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Stojanovic B, Horwood G, Joksic I, Bafna S, Djordjevic ML. Management of vaginoplasty canal complications. Curr Opin Urol 2024; 34:336-343. [PMID: 38898785 DOI: 10.1097/mou.0000000000001204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques. RECENT FINDINGS Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options. SUMMARY Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.
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Affiliation(s)
- Borko Stojanovic
- Belgrade Center for Urogenital Reconstructive Surgery
- Faculty of Medicine, University of Belgrade, Serbia
| | - Geneviève Horwood
- Belgrade Center for Urogenital Reconstructive Surgery
- Department of Obstetrics, gynecology and newborn care, The Ottawa Hospital, Ottawa, Canada
| | - Ivana Joksic
- Hospital for Gynecology and obstetrics, Belgrade, Serbia
| | - Sandeep Bafna
- Belgrade Center for Urogenital Reconstructive Surgery
- Apollo Hospitals Chennai, India
| | - Miroslav L Djordjevic
- Belgrade Center for Urogenital Reconstructive Surgery
- Faculty of Medicine, University of Belgrade, Serbia
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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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Awad L, Reed B, Bollen E, Langridge BJ, Jasionowska S, Butler PEM, Ponniah A. The emerging role of robotics in plastic and reconstructive surgery: a systematic review and meta-analysis. J Robot Surg 2024; 18:254. [PMID: 38878229 PMCID: PMC11180031 DOI: 10.1007/s11701-024-01987-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Accepted: 05/19/2024] [Indexed: 06/19/2024]
Abstract
The role of robotics has grown exponentially. There is an active interest amongst practitioners in the transferability of the potential benefits into plastic and reconstructive surgery; however, many plastic surgeons report lack of widespread implementation, training, or clinical exposure. We report the current evidence base, and surgical opportunities, alongside key barriers, and limitations to overcome, to develop the use of robotics within the field. This systematic review of PubMed, Medline, and Embase has been conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PROSPERO (ID: CRD42024524237). Preclinical, educational, and clinical articles were included, within the scope of plastic and reconstructive surgery. 2, 181, articles were screened; 176 articles met the inclusion criteria across lymph node dissection, flap and microsurgery, vaginoplasty, craniofacial reconstruction, abdominal wall reconstruction and transoral robotic surgery (TOR). A number of benefits have been reported including technical advantages such as better visualisation, improved precision and accuracy, and tremor reduction. Patient benefits include lower rate of complications and quicker recovery; however, there is a longer operative duration in some categories. Cost presents a significant barrier to implementation. Robotic surgery presents an exciting opportunity to improve patient outcomes and surgical ease of use, with feasibility for many subspecialities demonstrated in this review. However, further higher quality comparative research with careful case selection, which is adequately powered, as well as the inclusion of cost-analysis, is necessary to fully understand the true benefit for patient care, and justification for resource utilisation.
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Affiliation(s)
- Laura Awad
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK.
- Department of Plastic Surgery, Royal Free Hospital, London, UK.
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK.
| | - Benedict Reed
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Edward Bollen
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
| | - Benjamin J Langridge
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Sara Jasionowska
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
| | - Peter E M Butler
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
- Department of Surgery and Interventional Sciences, University College London, Royal Free Hospital, London, UK
| | - Allan Ponniah
- Charles Wolfson Centre of Reconstructive Surgery, University College London, Royal Free Hospital, London, UK
- Department of Plastic Surgery, Royal Free Hospital, London, UK
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Bene NC, Ferrin PC, Xu J, Dy GW, Dugi D, Peters BR. Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty. J Clin Med 2024; 13:2760. [PMID: 38792302 PMCID: PMC11122258 DOI: 10.3390/jcm13102760] [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: 04/01/2024] [Revised: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.
