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Mazzawi M, Maxwell A. Addressing the Healthcare Needs of Transgender Youth in the Emergency Department. Pediatr Emerg Care 2024; 40:486-491. [PMID: 38815145 DOI: 10.1097/pec.0000000000003194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
ABSTRACT Transgender is a term that refers to individuals who identify with a gender that is different from the sex assigned to them at birth. In addition to gender dysphoria, many transgender youth experience a number of challenges including homelessness, violence, and mental health problems such as suicidality. Although transgender people represent a growing subset of the population, most providers receive very little training specific to the unique healthcare needs of transgender patients. In this CME review article, we define relevant terminology then discuss best practices for clinical encounters involving transgender youth in the emergency department. Finally, we review gender-affirming care including behavioral modifications, hormones, and surgeries for transfeminine and transmasculine individuals.
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Affiliation(s)
- Malek Mazzawi
- From the Clinical Assistant Professor of Pediatrics, Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, USC Keck School of Medicine, Los Angeles, CA
| | - Angela Maxwell
- Assistant Instructor Emergency Medicine and Pediatrics, Division of Emergency Medicine, Children's National Hospital, The George Washington School of Medicine and Health Sciences, Washington, DC
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2
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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.
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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
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3
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Cripps C. Thinking outside the box: Alternative techniques for gender affirming phalloplasty. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25104] [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: 11/10/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Courtney Cripps
- Division of Plastic Surgery The University of Chicago Medicine & Biological Sciences Chicago Illinois USA
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4
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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
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5
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Neuville P, Carnicelli D, Boucher F, Carlier A, Ruffion A, Morel-Journel N. [Genital surgical care for trans people]. Med Sci (Paris) 2022; 38:919-925. [PMID: 36448899 DOI: 10.1051/medsci/2022153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Paul Neuville
- Service d'urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite Cedex, France - Université Claude Bernard Lyon 1, Lyon, France
| | - Damien Carnicelli
- Service d'urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite Cedex, France
| | - Fabien Boucher
- Service de chirurgie plastique et reconstructrice, Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Lyon, France
| | - Adélaïde Carlier
- Service de chirurgie maxillofaciale, stomatologie, chirurgie orale et chirurgie plastique de la face, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite Cedex, France
| | - Alain Ruffion
- Service d'urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite Cedex, France - Université Claude Bernard Lyon 1, Lyon, France
| | - Nicolas Morel-Journel
- Service d'urologie, Hospices Civils de Lyon, Hôpital Lyon Sud, Pierre-Bénite Cedex, France
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6
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Charoenmakpol N, Chiddaycha M, Wainipitapong S. The Arizona Sexual Experiences Scale-the Thai Translation (ASEX-Thai): Reliability and validity in Thai patients with mental disorders. F1000Res 2022; 11:503. [PMID: 36226038 PMCID: PMC9525992 DOI: 10.12688/f1000research.111051.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Sexual dysfunction is common among patients with mental disorders but receives less clinical attention, especially in Thailand and other Asian countries. The Arizona Sexual Experiences Scale-the Thai Translation (ASEX-Thai), a self-rated, brief, questionnaire is a potential tool for screening for sexual dysfunction in this population. Our study aimed to assess the reliability and validity of ASEX-Thai in Thai patients with mental disorders. Methods: We enrolled 202 patients from an outpatient psychiatric department at a tertiary hospital in Bangkok, Thailand. Demographic data, clinical data, and diagnosis of sexual dysfunction were assessed. ASEX-Thai was done, and we analyzed the test’s psychometric properties. Results: Most participants were diagnosed with major depressive disorder (48%). There was a positive correlation between the ASEX-Thai and sexual dysfunction diagnosis (r = 0.402, p < 0.001). The KMO coefficient was 0.77 and Barlett’s sphericity test was significant (χ
2 = 409.76, p<0.001). A score of ≥ 17 points of the ASEX-Thai was the most suitable for sexual dysfunction screening (sensitivity 77.23 %, and specificity 58.42 %). For reliability, the Cronbach’s alpha coefficient (0.831) showed good internal consistency. Conclusions: The ASEX-Thai is a valid and reliable self-rated questionnaire for screening for sexual dysfunction among Thai patients with mental disorders. The test could help clinicians to evaluate this undetected condition and deliver proper interventions.
