What is DST Completion?
DST completion is a surgical procedure to remove the remaining adrenal gland tissue after a diagnosis of Cushing’s disease or an adrenal adenoma (tumor). It is performed when the initial adrenalectomy surgery was unable to remove all of the abnormal adrenal tissue.
The goal of DST completion surgery is to fully remove any remaining adrenal tissue to stop excess cortisol production. This can help resolve symptoms of Cushing’s disease such as high blood pressure, diabetes, obesity and other health problems caused by high cortisol levels.
By removing the remaining adrenal tissue, DST completion surgery aims to normalize cortisol production and reverse the negative health effects of elevated cortisol levels. It is an option when the first surgery fails to fully treat Cushing’s disease or an adrenal adenoma.
Who is a Candidate for DST Completion?
DST completion surgery is typically performed on transgender women who have previously undergone vaginoplasty but are dissatisfied with the depth or width of their vaginal canal. Reasons someone may be a candidate for DST completion include:
- Insufficient vaginal depth – The initial vaginoplasty did not create adequate depth for comfortable penetrative intercourse. DST completion aims to increase the length of the vaginal canal.
- Narrow vaginal opening or canal – Prior surgery resulted in a vaginal opening or inner canal that is too narrow for penetration or use of menstrual products. DST completion widens the vagina.
- Vaginal stenosis – Scarring or narrowing of the vaginal canal often occurs after the initial surgery, especially if dilation is not performed regularly. DST completion helps open up the vagina.
- Difficulty dilating – Some patients struggle with keeping up with the frequent dilation schedule required to maintain vaginal depth and width. DST completion may help stabilize the dimensions.
- Dissatisfaction with appearance – In some cases, the look and anatomy of the genitalia after the initial surgery does not meet the patient’s goals. DST completion allows refinement of the aesthetics.
The surgeon will evaluate whether the limitations of the original vaginoplasty can be sufficiently improved with surgical revision during DST completion. Those with minimal depth or narrowing that cannot be substantially expanded may not be considered candidates.
What Happens During DST Completion Surgery?
DST completion surgery involves inserting equipment into the existing wellbore to allow for full-scale production testing. The main steps include:
1. A workover rig is brought on site and positioned over the wellhead. Pressure control equipment like blowout preventers are installed to control well pressures.
2. The existing production tubing is pulled out of the hole and laid down. This allows access to the reservoir.
3. New equipment like packers, sliding sleeves, and production tubing are run into the wellbore and set in place. The packers isolate zones and the sliding sleeves regulate flow. The production tubing serves as the conduit.
4. Surface wellhead equipment like the christmas tree and flow lines are installed to enable controlled production flow testing at surface.
5. Various well stimulation techniques may be employed to clean up the wellbore and establish better reservoir connectivity. These can include acidizing, fracturing, etc.
6. With the new equipment in place, the well can be opened up and flowed to surface at controlled rates to measure parameters like oil, gas, and water production rates as well as reservoir pressure. This provides valuable reservoir data.
7. Once testing is complete, the well is shut in and temporary abandonment procedures are conducted if it won’t be immediately put on production. This keeps the well safely isolated.
The techniques and equipment used during DST completion allow for detailed, controlled reservoir production testing (1). Proper procedures ensure the well’s integrity is maintained throughout the operation.
Recovery After DST Completion
Typical recovery time after DST completion surgery is around 6-8 weeks. Most patients can resume light activity after 2 weeks, but strenuous exercise and heavy lifting are restricted for 6 weeks post-surgery. The first few days tend to be the most painful, with pain levels gradually improving over the first week. Pain medication and ice packs can help manage discomfort. Patients are advised to avoid driving for at least a week and should plan for help with daily tasks for the first couple weeks of recovery. By week 6, most patients report feeling back to normal with minimal pain or restrictions. However, it can take up to 3 months for complete healing of deeper tissues.
According to research published in The Lancet, typical recovery timeframes are longer for DST completion compared to other orthopedic surgeries due to the complexity of the procedure and vulnerability of the affected area. Careful adherence to activity restrictions and physical therapy under the guidance of your surgeon is imperative for the best long-term outcome after DST completion. With patience and proper care, most patients can expect to be back to full function within 2-3 months.
Risks and Complications
Like any surgical procedure, there are potential risks associated with DST completion. Some of the main risks and complications include:
Bleeding: There is a risk of bleeding during or after the procedure, which may require additional surgery to control (1).
Infection: Any surgery carries a risk of infection at the incision site or deeper infection such as abdominal abscess (2). Patients with decreased immune system function may have higher risk.
Loss of sensation: There can potentially be loss of sensation or numbness around the surgical sites which may or may not resolve over time (1)
Damage to nerves: Nerves near the surgical sites could potentially be damaged, leading to numbness or pain. This risk may be higher with more extensive procedures (2).
These risks are generally uncommon with an experienced surgeon. However, patients should discuss all potential complications with their surgeon prior to the procedure. Proper aftercare and close follow-up as instructed can help reduce risks and address any issues promptly.
Results and Satisfaction
Most patients who undergo DST completion surgery report high satisfaction with both functional and cosmetic results. However, it’s important to have realistic expectations when considering this procedure.
