Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women

Management of vaginoplasty canal complications

PURPOSE OF THE REVIEW

Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques.

RECENT FINDINGS

Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options.

SUMMARY

Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.

Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes

Gender-affirming care is treatment that recognizes and affirms the gender identity of transgender and gender-diverse (TGD) individuals. Though not all TGD people choose to surgically transition, gender-affirming surgeries (GAS) are an important part of many TGD people's transition. GAS can include a wide array of procedures aimed at aligning an individual's physical characteristics and gender identity. This review describes the most common procedures considered to be GAS, detailing important relevant considerations for each procedure. These include transfeminine procedures (i.e., breast augmentation, penile inversion vaginoplasty, orchiectomy, tracheal shave, and facial feminization); transmasculine procedures (i.e., chest masculinization, hysterectomy, phalloplasty, and metoidioplasty); and other procedures (i.e., fertility preservation and hair removal). Patient outcomes and the legal landscape for GAS are also discussed to contextualize these procedures within largest discourses surrounding gender-affirming care.

Global and Latest Hotspots of Female Genital Plastic Surgery in the Past 20 Years: A Bibliometric and Visualized Review

BACKGROUND

An increasing number of surgical and nonsurgical interventions are available in the field of female genital plastic surgery. The rate of female genital plastic surgery has increased by nearly 220 percent over the past 5 years. Despite several studies on the topic, no relevant bibliometric analysis has been conducted.

METHODS

We searched the Web of Science Core Collection for articles related to female genital plastic surgery. CiteSpace 6.1.R2 (Drexel University, USA) and VOSviewer 1.6.10.0 (Leiden University, the Netherlands) were used, and national distribution, institutions, journals, authors, and key words were analyzed and calculated.

RESULTS

From 2003 to 2022, 1299 papers in the field of female genital plastic surgery were retrieved. There were more articles produced in the United States, and there were also two institutions in the Netherlands that were highly productive. A wide and close relationship has been established between researchers and institutions conducting female genital plastic surgery. Professor Bouman MB published the most articles on female genital plastic surgery in the Journal of Sexual Medicine. Female genital plastic surgery dominated the top 10 references with the highest local citation score. There were four clusters of key words with the most citations, and the most recently trending key words were "vaginal agenesis," "transgender," and "congenital adrenal hyperplasia."

CONCLUSIONS

The purpose of this article is to provide a summary of the current research status focusing on female genital plastic surgery. It is hoped that more efforts will be made to promote the development of female genital plastic surgery in the future.

Rectal Injury During Penile Inversion Vaginoplasty

OBJECTIVE

To evaluate the incidence, management, and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center.

METHODS

We performed a retrospective review of preoperative, intraoperative and post-operative findings of all patients with RI during GAV from January 2016 to September 2022. Descriptive statistics were calculated using Microsoft Excel.

RESULTS

RI occurred in 9 of 1011 primary GAV and colorectal surgery (CRS) consulted in 5 cases, which included sigmoidoscopy with an air leak test in 4 and with temporary bowel diversion in 2. Of the 9, 6 proceeded with full-depth GAV, and 3 were converted to minimal-depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 patients with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full-depth GAV developed vaginal stenosis postoperatively.

CONCLUSIONS

RI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full-depth GAV. It is reasonable to complete the full-depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Evaluation of Bi-layer Silk Fibroin Grafts for Inlay Vaginoplasty in a Rat Model

BACKGROUND

Autologous tissues derived from bowel, buccal mucosa and skin are primarily used to repair or replace diseased vaginal segments as well as create neovaginas for male-to-female transgenders. These grafts are often limited by scarce tissue supply, donor site morbidity and post-operative complications. Bi-layer silk fibroin (BLSF) biomaterials represent potential alternatives for vaginoplasty given their structural strength and elasticity, low immunogenicity, and processing flexibility. The goals of the current study were to assess the potential of acellular BLSF scaffolds for vaginal tissue regeneration in respect to conventional small intestinal submucosal (SIS) matrices in a rat model of vaginoplasty.

METHODS

Inlay vaginoplasty was performed with BLSF and SIS scaffolds (N = 21 per graft) in adult female rats for up to 2 months of implantation. Nonsurgical controls (N = 4) were investigated in parallel. Outcome analyses included histologic, immunohistochemical and histomorphometric evaluations of wound healing patterns; µ-computed tomography (CT) of vaginal continuity; and breeding assessments.

RESULTS

Animals in both scaffold cohorts exhibited 100% survival rates with no severe post-operative complications. At 2 months post-op, µ-CT analysis revealed normal vaginal anatomy and continuity in both graft groups similar to controls. In parallel, BLSF and SIS grafts also induced comparable constructive remodeling patterns and were histologically equivalent in their ability to support formation of vascularized vaginal neotissues with native tissue architecture, however with significantly less smooth muscle content. Vaginal tissues reconstructed with both implants were capable of supporting copulation, pregnancy and similar amounts of live births.

CONCLUSIONS

BLSF biomaterials represent potential "off-the-shelf" candidates for vaginoplasty.

Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

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.

Gynecologic Care of Transgender and Gender-Diverse People

The visibility and care of transgender and gender-diverse (TGD) people is an important component of gynecology. Transmasculine individuals require routine gynecologic and preventative care. Guidelines can be extrapolated from the cisgender female population, and using affirming language, acknowledging the challenges patients face with pelvic examination, and discussing individual gynecologic needs are important components of care. Transmasculine patients may seek hysterectomy for gender affirmation from gynecologists. Unique nuances exist in the considerations needed when preparing for hysterectomy, and patients should be thoroughly counseled with regard to concurrent vaginectomy or oophorectomy or both. Transfeminine patients often seek gynecologic care after gender-affirming surgery, and, unlike transmasculine patients, the gynecology visit is often very affirming and welcomed by patients. Becoming familiar with the perioperative and delayed postoperative care needs of transfeminine patients undergoing vaginoplasty can help improve the care provided by gynecologists. In general, prospective data on the outcomes of gender-affirming care in large cohorts of TGD patients are limited, but the body of literature is growing. Gynecologists remain central to the care of TGD patients, the academic advancement of the field of transgender health, and the advocacy needed to support this vulnerable patient population.