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Affiliation(s)
- Natthaphon Charoenmakpol
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Mayteewat Chiddaycha
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, 10330, Thailand
| | - Sorawit Wainipitapong
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, the Thai Red Cross Society, Bangkok, 10330, Thailand
- Center of Excellence in Transgender Health (CETH), Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
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7
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Lee WG, Christopher AN, Ralph DJ. Phalloplasty following penectomy for penile cancer. Asian J Urol 2022; 9:460-466. [PMID: 36381591 PMCID: PMC9643302 DOI: 10.1016/j.ajur.2022.05.005] [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: 12/11/2021] [Revised: 03/22/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Penile reconstruction or phalloplasty following penectomy can be offered where the functional penile length is inadequate for a man to void while standing or to have sexual intercourse. Phalloplasty is usually staged due to the complex surgical techniques required. This narrative review describes the technical concepts and summarises the contemporary outcomes following phalloplasty in this challenging cohort. Methods A retrospective review of the English literature was performed between January 1946 till November 2021. The data were synthesised and complemented by the expert opinion of the authors with 20 years of experience in this field. The flaps are ideally designed with an integrated urethra or alternatively, a further free flap urethroplasty can be offered. Phalloplasty is further complicated following penectomy by scarring from the previous surgery and the potential loss of structures that would normally be present at the recipient site. Results There are limited published data with a total of 19 men recorded in the literature. Only the radial artery forearm free flap and anterolateral thigh flap have been described in this cohort of patients. Functional outcomes including standing micturition, sensation in the neophallus, and the ability to orgasm are good. Overall quality of life and satisfaction was also good despite the high risk for long-term complications of the neophallus and donor site. Conclusion Phalloplasty following penectomy requires microsurgical transfer of a free flap or a pedicled flap to reconstruct a neophallus. An erectile device is inserted at a later stage to facilitate sexual intercourse, if desired. Surgical scarring from penectomy and the potential loss of vasculature that would normally be present at the recipient site may further complicate reconstruction. Surgical and functional outcomes are acceptable based on the limited published experience to date.
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Affiliation(s)
- Wai Gin Lee
- University College London Hospital, London, United Kingdom
- St Peter's Andrology, London, United Kingdom
- Corresponding author.University College London Hospital, London, United Kingdom
| | - A. Nim Christopher
- University College London Hospital, London, United Kingdom
- St Peter's Andrology, London, United Kingdom
| | - David J. Ralph
- University College London Hospital, London, United Kingdom
- St Peter's Andrology, London, United Kingdom
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8
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Gupta R, Gupta R, Puri A. A Comparative Study of Urinary Complication Rates before and after the Incorporation of a Urethral Lengthening Technique during Masculinizing Genital Gender Affirmation Surgery. Indian J Plast Surg 2022; 55:196-204. [PMID: 36017407 PMCID: PMC9398528 DOI: 10.1055/s-0042-1749104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 12/04/2021] [Indexed: 11/07/2022] Open
Abstract
Objectives
Masculinizing genital gender affirmation surgery (MgGAS) consists of operative procedures designed to help the transition of transmen in their journey toward male gender role. Phalloplasty and urethral lengthening remain the most challenging of these surgeries, as the female urethra (4 cm long) must be lengthened to male dimensions (15–29 cm) with anastomosis at two sites, the native urethra/pars fixa urethra and the pars fixa urethra-penile urethra. As a result, there is a high incidence of urinary complications such as strictures and fistulae. Authors incorporated a urethral lengthening technique to reduce urinary complications in MgGAS. They compare the rates of urinary complications rates in cohorts before and after the introduction of this technique.
Materials and Methods
Authors have been performing phalloplasty since past 27 years, utilizing mainly free radial artery forearm flap (fRAFFp 431 cases) and pedicled anterolateral thigh flap (pALTp 120 cases). A retrospective review and comparison of urinary complications were performed before and after the introduction of their new technique since March 2017.
