1
|
Kjölhede A, Huss F, Kratz G. A Study on Symptoms of Pelvic Floor Dysfunction in Assigned Female at Birth Patients Diagnosed with Gender Dysphoria Undergoing Vaginectomy. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5950. [PMID: 38957715 PMCID: PMC11219149 DOI: 10.1097/gox.0000000000005950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 05/09/2024] [Indexed: 07/04/2024]
Abstract
Background A person diagnosed with gender dysphoria who was assigned female at birth (AFAB) may request a vaginectomy as part of gender-affirming treatment. The aim of this study was to investigate the impact of vaginectomy on symptoms of pelvic floor dysfunction (PFD). Methods This is a cohort study on patient-reported symptoms of PFD in patients who were AFAB, diagnosed with gender dysphoria, and undergoing vaginectomy in a single surgical center. Patients responded to a questionnaire preoperatively and 1 year postoperatively. The questionnaire consisted of 33 questions, including a modified short-form version of the Pelvic Floor Distress Inventory (PFDI-20). Results Twenty-three consecutive patients were included in the study and 20 patients (87%) completed the 1-year follow-up. The preoperative median PFDI-20 score was 24 (0-114) compared with 32 (0-168) at the 1-year follow-up (P = 0.07). Patients who had previously undergone neophallus construction with a metoidioplasty (n = 15) had no significant change between the preoperative and the 1-year postoperative PFDI-20 score [median 17.5 (0-114) and 27.5 (0-145) (P = 0.65), respectively]; whereas those with a groin flap phalloplasty (n = 5) had a significant increase in reported symptoms [median 37 (10-95) and 124 (45-168), respectively (P = 0.04)]. Conclusions Overall, vaginectomy could be performed without any major impact on symptoms of PFD. However, this seemed to be true mainly for patients with previous metoidioplasty, whereas patients with previous groin flap phalloplasty reported worsening of symptoms.
Collapse
Affiliation(s)
- Anders Kjölhede
- From the Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University Hospital, Linköping, Sweden
| | - Fredrik Huss
- Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Gunnar Kratz
- From the Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Plastic Surgery, Hand Surgery, and Burns, Linköping University Hospital, Linköping, Sweden
| |
Collapse
|
2
|
Rezaei SJ, Miller AS, Miranda N, Ganor O. Gender-affirming surgeries for transgender and gender diverse individuals and associated health outcomes. BEHAVIORAL SCIENCES & THE LAW 2024. [PMID: 38889084 DOI: 10.1002/bsl.2684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 05/25/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024]
Abstract
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.
Collapse
Affiliation(s)
- Shawheen J Rezaei
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Stanford University School of Medicine, Stanford, California, USA
| | - Amitai S Miller
- Harvard University John F. Kennedy School of Government, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Noah Miranda
- Stanford University School of Medicine, Stanford, California, USA
- UMass Chan Medical School, Worcester, Massachusetts, USA
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Sun HH, Gupta S, Chen ML. Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty. Urology 2024; 188:156-161. [PMID: 38670276 DOI: 10.1016/j.urology.2024.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/04/2024] [Accepted: 03/12/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVE To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). METHODS A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. RESULTS Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. CONCLUSION UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.
Collapse
Affiliation(s)
- Helen H Sun
- Case Western Reserve University/University Hospitals of Cleveland, Cleveland, OH.
| | - Shubham Gupta
- Case Western Reserve University/University Hospitals of Cleveland, Cleveland, OH
| | | |
Collapse
|
4
|
Krakowsky Y, Shah G, Nguyen ALV, Kavanagh AG, Potter E, Remondini T, Goldsher YW, Millman A. Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know. BJU Int 2024; 133:124-131. [PMID: 38060336 DOI: 10.1111/bju.16249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
OBJECTIVE To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.
Collapse
Affiliation(s)
- Yonah Krakowsky
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Gresha Shah
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
| | - Anna-Lisa V Nguyen
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Alex G Kavanagh
- Gender Surgery Program of British Columbia, Vancouver Coastal Health, Vancouver, British Columbia, Canada
- Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emery Potter
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Taylor Remondini
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Wilk Goldsher
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexandra Millman
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
- Transition Related Surgery Program, Women's College Hospital, Toronto, Ontario, Canada
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Sato S, Imada S, Hayami R, Arai K, Kosugi R, Tsuneizumi M, Matsunuma R. Complexities in Adjuvant Endocrine Therapy for Breast Cancer in Female-to-Male Transgender Patients. Case Rep Oncol 2024; 17:208-216. [PMID: 38327829 PMCID: PMC10849748 DOI: 10.1159/000536212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
Introduction Managing breast cancer in female-to-male (FtM) transgender patients is complicated and challenging. Androgens play a crucial role in the development of secondary sexual identity in FtM transgender patients, but their effectiveness in breast cancer remains unclear. Furthermore, the considerations for adjuvant endocrine therapy in this population are highly intricate and warrant thorough discussion. Case Presentation We describe the case of a 44-year-old FtM transgender diagnosed with breast cancer 3 years after initiating androgen receptor agonist therapy as part of his gender identity transition. After mastectomy, adjuvant endocrine therapy was initiated, consisting of a combination of an aromatase inhibitor and a gonadotropin-releasing hormone agonist, along with a cross-sex hormone. Conclusion Estradiol levels were significantly reduced, and male-typical levels of sex hormones were attained.
Collapse
Affiliation(s)
- Shoko Sato
- Department of Breast Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Sae Imada
- Department of Breast Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Ryosuke Hayami
- Department of Breast Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Kazumori Arai
- Department of Pathology, Shizuoka General Hospital, Shizuoka, Japan
| | - Rieko Kosugi
- Center for Diabetes, Endocrinology and Metabolism, Shizuoka General Hospital, Shizuoka, Japan
| | - Michiko Tsuneizumi
- Department of Breast Surgery, Shizuoka General Hospital, Shizuoka, Japan
| | - Ryoichi Matsunuma
- Department of Breast Surgery, Shizuoka General Hospital, Shizuoka, Japan
| |
Collapse
|
6
|
Wu Q, Yang Z, Ma N, Wang W, Li Y. Phalloplasty With a Free Scapular Flap Improves Postoperative Sensation in Penile Reconstruction. Plast Surg (Oakv) 2023; 31:330-337. [PMID: 37915343 PMCID: PMC10617447 DOI: 10.1177/22925503211055524] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 09/06/2021] [Accepted: 09/12/2021] [Indexed: 11/03/2023] Open
Abstract
Objective We aimed to evaluate both the long-term surgical outcomes and patient-reported outcomes of free scapular flap (FSF) phalloplasty. Method The same surgical team performed phalloplasty in 66 patients using a FSF between March 2000 and September 2018. All patients had at least 24 months of follow-up. The surgical techniques used, complications observed, and surgical and patient-reported outcomes were retrospectively described. Results A total of 66 patients with indications of penile trauma (n = 19), micropenis (n = 42), and self-amputation (n = 5) underwent FSF phalloplasty. Two patients (3%) had total flap necrosis and 1 (1.5%) had partial flap necrosis. The urethral complication rate was 18.2% (12/66 patients). All patients were able to void while standing after revision procedures or urethroplasty. We found that an FSF is a reliable donor site for penile reconstruction. Conclusion The FSF phalloplasty creates an esthetically pleasing penis and allows voiding while standing. Most patients can engage in sexual activity. The main drawbacks of using this method are that patients experience different degrees of sensory recovery, and patients undergoing surgery with the "tube-in-tube" technique may find they are be limited by the thickness of the flap. However, by making full use of residual tissue, such as the micropenis glans or scrotal skin, patients can obtain good tactile and erogenous sensation. We believe that using an FSF complements the existing phalloplasty techniques.
