Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review

Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the "Y" shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9-13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien-Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.

Body Mass Index Requirements for Gender-Affirming Surgeries Are Not Empirically Based

Body mass index (BMI) requirements for gender affirmation surgery (GAS) are ubiquitous and vary across providers. Requirement variation is not surprising given little data to suggest an association between BMI and GAS outcomes. Implementation of subjective BMI requirements limits access to GAS and negatively impacts patient health and safety. We outline the literature on BMI and GAS outcomes, discuss clinical utility of GAS, and summarize dangers of prescribing weight loss as a prerequisite for surgery. We propose that providers use empirically supported indices of health and comorbidity instead of BMI to determine surgical eligibility for all patients considering GAS.

Surgical and demographic trends in genital gender-affirming surgery in transgender women: 40 years of experience in Amsterdam

This was a single-centre, retrospective study of transgender women undergoing genital gender-affirming surgery. A chart study was conducted, recording individual demographics, all genital surgical procedures, and surgical techniques. Procedure incidence, techniques employed, and demographic variations over the years were analysed.

Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction

INTRODUCTION

Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Sexual health post-vaginoplasty is an important aspect of quality of life that can have a significant impact on overall well-being.

OBJECTIVES

The objective of this review is to provide a summary of the literature on the sexual outcomes of transgender females post-vaginoplasty and identify treatment strategies for those experiencing sexual dysfunction.

METHODS

A literature review was conducted with a focus on sexual health outcomes in transgender females post-vaginoplasty as well as treatment options for sexual dysfunction.

RESULTS

Penile inversion vaginoplasty with or without free skin grafts or local tissue flaps and intestinal vaginoplasty are the options available to patients interested in transfeminine genital reconstructive surgery with a neovagina. Sexual satisfaction post-vaginoplasty is high regardless of the vaginoplasty technique, however up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance. Hormone treatment, pelvic floor physical therapy, sex therapy, and sex surrogacy are treatment options for patients with sexual dysfunctions.

CONCLUSION

Patient reported outcome measures appropriately validated for this patient population are necessary to better understand sexual function outcomes, sexual dysfunction and treatment options for post-vaginoplasty patients. Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2021;XX:XXX-XXX.

Caring for Transgender Patients: Complications of Gender-Affirming Genital Surgeries

Patients who undergo gender-affirming genital surgeries may present to the emergency department for their postsurgical complications. In this paper, we briefly describe the transfeminine and transmasculine genital procedures, review the diagnosis and management of both common and potentially life-threatening complications, and discuss the criteria for hospitalization and time frame for surgical consultation and referral.

Requirement of Mental-Health Referral Letters for Staged and Revision Genital Gender-Affirming Surgeries: An Unsanctioned Barrier to Care

BACKGROUND

The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental-health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health-insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines.

OBJECTIVES

This study investigates insurance requirements for referral letters and their negative impact on care.

MATERIALS AND METHODS

We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral-letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed.

RESULTS

Nearly all reviewed U.S. health-insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral-letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH.

DISCUSSION AND CONCLUSION

Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral-letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental-health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.

Penile inversion vaginoplasty outcomes: Complications and satisfaction

Penile inversion vaginoplasty helps to alleviate gender dysphoria and improve quality of life in many transgender individuals. Overall, the procedure is associated with high post-operative satisfaction, even when complications occur. Adverse events related to vaginoplasty are commensurate with other genitourinary reconstructive procedures performed for other diagnoses (ie, cancer or congenital issues). Here, we explore the incidence of complications following vaginoplasty, emphasizing the challenges in defining and managing these adverse events. In addition, outcome measures to assess patient satisfaction will be reviewed.

Sexual health after vaginoplasty: A systematic review

BACKGROUND

Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed.

OBJECTIVES

To investigate sexual health after gender-affirming vaginoplasty for TGD patients.

DATA SOURCES

MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design.

METHODS

We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids.

RESULTS

Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia.

CONCLUSIONS

The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

BACKGROUND

To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited.

METHODS

A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion.

RESULTS

Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low.

CONCLUSIONS

Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis

Supplemental Digital Content is available in the text.

Background:

Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes.

Methods:

A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed.