Results
There was a statistically significant reduction in the incidence of stricture with and without fistulae (25.94% with conventional and 4.17% with urethral lengthening technique
p
= 0.001) and fistulae alone (12.81% with conventional and 2.78% with urethral lengthening technique
p
= 0.011) in fRAFFp cases. In pALTp cases, the respective reductions were 43.08 to 17.07%,
p
= 0.006 (significant), and 13.85 to 4.88%,
p
= 0.197 (not statistically significant).
Conclusion
Over years, the rates of urinary complications in MgGAS have remained constant, varying from 25 to 58% for strictures and 17 to 75% for fistulae as noted by many authors. Authors noted that in most of their cases, strictures occurred at distal pars fixa urethra (DPFU)-penile urethra anastomosis and incorporated a urethral lengthening technique, which lengthens the DPFU by 3 to 5 cm at this anastomotic site, thus significantly reducing the anastomotic tension and the rate of urinary complications.
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Affiliation(s)
- Richie Gupta
- Department of Plastic, Aesthetic and Reconstructive Surgery and Gender Identity Clinic, Fortis Hospital, Shalimar Bagh, Delhi, India
| | - Rajat Gupta
- Department of Plastic, Aesthetic and Reconstructive Surgery and Gender Identity Clinic, Fortis Hospital, Shalimar Bagh, Delhi, India
| | - Anurag Puri
- Department of Urology and Kidney Transplant, Fortis Hospital, Shalimar Bagh, Delhi, India
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Roblee C, Horen SR, Jahromi AH. Commentary on Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging. Plast Reconstr Surg 2022; 150:704e-706e. [PMID: 35819988 DOI: 10.1097/prs.0000000000009373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Cole Roblee
- Rosalind Franklin University of Medicine & Science, Chicago, IL, 60064, United States
| | - Sydney R Horen
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Alireza Hamidian Jahromi
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States
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10
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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.
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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
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11
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Review on the Transgender Literature: Where Are We Now and a Step beyond the Current Practice? ENDOCRINES 2022. [DOI: 10.3390/endocrines3020026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The transgender concept is described as a clinically significant distress due to the incongruity between the experienced gender and assigned gender. A transgender person carries a gender identity that is different from their assigned sex at birth. Transgender people may be binary: male to female (transgender women) or female to male (transgender men) or genderqueer (non-binary, fluid or variable gender expression). The binary concept has been described in transgender population, where the term transwomen is used to describe people assigned male at birth (AMAB) who are recognized as females during gender transition; with the term transmen where they are assigned female at birth (AFAB) and are then recognized as males in gender transition. According to the DSM-5 classification, gender dysphoria is described when a transgender person develops clinically relevant bio-psychosocial suffering. Currently, the transgender population has gained massive public awareness through social media and gained a considerable level of attention globally. Several studies on transgender populations from different parts of the world have shown real discrimination and stigma towards transgender people, which sometimes acts as a barrier to the provision of the required care for them. Lack of access to the required information, legal issues, lack of solutions to fertility problems, financial constraints, and psychological and emotional obstacles, together with risk of sexually transmitted infections, including human immunodeficiency virus (HIV), all make the life of a transgender person more complicated. Testosterone therapy is a hormone-based therapy for transgender men that provides a body image tallying with the favored gender identification, whereas estrogen and androgen-suppressing agents are used in transgender females to produce changes compatible with their required gender identity. Gender affirmation surgery is a broad term, under which the genital reconstruction is described as a major component. Psychological conditions such as depression, substance abuse, suicidal deaths, and sexually transmitted infections, particularly among males having sex with males, are reported at a significantly higher rate among transgender populations. Cardiovascular morbidity is higher among this population, and continuous medical surveillance is warranted. Medical care provision to transgender populations should be handled with great care, while attending to the unmet needs of this population, as this care should extend beyond routine hormonal therapy and gender reassignment surgery.
