An Update on the Surgical Treatment for Transgender Patients

[New S2k guideline "Surgical techniques for gender incongruence"]

BACKGROUND

Various techniques for the surgical treatment of gender incongruence (GI) have been available for years. The spectrum is broad and covers various specialties. In recent years, there has been an increase in the number of clinics offering body-modifying procedures. This has led to a considerable variation in methods in some cases. Although the topic has recently found its way more and more into teaching and the relevant specialist literature, there are still no evidence-based recommendations on the various techniques.

AIM

A compendium of established surgical techniques was to be compiled, containing recommendations on indication, performance and aftercare as well as complication management and subjecting them to a consensus-based evaluation.

MATERIALS AND METHODS

In accordance with "Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften" (AWMF) regulations, the guideline was developed at level S2k, i.e., it is consensus based. The guideline group was founded in February 2019 in a formal constituent meeting. A total of 14 medical societies and 2 interest groups were recruited for the guideline work. In the end, two consensus meetings were held, which was due to the large number of recommendations and background texts to be adopted.

RESULTS

The guideline focuses on the choice and applicability of surgical techniques as well as the wishes of those seeking treatment and protection of fertility. There is a wide variety of methods and treatment goals for each individual. Taking into account medical standards, recommendations, and contraindications, an optimal result that minimizes individual suffering can be achieved together with the person seeking treatment.

CONCLUSION

The content of the guideline represents a unique compendium of surgical methods, recommendations for the selection of procedures, and common indications in the field of body-modifying surgery for gender incongruence.

Efficacy and safety of 1064-nm fractional picosecond laser for the treatment of postmastectomy scars in transgender men: A randomized controlled trial

OBJECTIVES

Subcutaneous mastectomy is a crucial component of gender affirmation therapy for transgender men (TM), but the scars that result from this procedure can frequently impair their quality of life. This study aimed to assess the efficacy and safety of 1064-nm fractional picosecond laser (FxPico) treatment for hypertrophic and atrophic postmastectomy scars in TM.

METHODS

Twenty-two patients with a total of 35 pairs of bilateral symmetric mastectomy scars were enrolled. One of each pair of symmetric scars was randomly assigned to receive four FxPico treatments at 4-week intervals. All scars were evaluated using the modified Vancouver Scar Scale (mVSS) and three-dimensional imaging for scar roughness, melanin index, and hemoglobin index before each treatment session and at 1, 3, and 6 months following the last treatment. Additionally, participant-rated scar satisfaction (PSS) and scar improvement (Global Assessment Score, GAS), as well as adverse events were recorded.

RESULTS

During the 6-month follow-up period after the end of laser treatment sessions, the treated scars showed significant reductions in the mVSS compared to the untreated controls (p < 0.001), whereas the melanin index and hemoglobin index were not significantly different. Subgroup analysis of hypertrophic scars demonstrated statistically significant reductions in mVSS at 1 (p = 0.003) and 3 months (p = 0.041) after the end of laser treatments. PSS was significantly higher on the laser-treated scars than the controls (p = 0.008), and a participant-rated GAS of 2.95 ± 0.65 was found. There were no serious adverse events reported.

CONCLUSIONS

1064-nm FxPico could be utilized to treat mastectomy scars among TM, particularly the hypertrophic type.

Requests for vulvoplasty as gender-affirming surgery: a cross-sectional study in Denmark

BACKGROUND

Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark.

AIM

In this study we sought to quantify the need for offering vulvoplasty in Denmark.

MATERIALS AND METHODS

An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022.

OUTCOMES

Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it.

RESULTS

A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future.

CLINICAL IMPLICATIONS

Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered.

STRENGTHS AND LIMITATIONS

Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated.

