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Christopher N, Ralph D, Lee WG. Anterolateral Thigh Flap Phalloplasty for Individuals Assigned Female at Birth. Eur Urol Focus 2023; 9:32-34. [PMID: 36621377 DOI: 10.1016/j.euf.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 12/16/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023]
Abstract
Anterolateral thigh flap phalloplasty is a suitable alternative for individuals assigned female at birth who do not want a visible donor site, but careful patient selection is essential to reduce the risk of complications.
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Affiliation(s)
- Nim Christopher
- Department of Urology, University College London Hospital, London, UK.
| | - David Ralph
- Department of Urology, University College London Hospital, London, UK
| | - Wai Gin Lee
- Department of Urology, University College London Hospital, London, UK
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de Rooij FPW, van der Sluis WB, Ronkes BL, Steensma TD, Al-Tamimi M, van Moorselaar RJA, Bouman MB, Pigot GLS. Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 24:487-498. [PMID: 37901060 PMCID: PMC10601502 DOI: 10.1080/26895269.2022.2110548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0-6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.
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Affiliation(s)
- Freek P. W. de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Wouter B. van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Brechje L. Ronkes
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Thomas D. Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Muhammed Al-Tamimi
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | | | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Garry L. S. Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
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Bonapace-Potvin M, Lorange E, Ma X, Medor MC, Bensimon É, Brassard P, Bélanger M. The Montréal Classification of urethral lengthening for phalloplasty in transmasculine patients-surgical techniques and urethral complications. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 24:461-468. [PMID: 37901062 PMCID: PMC10601514 DOI: 10.1080/26895269.2022.2104418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Introduction Phalloplasties are one of the most performed genital surgeries in the treatment of gender dysphoria for transmasculine patients. Urethral lengthening is an essential component of phalloplasties. Few techniques have been described for the creation of this pars fixa urethra. The purpose of this article is to present the Montréal Classification for pars fixa urethral lengthening, to detail the surgical techniques and to report on clinical outcomes. Materials and methods All patients undergoing phalloplasty from November 2016 to February 2019 were included in this study. Patient demographics, type of surgery and urological complications were recorded. Statistics were performed using student's T-test, Chi-squared test, Fisher's exact test and One-way ANOVA. Patients underwent either type 1, type 2, or type 3 urethral reconstruction. Results Of the 84 total patients, 45 underwent type 1 lengthening, 28 type 2, and 11 type 3. Eighteen and 33 patients underwent single-stage and two stage anastomosis of the pars fixa to the pars pendulans neourethra, respectively. Thirty-three patients have not had any additional surgeries to date. Post-operative urological complications for immediate anastomosis and two-stage anastomosis were reported in 77.7% and 18.2% of patients, respectively. Conclusions We propose a classification as well as a description of three types of urethral lengthening techniques. Over the last few years, we have shifted away from single-stage anastomosis and have adopted a two-stage anastomosis technique. Our experience allows us to classify urethral lengthening and to standardize care depending on patient characteristics, leading to excellent results.
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Affiliation(s)
- Michelle Bonapace-Potvin
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Elisabeth Lorange
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Xiya Ma
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Maria Cassandre Medor
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Éric Bensimon
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Pierre Brassard
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
| | - Maud Bélanger
- Plastic Surgery Department, Centre Métropolitain de Chirurgie, Montréal, Québec, Canada
- Université de Montréal, Montréal, Québec, Canada
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Lee WG, Christopher AN, Ralph DJ. Gender Affirmation Surgery, Transmasculine. Urol Clin North Am 2022; 49:453-465. [DOI: 10.1016/j.ucl.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Smith SM, Yuan N, Lee G, Stelmar J, Ray E, Garcia MM. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022; 10:100495. [PMID: 35255460 PMCID: PMC9023249 DOI: 10.1016/j.esxm.2022.100495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL). Aim To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL. Methods We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date. Outcomes Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries. Results All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57). Clinical Implications The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system. Strengths and Limitations Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time. Conclusion It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs. Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.
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Affiliation(s)
- Shannon M Smith
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute, Pasadena, CA, USA
| | - Grace Lee
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA
| | - Edward Ray
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; Cedars-Sinai Medical Center, Los Angeles, Division of Plastic Surgery, Los Angeles, CA, USA
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; University of California San Francisco, Department of Urology and Department of Anatomy, San Francisco, CA, USA.