Results:

After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%–2%] of fistula, 11% (95% CI 8%–14%) of stenosis and/or strictures, 4% (95% CI 1%–9%) of tissue necrosis, and 3% (95% CI 1%–4%) of prolapse. Overall satisfaction was 91% (81%–98%). Regret rate was 2% (95% CI <1%–3%). Average neovaginal depth was 9.4 cm (7.9–10.9 cm) for the penile skin inversion and 15.3 cm (13.8–16.7 cm) for the intestinal vaginoplasty.

Conclusions:

Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

A review of gender affirmation surgery: What we know, and what we need to know

BACKGROUND

Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature.

METHODS

PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized.

RESULTS

Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery.

CONCLUSION

Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.

Gender-affirmation surgery and bariatric surgery in transgender individuals in The Netherlands: Considerations, surgical techniques and outcomes

INTRODUCTION

The number of transgender individuals seeking medical and surgical care has increased over the last years. Within the transgender population overweight and obesity is more frequently observed when compared to the general population. Little is known on the prevalence of bariatric surgery in the transgender population and the effects on the surgical gender transition path of the individual transgender with overweight or obesity.

MATERIAL AND METHODS

All transgender individuals who underwent gender-affirming surgery (GAS) between 1980 and 2020 were retrospectively identified from our hospital registry. Those with a history of bariatric surgery were selected. A retrospective chart study was conducted, recording gender identity, bariatric surgery specifications, gender surgery specifications, complications, reoperations and clinical follow-up time.

RESULTS

A total of 15 transgender individuals (11 transgender men, 4 transgender women) who underwent bariatric surgery were identified. All individuals underwent bariatric surgery before any GAS procedure, except for one transgender man. At the first GAS procedure, all individuals experienced significant weight loss when compared to their weight at bariatric surgery (mean 13.1 ± 3.8 BMI points lost for transgender men, mean BMI points lost 14.3 ± 2.8 for transgender women, p < 0.01). Obesity was still frequently prevalent in transgender men after bariatric surgery. All included transgender men underwent mastectomy via the double incision with free nipple grafting technique. Only one transgender man underwent genital GAS. All transgender women underwent penile-inversion vaginoplasty, one in combination with prosthesis-based augmentation mammoplasty.

CONCLUSION

Surgical gender transition is possible after massive weight loss after bariatric surgery. Specific surgical subtechniques will be more prevalent in this population.

Labial Fat Grafting After Penile Inversion Vaginoplasty

BACKGROUND

Penile inversion vaginoplasty (PIV) has become the most commonly performed genital surgery for transfeminine patients. However, patients undergoing this procedure may still require revisions to achieve a satisfactory result.

OBJECTIVES

The authors report on the utilization of autologous fat grafting to the labia majora to improve results after PIV and complications that may predict the need for grafting.

METHODS

A retrospective chart review was conducted of a single surgeon's patients who underwent PIV between July 2014 and December 2019. Demographic information, operative information, and postoperative outcomes were abstracted from the health records. Wilcoxon rank sum tests and chi-squared test were employed for continuous variables and categorical, respectively.

RESULTS

A total of 182 transfeminine and gender-diverse patients underwent PIV, with 6 patients (3.3%) eventually undergoing labial fat grafting. The most common indication for labial fat grafting was flattened labia majora (83%). All fat grafting procedures were performed concurrently with other revisions of the vaginoplasty. There were no demographic or medical history differences detected between the fat grafting and non-fat grafting groups. Patients who underwent labial fat grafting were more likely to suffer from introital stenosis (33% vs 6%, P = 0.007) and prolonged granulation tissue greater than 6 weeks after initial vaginoplasty (83% vs 32%; P = 0.01).

CONCLUSIONS

Labial fat grafting is a safe and effective method to address defects in the labia majora after PIV. Prolonged granulation tissue and introital stenosis may predict the need for labial fat grafting, possibly due to increased scarring and contracture at the surgical site.

LEVEL OF EVIDENCE: 4

A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes

BACKGROUND

Vaginoplasty is a crucial part of genital gender-affirming surgery with the number of trans women undergoing this intervention steadily, however, up to date, there is still no standardized vaginoplasty technique.