Collapse
Affiliation(s)
- Qi Wu
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Yang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ning Ma
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Weixin Wang
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yangqun Li
- Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| |
Collapse
|
7
|
Butcher RL, Kinney LM, Blasdel GP, Elwyn G, Myers JB, Boh B, Luck KM, Moses RA. Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study. J Sex Med 2023; 20:1032-1043. [PMID: 37173118 PMCID: PMC10311073 DOI: 10.1093/jsxmed/qdad063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/05/2023] [Accepted: 04/06/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. AIM (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. METHODS This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. OUTCOMES Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. RESULTS We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. CLINICAL IMPLICATIONS The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. STRENGTHS AND LIMITATIONS This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. CONCLUSIONS This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.
Collapse
Affiliation(s)
- Rebecca L Butcher
- Center for Program Design and Evaluation, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, United States
| | - Linda M Kinney
- Center for Program Design and Evaluation, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, United States
| | - Gaines P Blasdel
- University of Michigan Medical School, Ann Arbor, MI 48109, United States
| | - Glyn Elwyn
- Coproduction Laboratory, Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Hanover, NH 03755, United States
| | - Jeremy B Myers
- Division of Urology, Department of Surgery, University of Utah Health, Salt Lake City, UT 84103, United States
| | - Benjamin Boh
- Affirm Endocrinology, Lebanon, NH 03766, United States
| | - Kaylee M Luck
- Section of Urology, Department of Surgery, Dartmouth Health, Lebanon, NH 03756, United States
| | - Rachel A Moses
- Section of Urology, Department of Surgery, Dartmouth Health, Lebanon, NH 03756, United States
- Geisel School of Medicine at Dartmouth, Hanover, NH 03755, United States
| |
Collapse
|
8
|
Fascelli M, Sajadi KP, Dugi DD, Dy GW. Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy. Transl Androl Urol 2023; 12:932-943. [PMID: 37305627 PMCID: PMC10251104 DOI: 10.21037/tau-22-675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/06/2023] [Indexed: 12/02/2023] Open
Abstract
Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.
Collapse
Affiliation(s)
- Michele Fascelli
- Urology, Plastic and Reconstructive Surgery, Transgender Health Program, Oregon Health and Sciences University, Portland, OR, USA
| | - Kamran P. Sajadi
- Urology and Urogynecology, Transgender Health Program, Oregon Health and Sciences University, Portland, OR, USA
| | - Daniel D. Dugi
- Urology, Plastic and Reconstructive Surgery, Transgender Health Program, Oregon Health and Sciences University, Portland, OR, USA
| | - Geolani W. Dy
- Urology, Plastic and Reconstructive Surgery, Transgender Health Program, Oregon Health and Sciences University, Portland, OR, USA
| |
Collapse
|
9
|
van de Grift TC. Masculinizing and defeminizing gender-affirming surgery. Best Pract Res Clin Obstet Gynaecol 2023:102323. [PMID: 36932000 DOI: 10.1016/j.bpobgyn.2023.102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/24/2023] [Accepted: 02/15/2023] [Indexed: 02/25/2023]
Abstract
Transmasculine transgender and gender-diverse individuals may request gender-affirming surgery, standalone or in addition to other interventions. The choices and preferred outcomes of surgery can be highly individual. Besides surgeons' technical skills and patient physique, professionals in this field should be able to cooperate with other disciplines and with patients. The most requested surgery is masculinizing chest surgery, aiming to create a masculine chest with minimal scarring. For genital surgery, metoidioplasty refers to the procedure where the hypertrophic clitoris is released and possibly a scrotum is created from local labia flaps, whereas phalloplasty refers to a procedure in which a neophallus is created from a flap. Possible other surgeries include hysterectomy/oophorectomy, colpectomy, and the implants of scrotal or erection prostheses. In order to guide patients and clinicians, standardized outcome measures as well as evidence-based decision aids have been developed. Such aids, in combination with collaborative medical and psychosocial care, may further leverage the long-term outcomes of these surgeries.
Collapse
Affiliation(s)
- Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VUmc location, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands; Department of Psychiatry and Medical Psychology, Zaans Medical Center, Zaandam, the Netherlands.
| |
Collapse
|
10
|
Iv Kyrazis CB, Stein EB, Carroll EF, Crissman HP, Kirkpatrick DL, Wasnik AP, Zavaletta V, Maturen KE. Imaging Care for Transgender and Gender Diverse Patients: Best Practices and Recommendations. Radiographics 2023; 43:e220124. [PMID: 36602923 DOI: 10.1148/rg.220124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Transgender and gender diverse (TGD) people experience health disparities, and many avoid necessary medical care because of fears of discrimination or mistreatment. Disparate care is further compounded by limited understanding of gender-affirming hormone therapy (GAHT) and gender-affirming surgery among the medical community. Specific to radiology, TGD patients report more negative imaging experiences than negative general health encounters, highlighting the need for guidance and best practices for inclusive imaging care. A patient's imaging journey provides numerous opportunities for improvement. Inclusive practice in a radiology department starts with ordering and scheduling the examination, facilitated by staff education on appropriate use of a patient's chosen name, gender identity, and pronouns. Contemporary electronic health record systems have the capacity for recording detailed sexual orientation and gender identity data, but staff must be trained to solicit and use this information. A welcoming environment can help TGD patients to feel safe during the imaging experience and may include institutional nondiscrimination policies, gender-neutral signage, and all-gender single-user dressing rooms and bathrooms. Image acquisition should be performed using trauma-informed and patient-centered care. Finally, radiologists should be aware of reporting considerations for TGD patients, such as avoiding the use of gender in reports when it is not medically relevant and using precise, respectful language for findings related to GAHT and gender-affirming surgical procedures. As a field, radiology has a range of opportunities for improving care delivery for TGD patients, and the authors summarize recommended best practices. See the invited commentary by Stowell in this issue. © RSNA, 2023 Quiz questions for this article are available in the supplemental material.
Collapse
Affiliation(s)
- Crysta B Iv Kyrazis
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Erica B Stein
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Evelyn F Carroll
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Halley P Crissman
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Daniel L Kirkpatrick
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Ashish P Wasnik
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Vaz Zavaletta
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| | - Katherine E Maturen
- From the Department of Radiology (C.B.I.K. [she/her]), E.B.S. [she/her], D.L.K. [he, him], A.P.W. [he, him], K.E.M. [she/her]) and Department of Obstetrics and Gynecology (H.P.C. [she/her], K.E.M.), University of Michigan Health System, 1500 E Medical Center Dr, B1 D502, Ann Arbor, MI 48109; Department of Radiology, Mayo Clinic, Rochester, Minn (E.F.C. [she/her]); and Department of Radiology, University of Colorado, Denver, Colo (V.Z. [they/them])
| |
Collapse
|
11
|
Stojanovic B, Djordjevic ML. Updates on metoidioplasty. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Borko Stojanovic
- Belgrade Center for Urogenital Reconstructive Surgery Belgrade Serbia
- School of Medicine University of Belgrade Beograd Serbia
| | - Miroslav L. Djordjevic
- Belgrade Center for Urogenital Reconstructive Surgery Belgrade Serbia
- School of Medicine University of Belgrade Beograd Serbia
- Icahn School of Medicine at Mount Sinai New York New York USA
| |
Collapse
|
12
|
Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in Gender Affirmation: A Review. Indian J Plast Surg 2022; 55:156-161. [PMID: 36017403 PMCID: PMC9398530 DOI: 10.1055/s-0041-1740081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.
Collapse
Affiliation(s)
- Borko Stojanovic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Bencic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav L. Djordjevic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
13
|
Vaginectomy in Transmasculine Patients: A Review of Techniques in an Emerging Field. Female Pelvic Med Reconstr Surg 2022; 28:e222-e230. [PMID: 35234183 DOI: 10.1097/spv.0000000000001132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE This report reviews the various techniques for vaginal obliterative surgery in the transmasculine patient population, including advantages and drawbacks with differing methods and reflects on the focus of future research and surgical efforts. FINDINGS Existing techniques for vaginal obliterative surgery by vaginectomy or colpocleisis vary without strong evidence to identify a superior approach. SUMMARY The increasing number of transmasculine patients seeking vaginectomy as a part of gender-affirming surgery must be matched by evidence-based techniques that provide a safe, long-term outcome.
