1
|
Zhang TR, Castle E, Dubach-Reinhold C, Blasdel G, Kloer C, Alford A, Bluebond-Langner R, Zhao LC. Pilot Test of A Gender-conscious Sexual Health Intake Questionnaire: Increasing Inclusivity and Mitigating Bias in Sexual History Taking. Plast Reconstr Surg Glob Open 2024; 12:e5614. [PMID: 38596592 PMCID: PMC11000753 DOI: 10.1097/gox.0000000000005614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 12/28/2023] [Indexed: 04/11/2024]
Abstract
Background Sexual health is critical to overall health, yet sexual history taking is challenging. LGBTQ+ patients face additional barriers due to cis/heteronormativity from the medical system. We aimed to develop and pilot test a novel sexual history questionnaire called the Sexual Health Intake (SHI) form for patients of diverse genders and sexualities. Methods The SHI comprises four pictogram-based questions about sexual contact at the mouth, anus, vaginal canal, and penis. We enrolled 100 sexually active, English-speaking adults from a gender-affirming surgery clinic and urology clinic from November 2022 to April 2023. All surveys were completed in the office. Patients also answered five feedback questions and 15 questions from the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction (PROMIS-SexFS) survey as a validated comparator. Results One hundred patients aged 19-86 years representing an array of racial/ethnic groups, gender identities, and sexuality completed the study. Forms of sexual contact varied widely and included all possible combinations asked by the SHI. Feedback questions were answered favorably in domains of clinical utility, inclusiveness of identity and anatomy, and comprehensiveness of forms of sexual behavior. The SHI captured more positive responses than PROMIS-SexFS in corresponding questions about specific types of sexual activity. The SHI also asks about forms of sexual contact that are not addressed by PROMIS-SexFS, such as penis-to-clitoris. Conclusions SHI is an inclusive, patient-directed tool to aid sexual history taking without cisnormative or heteronormative biases. The form was well received by a diverse group of participants and can be considered for use in the clinical setting.
Collapse
Affiliation(s)
- Tenny R. Zhang
- From the Department of Urology, NYU Langone Medical Center, New York, N.Y
- Department of Urology, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, New York, N.Y
| | - Elijah Castle
- From the Department of Urology, NYU Langone Medical Center, New York, N.Y
- Hunter Alliance for Research and Translation, Hunter College of the City University of New York, New York, N.Y
| | - Charlie Dubach-Reinhold
- From the Department of Urology, NYU Langone Medical Center, New York, N.Y
- University of California San Francisco Medical School, San Francisco, Calif
| | | | - Carmen Kloer
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Medical Center, New York, N.Y
| | - Ashley Alford
- From the Department of Urology, NYU Langone Medical Center, New York, N.Y
| | | | - Lee C. Zhao
- From the Department of Urology, NYU Langone Medical Center, New York, N.Y
| |
Collapse
|
2
|
Roblee C, Keyes O, Blasdel G, Haley C, Lane M, Marquette L, Hsu J, Kuzon WM. A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today. Semin Plast Surg 2024; 38:53-60. [PMID: 38495068 PMCID: PMC10942835 DOI: 10.1055/s-0043-1778042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
The University of Michigan has played an important role in advancing gender-affirming surgery programs in the United States. The University of Michigan was home to a little-known gender identity clinic shortly after the opening of the first such clinic at Johns Hopkins. Since 1995, the University of Michigan Comprehensive Services Program (UMCGSP) has been continually offering surgical services to transgender and gender diverse patients. Here, we present the history of both programs, drawn from program documents and oral history, and explore their implications for the future sustainability of gender-affirming surgery programs. The original gender identity clinic opened in 1968, and operated in a multidisciplinary fashion, similar to other clinics at the time. Eventually, the clinic was closed due to disinvestment and lack of sufficient providers to maintain the program, problems which are being increasingly recognized as barriers for similar programs. The modern program, UMCGSP is perhaps the longest continually running gender-affirming surgical program at an academic center. In spite of challenges, key investments in education, statewide community engagement, and the development of a comprehensive care model have helped UMCGSP avoid the pitfalls of the earlier clinic and remain relevant throughout its nearly 30-year history. In the face of rising challenges to gender-affirming care in the United States, much can be learned from the sustainability of the UMCGSP. Institutions seeking to maintain gender-affirming surgery programs should ensure the availability of comprehensive care and promote the education of the health care workforce.
Collapse
Affiliation(s)
- Cole Roblee
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Os Keyes
- Department of Human Centered Design and Engineering, University of Washington, Seattle, Washington
| | - Gaines Blasdel
- University of Michigan Medical School, Medical School, Ann Arbor, Michigan
| | - Caleb Haley
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Megan Lane
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lauren Marquette
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jessica Hsu
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - William M. Kuzon
- Section of Plastic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| |
Collapse
|
3
|
Blasdel G, Everhart A, St. Amand C, Gaddis M, Grimstad F. How Do Prescribing Clinicians Obtain Consent to Initiate Gender-Affirming Hormones? Transgend Health 2023; 8:526-533. [PMID: 38130984 PMCID: PMC10732162 DOI: 10.1089/trgh.2021.0208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose Multiple consent models exist for initiating gender-affirming hormone therapy (GAHT). Our study aim was to examine the variety of approaches utilized by clinicians. Methods Online and in-person recruitment of clinicians involved in gender-affirming care was undertaken from June 2019 through March 2020. Participants completed an online survey. Results Of the 175 respondents, 148 prescribed GAHT. Sixty-one (41.2%) prescribed to adults only, 11 (7.4%) to minors only, and 76 (51.4%) prescribed to adults and minors. Of those who prescribed to adults, more than half (n=74, 54.4%) utilized a written consent model, one-fourth only verbal consent (n=33, 24.3%), and one-fifth required an additional mental health assessment (MHA) (n=29, 21.3%). Of those prescribing to minors, most required either written consent (n=39, 44.8%) or an additional MHA (n=35, 40.2%). Only 11 (12.6%) utilized only verbal consent for minors. Rationales provided for requiring an additional MHA in adults included protection from litigation, lack of competence in assessing psychosocial readiness for GAHT, and believing that this is the best way to ensure the patient has processed the information. Practicing in multidisciplinary clinics was associated with not requiring an MHA for adult GAHT. Conclusion Clinicians across fields are utilizing different models to provide the same treatment, with varying rationales for the same model. As a result, patients receive nonstandard access to care despite similar clinical presentations. Our study highlights an important area for further improvement in GAHT care.