AIM

This retrospective single-center study compares single-stage vs two-stage penile skin inversion vaginoplasty techniques and their long-term outcomes.

METHODS

Medical records of 63 consecutive patients who underwent single-stage vaginoplasty, as described by Dr Preecha Tiewtranon, and 62 consecutive patients who underwent 2-stage vaginoplasty were reviewed.

RESULTS

The mean postoperative hospital stay was 7 days for patients who underwent single-stage vaginoplasty vs 16 days for patients who underwent 2-stage vaginoplasty. Neovaginal depth proved constant in patients who underwent single-stage vaginoplasty, whereas a loss of more than 30% was observed in patients who underwent 2-stage vaginoplasty during the first postoperative year. Early complications were more common than late-onset complications in both groups. The most common complication in the single-stage group was wound dehiscence (4.8%). There were significantly more complications in 2-stage collective, among which wound dehiscence (33.9%), unsatisfactory cosmetic outcome (25.8%), and urethral stenosis (14.5%) were the most common. In the single-stage cohort, 4 (6.4%) patients needed one revision surgery, whereas 35 (56.5%) patients in the 2-stage cohort necessitated one or more reoperations with up to 10 quaternary revisions. All patients reported to have sensitivity to neoclitoris in the single-stage group, whereas 3 (4.8%) patients in the 2-stage group were deprived of it because of neoclitoral necrosis.

CLINICAL IMPLICATIONS

Optimizing a vaginoplasty surgical technique and its postoperative protocol.

STRENGTHS & LIMITATIONS

The present retrospective study with a mean follow-up of more than 3.5 years offers the first ever comparison of 2 different PSI vaginoplasty surgical techniques performed in the same center.

CONCLUSION

Significantly lower complication and revision rates, shorter recovery time, and superior esthetic and functional outcomes were observed in the single-stage than in the two-stage penile skin inversion vaginoplasty surgical technique. Fakin RM, Giovanoli P. A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes. J Sex Med 2021;18:391-399.

Transfeminine Gender Confirmation Surgery with Penile Inversion Vaginoplasty: An Initial Experience

To detail the early experience with and results of a transfeminine (TF) genital reconstruction at an established plastic surgery practice in Western New York.

Methods

Between June 2016 and June 2019, 30 patients underwent penile inversion vaginoplasty for TF gender reassignment. All patients fulfilled World Professional Association for Transgender Health and NY State criteria for reassignment surgery. All surgeries were carried out at a large, government-owned tertiary care center.

Results

There were 30 patients in this retrospective study, with a mean age of 37 years (SD 5.4) and a mean body mass index of 27.3 kg/m² (SD 3.2 kg/m²). Nineteen patients never smoked, 4 were former smokers, and 7 were current smokers. Primary surgery was an orchiectomy and modified single-stage penile inversion vaginoplasty. Mean operative time was 6.0 hours. Mean initial hospital stay was 8.2 days. Three of the 30 (10%) patients required transfusion. There were 6 (20%) complications. Three complications (10%) required reoperation: 1 patient for wound dehiscence on postoperative day 7, 1 for rectal perforation identified on postoperative day 10, and 1 for urethrovaginal fistula. All complications were addressed without sequalae. Twenty of the 30 (66%) patients have undergone revision surgery. Indications for revision were prolapse correction/deepening, labiaplasty, clitoral hood construction/revision, meatal asymmetry, urinary fistula repair, and posterior vaginal flap revision. Twenty-one of 28 (75%) revisions were outpatient surgeries. There were no complications from these procedures. Overall satisfaction via survey was 92% (24 respondents).

Conclusions

TF gender reassignment is a novel, challenging set of procedures for the specialty of plastic surgery. With appropriate consideration and technique, penile inversion vaginoplasty is a safe, effective means of achieving this goal.

Emergency Care Considerations for the Transgender Patient: Complications of Gender-Affirming Treatments

The transgender population presents a unique challenge for the emergency nurse. There are types of surgeries, medications, complications, and differences in laboratory testing that are unique to transgender people. In addition, emergency nurses are increasingly encountering more transgender patients in the emergency department for care, referrals, and education. Yet, many emergency nurses lack the formal training to care for transgender patients and their families. A complete understanding of the terminology, gender-transforming surgeries, hormonal suppression and augmentation of sexual characteristics, adverse effects, complications of surgeries, and ongoing health risks owing to the altered hormonal milieu and potential risk for acquiring sexually transmitted diseases is important to provide the necessary emergency care for this emerging population.