Collapse
|
14
|
Wu CA, Jolly D, Boskey ER, Ganor O. A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty. JOURNAL OF RECONSTRUCTIVE MICROSURGERY OPEN 2022. [DOI: 10.1055/s-0042-1748884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Background As phalloplasty becomes more routinely performed, there is a growing need for an evidence base to guide surgical decision-making. Recent reviews have suggested that flap type and number of stages may affect the high rates of urethral complications seen with phalloplasty, but no rigorous comparison of both has been performed.
Methods A systematic review was conducted across PubMed, Google Scholar, and ScienceDirect (PROSPERO #158722). All included studies examined urethral complications following gender-affirming phalloplasty in transgender men. Data were extracted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. All searches, extractions, and grading were completed by two authors.
Results Twenty-five studies were included with a total of 1,674 patients. Identified flap types included radial forearm, anterolateral thigh, abdominal, and fibular flaps. Surgical techniques varied widely within the flap types. Number of stages ranged from one to four. Stricture and fistula were the most frequently reported complications with considerable variation in the reported rates between studies, even within singular flap types. Data extraction indicated serious quality issues with the published literature, with the majority of studies at high risk of bias due to short follow-up times, inconsistent and incomplete reporting of outcomes, and inconsistent reporting of surgical technique.
Conclusion To date, there is insufficient data to support a preferred flap type to minimize the urethral complication rates of phalloplasty. Further high-quality literature is required to determine the impact of potential factors affecting complications of gender-affirming phalloplasty. Improved literature quality may be facilitated by a standardized set of reporting guidelines.
Collapse
Affiliation(s)
| | - Divya Jolly
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
| | - Elizabeth R. Boskey
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Oren Ganor
- Department of Plastic and Oral Surgery, Center for Gender Surgery, Boston Children's Hospital, Boston, Massachusetts
- Department of Surgery, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
15
|
Wu SH, Shen BH, Perng CK, Wang TH, Shih YC, Ma H, Wu HY. Complications of free-flap procedures for phalloplasty in female-to-male transgender surgery: 25-year experience a single medical center. J Chin Med Assoc 2022; 85:341-345. [PMID: 35259134 DOI: 10.1097/jcma.0000000000000677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To present the complications of free-flap phalloplasty in three-staged female-to-male transgender surgery. METHODS This retrospective study included patients who underwent a three-staged free-flap phalloplasty for female-to-male transgender surgery between January 1988 and December 2013. Data regarding demographics, operative techniques, and complications were collected and analyzed. RESULTS A total of 101 patients with a mean age of 30.2 years were included. Phalloplasty with traditional free forearm tube-in-tube fasciocutaneous flap was performed in 25 (24.8%) patients, free forearm fasciocutaneous flap with vaginal mucosa for a prefabricated urethra in 30 (29.7%) patients, free radial forearm osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 22 (21.8%) patients, and free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra in 24 (23.8%) patients. Complication rates of partial flap loss, urethrocutaneous fistula, urethral stricture, and hair or stone formation were 12.9%, 49.5%, 24.8%, and 5.0%, respectively. Patients receiving fibula osteocutaneous flap phalloplasty had the lowest overall complication rate (33.3%), followed by those with radial forearm osteocutaneous flap (40.9%), forearm fasciocutaneous flap (43.3%), and forearm tube-in-tube fasciocutaneous flap (80.0%). Forearm tube-in-tube fasciocutaneous flap procedure was associated with significantly higher rates of overall complications (p = 0.05), urethrocutaneous fistula (p = 0.005), and hair or stone formation (p = 0.002) compared with the other three types of procedures. Rates of all complications did not significantly differ among fibula osteocutaneous flap, radial forearm osteocutaneous flap, and forearm fasciocutaneous flap procedures. CONCLUSION In free-flap phalloplasty for female-to-male transgender surgery, utilization of free fibula osteocutaneous flap with vaginal mucosa for a prefabricated urethra resulted in the lowest complication rate. Further comparisons among different procedures of phalloplasty are warranted.
Collapse
Affiliation(s)
- Szu-Hsien Wu
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Bing-Hwei Shen
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Cherng-Kang Perng
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tien-Hsiang Wang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Yu-Chung Shih
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Hsu Ma
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- Department of Surgery, School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Plastic and Reconstructive Surgery, Department of Surgery, School of Medicine, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Ho-Yu Wu
- Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| |
Collapse
|
16
|
Urethra Reconstruction and Revision Urethroplasty in Pedicled Anterolateral Thigh Flap Penile Reconstruction. Ann Plast Surg 2022; 89:201-206. [PMID: 35180748 DOI: 10.1097/sap.0000000000003100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Neophallic urethroplasty remains a significant challenge in penile reconstruction. Currently, there is no ideal recognized method. Through this article, we aimed to share our experiences of urethral reconstruction in the pedicled anterolateral thigh flap penile reconstruction using modified techniques and alternative flaps. METHODS In this single-center study from 2010 to 2020, 49 patients underwent penile reconstruction with a pedicled anterolateral thigh flap; 17 patients had a micropenis, 3 had iatrogenic defects, and 29 had penile defects after trauma. Different urethroplasty methods, complications, and revision methods were separately described. The tube-in-tube technique was used in 6 cases; the superficial iliac circumflex artery perforator (SCIAP) flap and pudendal-thigh flap were used in 26 and 11 cases, respectively, and the pedicled scrotal flap was used in 6 cases. Revision urethroplasty due to postoperative necrosis (n = 3), stricture (n = 8), and fistula (n = 2) were performed in 13 cases. RESULTS The urethral complications (flap necrosis, urinary fistula, and stricture) were as follows: tube-in-tube, 66.7%; SCIAP flap, 46.2%; pudendal-thigh flap, 38.5%; and scrotal septum flap, 50%. After revision procedures, all patients could urinate while standing. CONCLUSIONS The characteristics and requirements of patients should be considered before designing a surgical plan. The tube-in-tube technique is the first choice for reconstructing the penis and urethra in a single stage for thinner patients. For other patients, a different flap can be used as a substitute for urethral reconstruction. The SCIAP, pudendal-thigh, and pedicled scrotal flaps can be used to reconstruct the urethra. The tubed SCIAP flap and pudendal-thigh flap are reliable, simple, and suitable for revision urethroplasty.
Collapse
|
17
|
Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction). Ann Surg 2022; 275:e67-e74. [PMID: 34914663 DOI: 10.1097/sla.0000000000004717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress. METHODS A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes. RESULTS Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications. CONCLUSIONS Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.
Collapse
|
18
|
Massie JP, Sood R, Nolan IT, Sasson DC, Swanson M, Morrison SD, Placik O. Defining Aesthetic Preferences for the Penis: A Photogrammetric and Crowdsourcing Analysis. Aesthet Surg J 2021; 41:1293-1302. [PMID: 33569587 DOI: 10.1093/asj/sjab082] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Achieving an aesthetic phalloplasty result is important for patients with acquired or congenital defects of the penis, or with genital-related dysphoria. However, aside from length and girth, the aesthetic proportions of the male penis have not been defined. OBJECTIVES This study aimed to determine proportions of the male penis through photogrammetric analysis of nude male photographs and to verify these proportions with a crowdsourcing-based survey. METHODS Nude male photographs (n = 283) were analyzed to define aesthetic proportions of the male penis. Photographs were analyzed for the position of the penis on the torso in relation to the umbilicus and for the ratio of the dorsal and ventral glans of the penis in relation to the entire shaft length. Proportions were then further studied by crowdsourcing 1026 respondents with Amazon mechanical Turk. RESULTS The ideal position of the penis below the umbilicus is about 55% (6/11th) of the distance from the jugular notch to the umbilicus (measured average, 53.6%; survey-weighted average, 58.9%). The dorsal glans of the penis is about 33% (1/3rd) of the length of the entire shaft (measured average, 32.1%; survey-weighted average, 37.5%). The ventral glans of the penis is about 12.5% (1/8th) of the length of the entire shaft (measured average, 12.6%; survey-weighted average, 11.7%). CONCLUSIONS Measured proportions of the human penis follow exact fractions. Crowdsourcing data helped support photogrammetric analysis, with survey-preferred ratios within 5% of measured ratios. With further validation, these data can aid surgeons performing phalloplasty.