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021

Introduction:  In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods:  We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results:  We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion:  In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

Creation of a decellularized vaginal matrix from healthy human vaginal tissue for potential vagina reconstruction: experimental studies

BACKGROUND

When a disorder causes the absence of a healthy, full-size vagina, various neovaginal creation methods are available. Sometimes dilation or stretching of the vaginal cavity is sufficient, but intestinal or dermal flap tissue is generally required. However, different inherent tissue properties cause complications. Therefore, a lost body part should be replaced with a similar material. The use of organ-specific acellular vaginal tissue carries great potential, as its similar architecture and matrix composition make it suitable for vaginal regeneration.

METHODS

The authors developed an optimized protocol for decellularization of healthy human vaginal tissue. Resected colpectomy tissue from 12 healthy transgender patients was used. Successful decellularization was confirmed by applying acellular criteria from in-vivo remodeling reports. Suitability as a tissue-mimicking scaffold for vaginal reconstruction was determined by visible structural features, biocompatibility during stretching, and the presence of visible collagen, elastin, laminin, and fibronectin.

RESULTS

Histological examination confirmed the preservation of structural features, and minimal cellular residue was seen during fluorescence microscopy, DNA and RNA quantification, and fragment length examination. Biomechanical testing showed decreased peak load (55%, P <0.05), strain at rupture (23%, P <0.01), and ultimate tensile stress (55%, P <0.05) after decellularization, while the elastic modulus (68%) did not decrease significantly. Fluorescence microscopy revealed preserved Fibronectin-I/II/III and Laminin-I/II, while Collagen-I and Ficolin-2B were decreased but mostly retained.

CONCLUSIONS

The absence of cellular residue, moderately altered biomechanical extracellular matrix properties, and mostly preserved structural proteins appear to make our decellularized human vaginal matrix a suitable tissue-mimicking scaffold for vagina transplantation when tissue survival through vascularization and innervation are accomplished in the future.

The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series

Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47 ± 13.5 years, and the body mass index mean was 31 ± 4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89 ± 1.76 and the time to first revision mean was 15.89 ± 14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48 ± 8.66 months. A mean of 6.77 ± 5.35 cm was gained after the Integra® revision (4.92 ± 4.1 cm before versus 12.54 ± 3.07 cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34 ± 4.65 cm. Overall, the depth gain mean was 7.48 ± 5.77 cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.

[Vulvoplasty after gender-affirmating genital surgery]

Functional and aesthetic results after vaginoplasty in sexual reassignment surgery have improved in recent years. Improved surgical techniques, well-established expert teams and a growing demand for and interest in this type of surgery are some of the reasons for these results. However, there is a growing demand for genital cosmetic surgery, not only among cis women, but also among trans women. The main shortcomings in results are therefore presented and listed. The aesthetic revision surgery techniques specifically indicated are described. Labiaplasty and clitoridoplasty appear to be the two main requests for secondary surgery following trans vaginoplasty.

[Description of a vaginoplasty technique using a peritoneal flap harvested by coelioscopic approach for male-to-female gender affirmations (MtF)]

AIM

The aim of this article is to provide a comprehensive description of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery, particularly in cases of insufficient depth after penile inversion vaginoplasty.

RESULTS

Our short-term results reveal that the peritoneal flap vaginoplasty, adapted from the Davydov procedure, has shown significant potential for improving functional and aesthetic outcomes, including the creation of a self-lubricating neovagina. However, the complexity of the procedure requires advanced surgical expertise and appropriate postoperative care. Patient selection also plays an essential role as not all patients are ideal candidates for this procedure.

CONCLUSION

Despite its promises, the widespread adoption of the peritoneal flap technique in male-to-female (MtF) gender affirmation surgery is hindered by several challenges, including the need for specialized training and potential postoperative complications. Thus, this technique should be considered as an alternative or complement to traditional methods, depending on individual patient factors. Further research and extensive clinical trials are needed to better understand its potential and limitations in order to enhance the arsenal of effective surgical options for MtF gender affirmation surgery.

Improved sexuality and satisfactory lubrication after genital affirmation surgery using penile skin inversion in transgender women: A satisfaction study

INTRODUCTION

Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.

AIMS

Our aim was to evaluate transgender women's sexual function and lubrication after vaginoplasty by penile skin inversion.

METHODS

We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.

RESULTS

The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.

CONCLUSION

This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion's GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.

Gynecological concerns and vaginal practices and exposures among transfeminine individuals who have undergone vaginoplasty

BACKGROUND

Vaginoplasty is a gender-affirming surgery that is medically necessary for some transfeminine individuals. Little research exists describing vaginal health after the initial recovery from surgery, and evidence-based guidelines for vaginal care practices are unavailable.

AIM

The study sought to describe self-reported gynecological concerns and vaginal care practices among transfeminine persons who have undergone vaginoplasty.

METHODS

A total of 60 transfeminine participants 18+ years of age, living in Canada, and who had undergone vaginoplasty at least 1 year prior were recruited through social media, community groups, healthcare provider referrals, and study recontact. Participants completed a cross-sectional, online questionnaire detailing demographics, gynecological concerns, and genital practices and exposures. Hierarchical clustering was used to group participants based on behavioral practices and exposures. Associations between clusters and gynecological concerns were assessed.

OUTCOMES

Outcomes included self-reported gynecological concerns within the past year, recent vulvar or vaginal symptoms (past 30 days), and behavioral practices/exposures, including douching with varied products and dilating.

RESULTS

Participants reported a variety of concerns in the past year, including urinary tract infection (13%) and internal hair regrowth (23%). More than half (57%) had experienced at least 1 recent vaginal symptom, most commonly malodor (27%) and vaginal bleeding (21%). Of participants, 48% were dilating weekly and 52% reported douching in the past 30 days. Four distinct clusters of vaginal practices/exposures were identified: limited exposures; dilating, no douching; dilating and douching; and diverse exposures. No significant associations between cluster membership and gynecological concerns were identified, though cluster membership was significantly associated with surgical center (P = .03). Open-text write-ins provided descriptions of symptoms and symptom management strategies.