Collapse
Affiliation(s)
- Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Avery Everhart
- Population, Health, and Place Program, Spatial Sciences Institute, Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, California, USA
| | - Colt St. Amand
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Psychology, University of Houston, Houston, Texas, USA
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA
| | - Monica Gaddis
- Department of Biomedical and Health Informatics, University of Missouri Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, USA
| |
Collapse
|
4
|
Bruce L, Khouri AN, Bolze A, Ibarra M, Richards B, Khalatbari S, Blasdel G, Hamill JB, Hsu JJ, Wilkins EG, Morrison SD, Lane M. Long-Term Regret and Satisfaction With Decision Following Gender-Affirming Mastectomy. JAMA Surg 2023; 158:1070-1077. [PMID: 37556147 PMCID: PMC10413215 DOI: 10.1001/jamasurg.2023.3352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/10/2023]
Abstract
Importance There has been increasing legislative interest in regulating gender-affirming surgery, in part due to the concern about decisional regret. The regret rate following gender-affirming surgery is thought to be approximately 1%; however, previous studies relied heavily on ad hoc instruments. Objective To evaluate long-term decisional regret and satisfaction with decision using validated instruments following gender-affirming mastectomy. Design, Setting, and Participants For this cross-sectional study, a survey of patient-reported outcomes was sent between February 1 and July 31, 2022, to patients who had undergone gender-affirming mastectomy at a US tertiary referral center between January 1, 1990, and February 29, 2020. Exposure Decisional regret and satisfaction with decision to undergo gender-affirming mastectomy. Main Outcomes and Measures Long-term patient-reported outcomes, including the Holmes-Rovner Satisfaction With Decision scale, the Decision Regret Scale, and demographic characteristics, were collected. Additional information was collected via medical record review. Descriptive statistics and univariable analysis using Fisher exact and Wilcoxon rank sum tests were performed to compare responders and nonresponders. Results A total of 235 patients were deemed eligible for the study, and 139 responded (59.1% response rate). Median age at the time of surgery was 27.1 (IQR, 23.0-33.4) years for responders and 26.4 (IQR, 23.1-32.7) years for nonresponders. Nonresponders (n = 96) had a longer postoperative follow-up period than responders (median follow-up, 4.6 [IQR, 3.1-8.6] vs 3.6 [IQR, 2.7-5.3] years, respectively; P = .002). Nonresponders vs responders also had lower rates of depression (42 [44%] vs 94 [68%]; P < .001) and anxiety (42 [44%] vs 97 [70%]; P < .001). No responders or nonresponders requested or underwent a reversal procedure. The median Satisfaction With Decision Scale score was 5.0 (IQR, 5.0-5.0) on a 5-point scale, with higher scores noting higher satisfaction. The median Decision Regret Scale score was 0.0 (IQR, 0.0-0.0) on a 100-point scale, with lower scores noting lower levels of regret. A univariable regression analysis could not be performed to identify characteristics associated with low satisfaction with decision or high decisional regret due to the lack of variation in these responses. Conclusions and Relevance In this cross-sectional survey study, the results of validated survey instruments indicated low rates of decisional regret and high levels of satisfaction with decision following gender-affirming mastectomy. The lack of dissatisfaction and regret impeded the ability to perform a more complex statistical analysis, highlighting the need for condition-specific instruments to assess decisional regret and satisfaction with decision following gender-affirming surgery.
Collapse
Affiliation(s)
- Lauren Bruce
- University of Michigan Medical School, Ann Arbor
| | | | - Andrew Bolze
- University of Michigan Medical School, Ann Arbor
| | - Maria Ibarra
- University of Michigan Medical School, Ann Arbor
| | - Blair Richards
- Michigan Institute for Clinical Health Research, Ann Arbor, Michigan
| | | | | | | | - Jessica J. Hsu
- Section of Plastic Surgery, University of Michigan, Ann Arbor
| | - Edwin G. Wilkins
- Section of Plastic Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, Ann Arbor
| | | | - Megan Lane
- Section of Plastic Surgery, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, Ann Arbor
| |
Collapse
|
5
|
Zhang TR, Mishra K, Blasdel G, Alford A, Stifelman M, Eun D, Zhao LC. Preoperative stricture length measurement does not predict postoperative outcomes in robotic ureteral reconstructive surgery. World J Urol 2023; 41:2549-2554. [PMID: 37486404 DOI: 10.1007/s00345-023-04525-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 07/05/2023] [Indexed: 07/25/2023] Open
Abstract
PURPOSE We sought to determine whether preoperative stricture length measurement affected the choice of procedure performed, its correlation to intraoperative stricture length, and postoperative outcomes. METHODS The Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database was queried for patients undergoing robotic ureteral reconstructive surgery from 2013 to 2021 who had surgical stricture length measurement. From this cohort, we identified patients with and without preoperative stricture length measurement via retrograde pyelogram or antegrade nephrostogram. Outcomes evaluated included intraoperative complications, 30-day complications greater than Clavien-Dindo grade II, hardware-free status, and need for additional procedures. RESULTS Of 153 patients with surgical stricture length measurements, 102 (66.7%) had preoperative radiographic measurement. No repair type was more likely to have preoperative measurement. The Pearson correlation coefficient between surgical and radiographic stricture length measurements was + 0.79. The average surgical measurement was 0.71 cm (± 1.52) longer than radiographic assessment. Those with preoperative imaging waited on average 5.0 months longer for surgery, but this finding was not statistically significant (p = 0.18). There was no statistically significant difference in intraoperative complications, 30-day complication rates, hardware-free status at last follow-up, or need for additional procedures between patients with and without preoperative measurement. The only significant predictive factor was preoperative stricture length on 30-day postoperative complications. CONCLUSIONS Despite relatively high prevalence of preoperative radiographic stricture length measurement, there are few measures where it offers clinically meaningful diagnostic information towards the definitive surgical management of ureteral stricture disease.