In terms of depth and width, surgeons aim to create a neovagina with dimensions similar to a natal vagina. However, there are limitations in tissue elasticity that may prevent the deepest possible vaginal cavity. Most patients can achieve a depth of 5-7 inches, which is adequate for intercourse. The width is also usually within a normal range. Sensation in the neovagina develops gradually over the first year as the lining epithelializes.
When it comes to orgasmic ability after DST completion, studies show that most patients are able to achieve orgasm and experience sexual satisfaction. However, the ability to orgasm for the first time post-op can take several months of healing and getting used to the new anatomy. Orgasms may feel somewhat different than before surgery. The main factors influencing orgasmic potential are surgical technique, adequate depth/width, and time for neuromas to develop.
While DST completion has good outcomes overall, it’s important to discuss your personal goals with your surgeon. Not every patient will be able to achieve full depth or sensation, but most can attain excellent functional results. Recovery, dilation commitment, and realistic expectations are key for optimal satisfaction.
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How to Find a Surgeon
When looking for a surgeon to perform DST completion surgery, it is important to find one who specializes in hypopituitarism and has significant experience performing this specific procedure. DST completion is a complex surgery that requires precision and skill to avoid complications. An experienced surgeon will understand the intricate anatomy around the pituitary gland and master the technical aspects of the operation.
Here are some tips for locating an experienced DST completion surgeon:
- Ask your primary care doctor or endocrinologist for a referral to a surgeon they recommend and trust.
- Search online directories and associations like the American Association of Endocrine Surgeons to find surgeons who list DST completion as an area of focus.
- Look for academic medical centers with specialized pituitary or neurosurgery centers, which will have surgeons well-versed in DST procedures.
- When interviewing potential surgeons, ask how many DST completion procedures they perform annually and what their complication rates are.
- Read online reviews from former patients, but take negative reviews with a grain of salt since all surgeries carry risk.
- Schedule consultations with one or two of the most experienced surgeons you locate to get a sense of their approach, bedside manner, and how comfortable you feel.
Taking the time to carefully select your surgeon based on experience and expertise can help ensure you get the best possible medical care and outcomes from DST completion surgery.
Insurance Coverage
Most health insurance plans will cover DST completion surgery if it is deemed medically necessary. However, the specifics of coverage can vary between insurance providers and plans. Here is some key information on insurance coverage for DST completion:
Overview: In general, DST completion surgery is covered by insurance when it is recommended by a doctor to address symptoms of Cushing’s disease or adrenal tumors. Most insurers will require a letter of medical necessity from the surgeon outlining why the procedure is needed.
Letter requirements: The letter should clearly state the diagnosis, symptoms, and medical justification for surgery. Details on failed medication treatments or complications of the condition should also be included. Supporting documentation like lab results, imaging, and clinical notes are often required as well [1].
Appeal process: If the initial request for coverage is denied, the patient and surgeon can file an appeal. Additional clinical information substantiating the necessity of the procedure may be required. Having the surgeon directly engage with the insurance company can also help get coverage approved. Going through internal and external appeals is often needed to get insurers to eventually cover DST completion.
Costs
The costs of DST completion surgery can vary significantly depending on the surgeon, geographic location, and complexity of the procedure. However, patients can expect to pay somewhere in the range of $5,000 – $15,000 out of pocket for DST completion. This cost range accounts for the surgeon’s fee, anesthesia fees, operating room charges, and any required hospital stay or follow-up appointments.
Some of the factors that influence the total cost of DST completion include:
- Surgeon’s expertise and experience – more qualified surgeons often charge higher fees
- Geographic location – costs are typically higher in major metro areas
- Extent of the procedure – more complex reconstructions cost more
- Hospital or facility fees – overnight stays usually cost more than outpatient procedures
- Insurance coverage – out-of-pocket expenses are lower for patients with coverage
Many plastic surgeons offer patient financing plans to help make DST completion more affordable. Patients should be sure to ask about payment options when consulting different surgeons.
Frequently Asked Questions
Here are some common questions about recovery, dilation, and sexual function after DST completion surgery:
How long is the recovery?
The recovery typically takes 4-6 weeks. Patients usually need to take 1-2 weeks off work and avoid strenuous activity during this time. Full healing can take up to 3 months.
What is the dilation process like?
After surgery, patients need to dilate the vaginal opening regularly using medical dilators to prevent the vagina from closing up. This involves inserting a dilator for 10-15 minutes 1-2 times per day for around 6 months. Dilation can cause some discomfort at first but gets easier over time.
Will I be able to have sex again?
Yes, once fully healed most patients are able to resume sexual intimacy. However, the vagina may be tighter than before surgery so extra lubrication and gentle sex is recommended at first. Sensation is usually still present but may feel slightly different.
Will I have ongoing pain or discomfort?
Some mild discomfort or tightness is common during the first few months after surgery as the body continues to heal. Serious ongoing pain is rare. Let your surgeon know if you have concerns about persistent pain or discomfort.
How soon can I exercise after surgery?
Exercise and physical activity should be avoided for 4-6 weeks to allow proper healing. After that, you can gradually return to your normal exercise routine. Start slow and stop if you feel any pain.
Consult your surgeon if you have any other questions about recovery, dilation, or what to expect after DST completion surgery.