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Affiliation(s)
- Nicholas C. Bene
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
| | - Peter C. Ferrin
- Department of Surgery, Oregon Health and Science University, Portland, OR 97239, USA
| | - Jing Xu
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
| | - Geolani W. Dy
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Urology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Daniel Dugi
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
- Department of Urology, Oregon Health and Science University, Portland, OR 97239, USA
| | - Blair R. Peters
- Division of Plastic and Reconstructive Surgery, Oregon Health and Science University, Portland, OR 97239, USA
- Transgender Health Program, Oregon Health and Science University, Portland, OR 97239, USA
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De Rosa P, Kent M, Regan M, Purohit RS. Vaginal Stenosis After Gender-affirming Vaginoplasty: A Systematic Review. Urology 2024; 186:69-74. [PMID: 38364980 DOI: 10.1016/j.urology.2024.02.005] [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: 09/04/2023] [Revised: 01/04/2024] [Accepted: 02/06/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE To review the literature and report the incidence of vaginal stenosis (VS) after vaginoplasty and compare the incidence rates by surgical technique and follow-up duration. METHODS We performed a systematic literature review according to PRISMA guidelines. Original research on primary vaginoplasty was included. Exclusion criteria included non-English studies, mixed cohorts without subgroup analysis, revision vaginoplasty, and papers without stenosis rates. The search was ran in Pubmed, Embase, Scopus, and Cochrane on September 9, 2022. Stenosis rates were compared with descriptive statistics using SPSS. RESULTS Fifty-nine studies with a cumulative 7338 subjects were included. The overall incidence of VS was 5.83% (range 0%-34.2%). Combining VS with introital stenosis (IS) and contracture results in a cumulative incidence of 9.68%. The rate of VS in the penile inversion vaginoplasty subgroup (PIV) was 5.70%, compared to 0.20% in primary intestinal vaginoplasty. The rate of IS in the PIV group was 3.13% and 4.7% in the intestinal vaginoplasty subgroup. CONCLUSION The overall rate of VS was 5.83%, which is lower than previously documented. This may be related to the inclusion of more recent studies and analysis limited to primary vaginoplasty. The similar rate of IS in PIV and intestinal vaginoplasty subgroups may be secondary to multiple suture lines and the need for dilation through this anastomosis. Our research demonstrates a need for a standardized definition of VS.
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Affiliation(s)
- Paige De Rosa
- University of Iowa Hospitals and Clinics, Department of Urology, Iowa City, IA.
| | - Marissa Kent
- Beth Israel Deaconess Medical Center, Department of Urology, Boston, MA
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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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7
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Madec FX, Sabbagh P, Schirmann A, Morel-Journel N, Neuville P. [Genital gender affirming surgery in trans women: Vulvo-vaginoplasty review]. ANN CHIR PLAST ESTH 2023; 68:468-476. [PMID: 37648588 DOI: 10.1016/j.anplas.2023.08.002] [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: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION A trans woman is a woman who was assigned male at birth, and who has a female gender identity. The majority are requesting a gender affirming genital surgery by vulvo-vaginoplasty. The objective is to review this surgery based on its history, then by presenting the different surgical techniques and their success and complication rates. MATERIAL AND METHODS A narrative review was performed, based on a bibliography search with keywords from 2000 to 2022 on Pubmed. RESULTS Vulvo-vaginoplasty for trans women began in 1931, and the first case series date from 1969. The procedure includes excision of scrotal skin, orchiectomy, clitoroplasty, urethroplasty, labioplasty, recto-vesico-prostatic dissection and creation of a vaginal cavity (performed by penile skin inversion and graft, intestine, or peritoneum). Vulvo-vaginoplasty by penile skin inversion (VPPI) is today the reference surgical technique. It represents the vast majority of surgeries performed with the longest follow-up. The majority of trans women are satisfied with the procedure aesthetically (90%) and functionally (80%), with an active sexuality. Major complications are rare (< 5%), they correspond to fistulas or vaginal stenosis. CONCLUSION VPPI is the gold standard technique with satisfactory overall results, but long-term follow-up is requested.
