CONCLUSIONS: The use of IV-TXA significantly reduces minor hematomas in patients receiving gender-affirming vaginoplasty, a complication that causes patient distress and pain in the postoperative period. IV-TXA is also useful in decreasing blood loss, and does not significantly impact the rate of venous thromboembolic events, a feared complication of IV-TXA use. Despite no statistically significant difference in major bleeding events, the trend towards fewer readmissions for major hematomas in the IV-TXA cohort may suggest this intervention is worthwhile in preventing serious postoperative bleeding complications.