Collapse
Affiliation(s)
- Jonathan P Massie
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Rachita Sood
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, NYU School of Medicine, New York, NY, USA
| | - Daniel C Sasson
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| | - Marco Swanson
- Division of Plastic Surgery, Department of Surgery, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Otto Placik
- Division of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
19
|
Immediate Lymphovenous Bypass Treated Donor Site Lymphedema during Phalloplasty for Gender Dysphoria. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3822. [PMID: 34549009 PMCID: PMC8448062 DOI: 10.1097/gox.0000000000003822] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 07/28/2021] [Indexed: 12/04/2022]
Abstract
Demand for gender-affirming phalloplasty continues to grow worldwide, and the extended radial forearm flap phalloplasty remains one of the most commonly performed techniques. One potential morbidity that has emerged is postoperative donor site lymphedema, which was susceptible to develop after harvest of extended radial forearm flap. In the setting of preventative or immediate lymphovenous bypass (LVB) with axillary lymph node dissection for the treatment of breast cancer, it is possible that a subset of patients undergoing gender-affirmation surgery would benefit from immediate lymphatic reconstruction at the time of primary phalloplasty. Here, we report a case in which intraoperative indocyanine green lymphography demonstrated lymphatic obstruction within the left donor hand after flap harvest, and was treated with immediate LVB at the time of extended radial forearm phalloplasty. Two surgical teams operated simultaneously: the reconstructive urology team performed the vaginectomy, perineal urethral lengthening, scrotoplasty, and perineal reconstruction; and the microsurgery team harvested the extended radial forearm, constructed the penile urethra, shaped the phallus, and performed the immediate LVB. Lymphography showed no dermal backflow at 5 months follow-up; at 13 months, the patient demonstrated no signs or symptoms of lymphedema in the left forearm or hand. To the authors’ best knowledge, this is the first report of confirmed donor site lymphedema following extended radial forearm flap harvest, which was successfully treated with immediate LVB. Careful evaluation of lymphatic vessels with indocyanine green lymphography in the forearm before and after extended flap harvest may be warranted.
Collapse
|
20
|
Elfering L, van de Grift TC, Al-Tamimi M, Timmermans FW, de Haseth KB, Pigot GLS, Lissenberg-Witte BI, Bouman MB, Mullender MG. How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons. Sex Med 2021; 9:100413. [PMID: 34425361 PMCID: PMC8498953 DOI: 10.1016/j.esxm.2021.100413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Tactile and erogenous sensitivity of the neophallus after phalloplasty is assumed to affect the sexual well-being of transmasculine persons and, ultimately, their quality of life. The experienced and objective sensation of the neophallus and their association are largely unknown. AIM This study evaluated experienced tactile and erotic sensation of the neophallus in transmasculine persons and investigated how this was related to objective tactile sensitivity. METHODS Between August 2017 and January 2020, 59 transmasculine persons who underwent phalloplasty were recruited to participate in a prospective follow-up study. Tactile sensitivity of the neophallus and donor-site was measured (Semmes-Weinstein Monofilament test) and compared, and participants were asked to fill out a questionnaire about experienced sensation of the neophallus and sexual wellbeing. MAIN OUTCOME MEASURES Experienced and objective sensation of the neophallus were measured by using a questionnaire and Semmes-Weinstein Monofilament scores. RESULTS Neophallic tactile sensitivity was significantly reduced compared to the donor-site (n = 44), with the proximal part being more sensitive than the distal part (median follow-up of 1.8 years, range 1.0-7.2)). Sensitivity of the neophallus was not significantly associated with the surgical flap used, yet increased significantly with follow-up time. The questionnaire was completed by 26 participants of which 24 (92.3%) experienced (some degree of) tactile sensitivity in their neophallus. Erogenous sensation was experienced by 23 (88.5%). Experienced and objectified tactile sensitivity were not significantly correlated (Spearmans's rho = 0.23, P = .26). Answers to open-ended questions showed that results often do not match expectations. CONCLUSION Tactile sensation of the neophallus was reduced in most transmasculine persons and improved slowly over time. A significant association between subjective and objective measures could not be detected. Although experienced sensitivity varied between individuals, the vast majority reported to have tactile and erotic sensitivity in the neophallus.Transmasculine persons should be informed that sensitivity of the neophallus will likely be reduced. Elfering L, van de Grift TC, Al-Tamimi M, et al. How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons. Sex Med 2021;9:100413.
Collapse
Affiliation(s)
- Lian Elfering
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands; Department of Medical Psychology, Center of Expertise on Gender Dysphoria, Amsterdam UMC, Amsterdam, The Netherlands
| | - Muhammed Al-Tamimi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Floyd W Timmermans
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kristin B de Haseth
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Garry L S Pigot
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Margriet G Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| |
Collapse
|
21
|
El-Arabi AM, Barrera EP, McLaren HE, Gray M, Grimstad FW. Masculinizing Gender Affirming Surgery. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2021.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmad M. El-Arabi
- Department of Urology, University of Kansas Health System, Kansas City, Kansas, USA
| | - Ellis P. Barrera
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Hillary E. McLaren
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Frances W. Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
22
|
An Option for Shaft-Only Gender-Affirming Phalloplasty: Vaginal Preservation and Vulvoscrotoplasty. A Technical Description. Plast Reconstr Surg 2021; 147:480-483. [PMID: 33565834 DOI: 10.1097/prs.0000000000007579] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
SUMMARY Genital masculinizing gender-affirming surgery is a growing field. Because of a spectrum of gender identity, gender expression, sexual expression, patient desires, and patient tolerance for complications, options for surgery vary accordingly. Shaft-only phalloplasty avoids urethral lengthening, but may still be accompanied by hysterectomy, vaginectomy, scrotoplasty, clitoroplasty (burying of the clitoris), glansplasty, and placement of erectile devices and testicular implants. Patients who desire retention of vaginal canal patency are candidates for vaginal preservation vulvoscrotoplasty; however, there is a paucity of literature describing the procedure and its outcomes. In this article, the authors review the technique used by the senior author at Oregon Health and Science University and report surgical outcomes for four patients. Future studies regarding patient-recorded outcome measures, aesthetics, sexual function, urologic function, patient satisfaction, and conversion to other options will help surgeons better understand patients pursuing gender-affirming surgery through shaft-only phalloplasty.
Collapse
|
23
|
Hamidian Jahromi A, Boyd LC, Schechter L. An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know. World J Surg 2021; 45:3511-3521. [PMID: 33796924 DOI: 10.1007/s00268-021-06084-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2021] [Indexed: 12/14/2022]
Abstract
Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.
