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Lava CX, Berger LE, Li KR, Rohrich RN, Margulies IG, Singh A, Sharif-Askary B, Fan KL, Lisle DM, Del Corral GA. A comparative analysis of peritoneal flap and intestinal vaginoplasty for management of vaginal stenosis. J Plast Reconstr Aesthet Surg 2024; 98:55-63. [PMID: 39236396 DOI: 10.1016/j.bjps.2024.08.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 07/30/2024] [Accepted: 08/09/2024] [Indexed: 09/07/2024]
Abstract
BACKGROUND In transgender or non-binary patients (TGNB) with failed penile inversion vaginoplasty (PIV), peritoneal flap vaginoplasty (PFV) and intestinal segment vaginoplasty (ISV) facilitate restoration of neovaginal depth and sexual function. This study compared the outcomes of revision PFV and ISV in TGNB patients with failed PIV. METHODS TGNB patients who underwent secondary PFV or ISV from December 2018 to April 2023 were reviewed. RESULTS Twenty-one (5.8%) patients underwent secondary PFV and 24 (6.6%) underwent secondary ISV, due to vaginal stenosis (n = 45, 100.0%). Mean duration to first successful dilation and average vaginal depth were comparable between the groups. Seven (33.3%) PFV patients experienced short-term complications, including introital dehiscence (n = 2, 9.5%), vaginal stenosis (n = 2, 9.5%), vaginal bleeding (n = 2, 9.5%), and reoperation (n = 2, 9.5%). Nine (42.9%) experienced long-term complications, including urethrovaginal fistula formation (n = 2, 9.5%), hypergranulation (n = 2, 9.5%), vaginal stenosis (n = 7, 33.3%), and reoperation (n = 6, 28.6%). Ten (41.7%) ISV patients experienced short-term complications, including dehiscence (n = 4, 19.0%), ileus (n = 2, 8.3%), introital stenosis (n = 2, 9.5%), and reoperation due to vaginal bleeding (n = 2, 8.3%). Six (25.0%) experienced long-term complications, including introital stenosis (n = 3, 12.5%), mucosal prolapse (n = 2, 8.3%), and reoperation due to mucosal prolapse (n = 4, 16.7%). Secondary PFV had a higher rate of vaginal stenosis (p = 0.003). There were no cases of partial or full-thickness flap necrosis. CONCLUSION Revision PFV and ISV represent viable techniques for addressing vaginal stenosis secondary to PIV. Although PFV and ISV had comparable rates of short-term complications, ISV demonstrated a lower incidence of recurrent vaginal stenosis, which may inform operative decision-making.
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Affiliation(s)
- Christian X Lava
- Georgetown University School of Medicine, Washington, DC, USA; Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Lauren E Berger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA; Department of Plastic Surgery, New York University Langone Health's Hansjorg Wyss, New York, NY, USA
| | - Karen R Li
- Georgetown University School of Medicine, Washington, DC, USA; Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA; Department of Plastic Surgery, New York University Langone Health's Hansjorg Wyss, New York, NY, USA
| | - Rachel N Rohrich
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ilana G Margulies
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Anusha Singh
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Banafsheh Sharif-Askary
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - David M Lisle
- Department of Colon and Rectal Surgery, MedStar Franklin Square Medical Center, Baltimore, MD, USA
| | - Gabriel A Del Corral
- Department of Plastic and Reconstructive Surgery, MedStar Franklin Square Medical Center, Baltimore, MD, USA.
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Vedovo F, Pavan N, Bertolotto M, Giangreco M, Chiapparrone G, Ongaro L, Currò F, Liguori G, Barbone F, Trombetta C. Neoclitoral location may affect sexual function in transgender women: a preliminary pelvic MRI study. Int J Impot Res 2024; 36:526-530. [PMID: 37179422 DOI: 10.1038/s41443-023-00716-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023]
Abstract
Assigned female at birth with anorgasmia possess a smaller clitoral glans and clitoral components farther from the vagina lumen than women with normal orgasmic function. There are no studies evaluating this correlation in operated transgender women. We evaluated whether differences in MRI measurements of neoclitoris volume and distance between the neoclitoris and the neovagina were correlated with differences in sexual function. We recruited for a prospective survey study 40 operated male to female patients (oMtF) who had undergone genital gender affirming surgery and postoperative pelvic MRI. Individual pelvic MRIs were reviewed by two blinded investigators, the three axes of the neoclitoris were measured and the volume was calculated using the ellipsoid formula. The distance between the neoclitoris and the neovagina was also measured. Sexual functioning was assessed using the Female Sexual Function Index (FSFI) and the operated Male to Female Sexual Function Index (oMtFSFI). Mean scores differences in FSFI, oMtFSFI were examined; associations with clitoral size, location, sexual functioning and demographical variables were investigated as well. The response rate was 55%, 11 MtFs operated with pubic neoclitoris technique (PNT) and 11 with neo-urethroclitoroplasty according to Petrović (NCP). The NCP group presented a neoclitoris mean volume of 1.04 (SD 0.39) cc vs 1.31 (SD 0.78) cc of the other group (p = 0.55). The mean distance between neoclitoris and neovagina was 4.20 (SD 0.57) cm in the PNT group and 2.55 (SD 0.45) in the NCP group (p < 0.001). Patients who had undergone NCP achieved a higher FSFI and oMtFSFI mean Total Score than those operated with the previous technique (FSFI 25.81 SD 3.02 vs 18.62 SD 9.92 p = 0.08; oMtFSFI 37.63 SD 8.28 vs 43.36 SD 13.02 p = 0.23). According to pelvic MRI measurements, this study suggests a correlation between neoclitoral location and oMtF sexual satisfaction.
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Affiliation(s)
- Francesca Vedovo
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy.