CLINICAL IMPLICATIONS

The results provide insight for clinicians on common patient-reported gynecological concerns and current vaginal care practices and exposures, including symptom management strategies.

STRENGTHS AND LIMITATIONS

This was the first study to investigate vaginal health and genital practices/exposures among a community sample of transfeminine individuals. As participants self-enrolled for a detailed survey and swab collection, individuals experiencing concerns were likely overrepresented.

CONCLUSION

Transfeminine individuals reported a range of gynecological concerns outside of the surgical healing period. Genital practices/exposures varied across clusters, but no clear associations between clusters and symptoms were identified; instead, practice/exposure clusters were dependent on where the individual underwent vaginoplasty. There is a need for evidence to inform diagnostics, treatments, and vaginal care guidelines to support vaginal health.

New Solutions for Old Problems: How Reproductive Tissue Engineering Has Been Revolutionizing Reproductive Medicine

Acquired disorders and congenital defects of the male and female reproductive systems can have profound impacts on patients, causing sexual and endocrine dysfunction and infertility, as well as psychosocial consequences that affect their self-esteem, identity, sexuality, and relationships. Reproductive tissue engineering (REPROTEN) is a promising approach to restore fertility and improve the quality of life of patients with reproductive disorders by developing, replacing, or regenerating cells, tissues, and organs from the reproductive and urinary systems. In this review, we explore the latest advancements in REPROTEN techniques and their applications for addressing degenerative conditions in male and female reproductive organs. We discuss current research and clinical outcomes and highlight the potential of 3D constructs utilizing biomaterials such as scaffolds, cells, and biologically active molecules. Our review offers a comprehensive guide for researchers and clinicians, providing insights into how to reestablish reproductive tissue structure and function using innovative surgical approaches and biomaterials. We highlight the benefits of REPROTEN for patients, including preservation of fertility and hormonal production, reconstruction of uterine and cervical structures, and restoration of sexual and urinary functions. Despite significant progress, REPROTEN still faces ethical and technical challenges that need to be addressed. Our review underscores the importance of continued research in this field to advance the development of effective and safe REPROTEN approaches for patients with reproductive disorders.

Operative Management of Complications Following Intestinal Vaginoplasty: A Case Series and Systematic Review

OBJECTIVE

To describe the authors' experience with surgical management of complications following intestinal vaginoplasty and review the literature on incidence of complications following gender-affirming intestinal vaginoplasty.

METHODS

Retrospective chart review identified patients presenting with complications following prior intestinal vaginoplasty requiring operative management. Charts were analyzed for medical history, preoperative exam and imaging, intraoperative technique, and long-term outcomes. Systematic literature review was performed to identify primary research on complications following gender-affirming intestinal vaginoplasty.

RESULTS

Four patients presented to the senior authors' clinic requiring operative intervention for complications following intestinal vaginoplasty, all of whom underwent surgical revision. Complications included vaginal stenosis (2 patients, 50%), vaginal false passage (1 patient, 25%), and diversion colitis (1 patient, 25%). Postoperatively all patients were able to dilate successfully to a depth of at least 15 cm. Systematic review identified 10 studies meeting inclusion criteria. There were 215 complications reported across 654 vaginoplasties (33% overall complication rate). Average return to operating room rate was 18%. The most common complications were stenosis (11%), mucorrhea (7%), vaginal prolapse (6%), and malodor (5%). Six intestinal vaginoplasty segments developed vascular compromise leading to flap loss. There were 2 reported mortalities.

CONCLUSION

Intestinal vaginoplasty is associated with a range of complications including vaginal stenosis, mucorrhea, and vaginal prolapse. Intra-abdominal complications, including diversion colitis, anastomotic bowel leak, and intra-abdominal abscess can occur many years after surgery, be life-threatening and require prompt diagnosis and management.

Sexual health and treatment-related sexual dysfunction in sexual and gender minorities with prostate cancer

Prostate cancer treatment has substantial effects on sexual health and function. Sexual function is a vital aspect of human health and a critical component of cancer survivorship, and understanding the potential effects of different treatment modalities on sexual health is crucial. Existing research has extensively described the effects of treatment on male erectile tissues necessary for heterosexual intercourse; however, evidence regarding their effects on sexual health and function in sexual and gender minority populations is minimal. These groups include sexual minority - gay and bisexual - men, and transgender women or trans feminine people in general. Such unique effects in these groups might include altered sexual function in relation to receptive anal and neovaginal intercourse and changes to patients' role-in-sex. Sexual dysfunctions following prostate cancer treatment affecting quality of life in sexual minority men include climacturia, anejaculation, decreased penile length, erectile dysfunction, and problematic receptive anal intercourse, including anodyspareunia and altered pleasurable sensation. Notably, clinical trials investigating sexual outcomes after prostate cancer treatment do not collect sexual orientation and gender identity demographic data or outcomes specific to members of these populations, which perpetuates the uncertainty regarding optimal management. Providing clinicians with a solid evidence base is essential to communicate recommendations and tailor interventions for sexual and gender minority patients with prostate cancer.

Gender-affirming Vaginoplasty and Vulvoplasty: An Initial Experience

OBJECTIVE

To describe the initial outcomes of a new multidisciplinary gender-affirming surgery (GAS) program comprised of plastic and urologic surgeons.

METHODS

We retrospectively examined consecutive patients who underwent gender-affirming vaginoplasty or vulvoplasty between April 2018 and May 2021. We used logistic regression modeling to analyze associations between preoperative risk factors and postoperative complications.

