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Dominoni M, Gritti A, Pano MR, Sandullo L, Papa R, Torella M, Gardella B. Which Is the Best Surgical Approach for Female-to-Male Sexual Reassignment? A Systematic Review of Hysterectomy and Salpingo-Oophorectomy Options from the Gynecological Perspective. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1095. [PMID: 39064524 PMCID: PMC11278962 DOI: 10.3390/medicina60071095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/22/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024]
Abstract
Background and Objectives: Transgender people are defined as individuals whose gender identity does not entirely match their sex assigned at birth. Gender surgery typically represents the conclusive and irreversible step in the therapeutic process, especially for the impact on the reproductive sphere. The increased awareness of gender dysphoria and the expanding array of medical and surgical options, including minimally invasive techniques, contribute to the gradual increase in the social impact of transgender surgery. There are several surgical techniques for "gender assignment", such as vaginal, laparotomic, laparoscopic, and robotic, and the novel approach of vaginal natural orifice transluminal endoscopic surgery to perform a hysterectomy and bilateral salpingo-oophorectomy (BSO). The purpose of this review is to assess the various surgical approaches (hysterectomy and salpingo-oophorectomy) for gender reassignment in order to determine the best option in clinical practice for the female-to-male population in terms of surgical outcomes such as operative time, surgical complication, hospital discharge, postoperative pain, and bleeding. Materials and Methods: This systematic review includes studies from 2007 to 2024. Special consideration was given to articles documenting the characteristics and management of female-to-male reassignment surgery. Finally, eight papers were included in this review. Results: The literature analysis considered surgical techniques ranging from traditional surgery to innovative methods like vaginal natural orifice transluminal endoscopic surgery and robotic-assisted laparoscopic hysterectomy. Vaginal natural orifice transluminal endoscopic surgery and the robotic approach offer potential benefits such as reduced postoperative pain and shorter hospital stays. While vaginal natural orifice transluminal endoscopic surgery may encounter challenges due to narrow access and smaller vaginal dimensions, robotic single-site hysterectomy may face instrument conflict. Conclusions: The conventional laparoscopic approach remains widely used, demonstrating safety and efficacy. Overall, this review underscores the evolving landscape of surgical techniques for gender affirmation and emphasizes the necessity for personalized approaches to meet the specific needs of transgender patients.
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Affiliation(s)
- Mattia Dominoni
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (A.G.); (M.R.P.); (B.G.)
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Andrea Gritti
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (A.G.); (M.R.P.); (B.G.)
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Martina Rita Pano
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (A.G.); (M.R.P.); (B.G.)
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
| | - Lucia Sandullo
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy; (L.S.); (R.P.); (M.T.)
| | - Rossella Papa
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy; (L.S.); (R.P.); (M.T.)
| | - Marco Torella
- Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, 81100 Naples, Italy; (L.S.); (R.P.); (M.T.)
| | - Barbara Gardella
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy; (A.G.); (M.R.P.); (B.G.)
- Department of Obstetrics and Gynecology, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy
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Donmez EE, Elci E, Elci G. Total vNOTES hysterectomy versus conventional total laparoscopic hysterectomy in virgin transgender men. MINIM INVASIV THER 2024; 33:163-170. [PMID: 38353421 DOI: 10.1080/13645706.2024.2309960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 01/08/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND AND AIM Comparison of the applicability, safety, and surgical outcomes of total vaginal NOTES hysterectomy (TVNH) using natural orifice transluminal endoscopic surgery, which is considered a natural orifice surgery for hysterectomy with bilateral salpingo-oophorectomy (HBSO) in virgin transgender men, with conventional total laparoscopic hysterectomy (TLH). MATERIAL AND METHODS A retrospective cohort study was conducted between 2019 and 2021. The results of transgender male individuals who underwent HBSO operations using TVNH (n = 21) were compared with those who underwent operations using TLH (n = 62). RESULTS TVNH was performed in 21 individuals, while TLH was performed in 62 individuals. Patients in the TVNH approach group had a longer operation duration than those in the TLH group (p = .001). Patients in the TVNH group experienced less pain at two hours (5 ± 1.56), six hours (4 ± 1.57), 12 h (2 ± 0.91), and 24 h (1 ± 0.62) postoperatively (p = .001). The postoperative hospitalization duration was shorter in the TVNH group (1.6 ± 1.01) than in the TLH group (2.9 ± 0.5) (p = .001). CONCLUSIONS For the HBSO operation of female-to-male transgender individuals, TVNH, which is completely endoscopically performed, can be preferred and safely conducted as an alternative surgical method to conventional laparoscopy.