| | - Nicola Pavan
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Michele Bertolotto
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Manuela Giangreco
- Institute for Maternal and Child Health-IRCCS "BurloGarofolo", Trieste, Italy
| | - Gaetano Chiapparrone
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Luca Ongaro
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Francesca Currò
- Department of Radiology, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Giovanni Liguori
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
| | - Fabio Barbone
- Institute for Maternal and Child Health-IRCCS "BurloGarofolo", Trieste, Italy
- University of Udine, Medical Area, Udine, Italy
| | - Carlo Trombetta
- Urologic Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy
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Tran S, Guillot-Tantay C, Sabbagh P, Vidart A, Bosset PO, Lebret T, Biardeau X, Schirmann A, Madec FX. Systematic Review of Neovaginal Prolapse After Vaginoplasty in Trans Women. EUR UROL SUPPL 2024; 66:101-111. [PMID: 39076246 PMCID: PMC11284383 DOI: 10.1016/j.euros.2024.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2024] [Indexed: 07/31/2024] Open
Abstract
Background and objective Most trans women are requesting a gender affirming genital surgery by vulvovaginoplasty. However, long-term complications such as genital prolapse are unknown. Through this systematic review, our objective was to provide an overview of the published outcomes related to genital prolapse after vaginoplasty in male-to-female transgender individuals, including prevalence, identified risk factors, and treatment. Methods We included all studies reporting genital prolapse rates following vulvovaginoplasty from 1995 to the present. Only studies that focused on the transgender population were included. The primary outcome was the genital prolapse rate. The secondary outcomes included risk factors and treatment of genital prolapse after vulvovaginoplasty. Article selection was performed by two independent reviewers. Key findings and limitations Twenty-four studies, involving 3166 patients, that presented sufficient data were analyzed. The mean age at the time of vulvovaginoplasty was 37.7 yr. The mean follow-up time was 22.5 mo. Most of the studies were retrospective case series of low to intermediate quality. The penile skin inversion technique was the most frequently employed method (in 85% of the 3166 patients). The prevalence of prolapse ranged from 0% to 7% with the penile skin inversion technique and from 1.6% to 22.7% with intestinal vaginoplasty. Upon consolidating the results, an overall rate of 2.7% was observed. Specifically, the prolapse rate within the penile inversion technique subgroup was 2.5%, while the rate for the intestinal-derived neovagina subgroup was 3.5%. The only significant risk factor identified was a high body mass index at the time of surgery. The most employed intraoperative technique to prevent neovaginal prolapse involves fixation to the sacrospinous ligament, coupled with systematic vaginal packing. Few case reports addressed the surgical treatment of neovaginal prolapse, predominantly using open abdominal or laparoscopic approaches. None of these considered transvaginal or perineal approaches. No recommendation exists about the use of vaginal prosthesis. Conclusions and clinical implications Neovaginal prolapse in male-to-female transgender patients remains a rare complication, but its significance is growing as the transgender population ages. Scarce information is available regarding preventative techniques and treatments, necessitating further exploration, hampered by its infrequent occurrence. Patient summary Neovaginal prolapse in male-to-female transgender patients is a rare complication, with the only recognized risk factor being a high body mass index. However, its importance is growing with the aging of the transgender population. Long-term complications, preventive techniques, and management of these prolapses need to be explored through further research.
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Affiliation(s)
- Stephanie Tran
- Department of Urology, Foch Hospital, Suresnes, France
- Department of Urology, Pitié-Salpétrière Hospital, Paris, France
| | | | - Paul Sabbagh
- Department of Urology, University Hospital of Rouen, Rouen, France
| | - Adrien Vidart
- Department of Urology, Foch Hospital, Suresnes, France
| | | | | | - Xavier Biardeau
- Department of Urology, University Hospital of Lille, Lille, France
| | | | - François-Xavier Madec
- Department of Urology, Foch Hospital, Suresnes, France
- UMR 1179, Inserm Faculty of Medicine, Versailles Saint-Quentin University, Paris Saclay, 78180 Montigny le Bretonneux, France
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Wascher J, Hazra A, Fisher AR. Sexual Health for Transgender and Gender Diverse Individuals: Routine Examination, Sexually-Transmitted Infection Screening, and Prevention. Obstet Gynecol Clin North Am 2024; 51:405-424. [PMID: 38777492 DOI: 10.1016/j.ogc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Gynecologists play a critical role in the office evaluation of transgender and gender diverse individuals. This includes the provision of essential healthcare services including the treatment and prevention of human immunodeficiency virus and sexually-transmitted infections and screening for human papillomavirus infection-related diseases and cancers. Caring for patients who identify as transgender or gender diverse (TGD) and who have undergone gender-affirming surgical treatments is challenging due in part to clinical gaps in knowledge resulting from insufficient training and educational resources. A patient-centered approach to the care of TGD individuals requires knowledge of the general principles of affirming, holistic care with attention to the risk factors, and anatomic considerations unique to this population. This review aims to provide basic knowledge needed for the successful gynecologic evaluation of a gender diverse patient.
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Affiliation(s)
- Jocelyn Wascher
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Aniruddha Hazra
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA; Pritzker School of Medicine, 924 E 57th Street #104, Chicago, IL 60637, USA
| | - Andrew R Fisher
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA; Pritzker School of Medicine, 924 E 57th Street #104, Chicago, IL 60637, USA.
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5
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Luther R, Sabino J, Llewellyn C, Hohman M, Teixeira J, Dorner E, Salter CA. Combined Multidisciplinary Gender-Affirming Surgery During the Covid-19 Pandemic: A Model to Optimize Access to Care, Resource Utilization and Medical Readiness for Military Patients. Mil Med 2024; 189:e1240-e1245. [PMID: 37756619 DOI: 10.1093/milmed/usad372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/25/2023] [Accepted: 09/09/2023] [Indexed: 09/29/2023] Open
Abstract
INTRODUCTION 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. MATERIALS AND METHODS 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. RESULTS 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). CONCLUSIONS 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.
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Affiliation(s)
- Ross Luther
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Urology, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Jennifer Sabino
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Plastic Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Charles Llewellyn
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Marc Hohman
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Jeffrey Teixeira
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Otolaryngology-Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, MD 20814, USA
| | - Eric Dorner
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Urology, Madigan Army Medical Center, Tacoma, WA 98431, USA
- Otolaryngology-Head and Neck Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Carolyn A Salter
- Madigan Army Medical Center, Tacoma, WA 98431, USA
- Urology, Madigan Army Medical Center, Tacoma, WA 98431, USA
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Krakowsky Y, Shah G, Nguyen ALV, Kavanagh AG, Potter E, Remondini T, Goldsher YW, Millman A. Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know. BJU Int 2024; 133:124-131. [PMID: 38060336 DOI: 10.1111/bju.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.
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Affiliation(s)
- Yonah Krakowsky
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gresha Shah
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
| | - Anna-Lisa V Nguyen
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alex G Kavanagh
- Gender Surgery Program of British Columbia, Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emery Potter
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Taylor Remondini
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Wilk Goldsher
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Millman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Sineath RC, Hennig F, Dy GW. Management of Urologic Complications After Genital Gender-Affirming Surgery in Transgender and Nonbinary Patients. Urol Clin North Am 2023; 50:587-596. [PMID: 37775217 DOI: 10.1016/j.ucl.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
Transgender and nonbinary (TGNB) patients are a population with unique urologic needs that are often overlooked in urologic training. Most urology residents think that learning to take care of this population is important in their training; however, there is much variation in this educational content within urology residency programs. This review provides information on the current state of teaching regarding the unique needs of caring for TGNB patients as urologists and overviews some basic principles that every urologist should know.
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Affiliation(s)
- R Craig Sineath
- Department of Urology, Oregon Health and Science University, 3303 South Bond Avenue Building 1, 10th Floor, Portland, OR 97239, USA.
