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Hegde S, Carroll EF, Doo FX, Drzewiecki B, Jensen KK, Sertic M, Pierce TT. Imaging the acute complications of gender-affirming surgeries: a primer for radiologists in the emergency setting. Abdom Radiol (NY) 2024:10.1007/s00261-024-04385-7. [PMID: 38832942 DOI: 10.1007/s00261-024-04385-7] [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: 04/15/2024] [Revised: 05/09/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024]
Abstract
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.
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Affiliation(s)
- Siddhi Hegde
- Department of Radiology, Center for Ultrasound Research and Translation (CURT), Massachusetts General Hospital, 101 Merrimac St, Boston, MA, 02114, USA.
| | - Evelyn F Carroll
- Breast Imaging/Hospital and Emergency Radiology Divisions, Mayo Clinic, Rochester, MN, USA
| | - Florence X Doo
- Body/Abdominal Imaging Division, University of Maryland Medical Center, Baltimore, MD, USA
| | - Beth Drzewiecki
- Pediatric Surgical Services (MGfC), Massachusetts General Hospital, Boston, MA, USA
| | - Kyle K Jensen
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, OR, USA
| | - Madeleine Sertic
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
| | - Theodore T Pierce
- Department of Radiology, Center for Ultrasound Research and Translation (CURT), Massachusetts General Hospital, 101 Merrimac St, Boston, MA, 02114, USA
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
- Department of Radiology, Harvard Medical School, Boston, MA, USA
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2
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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.
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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
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3
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Pratt-Chapman ML, Astorino J, Goyal S, Schmit B, Yap ML, Bajaj S, Angiulo E. Radiology and radiation oncology considerations for transgender and intersex patients: A qualitative study. J Med Imaging Radiat Oncol 2023; 67:185-192. [PMID: 36790031 DOI: 10.1111/1754-9485.13516] [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: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023]
Abstract
INTRODUCTION In this qualitative study, we explored experiences of radiologists and radiation oncologists in providing clinical care to transgender, gender diverse (TGD), and intersex patients by asking about comfort level, relevant past training and training gaps, and clinical recommendations for TGD and intersex patient care. METHODS A purposive sample of radiology and radiation oncology professionals (n = 16) from diverse practice settings were interviewed on a videoconferencing platform. Transcripts were auto-populated and checked manually for accuracy. Two coders used a mix of deductive and inductive coding to identify key themes. Member checking was conducted with interviewees. RESULTS Participants reported major gaps in training, knowledge, and confidence related to all aspects of TGD and intersex patient care. Recommendations for improvements included training that encompassed key terminology, how to conduct a physical exam on TGD and intersex patients, radiology and radiation oncology adaptations for TGD and intersex patients, and care coordination among multi-disciplinary oncology team members and gender affirming care providers. Exposure to diverse TGD and intersex persons in personal and professional life contributed to higher levels of comfort among providers in caring for TGD and intersex patients. CONCLUSION Gaps in knowledge and limited confidence characterized the sample. Training at all levels is needed to improve radiology and radiation oncology care for TGD and intersex patients.
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Affiliation(s)
- Mandi L Pratt-Chapman
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA.,Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
| | - Joseph Astorino
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Sharad Goyal
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Berndt Schmit
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Mei Ling Yap
- Collaboration for Cancer Outcomes, Research and Evaluation (CCORE), UNSW Sydney, Sydney, New South Wales, Australia.,The George Institute for Global Health, UNSW Sydney, Sydney, New South Wales, Australia.,Liverpool and Macarthur Cancer Therapy Centres, Western Sydney University, Sydney, New South Wales, Australia.,School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Shiv Bajaj
- GW Cancer Center, School of Medicine and Health Sciences, The George Washington University, Washington, District of Columbia, USA
| | - Emily Angiulo
- Milken Institute School of Public Health, The George Washington University, Washington, District of Columbia, USA
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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.
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Revels JW, Wang SS, Weaver JS, Foreman JR, Gallegos MA, Thompson WM, Katz D, Moshiri M. A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment. Br J Radiol 2022; 95:20211034. [PMID: 35001669 PMCID: PMC10996428 DOI: 10.1259/bjr.20211034] [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: 09/05/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 11/05/2022] Open
Abstract
Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.