RESULTS

Between April 2018 and May 2021, 77 genital GAS (gender-affirming surgery) procedures were performed at our institution (56 vaginoplasties, 21 vulvoplasties). All surgeries were performed in combination with urology and plastic surgery primarily using the perineal penile inversion technique. Mean patient age was 39.6 years, and mean BMI was 26.2 (Table 1a). The most common pre-existing conditions were hypertension and depression, with nearly 14% of patients reporting a previous suicide attempt. The complication rate for vaginoplasty was 53.7% within the first 30 days (Table 4). The most common complications were yeast infection (14.8%) and hematoma (9.3%). For vulvoplasty, the 30-day complication rate was 57.1%, with urinary tract infection (14.3%) and granulation tissue (9.5%) being the most common. 88.1% and 91.7% of the complications were Clavien-Dindo grade I or II for vaginoplasties and vulvoplasties, respectively. No association was found between preoperative patient factors and postoperative complications. Revision surgeries were performed for 38.9% of vaginoplasty patients during the study period, most commonly including urethral revision (29.6%), labia majoraplasty (20.4%), and labia minoraplasty (14.8%).

CONCLUSION

Collaboration between urology and plastic surgery is a safe and effective means to establish a GAS program.

Emergency Medicine Considerations in the Transgender Patient

Transgender patients are at high risk for poor health outcomes and many harbor fear of healthcare settings secondary to prior discrimination, perceived sensationalism, clinician unfamiliarity, and unwanted exams. It is essential to approach transgender patients without judgement and with empathy. Asking open ended questions with explanation as to why your questions are pertinent to their specific care will help create rapport and trust. Through a basic working knowledge of terminology, types of hormone therapy, non-surgical techniques, garments, and surgical procedures typically encountered by such patients, and their respective potential side effects and complications, clinicians can provide quality care to transgender patients.

Vaginal self-lubrication following peritoneal, penile inversion, and colonic gender-affirming vaginoplasty: a physiologic, anatomic, and histologic review

INTRODUCTION

Vaginal self-lubrication is central to the sexual satisfaction and healthy genitourinary function of patients who have undergone gender-affirming vaginoplasty (GAV). Secretory capacities of different neovaginal lining tissues have been variably described in the literature, with little evidence-based consensus on their success in providing a functionally self-lubricating neovagina. We review the existing neovaginal lubrication data and the anatomy, histology, and physiology of penile and scrotal skin, colon, and peritoneum to better characterize their capacity to be functionally self-lubricating when used as neovaginal lining.

OBJECTIVES

The study sought to review and compare the merits of penile and scrotal skin grafts, spatulated urethra, colon, and peritoneal flaps to produce functional lubrication analogous to that of the natal vagina in the setting of GAV.

METHODS

We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Medline, EMBASE, ClinicalTrials.gov, and the Cochrane Library databases were searched for peer-reviewed studies published prior to December 12, 2022, that (1) included data specific to transfeminine individuals; (2) were full-text randomized controlled studies, case reports, case series, retrospective cohort studies, prospective cohort studies, qualitative studies, and cross-sectional studies; and (3) included specific discussion of vaginal lubrication or fluid secretion following GAV utilizing penile skin, colonic tissue, or peritoneum.

RESULTS

We identified 580 studies, of which 28 met our inclusion criteria. Data on neovaginal lubrication were limited to qualitative clinician observations, patient-reported outcomes, and satisfaction measures. No studies quantifying neovaginal secretions were identified for any GAV graft or flap technique. Anatomically, penile and scrotal skin have no self-lubricating potential, though penile inversion vaginoplasty may produce some sexually responsive secretory fluid when urethral tissue is incorporated and lubricating genitourinary accessory glands are retained. Colonic and peritoneal tissues both have secretory capacity, but fluid production by these tissues is continuous, nonresponsive to sexual arousal, and likely inappropriate in volume, and so may not meet the needs or expectations of some patients. The impact of surgical tissue translocation on their innate secretory function has not been documented.

CONCLUSIONS

None of penile/scrotal skin, colon, or peritoneum provides functional neovaginal lubrication comparable to that of the adult natal vagina. Each tissue has limitations, particularly with respect to inappropriate volume and/or chronicity of secretions. The existing evidence does not support recommending one GAV technique over others based on lubrication outcomes. Finally, difficulty distinguishing between physiologic and pathologic neovaginal fluid secretion may confound the assessment of neovaginal self-lubrication, as many pathologies of the neovagina present with symptomatic discharge.

Genital gender-affirming surgery for transgender women

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.

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.

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database

IMPORTANCE

Gender-affirming orchiectomy may be performed in isolation, as a bridge to vaginoplasty, or concurrently with vaginoplasty for transgender and nonbinary persons, although there is a paucity of data on immediate postoperative outcomes on the various procedural approaches.

OBJECTIVE

The aim of the study is to compare 30-day surgical outcomes after gender-affirming orchiectomy and vaginoplasty as separate and isolated procedures.

STUDY DESIGN

This was a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database to compare surgical outcomes of orchiectomy alone and vaginoplasty alone to concurrent orchiectomy with vaginoplasty using bivariate and adjusted multivariable regression statistics.

RESULTS

Concurrent orchiectomy and vaginoplasty were associated with greater 30-day surgical complications compared with orchiectomy alone (15.4% vs 2.9%, P < 0.01) and similar odds of 30-day surgical complications compared with vaginoplasty alone (15.4% vs 11.1%, P = 0.15). On multivariable logistic regression analysis, compared with orchiectomy alone, concurrent orchiectomy and vaginoplasty were associated with higher increased odds of 30-day surgical complications (adjusted odds ratio, 6.48; 95% confidence interval, 2.83-14.86) as well as vaginoplasty alone (adjusted odds ratio 4.30; 95% confidence interval, 1.85-10.00).

CONCLUSIONS

This study highlights the perioperative outcomes for isolated versus concurrent gender-affirming orchiectomy and vaginoplasty, demonstrating lower morbidity for orchiectomy alone and similar morbidity for vaginoplasty alone when compared with concurrent procedures. These data will aid health care providers in preoperative counseling and surgical planning for gender-affirming genital surgery, particularly for patients considering concurrent versus staged orchiectomy and vaginoplasty.

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic

IMPORTANCE

Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery.

OBJECTIVE

To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables.

RESULTS

The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%).

CONCLUSIONS AND RELEVANCE

Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

Postoperative adverse events following gender-affirming vaginoplasty: an American College of Surgeons National Surgical Quality Improvement Program study

BACKGROUND

As a part of gender-affirming care, many transgender women undergo vaginoplasty surgery, which is increasingly being performed in the United States. There are considerable knowledge gaps about adverse events associated with vaginoplasty as most published articles report single-center results.