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Affiliation(s)
- Emin Erhan Donmez
- Department of Gynecology Oncology, Koc University Faculty of Medicine, Istanbul, Turkey
| | - Erkan Elci
- Department of Obstetrics and Gynecology, Istinye University Faculty of Medicine, Istanbul, Turkey
| | - Gulhan Elci
- Department of Obstetrics and Gynecology, University of Healty Sciences Sancaktepe Training and Research Hospital, Istanbul, Turkey
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Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022; 10:636-647. [PMID: 37051961 DOI: 10.1016/j.sxmr.2022.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/20/2022] [Accepted: 03/23/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The transmasculine and gender diverse (TMGD) spectrum includes transgender men and non-binary individuals whose sex was assigned female at birth. Many TMGD patients pursue treatment with exogenous testosterone to acquire masculine characteristics. Some may choose to undergo gynecological gender-affirming surgery for total hysterectomy with bilateral salpingectomy and/or bilateral oophorectomy (TH/BSO). The decision to retain or remove the ovaries in the setting of chronic testosterone therapy has implications on reproductive health, oncologic risk, endocrine management, cardiovascular health, bone density and neurocognitive status. However, there is limited evidence on the long-term outcomes from this intervention. OBJECTIVE Here we review health-related outcomes of oophorectomy in TMGD population treated with chronic testosterone therapy in order to guide clinicians and patients in the decision to retain or remove their ovaries. METHOD We conducted a systematic literature review following PRISMA guidelines. MEDLINE, EMBASE, ClinicalTrials.gov, and Cochrane Library databases were searched for peer-reviewed studies published prior to October 26, 2021 that: (i) included transgender men/TMGD individuals in the study populations; (ii) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (iii) specifically discussed ovaries, hysterectomy, oophorectomy, ovariectomy, or gonadectomy. RESULTS We identified 469 studies, of which 39 met our inclusion criteria for this review. Three studies discussed fertility outcomes, 11 assessed histopathological changes to the ovaries, 6 discussed ovarian oncological outcomes, 8 addressed endocrine considerations, 3 discussed cardiovascular health outcomes, and 8 discussed bone density. No studies were found that examined surgical outcomes or neurocognitive changes. CONCLUSION There is little information to guide TMGD individuals who are considering TH/BSO versus TH/BS with ovarian retention. Our review suggests that there is limited evidence to suggest that fertility preservation is successful after TH/BS with ovarian retention. Current evidence does not support regular reduction in testosterone dosing following oophorectomy. Estradiol levels are likely higher in individuals that choose ovarian retention, but this has not been clearly demonstrated. Although bone mineral density decreases following oophorectomy, data demonstrating an increased fracture risk are lacking. No studies have described the specific impact on neurocognitive function, or changes in operative complications. Further research evaluating long-term health outcomes of oophorectomy for TMGD individuals treated with chronic testosterone therapy is warranted to provide comprehensive, evidence-based healthcare to this patient population. Sahil Kumar, Smita Mukherjee, Cormac O'Dwyer, et al. Health Outcomes Associated With Having an Oophorectomy Versus Retaining One's Ovaries for Transmasculine and Gender Diverse Individuals Treated With Testosterone Therapy: A Systematic Review. Sex Med Rev 2022;XX:XXX-XXX.
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Ultra-minimally invasive surgery in gynecological patients: a review of the literature. Updates Surg 2022; 74:843-855. [PMID: 35366181 PMCID: PMC9213331 DOI: 10.1007/s13304-022-01248-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 01/21/2022] [Indexed: 01/18/2023]
Abstract
In the last decade, Ultra-minimally invasive surgery (UMIS) including both minilaparoscopic (MH) and percutaneous (PH) endoscopic surgery achieved widespread use around the world. Despite UMIS has been reported as safe and feasible surgical procedure, most of the available data are drawn from retrospective studies, with a limited number of cases and heterogeneous surgical procedures included in the analysis. This literature review aimed to analyze the most methodologically valid studies concerning major gynecological surgeries performed in UMIS. A literature review was performed double blind from January to April 2021. The keywords ‘minilaparoscopy’; ‘ultra minimally invasive surgery’; ‘3 mm’; ‘percutaneous’; and ‘Hysterectomy’ were selected in Pubmed, Medscape, Scopus, and Google scholar search engines. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines were followed for the drafting of the systematic review. The systematic literature research provided 298 studies, of which 9 fell within the inclusion criteria. Two hundred ninety-six total patients were included, 148 for both PH and MH groups. Median age (48 years), BMI (24 kg/m2), OT (90 min), EBL (50 ml), time to discharge (1 day), self scar evaluation (10/10), and VAS (3/10) were reported. The most frequent intraoperative complication in both the PH and MH groups was surgical bleeding. The UMIS approaches were feasible and safe even for complex gynecological procedures. Operative times and complications were superimposable to the “classical” minimally invasive approaches reported in the literature. The reported results apply only to experienced surgeons.
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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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Fagundes Ferreira F, La Rosa VL, Nepomuceno Benites M, Marques Cerentini T, Machado de Souza C, Caruso S, da Silva Klahr P, Telles da Rosa LH, Della Corte L, Viana da Rosa P. Sexual function evaluation in Brazilian women accessing a public health service: an observational cross-sectional study. SEXUAL AND RELATIONSHIP THERAPY 2020. [DOI: 10.1080/14681994.2020.1817365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | | | | | | | | | - Salvatore Caruso
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
- Research Group for Sexology, University of Catania, Catania, Italy
| | | | | | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples "Federico II", Naples, Italy
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Laganà AS, Garzon S, Raffaelli R, Gullo G, Franchi M. Robotic Surgery in Female-To-Male Transition: A Possible Way for Further Improvement. J INVEST SURG 2019; 34:651-652. [DOI: 10.1080/08941939.2019.1686092] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Antonio Simone Laganà
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Simone Garzon
- Department of Obstetrics and Gynecology, “Filippo Del Ponte” Hospital, University of Insubria, Varese, Italy
| | - Ricciarda Raffaelli
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, AOOR Villa Sofia Cervello, IVF Public Center, Palermo, Italy
| | - Massimo Franchi
- Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy
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