Collapse
Affiliation(s)
- Tenny R Zhang
- Department of Urology, NYU Langone Medical Center, New York, NY, USA
- Department of Urology, NewYork-Presbyterian/Weill Cornell Medical Center, New York, NY, USA
| | - Kirtishri Mishra
- Department of Urology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Gaines Blasdel
- Department of Urology, NYU Langone Medical Center, New York, NY, USA
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Ashley Alford
- Department of Urology, NYU Langone Medical Center, New York, NY, USA
| | - Michael Stifelman
- Department of Urology, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Daniel Eun
- Department of Urology, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA
| | - Lee C Zhao
- Department of Urology, NYU Langone Medical Center, New York, NY, USA.
| |
Collapse
|
6
|
Castle E, Kimberly L, Blasdel G, Parker A, Bluebond-Langner R, Zhao LC. Should BMI Help Determine Gender-Affirming Surgery Candidacy? AMA J Ethics 2023; 25:E496-506. [PMID: 37432002 DOI: 10.1001/amajethics.2023.496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Use of body mass index (BMI) as a health care metric is controversial, especially in candidacy assessments for gender-affirming surgery. When considering experiences of fat trans individuals, it is important to advocate for equitable divisions of responsibility for and recognition of systemic fat phobia. This commentary on a case suggests strategies for increasing equitable access to safe surgery for all body types. If surgeons use BMI thresholds, simultaneous effort must be made to advocate for data collection so that surgical candidacy criteria are evidence-based and equitably applied.
Collapse
Affiliation(s)
- Elijah Castle
- Associate research coordinator in the Department of Urology at New York University Langone Health in New York City
| | - Laura Kimberly
- Assistant professor in the Hansjörg Wyss Department of Plastic Surgery and the Department of Population Health at the New York University Grossman School of Medicine in New York City
| | - Gaines Blasdel
- Second-year medical student at the University of Michigan Medical School in Ann Arbor
| | - Augustus Parker
- Third-year medical student at New York University Grossman School of Medicine in New York City
| | - Rachel Bluebond-Langner
- Laura and Isaac Perlmutter Associate Professor of Reconstructive Plastic Surgery in the Hansjörg Wyss Department of Plastic Surgery at the New York University Grossman School of Medicine
| | - Lee C Zhao
- Reconstructive urologist and a co-director of the Transgender Reconstructive Surgery Program at New York University Langone Health in New York City
| |
Collapse
|
7
|
Robinson I, Chao BW, Blasdel G, Levine JP, Bluebond-Langner R, Zhao LC. Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes. Urology 2023; 177:204-212. [PMID: 37054922 DOI: 10.1016/j.urology.2023.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/13/2023] [Accepted: 03/29/2023] [Indexed: 04/15/2023]
Abstract
OBJECTIVE 1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.
Collapse
Affiliation(s)
- Isabel Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Brian W Chao
- Department of Urology, New York University Langone Health, New York, NY
| | - Gaines Blasdel
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY; Department of Urology, New York University Langone Health, New York, NY
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY; Department of Urology, New York University Langone Health, New York, NY
| | - Lee C Zhao
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY; Department of Urology, New York University Langone Health, New York, NY.
| |
Collapse
|
8
|
Blasdel G, Dy GW, Nikolavsky D, Ferrando CA, Bluebond-Langner R, Zhao LC. "Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots". Plast Reconstr Surg 2023; Publish Ahead of Print:00006534-990000000-01971. [PMID: 37289945 DOI: 10.1097/prs.0000000000010813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Urologic complications in genital gender-affirming surgery (GGAS) are imperfectly measured, with existing evidence limited by "blind spots" which will not be resolved through implementation of patient-reported outcomes alone. Some blind spots are expected in a surgical field with rapidly expanding techniques, and may be exacerbated by factors related to transgender health. METHODS We provide a narrative review of systematic reviews published in the last decade to describe the current options for genital gender-affirming surgery and surgeon-reported complications, as well as contrasting peer-reviewed sources with data not reported by primary surgeon. In combination with expert opinion, these findings describe complication rates. RESULTS Eight systematic reviews describe complications in vaginoplasty patients, including 5%-16.3% mean incidence of meatal stenosis and 7%-14.3% mean incidence of vaginal stenosis. Compared to surgeon-reported cohorts, vaginoplasty and vulvoplasty patients in alternate settings report higher rates of voiding dysfunction (47%-66% vs 5.6%-33%), incontinence (23%-33% vs. 4%-19.3%) and misdirected urinary stream (33%-55% vs 9.5%-33%). Outcomes in six reviews of phalloplasty and metoidioplasty included urinary fistula (14%-25%), urethral stricture and/or meatal stenosis (8%-12.2%), and ability to stand to void (73%-99%). Higher rates of fistula (39.5%-56.4%) and stricture (31.8%-65.5%) were observed in alternate cohorts, along with previously unreported complications such as vaginal remnant requiring reoperation. CONCLUSION The extant literature does not completely describe urologic complications of GGAS. In addition to standardized, robustly validated patient-reported outcome measures, future research on surgeon-reported complications would benefit from using the IDEAL (Idea, Development, Exploration, Assessment, and Long-term Study) framework for surgical innovation.