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12
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Urethral reconstruction with peritoneal graft in phalloplasty for male transgender. J Plast Reconstr Aesthet Surg 2022; 75:2387-2440. [PMID: 35599225 DOI: 10.1016/j.bjps.2022.04.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 01/27/2022] [Accepted: 04/12/2022] [Indexed: 11/20/2022]
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The assessment of sexual wellbeing in treatment-seeking transgender individuals: a systematic review of the medical literature. Int J Impot Res 2022; 35:121-131. [PMID: 35115682 DOI: 10.1038/s41443-022-00529-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 01/10/2022] [Indexed: 01/09/2023]
Abstract
Sexual-wellbeing is recognized as an important aspect of quality-of-life. Yet, no overview exists of which aspects of sexual-wellbeing have been assessed in trans individuals seeking or undergoing medical treatment, nor is it clear what tools are used to evaluate the effect of medical treatment on sexual-wellbeing. First, to identify which topics pertaining to sexual-wellbeing have been assessed in transgender individuals in a medical context. Second, to determine which tools have been used for measuring aspects of sexual-wellbeing. A conceptual framework of sexual-wellbeing, was used as reference. A literature search (in PubMed, Embase, Cochrane Library) was performed up to March 10th, 2020. Studies that assessed aspects of sexual-wellbeing in transgender individuals' medical context were included in this review. Specific sexual topics addressed in each study were extracted by two independent reviewers. Thematic analysis was performed to identify sexual themes. Additionally, tools used to measure topics related to sexuality in transgender individuals were identified. In 172 papers, a total of 178 topics related to sexual-wellbeing were identified. Ten overarching themes were identified; sexuality, enacted sexual script, sexual activities, sexual relations, sexual response cycle, genital function, sexual function, sexual pleasure, sexual satisfaction, and quality-of-sex-life. Functional aspects of sexuality are assessed most frequently. A variety of methods was used to evaluate aspects related to sexual-wellbeing in trans individuals and over 50 different tools were identified. Self-developed questionnaires were used most frequently (n = 80), followed by chart reviews (n = 50), self-developed structured interviews (n = 37) and physical examination (n = 13). 23 previously developed questionnaires were used, all of which were developed for a cisgender population. Many studies in trans individuals touch on topics related to sexual-wellbeing, however, a comprehensive conceptualisation of (10 themes of) sexual-wellbeing is still lacking. Still, no valid tool exists for assessing sexual-wellbeing in the trans population, but is much needed.
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Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2021; 10:100471. [PMID: 34971864 PMCID: PMC8847816 DOI: 10.1016/j.esxm.2021.100471] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. Aim To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. Methods The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. Main Outcomes Measure The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. Results The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. Conclusion The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.
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Affiliation(s)
- Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sahaand Poor Toulabi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marlon E Buncamper
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marta R Bizic
- Department of Pediatric Urology, University of Belgrade, Belgrade, Serbia
| | | | - Marco Falcone
- Department of Urology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Nim A Christopher
- Department of Urology, St Peter's Andrology Centre and The Institute of Urology, London, UK
| | - Daniel Simon
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Luis Capitán
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
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Ottaiano N, Pincus J, Tannenbaum J, Dawood O, Raheem O. Penile reconstruction: An up-to-date review of the literature. Arab J Urol 2021; 19:353-362. [PMID: 34552786 PMCID: PMC8451639 DOI: 10.1080/2090598x.2021.1957410] [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] [Indexed: 12/31/2022] Open
Abstract
Objective : To review the literature on adult penile reconstruction due to Peyronie’s disease, trauma and cosmesis, while emphasising specific surgical techniques and procedures such as phalloplasty, radial forearm free flap reconstruction, and penile transplant. Methods : A comprehensive review of the literature for the years 1992–2020 of the PubMed and SpringerLink databases was performed to identify articles on penile reconstruction. Search terms included ‘penile reconstruction’, ‘penile trauma’, ‘phalloplasty’, ‘penile transplant’, and ‘treatment of Peyronie’s’. Relevant articles were selected. All included studies were performed on adults and written in English. Results : We were able to identify 46 papers from PubMed and SpringerLink that included the research terms. From these, we included technical details of procedures and gleaned photographs of their works. Additionally, we included photographs from our institution’s own plication surgery cases. Conclusions : The field of adult penile reconstruction is performed for a plethora of reasons. From cosmetic to urgent and from routine to complex, it is most certainly a growing subset of Urology that plays a vital role for the men who need it. To our knowledge, this is the most up-to-date review of adult penile reconstruction.
