Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis

INTRODUCTION

Phalloplasty is one of the genital genders affirming surgeries sought by transmasculine transgender patients during transition. Despite current advances in surgical techniques, the lack of consistency in outcomes evaluation for phalloplasty leads to significant challenges in guiding patients in clinical decision making.

AIMS

This systematic review and meta-analysis aims to assess outcomes for different phalloplasty surgical techniques.

METHODS

The literature was searched using Medical Literature Analysis and Retrieval System Online (MEDLINE; PubMed), Excerpta Medica database, and Cochrane Database of Systematic Reviews. All English-language randomized control trials, prospective and retrospective cohort studies, case series, and case reports of at least 4 patients were included. The primary outcome was postoperative complications, and the secondary outcomes were functional and aesthetic results. Proportional meta-analysis was used to pool complication rates using a random-effects model.

RESULTS

Database searching generated 39 final articles, with 19 case series, 3 cross-sectional studies, and 17 retrospective cohort studies. A total of 1731 patients underwent phalloplasty, with the most common type of reconstruction performed being the radial forearm free flap (75.1%). Overall complication rate was high at 76.5%, of which urethral complications were high in all reconstructive subgroups (urethral fistula rate of 34.1% and urethral stricture rate of 25.4%). Postoperative functional outcomes were reported in 57.6% of patients, finding that most had tactile sensation (93.9%) and can void while standing (92.2%). Aesthetic outcomes were only reported in 6.3% of patients, with mean length achieved being 12.26 cm (SD = 0.81 cm) and mean circumference being 10.18 cm (SD = 3.69 cm).

CONCLUSION

In the transmasculine transgender population, current evidence of the various phalloplasty surgical techniques and their expected postoperative outcomes is weak. Future research may consider developing a standardized core outcome set to improve clinical decision making. Wang AMQ, Tsang V, Mankowski P, et al. Outcomes Following Gender Affirming Phalloplasty: A Systematic Review and Meta-Analysis. Sex Med Rev 2022;10:499-512.

Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty

INTRODUCTION

No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is important to patients and is determined by available skin and available anatomic space within the pelvis and varies with surgical technique.

AIM

We endeavored to create a nomogram to predict expected postoperative vaginal depth.

METHODS

Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n = 60). Pre-op: Dorsal penile and midline scrotal skin length were measured. Intra-op: Tubularized scrotal skin length measured on a dilator. Immediate post-op: Final vaginal depth measured with a dilator.

OUTCOMES

The amount of available penile and scrotal skin was not associated with vaginal depth. The only variable that did significantly increase depth was the use of penile + scrotal skin, as compared to penile skin alone. (P < .001) RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 ± 1.9 cm) was 87% of pre-op measured penile skin length (15.3 ±- 3.0 cm). In patients who underwent PIV+SS, pre-op penile skin length was 11.1 ± 4.7±cm and pre-op midline scrotal length was 22.8 ± 2.6 cm. with a final post-op vaginal canal depth of 15.2 ± 1.3 cm. In 45/46 (98%) surgeries utilizing SS grafts, SS tube length exceeded the length necessary to achieve maximal vaginal depth, and required trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be surgically dissected, and was not limited by the amount of available skin.

CLINICAL IMPLICATIONS

Our findings suggest that for most patients it should not be necessary to include additional tissue sources (eg, peritoneum) to create a vaginal canal during primary vaginoplasty.

STRENGTHS AND LIMITATIONS

Any penile skin that was discarded due to poor quality (eg, tight phimosis, poor viability) was not measured and accounted for. This likely resulted in a slight overestimation of the contribution of the penile skin to the final vaginal depth, but did not change the overall finding that final depth was not limited by available skin.

CONCLUSION

SS grafts, when harvested and tubularized using optimized technique, supplied an excess of skin necessary to line a vaginal canal space of maximal achievable depth. We found that additional tissue sources can, instead, be reserved for future salvage surgery if it becomes necessary to augment depth. Smith SM, Yuan N, Stelmar J, et al. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022;10:100569.

Gender Affirming Medical Treatment Desire and Treatment Motives in Binary and Non-Binary Transgender Individuals

BACKGROUND

It is currently unknown whether there are differences in desire for gender affirming medical treatment (GAMT) between binary and non-binary transgender individuals, although the latter seek treatment less prevalently.

AIM

To investigate differences between binary and non-binary individuals on received GAMT, desire for GAMT, and motives for (not) wanting GAMT, and to explore the association between having an unfulfilled treatment desire and general and sexual well-being.

METHODS

We conducted an online questionnaire in a community sample of 125 transgender men, 72 transgender women, and 62 non-binary transgender individuals (age: M = 30.4, SD = 11.31, range 18-69).

OUTCOME MEASURES

Undergone GAMT, GAMT desire, motives for (not) wanting (further) GAMT, Utrecht Gender Dysphoria Scale, Satisfaction With Life Scale, Hospital Anxiety and Depression Scale, Global Measure of Sexual Satisfaction, transgender-specific body image worries, and sexual self-concept discrepancies.