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Affiliation(s)
- F-X Madec
- Service d'urologie, hôpital Foch, Suresnes, France.
| | - P Sabbagh
- Service d'urologie, hôpital Foch, Suresnes, France
| | - A Schirmann
- Service d'urologie, hôpital Foch, Suresnes, France
| | | | - P Neuville
- Service d'urologie, CHU de Lyon Sud, Pierre-Bénite, France
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Bertrand B, Perchenet AS, Casanova D. [The history of vaginoplasty: Technical and sociological advances]. ANN CHIR PLAST ESTH 2023; 68:389-396. [PMID: 37735028 DOI: 10.1016/j.anplas.2023.07.001] [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: 06/29/2023] [Accepted: 07/02/2023] [Indexed: 09/23/2023]
Abstract
Technical advances in gender-affirming genital surgery have allowed the modern surgeon to create a vagina, vulva and clitoris from a male sex. This surgery, commonly known as vaginoplasty, should in fact be identified as aidopoiesis, since it is not a question of improving an already existing vagina but of creating a female sex. Numerous technical advances made since 1930 throughout the world now offer a safe and proven surgical strategy for female genital gender affirmation. Most of these techniques are derived from advances in intersex genital surgery. The first vaginoplasties described in the context of gender affirmation were performed in Berlin in the 1930s. After the Second World War, the greatest advances in vaginoplasty were made in Denmark. It was not until Geroges Burou in Casablanca and Harold Gillies, aided by Ralph Millard in England, in the mid-fifties that the modern technique of invagination of the penile skin took over from neo-vaginal grafting techniques. The creation of the clitoris from the glans penis and a more aesthetic vulva were the major advances from the 1970s. Other flap or intestinal transplant techniques were also developed, often to correct the failure of penile skin invagination. Some of the patients who benefited from these early technical advances, such as Lili Elbe and Christine Jorgensen later on, helped to make this surgery, which had long remained taboo, popular with the general public. Pioneers such as the gynaecologist Georges Burou in Casablanca have contributed, with the greatest discretion, to the well-being of gender-affirmed people by improving these techniques. Today, this hard-won heritage cannot be ignored by surgeons interested in vaginoplasty.
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Affiliation(s)
- Baptiste Bertrand
- Service de chirurgie plastique, réparatrice et esthétique, hôpital de la conception, Assistance publique-Hôpitaux de Marseille, Marseille, France.
| | - Anne-Sophie Perchenet
- Service de chirurgie plastique, réparatrice et esthétique, Hôpital Saint-Anne du service de santé des Armées, Toulon, France
| | - Dominique Casanova
- Service de chirurgie plastique, réparatrice et esthétique, hôpital de la conception, Assistance publique-Hôpitaux de Marseille, Marseille, France
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Robinson IS, Cripps CN, Bluebond-Langner R, Zhao LC. Operative Management of Complications Following Intestinal Vaginoplasty: A Case Series and Systematic Review. Urology 2023; 180:105-112. [PMID: 37479146 DOI: 10.1016/j.urology.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 06/06/2023] [Accepted: 07/03/2023] [Indexed: 07/23/2023]
Abstract
OBJECTIVE To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications following gender-affirming intestinal vaginoplasty. METHODS Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender-affirming intestinal vaginoplasty. RESULTS Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%), and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15 cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to operating room rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities. CONCLUSION Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.
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Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Courtney N Cripps
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY; Department of Urology, NYU Langone Health, New York, NY
| | - 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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10
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Robinson IS, Zhao LC, Bluebond-Langner R. Robotics in Gender Affirming Surgery: Current Applications and Future Directions. Semin Plast Surg 2023; 37:193-198. [PMID: 38444954 PMCID: PMC10911895 DOI: 10.1055/s-0043-1771302] [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: 03/07/2024]
Abstract
Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.
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Affiliation(s)
- Isabel S. Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
| | - Lee C. Zhao
- Department of Urology, New York University Langone Health, New York, New York
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York
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11
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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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12
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van der Sluis WB, Schäfer T, Nijhuis THJ, Bouman MB. Genital gender-affirming surgery for transgender women. Best Pract Res Clin Obstet Gynaecol 2023; 86:102297. [PMID: 36599721 DOI: 10.1016/j.bpobgyn.2022.102297] [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] [Received: 11/01/2022] [Revised: 11/17/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.
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Affiliation(s)
- Wouter B van der Sluis
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands; Gender Clinic, Bosch en Duin, the Netherlands.
| | - Tim Schäfer
- Gender Clinic, Bosch en Duin, the Netherlands; Department of Plastic Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Tim H J Nijhuis
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands; Gender Clinic, Bosch en Duin, the Netherlands; Amsterdam Public Health (APH) Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
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13
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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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Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review. Eur Urol Focus 2023; 9:35-41. [PMID: 36396559 DOI: 10.1016/j.euf.2022.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/16/2022] [Accepted: 11/02/2022] [Indexed: 11/16/2022]
Abstract
CONTEXT Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice. OBJECTIVE To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS). EVIDENCE ACQUISITION We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported. EVIDENCE SYNTHESIS The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development. CONCLUSIONS Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes. PATIENT SUMMARY Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.