CONCLUSION

The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

[Psychiatric, socio-legal and perioperative aspects of vaginoplasty]

The number of scientific papers on gender-confirming surgeries as well as the surgeries themselves have increased by leaps and bounds in recent years. This leads to sometimes considerable waiting times for people seeking treatment. Social media and the internet do not always provide reliable and high-quality information. Therefore, it is necessary that both surgically and conservatively active urologists are familiar with topics regarding transgender persons. The establishment of structured training, the guarantee of minimum quality standards in the treatment of transgender persons and the further education and training of medical staff pose particular challenges. The German Society for Urology (DGU) and the German Society for Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) have already founded their own working groups on the surgical side, which coordinate their work. Under the auspices of the professional societies DGU and DGPRÄC, a guideline on surgical procedures for gender incongruence was developed under the umbrella of the AWMF ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften") which is currently being finalised. For a long time, the health care of transgender people has been moving in a field of tension between the right of self-determination of those seeking treatment, on the one hand, and the fear of making the wrong medical decisions, on the other. In contrast to most other conditions in urology, the goal of treatment is largely determined by the person seeking treatment and does not necessarily follow predetermined schedules or content. The treatment should primarily aim at reducing the individual's suffering and promoting quality of life.

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Shallow-depth vaginoplasty: preoperative goals, postoperative satisfaction, and why shallow-depth vaginoplasty should be offered as a standard feminizing genital gender-affirming surgery option

BACKGROUND

Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV), or vaginoplasty with creation of a vaginal canal. SDV is associated with fewer short- and long-term risks and shorter recovery, and does not require a lifelong commitment to vaginal dilation and douching.

AIM

To describe a surgical technique for SDV that creates a dimpled introitus, together with clinical outcomes, decision-making prioritization, and satisfaction data. We hypothesize that SDV patients prioritize comparable appearance and sexual function to FDV over shorter-term risk factors, and experience high satisfaction.

METHODS

We describe (1) a surgical technique for SDV; (2) the proportion of patients who underwent SDV vs. FDV, with SDV complication rates; and (3) the results of an anonymous, electronic questionnaire administered via Qualtrics that assessed SDV patient demographics, terminology preferences, prioritization of decision-guiding factors for choosing SDV over FDV, and postoperative satisfaction across various domains.

OUTCOMES

A total of 110 patients underwent primary feminizing genital gender-affirming surgery at a single institution between April 2017 and July 2022: 35 (32%) of 110 underwent SDV and 75 (68%) underwent FDV. The 35 SDV patients were invited to answer the study questionnaire, of which 29 (83%) completed it (mean age 51.9 ± 16.7 years, mean body mass index 27.3 ± 5.3 kg/m2).

RESULTS

All but one survey respondent met one or more of the following characteristics: (1) ≥40 years of age, (2) exclusively feminine-identifying sexual partners, and/or (3) significant aversion to performing long-term vaginal dilation and douching. Ranking of 8 decision-guiding factors revealed prioritization of long-term over short-term outcomes. Postoperatively, patients reported high satisfaction across all 3 domains. When asked if they had to choose between SDV and FDV over again, 86% reported that they would choose SDV. While 14% would choose FDV, all but one reported new interest in receptive vaginal intercourse due to finding masculine-identifying partners post-SDV surgery. A total of 27% of SDV patients experienced complications that required additional surgeries; 82% of complications were related to urinary spraying.

CLINICAL IMPLICATIONS

SDV is a lower-risk alternative to FDV and is associated with reduced postoperative maintenance and high postoperative satisfaction.

STRENGTHS AND LIMITATIONS

This study describes the clinical outcomes of the largest documented cohort of patients to undergo SDV to date. Limitations include recall bias due to the retrospective survey and use of nonvalidated questions attributed to the paucity of validated gender-affirming surgery questionnaires.

CONCLUSION

SDV's appeal to a large subset of patients (32% in this study), low complication rate, high satisfaction, and low decisional regret suggests that this surgical option should be offered to all patients seeking feminizing genital gender-affirming surgery.

Effect of Gender-affirming Facial Feminization Surgery on Psychosocial Outcomes

OBJECTIVE

This study investigates the effect of gender-affirming facial feminization surgery (FFS) on psychosocial outcomes in patients with gender dysphoria.

BACKGROUND

Comprehensive analyses of psychosocial outcomes after gender-affirming FFS are absent in the literature resulting in a paucity of information on the impact of FFS on quality of life as well as ramifications in health insurance coverage of FFS.