| | - Finn Hennig
- Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, 955 Main Street, Buffalo, NY 14203, USA
| | - Geolani W Dy
- Department of Urology, Oregon Health and Science University, 3303 South Bond Avenue Building 1, 10th Floor, Portland, OR 97239, USA
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8
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Hallarn J, Bauer GR, Potter E, Wilcox H, Newfeld J, Krakowsky Y, Ravel J, Prodger JL. Gynecological concerns and vaginal practices and exposures among transfeminine individuals who have undergone vaginoplasty. J Sex Med 2023; 20:1344-1352. [PMID: 37700562 PMCID: PMC10627778 DOI: 10.1093/jsxmed/qdad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/04/2023] [Accepted: 07/28/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Vaginoplasty is a gender-affirming surgery that is medically necessary for some transfeminine individuals. Little research exists describing vaginal health after the initial recovery from surgery, and evidence-based guidelines for vaginal care practices are unavailable. AIM The study sought to describe self-reported gynecological concerns and vaginal care practices among transfeminine persons who have undergone vaginoplasty. METHODS A total of 60 transfeminine participants 18+ years of age, living in Canada, and who had undergone vaginoplasty at least 1 year prior were recruited through social media, community groups, healthcare provider referrals, and study recontact. Participants completed a cross-sectional, online questionnaire detailing demographics, gynecological concerns, and genital practices and exposures. Hierarchical clustering was used to group participants based on behavioral practices and exposures. Associations between clusters and gynecological concerns were assessed. OUTCOMES Outcomes included self-reported gynecological concerns within the past year, recent vulvar or vaginal symptoms (past 30 days), and behavioral practices/exposures, including douching with varied products and dilating. RESULTS Participants reported a variety of concerns in the past year, including urinary tract infection (13%) and internal hair regrowth (23%). More than half (57%) had experienced at least 1 recent vaginal symptom, most commonly malodor (27%) and vaginal bleeding (21%). Of participants, 48% were dilating weekly and 52% reported douching in the past 30 days. Four distinct clusters of vaginal practices/exposures were identified: limited exposures; dilating, no douching; dilating and douching; and diverse exposures. No significant associations between cluster membership and gynecological concerns were identified, though cluster membership was significantly associated with surgical center (P = .03). Open-text write-ins provided descriptions of symptoms and symptom management strategies. CLINICAL IMPLICATIONS The results provide insight for clinicians on common patient-reported gynecological concerns and current vaginal care practices and exposures, including symptom management strategies. STRENGTHS AND LIMITATIONS This was the first study to investigate vaginal health and genital practices/exposures among a community sample of transfeminine individuals. As participants self-enrolled for a detailed survey and swab collection, individuals experiencing concerns were likely overrepresented. CONCLUSION Transfeminine individuals reported a range of gynecological concerns outside of the surgical healing period. Genital practices/exposures varied across clusters, but no clear associations between clusters and symptoms were identified; instead, practice/exposure clusters were dependent on where the individual underwent vaginoplasty. There is a need for evidence to inform diagnostics, treatments, and vaginal care guidelines to support vaginal health.
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Affiliation(s)
- Jason Hallarn
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Greta R Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
- Institute for Sexual and Gender Health, University of Minnesota Medical School, Minneapolis, MN 55415, United States
| | - Emery Potter
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5G 1N8, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Hannah Wilcox
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
| | - Jacy Newfeld
- Department of Ecology and Evolutionary Biology, University of Toronto, Toronto, ON M5S 1A1, Canada
- Department of Biology, University of Toronto Mississauga, Mississauga, ON L5L 1C6, Canada
| | - Yonah Krakowsky
- Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5G 1N8, Canada
- Transition Related Surgery, Department of Surgery, Women’s College Hospital, University of Toronto, Toronto, ON M5G 1N8, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, ON M5S 1A1, Canada
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD 21201, United States
- Department of Microbiology and Immunology, University of Maryland School of Medicine, Baltimore, MD 21201, United States
| | - Jessica L Prodger
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
- Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON N6A 3K7, Canada
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9
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Koehler A, Strauß B, Briken P, Fisch M, Riechardt S, Nieder TO. (De-)centralized health care delivery, surgical outcome, and psychosocial health of transgender and gender-diverse people undergoing vaginoplasty: results of a retrospective, single-center study. World J Urol 2023; 41:1775-1783. [PMID: 36961526 PMCID: PMC10352146 DOI: 10.1007/s00345-023-04348-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/23/2023] [Indexed: 03/25/2023] Open
Abstract
PURPOSE Previous research on genital gender-affirming surgery lacked to build a framework that took various surrounding factors into account. E.g., transgender health care services are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). The present study investigated the effects of different structural and clinical aspects of gender-affirming genital surgery on psychosocial outcomes. METHODS We surveyed former transgender and gender-diverse people who completed a vaginoplasty between 2014 and 2018. 45 participants were included in the study. We calculated hierarchical linear regression analyses to assess the relationship between psychosocial outcome measures (gender congruence, mental health, quality of life) and different aspects of gender-affirming genital surgery (e.g., setting of service delivery). To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identify predictors that are actually related to the outcomes. RESULTS A non-responder analysis revealed no systematic bias in the recruitment procedure. Treatment satisfaction was a significant predictor for gender congruence. Moreover, we found the setting of service delivery (centralized, decentralized) to predict psychological health and the physical health dimension of quality of life. The effect sizes of our models were moderate to high, and models explained up to 26% of the total variance with a power up to 0.83. CONCLUSION The present study is an exploratory attempt into the manifold relationships between treatment-related factors (e.g., aesthetic outcome), the setting of service delivery, and their effects on gender-affirming genital surgery.
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Affiliation(s)
- Andreas Koehler
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Strauß
- Institute of Psychosocial Medicine, Psychotherapy, and Psycho-Oncology, University Hospital Jena, Jena, Germany
| | - Peer Briken
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Margit Fisch
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department for Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Silke Riechardt
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department for Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Timo O Nieder
- Institute for Sex Research, Sexual Medicine, and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Interdisciplinary Transgender Health Care Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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10
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Parker A, Brydges H, Blasdel G, Bluebond-Langner R, Zhao LC. Mending the Gap: AlloDerm as a Safe and Effective Option for Vaginal Canal Lining in Revision Robotic Assisted Gender Affirming Peritoneal Flap Vaginoplasty. Urology 2023; 173:204-208. [PMID: 36642117 DOI: 10.1016/j.urology.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.
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Affiliation(s)
| | - Hilliard Brydges
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Gaines Blasdel
- Department of Urology, NYU Langone Health, New York, NY; University of Michigan Medical School, Ann Arbor, MI
| | | | - Lee C Zhao
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY; Department of Urology, NYU Langone Health, New York, NY.
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11
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Principles and outcomes of gender-affirming vaginoplasty. Nat Rev Urol 2023; 20:308-322. [PMID: 36726039 DOI: 10.1038/s41585-022-00705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2022] [Indexed: 02/03/2023]
Abstract
Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.
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12
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Potter E, Sivagurunathan M, Armstrong K, Barker LC, Du Mont J, Lorello GR, Millman A, Urbach DR, Krakowsky Y. Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic. Neurourol Urodyn 2023; 42:523-529. [PMID: 36630152 DOI: 10.1002/nau.25132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/28/2022] [Indexed: 01/12/2023]
Abstract
IMPORTANCE Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery. OBJECTIVE To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic. DESIGN, SETTINGS, AND PARTICIPANTS A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables. RESULTS The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%). CONCLUSIONS AND RELEVANCE Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.