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Pidgeon TE, Franchi T, Lo ACQ, Mathew G, Shah HV, Iakovou D, Borrelli MR, Sohrabi C, Rashid T. Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 24:149-173. [PMID: 37122823 PMCID: PMC10132236 DOI: 10.1080/26895269.2022.2147117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Background Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS. Results After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general. Discussion The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.
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Affiliation(s)
| | | | - Andre C. Q. Lo
- University of Cambridge School of Clinical Medicine, Cambridge, UK
| | | | | | - Despoina Iakovou
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Mimi R. Borrelli
- Department of Plastic Surgery, Brown University, Rhode Island Hospital, Providence, RI, USA
| | - Catrin Sohrabi
- Barts and the London School of Medicine and Dentistry, London, UK
| | - Tina Rashid
- Department of Gender Surgery, Parkside Hospital, London, UK
- Department of Urology, St George’s University Hospital NHS Foundation Trust, London, UK
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16
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Ferrando CA. Updates on feminizing genital affirmation surgery (vaginoplasty) techniques. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 10/30/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Cecile A. Ferrando
- Center for Urogynecology & Pelvic Reconstructive Surgery, Subspecialty Care for Women, Women's Health Institute Cleveland Clinic Cleveland Ohio USA
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17
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Huang JB, Lai A, Morgantini LA, Smith JB, Millman AL, Cedeno JD, Crivellaro S, Acar O, Kocjancic E. Gender‐affirming vaginoplasty: Technical considerations in patients with genital skin deficiency. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Jason B. Huang
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Andrew Lai
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Luca A. Morgantini
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - John B. Smith
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Alexandra L. Millman
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
- Department of Surgery Women's College Hospital Toronto Ontario Canada
| | - Juan D. Cedeno
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Simone Crivellaro
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Omer Acar
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
| | - Ervin Kocjancic
- Department of Urology University of Illinois at Chicago Chicago Illinois USA
- Department of Surgery The University of Chicago Medicine Chicago Illinois USA
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Smith SM, Yuan N, Stelmar J, PA-C GL, Gupta A, Kim HL, Garcia MM. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022; 10:100572. [PMID: 36183656 PMCID: PMC9780766 DOI: 10.1016/j.esxm.2022.100572] [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] [Received: 05/09/2022] [Revised: 08/19/2022] [Accepted: 08/26/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Gender-affirming peritoneal vaginoplasty has been described, and previous descriptions are modifications of the Davydov technique. AIM To describe our alternative technique for gender-affirming peritoneal vaginoplasty (PV) using a single-pedicled, urachus-peritoneal hinge flap, discussing proposed advantages. METHODS Retrospective review of all consecutive transfeminine patients with neovaginal shortening after prior penile inversion vaginoplasty (PIV) who underwent our PV technique from May 2019 to July 2022. PV was performed via combined transperineal and laparoscopic (robot-assisted) approaches. After spatulation of the neovaginal remnant, a midline, inferiorly based urachus-peritoneal hinge flap was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The free end of the flap was flipped posteriorly and sutured to posterior edge of the open canal remnant, forming a peritoneal pouch. The lateral edges of the pouch were sutured together for water-tight closure. Patients resumed dilation on POD 6 and douching on POD 10. MAIN OUTCOME MEASURES Ten transfeminine patients underwent PV, with good outcomes. We measured: Pre-op penile and scrotal skin lengths, intra-op tubularized scrotal skin length, pre and post-op vaginal depth and width (immediate and at last follow-up). RESULTS Pre-op: mean neovaginal depth was 9.2cm (SD 1.5); width was 12cm. Immediate post-op: mean depth was 15.1 cm (SD 2.2 cm, mean net increase: 5.9 cm). At mean follow-up of 18.3 months, mean depth was 12.5 cm (SD 2.1 cm, mean net increase: 3.3 cm) and width was 12 cm. There were no immediate post-op complications. Eight (80%) of the 10 patients report satisfactory vaginal receptive intercourse. The other 2 have not yet attempted vaginal receptive intercourse. CLINICAL IMPLICATIONS Advantages of the proposed technique over existing techniques include no tension on peritoneal suture lines and total exclusion of the rectum. STRENGTHS AND LIMITATIONS Strengths include a short learning curve for urologic surgeons with robotic experience. The study is limited by small sample size. CONCLUSIONS Our PV technique is a safe and effective option for salvage peritoneal vaginoplasty after primary PIV. Smith SM, Yuan N, Stelmar J, et al. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022;10:100572.