[Gender reassignment surgery from male to female]

For many trans*women, the surgical assignment of the male genital into a female is a fundamental part of the transition. Erogenous sensation of the neoclitoris is achieved by meticulous preparation of the penile glans with the neurovascular bundle. Several techniques are available for the formation of a neovagina, the penile inversion technique developed by Burou in the 1950s being the gold standard. With this technique, the inverted penile shaft skin is used as a pedicled flap to line the neovaginal canal. Alternatively, free skin grafts can be used, which serve primarily as a technique for redo procedures. Another technique is the use of intestinal segments to line the vaginal canal. This method is mostly used for redo procedures, but can also be performed primarily if penile skin is too small. Due to the numerous steps involved in the preparation, a wide variety of complications must be expected. Injury to the rectum during dissection of the neovaginal space, with an incidence of 4.5%, represents the greatest challenge. The most common complications are urethra-associated; hereby both a deviation of the urinary stream and strictures of the urethra are possible. The subjective satisfaction of trans*women with the surgical outcome is high and is reported in various studies to be 72-92%. On the basis of validated questionnaires it could also be shown that gender reassignment surgery leads to an increase in the trans*specific quality of life and promotes both subjectively perceived well-being and sexual satisfaction.

Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems

BACKGROUND

Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved.

OBJECTIVE

To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems.

DESIGN, SETTING, AND PARTICIPANTS

A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up.

SURGICAL PROCEDURE

Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex.

MEASUREMENTS

Demographics, perioperative data, and clinical outcomes were evaluated.

RESULTS AND LIMITATIONS

A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%).

CONCLUSIONS

RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches.

PATIENT SUMMARY

We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.

Gender-affirming surgical techniques, complications, and imaging considerations for the abdominal radiologist

Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.

Urethral complications after gender reassignment surgery: a systematic review

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms (("Transsexualism"[Mesh])) AND ("Sex Reassignment Surgery"[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19-54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes

Background: Different surgical procedures are available for transgender women wishing to undergo genital gender-affirming surgery. Aim: To assess preoperative motivations, the frequency of orchiectomy procedures, and postoperative outcomes of orchiectomy in transgender individuals. Methods: All transgender individuals who underwent orchiectomy in the period between January 2012 and January 2020 at our institution were retrospectively identified. A chart study was conducted, recording motivations, demographics, perioperative characteristics and surgical outcomes. The frequency of orchiectomy and vaginoplasty procedures during the study period were determined and compared. Results: During the study period, an increase of performed orchiectomy procedures was observed. The orchiectomy/vaginoplasty ratio was 0.01-0.07 in the period 2012-2018 and 0.24 in 2019. A total of 43 transgender individuals were retrospectively identified. Sixteen (37%) initially wished to undergo a vaginoplasty, but did not meet institutional requirements (nonsmoker, BMI < 30kg/m²) or were not eligible for vaginoplasty surgery because of interfering somatic or mental health issues. Fourteen (33%) individuals who underwent orchiectomy regarded it as a preceding step to a future vaginoplasty procedure. Out of these fourteen, one person is now on the waiting list for vaginoplasty surgery. Thirteen (30%) others did not report a desire to pursue vaginoplasty in the future. This was mostly motivated by the absence of genital dysphoria or motivations related to their gender identity, with a desire to discontinue anti-testosterone treatment. The postoperative course was uncomplicated in 39 (91%) individuals. Conclusion: In the Netherlands, especially in the last year, the frequency of orchiectomy procedures has increased. Reasons that people chose to undergo this procedure include: not being eligible for a vaginoplasty procedure, seeing it as a preceding step to a possible future vaginoplasty or other identity-related motivations (i.e., non-binary gender identification or absence of genital dysphoria).

Transgender Surgery and Outcomes: Focused for the FPMRS Provider

OVERVIEW

As visibility of the transgender population increases, understanding of the social, psychological, medical, and surgical aspects of these patients care is vital for the practicing female pelvic medicine and reconstructive surgery urologist. The aim of this review is to describe proper terminology, psychosocial considerations specific to transgender patients, in addition to outlining contemporary surgical techniques and complications.