Collapse
Affiliation(s)
| | - Louisa C Boyd
- Division of Plastic and Reconstructive Surgery, Saint Louis University School of Medicine, Saint Louis, MO, USA
| | - Loren Schechter
- Department of Plastic Surgery, Rush University Medical Center, Chicago, USA. .,The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, The University of Illinois At Chicago, Chicago, USA.
| |
Collapse
|
24
|
Neuville P, Carnicelli D, Paparel P, Ruffion A, Morel-Journel N. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021; 18:830-836. [PMID: 33741289 DOI: 10.1016/j.jsxm.2021.01.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/23/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Metoidioplasty is a possibility for penis reconstruction in transmen that could be enhanced by a semi-rigid prosthesis support. AIM Describe the surgical technique of metoidioplasty with implantation of a specifically designed semi-rigid prosthesis -the ZSI100D4- and analyze preliminary results. METHODS Implantation of semi-rigid prosthesis was proposed to transmen who chose metoidioplasty for genital gender affirming surgery in a specialized university hospital. OUTCOMES Surgical outcomes were collected from medical files. Functional outcomes and satisfaction were collected post-operatively with a questionnaire. RESULTS A total of 15 patients were operated; the mean length of followup was 22 months (SD = 8.7). Median prosthesis size was 8.5 cm (range: 8.5-10). Seven (46.7%) minor complications (Clavien-Dindo grade 2; 5 wound dehiscence and 2 fistula, managed conservatively) and 1 severe (Clavien-Dindo grade 3b) complication (Hematoma that need surgical revision) occurred. Thirteen patients (86.6%) answered the questionnaire; 11 (84.6%) reported being either "very satisfied" or "satisfied" with the appearance of the new genitalia; 10 (76.9%) could void while standing; and 12 patients (92.3%) answered "not at all" to the question "do you have regrets about this surgery ?". CONCLUSION Implantation of a semi-rigid prosthesis in an enlarged clitoris seems to be a valuable option and can be proposed as another possibility for the complex surgical answer to neophallus reconstruction in transmen. Neuville P, Carnicelli D, Paparel P, et al. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021;18:830-836.
Collapse
Affiliation(s)
- Paul Neuville
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France.
| | - Damien Carnicelli
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Philippe Paparel
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Alain Ruffion
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Nicolas Morel-Journel
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| |
Collapse
|
25
|
Akhavan AA, Sandhu S, Ndem I, Ogunleye AA. A review of gender affirmation surgery: What we know, and what we need to know. Surgery 2021; 170:336-340. [PMID: 33741180 DOI: 10.1016/j.surg.2021.02.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature. METHODS PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized. RESULTS Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery. CONCLUSION Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.
Collapse
Affiliation(s)
- Arya Andre Akhavan
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Shabaaz Sandhu
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Idorenyin Ndem
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Adeyemi A Ogunleye
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
26
|
Neurolysis of the Dorsal Nerve to the Penis to Restore Function After Trauma. Ann Plast Surg 2021; 84:307-311. [PMID: 31904648 DOI: 10.1097/sap.0000000000002144] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Loss of penile sensation or development of a painful penis and erectile dysfunction can occur after injury to the dorsal branch of the pudendal nerve. Although recovery of genital sensibility has been discussed frequently in transmen, this subject has been reported rarely in cismen. The purpose of this report is to review our experience with recovery of sensation in men after decompression of the dorsal branch of the pudendal nerve after trauma. METHODS A retrospective chart review of men who have had decompression of the dorsal branch of the pudendal nerve was carried out from 2014 to 2018. Patients were included in the cohort if they had a loss of penile sensation or the development of a painful penis after trauma. Primary outcomes measured were the change in penile symptoms, including erection, ejaculation, ejaculatory pain, erogenous sensation, numbness, and penile pain. RESULTS For the 7 men included in this study, the mean follow-up time was 57 weeks (range, 28-85 weeks). Bilateral surgery was done in 71% (5/7). Of the 6 patients with loss of penile sensation, complete recovery of erogenous sensibility occurred in 5 (83%) patients, with partial relief in 1 (17%) patient. Of the 3 men who had erectile dysfunction, normal erections were restored in 2 (67%) patients. Of the 2 patients unable to ejaculate, 1 (50%) patient regained ejaculatory function. Of the 4 patients with ejaculatory pain, complete relief of pain occurred in 2 (50%) patients, with partial relief in 2 (50%) patients. Of the 6 patients with penile pain in the absence of ejaculation, complete relief of pain occurred in 3 (50%) patients, with partial relief in 3 (50%) patients. CONCLUSION Neurolysis of the dorsal nerve to the penis at the inferior pubic ramus canal can be successful in relieving pain, and restoring sensation and erectile function in men who sustained an injury along the inferior pubic ramus.
Collapse
|
27
|
Staud CJ, Zaussinger M, Duscher D, Radtke C, Wenny R, Schmidt M, Huemer GM. A modified microvascular "Tube-in-Tube" concept for penile construction in female-to-male transsexuals: Combined radial forearm free flap with anterolateral thigh flap. J Plast Reconstr Aesthet Surg 2021; 74:2364-2371. [PMID: 33622542 DOI: 10.1016/j.bjps.2021.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 01/24/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Phalloplasty is a complex surgical task and remains a significant challenge in plastic surgery. To date, there are various techniques; however, complication rates are still not satisfactory. Here, we present our surgical approach of a modified tube-in-tube concept combining a radial forearm free flap and an anterolateral thigh flap and assess its outcome in a series of female-to-male transsexuals. PATIENTS AND METHODS In this report, 21 female-to-male transsexual patients were included. The first surgical step includes colpectomy and elongation of the fixed part of the urethra with a full-thickness skin graft. Subsequently, a radial forearm free flap was adapted to build the inner tube which represents the neourethra. For the last step, a free anterolateral thigh flap is utilized as the outer tube of the neophallus. All patients were evaluated regarding aesthetic and functional outcomes as well as postoperative complications and revision surgeries. RESULTS Our results showed a 100% flap survival rate with a mean follow-up of 4.4 years (range, 2.7-6). Three radial forearm free flaps and one free anterolateral thigh flap presented with partial flap necrosis. Generally, complications occurred in 11 patients (52.4%). The most common complications were related to urethral reconstruction including fistula formation (n = 8) and stenosis (n = 5). All except one patient obtained the ability to void while standing. CONCLUSION Despite the complexity, the initial results are very promising for a single-stage phalloplasty with complete functional creation of a neophallus. Further improvements have to be implemented for reduction of postoperative complications particularly regarding urethral reconstruction. LEVEL OF EVIDENCE IV (Therapeutic).
Collapse
Affiliation(s)
- Clement J Staud
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Maximilian Zaussinger
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria; Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Dominik Duscher
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria; Department of Plastic and Hand Surgery, University Hospital Rechts der Isar, Munich Technical University, Germany
| | - Christine Radtke
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Spitalgasse 23, 1090 Vienna, Austria
| | - Raphael Wenny
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Manfred Schmidt
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria
| | - Georg M Huemer
- Section of Plastic and Reconstructive Surgery, Kepler University Hospital Linz, Krankenhausstrasse 9, 4020 Linz, Austria; Medical Faculty, Johannes Kepler University Linz, Altenberger Straße 69, 4040 Linz, Austria.
| |
Collapse
|
28
|
Yorozuya W, Ichihara K, Yamana A, Masumori N. [CLINICAL OUTCOMES OF GENDER AFFIRMING SURGERY FOR GENDER DYSPHORIA/INCONGRUENCE: A SINGLE-INSTITUTE EXPERIENCE]. Nihon Hinyokika Gakkai Zasshi 2021; 112:123-130. [PMID: 35858806 DOI: 10.5980/jpnjurol.112.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence. (Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes. (Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m2 or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery. (Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.