METHODS

Scores from 11 validated, quantitative instruments from the Patient-Reported Outcomes Measurement Information System (PROMIS) assessing anxiety, anger, depression, global mental health, global physical health, satisfaction with sex life, positive affect, emotional support, social isolation, companionship, and meaning and purpose. Patients within the preoperative group (pre-FFS) were evaluated >30 days before surgery and patients within the postoperative group (post-FFS) were evaluated ≥10 weeks after surgery.

RESULTS

A total of 169 patients [mean (SD) age, 33.5 (10.8) years] were included. Compared with the pre-FFS group (n=107), the post-FFS group (n=62) reported improved scores anxiety (56.8±8.8 vs 60.1±7.9, P =0.01), anger (47.4±7.6 vs 51.2±9.6, P =0.01), depression (52.2±9.2 vs 57.0±8.9, P =0.001), positive affect (46.6±8.9 vs 42.9±8.7, P =0.01), meaning and purpose (49.9±10.7 vs 46.2±10.5, P =0.03), global mental health (46.7±7.6 vs 43.1±9.2, P =0.01), and social isolation (52.2±7.5 vs 55.4±7.4, P =0.01). Multivariable analysis to account for the effects of other gender-affirming surgeries, hormone therapy duration, preexisting mental health diagnoses, socioeconomic disparities, and patient-reported quality of social relationships on psychosocial functioning demonstrated that completion of FFS was independently predictive of improved scores.

CONCLUSIONS

Gender-affirming FFS improves the quality of life by multiple psychosocial domains in transfeminine patients.

Principles and outcomes of gender-affirming vaginoplasty

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.

Urological and Gynaecological Considerations for the Use of Gonadotropin-releasing Hormone Analogues in Transgender and Nonbinary Adolescents: A Narrative Review

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.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Modification of the single-tube radial forearm phalloplasty technique to allow for urinary meatal reconstruction: A report of two cases

The free radial forearm flap is the gold standard technique for transgender phalloplasty due to superior complication rates compared to other methods. However, reconstruction of the urinary tract, including urethral lengthening and creation of a pars pendula urethra within the flap, carries a high rate of complications. The risk of complications and a lack of desire for standing urination are reasons patients elect for single-tube phalloplasty. However, to date, single-tube phalloplasties lack creation of a urinary meatus, which affects the aesthetics of the reconstruction. The purpose of this report is to describe a technique for creating an aesthetic urinary meatus in single-tube phalloplasty. We herein describe the technique in the use of two healthy transgender males (ages 31 and 39). Both patients did not desire micturition through the neophallus, but still desired the appearance of a meatus at the tip of the neophallus. Single-tube radial forearm phalloplasty was performed for both patients. The radial forearm flaps for each patient were 14 × 15 cm. Meatoplasty was performed at the time of flap elevation utilizing an intact 1 × 4 cm intact strip of ulnar sided skin during flap tubularization. This strip of skin was then invaginated to create a neomeatal pouch. The postoperative course was uncomplicated for both patients following at 5-day hospital stay for flap monitoring. Follow up time was 7 and 8 months. The neomeatal pouch persisted in both patients and the patients were satisfied with the appearance of the tips of the neophalluses.

Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice?

The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.

Patient reported outcomes in genital gender-affirming surgery: the time is now

Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.

Gender Affirming Body Contouring and Physical Transformation in Transgender Individuals

There is a subset of transgender individuals, who after having undergone gender affirming surgeries want body contouring so that the overall body shape is congruent to the body image. Hormonal therapy can bring about a considerable change in the physical transformation. However, there is an increase in requests for specific body contouring procedures because of increased awareness in the society.

There are significant differences between the skeletal as well as soft tissue characteristics of male and female body. Body contouring in transgender individuals can be achieved by altering the skeletal structure or the overlying soft tissues or combining both. In this article, we discuss body contouring as an adjunct to gender affirming surgeries, in both male to female and female to male transgender individuals.

ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"

Introduction

Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.

Aim

To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.

Methods

The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.

Main Outcomes Measure

The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.

Results

The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.

Conclusion

The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.