Collapse
Affiliation(s)
- Gaines Blasdel
- Gaines Blasde. Department of Urology, New York University; New York, New York
| | - Geolani W Dy
- Geolani W. Dy. Transgender Health Program, Department of Urology, Oregon Health & Science University; Portland, Oregon
| | - Dmitriy Nikolavsky
- Dmitriy Nikolavsky. Department of Urology, SUNY Upstate Medical University, Syracuse, New York
| | - Cecile A Ferrando
- Cecile A. Ferrando. Center for Urogynecology & Pelvic Reconstructive Surgery; Obstetrics, Gynecology & Women's Health Institute, Cleveland Clinic, Cleveland, Ohio
| | - Rachel Bluebond-Langner
- Rachel Bluebond-Langner. Hansjörg Wyss Department of Plastic Surgery, New York University; New York, New York
| | - Lee C Zhao
- Lee C. Zhao. Department of Urology, New York University; New York, New York
| |
Collapse
|
9
|
Zhao LC, Blasdel G, Parker A, Bluebond-Langner R. How Should Surgeons Approach Gender-Affirming Surgery Revisions When Patients Were Not, Perhaps, Well Informed in Prior Counseling? AMA J Ethics 2023; 25:E391-397. [PMID: 37285292 DOI: 10.1001/amajethics.2023.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Surgeons often encounter patients with realistic goals yet who desire unrealistic means of achieving them. This tension is compounded when surgeons consult with patients eager to revise a prior gender-affirming procedure completed by another surgeon. Two key factors of ethical and clinical relevance are that (1) a consulting surgeon's job is complicated when a population-specific evidence base is lacking and (2) a patient's marginalization is exacerbated by their having suffered the downstream effects of compromised initial access to comprehensive, realistic surgical care. This case commentary about revision of gender-affirming phalloplasty canvasses the pitfalls of a limited evidence base and focuses on strategies surgeons can use to help guide consultation. In particular, informed consent discussion may need to reframe a patient's expectations about clinical accountability for irreversible interventions.
Collapse
Affiliation(s)
- Lee C Zhao
- Associate professor of urology at NYU Langone Health in New York City
| | - Gaines Blasdel
- First-year medical student at the University of Michigan Medical School in Ann Arbor
| | - Augustus Parker
- Third-year medical student at the NYU Grossman School of Medicine in New York City
| | - Rachel Bluebond-Langner
- Laura and Isaac Perlmutter Associate Professor of Reconstructive Plastic Surgery at NYU Langone Health in New York City
| |
Collapse
|
10
|
Parker A, Brydges H, Blasdel G, Bluebond-Langner R, Zhao LC. Mending the Gap: AlloDerm as a Safe and Effective Option for Vaginal Canal Lining in Revision Robotic Assisted Gender Affirming Peritoneal Flap Vaginoplasty. Urology 2023; 173:204-208. [PMID: 36642117 DOI: 10.1016/j.urology.2023.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 12/25/2022] [Accepted: 01/02/2023] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.
Collapse
Affiliation(s)
| | - Hilliard Brydges
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | - Gaines Blasdel
- Department of Urology, NYU Langone Health, New York, NY; University of Michigan Medical School, Ann Arbor, MI
| | | | - Lee C Zhao
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY; Department of Urology, NYU Langone Health, New York, NY.
| |
Collapse
|
11
|
Ortengren CD, Blasdel G, Damiano EA, Scalia PD, Morgan TS, Bagley P, Blunt HB, Elwyn G, Nigriny JF, Myers JB, Chen ML, Moses RA. Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review. Transl Androl Urol 2022; 11:1762-1770. [PMID: 36632157 PMCID: PMC9827403 DOI: 10.21037/tau-22-174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 10/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background There is currently a paucity of data on urethral-related outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) with urethral lengthening (UL)and vaginectomy. Methods A systematic review was performed utilizing MEDLINE, Web of Science, Cochrane Library, Europe PMC, OSF Preprints, and EMBASE. Methodologic quality was scored using Methodological Index for Non-Randomized Studies (MINORS) criteria. Four independent reviewers performed the article evaluation, data extraction, and methodologic quality assessment. Primary outcomes included standing to urinate/pee (STP), penile length, glanular meatus, urethral stricture, fistula, and flap necrosis. Results were summarized qualitatively with descriptive statistics. Results A total of 2,881 articles of which 11 retrospective reviews of 13 cohorts met criteria; 4.3/16 average (avg) MINORS score. Six metoidioplasty cohorts had an average penile length of 6 cm, 74% reported successful STP, and a quarter developed stricture or fistula. Phalloplasty cohorts included radial forearm flap (RF) and Anterolateral Thigh flap (ALT). Of the 4 RF studies nearly a third developed a stricture or fistula and only one study reported 99% STP with a glanular meatus. Three ALT studies reported no length but had 80-90% STP with a glanular meatus and a quarter with stricture or fistula. Conclusions Urethral complications in MaPGAS-UL in a cohort with prior vaginectomy are common and variably reported. Patient centered outcome measures as well as clearly defined outcome metrics created in partnership with community members are needed.
Collapse
Affiliation(s)
| | - Gaines Blasdel
- Langone Medical Center, New York University, New York, NY, USA
| | - Ella A. Damiano
- Department of Obstetrics and Gynecology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Peter D. Scalia
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, Lebanon, NH, USA
| | - Tamara S. Morgan
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Pamela Bagley
- Biomedical Libraries, Dartmouth College, Hanover, USA
| | | | - Glyn Elwyn
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Williamson Translational Building, Lebanon, NH, USA
| | - John F. Nigriny
- Section of Plastic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jeremy B. Myers
- Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, USA
| | | | - Rachel A. Moses
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| |
Collapse
|
12
|
Blasdel G, Robinson I, Parker A, Zhao LC, Bluebond-Langner R. Familiar Infections in Novel Anatomy: Patient Reports of Sexually Transmitted Infections After Gender-Affirming Penile Reconstruction. Sex Transm Dis 2022; 49:437-442. [PMID: 35171129 DOI: 10.1097/olq.0000000000001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Sexually transmitted infections (STIs) after penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations have not previously been described, despite known risk factors in the population. After T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines. METHODS A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups. RESULTS A total of 128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups from January to May 2020. Seven respondents (5.5%) self-reported 1 or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (P = 0.002). Sexually transmitted infections were correlated with reporting sex with cisgender men (P = 0.001), transgender men (P = 0.009), and transgender women (P = 0.012). Of health care access variables, only receiving health care at a community health center was correlated with STI history (P = 0.003). CONCLUSIONS This exploratory survey indicates that STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of postreconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of health care provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm after gender-affirming penile reconstruction.