Genital Reconstructive Surgery in Male to Female Transgender Patients: A Systematic Review of Primary Surgical Techniques, Complication Profiles, and Functional Outcomes from 1950 to Present Day

CONTEXT

Genital reconstructive surgery (GRS) is a necessary part of transitioning for many transwomen, and there is evidence of positive effects on a person's well-being and sexual function. Surgical techniques have evolved, from pursuing aesthetic outcome to now functional outcome with natal females as the standard.

OBJECTIVE

To systematically review the evidence, identifying the surgical techniques used in primary GRS, their complications, functional outcomes, and the tools used to assess them.

EVIDENCE ACQUISITION

The clinical question was designed using the standard PICOS format. The search complied with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 statement and was performed by two independent reviewers.

EVIDENCE SYNTHESIS

Europe, USA, and Thailand favour the penoscrotal technique for vaginoplasty, whereas in the UK, the penile inversion (PI) technique predominates. Primary vaginoplasty using a segment of bowel is less common, and all three techniques have comparable rates of intraoperative rectal injury. The incidence of rectovaginal fistula is reportedly higher in the PI technique. Wound haematoma and vaginal prolapse rates are comparable. Higher rates of clitoral necrosis, urethral meatal stenosis, and wound infection are reported in PI. However, the ability to orgasm, ability to have penetrative sexual intercourse, and satisfaction with aesthetic result are better with PI.

CONCLUSIONS

The evidence for GRS complications and functional outcomes is of low level. Standardised nomenclature reporting of adverse events and robust patient-reported outcome measures (PROMs) are lacking. PROMs are a powerful assessment tool, and standardised definitions of adverse events and functional outcomes should be a priority of future research.

PATIENT SUMMARY

We looked at all studies published on genital reconstructive surgery from 1950 to the present day. We assessed each surgical technique and their associated complication rates, sexual and urinary function outcomes, and how they were reported. We found the evidence to be low and weak. We suggest more robust ways of reporting complications, and the impact on patients' quality of life should be investigated.

Outcomes and Predictors of Revision Labiaplasty and Clitoroplasty after Gender-Affirming Genital Surgery

BACKGROUND

Penile inversion vaginoplasty is the most common gender-affirming procedure for transfeminine patients. Patients undergoing this procedure may require revision labiaplasty and clitoroplasty. This study describes complications and outcomes from the largest reported cohort in the United States to undergo penile inversion vaginoplasty with subsequent revision labiaplasty and/or clitoroplasty.

METHODS

A retrospective chart review was performed of a single surgeon's experience with penile inversion vaginoplasty with or without revision labiaplasty and/or clitoroplasty between July of 2014 and June of 2016 in a cohort of gender-diverse patients assigned male at birth. Patient demographic data, complications, and quality of life data were collected. Univariate and multivariate comparisons were completed.

RESULTS

A total of 117 patients underwent penile inversion vaginoplasty. Of these, 28 patients (23.9 percent) underwent revision labiaplasty and/or clitoroplasty, with nine patients (7.7 percent) undergoing both procedures. Patients who underwent penile inversion vaginoplasty necessitating revision were significantly more likely to have granulation tissue (p = 0.006), intravaginal scarring (p < 0.001), and complete vaginal stenosis (p = 0.008). The majority of patients who underwent revision labiaplasty and/or clitoroplasty reported satisfaction with their final surgical outcome (82.4 percent) and resolution of their genital-related dysphoria (76.5 percent).

CONCLUSIONS

Patients who developed minor postoperative complications following penile inversion vaginoplasty were more likely to require revision surgery to address functional and aesthetic concerns. Patients responded with high levels of satisfaction following revision procedures, with the majority of patients reporting resolution of genital-related dysphoria. Transfeminine patients who undergo penile inversion vaginoplasty should be counseled on the possibility of revisions during their postoperative course.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Penile Inversion Vaginoplasty Technique

Penile inversion vaginoplasty is a technique of gender-affirming genital surgery that uses primarily genital skin to construct the vulva and neovagina for patients assigned male sex at birth. This article presents present the authors' techniques and other contemporary techniques for this surgery, with particular attention to neovaginal canal construction, neoclitoral construction, and urethroplasty.