Refinement of recto-sigmoid colon vaginoplasty using a three-dimensional laparoscopic technique

To investigate the feasibility, safety, and outcomes of three-dimensional (3D) laparoscopic vaginoplasty with a rectosigmoid colon flap for vaginal reconstruction.Following appropriate preoperative patient counseling, 17 consecutive patients underwent vaginoplasty using a 3D laparoscopic system. Perioperative and postoperative outcomes were retrospectively evaluated.Between September 2016 and February 2020, 17 patients underwent 3D laparoscopic vaginoplasty with a rectosigmoid colon flap. Of them, 15 (88%) were transgender female patients, and 2 (12%) were cisgender female patients with congenital deformities. Among the 15 transgender patients, 12 (80%) underwent de novo surgeries and 3 (20%) underwent re-do surgeries. The mean age at the time of operation was 33.0 years, and the mean total operation time was 529 ± 128 minutes. The initial intraoperative mean vaginal depth was 15.2 ± 1.3 cm, and the 30-day readmission rate was 5.9% (1/17 cases). The mean follow-up duration was 24.8 months.Perioperative and postoperative outcomes suggest that 3D laparoscopic rectosigmoid colon vaginoplasty is a potentially acceptable, effective, and safe method for vaginal reconstruction.

Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.

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

INTRODUCTION

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Total phallic construction techniques in transgender men: an updated narrative review

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes

Introduction

There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men’s equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty.

Aim

To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction.

Methods

We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors.

Main Outcome Measures

Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula.

Results and Conclusion

A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique.

Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294

An abnormal clinical Allen's Test is not a contraindication for free radial forearm flap

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

[Gender reassignment surgery from male to female]

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

The Hidden Curriculum: Strategies for Preparing Residents for Practice

PURPOSE OF REVIEW

The goal of this paper was to identify areas of importance in modern urology education that are not currently emphasized in current urological curricula.

RECENT FINDINGS

We identified curricular deficits in robotic surgical simulation, transgender health, leadership, business management, and social media training. Few practicing urologists feel comfortable managing transgender-specific needs, and most training programs do not adequately address transgender health. Urology programs also do not sufficiently emphasize topics in leadership, business management, or appropriate social media usage. With respect to simulation, while it is currently included in the Accreditation Council for Graduate Medical Education (ACGME) program requirements, it is currently under-utilized for training in robotic surgery. It is important for urologists to receive adequate training for the modern practice landscape. Where knowledge gaps among early practicing urologists arise, programs should adapt their curricula to address them.

European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction"

BACKGROUND

There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice.

AIM

We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction.

METHODS

The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available.

OUTCOMES

The foci of the study are assessment and hormonal aspects of trans health care.

RESULTS

As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment.

CLINICAL IMPLICATIONS

This is an up-to-date ESSM position statement.

STRENGTHS & LIMITATIONS

These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited.

CONCLUSION

This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.

HPV-Related Neovaginal Squamous Cell Carcinoma Presenting as Lung Metastasis after Male-to-Female Gender Confirmation Surgery

There have been 4 reported cases of squamous cell carcinoma (SCC) of the neovagina in transgender women. In this report, we present another case of neovaginal SCC in a transgender woman, which was HPV-related, with lung metastasis as the initial presentation, and which was also complicated by her previous history of metastatic renal cell carcinoma. This unique case highlights the diagnostic challenges in these unusual scenarios. Through this report, we hope to address the benefits of multidisciplinary tumor board rounds, provision of detailed clinical information, and familiarization of the transgender anatomy within the pelvis in this group of patients. We also propose that transgender women undergo a continuous annual follow-up after postoperative follow-up is completed.

Localized disease: types of reconstruction/plastic surgery techniques after glans resurfacing/glansectomy/partial/total penectomy

PURPOSE OF REVIEW

The aim of this article is to provide an overview of the current literature specific to surgery for localized penile cancer including novel reconstructive techniques.Centralization of penile cancer services in many European countries and in particular the United Kingdom has resulted in an increased proportion of men undergoing organ-sparing surgery (OSS) rather than partial or total penectomy. In this review, we focus on reconstructive techniques following surgery for the primary penile tumour.