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Affiliation(s)
- Emery Potter
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | - Kathleen Armstrong
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
| | - Lucy C Barker
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Janice Du Mont
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Gianni R Lorello
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada.,The Wilson Centre, University Health Network, Toronto, Ontario, Canada
| | - Alexandra Millman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Transition Related Surgery Program, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada
| | - David R Urbach
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Transition Related Surgery Program, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Surgery, Women's College Hospital, Toronto, Ontario, Canada
| | - Yonah Krakowsky
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada.,Transition Related Surgery Program, Women's College Hospital, University of Toronto, Toronto, Ontario, Canada.,Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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13
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Weinstein B, Schechter L. Wound healing complications in gender‐affirming surgery. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022]
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14
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Abstract
BACKGROUND Gender dysphoria is a condition that often leads to significant patient morbidity and mortality. Although gender-affirming surgery (GAS) has been offered for more than half a century with clear significant short-term improvement in patient well-being, few studies have evaluated the long-term durability of these outcomes. METHODS Chart review identified 97 patients who were seen for gender dysphoria at a tertiary care center from 1970 to 1990 with comprehensive preoperative evaluations. These evaluations were used to generate a matched follow-up survey regarding their GAS, appearance, and mental/social health for standardized outcome measures. Of 97 patients, 15 agreed to participate in the phone interview and survey. Preoperative and postoperative body congruency score, mental health status, surgical outcomes, and patient satisfaction were compared. RESULTS Both transmasculine and transfeminine groups were more satisfied with their body postoperatively with significantly less dysphoria. Body congruency score for chest, body hair, and voice improved significantly in 40 years' postoperative settings, with average scores ranging from 84.2 to 96.2. Body congruency scores for genitals ranged from 67.5 to 79 with free flap phalloplasty showing highest scores. Long-term overall body congruency score was 89.6. Improved mental health outcomes persisted following surgery with significantly reduced suicidal ideation and reported resolution of any mental health comorbidity secondary to gender dysphoria. CONCLUSION Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret.
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15
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Riechardt S, Waterloos M, Lumen N, Campos-Juanatey F, Dimitropoulos K, Martins FE, Osman NI, Barratt R, Chan G, Esperto F, Ploumidis A, Verla W, Greenwell T. European Association of Urology Guidelines on Urethral Stricture Disease Part 3: Management of Strictures in Females and Transgender Patients. Eur Urol Focus 2022; 8:1469-1475. [PMID: 34393082 DOI: 10.1016/j.euf.2021.07.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/15/2021] [Accepted: 07/29/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT Urethral stricture management guidelines are an important tool for guiding evidence-based clinical practice. OBJECTIVE To present a summary of the 2021 version of the European Association of Urology (EAU) guidelines on management of urethral strictures in females and transgender patients. EVIDENCE ACQUISITION The panel performed a literature review on these topics covering a time frame between 2008 and 2018 and used predefined inclusion and exclusion criteria for study selection. Key papers beyond this time period could be included as per panel consensus. A strength rating for each recommendation was added based on the review of the available literature and after panel discussion. EVIDENCE SYNTHESIS Management of urethral strictures in females and transgender patients has been described in a few case series in the literature. Endoluminal treatments can be used for short, nonobliterative strictures in the first line. Repetitive endoluminal treatments are not curative. Urethroplasty encompasses a multitude of techniques and adaptation of the technique to the local conditions of the stricture is crucial to obtain durable patency rates. CONCLUSIONS Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations. PATIENT SUMMARY Although different techniques are available to manage narrowing of the urethra (called a stricture), not every technique is appropriate for every type of stricture. These guidelines, developed on the basis of an extensive literature review, aim to guide physicians in selecting the appropriate technique(s) to treat a specific type of urethral stricture in females and transgender patients. TAKE HOME MESSAGE: Although different techniques are available to manage urethral strictures, not every technique is appropriate for every type of stricture. Management of urethral strictures in females and transgender patients is complex and a multitude of techniques are available. Selection of the appropriate technique is crucial and these guidelines provide relevant recommendations.
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Affiliation(s)
- Silke Riechardt
- Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Marjan Waterloos
- Division of Urology, Gent University Hospital, Gent, Belgium; Division of Urology, AZ Maria Middelares, Gent, Belgium
| | - Nicolaas Lumen
- Division of Urology, Gent University Hospital, Gent, Belgium
| | | | | | - Francisco E Martins
- Department of Urology, Santa Maria University Hospital, University of Lisbon, Lisbon, Portugal
| | - Nadir I Osman
- Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK
| | - Rachel Barratt
- Department of Urology, University College London Hospital, London, UK
| | - Garson Chan
- Division of Urology, University of Saskatchewan, Saskatoon, Canada
| | - Francesco Esperto
- Department of Urology, Campus Biomedico University of Rome, Rome, Italy
| | | | - Wesley Verla
- Division of Urology, Gent University Hospital, Gent, Belgium
| | - Tamsin Greenwell
- Department of Urology, University College London Hospital, London, UK
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16
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Vazquez IM, Labanca T, Arno AI. Functional, Aesthetic and Sensory Postoperative Complications of Female Genital Gender Affirmation Surgery: a Prospective Study. J Plast Reconstr Aesthet Surg 2022; 75:4312-4320. [DOI: 10.1016/j.bjps.2022.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 06/10/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
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17
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Gender Affirmation Surgery, Transfeminine. Urol Clin North Am 2022; 49:437-451. [DOI: 10.1016/j.ucl.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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18
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Maurer V, Howaldt M, Feldmann I, Ludwig T, Vetterlein MW, Gild P, Weis S, Marks P, Soave A, Meyer CP, Fisch M, Dahlem R, Riechardt S. Penile Flap Inversion Vaginoplasty in Transgender Women: Contemporary Morbidity and Learning-Curve Analysis From a High-Volume Reconstructive Center. Front Surg 2022; 9:836335. [PMID: 35284483 PMCID: PMC8906498 DOI: 10.3389/fsurg.2022.836335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/25/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives Numbers of PIV are rising. The aim of this study is to analyze the surgical learning-curve (LC) on the grounds of perioperative complications. Patients and Methods 108 PIVs, performed by a single surgeon between 2015 and 2018 have been analyzed. Learning-curve analysis was based on three factors: operating time, vaginal depth and complications. Results The median FU was 6.3 months. Median age at surgery was 36 years, median time of hormone treatment was 36 months. The median CI was 0.3 and the median BMI was 25 kg/cm3. Median CCI® was 8.08. 40.7% of the patients developed short-term complications, more than half of which were Clavien I. Overall only 1.9% had Clavien IIIb complications. There were no Clavien IV or V complications. 17.6% of patients had wound infections, 13% wound dehiscence, 9.3% introitus strictures, 13.9% suffered from atrophy of the neovagina, i.e. loss of depth or width, and 8.3% from meatus urethrae strictures. Duration of hormonal therapy, BMI and CI had no impact on surgical outcome. Age had a significant impact on CCI®, as younger patients had a higher risk for complications. Use of scrotal skin and surgeries performed had a significant influence. LC analysis via CUSUM analysis showed that after 32 surgeries, the PIV is performed safely. Conclusion The PIV is a safe GAS-technique, associated with minor complications leading to low rates of revision surgery. Younger age, the use of scrotal skin and surgeon's experience has significant impact on complications. Duration of hormonal therapy, circumcision and BMI has no impact on complications.
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19
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Krakowsky Y, Potter E, Hallarn J, Monari B, Wilcox H, Bauer G, Ravel J, Prodger JL. The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People. Front Cell Infect Microbiol 2022; 11:769950. [PMID: 35127550 PMCID: PMC8814107 DOI: 10.3389/fcimb.2021.769950] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/14/2021] [Indexed: 01/07/2023] Open
Abstract
Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research.