Collapse
Affiliation(s)
| | - Isabel Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health
| | - Augustus Parker
- New York University Grossman School of Medicine, New York, NY
| | | | | |
Collapse
|
13
|
Affiliation(s)
- Geolani W Dy
- Department of Urology, Transgender Health Program, Oregon Health & Science University, Portland
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York
| | - Jae M Downing
- Oregon Health & Science University, Portland State University School of Public Health, Portland
| |
Collapse
|
14
|
Blasdel G, Kloer C, Parker A, Castle E, Bluebond-Langner R, Zhao LC. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022; 19:781-788. [PMID: 35337785 DOI: 10.1016/j.jsxm.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 02/05/2022] [Accepted: 02/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints. AIM Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling. METHODS A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic. OUTCOMES Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record. RESULTS A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy. CLINICAL IMPLICATIONS Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery. STRENGTHS & LIMITATIONS This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm. CONCLUSION The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery. Blasdel G, Kloer C, Parker A, et al. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022;19:781-788.
Collapse
Affiliation(s)
- Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA.
| | - Carmen Kloer
- Duke University School of Medicine, Durham, NC, USA
| | - Augustus Parker
- New York University Grossman School of Medicine, New York, NY, USA
| | - Elijah Castle
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| |
Collapse
|
15
|
Blasdel G, Castle E, Kloer C, Parker A, Bluebond-Langner R, Zhao L. MP20-13 QUANTIFYING TIME TO ORGASM AFTER GENDER AFFIRMING VAGINOPLASTY. J Urol 2022. [DOI: 10.1097/ju.0000000000002553.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Clennon EK, Martin LH, Fadich SK, Zeigen L, Blasdel G, Sineath C, Dy GW. Community Engagement and Patient-Centered Implementation of Patient-Reported Outcome Measures (PROMs) in Gender Affirming Surgery: a Systematic Review. Curr Sex Health Rep 2022. [DOI: 10.1007/s11930-021-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
|
17
|
Robinson IS, Blasdel G, Bluebond-Langner R, Zhao LC. The Management of Intra-abdominal Complications Following Peritoneal Flap Vaginoplasty. Urology 2022; 164:278-285. [PMID: 35150666 DOI: 10.1016/j.urology.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/08/2022] [Accepted: 01/23/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSIONS Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare. In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.
Collapse
Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
| | | | | | - Lee C Zhao
- Department of Urology, NYU Langone Health, New York, NY.
| |
Collapse
|
18
|
Parker A, Blasdel G, Kloer C, Kimberly L, Shakir N, Robinson I, Bluebond-Langner R, Zhao LC. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022; 19:385-393. [PMID: 34920952 DOI: 10.1016/j.jsxm.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/15/2021] [Accepted: 10/10/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.
Collapse
Affiliation(s)
- Augustus Parker
- NYU Grossman School of Medicine, NYU Langone Health Systems, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Carmen Kloer
- Duke University School of Medicine, Duke Health Systems, Durham, NC, USA; Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Laura Kimberly
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Nabeel Shakir
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Isabel Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA.
| |
Collapse
|
19
|
Sineath RC, Blasdel G, Dy GW. Addressing urologic health disparities in sexual and gender minority communities through patient-centered outcomes research. Urology 2021; 166:66-75. [PMID: 34774931 DOI: 10.1016/j.urology.2021.08.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 06/28/2021] [Accepted: 08/11/2021] [Indexed: 10/19/2022]
Abstract
Sexual and gender minority (SGM) communities face stigma and discrimination that impact all aspects of health. To better understand and improve their urologic health outcomes, we must study SGM patients as a distinct population and pursue research on outcomes identified as priorities to SGM communities. Patient-centered outcomes research (PCOR) is a methodology which is increasingly familiar to urologists and is crucial to adequately addressing SGM health in future urological research. We review existing literature focused on urologic outcomes of SGM populations and highlight specific PCOR initiatives built on SGM community engagement.
Collapse
Affiliation(s)
- R Craig Sineath
- Department of Urology, Oregon Health & Science University, Portland, Oregon.