RECENT FINDINGS

The widespread adoption of penile preserving techniques in Europe and North America has shown both oncological safety as well as good cosmetic and functional outcomes. Recent evidence has suggested that narrower surgical margins do not affect overall cancer-specific survival or local recurrence rates. Therefore, excellent cosmetic and functional outcomes can be achieved using techniques such as glans resurfacing using split-thickness skin grafts, dorsal or ventral V-Y skin advancement and urethral centralization after partial penectomy. For patients requiring more radical surgery such as total penectomy, phallic reconstruction is a suitable option using free flaps or pedicled flaps.

SUMMARY

The use of OSS has transformed the lives of penile cancer patients who can avoid the significant clinical and psychological consequences of more radical surgical treatments. Careful case selection and preoperative counselling is advised prior to reconstructive techniques. Close postoperative clinical surveillance is necessary for early detection of local recurrence.

Time trends in referrals to child and adolescent gender identity services: a study in four Nordic countries and in the UK

Purpose: To explore whether the increase observed in referrals to child and adolescent gender identity services (GIDSs) has been similar in four Nordic countries and in the UK.Materials and methods: Numbers of referrals per year in 2011-2017 were obtained from all GIDS in Denmark, Finland, Norway, Sweden and the UK and related to population aged <18.Results: A similar pattern of increase in referral rates was observed across countries, resulting in comparable population adjusted rates in 2017. In children, male:female birth sex ratio was even; in adolescents, a preponderance of females (birth sex) was observed, particularly in Finland.Conclusions: The demand for GIDSs has evolved similarly across Nordic countries and the UK. The reasons for the increase are not known but increased awareness of gender identity issues, service availability, destigmatization as well as social and media influences may play a role.

Orchiectomy as Bridge or Alternative to Vaginoplasty

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

Gender affirming medical care of transgender youth

The number of gender diverse and transgender youth presenting for treatment are increasing. This is a vulnerable population with unique medical needs; it is essential that all pediatricians attain an adequate level of knowledge and comfort caring for these youth so that their health outcomes may be improved. There are several organizations which provide clinical practice guidelines for the treatment of transgender youth including the WPATH and the Endocrine Society and they recommend that certain eligibility criteria should be met prior to initiation of gender affirming hormones. Medical intervention for transgender youth can be broken down into stages based on pubertal development: pre-pubertal, pubertal and post-pubertal. Pre-pubertally no medical intervention is recommended. Once puberty has commenced, youth are eligible for puberty blockers; and post-pubertally, youth are eligible for feminizing and masculinizing hormone regimens. Treatment with gonadotropin releasing hormone agonists are used to block puberty. Their function is many-fold: to pause puberty so that the youth may explore their gender identity, to delay the development of (irreversible) secondary sex characteristics, and to obviate the need for future gender affirmation surgeries. Masculinizing hormone regimens consists of testosterone and feminizing hormone regimens consist of both estradiol as well as spironolactone. In short term studies gender affirming hormone treatment with both estradiol and testosterone has been found to be safe and improve mental health and quality of life outcomes; additional long term studies are needed to further elucidate the implications of gender affirming hormones on physical and mental health in transgender patients. There are a variety of surgeries that transgender individuals may desire in order to affirm their gender identity; it is important for providers to understand that desire for medical interventions is variable among persons and that a discussion about individual desires for surgical options is recommended.

Urethral lithiasis after phalloplasty

Female-to-male transsexual patient, 22 years old, with neophallus from radial forearm free flap (phalloplasty in March 2014), history of urethral fistula and urethral stricture 1 year later treated with surgical correction (fistulectomy) and suprapubic urinary diversion. Subsequently, he developed a new urethral stenosis located in the urethral anastomosis. Immediately proximal to the stenosis, there was a urethral dilatation (pseudodiverticulum) with a fibrous septum and several retracted stones. The stones were fragmented, the fibrous septum destroyed and the urethral stricture corrected, all with holmium laser. After 40 months of follow-up the patient shows satisfactory urinary flow with no signs of residual lithiasis or stricture.

