Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization andMedical Readiness forMilitary Patients.

Abstract

Access to surgical care for gender-affirming surgery (GAS) has been a persistent challenge within the DoD due to long waiting lists, strict insurance requirements, and surgeon/subspecialty scarcity. These issues were magnified during the COVID-19 pandemic response, as limited resources led to postponement of "elective" surgeries. To remedy this, our center organized a multidisciplinary collaboration to perform simultaneous GAS. This model is necessary to optimize the quality-of-life and medical readiness for a particularly marginalized population within the U.S. Military who now constitute roughly 1% of all active duty personnel. In addition, one-stage surgery provides a feasible solution to streamlining care and decreasing DoD personnel health care costs. We present a case describing successful multidisciplinary surgical management of a transgender woman desiring multiple GASs. We include a comparative, cost-benefit analysis to emphasize the advantages of single-stage over multistage surgeries. Our patient is a 24-year-old active duty transgender female who underwent breast augmentation and fat harvesting with plastic surgery, which was immediately followed by simultaneous simple orchiectomy by urology and facial feminizing surgery with otolaryngology. Total operative time was 8.3 hours. Our patient was discharged on post-operative day 1 and had an uneventful recovery without complications. Keys to successful implementation included the judicious, coordinated use of local analgesia as well as the organization of separate operating room bedside tables and scrub techs for each team. Total convalescent leave time and temporary profile duration were reduced by 50% relative to the staged approach: 4 weeks and 3 months versus 8 weeks and 6 months, respectively. Of note, anesthesia provider fees total ∼$8,213 when surgeries are performed as three separate events. For one-stage surgery, anesthesia fees amount to only $1,063 (assuming ∼10 hour anesthesia time with a CRNA provider). Our case study demonstrates that one-stage multidisciplinary surgery can be accomplished without added risk to the patient. Judicious surgical planning, including having surgeons operating at the same time, reduces operative time and provides for efficient operating room utilization. Simultaneous GAS is an effective approach to improve access to surgical care for transgender patients. A single anesthetic enables patients to achieve their surgical goals sooner and to lessen their overall recovery time. This allows service members to return to duty sooner, supporting the Defense Health Agency mission to ensure a medically-ready force. This model should become the standard within MTFs across the DoD, as it promotes improved quality-of-life for patients, decreases personnel costs, and ensures medical readiness.