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Affiliation(s)
- Jonathan Wesley Revels
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Sherry S Wang
- Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah,
United States
| | - Jennifer S Weaver
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Jordan R Foreman
- Department of Urology, University of New Mexico,
Albuquerque, New Mexico, United
States
| | - Maxx A Gallegos
- Department of Urology, University of New Mexico,
Albuquerque, New Mexico, United
States
| | - William M Thompson
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Douglas Katz
- Department of Radiology, NYU Langone Hospital - Long
Island, Mineola, New York,
United States
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University,
Nashville, Tennessee, United
States
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Classification and Segmentation Algorithm in Benign and Malignant Pulmonary Nodules under Different CT Reconstruction. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:3490463. [PMID: 35495882 PMCID: PMC9050279 DOI: 10.1155/2022/3490463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 03/01/2022] [Accepted: 04/08/2022] [Indexed: 11/17/2022]
Abstract
Methods The imaging data of 55 patients with chest CT plain scan in the Xuancheng People's Hospital were collected retrospectively. The data of each patient included lung window reconstruction, mediastinum reconstruction, and bone window reconstruction. The depth neural network and 3D convolution neural network were used to construct the model and train the classification and segmentation algorithm. The pathological results were the gold standard for benign and malignant pulmonary nodules. The classification and segmentation algorithms under three CT reconstruction algorithms were compared and analyzed by analysis of variance. Results Under the three CT reconstruction algorithms, the classification accuracy of pulmonary nodule density types was 98.2%, 96.4%, and 94.5%, respectively. The Dice coefficients of all nodule segmentation were 80.32% ± 5.91%, 79.83% ± 6.12%, and 80.17% ± 5.89%, respectively. The diagnostic accuracy between benign and malignant pulmonary nodules under different reconstruction algorithms was 98.2%, 96.4%, and 94.5%, respectively. There was no significant difference in the classification accuracy, Dice coefficients, and diagnostic accuracy of pulmonary nodules under three different reconstruction algorithms (all P > 0.05). Conclusion The depth neural network algorithm combined with 3D convolution neural network has a good efficiency in identifying benign and malignant pulmonary nodules under different CT reconstruction classification and segmentation algorithms.
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Kakadekar A, Greene DN, Schmidt RL, Khalifa MA, Andrews AR. Nonhormone-Related Histologic Findings in Postsurgical Pathology Specimens From Transgender Persons. Am J Clin Pathol 2022; 157:337-344. [PMID: 34596219 DOI: 10.1093/ajcp/aqab143] [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: 03/23/2021] [Accepted: 07/28/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The objective of this review is to characterize the literature addressing postprocedural complications in persons undergoing gender-affirming surgeries. METHODS A literature search using the OVID MEDLINE and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender persons from 1946 to April 2021. The studies describing postsurgical complications were categorized based on anatomic site, type of complication, study design, publication region, and date. RESULTS Thirty-nine studies describing postsurgical complications in transgender women were identified. The most common sites of postprocedural pathology included the breasts and neovagina, with additional studies including buttocks and thighs, cutaneous sites, and the pulmonary system. Most of the literature comprised case reports, followed by case series and comparative studies. The search did not identify any studies of complications secondary to masculinizing surgeries. CONCLUSIONS This body of literature is small but growing. Most studies are case reports. There are significant gaps in the literature. The literature in this area is not yet mature enough to support a meta-analysis.