OBJECTIVE

This study aimed to describe severe and overall 30-day adverse events after gender-affirming vaginoplasty using a large multicenter database.

STUDY DESIGN

This was a retrospective cohort study of transgender women who underwent vaginoplasty between 2011 and 2019 using the American College of Surgeons National Surgical Quality Improvement Program database. Cases were initially identified by diagnosis codes for gender identity disorders and procedure codes for male-to-female vaginoplasty. Adverse events at 30 days were identified, including unplanned reoperation or readmission, blood transfusion, wound dehiscence, surgical site infections, thromboembolic disease, sepsis, cerebrovascular or cardiac events, and urinary tract infection. Surgical procedures were further stratified by Clavien-Dindo grade, a standardized classification system for registering surgical complications. A score of 0 is given if there is no adverse event, whereas scores of 1 and 2 refer to deviations from the normal postoperative course, which may include additional pharmacologic treatment, bedside-managed wound complications, and blood transfusions. Clavien-Dindo grades of 3 to 4 include surgical interventions or life-threatening complications requiring intensive care unit management. A Clavien-Dindo grade of 5 is given for any complication resulting in death.

RESULTS

A total of 488 cases were eligible for inclusion in this study. The mean age of the cohort was 37.5 years, and race distribution was as follows: 71.1% White, 15.2% Black, 5.5% Asian or Pacific Islander, and 8.2% other. Of the cohort, 18.6% were Hispanic. Surgeries were performed by plastic surgeons (87.9%), urologists (8.6%), gynecologists (1.8%), and other specialists (1.6%). Concurrent nongenital surgery was performed in 17% of cases. The median operative time for all cases was 271 minutes (interquartile range, 214-344). There was no reported death in the 30-day period (Clavien-Dindo grade 5), and 27 cases (5.5%) had a Clavien-Dindo grade of 3 to 4. On multivariate analysis, body mass index and higher American Society of Anesthesiologists class were associated with higher odds of having a Clavien-Dindo grade of 3 to 4 (adjusted odds ratios, 2.9 [95% confidence interval, 1.32-4.21; P=.01] and 1.23 [95% confidence interval, 0.56-2.57; P=.05], respectively). Wound dehiscence, superficial surgical site infection, or deep surgical site infection occurred in 46 cases (9.0%). The readmission rate was 4.3% (n=21). Several preoperative factors had higher odds of readmission: body mass index (adjusted odds ratio, 9.81; 95% confidence interval, 1.77-22.13; P=.005), higher American Society of Anesthesiologists class (adjusted odds ratio, 3.23; 95% confidence interval, 1.23-9.03; P=.003), diabetes mellitus (adjusted odds ratio, 5.39; 95% confidence interval, 1.42-20.45; P=.006), and hypertension (adjusted odds ratio, 3.63; 95% confidence interval, 1.26-10.47; P=.01). The reoperation rate was 4.7% (n=23), with no significant patient factor associated with this complication. Of the reoperations, 68.2% of cases were due to wound problems, vaginal bleeding, or hematoma.

CONCLUSION

In transgender women undergoing vaginoplasty for gender affirmation, severe postoperative complications were rare, occurring in 1 of 20 patients. Most patients experienced minor complications or no complication after surgery.

Cosmetic Revision Surgeries after Transfeminine Vaginoplasty

BACKGROUND

Vaginoplasty is the most frequent genital gender-affirming surgery. Although both functional and aesthetic outcomes after transfeminine vaginoplasty have improved over the years, cosmetic revision surgeries demand after transfeminine vaginoplasty appears to be increasing and requires updated knowledge.

METHODS

All patients who underwent vulvar cosmetic revision surgeries at our institution following transfeminine vaginoplasty from January 2014 to April  2022 were studied. The prevalence, topography and surgical techniques of cosmetic revision surgeries after transfeminine genital gender-affirming surgery were examined using clinical charts review and statistical analysis.

RESULTS

During the study period, 354 patients underwent gender-affirming vaginoplasty at our single institution (212 penile inversion vaginoplasty, 122 colovaginoplasty and 20 penile inversion vaginoplasty with scrotal skin graft patients). Forty out of these 354 patients (11.29%) required cosmetic revision surgery after transfeminine vaginoplasty; additionally, 44 patients with vaginoplasty performed at other centres also underwent vulvar cosmetic revision surgery at our clinic during the study period. From all performed cosmetic revision surgeries, most of them (31.42%) were labia corrections, followed by clitoris (23.26%) repair surgeries. Mons Venus (10.20%), urethral meatus (9.38%), spongiosus tissue remnants (8.57%) and introitus (6.53%) revisions followed in frequency. Corrections of peri-inguinal scars (5.30%), anterior commissure (2.84%) and inferior fourchette (2.42%) were less prevalent. No differences were found among the different studied vaginoplasty techniques regarding cosmetic revision surgery prevalence or topography following transfeminine vaginoplasty (p < 0.05).

CONCLUSIONS

Cosmetic revision surgeries after transfeminine vaginoplasty are frequent. In our large and long-term cohort study, labiaplasty followed by clitoroplasty were found as the most required cosmetic revision surgical procedures. Further multicentre, prospective and controlled studies are necessary to improve cosmetic outcomes and scientific evidence after transfeminine vaginoplasty.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcome measures reported following feminizing genital gender affirmation surgery for transgender women and gender diverse individuals: A systematic review

Background

Feminizing genital gender affirmation surgery (fgGAS) may be an essential adjunct in the care of some transgender women and gender diverse individuals with gender incongruence. However, the comparison of different techniques of fgGAS may be confounded by variable outcome reporting and the use of inconsistent outcomes in the literature. This systematic review provides the most in-depth examination of fgGAS studies to date, and summarizes all reported outcomes, definitions, and the times when outcomes were assessed following these surgical interventions. Aims/Methods: This work intends to quantify the levels of outcome variability and definition heterogeneity in this expanding field and provides guidance on outcome reporting for future study authors. Candidate studies for this systematic review were sourced via an electronic, multi-database literature search. All primary, clinical research studies of fgGAS were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction to document the outcomes, definitions, and times of outcome assessment following fgGAS.

