Postoperative imaging of phalloplasties and their complications

Imaging the acute complications of gender-affirming surgeries: a primer for radiologists in the emergency setting

Gender-affirming surgery (GAS) is increasingly being performed. GAS is tailored to the patient leading to a diverse spectrum of radiologic post-operative findings. Radiologists who are unfamiliar with expected anatomic alterations after GAS may misdiagnose important complications leading to adverse patient outcomes. This collaborative multi-institutional review aims to: Describe relevant embryology and native anatomy. Describe relevant Gender-Affirming Surgery (GAS) techniques and expected neo-anatomy with associated complications, including common terminology. Review expected imaging appearance of neo-anatomy/postoperative findings. Review multi-modality [ultrasound, plain film, retrograde urethrogram, computed tomography] emergent imaging findings. Understand unique patient evaluation and imaging protocol considerations in the GAS population. Discuss pearls and pitfalls of imaging in the acute post-GAS setting.

Revision Phalloplasty: Evaluation, Algorithms, and Techniques for Salvage after Major Complications

BACKGROUND

Phalloplasty is among the most complex and technically demanding reconstructive procedures. As a larger pool of surgeons perform this difficult procedure, more patients will present with major complications. There are few published data on the comprehensive evaluation and management of these patients, particularly those needing correction of multiple ongoing complications, which may require consideration of starting over with a new microsurgical procedure versus salvage of the existing flap.

METHODS

A literature review on complications of phalloplasty was conducted in combination with drawing upon the experience of 2 high-volume phalloplasty teams (Johns Hopkins/Harvard and GU Recon Clinic/Buncke Clinic) in treating patients with severe postsurgical issues. The purpose was to analyze critical factors and develop algorithms for secondary revision.

RESULTS

Common complications of phalloplasty include urethral strictures and fistulas, diverticula, excess bulk, phalloplasty malposition, hypertrophic or keloidal scarring, and partial or total flap loss. In severe cases, local flaps or free flaps may be required for reconstruction. The decision to revise the existing neophallus or start over with a new flap for phalloplasty is particularly critical. Multidisciplinary team collaboration is essential to develop comprehensive plans that will resolve multiple concomitant problems while meeting patient goals for a functional and aesthetic neophallus.

CONCLUSIONS

Preserving the original flap for phalloplasty is ideal when feasible. Additional local or free flaps are sometimes necessary in situations of significant tissue loss. In severe cases, complete redo phalloplasty is required. The algorithms proposed provide a conceptual framework to guide surgeons in analyzing and managing severe complications after phalloplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

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.

One or Two Stage Buccal Augmented Urethroplasty has a High Success Rate in Treating Post Phalloplasty Anastomotic Urethral Stricture

OBJECTIVE

To describe the outcomes of single-stage and staged repairs in properly selected patients with phalloplasty anastomotic strictures.

METHODS

A bi-institutional retrospective review was performed of all patients who underwent anastomotic stricture repairs between 7/2014-8/2020. Those who had prior augmented urethroplasties or poorly vascularized tissue underwent two-stage repairs (Group-2), all others underwent single-stage repair with a double-face (dorsal inlay and ventral onlay) buccal mucosal graft urethroplasty (Group-1). Postoperatively, urethral patency and patient reported outcome measures (PROMs) were assessed.

RESULTS

Twenty-three patients with anastomotic strictures were identified. Fourteen patients met inclusion criteria and had 1-year follow-up (9 in Group-1; 5 in Group-2). Nine patients (64%) had prior failed interventions (56% Group-1; 80% Group-2). At a mean follow-up of 33.9 (Group-1) and 35.2 months (Group-2) there were two stricture recurrences in Group-1 (22%) and none in Group-2. PROMs were completed by 12 patients. All patients reported the ability to void standing. Post-void dribbling was present in the majority of patients (7/7 Group-1; 2/4 in Group-2). Mean IPSS was 3.9 (0-14) for Group-1 and 1 (0-3) for Group-2. All reported at least a moderate improvement in their condition on GRA (Group-1 +3 71%, +2 29%; Group-2 +3 100%).

CONCLUSION

Single-stage repairs are feasible for patients with anastomotic strictures who have well vascularized tissue and no prior single-stage buccal mucosa augmented urethroplasty failures. Staged repairs are feasible for patients with poor tissue quality. Proper patient selection is important for successful reconstruction.

Total phallic construction techniques in transgender men: an updated narrative review

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.

Single versus two-stage phalloplasty for transgender female-to-male patients: a systematic review of the literature

Phalloplasty is the main treatment for gender dysphoria disorder. It is difficult to ascertain if staging of phalloplasty influences the rate of complications. We aim to describe and compare the rates of complication between single versus two-stage phalloplasty for transgender female-to-male patients. PubMed, Ovid Medline, EMBASE and SCOPUS databases were queried for studies reporting complications of female-to-male transgender patients who underwent phalloplasty. The keywords "phalloplasty", "female to male", "outcome", "complication" and synonyms in different combinations were used for the search. Only studies that could identify whether phallic shaft creation was performed in a single or two-stage procedure were included. From a total of 336 articles, 20 met the inclusion criteria. Sixteen studies reported complications associated with a single-stage phalloplasty and seven studies identified complications after a two-stage procedure. The most common complications found for both groups of staging were fistula, stricture and total/partial flap necrosis. Patients who underwent two-stage phalloplasty had higher complication rates (partial or total flap necrosis and fistulas), compared with the single-stage procedure (P<0.05). In conclusion, this systematic review identified the impact of staging in the rate of complications related to phalloplasty for transgender female-to-male patients; a two-stage phalloplasty has a higher rate of complications.