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Affiliation(s)
- Yonah Krakowsky
- Division of Urology, Department of Surgery, Women’s College Hospital and Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada,Transition Related Surgery, Department of Surgery, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Emery Potter
- Transition Related Surgery, Department of Surgery, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Jason Hallarn
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Bern Monari
- Program in Molecular Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Hannah Wilcox
- Department of Microbiology and Immunology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Greta Bauer
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Jacques Ravel
- Institute for Genome Sciences, University of Maryland School of Medicine, Baltimore, MD, United States,Department of Microbiology & Immunology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jessica L. Prodger
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada,Department of Microbiology and Immunology, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada,*Correspondence: Jessica L. Prodger,
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20
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D'Antoni AV, Tubbs RS, Patti AC, Higgins QM, Tiburzi H, Battaglia F. The Critical Appraisal Tool for Anatomical Meta-analysis (CATAM): A framework for critically appraising anatomical meta-analyses. Clin Anat 2022; 35:323-331. [PMID: 35015336 DOI: 10.1002/ca.23833] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 01/06/2022] [Indexed: 11/06/2022]
Abstract
The hallmark of evidence-based medicine is the meta-analysis (MA). For much of its rich history, the field of anatomy has been dominated by descriptive, cadaveric studies. In the last two decades, quantitative measurements and statistical analyses have frequently accompanied such studies. These studies have directly led to the publication of anatomical MAs, which have ushered in the exciting field of evidence-based anatomy. Although critical appraisal tools exist for clinical MAs, none of them are specifically tailored for anatomical MAs. Therefore, the purpose of this paper is to provide a framework by which clinical anatomists and others can critically appraise anatomical MAs using the Critical Appraisal Tool for Anatomical Meta-analysis (CATAM). Using a running example from a recently published MA, we show how to use the CATAM rubric in a step-by-step fashion. Each scored section of the CATAM rubric is summated into a total score (maximum 50 points). This score is then referenced to a conversion chart, which assigns a qualitative value to the MA in a range from "very good" to "poor." Future studies can investigate the interrater reliability of the instrument, and possibly subject the CATAM rubric to a Delphi panel. As anatomical MAs become more commonplace at surgical grand rounds and journal clubs in academic medical centers throughout the world, we hope that the CATAM rubric can help facilitate meaningful discussions about the quality and clinical relevance of anatomical MAs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Anthony V D'Antoni
- Physician Assistant Program, Wagner College, Staten Island, New York, USA.,Division of Anatomy, Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Department of Neurosurgery and Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA.,University of Queensland, Brisbane, Australia
| | | | | | | | - Fortunato Battaglia
- Department of Medical Sciences and Neurology, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
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21
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Vaginoplasty in Male to Female transgenders: single center experience and a narrative review. Int J Impot Res 2021; 33:726-732. [PMID: 34561673 DOI: 10.1038/s41443-021-00470-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 08/27/2021] [Accepted: 09/10/2021] [Indexed: 11/08/2022]
Abstract
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.
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22
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Henckes NAC, Faleiro D, Chuang LC, Cirne-Lima EO. Scaffold strategies combined with mesenchymal stem cells in vaginal construction: a review. CELL REGENERATION (LONDON, ENGLAND) 2021; 10:26. [PMID: 34337675 PMCID: PMC8326237 DOI: 10.1186/s13619-021-00088-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 06/17/2021] [Indexed: 11/10/2022]
Abstract
Tissue engineering has provided new treatment alternatives for tissue reconstruction. Advances in the tissue engineering field have resulted in mechanical support and biological substitutes to restore, maintain or improve tissue/organs structures and functions. The application of tissue engineering technology in the vaginal reconstruction treatment can not only provide mechanical requirements, but also offer tissue repairing as an alternative to traditional approaches. In this review, we discuss recent advances in cell-based therapy in combination with scaffolds strategies that can potentially be adopted for gynaecological transplantation.
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Affiliation(s)
- Nicole Andréa Corbellini Henckes
- Programa de Pós-Graduação em Ciências da Saúde-Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil.
| | - Dalana Faleiro
- Programa de Pós-Graduação em Ciências da Saúde-Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Laura Chao Chuang
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Elizabeth Obino Cirne-Lima
- Programa de Pós-Graduação em Ciências da Saúde-Ginecologia e Obstetrícia, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Laboratório de Embriologia e Diferenciação Celular, Centro de Pesquisa Experimental, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Departamento de Patologia Clínica Veterinária, Faculdade de Veterinária, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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23
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Jun MS, Gonzalez E, Zhao LC, Bluebond-Langner R. Penile Inversion Vaginoplasty with Robotically Assisted Peritoneal Flaps. Plast Reconstr Surg 2021; 148:439-442. [PMID: 34398096 PMCID: PMC10538597 DOI: 10.1097/prs.0000000000008198] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 02/04/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Min S. Jun
- From the Department of Urology and the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine
| | - Eduardo Gonzalez
- From the Department of Urology and the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine
| | - Lee C. Zhao
- From the Department of Urology and the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine
| | - Rachel Bluebond-Langner
- From the Department of Urology and the Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine
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24
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Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2021; 10:77-90. [PMID: 34219008 DOI: 10.1016/j.sxmr.2021.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
| | - Dmitriy Nikolavsky
- Department of Urology, SUNY Upstate Medical University, Syracuse, NY, USA
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Hanley K, Wittenberg H, Gurjala D, Safir MH, Chen EH. Caring for Transgender Patients: Complications of Gender-Affirming Genital Surgeries. Ann Emerg Med 2021; 78:409-415. [PMID: 34148664 DOI: 10.1016/j.annemergmed.2021.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Kevin Hanley
- Department of Emergency Medicine, University of California, San Francisco, CA.
| | | | | | | | - Esther H Chen
- Department of Emergency Medicine, University of California, San Francisco, CA
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Bernal Riquelme J, Falcon Naser N, Barros Puertas J, Arenas Kalil J, Cifuentes Arévalo M. Cirugías de afirmación de género en mujeres trans: resultados estéticos, sexuales y urinarios de una serie inicial de vaginoplastias. Actas Urol Esp 2021. [DOI: 10.1016/j.acuro.2020.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Mann RA, Kasabwala K, Kim N, Pariser JJ. The Management of Complications of Feminizing Gender Affirming Genital Surgery. Urology 2021; 152:67-73. [PMID: 33493512 DOI: 10.1016/j.urology.2021.01.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/13/2021] [Indexed: 11/29/2022]
Abstract
Penile inversion vaginoplasty is the most common technique used for gender affirming genital surgery in the treatment of gender dysphoria among transwomen. As vaginoplasty becomes more widely available, the management of associated complications has become its own field. There is a relative dearth of literature on surgery for complications following vaginoplasty. This review illustrates surgical technique and management options for patient reported complaints and complications following vaginoplasty. The goal of this manuscript is 2-fold (1) to introduce community surgeons to common postoperative issues they may encounter and (2) provide a systematic operative approach to complications for reconstructive surgeons who see transgender patients regularly.