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Affiliation(s)
- Archan Kakadekar
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Canada
| | - Dina N Greene
- Department of Laboratory Medicine, University of Washington, Seattle, WA,USA
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City, UT,USA
| | - Mahmoud A Khalifa
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Alicia R Andrews
- Department of Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, Canada
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Perineal Cyst in Transgender Men: A Rare Complication Following Gender Affirming Surgery - A Case Series and Literature Overview. Sex Med 2021; 9:100415. [PMID: 34348219 PMCID: PMC8498948 DOI: 10.1016/j.esxm.2021.100415] [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: 01/13/2021] [Revised: 06/28/2021] [Accepted: 07/02/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Genital gender affirming surgery (gGAS) is usually the final stage in the medical transition for transgender men and consists of creating a neophallus and neo-scrotum, with or without urethral lengthening(UL). To reduce the complication risks of UL, a mandatory colpectomy is performed prior to UL. Colpectomy is considered a complex surgery, which may lead to various perioperative complications. There are few long-term complications reported. Aim To describe the clinical presentation and management of 3 consecutive transgender men presenting with a perineal cyst following gGAS. Methods After obtaining informed consent all clinical data was collected, including medical history, current symptoms, imaging, as well as surgery and histological outcomes. Furthermore, a literature search was performed. Main outcome measure To hypothesize the aetiology of the perineal cyst based on current published literature. Results Three otherwise healthy transgender men, ages 26–46 with a similar medical history, presented with a perineal cyst several months or years following colpectomy and gGAS with UL. All patients underwent surgery to remove the cyst. Several theories regarding aetiology of this perineal cyst are discussed in this report. Conclusion There remain several gaps in our knowledge regarding the aetiology and management of this perineal cyst. Therefore, further research is necessary. Asseler JD, Ronkes BL, Groenman FA, et al. Perineal Cyst in Transgender Men: A Rare Complication Following Gender Affirming Surgery – A Case Series and Literature Overview. J Sex Med 2021;9:100415.
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Hassan O, Sun D, Jha P. Imaging in Gender Affirmation Surgery. Curr Urol Rep 2021; 22:14. [PMID: 33515366 PMCID: PMC7847456 DOI: 10.1007/s11934-020-01029-3] [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] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose of Review This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation. Recent Findings The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Summary Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.
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Affiliation(s)
- Omar Hassan
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA.
| | - Derek Sun
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| | - Priyanka Jha
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
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Theisen JG, Amarillo IE. Creating Affirmative and Inclusive Practices When Providing Genetic and Genomic Diagnostic and Research Services to Gender-Expansive and Transgender Patients. J Appl Lab Med 2020; 6:142-154. [PMID: 33236080 DOI: 10.1093/jalm/jfaa165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/24/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Gender expansive and transgender (GET) healthcare extends beyond gender-affirming therapies, reaching every medical specialty and subspecialty. As the number of GET patients seeking health services has increased, so has the need for standards of care regarding GET-affirmative practices throughout the healthcare system. As such, the number of publications surrounding GET-affirmative practices has steadily risen. However, even as such research has gained ground in other areas, one realm in which there has been a relative lag is genetics and genomics (GG). CONTENT In this article, we track the GET patient and their laboratory sample from the clinic to the GG laboratory and back. Throughout the preanalytical, analytical, and postanalytical phases, we identify publications, recommendations, and guidelines relevant to the care of the GET community. We also identity knowledge gaps in each area and provide recommendations for affirmative and inclusive processes for addressing those gaps. SUMMARY We have identified the practices involved in GG services that would benefit from GET-affirmative process improvement, reviewing relevant affirmative guidelines. Where guidelines could not be found, we identified those knowledge gaps and suggested potential solutions and future directions for implementing GET-affirmative practices.
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Affiliation(s)
- J Graham Theisen
- Department of Obstetrics and Gynecology, Section of Reproductive Endocrinology, Infertility, and Genetics, Medical College of Georgia, Augusta University, Augusta, GA
| | - Ina E Amarillo
- Division of Laboratory and Genomic Medicine, Department of Pathology and Immunology, Washington University School of Medicine in Saint Louis, MO
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Nazarian M, Bluebond-Langner R, Smereka P, Zhao L, Ream J, Hindman N. Spectrum of imaging findings in gender-affirming genital surgery: Intraoperative photographs, normal post-operative anatomy, and common complications. Clin Imaging 2020; 69:63-71. [PMID: 32659682 DOI: 10.1016/j.clinimag.2020.06.039] [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: 03/18/2020] [Revised: 05/30/2020] [Accepted: 06/26/2020] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Matthew Nazarian
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA.
| | | | - Paul Smereka
- NYU Langone Medical Center, 560 First Avenue, New York, NY 10016, USA.
| | - Lee Zhao
- NYU Langone Medical Center, 222 E 41st St, New York, NY 10017, USA.
| | - Justin Ream
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA
| | - Nicole Hindman
- NYU Langone Medical Center, 660 First Avenue, New York, NY 10016, USA.
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