Collapse
Affiliation(s)
- Wakako Yorozuya
- Department of Urology, Sapporo Medical University, School of Medicine
| | | | - Azusa Yamana
- Department of Urology, Sapporo Medical University, School of Medicine
| | - Naoya Masumori
- Department of Urology, Sapporo Medical University, School of Medicine
| |
Collapse
|
29
|
Terris-Feldman A, Chen A, Poudrier G, Garcia M. How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers. Sex Med 2020; 8:664-672. [PMID: 33023854 PMCID: PMC7691873 DOI: 10.1016/j.esxm.2020.08.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 12/01/2022] Open
Abstract
INTRODUCTION In the United States, 1.4-1.65 million people identify as transgender, many of whom will seek genital gender-affirming surgery (GAS). The number of surgeons, geographic proximity thereof, and exclusionary insurance policies has limited patient access to genital GAS. AIM To assess the accessibility of both feminizing and masculinizing genital GAS (vaginoplasty, metoidioplasty, and phalloplasty) by identifying the location of GAS surgeons, health insurance, or payment forms accepted. METHODS Between February and April 2018, genital GAS surgeons were identified via Google search. Surgeons' offices were contacted by telephone or e-mail. MAIN OUTCOME MEASURE We queried the type of genital GAS performed, the health insurance or payment forms accepted, and the type of medical practice (academic, private, or group managed-care practice). RESULTS We identified 96 surgeons across 64 individual medical centers offering genital GAS. The survey response rate was 83.3%. Only 61 of 80 (76.3%) surgeons across 38 of 53 (72%) locations confirmed offering genital GAS. Only 20 (40%) U.S. states had at least one genital GAS provider. 30 of 38 (79%) locations reported accepting any form of insurance. Only 24 of 38 (63%) locations (14 academic; 10 private/group) accepted Medicaid (P = .016); 18 of 38 (47%) locations (13 academic; 5 private/group) accepted Medicare (P = .001). CLINICAL TRANSLATION Reconciliation of the public policies regarding insurance coverage for GAS with the actual practices of the providers is necessary for improving access to GAS for transgender individuals. STRENGTHS & LIMITATIONS We purposefully used a methodology mirroring how a patient would find GAS surgeons, which also accounts for key limitations: only surgeons whose services were featured on the internet were identified. We could not verify the services or insurance-related information surgeons reported. CONCLUSION This study suggests that access to genital GAS is significantly limited by the number of providers and the uneven geographic distribution across the United States, in which only 20 of 50 U.S. states have at least one genital GAS surgeon. Feldman AT, Chen A, Poudrier G, et al. How Accessible Is Genital Gender-Affirming Surgery for Transgender Patients With Commercial and Public Health Insurance in the United States? Results of a Patient-Modeled Search for Services and a Survey of Providers. Sex Med 2020;8:664-672.
Collapse
Affiliation(s)
- Alexandra Terris-Feldman
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Alessandra Chen
- Department of Dermatology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Grace Poudrier
- Department of Sociology & Anthropology, Northeastern University, Boston, MA, USA
| | - Maurice Garcia
- Division of Urology, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program Cedars-Sinai Medical Center, Los Angeles, CA, USA; Department of Urology & Department of Anatomy, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
30
|
Kopetti C, Schaffer C, Zaman K, Liapi A, di Summa PG, Bauquis O. Invasive Breast Cancer in a Trans Man After Bilateral Mastectomy: Case Report and Literature Review. Clin Breast Cancer 2020; 21:e154-e157. [PMID: 33341378 DOI: 10.1016/j.clbc.2020.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 10/09/2020] [Accepted: 10/15/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Camille Kopetti
- Département de Chirurgie Plastique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland.
| | - Clara Schaffer
- Département de Chirurgie Plastique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Khalil Zaman
- Departement d'oncologi, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Aikaterini Liapi
- Departement d'oncologi, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Pietro Giovanni di Summa
- Département de Chirurgie Plastique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Olivier Bauquis
- Département de Chirurgie Plastique, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| |
Collapse
|
31
|
Median Nerve Neuropathy following Radial Forearm Free Flap Phalloplasty: A Case Report. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3027. [PMID: 32983782 PMCID: PMC7489613 DOI: 10.1097/gox.0000000000003027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/11/2020] [Indexed: 11/26/2022]
Abstract
As the transgender population increases, gender-affirming surgeries are being performed at unprecedented rates. Despite this increase, complications and long-term outcomes of gender-affirming interventions are largely understudied. We present a transgender patient who underwent radial forearm free flap (RFFF) phalloplasty as part of gender affirmation. Immediately following surgery, the patient reported paresthesia in the donor arm in the median nerve distribution followed by a neuropathic pain after 1 week. The patient complained of shooting and burning pain and reported a loss of sensation and function at the donor site. Electromyography and magnetic resonance imaging results indicated median nerve damage several inches above the donor site. The symptoms persisted for several months before spontaneously resolving. The spontaneous resolution and location of injury suggest that nerve damage occurred as a result of pneumatic tourniquet application despite adherence to all clinical guidelines for a safe tourniquet application of the same. This is the first reported case of neuropathic pain following RFFF phalloplasty occurring at the donor site. Given the large donor area and the long time of tourniquet application, surgeons offering RFFF phalloplasty must be aware of and actively counsel patients seeking this procedure about the potential for nerve-related damages before surgery.
Collapse
|
32
|
Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res 2020; 33:762-770. [PMID: 32826970 DOI: 10.1038/s41443-020-00346-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 11/09/2022]
Abstract
Number of gender dysphoric people increased over the last few decades with positive social acceptance of transpopulation. Genital gender affirming surgeries are of utmost importance in order to adjust body to the mind of these individuals. Creation of the phallus is usually the last step in transmen transition, which remains demanding and challenging for surgeons, with different options for phalloplasty available. The ideal phallus is esthetically appealing, with preserved tactile and erogenous sensation, enables standing micturition and sexual function with minimal donor-site morbidity. Metoidioplasty, as a variant of phalloplasty, uses the hormonally hypertrophied clitoris to create the neophallus. Metoidioplasty can be considered as a method of choice for thin-built individuals looking for male genitalia with preserved erogeneity, in one-stage genital gender affirming surgery. It can be combined together with removal of reproductive organs and vaginectomy. Preoperative consultation with patients and postoperative follow-up as well as multidisciplinary approach are essential for successful treatment.This literature review aims to assess and discuss different metoidioplasty approaches with a special reference to authors' current metoidioplasty technique.
Collapse
Affiliation(s)
- Marta Bizic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. .,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.
| | - Borko Stojanovic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Marko Bencic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Noémi Bordás
- Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.,Department of Urology, Kiskunhalasi Semmelweis Kórház, Kiskunhalas, Hungary
| | - Miroslav Djordjevic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| |
Collapse
|
33
|
Stowell JT, Horowitz JM, Thomas S. Gender-affirming surgical techniques, complications, and imaging considerations for the abdominal radiologist. Abdom Radiol (NY) 2020; 45:2036-2048. [PMID: 31915851 DOI: 10.1007/s00261-019-02398-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Gender-affirming surgery is a group of surgical procedures that alters the physical appearance of a transgender person to resemble that socially associated with their identified gender. Masculinization and feminization surgeries include chest and breast surgery as well as genital reconstruction. The genital reconstruction surgeries have unique anatomic imaging features and are associated with complications that may require radiologic evaluation. This review provides a review of the imaging anatomy, expected findings, and complications associated with gender-affirming surgeries.
Collapse
Affiliation(s)
- Justin T Stowell
- Department and Institution Department of Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jeanne M Horowitz
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Stephen Thomas
- Department of Radiology, Sharp Rees-Stealy Medical Group, San Diego, CA, USA.
| |
Collapse
|
34
|
Effective Secondary Reconstruction of Refractory Urethrocutaneous Fistula after Metoidioplasty Using Folded Superficial Circumflex Iliac Artery Perforator Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2716. [PMID: 32537365 PMCID: PMC7253264 DOI: 10.1097/gox.0000000000002716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/28/2020] [Indexed: 11/25/2022]
Abstract
Supplemental Digital Content is available in the text. One of the primary goals of penile reconstruction for female-to-male transsexuals is to enable voiding while standing. Metoidioplasty represents a viable option, but it is associated with a high rate of postoperative fistula formation and recurrence, which affects the aesthetic and functional outcomes. Subsequent surgical repair using scarred and inadequate local tissue may contribute to fistula recurrence. The folded superficial circumflex iliac artery perforator (SCIP) island flap offers sufficient well-vascularized tissue and skin envelope for the reconstruction of the urethra and outer skin after failed metoidioplasty. The SCIP flap can be elevated as a hairless thin flap, making it useful in urethral reconstruction even when it is folded. We describe a case of a 44-year-old female-to-male transsexual patient who developed a refractory urethrocutaneous fistula after metoidioplasty. Surgical repairs were attempted using local tissue 4 times without success. The patient presented to our hospital, and we performed urethral reconstruction using a folded, pedicled SCIP flap for both urethra and skin augmentation. The postoperative course was uneventful, with satisfactory functional results and low donor-site morbidity. No fistula recurrence was observed during the 2 years of follow-up. This novel procedure offers a viable alternative technique for refractory urethrocutaneous fistula repair.