Imaging evaluation for the diagnosis and management of complications of gender-affirming surgeries

Gender-affirming surgeries (GS) allow transgender individuals to align their physical sexual characteristics with their gender identity, which can result in profound changes to native anatomy. Medical imaging is a useful tool for evaluation of patients who have undergone or plan to pursue GS. Given the complex nature of some GS, complications may arise. The choice of imaging modality can be guided by the clinically suspected complications. For example, urethral complications of phalloplasty are best evaluated with fluoroscopic urethrography. Pelvic magnetic resonance imaging provides detailed depiction of pelvic neo-anatomy after vaginoplasty. Many GS involve the creation of vascular pedicles for tissue grafts, which are at risk of thrombosis and graft ischemia. Doppler ultrasound and computed tomography (CT) angiography are important for diagnosis of these dreaded complications. Moreover, interventional radiologists may participate in endovascular treatments for such complications. Various imaging modalities may assist the surgeon in the postoperative evaluation of patients with suspected complications after GS, and imaging protocol modifications may be required to improve diagnostic accuracy. For example, rectal or neovaginal contrast material may be necessary to ensure accurate imaging evaluation, such as delineation of fistulas. Working together, surgeons and radiologists can ensure accurate imaging assessment while accommodating for patient comfort.

Systematic Review of Transgender-Related Research in Radiology Over a Decade: There Is Work to Be Done

PURPOSE

The ACR has established that diversity and inclusion are central to its mission of excellence in the radiologic professions; therefore, radiologists have a responsibility to serve the imaging needs of the transgender community. To understand radiologists' current knowledge of transgender topics, the authors performed a systematic review of publications from radiology journals.

METHODS

A lexicon of 14 transgender-related terms was created and expanded through a PubMed keyword search. From the 129 journals from the radiology, nuclear medicine, and medical imaging category of Journal Citation Reports, 106 journals met the inclusion criteria, including English translation and Scopus data for the study period. Using the Scopus advanced search feature, articles with titles, abstracts, Medical Subject Headings terms, or key words including 1 of 14 transgender terms were identified and analyzed.

RESULTS

Of the more than 200,000 articles published by the 106 journals from January 2008 to July 2019, 29 relevant articles were identified. Only 14 of the 106 journals published any transgender-related topics. The volume of articles has increased over time. The largest proportion of articles was published under the "general radiology" subsection, with the majority of these being editorials (6 of 10). Most of the original research was published under "neuroradiology" (7 of 13). Use of nonpreferred language, such as "transsexual" and "natal sex" was present through 2019.

CONCLUSIONS

Publication on transgender-related topics was uncommon among radiology journals. It is important to encourage further research and publication on transgender topics, as well as use of respectful, accepted language in radiology journals.

Spectrum of imaging findings in gender-affirming genital surgery: Intraoperative photographs, normal post-operative anatomy, and common complications

Gender-affirming surgery is becoming more accessible, and radiologists must be familiar with both terminology and anatomy following gender-affirming surgical procedures. This essay will review the most common gender-affirming genital surgeries, their post-operative anatomy, and common complications by providing intraoperative photographs, illustrations, and cross-sectional images. Routine radiologic imaging recommendations for transgender patients will also be reviewed.

Gender-affirming surgical techniques, complications, and imaging considerations for the abdominal radiologist

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.

Peripheral Vascular Complication of Transgender Reassignment Surgery

BACKGROUND

Gender-reassignment surgeries are technically challenging and associated with detrimental vascular complications.

METHODS

A 49 year-old female status-post phalloplasty presented with peripheral vascular complication resulting in disabling claudication. Initial anastomotic attempt was rendered nonviable to sustain the constructed phallus resulting in superficial femoral artery stenosis. Covered stent placement corrected the stenosis and alleviated the claudication.

RESULTS

As gender-reassignment surgeries increase, greater understanding of potential vascular complications is needed. Involvement of multidisciplinary teams is necessary to optimize patient safety and outcomes.

CONCLUSIONS

Vascular surgery should play a larger role in these complex revascularizations and vessel anastomoses to ensure quality blood flow to the reconstructed genitalia.

Imaging of transgender patients: expected findings and complications of gender reassignment therapy

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.

Urethral lithiasis after phalloplasty

Female-to-male transsexual patient, 22 years old, with neophallus from radial forearm free flap (phalloplasty in March 2014), history of urethral fistula and urethral stricture 1 year later treated with surgical correction (fistulectomy) and suprapubic urinary diversion. Subsequently, he developed a new urethral stenosis located in the urethral anastomosis. Immediately proximal to the stenosis, there was a urethral dilatation (pseudodiverticulum) with a fibrous septum and several retracted stones. The stones were fragmented, the fibrous septum destroyed and the urethral stricture corrected, all with holmium laser. After 40 months of follow-up the patient shows satisfactory urinary flow with no signs of residual lithiasis or stricture.