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Affiliation(s)
- Rachel A Mann
- University of Minnesota, Department of Urology, Minneapolis, MN.
| | | | - Nicholas Kim
- University of Minnesota, Department of Surgery, Division of Plastic Surgery, Minneapolis, MN
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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 2020; 18:391-399. [PMID: 33288438 DOI: 10.1016/j.jsxm.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/29/2020] [Accepted: 09/28/2020] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Richard M Fakin
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Pietro Giovanoli
- Division of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
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Mishra K, Bukavina L, Gupta S. Understanding Male to Female Transgender Surgery and Associated Complications—a Comprehensive Review. CURRENT SEXUAL HEALTH REPORTS 2020. [DOI: 10.1007/s11930-020-00292-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Köhler A, Strauß B, Briken P, Riechardt S, Fisch M, Nieder TO. [Feminizing Genital Gender-affirmative Surgery in Centralized and Decentralized Health Care Settings - The Hamburg TransCare study]. Psychother Psychosom Med Psychol 2020; 71:132-140. [PMID: 33063307 DOI: 10.1055/a-1243-0715] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Gender Dysphoria (GD, formerly known as transsexualism) describes distress and impairment in an individual caused by the incongruence between the experienced gender and the sex assigned at birth (Gender Incongruence: GI). Transgender health care focusses on gender-affirmative treatments (e. g., hormone therapy) and associated needs (e. g., psychotherapy). Moreover, genital surgery is considered an effective treatment to reduce GI/GD and improve mental health and quality of life. Interdisciplinary cooperation between the associated medical facilities is regarded as evidence-based health care. OBJECTIVES To date, THC is delivered in zwei different health care settings: interdisciplinary and centralized from one medical institution vs. decentralized, spread over several medical institutions. In Germany, individuals with GI/GD access health care mostly in decentralized structures. The consequences of feminizing genital surgery carried out in centralized and decentralized health care structures in terms of quality and effectiveness have not been investigated so far. The goal of the TransCare study is to prospectively examine individuals with GI/GD seeking feminizing genital surgery regarding demographics and clinical characteristics as well as to analyze the influence of centralized and decentralized health care settings on the psychosocial and clinical outcome. MATERIALS AND METHODS To recruit a valid and comprehensive sample, participants were questioned prospectively. RESULTS The results of the study should help gain new insights into the influence of centralized and decentralized health care settings carrying out feminizing genital surgery on psychosocial and clinical outcomes for the patients. CONCLUSION Based on the TransCare study, we suggest that health care should be improved according to individual patient needs.
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Affiliation(s)
- Andreas Köhler
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
| | - Bernhard Strauß
- Institut für Psychosoziale Medizin und Psychotherapie, Universitätsklinikum Jena
| | - Peer Briken
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
| | - Silke Riechardt
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf
| | - Margit Fisch
- Klinik und Poliklinik für Urologie, Universitätsklinikum Hamburg-Eppendorf
| | - Timo O Nieder
- Institut für Sexualforschung, Sexualmedizin und Forensische Psychiatrie, Universitätsklinikum Hamburg-Eppendorf
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Surgical Options for Patients Seeking Gender-Affirming Surgery. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2020. [DOI: 10.1007/s13669-020-00300-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Adverse events associated with gender affirming vaginoplasty surgery. Am J Obstet Gynecol 2020; 223:267.e1-267.e6. [PMID: 32446999 DOI: 10.1016/j.ajog.2020.05.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is an abundance of reports on the surgical techniques for vaginoplasty surgery. However, careful review reveals a paucity of evidence-based data in addition to few reports on outcomes related to all of the varying techniques. OBJECTIVE This study aimed to describe the perioperative adverse events related to vaginoplasty surgery for transgender women and to determine a threshold case number needed to reduce adverse events. STUDY DESIGN This was a retrospective study of all women who underwent vaginoplasty surgery for gender affirmation at a tertiary care center. All cases were performed by a single board-certified female pelvic medicine and reconstructive surgery specialist. Women were included if 6-month outcomes were available. Once patients were identified, perioperative data were collected. Comparisons of adverse events and perioperative outcomes were made between varying threshold case numbers to determine the case number needed to significantly reduce adverse events. An a priori review of the literature was done to determine the incidence of commonly reported adverse events, and these incidences were used as a frame of reference to determine a threshold case number needed to replicate these reported incidence rates. Once this threshold was determined, outcomes were compared between cases performed before and after this threshold. RESULTS Between December 2015 and March 2019, 76 vaginoplasty surgeries were performed. Six-month outcomes data were available for all patients. Mean age and body mass index of all patients were 41 (±17) years and 27.3 (±5.1) kg/m2, respectively. Median (range) time on hormone therapy preceding surgery was 36 (12-360) months, and 7.9% (6) of patients had undergone previous orchiectomy. Of the patients, 83.4% (71) underwent full-depth vaginoplasty, whereas the remaining patients underwent a zero-depth procedure. Median (range) surgical time was 210 (138-362) minutes. Median (range) follow-up for all patients was 12.5 (6-50) months. The incidence of any intraoperative adverse event was 2.6% (95% confidence interval, 1.8-4.1) for all patients, whereas the incidence of any immediate (<30 days) and delayed (>30 days and <6 months) postoperative event was 19% (95% confidence interval, 16.4-22.2) and 25% (95% confidence interval, 22.4-28.4), respectively. Performance of 50 cases was identified to be a threshold that reduced adverse events in both clinically and statistically significant ways. Cases performed after the first 50 cases had lower surgical times (187 (138-224) vs 240 (162-362) minutes, P<.0001), a lower incidence of delayed postoperative adverse events (15.4% vs 36%, P=.007), including a lower incidence of urinary stream abnormalities, introital stenosis, and the need for revision surgery. The incidence of intraoperative and immediate adverse events was not different between the groups. CONCLUSION The incidence of serious adverse events related to vaginoplasty surgery is low, whereas minor events are common. After a threshold of 50 vaginoplasty surgeries, these events were reduced, including the need for revision surgery.
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Grimstad F, Boskey E. Empowering Transmasculine Youth by Enhancing Reproductive Health Counseling in the Primary Care Setting. J Adolesc Health 2020; 66:653-655. [PMID: 32473720 DOI: 10.1016/j.jadohealth.2020.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/03/2020] [Accepted: 03/07/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts.
| | - Elizabeth Boskey
- Department of Plastic Surgery, Boston Children's Hospital, Boston, Massachusetts
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Birse KD, Kratzer K, Zuend CF, Mutch S, Noël-Romas L, Lamont A, Abou M, Jalil E, Veloso V, Grinsztejn B, Friedman RK, Broliden K, Bradley F, Poliquin V, Li F, Yanavich C, Burgener A, Aldrovandi G. The neovaginal microbiome of transgender women post-gender reassignment surgery. MICROBIOME 2020; 8:61. [PMID: 32370783 PMCID: PMC7201977 DOI: 10.1186/s40168-020-00804-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/10/2020] [Indexed: 05/16/2023]
Abstract
BACKGROUND Gender reassignment surgery is a procedure some transgender women (TW) undergo for gender-affirming purposes. This often includes the construction of a neovagina using existing penile and scrotal tissue and/or a sigmoid colon graft. There are limited data regarding the composition and function of the neovaginal microbiome representing a major gap in knowledge in neovaginal health. RESULTS Metaproteomics was performed on secretions collected from the neovaginas (n = 5) and rectums (n = 7) of TW surgically reassigned via penile inversion/scrotal graft with (n = 1) or without (n = 4) a sigmoid colon graft extension and compared with secretions from cis vaginas (n = 32). We identified 541 unique bacterial proteins from 38 taxa. The most abundant taxa in the neovaginas were Porphyromonas (30.2%), Peptostreptococcus (9.2%), Prevotella (9.0%), Mobiluncus (8.0%), and Jonquetella (7.2%), while cis vaginas were primarily Lactobacillus and Gardnerella. Rectal samples were mainly composed of Prevotella and Roseburia. Neovaginas (median Shannon's H index = 1.33) had higher alpha diversity compared to cis vaginas (Shannon's H = 0.35) (p = 7.2E-3, Mann-Whitney U test) and were more similar to the non-Lactobacillus dominant/polymicrobial cis vaginas based on beta diversity (perMANOVA, p = 0.001, r2 = 0.342). In comparison to cis vaginas, toll-like receptor response, amino acid, and short-chain fatty acid metabolic pathways were increased (p < 0.01), while keratinization and cornification proteins were decreased (p < 0.001) in the neovaginal proteome. CONCLUSIONS Penile skin-lined neovaginas have diverse, polymicrobial communities that show similarities in composition to uncircumcised penises and host responses to cis vaginas with bacterial vaginosis (BV) including increased immune activation pathways and decreased epithelial barrier function. Developing a better understanding of microbiome-associated inflammation in the neovaginal environment will be important for improving our knowledge of neovaginal health. Video Abstract.