Collapse
|
35
|
Jones NC, Otto AK, Ketcher DE, Permuth JB, Quinn GP, Schabath MB. Inclusion of transgender and gender diverse health data in cancer biorepositories. Contemp Clin Trials Commun 2020; 19:100597. [PMID: 32613134 PMCID: PMC7317667 DOI: 10.1016/j.conctc.2020.100597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 02/08/2023] Open
Abstract
Biobanks have the potential to be robust resource for understanding potential cancer risks associated with gender-affirming interventions. In this narrative review, we synthesized the current published literature regarding the inclusion of TGD health data in cancer biorepositories and cancer research conducted on biospecimens. Of the 6986 initial results, 153 (2.2%) assessed the biological effects of gender-affirming interventions on TGD tissues. Within that category, only one paper examined transgender tissues in relation to cancer biobanks. Strategies are offered to address the inequities in TGD tissue-based research and diversify the field of biobanking as a whole.
Collapse
Affiliation(s)
- Nat C Jones
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA.,H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Amy K Otto
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Dana E Ketcher
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | | | | | - Matthew B Schabath
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA.,H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| |
Collapse
|
36
|
Abstract
OVERVIEW As visibility of the transgender population increases, understanding of the social, psychological, medical, and surgical aspects of these patients care is vital for the practicing female pelvic medicine and reconstructive surgery urologist. The aim of this review is to describe proper terminology, psychosocial considerations specific to transgender patients, in addition to outlining contemporary surgical techniques and complications.
Collapse
|
37
|
Kocjancic E, Acar O, Talamini S, Schechter L. Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening. Int J Impot Res 2020; 34:120-127. [PMID: 32203431 DOI: 10.1038/s41443-020-0259-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/27/2020] [Accepted: 03/06/2020] [Indexed: 11/09/2022]
Abstract
Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors' preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.
Collapse
Affiliation(s)
- Ervin Kocjancic
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA
| | - Omer Acar
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA.
| | - Susan Talamini
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA
| | - Loren Schechter
- Weiss Memorial Hospital, Center for Gender Confirmation Surgery, Division of Plastic and Reconstructive Surgery, Chicago, IL, USA
| |
Collapse
|
38
|
Al-Tamimi M, Pigot GL, Ronkes B, de Haseth KB, van de Grift TC, van Moorselaar RJA, Mullender MG, Stojanovic B, van der Sluis WB, Djordjevic M, Bouman MB. The First Experience of Using the Pedicled Labia Minora Flap for Urethral Lengthening in Transgender Men Undergoing Anterolateral Thigh and Superficial Circumflex Iliac Artery Perforator Flap Phalloplasty: A Multicenter Study on Clinical Outcomes. Urology 2020; 138:179-187. [PMID: 31911083 DOI: 10.1016/j.urology.2019.10.041] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/10/2019] [Accepted: 10/12/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To describe the novel surgical technique of urethral lengthening in anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty with a pedicled labia minora flap (PLMF) and report on the clinical outcomes. METHODS Between March 2014 and August 2018, 16 transgender men underwent phalloplasty with a PLMF for urethral lengthening at the Amsterdam UMC (VU university), the Netherlands and the Belgrade University Hospital, Serbia. Patient demographics, surgical characteristics, neourethra characteristics, intra- and postoperative complications, pre-and postoperative voiding evaluation, and the length of hospital stay were retrospectively identified from chart reviews. RESULTS The mean neourethral length was 16.8 ± 2.3 cm, and the pars pendulans 11.7 ± 2.2 cm. The neomeatus was localized on top of the neophallus in 12 (75%) patients. No intraoperative complications occurred. Urethral fistula formation occurred in 4 (25%) patients and strictures in 6 (37.5%) patients. In 3 (18.7%) patients a (temporary) perineostomy had to be performed. Voiding from a standing position was possible in 9 (56.3%) patients. CONCLUSION The PLMF for urethral reconstruction, both pars fixa and pars pendulans, in phalloplasty is a feasible surgical technique in transgender men undergoing anterolateral thigh or superficial circumflex iliac artery perforator flap phalloplasty with sufficient labia minora tissue.
Collapse
Affiliation(s)
- Muhammed Al-Tamimi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Department of Urology, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands.
| | - Garry L Pigot
- Department of Urology, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Brechje Ronkes
- Department of Urology, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Kristin B de Haseth
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Tim C van de Grift
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | | | - Margriet G Mullender
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Borko Stojanovic
- Department of Urology, Belgrade University Hospital, Belgrade, Serbia
| | - Wouter B van der Sluis
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | | | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Amsterdam Public Health research institute, Amsterdam UMC, VU University, Amsterdam, The Netherlands; Centre of Expertise on Gender Dysphoria, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| |
Collapse
|
39
|
Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018. Plast Reconstr Surg 2020; 145:153e-161e. [DOI: 10.1097/prs.0000000000006385] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
40
|
Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist. AJR Am J Roentgenol 2019; 213:1194-1203. [PMID: 31414889 DOI: 10.2214/ajr.19.21686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
41
|
Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, van Moorselaar RJA, Mullender MG, Weigert R, Buncamper ME, Özer M, de Haseth KB, Djordjevic ML, Salgado CJ, Belanger M, Suominen S, Kolehmainen M, Santucci RA, Crane CN, Claes KE, Monstrey S, Bouman MB. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019; 16:1849-1859. [DOI: 10.1016/j.jsxm.2019.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/19/2019] [Accepted: 07/31/2019] [Indexed: 10/26/2022]
|
42
|
Dy GW, Granieri MA, Fu BC, Vanni AJ, Voelzke B, Rourke KF, Elliott SP, Nikolavsky D, Zhao LC. Presenting Complications to a Reconstructive Urologist After Masculinizing Genital Reconstructive Surgery. Urology 2019; 132:202-206. [DOI: 10.1016/j.urology.2019.04.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/23/2019] [Accepted: 04/27/2019] [Indexed: 11/29/2022]
|
43
|
Stowell JT, Grimstad FW, Kirkpatrick DL, Brown ER, Santucci RA, Crane C, Patel AK, Phillips J, Ferreira MA, Ferreira FR, Ban AH, Baroni RH, Wu CC, Swan KA, Scott SA, Andresen KJ. Imaging Findings in Transgender Patients after Gender-affirming Surgery. Radiographics 2019; 39:1368-1392. [DOI: 10.1148/rg.2019190010] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
44
|
Abstract
Gender affirmation surgery for transmale patients is still challenging, as creation of the neophallus is one of the most demanding steps in surgical treatment. Metoidioplasty, as a one-stage procedure, can be considered in patients who desire gender affirmation surgery without undergoing a complex, multistage procedure with creation of an adult-sized neophallus. Metoidioplasty presents one of the variants of phalloplasty for patients in whom the clitoris is large enough under testosterone treatment. Advanced urethral reconstruction provides low complication rates with satisfying results of standing micturition.