Orchiectomy as Bridge or Alternative to Vaginoplasty

Simple orchiectomy for gender affirmation is a low-risk, minimally invasive, generalizable procedure that eliminates circulating endogenous testosterone, allowing reduced hormonal supplementation. This article describes a technique that serves as a step in definitive phenotypic transition while maximally preserving healthy tissue for future sex reassignment surgery. Orchiectomy should be offered routinely as a bridge or alternative to vaginoplasty, particularly in the setting of limited access to specialized centers for transgender surgery.

Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases

BACKGROUND

Gender affirmation surgery (GAS) is a heterogeneous group of body transformational procedures to match one's gender identity. There is a paucity of literature on the outcomes and safety profile of GAS. This study aims to examine trends and outcomes of GAS from 2010 to 2015 using the American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample databases.

METHODS

Patients with a primary diagnosis of gender dysphoria at the time of surgery were identified in both databases. Thirty-day complication rates were determined using the National Surgery Quality Improvement Program database. Patient socioeconomic status and hospital characteristics were examined using the National Inpatient Sample database.

RESULTS

The number of cases per year increased from 5 in 2010 to 231 in 2015. The overall 30-day complication rate was 5.5%. Younger age was an independent risk factor for overall complications and reoperation. Total operating time was an independent risk factor for overall complications and infection. Black/African American race was associated with an increased risk of reoperation and readmission. Most patients (80%) had income at or above the national median income level; most were self-pay or had private insurance (90%). The typical hospitals providing GAS were large, urban, nonteaching, private nonprofit institutions in the US West Coast and Northeast.

CONCLUSIONS

Gender affirmation surgery has an acceptable safety profile. The marked increase in case numbers likely reflects recent improvements in social climate and access to care. However, there are socioeconomic disparities in utilization and surgical outcomes among this already vulnerable patient population.

[Postoperative complications after genital gender confirming surgery in transgender women]

Genital gender affirmation surgery in transgender women is usually performed by single-stage penile inversion vaginoplasty, with creation of vagina, perineal urethral meatus, majora and minora labia, and clitoris. Postoperative functional or aesthetic complications are common, affecting every reconstructed part of the neovulva. Patients should be preoperatively informed of those possible complications. Postoperative close follow-up must be conducted, beginning with therapeutic learning of the self-dilation regimen, detecting and treating any complication, and ending up when complete healing is obtained among satisfied patient.

Injury in the transgender population: What the trauma surgeon needs to know

Gender dysphoria, or the distress caused by the incongruence between a person's assigned and experienced gender, can lead to significant psychosocial sequelae and increased risk of suicide (>40% of this population) and assault (>60% of this population). With an estimated 25 million transgender individuals worldwide and increased access to care for the transgender population, trauma surgeons are more likely to care for patients who completed or are in the process of medical gender transition. As transgender health is rarely taught in medical education, knowledge of the unique health care needs and possible alterations in anatomy is critical to appropriately and optimally treat transgender trauma victims. Considerations of cross-gender hormones and alterations of the craniofacial, laryngeal, chest, and genital systems are offered in this review. Further research on the optimal treatment mechanisms for transgender patients is needed.

Ethical Issues Considered When Establishing a Pediatrics Gender Surgery Center

As part of establishing a gender surgery center at a pediatric academic hospital, we undertook a process of identifying key ethical, legal, and contextual issues through collaboration among clinical providers, review by hospital leadership, discussions with key staff and hospital support services, consultation with the hospital's ethics committee, outreach to other institutions providing transgender health care, and meetings with hospital legal counsel. This process allowed the center to identify key issues, formulate approaches to resolving those issues, and develop policies and procedures addressing stakeholder concerns. Key issues identified during the process included the appropriateness of providing gender-affirming surgeries to adolescents and adults, given the hospital's mission and emphasis on pediatric services; the need for education on the clinical basis for offered procedures; methods for obtaining adequate informed consent and assent; the lower and upper acceptable age limits for various procedures; the role of psychological assessments in determining surgical eligibility; the need for coordinated, multidisciplinary patient care; and the importance of addressing historical access inequities affecting transgender patients. The process also facilitated the development of policies addressing the identified issues, articulation of a guiding mission statement, institution of ongoing educational opportunities for hospital staff, beginning outreach to the community, and guidance as to future avenues of research and policy development. Given the sensitive nature of the center's services and the significant clinical, ethical, and legal issues involved, we recommend such a process when a establishing a program for gender surgery in a pediatric institution.