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Affiliation(s)
- Shannon M. Smith
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute, Pasadena, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Grace Lee PA-C
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Amit Gupta
- Beverly Hills Urology, Beverly Hills, CA, USA
| | - Hyung L. Kim
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Maurice M. Garcia
- Cedars-Sinai Transgender Surgery and Health Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA,Departments of Anatomy and Urology, University of California San Francisco, San Francisco, CA, USA,Corresponding Author: Maurice M. Garcia, MD, MAS, 8635 W. Third St., Suite 1070W, Los Angeles, CA 90048, USA.
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Robotic Peritoneal Flap vs. Perineal Penile Inversion Techniques for Gender-Affirming Vaginoplasty. Curr Urol Rep 2022; 23:211-218. [PMID: 36040679 DOI: 10.1007/s11934-022-01106-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW To discuss perineal and robotic approaches to gender-affirming vaginoplasty. RECENT FINDINGS The Davydov peritoneal vaginoplasty has its origins in neovaginal reconstruction for vaginal agenesis. It has been adapted as a robotic-assisted laparoscopic procedure and provides an alternative to perineal canal dissection in gender-affirming vaginoplasty. Both techniques represent variations of penile inversion vaginoplasty with successful outcomes and overall low rates of major complications reported in the literature. However, there are differing advantages and considerations to each approach. A perineal approach has been the gold standard to gender-affirming vaginoplasty for many decades. Robotic peritoneal gender-affirming vaginoplasty (RPGAV) is an emerging alternative, with potential advantages including less reliance on extragenital skin grafts in individuals with minimal genital tissue, especially among patients presenting with pubertal suppression, and safer dissection in revision vaginoplasty for stenosis of the proximal neovaginal canal. Additional risks of RPGAV include those associated with robotic abdominal surgeries.
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Xu AJ, Mishra K, Lee YS, Zhao LC. Robotic-Assisted Lower Genitourinary Tract Reconstruction. Urol Clin North Am 2022; 49:507-518. [DOI: 10.1016/j.ucl.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Jimenez C, Stanton E, Sung C, Wong AK. Does plastic surgery need a rewiring? A survey and systematic review on robotic-assisted surgery. JPRAS Open 2022; 33:76-91. [PMID: 35812356 PMCID: PMC9260262 DOI: 10.1016/j.jpra.2022.05.006] [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] [Received: 04/20/2022] [Accepted: 05/11/2022] [Indexed: 01/28/2023] Open
Abstract
Background This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions. Methods A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery. Results The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review. Conclusions Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.
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Affiliation(s)
- Christian Jimenez
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Eloise Stanton
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA
| | - Cynthia Sung
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA
| | - Alex K. Wong
- Keck School of Medicine of USC, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, Keck School of Medicine, Los Angeles, CA,Division of Plastic and Reconstructive Surgery, City of Hope National Medical Center, Duarte, CA,Corresponding author: Alex K. Wong, Division of Plastic and Reconstructive Surgery, City of Hope, 1500 E Duarte Rd, Duarte, CA 91010.
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22
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Blasdel G, Kloer C, Parker A, Castle E, Bluebond-Langner R, Zhao LC. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022; 19:781-788. [PMID: 35337785 DOI: 10.1016/j.jsxm.2022.02.015] [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] [Received: 10/17/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints. AIM Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling. METHODS A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic. OUTCOMES Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record. RESULTS A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy. CLINICAL IMPLICATIONS Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery. STRENGTHS & LIMITATIONS This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm. CONCLUSION The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery. Blasdel G, Kloer C, Parker A, et al. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022;19:781-788.
