Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

Exploring Decisional Conflict Experienced by Individuals Considering Metoidioplasty and Phalloplasty Gender-affirming Surgery

Background

Metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) is increasingly performed and requires patients to make complex decisions that may lead to decisional uncertainty. This study aimed to evaluate decisional conflict in individuals considering MaPGAS.

Methods

We administered a cross-sectional survey to adult participants assigned female sex at birth and considering MaPGAS, recruited via social media platforms and community health centers. We collected data on demographics, medical and surgical history, MaPGAS type considered, and the Decisional Conflict Scale (DCS). DCS scores range from 0 to 100 (>37.5 indicates greater decisional conflict). Demographic characteristics and DCS scores were compared between subgroups, using descriptive and chi-square statistics. Participants commented on MaPGAS uncertainty, and their comments were evaluated and thematically analyzed.

Results

Responses from 264 participants were analyzed: mean age 29 years; 64% (n = 168) trans men, 80% (n = 210) White, 78% (n = 206) nonrural, 45% (n = 120) privately insured, 56% (n = 148) had 4 or more years of college, 23% (n = 84) considering metoidioplasty, 24% (n = 87) considering phalloplasty, and 26% (n = 93) considering metoidioplasty and phalloplasty. DCS total scores were significantly higher (39.8; P < 0.001) among those considering both MaPGAS options, as were mean ratings on the Uncertainty subscale [64.1 (SD 25.5; P < 0.001)]. Concerns surrounding complications were the top factor contributing to uncertainty and decisional conflict.

Conclusions

In a cross-sectional national sample of individuals seeking MaPGAS, decisional uncertainty was the highest for those considering both MaPGAS options compared with metoidioplasty or phalloplasty alone. This suggests this cohort would benefit from focused decision support.

Incidence, Complications, and Long-term Outcomes of Gender-affirming Phalloplasty: Analysis of a Large Statewide Population-based Dataset

OBJECTIVE

To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset.

METHODS

Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis.

RESULTS

We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications.

CONCLUSION

This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy.

Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know

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.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

Robotics in Gender Affirming Surgery: Current Applications and Future Directions

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.

Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study

BACKGROUND

Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information.

AIM

(1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid.

METHODS

This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework.

OUTCOMES

Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables.

RESULTS

We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing.

CLINICAL IMPLICATIONS

The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty.

STRENGTHS AND LIMITATIONS

This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway.

CONCLUSIONS

This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Does Genital Self-image Correspond with Sexual Health before and after Vaginoplasty?

Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty.

Methods

A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction.

Results

A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort.

Conclusions

Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

BACKGROUND

Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI).

AIM

We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA.

OUTCOMES

Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty.

RESULTS

Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction.

CLINICAL TRANSLATION

The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery.

STRENGTHS & LIMITATIONS

This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center.

CONCLUSION

Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

BACKGROUND

Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.

AIM

The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.

METHODS

Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.

OUTCOMES

Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.

RESULTS

Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).

CLINICAL IMPLICATIONS

This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.

STRENGTHS & LIMITATIONS

This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.

CONCLUSION

Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

Setting a research agenda in trans health: An expert assessment of priorities and issues by trans and nonbinary researchers

BACKGROUND

This article is by a group of trans and nonbinary researchers and experts in the field of trans health who have conducted an analysis of trans health research needs.

AIMS

To highlight topics that need further research and to outline key considerations for those conducting research in our field.

METHODS

The first author conducted semi-structured interviews with all coauthors, and these were used to create a first draft of this manuscript. This draft was circulated to all authors, with edits made until consensus was reached among the authors.

RESULTS

More comprehensive long-term research that centers trans people's experiences is needed on the risks and benefits of gender affirming hormones and surgeries. The trans health research field also needs to have a broader focus beyond medical transition or gender affirmation, including general health and routine healthcare; trans people's lives without, before, and after medical gender affirmation; and sexuality, fertility, and reproductive healthcare needs. More research is also needed on social determinants of health, including ways to make healthcare settings and other environments safer and more supportive; social and legal gender recognition; the needs of trans people who are most marginalized; and the ways in which healing happens within trans communities. The second part of this article highlights key considerations for researchers, the foremost being acknowledging trans community expertise and centering trans community members' input into research design and interpretation of findings, in advisory and/or researcher roles. Ethical considerations include maximizing benefits and minimizing harms (beneficence) and transparency and accountability to trans communities. Finally, we note the importance of conferences, grant funding, working with students, and multidisciplinary teams.

DISCUSSION

This article outlines topics and issues needing further consideration to make the field of trans health research more responsive to the needs of trans people. This work is limited by our authorship group being mostly White, all being Anglophone, and residing in the Global North.

Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review

BACKGROUND

Many transgender women and men undergo gender-affirming surgeries. Existing work shows that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive quality of life outcomes. Less work, however, examines these outcomes in the longer-term.

AIMS

To conduct a systematic literature review into the longer-term (i.e., ≥ 1 year) surgical satisfaction and quality of outcomes following various forms of gender-affirming surgery in transgender populations. Specifically, we aim to examine research on such outcomes at least one-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries.

METHODS

Studies were identified through Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. We considered all studies published until October 2021. Two reviewers extracted data from suitable studies using Covidence. Both reviewers also independently assessed the identified studies' risk of bias and strength of evidence.

RESULTS

Seventy-nine low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggest that most transgender patients are satisfied with surgical outcomes when assessed at least one-year post-surgery. Low quality research also indicates that transgender women and men typically report positive psychological and sexual wellbeing post-surgery, and similar wellbeing outcomes as those who have not had surgery.

DISCUSSION

To the best of our knowledge, this literature review is the first to critically summarize and evaluate all published studies on the longer-term quality of life outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. While the results suggest promising surgical satisfaction and quality of life outcomes following surgery, many studies only draw on small samples, and most studies do not allow for causal conclusions. Further, few studies have compared surgical outcomes between transgender women and men. We conclude by offering concrete suggestions for future research.

Genital Self-Image and Aesthetic Genital Surgeries: Novel Perspectives Across the Cisgender and Transgender Spectrum

Genital-focused body image concerns or negative genital self-image are a common experience across the gender spectrum, including among cisgender and transgender populations. Such concerns can result in lower psychological and sexual well-being. In this article, it is proposed that the development of genital self-image concerns may be partly explained by the theoretical framework of cisgenderism. This theory proposes that there are only 2 genders-men and women-and these are dictated solely by the appearance of the genitals. Any deviation from these 2 categories can result in discrimination, which particularly impacts transgender individuals. An increasing number of cisgender and transgender people are seeking out aesthetic genital procedures to alleviate genital self-image concerns (and gender dysphoria in transgender populations). The growing body of research suggests that cisgender and transgender men and women are relatively satisfied with the results of their genital procedures. However, this research is limited by a lack of standardized and validated patient-reported measures to evaluate surgical outcomes. Furthermore, despite negative genital self-image being a key motivator for surgery, it is often not included as an outcome measure. In this article, recommendations are proposed for conducting higher-quality evaluation studies of aesthetic genital procedures in cisgender and transgender populations. Moreover, future research and clinical directions are suggested to assist transgender men and women who choose not to undergo genital gender-confirming surgery. The vast majority of transgender individuals do not have this surgery and so are in great need of support in managing their gender dysphoria and negative genital self-image.