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Affiliation(s)
- Nicholas Ottaiano
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Joshua Pincus
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Jacob Tannenbaum
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Omar Dawood
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Omer Raheem
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
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de Brouwer IJ, Elaut E, Becker-Hebly I, Heylens G, Nieder TO, van de Grift TC, Kreukels BPC. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021; 18:1921-1932. [PMID: 37057483 DOI: 10.1016/j.jsxm.2021.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/31/2021] [Accepted: 08/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions. AIM To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics. METHODS As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis. OUTCOMES Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics. RESULTS Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care. CLINICAL IMPLICATIONS Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare. STRENGTHS & LIMITATIONS We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare. CONCLUSION These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.
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Affiliation(s)
- Iris J de Brouwer
- Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands; Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Els Elaut
- University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium; Ghent University, Department of Experimental-Clinical and Health Psychology, Ghent, Belgium
| | - Inga Becker-Hebly
- University Medical Center Hamburg-Eppendorf, Department of Child and Adolescent Psychiatry, Psychotherapy and Psychosomatics, Hamburg, Germany
| | - Gunter Heylens
- University Hospital Ghent, Center of Sexology and Gender, Ghent, Belgium
| | - Timo O Nieder
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tim C van de Grift
- Amsterdam University Medical Center (location VUmc), Department of Plastic, Reconstructive and Hand Surgery, Amsterdam, the Netherlands; Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands.
| | - Baudewijntje P C Kreukels
- Amsterdam University Medical Center (location VUmc), Department of Medical Psychology, Amsterdam, the Netherlands; Amsterdam Public Health Institute, Amsterdam, the Netherlands
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Walton AB, Hellstrom WJG, Garcia MM. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021; 9:605-618. [PMID: 34493480 DOI: 10.1016/j.sxmr.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated. OBJECTIVES To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy. METHODS A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries). RESULTS The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or "watershed" procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes. CONCLUSION There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605-618.
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Affiliation(s)
- Alice B Walton
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA.
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Department of Urology, Los Angeles, CA, USA
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Falcone M, Preto M, Blecher G, Timpano M, Gontero P. Total phallic construction techniques in transgender men: an updated narrative review. Transl Androl Urol 2021; 10:2583-2595. [PMID: 34295745 PMCID: PMC8261414 DOI: 10.21037/tau-20-1340] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/25/2021] [Indexed: 11/06/2022] Open
Abstract
From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.
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Affiliation(s)
- Marco Falcone
- Department of Neurourology, A.O.U. Città della Salute e della Scienza di Torino - Unità Spinale Unipolare, Turin, Italy.,Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Mirko Preto
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Gideon Blecher
- Department of Urology, The Alfred Hospital, Melbourne, Australia.,Monash Health, Bentleigh East, Australia
| | - Massimiliano Timpano
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
| | - Paolo Gontero
- Department of Urology, A.O.U. Città della Salute e della Scienza di Torino - Molinette Hospital, Turin, Italy
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Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: Surgical Options and Outcomes in 813 Cases. Front Endocrinol (Lausanne) 2021; 12:760284. [PMID: 34721306 PMCID: PMC8548780 DOI: 10.3389/fendo.2021.760284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements. METHODS During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction. RESULTS Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus. CONCLUSION Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.