| | - Gaines Blasdel
- Department of Urology, New York University Grossman School of Medicine, New York, New York
| | - Geolani W Dy
- Department of Urology, Oregon Health & Science University, Portland, Oregon
| |
Collapse
|
20
|
Blasdel G, Shakir N, Parker A, Bluebond-Langner R, Zhao L. Letter to the Editor from Blasdel et al: "No Venous Thromboembolism Increase Among Transgender Female Patients Remaining on Estrogen for Gender-affirming Surgery". J Clin Endocrinol Metab 2021; 106:e3783-e3784. [PMID: 33846750 DOI: 10.1210/clinem/dgab243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY 10017, USA
| | - Nabeel Shakir
- Department of Urology, New York University Langone Health, New York, NY 10017, USA
| | - Augustus Parker
- NYU Grossman School of Medicine, New York University Langone Health, New York, NY 10016, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY 10017, USA
| | - Lee Zhao
- Department of Urology, New York University Langone Health, New York, NY 10017, USA
| |
Collapse
|
21
|
Affiliation(s)
- Carmen Kloer
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
- Duke University School of Medicine, Duke Health Systems, Durham, North Carolina, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Miranda Morris
- Duke University School of Medicine, Duke Health Systems, Durham, North Carolina, USA
| | - Lee C. Zhao
- Department of Urology, New York University Langone Health, New York, New York, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York, USA
| |
Collapse
|
22
|
Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. AUTHOR REPLY. Urology 2021; 154:314. [PMID: 34389077 DOI: 10.1016/j.urology.2021.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Geolani W Dy
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Nabeel A Shakir
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Lee C Zhao
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| |
Collapse
|
23
|
Kloer C, Parker A, Blasdel G, Kaplan S, Zhao L, Bluebond-Langner R. Sexual health after vaginoplasty: A systematic review. Andrology 2021; 9:1744-1764. [PMID: 33882193 DOI: 10.1111/andr.13022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/26/2021] [Accepted: 04/12/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Vaginoplasty is a gender-affirming procedure for transgender and gender diverse (TGD) patients who experience gender incongruence. This procedure reduces mental health concerns and enhances patients' quality of life. A systematic review investigating the sexual health outcomes of vaginoplasty has not been performed. OBJECTIVES To investigate sexual health after gender-affirming vaginoplasty for TGD patients. DATA SOURCES MEDLINE/PubMed, Embase, Scopus, and PsycINFO databases were searched, unrestricted by dates or study design. METHODS We included primary literature that incorporated TGD patients, reported sexual health outcomes after vaginoplasty intervention and were available in English. Outcomes included at least one of these sexual health parameters: sexual desire, arousal, sensation, activity, secretions, satisfaction, pleasure, orgasm, interferences, or aids. RESULTS Our search yielded 140 studies with 12 different vaginoplasty surgical techniques and 6,953 patients. The majority of these studies were cross-section or retrospective cohort observational studies (66%). 17.4%-100% (median 79.7%) of patients (n = 2,384) were able to orgasm postoperatively regardless of revision or primary vaginoplasty techniques. Female Sexual Function Index was the most used standardized questionnaire (17 studies, ranging from 16.9 to 28.6). 64%-98% (median 81%) of patients were satisfied with their general sexual satisfaction. The most common interference of sexual activity was dyspareunia. CONCLUSIONS The heterogenous methods of measuring sexual outcomes reflect the difficulty in comparing single-center surgical outcomes, encouraging the need for a standardized and validated metric for reporting sexual health after vaginoplasty for TGD patients. The most common sexual health parameter reported is sexual activity while therapeutic aids and pleasure were the least reported parameters. Future studies are needed to improve and expand methods of measuring sexual health, including prospective studies, validated questionnaires, and inclusive metrics. Systematic review registration number: PROSPERO 01/01/2021: CRD42021224014.
Collapse
Affiliation(s)
- Carmen Kloer
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.,Duke University School of Medicine, Duke Health Systems, Durham, NC, USA
| | - Augustus Parker
- NYU Grossman School of Medicine, New York University Langone Health, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Samantha Kaplan
- Duke University School of Medicine, Duke Health Systems, Durham, NC, USA
| | - Lee Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| |
Collapse
|
24
|
Dy GW, Blasdel G, Shakir NA, Bluebond-Langner R, Zhao LC. Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: a Novel Technique for Treating Neovaginal Stenosis. Urology 2021; 154:308-314. [PMID: 33823174 DOI: 10.1016/j.urology.2021.03.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/13/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization. METHODS Twenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017 to 2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications. RESULTS Mean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis. CONCLUSIONS Robotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.
Collapse
Affiliation(s)
- Geolani W Dy
- Department of Urology, Oregon Health & Sciences University, Portland, OR
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Nabeel A Shakir
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Lee C Zhao
- Department of Urology, New York University Langone Medical Center, New York, NY.
| |
Collapse
|
25
|
Narayan SK, Hontscharuk R, Danker S, Guerriero J, Carter A, Blasdel G, Bluebond-Langner R, Ettner R, Radix A, Schechter L, Berli JU. Guiding the conversation-types of regret after gender-affirming surgery and their associated etiologies. Ann Transl Med 2021; 9:605. [PMID: 33987303 DOI: 10.21037/atm-20-6204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background A rare, but consequential, risk of gender affirming surgery (GAS) is post-operative regret resulting in a request for surgical reversal. Studies on regret and surgical reversal are scarce, and there is no standard terminology regarding either etiology and/or classification of the various forms of regret. This study includes a survey of surgeons' experience with patient regret and requests for reversal surgery, a literature review on the topic of regret, and expert, consensus opinion designed to establish a classification system for the etiology and types of regret experienced by some patients. Methods This anonymous survey was sent to the 154 surgeons who registered for the 2016 World Professional Association for Transgender Health (WPATH) conference and the 2017 USPATH conference. Responses were analyzed using descriptive statistics. A MeSH search of the gender-affirming outcomes literature was performed on PubMed for relevant studies pertaining to regret. Original research and review studies that were thought to discuss regret were included for full text review. Results The literature is inconsistent regarding etiology and classification of regret following GAS. Of the 154 surgeons queried, 30% responded to our survey. Cumulatively, these respondents treated between 18,125 and 27,325 individuals. Fifty-seven percent of surgeons encountered at least one patient who expressed regret, with a total of 62 patients expressing regret (0.2-0.3%). Etiologies of regret were varied and classified as either: (I) true gender-related regret (42%), (II) social regret (37%), and (III) medical regret (8%). The surgeons' experience with patient regret and request for reversal was consistent with the existing literature. Conclusions In this study, regret following GAS was rare and was consistent with the existing literature. Regret can be classified as true gender-related regret, social regret and medical regret resulting from complications, function, pre-intervention decision making. Guidelines in transgender health should offer preventive strategies as well as treatment recommendations, should a patient experience regret. Future studies and scientific discourse are encouraged on this important topic.