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Affiliation(s)
- Kenzie D Birse
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Kateryna Kratzer
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Christina Farr Zuend
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah Mutch
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Laura Noël-Romas
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Alana Lamont
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada
| | - Max Abou
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada
| | - Emilia Jalil
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Valdiléa Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | | | - Kristina Broliden
- Department of Medicine Solna, Center for Molecular Medicine, Unit of Infectious Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Frideborg Bradley
- Department of Medicine Solna, Center for Molecular Medicine, Unit of Infectious Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Vanessa Poliquin
- Department of Obstetrics & Gynecology, University of Manitoba, Winnipeg, MB, Canada
| | - Fan Li
- University of California, Los Angeles, CA, USA
| | | | - Adam Burgener
- National HIV and Retrovirology Labs, JC Wilt Infectious Disease Research Centre, Public Health Agency of Canada, 745 Logan Ave, Winnipeg, MB, R3E 3 L5, Canada.
- Departments of Medical Microbiology and Infectious Disease, University of Manitoba, Winnipeg, MB, Canada.
- Department of Medicine Solna, Center for Molecular Medicine, Unit of Infectious Diseases, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
- Department of Obstetrics & Gynecology, University of Manitoba, Winnipeg, MB, Canada.
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Lee TH, Yoon JS, Ahn HC. Reconstruction of a completely obstructed rectosigmoid vaginal introitus in a transgender woman. ARCHIVES OF AESTHETIC PLASTIC SURGERY 2020. [DOI: 10.14730/aaps.2020.02033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
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.
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Historical and Current State of Dermatologic Care for Sexual and Gender Minority Populations. Dermatol Clin 2019; 38:177-183. [PMID: 32115126 DOI: 10.1016/j.det.2019.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The lesbian, gay, bisexual, transgender, and queer or questioning/sexual and gender minority (LGBTQ/SGM) community is a growing population with unique lifestyles, sexual practices, beliefs, health issues, and concerns. Although significant advances have been achieved in recent years to establish better care for LGBTQ/SGM patients, they still face insurmountable stigmatization and health care inequality. Dermatologists play an important role in LGBTQ/SGM patients' well-being because they not only treat their skin conditions, but also help them achieve desirable physical characteristics. This article discusses historical perspectives and current state of LGBTQ/SGM dermatology and attempts to define directions for future research and improvement.
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Abstract
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.
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Affiliation(s)
- Poone Shoureshi
- Department of Urology, Oregon Health & Science University, 3303 Southwest Bond Avenue, CH-10-U, Portland, OR 97210, USA
| | - Daniel Dugi
- Department of Urology, Transgender Health Program, Oregon Health & Science University, 3303 Southwest Bond Avenue, CH-10-U, Portland, OR 97210, USA.
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Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Male-to-Female Gender Reassignment Surgery: An Institutional Analysis of Outcomes, Short-term Complications, and Risk Factors for 240 Patients Undergoing Penile-Inversion Vaginoplasty. Urology 2019; 131:228-233. [DOI: 10.1016/j.urology.2019.03.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/13/2019] [Accepted: 03/16/2019] [Indexed: 11/19/2022]
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Abstract
To date, no study has looked at the prevalence of HIV and the high-risk behaviors among transgender women in Iran. Between May 2013 and February 2014, 104 transgender women were recruited for participation in this study. Inclusion criteria consisted of having an official letter from the Tehran Psychiatric Institute, or a well-known psychiatrist, that showed a diagnosis of gender dysphoria and/or completed Gender-Affirming Surgery at least 6 months prior to this study. Of the 104 participants, 2 were diagnosed with HIV, which translates to a HIV prevalence of 1.9%. Condom use with a non-paying partner, casual partner, and paying partner was respectively 39.7%, 34.6%, and 53.3%. A high percentage of transgender women in Tehran engage in high-risk sexual behaviors including condomless receptive anal sex, which is of particular concern given the low rates of HIV testing. Targeted public intervention programs and research are desperately needed for this high-risk group.
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Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery. Transl Androl Urol 2019; 8:191-208. [PMID: 31380226 DOI: 10.21037/tau.2019.06.19] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.
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Affiliation(s)
| | - Polina Reyblat
- Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Melissa M Poh
- Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Amanda C Chi
- Southern California Permanente Medical Group, Los Angeles, CA, USA
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Abstract
PURPOSE OF REVIEW Gender-affirming surgery has become a more common procedure in the last 5 years. Feminizing genitoplasty typically involves inversion of penile skin as a neovagina, urethral shortening, and glans reduction to create a neoclitoris. Masculinizing genitoplasty is more complex, typically is performed in multiple stages, and has more inherent urologic risks. RECENT FINDINGS The most common urologic complications involve voiding dysfunction, specifically meatal stenosis or fistula to the urinary tract. Urethral stricture, fistula, urinary retention, and voiding dysfunction are very common and require early recognition and intervention. This includes placement of catheter drainage, if necessary with the appropriate urologic instrumentation. Genital risks relating to phallus health are rare, but risks associated with placement of penile prosthesis for sexual function are common and require immediate attention. Urological complications after gender-affirming surgery are common, and the general urologist and urogynecologist should be able to identify and treat problems in this population after review of this chapter.
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Affiliation(s)
- Campbell Bryson
- Department of Urology, Yale School of Medicine, 789 Howard Avenue, FMP 302, New Haven, CT, 06519, USA
| | - Stanton C Honig
- Department of Urology, Yale School of Medicine, 330 Orchard St. Suite 164, New Haven, CT, 06511, USA.