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Affiliation(s)
- Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA.
| | - Carmen Kloer
- Duke University School of Medicine, Durham, NC, USA
| | - Augustus Parker
- New York University Grossman School of Medicine, New York, NY, USA
| | - Elijah Castle
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
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Zilavy AJ, Santucci RA, Gallegos MA. The History of Gender-Affirming Vaginoplasty Technique. Urology 2022; 165:366-372. [DOI: 10.1016/j.urology.2022.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 11/28/2022]
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A Systematic Approach to Incision Planning and Graft Excision in Gender-affirming Vaginoplasty. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4103. [PMID: 35186642 PMCID: PMC8846344 DOI: 10.1097/gox.0000000000004103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 11/25/2022]
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Robinson IS, Blasdel G, Bluebond-Langner R, Zhao LC. The Management of Intra-abdominal Complications Following Peritoneal Flap Vaginoplasty. Urology 2022; 164:278-285. [PMID: 35150666 DOI: 10.1016/j.urology.2022.01.036] [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: 12/06/2021] [Revised: 01/08/2022] [Accepted: 01/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSIONS Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare. In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.
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Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | | | | | - Lee C Zhao
- Department of Urology, NYU Langone Health, New York, NY.
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Van Gerwen OT, Aryanpour Z, Selph JP, Muzny CA. Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review. Int J STD AIDS 2022; 33:106-113. [PMID: 34615399 PMCID: PMC9713597 DOI: 10.1177/09564624211046997] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.
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Affiliation(s)
- Olivia T Van Gerwen
- Department of Medicine, Division of Infectious Diseases, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zain Aryanpour
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
| | - John P Selph
- Department of Urology, 9968University of Alabama at Birmingham, Birmingham, AL, USA.Increase
| | - Christina A Muzny
- Department of Medicine, 9967University of Alabama School of Medicine, Birmingham, AL, USA
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Response to Letter to Editor: Re: Xu AJ, Shakir NA, Jun MS, Zhao LC. Robotic Assisted Repair of Post-Ileal Conduit Parastomal Hernia: Technique and Outcomes. Urology. 2021;S0090- 4295(21)00819-0. doi:10.1016/j.urology.2021.08.030. Urology 2021; 161:157-158. [PMID: 34954216 DOI: 10.1016/j.urology.2021.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/28/2021] [Indexed: 11/22/2022]
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Melancon DM, Walton AB, Mundinger G, Benson C. Surgical Outcomes and Complications of Genital Gender Affirmation Surgery. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Preclinical evaluation of the new EDGE SP 1000 single-port robotic surgical system in gynecology minimal access surgery. Surg Endosc 2021; 36:4780-4785. [PMID: 34697678 DOI: 10.1007/s00464-021-08819-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/17/2021] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate the feasibility and safety of a new single-port robotic surgical system for gynecological surgery in the porcine model. MATERIALS AND METHODS Six female Tibetan miniature pigs underwent robot-assisted single-port laparoscopic total hysterectomy with the newly developed single-port EDGE SP1000 platform. Estimated blood loss (EBL), docking time, operative time, and intraoperative and postoperative complications were recorded. Postoperative pain was assessed by VAS (visual analog scale) score at 6 h, 12 h, 24 h, and 48 h. Then the experimental animals were observed for one week after surgery to assess their mental status, incisional infections and finally euthanized for necropsy to assess the recovery of the vaginal stump. RESULTS Six hysterectomies of pigs were successfully completed. There were no significant intraoperative complications in the six surgeries. The average total operation time was 113.33 min (95-143 min), and the average docking time was 5.5 min (4-7 min). The average EBL was 10 ml (5 ~ 20 ml). The mean VAS scores at 6, 12, 24, and 48 h postoperatively were 6.3, 5.7, 5, 3, respectively. At 7 days postoperatively, no significant incisional infections or other complications were observed. Post-euthanasia examination of the pelvis showed no significant abnormalities in the vaginal stump. CONCLUSION This preclinical study of a new single-port surgical system for gynecologic procedures demonstrated the safety and feasibility of the EDGE SP1000 system in porcine models. Further studies are required to assess its clinical utility in the future.