A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty

OBJECTIVES

To assess surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty.

PATIENTS AND METHODS

Transgender men who underwent penile prosthesis implantation after phalloplasty between January 1989 and September 2018 were retrospectively identified. A chart study was performed recording patient demographics, perioperative complications, and reoperations.

RESULTS

A total of 32 patients were identified: 22 underwent free radial forearm flap, 5 anterolateral thigh, 4 anterolateral thigh/free radial forearm flap, and 1 fibular flap phalloplasty. The median age at prosthesis implantation was 36 (range 21-59) years, the mean BMI 25.9 ± 4.0 kg/m². At first implantation, 16 inflatable (AMS Dynaflex (n = 13), AMS Ambicor (n = 3)) and 16 malleable (Coloplast genesis (n = 14), AMS Spectra (n = 2)) prostheses were placed. Of these, 5 (16%) were removed/replaced because of infection, 2 (6%) because of leakage, 2 because of extrusion, 2 because of dislocation, 2 because of dysfunction, and 1 (3%) because of pain. The postoperative course was completely uneventful in 10 (31.3%) patients. Of all implanted prostheses, including revision procedures (n = 45), 21 (44%) were surgically replaced or removed.

CONCLUSION

Prosthesis explantation, replacement, or revision surgery occurs frequently after penile prosthesis implantation. Patients need to be well-informed preoperatively on these complication rates.

Gender Confirmation Surgery for the Endocrinologist

Endocrinologists are at the front line for providing gender-affirming care for transgender patients by managing hormone regiments before and after surgery. This article provides the endocrinologist with an overview of the surgical options for transgender and nonbinary patients considering gender confirmation surgery, including feminizing and masculinizing facial, chest, and genital reconstruction. Discussions of the impact of hormones on surgery, and vice versa, as well as information on surgical decision making are provided to help inform patient education via the endocrinologist.

Dermatologic Surgical Care for Transgender Individuals

BACKGROUND

Transgender individuals experience common and unique dermatologic concerns from severe acne associated with testosterone therapy in transmen to complications due to illicit silicone injections in transwomen. Currently, 2 survey studies and 4 reviews have addressed the dermatologic care of transgender individuals. However, none of them provide a focus on the dermatologic surgeon.

OBJECTIVE

To assess the dermatologic considerations in transgender individuals and the role of dermatologic surgeon in their care.

METHODS

The PubMed and MEDLINE databases were reviewed in June 2018 using keywords, such as transgender, procedures, hair removal, laser, and hormone therapy.

RESULTS

In total, 48 relevant publications addressing dermatologic care in transgender patients were reviewed. According to the literature, there are several critical dermatologic considerations in transgender patients, including hair growth and removal, acne vulgaris, facial procedures to masculinize and feminize the face, scar removal, and sexually transmitted infections.

CONCLUSION

As dermatologic surgeons have the privilege to improve the health care of transgender patients, they must understand the common and unique concerns of transgender individuals. Given the considerable spectrum of physical goals expressed by transmen and transwomen, individual patient preference must ultimately guide his/her/their dermatologic care.

Urethral Reconstruction in Anterolateral Thigh Flap Phalloplasty: A 93-Case Experience

BACKGROUND

Urethral reconstruction in anterolateral thigh flap phalloplasty cannot always be accomplished with one flap, and the ideal technique has not been established yet. In this article, the authors' experience with urethral reconstruction in 93 anterolateral thigh flap phalloplasties is reported.

METHODS

Ninety-three anterolateral thigh phalloplasties performed over 13 years at a single center were retrospectively reviewed to evaluate outcomes of the different urethral reconstruction techniques used: anterolateral thigh alone without urethral reconstruction (n = 7), tube-in-tube anterolateral thigh flap (n = 5), prelaminated anterolateral thigh flap with a skin graft (n = 8), anterolateral thigh flap combined with a free radial forearm flap (n = 29), anterolateral thigh flap combined with a pedicled superficial circumflex iliac artery perforator flap (n = 38), and anterolateral thigh flap combined with a skin flap from a previous phalloplasty (n = 6). Seventy-nine phalloplasties were performed for female-to-male sex reassignment surgery. The others were performed in male patients with severe penile insufficiency.