Results

After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on nonspecific ranges of follow-up dates. "Attainment of orgasm", "Neovaginal stenosis", and "Neovaginal depth/length" were among the most commonly reported outcomes. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general.

Discussion

The results demonstrate a need for clear outcomes, agreed definitions, and times of outcome assessment following fgGAS in transgender women and gender diverse individuals. The adoption of a consistent set of outcomes and definitions reported by all future studies of fgGAS (a Core Outcome Set) will aid in improving treatment comparisons in this patient group. This review is the first step in that process.

Sexual Function and Quality of Life in Brazilian Transgender Women Following Gender-Affirming Surgery: A Cross-Sectional Study

This cross-sectional and descriptive study aimed to evaluate the sexual function, urinary function, and quality of life of 26 Brazilian trans women who have undergone gender-affirming surgery (GAS) using the gold standard technique (penile inversion vaginoplasty) in the Gender Identity Transdisciplinary Program at Hospital de Clínicas de Porto Alegre, Brazil, between March 2016 and July 2017. The Female Sexual Function Index, the SF-36 Health Survey, and the International Consultation on Incontinence Questionnaire-Short Form were used. Regarding their surgical results, 84.6% of the women said they were satisfied, 73.1% were sexually functional, and 15.4% reported urinary incontinence not associated with surgery. Participants also reported a good quality of life, despite low scores of pain and physical vitality. Transgender women in our sample reported a good quality of life and sexual function after GAS. Further studies are required to improve the psychosexual wellbeing of this specific population.

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.

Robotic Peritoneal Flap vs. Perineal Penile Inversion Techniques for Gender-Affirming Vaginoplasty

PURPOSE OF REVIEW

To discuss perineal and robotic approaches to gender-affirming vaginoplasty.

RECENT FINDINGS

The Davydov peritoneal vaginoplasty has its origins in neovaginal reconstruction for vaginal agenesis. It has been adapted as a robotic-assisted laparoscopic procedure and provides an alternative to perineal canal dissection in gender-affirming vaginoplasty. Both techniques represent variations of penile inversion vaginoplasty with successful outcomes and overall low rates of major complications reported in the literature. However, there are differing advantages and considerations to each approach. A perineal approach has been the gold standard to gender-affirming vaginoplasty for many decades. Robotic peritoneal gender-affirming vaginoplasty (RPGAV) is an emerging alternative, with potential advantages including less reliance on extragenital skin grafts in individuals with minimal genital tissue, especially among patients presenting with pubertal suppression, and safer dissection in revision vaginoplasty for stenosis of the proximal neovaginal canal. Additional risks of RPGAV include those associated with robotic abdominal surgeries.

Comparison of Permanent Hair Removal Procedures before Gender-Affirming Vaginoplasty: Why We Should Consider Laser Hair Removal as a First-Line Treatment for Patients Who Meet Criteria

Introduction

Permanent genital hair removal is required before gender-affirming vaginoplasty to prevent hair-related complications. No previous studies have directly compared the relative efficacy, costs, and patient experiences with laser hair removal (LHR) vs electrolysis treatments. Food and Drug Administration (FDA) oversight of medical devices is poorly understood and commonly misrepresented, adversely affecting patient care.

Aim

This study compares treatment outcomes of electrolysis and LHR for genital hair removal and investigates FDA regulation of electrolysis and LHR devices.

Methods

Penile-inversion vaginoplasty and shallow-depth vaginoplasty patients completed surveys about their preoperative hair removal, including procedure type, number/frequency of sessions, cost, and discomfort. Publicly available FDA-review documents and databases were reviewed.

Main Outcomes Measure

Compared to electrolysis, LHR was associated with greater efficiency, decreased cost, decreased pain, and improved patient satisfaction.

Results

Of 52 total (44 full-depth and 8 shallow-depth) vaginoplasty patients, 22 of 52 underwent electrolysis only, 15 of 52 underwent laser only, and 15 of 52 used both techniques. Compared to patients that underwent LHR only, patients that underwent only electrolysis required a significantly greater number of treatment sessions (mean 24.3 electrolysis vs 8.1 LHR sessions, P < .01) and more frequent sessions (every 2.4 weeks for electrolysis vs 5.3 weeks for LHR, P < .01) to complete treatment (defined as absence of re-growth over 2 months). Electrolysis sessions were significantly longer than LHR sessions (152 minutes vs 26 minutes, P < .01). Total treatment costs for electrolysis ($5,161) were significantly greater than for laser ($981, P < .01). Electrolysis was associated with greater pain and significantly increased need for pretreatment analgesia, which further contributed to higher net costs for treatment with electrolysis vs laser. Many LHR and electrolysis devices have been FDA-cleared for safety, but the FDA does not assess or compare clinical efficacy or efficiency.

Clinical Implications

For patients with dark-pigmented hair, providers should consider LHR as the first-line treatment option for preoperative hair removal before gender-affirming vaginoplasty.

Strength and Limitations

This is the first study to compare electrolysis and LHR for genital hair removal. The discussion addresses FDA review/oversight of devices, which is commonly misrepresented. Limitations include the survey format for data collection.

Conclusion

When compared with electrolysis, LHR showed greater treatment efficiency (shorter and fewer treatment sessions to complete treatment), less pain, greater tolerability, and lower total cost. Our data suggests that, for patients with dark genital hair, providers should consider recommending laser as the first-line treatment for permanent genital hair removal before vaginoplasty.

Yuan N, Feldman A, Chin P, et al. Comparison of Permanent Hair Removal Procedures before Gender-Affirming Vaginoplasty: Why We Should Consider Laser Hair Removal as a First-Line Treatment for Patients Who Meet Criteria. Sex Med 2022;10:100545.