Transgender vaginoplasty: techniques and outcomes

Gender affirmation surgery is paramount in the treatment of gender dysphoria for transgender individuals. For transgender women, vaginoplasty offers the opportunity for removal of masculine-appearing genitalia and replacement with a gender-congruent appearance. While numerous techniques have been described in the past, approaches have standardized considerably. Herein, we describe a technique to penile inversion vaginoplasty and focus on some of the critical steps of the procedure to try to optimize patient outcomes. We also review relevant literature regarding perioperative outcomes.

Sigma-lead Male-to-Female Gender Affirmation Surgery: Blending Cosmesis with Functionality

Supplemental Digital Content is available in the text.

Background:

Current male-to-female (MtF) sex-reassignment-surgery techniques have not been fully successful to achieve the ideal objectives. The ordeal of multiple procedures, associated complications, and suboptimal results leads to high rate of dissatisfaction. We have tried to overcome functional inadequacy and address the esthetic issues for outer genitalia and vagina with our innovative “true shape sigma-lead SRS: Kaushik’s technique,” which has now become the technique of choice for MtF genital SRS for our patients.

Methods:

Between April 2007 and April 2017, authors performed 386 sigma-lead SRS in MtF transsexuals. Results were analyzed based on complications, resurgeries, and esthetic/functional outcomes. Corrective SRS using rectosigmoid constituted 145 cases and is not a part of this study.

Results:

Maximum follow-up was 7 years (average 34 months). Seventy-eight (20.2%) patients had complications, majority being minor (97.4%). Forty-four (11.4%) required resurgeries, 10 (2.6%) were corrective for introital stricture and mucosal prolapse, whereas 34 (8.8%) opted for optional minor esthetic enhancement. The overall satisfaction rate for cosmetic and functional outcomes was 4.7 out of 5. In addition to review of the literature, innovations in the technique have been explained.

Conclusions:

Kaushik’s sigma-lead MtF SRS technique is a step short to become the gold standard of genital SRS because it has proven to be safe and reliable. It allows faster healing, minimal dilation, and nearly natural cosmetic results in the form of clitoris/clitoral hood, labia minora, labia majora along with self-lubricating, fully deep, and sensate neovagina with orgasmic capabilities. This is perhaps the largest reported series of rectosigmoid use in transsexuals carried out for primary vaginoplasty.

Evaluation of BMI as a Risk Factor for Complications following Gender-affirming Penile Inversion Vaginoplasty

Background:

Gender affirmation surgery (GAS) has a positive impact on the health of transgender patients; however, some centers employ body mass index (BMI) as a strict selection criterion for surgical candidacy. Several single-center studies have found no clear correlation between BMI and complication rates. We conducted a retrospective multicenter study at 2 university-based centers to test the null hypothesis: obesity is not a significant determinant of the risk of acute surgical complications in patients undergoing penile inversion vaginoplasty (PIV).

Methods:

This is a retrospective chart review of all adult patients at the University of Michigan and the University of Miami undergoing gender-affirming PIV with minimum follow-up time of 3 months between 1999 and 2017. A logistic regression model of analysis is used to examine the predictive factors for surgical complications and delayed revision urethroplasty in our patient sample.

Results:

One hundred and one patients met inclusion criteria for this study. The mean BMI at the time of procedure was 26.9kg/m² (range 17.8–48.2). Seventeen patients (16.8%) had major complications and 36 patients (35.6%) had minor complications. On logistic regression analysis, none of the recorded covariates were significant predictors of delayed revision urethroplasty or major, minor, or any complications.

Conclusions:

We found that obese patients can safely undergo GAS and that BMI alone should not preclude appropriately selected patients from undergoing GAS. We acknowledge that selection based on overall health and other medical comorbidities is certainly warranted for gender-affirming PIV and all other surgical procedures.