Collapse
Affiliation(s)
- Sasha Karan Narayan
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Rayisa Hontscharuk
- Department of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Sara Danker
- Division of Plastic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jess Guerriero
- Transgender Health Program, Oregon Health & Science University, Portland, OR, USA
| | | | | | | | | | - Asa Radix
- Callen-Lorde Community Health Center, New York, NY, USA
| | - Loren Schechter
- The University of Illinois at Chicago, Chicago, IL, USA.,Rush University Medical Center, Chicago, IL, USA.,The Center for Gender Confirmation Surgery, Weiss Memorial Hospital, Chicago, IL, USA
| | - Jens Urs Berli
- Division of Plastic & Reconstructive Surgery, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
26
|
Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021; 18:800-811. [PMID: 33663938 DOI: 10.1016/j.jsxm.2021.01.183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/07/2021] [Accepted: 01/25/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.
Collapse
Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.
| |
Collapse
|
27
|
Blasdel G, Bluebond-Langner R, Zhao LC. PROMs Beyond the Penis: A Letter to the Editor on the Article by Pigot et al. J Sex Med 2021; 18:839-840. [PMID: 33648902 DOI: 10.1016/j.jsxm.2021.01.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 01/20/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY, USA.
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Medical Center, New York, NY, USA
| |
Collapse
|
28
|
Jun MS, Shakir NA, Blasdel G, Cohen O, Levine JP, Bluebond-Langner R, Zhao LC. Robotic-assisted Vaginectomy During Staged Gender-affirming Penile Reconstruction Surgery: Technique and Outcomes. Urology 2021; 152:74-78. [PMID: 33493507 DOI: 10.1016/j.urology.2021.01.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report our novel technique and mid-term follow-up for robotic-assisted laparoscopic vaginectomy (RALV), a component procedure of staged gender-affirming penile reconstructive surgery. MATERIALS AND METHODS The records of patients seeking gender-affirming penile reconstructive surgery who underwent RALV, performed by a single surgeon at our institution, between May 2016 and January 2020 were reviewed retrospectively for demographic and perioperative data. Patients were included irrespective of history of previous phalloplasty. A subset of these patients elected to have urethral lengthening during second stage phalloplasty for which an anterior vaginal mucosa flap urethroplasty was performed. Postoperative complications and outcomes and most recent follow-up were obtained. RESULTS A total of 42 patients were reviewed, of whom 19 (45%) patients ultimately had radial forearm free flap, 15 (41%) had anterolateral thigh flap, 5 (12%) had metoidioplasty, and 1 (2.4%) had abdominal phalloplasty. A vaginal mucosa and gracilis flap was used in all of 36 (86%) patients in whom a pars fixa was created. Average operative time was 299 minutes (range 153-506). Median estimated blood loss was 200 mL (range 100-400). Median length of stay was 3 days (range 1-7). Complications within 30 days from surgery occurred in 15 patients (36%), of whom 12/15 were Clavien-Dindo grade 1 or 2, and 11/15 had complications unrelated to vaginectomy. Of the 4 patients who had vaginectomy-related complications, all resolved with conservative management. Median overall follow-up was 15.8 months. CONCLUSION RALV offers a safe and efficient approach during staged gender-affirming penile reconstruction and may mitigate the subsequent risk of urethral complications.
Collapse
Affiliation(s)
- Min Suk Jun
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Nabeel Ahmad Shakir
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY
| | - Lee C Zhao
- Department of Urology, New York University Langone Medical Center, New York, NY.
| |
Collapse
|
29
|
Abstract
PURPOSE To describe the effect of transgender health-related objective structured clinical examination (THOSCE) case exposure on learner activation regarding gender-affirming care. METHOD A modified grounded theory approach was applied to identify the educational value of THOSCE cases. Focus groups with current and former primary care internal medicine residents who participated in THOSCE cases were conducted in 2018-2019. Transcripts were analyzed and coded until saturation to identify themes. RESULTS Eighteen (72%) eligible learners participated in the focus groups. Themes were identified relating to gender-affirming care, and modified grounded theory analysis was used as a framework to organize the themes into 4 stages of learner activation: (1) believing the learner role is important, (2) having the confidence and knowledge necessary to take action, (3) taking action to maintain and improve one's skills, and (4) staying the course even under stress. CONCLUSIONS Residents were grateful for the opportunity to practice the skills involved in transgender health in a simulation. Many felt unprepared and were concerned about how they were perceived by the standardized patient and faculty. Residents identified feeling more comfortable with gender-affirming language in the inpatient setting, which may provide an opportunity for learning in the future. Residents identified the psychosocial skills of gender-affirming care as more directly relevant while biomedical aspects of gender-affirming care seemed less accessible to residents, given the lack of outpatient experience. The authors propose a staged approach to teaching the skills of gender-affirming care using simulation to address learners of all levels.
Collapse
Affiliation(s)
- Richard E Greene
- R.E. Greene is associate professor of internal medicine and director, Health Disparities Education, Office of Diversity Affairs, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0001-8618-7723
| | - Gaines Blasdel
- G. Blasdel is research associate, Department of Urology, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0002-5431-6540
| | - Tiffany E Cook
- T.E. Cook is program manager, Training and Professional Development, Office of Diversity Affairs, New York University Grossman School of Medicine, New York, New York
| | - Colleen Gillespie
- C. Gillespie is associate professor, Department of Medicine, and director, Division of Educational Quality, Institute for Innovations in Medical Education, New York University Grossman School of Medicine, New York, New York
| |
Collapse
|
30
|
Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC. Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems. Eur Urol 2020; 79:676-683. [PMID: 32624272 DOI: 10.1016/j.eururo.2020.06.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 06/17/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved. OBJECTIVE To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems. DESIGN, SETTING, AND PARTICIPANTS A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up. SURGICAL PROCEDURE Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex. MEASUREMENTS Demographics, perioperative data, and clinical outcomes were evaluated. RESULTS AND LIMITATIONS A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%). CONCLUSIONS RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches. PATIENT SUMMARY We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.