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Affiliation(s)
- Noemi Bordas
- Department of Urology, Semmelweis Hospital, Kiskunhalas, Hungary
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Arpad Szanto
- Urology Clinic, University of Pecs, Pecs, Hungary
| | - Miroslav L. Djordjevic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Miroslav L. Djordjevic,
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20
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D'Amico MJ, Kirshenbaum E, Gonzalez CM. Squamous Cell Carcinoma in a Transgender Man's Neo-Urethra after Metoidioplasty. Curr Urol 2020; 14:219-221. [PMID: 33488341 DOI: 10.1159/000499235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 09/10/2019] [Indexed: 01/13/2023] Open
Abstract
Metoidioplasty is a gender-affirming surgery for transgender men, which creates a neophallus using vaginal mucosa and labia majora. One known complication of this procedure is urethral stricture. We report the novel case of a patient with urethral stricture 4 years after metoidioplasty found to have squamous cell carcinoma in situ likely originating from the vaginal mucosa grafted to the neourethra, and highlight the importance of sending such strictures for pathologic evaluation.
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Affiliation(s)
| | - Eric Kirshenbaum
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
| | - Chris M Gonzalez
- Department of Urology, Loyola University Medical Center, Maywood, IL, USA
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21
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Latissimus dorsi free flap phalloplasty: a systematic review. Int J Impot Res 2020; 33:746-753. [PMID: 33184508 DOI: 10.1038/s41443-020-00371-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 01/04/2023]
Abstract
A phalloplasty is a complex genital reconstruction procedure of creating a neophallus. Several techniques to create a neophallus are described, based on different vascularized flaps, and each of them has its advantages and drawbacks. The aim of this study is to present musculocutaneous latissimus dorsi (MLD) flap as a viable option for total phalloplasty, with an interest in clinical outcomes and complications. A comprehensive literature review of all available reports about MLD flap phalloplasty was made. The following keywords were used on PubMed: latissimus dorsi musculocutaneous/myocutaneous free flap and phalloplasty. Research criteria revealed five articles and the results of 182 patients were analyzed. A total number of the patients, indications, operative technique, follow-up period, postoperative results, and complications were presented. In conclusion, MLD free flap presents a good choice for phalloplasty providing sufficient amount of tissue for safe implantation of penile prosthesis and successful penetrative sexual intercourse. The erogenous sensitivity is preserved with clitoris or glans penis incorporated into the base of the neophallus, and voiding in a standing position is achievable after urethral reconstruction. The main drawback is the lack of tactile sensation of the neophallus and the significant advantage is a well-concealed donor site.
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22
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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.
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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
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23
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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.
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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
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24
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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]
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25
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Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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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.
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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
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27
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Abstract
Phalloplasty represents the latest step in female-to-male transitioning and still remains a great challenge for transgender surgeons. Since we have two options in this transitioning-metoidioplasty and total phalloplasty-the transgender surgeon has to fully inform the individual about all aspects such as surgical steps, outcomes, advantages and disadvantages, possible complications, and expectations. Total phalloplasty with the creation of a neophallus of a similar volume to that in genetic males, is a complex and multi-staged procedure. Many different tissues (i.e., flaps) can be used, and the ideal procedure is still not established. In contrast to the above complexities involved in total phalloplasty, metoidioplasty presents a simple and one-stage procedure for the creation of a neophallus from a hormonally enlarged clitoris. This technique is very promising for individuals who desire gender-affirmation surgery without having to undergo the difficult and multistage creation of a male-sized neophallus. Also, this technique prevents scarring to the extragenital region, making the final results more acceptable for transgender individuals. Our goal is to objectively present the techniques for metoidioplasty and to define their value based on postoperative results.
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Affiliation(s)
- Miroslav L Djordjevic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
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Abstract
PURPOSE OF REVIEW Over 1.4 million adults are identified as transgender in 2014. Many of these individuals have undergone, or plan to undergo, gender-affirming surgery. This review summarizes the medical and surgical options available for the transgender population and reviews screening guidelines and fertility preservation options. In addition, it highlights the role gynecologists have in caring for this population. RECENT FINDINGS Gynecologists perform certain gender-affirming surgeries, such as hysterectomies and bilateral salpingooophorectomies. They also can play an important role in providing hormone therapy, anatomy specific cancer screening, and discussion of and/or referral for fertility preservation. SUMMARY Gynecologists are skilled to perform certain gender-affirming surgeries and play an important role in gender-affirming care.
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