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Shakir NA, Alsikafi NF, Buesser JF, Amend G, Breyer BN, Buckley JC, Erickson BA, Broghammer JA, Parker WP, Zhao LC. Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study. Eur Urol 2021; 81:176-183. [PMID: 34521553 DOI: 10.1016/j.eururo.2021.08.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/11/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Refractory vesicourethral anastomotic stenosis (VUAS) after radical prostatectomy poses challenges distinct from bladder neck contracture, due to close proximity to the sphincter mechanism. Open reconstruction is technically demanding, risking de novo stress urinary incontinence (SUI) or recurrence. OBJECTIVE To demonstrate patency and continence outcomes of robotic-assisted VUAS repair. DESIGN, SETTING AND PARTICIPANTS Patients with VUAS underwent robotic-assisted reconstruction from 2015 to 2020 in the Trauma and Urologic Reconstructive Network of Surgeons (TURNS) consortium of institutions. The minimum postoperative follow-up was 3 mo. SURGICAL PROCEDURE The space of Retzius is dissected and fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic or an anterior bladder flap-based technique. MEASUREMENTS Patency was defined as either the passage of a 17 French flexible cystoscope or a peak flow on uroflowmetry of >15 ml/s. De novo SUI was defined as either more than one pad per day or need for operative intervention. RESULTS AND LIMITATIONS A total of 32 patients met the criteria, of whom 16 (50%) had a history of pelvic radiation. Intraoperatively, 15 (47%) patients had obliterative VUAS. The median length of hospital stay was 1 d. At a median follow-up of 12 mo, 24 (75%) patients had patent repairs and 26 (81%) were voiding per urethra. Of five men with 30-d complications, four were resolved conservatively (catheter obstruction and ileus). In eight patients, recurrent stenoses were managed with redo robotic reconstruction (in two), endoscopically (in four), or catheterization (in two). Of 13 patients without preexisting SUI, 11 (85%) remained continent at last follow-up. No patients underwent urinary diversion. CONCLUSIONS Robotic-assisted VUAS reconstruction is a viable and successful management option for refractory anastomotic stenosis following radical prostatectomy. The robotic transabdominal approach demonstrates high patency and continence rates. PATIENT SUMMARY We studied the outcomes of robotic-assisted repair for vesicourethral anastomotic stenosis. Most patients, after the procedure, were able to void per urethra and preserve existing continence.
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Affiliation(s)
- Nabeel A Shakir
- Department of Urology, New York University, New York, NY, USA
| | | | | | - Gregory Amend
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Benjamin N Breyer
- Department of Urology, University of California-San Francisco, San Francisco, CA, USA
| | - Jill C Buckley
- Department of Urology, University of California-San Diego, San Diego, CA, USA
| | | | - Joshua A Broghammer
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - William P Parker
- Department of Urology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Lee C Zhao
- Department of Urology, New York University, New York, NY, USA.
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Xu AJ, Shakir NA, Jun MS, Zhao LC. Robotic Assisted Repair of Post-Ileal Conduit Parastomal Hernia: Technique and Outcomes. Urology 2021; 158:232-236. [PMID: 34481825 DOI: 10.1016/j.urology.2021.08.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/01/2021] [Accepted: 08/19/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe a novel method of robotic assisted laparoscopic parastomal hernia repair (RAL-PHR), including the evolving use of the Da Vinci Single Port (SP) robotic system. METHODS Demographic, intraoperative, and postoperative variables were collected for patients who underwent RAL-PHR. The technique for RAL-PHR utilizes a 3 cm incision in the contralateral upper quadrant for the robotic trocar and a 12 mm assistant port. The hernia sac is freed from the fascial defect. Dual Surface Mesh is approximated to the fascial edges with a portion excised to tailor the conduit. RESULTS Four patients underwent RAL-PHR and three utilized the SP robot. Median age was 74.4 (range: 69.0-76.9) and median BMI 28.6 (26.5-43.2). All patients underwent cystectomy for bladder cancer and median time from index operation to parastomal hernia repair was 47.3 (40.4-11.48) months. Concurrent operations to hernia repair included ureteroenteric stricture repair, panniculectomy, abdominal wall reconstruction, stoma revision, and incisional hernia repair. Median operative time was 3.9 (2.6-8.7) hours including concurrent operations, median EBL was 50 (10-100) cc, mesh used in 3 cases, with no intraoperative complications reported. Median length of stay was 1 day and 1 post-operative complication greater than Clavien 2 reported. At median follow up of 18.3 (3.63-38.3) months, no recurrences were reported and 1 patient had undergone stoma dilation in the OR. CONCLUSION RAL-PHR using the SP system maximizes advantages of laparoscopic repair while allowing for flexibility to perform concurrent procedures and safer takedown of adhesions through just two incisions. RAL-PHR is a safe and effective alternative to open and laparoscopic parastomal hernia repair with several additional benefits.