Collapse
Affiliation(s)
- Geolani W Dy
- Department of Urology, Oregon Health & Science University, Portland, OR, USA
| | - Min Suk Jun
- Department of Urology, New York University Langone Medical Center, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Medical Center, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Medical Center, New York, NY, USA.
| |
Collapse
|
31
|
Nolan IT, Blasdel G, Dubin SN, Goetz LG, Greene RE, Morrison SD. Current State of Transgender Medical Education in the United States and Canada: Update to a Scoping Review. J Med Educ Curric Dev 2020; 7:2382120520934813. [PMID: 32637641 PMCID: PMC7315660 DOI: 10.1177/2382120520934813] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 05/19/2020] [Indexed: 05/17/2023]
Abstract
BACKGROUND The published literature on education about transgender health within health professions curricula was previously found to be sporadic and fragmented. Recently, more inclusive and holistic approaches have been adopted. We summarize advances in transgender health education. METHODS A 5-stage scoping review framework was followed, including a literature search for articles relevant to transgender health care interventions in 5 databases (Education Source, LGBT Source, MedEd Portal, PsycInfo, PubMed) from January 2017 to September 2019. Search results were screened to include original articles reporting outcomes of educational interventions with a transgender health component that included MD/DO students in the United States and Canada. A gray literature search identified continuing medical education (CME) courses from 12 health professional associations with significant transgender-related content. RESULTS Our literature search identified 966 unique publications published in the 2 years since our prior review, of which 10 met inclusion criteria. Novel educational formats included interdisciplinary interventions, post-residency training including CME courses, and online web modules, all of which were effective in improving competencies related to transgender health care. Gray literature search resulted 15 CME courses with learning objectives appropriate to the 7 professional organizations who published them. CONCLUSIONS Current transgender health curricula include an expanding variety of educational intervention formats driven by their respective educational context, learning objectives, and placement in the health professional curriculum. Notable limitations include paucity of objective educational intervention outcomes measurements, absence of long-term follow-up data, and varied nature of intervention types. A clear best practice for transgender curricular development has not yet been identified in the literature.
Collapse
Affiliation(s)
- Ian T Nolan
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Gaines Blasdel
- Hansjörg Wyss Department of Plastic Surgery, New York University Grossman School of Medicine, New York, NY, USA
| | - Samuel N Dubin
- New York University Grossman School of Medicine, New York, NY, USA
| | - Laura G Goetz
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Richard E Greene
- Department of Internal Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Shane D Morrison
- Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Seattle, WA, USA
| |
Collapse
|
32
|
Blasdel G, Campbell D. Functional retinotopy of monkey visual cortex. J Neurosci 2001; 21:8286-301. [PMID: 11588200 PMCID: PMC6763878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
Abstract
The operations of primary visual cortex generate continuous representations of orientation, ocular dominance, and retinotopy that, to fit in two dimensions, organize at separate but overlapping scales (e.g., 20-500 microm, 200 microm to 5 mm, and 2-33 mm). Where their scales overlap, these organizations interact; iso-orientation contours cross ocular dominance columns at right angles, and ocular dominance columns distort retinotopy near the V1/V2 border. To explore these interactions, we developed an optical technique for visualizing retinotopy in vivo that allows us to analyze it in relation to ocular dominance and orientation patterns. Our results show local retinotopic distortions in every region of macaque V1 that we examine, including regions far from the V1/V2 border. They also show a consistent relation between local axes of distortion and ocular dominance slabs, which they intersect at angles of approximately 90 degrees. A further correlation is provided by retinotopic maps from New World primates that show less distortion (9 vs 60%) in two species characterized by an absence of pronounced ocular dominance columns. Retinotopic maps from these New World primates also revealed an unexpected tilt of the vertical midline representation that diverged from the V1/V2 border by an angle of approximately 20 degrees. Overall, these results suggest a general tendency for slab-based organizations to distort retinotopy by representing the same part of space more than once in adjacent slabs.
Collapse
Affiliation(s)
- G Blasdel
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|
33
|
Affiliation(s)
- G Blasdel
- Department of Neurobiology, Harvard Medical School, Boston, Massachusetts 02115, USA.
| |
Collapse
|
34
|
Abstract
Previous work has shown that small, stimulus-dependent changes in light absorption can be used to monitor cortical activity, and to provide detailed maps of ocular dominance and optimal stimulus orientation in the striate cortex of adult macaque monkeys (Blasdel & Salama, 1986; Ts'o et al., 1990). We now extend this approach to infant animals, in which we find many of the organizational features described previously in adults, including patch-like linear zones, singularities, and fractures (Blasdel, 1992b), in animals as young as 3 1/2 weeks of age. Indeed, the similarities between infant and adult patterns are more compelling than expected. Patterns of ocular dominance and orientation, for example, show many of the correlations described previously in adults, including a tendency for orientation specificity to decrease in the centers of ocular dominance columns, and for iso-orientation contours to cross the borders of ocular dominance columns at angles of 90 deg. In spite of these similarities, there are differences, one of which entails the strength of ocular dominance signals, which appear weaker in the younger animals and which increase steadily with age. Another, more striking, difference concerns the widths of ocular dominance columns, which increase by 20% during the first 3 months of life. Since the cortical surface area increases by a comparable amount, during the same time, this 20% expansion implies that growth occurs anisotropically, perpendicular to the ocular dominance columns, as the cortical surface expands. Since the observed patterns of orientation preference expand more slowly, at approximately half this rate, these results also imply that ocular dominance and orientation patterns change their relationship, and may even drift past one another, as young animals mature.
Collapse
Affiliation(s)
- G Blasdel
- Department of Physiology, University of Calgary, Alberta, Canada
| | | | | |
Collapse
|