Collapse
Affiliation(s)
- Marta R Bizic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Department of Urology, Faculty of Medicine, University of Belgrade, Tirsova 10, Belgrade 11000, Serbia.
| | - Borko Stojanovic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Joksic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Clinic for Gynecology and Obstetrics "Narodni Front", Kraljice Natalije 62, Belgrade 11000, Serbia
| | - Miroslav L Djordjevic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
45
|
Shergill AK, Camacho A, Horowitz JM, Jha P, Ascher S, Berchmans E, Slama J, Nougaret S, Wasnik AP, Robbins JB, Dighe MK, Wang CL, Nimhuircheartaigh JM, Phillips J, Menias C, Brook OR. Imaging of transgender patients: expected findings and complications of gender reassignment therapy. Abdom Radiol (NY) 2019; 44:2886-2898. [PMID: 31154481 DOI: 10.1007/s00261-019-02061-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). In this paper we describe expected findings and complications of gender reassignment therapy. METHODS Collaborative multi-institutional project supported by Ovarian and Uterine Cancer Disease Focused panel of Society of Abdominal Radiology. RESULTS Gender dysphoria is defined as a conflict between the biological gender and the gender with which the person identifies. Gender reassignment therapy can alter external sexual features to resemble those of the desired gender and are broadly classified into two types, female to male (FTM) and male to female (MTF). These therapies include hormonal treatment as well as surgical procedures. FTM genital reconstructive therapy includes creation of a neophallus, which can be achieved by metoidioplasty or phalloplasty with mastectomy, along with testosterone administration. MTF gender reassignment surgery includes complete removal of external genitalia with penectomy and orchiectomy, with vaginoplasty, clitoroplasty, labiaplasty, and breast augmentation along with estrogen supplements. CONCLUSION Surgical techniques alter the standard anatomy and make imaging interpretation challenging if radiologists are unfamiliar with expected post-operative appearances. It is important to recognize the complications related to surgical and non-surgical treatment of gender dysphoria to avoid interpretation errors. Furthermore, increasing the prevalence of transgender patients requires increased sensitivity when interpreting imaging studies to reduce the potential for misdiagnoses in reporting due to frequently incomplete available clinical history.
Collapse
Affiliation(s)
- Arvind K Shergill
- Valley Medical Imaging, Abbotsford, BC, Canada
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - Priyanka Jha
- University of California, San Francisco, CA, USA
| | | | | | - Jaromir Slama
- Department of Plastic Surgery, Boston Medical Center, Boston, MA, USA
| | | | | | | | | | | | | | | | | | - Olga R Brook
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
| |
Collapse
|
46
|
|
47
|
Kjölhede A, Cornelius F, Huss F, Kratz G. Metoidioplasty and groin flap phalloplasty as two surgical methods for the creation of a neophallus in female-to-male gender-confirming surgery: A retrospective study comprising 123 operated patients. JPRAS Open 2019; 22:1-8. [PMID: 32158891 PMCID: PMC7061636 DOI: 10.1016/j.jpra.2019.07.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/04/2019] [Indexed: 11/30/2022] Open
Abstract
Background In gender-confirming surgery of the female-to-male gender dysphoric patient, there is currently no ideal method for the creation of a neophallus. Historically, in our clinic, groin flap phalloplasty (GFP) has been the dominating method, but during the last 20 years, it has gradually been replaced with metoidioplasty (MP). The aim of this study was to investigate whether this change of method has influenced factors such as the frequency of complications and the number of operations needed to complete the reconstruction of the neophallus. Methods This is a retrospective, single-centre, study comprising 123 consecutive female-to-male patients receiving a neophallus by GFP or MP between 2002 and 2015 at Linköping University Hospital, Sweden. Results One-hundred twenty-three patients underwent 126 primary surgical procedures (39 GFPs and 87 MPs) with the intention of reconstructing a neophallus. The mean number of procedures required in the GFP group was 5.2 ± 2.7 compared with that of 2.4 ± 1.7 in the MP group (p < 0.001). In the GFP group, 18/39 (46.2%) had a documented complication compared with 30/87 (34.5%) in the MP group; however, the difference was not statistically significant (p = 0.21). Conclusions The present study shows that the shift in method from GFP to MP has resulted in a decreased number of complications as well as a decrease in total surgical occasions. Both methods were found to be associated with relatively high frequencies of complications, however, mostly minor.
Collapse
Affiliation(s)
- A Kjölhede
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - F Cornelius
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - F Huss
- Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Plastic Surgery, Uppsala University, Uppsala, Sweden
| | - G Kratz
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden.,Department of Plastic Surgery, Linköping University Hospital, Linköping, Sweden
| |
Collapse
|
48
|
Abstract
BACKGROUND Modern approaches to erectile dysfunction (ED) often entail the use of multimodal medical therapy and surgery; however, with recent advances in microsurgery, new options may exist for patients suffering from ED. This comprehensive review of the literature serves to reevaluate anatomical and physiological principles that mediate erection to improve understanding for reconstructive surgeons hoping to offer new interventions. METHODS A search strategy for this review was agreed upon by all authors. Articles were divided into 2 categories - primary and secondary. Primary articles were defined as those in which the anatomy of the pelvis and/or perineum was the primary focus of the article, whereas secondary did not directly focus on anatomic considerations. Select historical texts and textbook chapters were also included to provide well established and critical anatomical evidence for this review. RESULTS Several approaches may be used to restore nerve function to treat neurogenic and vasculogenic ED. Somatic sensory loss can be treated by either direct neurorrhaphy or neuroplasty in the location of disruption. Microvascular techniques also exist to improve flow or to repair small vessels injured in the pelvis. Classical approaches to impotence include vein stripping to reduce venous outflow or direct vascularization to improve inflow. CONCLUSIONS Postradical prostatectomy ED has been demonstrated to improve with microsurgical interventions. In the coming years, innovation will continue and collaboration between plastic surgeons and urologists will allow us to tackle this common and difficult problem.
Collapse
|
49
|
van der Sluis WB, Pigot GLS, Al-Tamimi M, Ronkes BL, de Haseth KB, Özer M, Smit JM, Buncamper ME, Bouman MB. A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty. Urology 2019; 132:195-201. [PMID: 31229517 DOI: 10.1016/j.urology.2019.06.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty. PATIENTS AND METHODS Transgender men who underwent penile prosthesis implantation after phalloplasty between January 1989 and September 2018 were retrospectively identified. A chart study was performed recording patient demographics, perioperative complications, and reoperations. RESULTS A total of 32 patients were identified: 22 underwent free radial forearm flap, 5 anterolateral thigh, 4 anterolateral thigh/free radial forearm flap, and 1 fibular flap phalloplasty. The median age at prosthesis implantation was 36 (range 21-59) years, the mean BMI 25.9 ± 4.0 kg/m2. At first implantation, 16 inflatable (AMS Dynaflex (n = 13), AMS Ambicor (n = 3)) and 16 malleable (Coloplast genesis (n = 14), AMS Spectra (n = 2)) prostheses were placed. Of these, 5 (16%) were removed/replaced because of infection, 2 (6%) because of leakage, 2 because of extrusion, 2 because of dislocation, 2 because of dysfunction, and 1 (3%) because of pain. The postoperative course was completely uneventful in 10 (31.3%) patients. Of all implanted prostheses, including revision procedures (n = 45), 21 (44%) were surgically replaced or removed. CONCLUSION Prosthesis explantation, replacement, or revision surgery occurs frequently after penile prosthesis implantation. Patients need to be well-informed preoperatively on these complication rates.
Collapse
Affiliation(s)
- Wouter B van der Sluis
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Garry L S Pigot
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Muhammed Al-Tamimi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Brechje L Ronkes
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands; Department of Urology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Kristin B de Haseth
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Maerten Smit
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marlon E Buncamper
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
50
|
Howard KN, Zhao LC, Weinberg AC, Granieri M, Bernstein MA, Grucela AL. Robotic transanal minimally invasive rectal mucosa harvest. Surg Endosc 2019; 33:3478-3483. [DOI: 10.1007/s00464-019-06893-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 06/04/2019] [Indexed: 01/23/2023]
|