Achieving Correct Axis and Good Depth in Gender Affirming Vaginoplasties by Penile-Perineoscrotal Flap Vaginoplasty

Objectives Vaginoplasty as a part of feminizing genitoplasty (FG) in transwomen helps alleviate gender dysphoria and improves mental health, sexual and psychosocial functioning, and quality of life in these individuals. Penile inversion technique (PSFV) remains the gold standard procedure for FG with least morbidity but has inherent limitations often resulting in inadequate depth and incorrect (posteroinferior) vaginal axis, precluding sexual intercourse.

Material and Methods Over the past 27 years, the senior author has refined his technique considerably incorporating several modifications penile perineo-scrotal flap vaginoplasty (PPSFV) to overcome the limitations in PSFV. Most of these modifications were in place by March 2015. Out of 630 primary FGs, retrospective review of all PPSFV with minimum 6 months follow-up operated during the period March 2015 to July 2020 was done for intra and postoperative complications.

Results There were 183 patients who underwent PPSFV during the study period. Average follow-up was 31 (6–62) months. There were no cases of injury to bladder, rectum, urethral stenosis, or neovaginal prolapse. Average operative time was 4 hours and eight (4.37%) patients required blood transfusion. The vaginal depth was 13 to 14 cm or more in 159 (86.88%), 10 to 12 cm in 17 (9.29%), and 7.5 to 9 cm in seven (3.82%) patients. Ten (5.46%) patients complained of intravaginal hair growth. Touch up procedures in the form of anterior commissure and labia plasty were required in 13 (7.10%) patients. All (100%) patients had good clitoral sensitivity and preserved posterosuperior vaginal axis. One-hundred thirty nine (75.96%) patients were able to have satisfactory penetrative sexual intercourse, while 39 (21.31%) had not attempted intercourse and five (2.73%) complained of poor sexual experience on account of inadequate vaginal dimensions.

Conclusion PPSFV addresses the limitations in PSFV and results in good vaginal depth and posterosuperior axis, which facilitates penetrative sexual intercourse, at the same time, avoiding potential complications of procedures such as intestinal vaginoplasties.

Gender-Affirming Hormone Therapy: What the Head and Neck Surgeon Should Know

The use of gender-affirming hormone therapy is found almost universally in transgendered and nonbinary patients presenting for gender-affirming surgical procedures of the face, neck, and voice. Surgeons caring for this population need to be aware of the effects, reasonable expectations, and limitations as well as potential perioperative risks of both continuation and discontinuation of hormone therapy.

External Genital Revisions after Gender-Affirming Penile Inversion Vaginoplasty: Surgical Assessment, Techniques, and Outcomes

BACKGROUND

Following gender-affirming penile inversion vaginoplasty or vulvoplasty, patients may seek vulvar revision procedures for a variety of common aesthetic and functional concerns. These indications for revision and accompanying techniques are not well-described in the literature.

METHODS

Patients who underwent vulvar revision surgery at the authors' institution were identified, and patient demographics, surgical indications, operative details, and complications were described. Common complaints requiring external genital revision were sorted into four categories: clitoral, labial, introital, and urethral.

RESULTS

Thirty-five patients with a history of vaginoplasty underwent vulvar revision between May of 2017 and December of 2019. The mean age at surgical correction was 38.9 years. Ten patients (28.6 percent) had undergone prior secondary procedures (range, 1 to 3). Mean follow-up after revision surgery was 10.7 ± 8.7 months (range, 0 to 30.6 months). The majority of patients underwent concurrent revisions in multiple "categories". Labial aesthetic concerns were most common (n = 27, 77.1 percent), followed by clitoral (n = 20, 57.1 percent), urologic (n = 17, 48.6 percent), and introital complaints (n = 12, 34.3 percent). Twelve patients (34.3 percent) had canal stenosis requiring concurrent robot-assisted canal revision with peritoneal flaps. Complications included labial abscess (n = 1) and deep vein thrombosis (n = 1). Three patients (8.6 percent) underwent subsequent external genital revisions. Management approaches and surgical techniques for each of these common revision categories are provided.

CONCLUSION

As more individuals seek vaginoplasty and vulvoplasty, surgeons must be prepared to address a range of common aesthetic and functional complaints requiring vulvar revision.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Common Revisions after Penile Inversion Vaginoplasty: Techniques and Clinical Outcomes

SUMMARY

Up to one-third of patients are reported to undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty. The most commonly performed revisions are posterior introital web release, clitoroplasty, labiaplasty, and urethroplasty. To illustrate effective strategies for each of these revisions, this Video Plus article reviews the case of a 32-year-old transgender woman undergoing revision surgery to correct functionally limiting posterior introital webbing and to improve clitoral and labial appearance. Intraoperative steps and postoperative considerations are detailed in the accompanying videos.

Utilisation of a rectal hydrogel spacer for vaginoplasty in a cadaver model

Background:

A major source of complications in vaginoplasty results from injury to the rectum during dissection of the neovaginal cavity. The SpaceOAR™ System is a rectal hydrogel spacer mostly used as a safety technique during prostate cancer treatment.

Objective:

This was a feasibility study performed in a single cadaveric perineum.Methods: Prior to standard cavity dissection, SpaceOAR was injected transperineally into the Denonvilliers’ fascia under guidance of transrectal ultrasound. Dissection of the neovaginal cavity with spacer gel was qualitatively assessed to be significantly easier, allowing for a blunt and quick approach.

Results:

A satisfactory vaginal length was achieved rapidly and safely.

Conclusions:

We show that transgender vaginoplasty using this adaptation of SpaceOAR is technically feasible in the cadaveric model and may reduce the incidence of rectal injury or rectovaginal fistula during neovaginal cavity creation. Future experimental endeavours should focus on the reproducibility of this approach and characterise the degree of rectal protection provided.

