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Jung H, Chen ML, Wassersug R, Mukherjee S, Kumar S, Mankowski P, Genoway K, Kavanagh A. Urethroplasty Outcomes for Pars Fixa Urethral Strictures Following Gender-affirming Phalloplasty and Metoidioplasty: A Retrospective Study. Urology 2023; 182:89-94. [PMID: 37467808 DOI: 10.1016/j.urology.2023.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/03/2023] [Accepted: 07/05/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE To evaluate outcomes of three urethroplasty techniques for pars fixa (PF) urethral strictures and provide a treatment algorithm based on stricture characteristics. The PF is an essential anatomic region of the neourethra created in gender-affirming phalloplasty and metoidioplasty. Urethral strictures in this region present a reparative challenge given its unique anatomy and vascularization. METHODS A total of 41 urethroplasties performed on 41 patients between March 2018 and June 2021 were reviewed at two surgical centers. A Heineke-Mikulicz (HM) repair was done for strictures under 20 mm when the proximal and distal urethral segments were mobile and supported a tension-free closure. Substitution urethroplasty with ventral onlay buccal mucosal graft was utilized for strictures under 40 mm not suitable for HM repair. Complex or long (≥40 mm) strictures were treated by two-stage Johansen urethroplasty. Success of each surgical approach was defined by a minimum of 12-month follow-up without the need for a repeat intervention. RESULTS Mean follow-up was 30.2 months (range: 12.4-52.0 months). Mean stricture length was 16.9 mm (range: 2-55 mm). Most strictures (46%) were located at the distal PF. HM urethroplasty had a success rate of 44% (n = 16). Substitution urethroplasty had a success rate of 92% (n = 13). Two-stage Johansen urethroplasty had a success rate of 75% (n = 12). CONCLUSION The success rates of PF urethral stricture repair ranged from 44% to 92% depending on the surgical approach, and the best reparative procedure depends on stricture length, severity, and local tissue mobility.
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Affiliation(s)
- Hoyoung Jung
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | | | - Richard Wassersug
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Smita Mukherjee
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Sahil Kumar
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Peter Mankowski
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krista Genoway
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Kavanagh
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
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Elyaguov J, Isakov R, Nikolavsky D. Evaluation and management of urologic complications following transmasculine genital reconstructive surgery. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Jason Elyaguov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Roman Isakov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Dmitriy Nikolavsky
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
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de Rooij FPW, Falcone M, Waterschoot M, Pizzuto G, Bouman MB, Gontero P, Lumen N, Pigot GLS. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022; 19:377-384. [PMID: 34974989 DOI: 10.1016/j.jsxm.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Several treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes. AIM The aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty. METHODS A multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers. OUTCOMES The primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively. RESULTS Of 96 transmen included in this study with a urethral complication, 44 (46%) experienced a urethral fistula, 31 (32%) a urethral stricture, and 21 (22%) both complications simultaneously. The recurrence-free rate for urethral strictures following endoscopic management (ie, urethral dilation or direct visual internal urethrotomy) was 61% after 1, 50% after 2, and 43% after 3 years, compared to 82% following open treatment options after 1, 2, and 3 years (P = .002). Open treatment options were Heineke-Mikulicz procedure (7/9, 78% success), excision and primary anastomosis (3/3, 100%), 2-stage without graft (9/9, 100%), pedicled flap urethroplasty (1/1, 100%), and buccal mucosa graft urethroplasty (2/4 [50%] single-stage, 1/1 [100%] 2-stage). The recurrence-free rate for small urethral fistulas located at the pendulous urethra was 79% after 1, and 72% after 2 and 3 years, compared to 45% after 1, and 41% after 2 and 3 years for large fistulas, generally located at the urethral anastomoses of the fixed urethra. Treatment options for urethral fistulas were fistulectomy (26/48, 54%), fistulectomy & (redo) colpectomy (7/11, 64%), buccal mucosa graft urethroplasty (1/1, 100%), and retubularization of the urethral plate (3/4, 75%). A colpectomy before or during reoperation of a urethral fistula at the proximal urethral anastomosis showed higher success rates compared to without a colpectomy (7/11 [64%] vs 2/13 [15%] respectively, P = .03). CLINICAL IMPLICATIONS This study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen. STRENGTHS & LIMITATIONS Strengths were the relatively large sample size and the overview of multiple treatment options available. Limitations were the heterogeneity of the cohort, underexposure of some surgical modalities, and absence of patient-reported outcomes. CONCLUSION Open surgical techniques show better long-term outcomes in the management of urethral strictures compared to endoscopic options, and a colpectomy is beneficial before or during urethral fistula repair at the proximal urethral anastomosis. de Rooij FPW, Falcone M, Waterschoot M, et al. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022;19:377-384.
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Affiliation(s)
- Freek P W de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands.
| | - Marco Falcone
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | | | - Giuseppe Pizzuto
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Paolo Gontero
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Garry L S Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
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Treatment of Urethral Strictures in Transmasculine Patients. J Clin Med 2021; 10:jcm10173912. [PMID: 34501359 PMCID: PMC8432136 DOI: 10.3390/jcm10173912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/02/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.
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de Rooij FPW, Peters FRM, Ronkes BL, van der Sluis WB, Al-Tamimi M, van Moorselaar RJA, Bouman MB, Pigot GLS. Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men. BJU Int 2021; 129:63-71. [PMID: 34046987 PMCID: PMC9291467 DOI: 10.1111/bju.15500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/30/2021] [Accepted: 05/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.
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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 at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Femke R M Peters
- Department of Urology, 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 at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Wouter B van der Sluis
- Center of Expertise on Gender Dysphoria at the 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
| | - Muhammed Al-Tamimi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - R Jeroen A van Moorselaar
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria at the 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 at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
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Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2021; 18:974-981. [PMID: 33896759 DOI: 10.1016/j.jsxm.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL). AIM The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up. METHODS A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. OUTCOMES Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction. RESULTS Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P < .001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P < .001) and with voiding (P = .02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P = .48 and P = .95 respectively). CLINICAL IMPLICATIONS Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. STRENGTHS & LIMITATIONS Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey. CONCLUSION No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974-981.
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Hamidian Jahromi A, Boyd LC, Schechter L. An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know. World J Surg 2021; 45:3511-3521. [PMID: 33796924 DOI: 10.1007/s00268-021-06084-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.
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Affiliation(s)
| | - Louisa C Boyd
- Division of Plastic and Reconstructive Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Loren Schechter
- Department of Plastic Surgery, Rush University Medical Center, Chicago, USA. .,The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois At Chicago, Chicago, USA.
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