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Milrod C, Monto M, Karasic DH. Recommending or Rejecting "the Dimple": WPATH-Affiliated Medical Professionals' Experiences and Attitudes Toward Gender-Confirming Vulvoplasty in Transgender Women. J Sex Med 2019; 16:586-595. [PMID: 30833148 DOI: 10.1016/j.jsxm.2019.01.316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 12/11/2018] [Accepted: 01/28/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Rising numbers of trans women are undergoing genital surgeries, such as vulvoplasty or vulvovaginoplasty, to create a neovagina. Medical professionals who adhere to the World Professional Association for Transgender Health (WPATH) Standards of Care, Version 7, and who recommend or perform these procedures, are expected to balance best practices with patient preferences, specifically the decision to create or omit the vaginal canal. Due to a paucity of literature on gender-confirming vulvoplasty (GCV) in trans women, there has been no documentation of factors that prompt practitioners to reject or recommend the procedure. AIM The aim of the study was to provide descriptive data of WPATH-affiliated medical professionals' knowledge, experiences, and attitudes toward GCV; surgical risks, benefits, and any considerations when referring transgender women 18-21 years of age for this procedure. METHODS Purposive sampling of all physicians, surgeons, nurse practitioners, physician assistants, and registered nurses listed in the WPATH membership directory was initiated via invitational e-mails. The 32-item survey focused on demographics, medical practices, surgical techniques, and reasons for recommending or rejecting the procedure. Data analysis included frequencies and Pearson's χ2 test. MAIN OUTCOME MEASURES Key outcome measures included frequency of cases performed; reasons for recommending, rejecting, or performing GCV; and differences in attitudes toward the procedure among various medical professionals. RESULTS N = 198 (20.7%) of 956 solicited professionals completed the survey. Surgeons (n = 61) comprised 30.8% of the total sample. 46 surgeons (76.7%) reported having performed vulvovaginoplasty, and 25 (41.7%) had performed GCV. "Patient request" was the most common reason for recommending or performing GCV. Surgeons were more likely to either agree and perform (30.4%), or reject (32.1%) GCV in a patient aged 18-21 than other practitioners, who were more likely to be "unsure" (68.5%). These differences were statistically significant (χ2 = 16.467 [2]; n = 193; P < .001). CLINICAL IMPLICATIONS The data identify a lack of standardized terminology and surgical techniques concerning GCV. STRENGTH & LIMITATIONS This is the first exploratory study to assess medical practitioner experiences and attitudes toward a seldom documented procedure. A larger, more inclusive sample would increase the statistical strength and representative aspect of the study. CONCLUSION The study shows divergence in attitudes and knowledge among medical practitioners who recommend or perform GCV, and uncertainty when the patient is 18-21 years old. The study contributes to an expanded description and specific indications of performing GCV in the updated WPATH SOC Version 8. Milrod C, Monto M, Karasic DH. Recommending or Rejecting "the Dimple": WPATH-Affiliated Medical Professionals' Experiences and Attitudes Toward Gender-Confirming Vulvoplasty in Transgender Women. J Sex Med 2019;16:586-595.
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Affiliation(s)
- Christine Milrod
- Southern California Transgender Counseling, Los Angeles, CA, USA.
| | - Martin Monto
- Southern California Transgender Counseling, Los Angeles, CA, USA
| | - Dan H Karasic
- Southern California Transgender Counseling, Los Angeles, CA, USA
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Abstract
Trans women are a key, yet under-researched, population in the HIV epidemic. However, there remains a paucity of data on the health and wellbeing of trans women at risk of, or living with, HIV in the United Kingdom. This article provides a narrative review of key empirical research into HIV among trans women. In an effort to explore individual and social factors in relation to HIV in this population, we outline key tenets of identity process theory from social psychology and the concept of structural violence from medical anthropology. We focus on published studies around the following themes: (1) epidemiological data, (2) syndemic factors (3) barriers to social support, (4) HIV and gender transitioning, and (5) access to and engagement with health care. We identify lacunae and thus call for United Kingdom-based research in the following areas: (1) the prevalence and incidence of HIV in trans women, (2) the impact of syndemic factors on HIV risk and acquisition in trans women, (3) the nature of social support for coping with syndemic factors, (4) the interface of gender transitioning and HIV, and (5) barriers to accessing HIV prevention and care services. There is great scope (and urgency) for research into HIV among trans women, especially in the United Kingdom, to reduce incidence in this group, to enhance engagement in HIV care across the care continuum, and to improve the health and wellbeing of those living with HIV. A tentative model for HIV prevention and care is presented in this article.
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Affiliation(s)
- Rusi Jaspal
- Faculty of Health & Life Sciences, De Montfort University, Leicester, United Kingdom.,Minority Research Profile, Åbo Akademi University, Turku, Finland
| | - Lauren Kennedy
- Faculty of Health & Life Sciences, De Montfort University, Leicester, United Kingdom
| | - Shema Tariq
- Centre for Clinical Research in Infection and Sexual Health, University College London, London, United Kingdom
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Gupta A, Francis S, Stewart R, Hobson D, Meriwether KV. Repair of colonic neovaginal stenosis using a biological graft in a male-to-female transgender patient. Int Urogynecol J 2018; 30:661-663. [DOI: 10.1007/s00192-018-3800-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/19/2018] [Indexed: 11/28/2022]
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Zurada A, Salandy S, Roberts W, Gielecki J, Schober J, Loukas M. The evolution of transgender surgery. Clin Anat 2018; 31:878-886. [DOI: 10.1002/ca.23206] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 01/16/2023]
Affiliation(s)
- Anna Zurada
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Sonja Salandy
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Wallisa Roberts
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
| | - Jerzy Gielecki
- Department of Radiology, Collegium Medicum, School of Medicine; University of Warmia and Mazury; Olsztyn Poland
- Department of Anatomy; University of Warmia and Mazury; Olsztyn Poland
| | - Justine Schober
- Department of Pediatric Urology; UPMC Hamot; Erie Pennsylvania
| | - Marios Loukas
- Department of Anatomical Sciences, School of Medicine; St. George's University; Grenada West Indies
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Mundluru SN, Larson AR. Medical dermatologic conditions in transgender women. Int J Womens Dermatol 2018; 4:212-215. [PMID: 30627619 PMCID: PMC6322154 DOI: 10.1016/j.ijwd.2018.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 12/11/2022] Open
Abstract
Many previous reviews and studies on transgender dermatology have highlighted the expected dermatologic manifestations of hormone affirmation therapy in transgender patients. Others have highlighted attitudes and practices of both transgender patients and medical professionals taking care of these patients. This review compiles data from other, lesser known aspects of transgender dermatology, including neovaginal concerns, neoplastic concerns (both neovaginal and cutaneous), autoimmune conditions, and the sequelae of injectable substances that have not been approved by the U.S. Food and Drug Administration. This review, like others, will be a stepping-stone and serve as an impetus for future research in transgender dermatology.
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Affiliation(s)
- S N Mundluru
- Department of Internal Medicine, Kaiser Permanente Oakland Medical Center, Oakland, California
| | - A R Larson
- Department of Dermatology, Boston University School of Medicine, Boston, Massachusetts
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Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Male-to-Female Reassignment Surgery. Aesthetic Plast Surg 2018; 42:491-497. [PMID: 29383415 DOI: 10.1007/s00266-018-1088-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/15/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. PURPOSE The aim of this study is to compare the results of amnion grafts with amnion seeded with autograft fibroblasts. MATERIALS AND METHODS Over 8 years, we compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction. Sixteen patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. RESULTS The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed up from 30 months to 8 years, (mean 36 ± 4) after surgery. The depth of the vaginas for group A was 14-16 and 13-16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34-38 mm in group A and 33-38 cm in group B. We only had two cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina. Seventy-five percent of patients had sexual experience and of those, 93.7% in group A and 87.5% in group B expressed satisfaction. CONCLUSION The creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7% of patients had satisfaction with sexual intercourse. Amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a two-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. LEVEL OF EVIDENCE IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Affiliation(s)
- Kamal Seyed-Forootan
- Plastic and Reconstructive Surgery, Iran University of Medical Sciences, Tehran, Iran
| | - Hamid Karimi
- Plastic and Reconstructive Surgery, Iran University of Medical Sciences, Tehran, Iran.
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