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Affiliation(s)
- Alex J Xu
- NYU Langone Health, Department of Urology, New York, NY.
| | | | - Min S Jun
- NYU Langone Health, Department of Urology, New York, NY
| | - Lee C Zhao
- NYU Langone Health, Department of Urology, New York, NY
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Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg 2021; 92:373-378. [PMID: 34427039 DOI: 10.1111/ans.17147] [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: 05/08/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Gender dysphoria is defined as discomfort or distress that is caused by a discrepancy between a person's gender identity and that person's sex assigned at birth. The main objective of this study was to review the application, efficacy and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery. Specific outcome parameters include (1) healing time (2) depth of cavity achieved (3) alleviation of dysphoria (4) morbidity of the surgery. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained prior to commencement (PROSPERO CRD42020206736). A search was performed in OVID MEDLINE, EMBASE, Willey Online Library and PubMed. Specialty-related journals, grey literature and reference lists of relevant articles were manually searched. RESULTS From 476 potentially relevant articles, 12 articles were analysed. The publications were all level 4 or level 5 evidence. Healing times were poorly reported or often not mentioned. Eight authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction. Alleviation of dysphoria was not discussed by any of the publications and only six reported complications. Average follow up reported ranged from 6 weeks to 14.8 months. CONCLUSION The application of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel. However, there is a paucity of data. Further research and longer-term data are required to assess the efficacy and safety of this technique. Patients seeking this surgery overseas should be informed of the potential difficulties they may face.
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Affiliation(s)
- Yu Ting Tay
- Department of Plastic and Reconstructive Surgery, Monash Health (Dandenong Hospital), Dandenong, Victoria, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Cheng Hean Lo
- Department of Plastic and Reconstructive Surgery, Monash Health (Dandenong Hospital), Dandenong, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Shakir NA, Zhao LC. Robotic-assisted genitourinary reconstruction: current state and future directions. Ther Adv Urol 2021; 13:17562872211037111. [PMID: 34377155 PMCID: PMC8326819 DOI: 10.1177/17562872211037111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 07/16/2021] [Indexed: 11/16/2022] Open
Abstract
With the widespread dissemination of robotic surgical platforms, pathology previously deemed insurmountable or challenging has been treated with reliable and replicable outcomes. The advantages of precise articulation for dissection and suturing, tremor reduction, three-dimensional magnified visualization, and minimally invasive trocar sites have allowed for the management of such diverse disease as recurrent or refractory bladder neck stenoses, and radiation-induced ureteral strictures, with excellent perioperative and functional outcomes. Intraoperative adjuncts such as near-infrared imaging aid in identification and preservation of healthy tissue. More recent developments include robotics via the single port platform, gender-affirming surgery, and multidisciplinary approaches to complex pelvic reconstruction. Here, we review the recent literature comprising developments in robotic-assisted genitourinary reconstruction, with a view towards emerging technologies and future trends in techniques.
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Affiliation(s)
- Nabeel A Shakir
- Department of Urology, NYU Langone Medical Center, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, NYU Langone Medical Center, 222 41st Street, 11th Floor, New York, NY 10017, USA
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Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: a Novel Technique for Treating Neovaginal Stenosis. Urology 2021; 154:308-314. [PMID: 33823174 DOI: 10.1016/j.urology.2021.03.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/13/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization. METHODS Twenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017 to 2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications. RESULTS Mean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis. CONCLUSIONS Robotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.
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Affiliation(s)
- Geolani W Dy
- Department of Urology, Oregon Health & Sciences University, Portland, OR
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Nabeel A Shakir
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Lee C Zhao
- Department of Urology, New York University Langone Medical Center, New York, NY.
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