Level of evidence:

Not applicable

Chronic Kidney Disease in the Transgender, Nonbinary, or Gender Diverse Person

Nephrologists are increasingly providing care to transgender, nonbinary, and gender diverse (TNBGD) individuals with chronic kidney disease. This narrative review discusses the care of TNBGD individuals from a nephrology perspective. TNBGD individuals are under-represented in the nephrology literature. TNBGD individuals are at an increased risk of adverse outcomes compared with the cisgender population including mental health, cardiovascular disease, malignancy, sexually transmitted infections, and mortality. Gender-affirming hormone therapy (GAHT) with estradiol in transfeminine individuals potentially increases the risk of venous thromboembolism and cardiovascular disease. GAHT with testosterone in transmasculine individuals potentially increases the risk of erythrocytosis and requires careful monitoring. GAHT modifies body composition and lean muscle mass, which in turn influence creatinine generation and excretion, which may impact the performance of estimated glomerular filtration rate (GFR) equations and the estimation of 24-hour urine values from spot urine albumin/protein to creatinine ratios. There are limited studies regarding TNBGD individuals with chronic kidney disease. Additional research is needed to evaluate the effects of GAHT on GFR and biomarkers of kidney function and the performance of the estimated GFR equation in TNBGD populations.

Preoperative Body Image Factors Are Associated with Complications after Breast Reconstruction

BACKGROUND

Psychological factors are broadly understood to contribute to overall health, but their contribution to wound healing is less well defined. Limited data exist on the association of preoperative psychological factors such as body image and postoperative complications. The present study analyzed the association between preoperative body image factors and postoperative complications following breast reconstruction.

METHODS

This was a prospective cohort study of 302 breast cancer patients undergoing breast reconstruction from 2011 to 2015. All patients completed the BREAST-Q; demographics, surgical details, and postoperative complications were recorded. The association of body image factors by means of the BREAST-Q and postoperative complications was analyzed.

RESULTS

On univariate analysis, patients who reported lower preoperative satisfaction with how they appeared in the mirror unclothed, or felt less self-confident or attractive, were significantly more likely to develop an infection postoperatively. Preoperative satisfaction scores were not associated with complications when analyzed in a multivariate fashion. On binomial logistic regression analysis, after controlling for age, body mass index, reconstruction technique, and use of radiotherapy, patients who reported less preoperative satisfaction with how comfortably bras fit or how they appeared in a mirror unclothed were at an increased risk for delayed wound healing.

CONCLUSIONS

Patients with lower preoperative body satisfaction were found to have an increased incidence of infections and delayed wound healing. Although postoperative outcomes are multifactorial, the data suggest that baseline psychological factors such as body image may play a role in postoperative outcomes. Broader use of prehabilitative therapies, targeted at psychosocial factors, may warrant further investigation to optimize postoperative outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Penile Flap Inversion Vaginoplasty in Transgender Women: Contemporary Morbidity and Learning-Curve Analysis From a High-Volume Reconstructive Center

Objectives

Numbers of PIV are rising. The aim of this study is to analyze the surgical learning-curve (LC) on the grounds of perioperative complications.

Patients and Methods

108 PIVs, performed by a single surgeon between 2015 and 2018 have been analyzed. Learning-curve analysis was based on three factors: operating time, vaginal depth and complications.

Results

The median FU was 6.3 months. Median age at surgery was 36 years, median time of hormone treatment was 36 months. The median CI was 0.3 and the median BMI was 25 kg/cm3. Median CCI® was 8.08. 40.7% of the patients developed short-term complications, more than half of which were Clavien I. Overall only 1.9% had Clavien IIIb complications. There were no Clavien IV or V complications. 17.6% of patients had wound infections, 13% wound dehiscence, 9.3% introitus strictures, 13.9% suffered from atrophy of the neovagina, i.e. loss of depth or width, and 8.3% from meatus urethrae strictures. Duration of hormonal therapy, BMI and CI had no impact on surgical outcome. Age had a significant impact on CCI®, as younger patients had a higher risk for complications. Use of scrotal skin and surgeries performed had a significant influence. LC analysis via CUSUM analysis showed that after 32 surgeries, the PIV is performed safely.

Conclusion

The PIV is a safe GAS-technique, associated with minor complications leading to low rates of revision surgery. Younger age, the use of scrotal skin and surgeon's experience has significant impact on complications. Duration of hormonal therapy, circumcision and BMI has no impact on complications.

The Effect of Gender-Affirming Medical Care on the Vaginal and Neovaginal Microbiomes of Transgender and Gender-Diverse People

Transgender and gender diverse individuals may seek gender-affirming medical care, such as hormone therapy or surgery, to produce primary and/or secondary sex characteristics that are more congruent with their gender. Gender-affirming medical care for transmasculine individuals can include testosterone therapy, which suppresses circulating estrogen and can lead to changes in the vaginal epithelium that are reminiscent of the post-menopausal period in cisgender females. Among transfeminine individuals, gender-affirming medical care can include vaginoplasty, which is the surgical creation of a vulva and neovaginal canal, commonly using penile and scrotal skin. The effect of gender-affirming medical care on the vagina of transmasculine individuals and on the neovagina of transfeminine individuals is poorly characterized. This review summarizes what is known of the epithelium and local microbiota of the testosterone-exposed vagina and the neovagina. We focus on potential pathogens and determinants of gynecological health and identify key knowledge gaps for future research.

Vaginoplasty in Male to Female transgenders: single center experience and a narrative review

Vaginoplasty in Male to Female (M to F) transgenders is a challenging procedure, often accompanied by numerous complications. Nowadays the most commonly used technique involves inverted penile and scrotal flaps. In this paper the data of 47 M to F patients who have undergone sex affirmation surgery at the Department of Urology of the University of Trieste, Italy since 2014, using our modified vaginoplasty technique with the "Y" shaped urethral flap, have been retrospectively reviewed. Moreover, a non structured review of the literature with regards to short and long-term complications of vaginoplasty has been provided. All patients followed a standardized neo-vaginal dilation protocol. At follow up 2 patients were lost. At 12 months 88.9% of patients (40/45) were able to reach climax, 75.6% (34/45) were having neo-vaginal intercourses and median neo-vaginal depth was 11 cm (IQR 9-13.25): no statistically significant decrease in depth was found at follow up. Only one patient was dissatisfied with aesthetic appearance at 12 months. Our technique provided excellent cosmetic and functional results without severe complications (Clavien-Dindo ≥ 3). The review of the literature has highlighted the need to standardize a postoperative follow up protocol with particular regard to postoperative dilatation regimen. Further, larger randomized clinical trials are pending to draw definitive conclusions.