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Melancon DM, Walton AB, Mundinger G, Benson C. Surgical Outcomes and Complications of Genital Gender Affirmation Surgery. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Neophallus Construction and Penile Prosthesis Implantation: Techniques and Complications. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Walton AB, Hellstrom WJG, Garcia MM. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021; 9:605-618. [PMID: 34493480 DOI: 10.1016/j.sxmr.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated. OBJECTIVES To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy. METHODS A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries). RESULTS The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or "watershed" procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes. CONCLUSION There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605-618.
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Affiliation(s)
- Alice B Walton
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA.
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Department of Urology, Los Angeles, CA, USA
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Abstract
BACKGROUND The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals. OBJECTIVE The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty. MATERIAL AND METHODS Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years. RESULTS Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%. CONCLUSION Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.
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Affiliation(s)
- M Sohn
- Urologische Klinik und Klinik für robotisch assistierte Urologie, Agaplesion Markus Krankenhaus, Wilhelm-Epstein-Str. 4, 60431, Frankfurt, Deutschland.
| | - U Rieger
- Klinik für Plastische, Ästhetische Chirurgie, Wiederherstellungs- und Handchirurgie, Agaplesion Markus Krankenhaus Frankfurt, Frankfurt, Deutschland
| | - S Morgenstern
- Urologische Klinik und Klinik für robotisch assistierte Urologie, Agaplesion Markus Krankenhaus, Wilhelm-Epstein-Str. 4, 60431, Frankfurt, Deutschland
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Mokken SE, Özer M, van de Grift TC, Pigot GL, Bouman MB, Mullender M. Evaluation of the Decision Aid for Genital Surgery in Transmen. J Sex Med 2020; 17:2067-2076. [PMID: 32753281 DOI: 10.1016/j.jsxm.2020.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/18/2020] [Accepted: 06/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Multiple options of genital gender-affirming surgery are available to transmen. The transman should be able to weigh these options based on the outcomes, risks, and consequences that are most important to him. For this reason, a decision aid for genital surgery in transmen (DA-GST) was developed. It aims to support the transman in making thoughtful choices among treatment options and facilitate shared decision-making between the healthcare professionals and the transindividual. AIM The aim of this study was to evaluate the newly developed DA-GST. METHODS This was a cross-sectional study using mixed methods. Transmen considering to undergo genital surgery were eligible to partake in the study. The questionnaires used in this study were developed by adapting the validated Dutch translation of the "Decisional Conflict Scale," the "Measures of Informed Choice," and the "Ottawa Preparation for Decision-Making Scale." Qualitative interviews were conducted querying their subjective experience with the DA-GST. The data from the questionnaires were statistically analyzed, and the data from the interviews were thematically analyzed. OUTCOMES The main outcome measures were decisional conflict and decisional confidence measured via self-report items and qualitative data regarding the use of the DA-GST via interviews. RESULTS In total, 51 transmen participated in the questionnaires study, 99 questionnaires were analyzed, and 15 interviews were conducted. Although confident in their decision, most transmen felt responsible to collect the necessary information themselves. The ability to go through the decision aid independently aided the decision-making process by providing information and highlighting their subjective priorities. Suggested additions are pictures of postoperational outcomes and personal statements from experienced transmen. CLINICAL TRANSLATION The DA-GST could be implemented as an integral part of transgender health care. Clinicians could take the individual personal values into account and use it to accurately tailor their consult. This would ultimately improve the doctor-patient relationship and decrease decisional regret by enhancing effective shared decision-making. STRENGTHS & LIMITATIONS This mixed-method design study confirmed the use of the DA-GST while taking a broad range of decisional factors into account. Limitations include the absence of a baseline analysis and the limited power for the comparison of treatment groups. CONCLUSIONS This study suggests that the DA-GST helped transmen feel more prepared for their personal consult with the surgeon, reduced decisional conflict, and increased their decisional confidence. Mokken SE, Özer M, van de Grift TC, et al. Evaluation of the Decision Aid for Genital Surgery in Transmen. J Sex Med 2020;17:2067-2076.
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Affiliation(s)
- Sterre E Mokken
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
| | - Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Garry L Pigot
- Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Department of Urology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Gender Surgery Amsterdam, Amsterdam, The Netherlands
| | - Margriet Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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