Urologic Complications After Phalloplasty or Metoidioplasty

In the past decade, issues facing transgender individuals have come to the forefront of popular culture, political discourse, and medical study. The evaluating physician should have knowledge of the reconstructed anatomy, as well as potential postoperative complications. This knowledge will aid in providing appropriate care and recognizing issues that may require specialized urologic care. Transgender anatomic definitions and a synopsis of common urologic complications specific to transmen, including urethrocutaneous fistulae, neourethral strictures, and persistent vaginal cavities are discussed.

Masculinizing Genital Gender Confirmation Surgery

INTRODUCTION

This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity.

AIM

To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation.

METHODS

A review of relevant literature through May 2017 was performed via PubMed.

MAIN OUTCOME MEASURES

To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty.

RESULTS

A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications.

CONCLUSION

A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, et al. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.

Anatomy of the pedicled anterolateral thigh flap for phalloplasty in transitioning-males

Incidence of transexualism and request for neophalloplasty is increasing yielding a current prevalence of trans-male in the USA of 1:2500. Surgeons have explored various techniques to improve desirable outcomes of neophallic construction, decrease the length of surgery, and minimize stigmatizing scars. The anterolateral thigh (ALT) flap is an alternative to the traditional radial forearm flap for patients who do not want a forearm scar. Surgical text descriptions were enhanced by the creation of new anatomic illustrations. Anatomy of the donor and recipient sites as well as the surgical technique leading to creation of the neophallus are demonstrated in detail with new relevant illustrations. The ALT flap is a skin, fat and fascia flap that is usually supplied by the descending branch of the lateral circumflex femoral vessels and the lateral femoral cutaneous nerve. However, variability in neurovascular supply does exist with important clinical implications. In the pedicled surgical procedure, neurovascular supply is left partly attached to the donor site ("pedicle") and simply transposed to the perineum, keeping the pedicle intact as a conduit to supply the tissue with blood and innervation. ALT flap offers clinical advantages of less obvious donor site concealable with clothing, decreased surgical time, preservation of erogenous sensation and vascular supply of the flap without microsurgical anastomosis of nerves and vessels, and good potential for urethroplasty. This surgery may be difficult in patients with thicker skin and more subcutaneous thigh fat. Clin. Anat, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Total phallic reconstruction using radial forearm free flap after iatrogenic penile amputation

INTRODUCTION

The iatrogenic loss of the penis is a rare situation. We present a challenging case of deferred total penile reconstruction in a genetic male.

MATERIAL AND METHODS

A 57-year-old man with the loss of the penis due to a penile abscess and necrosis secondary to penile curvature surgery. The reconstruction was performed over several operations using a radial forearm free flap (RFFF) and placement of a customised inflatable prosthesis a year later.

RESULTS

During the first operation, the penile abscess was drained, the necrotic residues were debrided and placement of hypogastric drainage. Seven weeks later, phalloplasty was performed with RFFF and a tube-in-tube neourethra was constructed. Multiple microsurgical anastomosis was performed, and the donor site was coated with a skin graft from the thigh of partial thickness. The surgery lasted 10hours and had the complication of hair growth in the neourethra, which required mechanical endoscopic depilation on repeated occasions. The patient regained penile sensitivity. Eighteen months after the phalloplasty, a Zephyr single-body inflatable prosthesis (Geneva, Switzerland) was implanted, using the tunica albuginea of the proximal corpus cavernosum. The patient was satisfied with the aesthetics and urinary and sensory function. Four months later, the patient is gaining confidence to consider penetration.

CONCLUSIONS

Despite the risk of postoperative complications and the need for multiple operations, phallic reconstruction with RFFF and the placement of a customised prosthetic implant can improve urinary and sexual function secondary to the loss of the penis.

Mystery and realities of phalloplasty: a systematic review

The neophallus creation is still a mystery and it remains challenging even today. In this article, we performed a comprehensive review of the literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016. In this review, we have included 15 research articles and the results of 276 patients were examined. Studies revealed several indications and when indications were reviewed, 191 patients were female-to-male transgender, 9 patients had disorder of sex development/micropenis, 16 had penile amputation/trauma, 9 had ambiguus genitalia, 40 had exstrophy and/or epispadias, 11 had other problems. As a result of this review, phalloplasty is a reliable and useful operation with good functional and aesthetical results.

Urologic Sequelae Following Phalloplasty in Transgendered Patients

In recent years, the issues of the transgender population have become more visible in the media worldwide. Transgender patients at various stages of their transformation will present to urologic clinics requiring general or specialized urologic care. Knowledge of specifics of reconstructed anatomy and potential unique complications of the reconstruction will become important in providing urologic care to these patients. In this article, we have concentrated on describing diagnosis and treatment of the more common urologic complications after female-to-male reconstructions: urethrocutaneous fistulae, neourethral strictures, and symptomatic persistent vaginal cavities.