RESULTS

Urethral complication rates (fistulas and strictures) were as follows: tube-in-tube anterolateral thigh flap, 20 percent; prelaminated anterolateral thigh flap, 87.5 percent; free radial forearm flap urethra, 37.9 percent; superficial circumflex iliac artery perforator urethral reconstruction, 26.3 percent; and skin flap from previous phalloplasty, 16.7 percent.

CONCLUSIONS

When tube-in-tube urethra reconstruction is not possible (94.2 percent of cases), a skin flap such as the superficial circumflex iliac artery perforator flap or the radial forearm flap is used for urethral reconstruction in anterolateral thigh phalloplasties. Flap prelamination is a second choice that gives high stricture rates. If a penis is present, its skin should be used for urethral reconstruction and covered with an anterolateral thigh flap. With these techniques, 91.86 percent of patients are eventually able to void while standing.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Breast and Body Contouring for Transgender and Gender Nonconforming Individuals

Even after long-term hormone therapy, many transwomen still have challenges in the size and shape of their breasts and also of the contour of their trunk areas. Though distinct anthropomorphic differences in skeletal structure exist and pose limitations to an ideal result, considerable improvements can be obtained through breast augmentation and trunk feminization. There are challenges that are unique to the transfeminine chest and trunk, and important considerations for the priority of fat grafting to the buttocks and hips when grafted fat is in short supply.

MANAGEMENT OF ENDOCRINE DISEASE: Approach to the management of children and adolescents with Gender Dysphoria

Over the past 20 years, the care for transgender adolescents has developed throughout many countries following the "Dutch Approach" initiated in the 90's in pioneer countries as the Netherlands, United States and Canada, with increasing numbers of children and adolescents seeking care in transgender clinics. This medical approach has considerable positive impacts on the psychological outcomes of these adolescents and several studies have been recently published underlining the relative safety of such treatments. This paper reviews the current standards of care for transgender children and adolescents with particular emphasis on disparities among countries and short to medium-term outcomes. Finally it highlights ethical considerations regarding categorization of gender dysphoria, timing of treatment initiation, infertility, and how to deal with the long-term consequences.

Masculinizing Genital Gender Confirmation Surgery

INTRODUCTION

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity.

AIM

To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation.

METHODS

A review of relevant literature through May 2017 was performed via PubMed.

MAIN OUTCOME MEASURES

To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty.

RESULTS

A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications.

CONCLUSION

A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, et al. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

Gender-Affirming Surgery in Persons with Gender Dysphoria

The landscape of gender dysphoria has changed dramatically in recent years secondary to increased societal acceptance, legislative changes, and medical providers' increased awareness of the associated psychosocial burden associated with the diagnosis. National and global advocacy efforts, in conjunction with expanded third-party insurance coverage, have resulted in new health care opportunities for patients suffering from gender dysphoria. Delivering quality, streamlined health care to these patients requires a complex multidisciplinary approach, involving multiple medical and mental health disciplines, including plastic surgeons. To accommodate the expanding demand for gender-affirmation surgery, academic medical centers specializing in these procedures are gradually emerging. Advancing surgical techniques in the setting of rising patient demand encourage plastic surgeons to increasingly provide high-quality health care to this diverse patient population in an effort to optimize psychosocial functioning and minimize the burden of gender dysphoria. Although the current literature is replete with the evolving surgical and technical approaches to gender-affirming surgery, there remain critical gaps in the plastic surgery literature describing the delivery of comprehensive care to these patients. To address these gaps, the authors establish a framework that plastic surgeons can use to guide their management of patients with gender dysphoria to optimize surgical and psychosocial outcomes. First, the authors describe a timeline of events that have shaped present-day transgender medicine and characterize the current role of the plastic surgeon in the management of gender dysphoria. Subsequently, the authors discuss psychosocial and ethical considerations surrounding gender dysphoria. Finally, the authors discuss the future scope of transgender medicine.