RESULTS

Binary transgender participants reported having undergone more GAMT procedures than non-binary transgender participants (P < .001 for both gender affirming hormone treatment (GAHT) and gender affirming surgery (GAS)). While binary participants reported a stronger desire for GAHT compared to non-binary participants (X2(1, N = 93) = 32.63, P < .001), the groups did not differ in their desire for GAS (X2(1, N = 247) = 0.68, P = .411). Binary and non-binary participants reported similar reasons for wanting treatment, mostly related to body and/or gender incongruence and gender affirmation. In terms of not wanting treatment, the non-binary group reported their gender identity as the most important reason, while the binary group mostly mentioned possible medical complications. The majority of both groups had an unfulfilled treatment desire (69% of binary participants and 64.5% of non-binary participants), which was related to lower levels of general life satisfaction (P < .001) and sexual satisfaction (P = .005), more anxiety (P = .006) and transgender-specific body image worries (P < .001), and larger sexual self-concept discrepancies (P < .001 for actual and/or ideal, P < .001 for actual and/or ought).

CLINICAL IMPLICATIONS

Systemic barriers to GAMT (especially GAS) should be removed not only for binary but also for non-binary identifying transgender individuals to decrease the discrepancy between treatment desire and actually seeking treatment.

STRENGTHS & LIMITATIONS

This study was the first to systematically investigate differences in treatment desire motives between binary and non-binary transgender individuals, while also showing the possible negative consequences of an unfulfilled treatment desire. Given the online character of the study, results may not generalize to the broader transgender community.

CONCLUSION

Similarly to binary transgender individuals, many non-binary transgender individuals have a desire for GAMT, and not being able to receive GAMT has a negative effect on their mental and sexual health. Further efforts should be made to make GAMT accessible for all transgender individuals, regardless of gender identity. Kennis M, Duecker F, T'Sjoen G, et al. Gender Affirming Medical Treatment Desire and Treatment Motives in Binary and Non-Binary Transgender Individuals. J Sex Med 2022;19:1173-1184.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications

BACKGROUND

Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals.

AIM

To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions.

METHODS

Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients).

OUTCOMES

Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion).

RESULTS

There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates.

CLINICAL IMPLICATIONS

Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated STRENGTHS & LIMITATIONS: Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected.

CONCLUSION

We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641-649.

ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery"

Introduction

Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking.

Aim

To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine.

Methods

The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS.

Main Outcomes Measure

The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately.

Results

The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing.

Conclusion

The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.

New Insights Into Extended Steroid Hormone Profiles in Transwomen in a Multi-Center Setting in Germany

BACKGROUND

Little information is available on steroid hormone profiles in transwomen on the day of gender affirming surgery (GAS) after gender affirming hormone therapy (GAHT).

AIM

We compared extended serum steroid hormone profiles of 77 transwomen with 3 different treatment regimens in order to get more insight on how GAHT changes the hormone system.

METHODS

Samples were obtained from 3 independent clinics. Individuals in clinic A (n = 13) and B (n = 51) discontinued GAHT 4-6 weeks and 2 weeks before GAS, individuals in clinic C (n = 13) continued treatment. Testicular tissue, blood samples and questionnaires on age, weight, height, and medication use were received from each patient. Steroid hormones were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), 6 sex hormones were determined by immunofluorometric assays, and ELISA. Spermatogenesis was scored using the Bergman/Kliesch score.

OUTCOMES

Participants were not different with regard to age, BMI, treatment duration, and dosage. Feminized blood serum levels with low LH, low FSH and low testosterone, however, were achieved in persons taking GAHT until GAS. Significantly reduced cortisone levels were seen after stopping GAHT before GAS.

RESULTS

GAHT had marked effects on the sex-steroid profile in each person. Factor analysis provided a model explaining 78% of the variance and interdependency of sex steroid levels. Stopping treatment was inversely associated with intactness of the corticosteroid-axis with adrenal steroidogenesis as well as it was inversely associated with pituitary-gonadal hormone production.

CLINICAL IMPLICATIONS

Transwomen generally did not have elevated cortisone levels but differed significantly depending on and when GAHT was stopped.

STRENGTHS & LIMITATIONS

This is the first study examining the steroid hormone profiles of transgender persons on the day of GAS in a multi-center setting. Additional studies (including follow ups before and after GAS and stress questionnaires) will be necessary to assess these conflicting results about the possible psychological impact on persons undergoing GAS to improve care.

CONCLUSION

Concerning feminized blood serum levels, continued GAHT seems the better alternative, however stopping treatment 4-6 weeks prior to surgery was associated with reduced cortisone levels. Schneider F, Wistuba J, Holterhus P-M, et al. New Insights Into Extended Steroid Hormone Profiles in Transwomen in a Multi-Center Setting in Germany. J Sex Med 2021;18:1807-1817.

How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons

INTRODUCTION

Tactile and erogenous sensitivity of the neophallus after phalloplasty is assumed to affect the sexual well-being of transmasculine persons and, ultimately, their quality of life. The experienced and objective sensation of the neophallus and their association are largely unknown.

AIM

This study evaluated experienced tactile and erotic sensation of the neophallus in transmasculine persons and investigated how this was related to objective tactile sensitivity.

METHODS

Between August 2017 and January 2020, 59 transmasculine persons who underwent phalloplasty were recruited to participate in a prospective follow-up study. Tactile sensitivity of the neophallus and donor-site was measured (Semmes-Weinstein Monofilament test) and compared, and participants were asked to fill out a questionnaire about experienced sensation of the neophallus and sexual wellbeing.

MAIN OUTCOME MEASURES

Experienced and objective sensation of the neophallus were measured by using a questionnaire and Semmes-Weinstein Monofilament scores.

RESULTS

Neophallic tactile sensitivity was significantly reduced compared to the donor-site (n = 44), with the proximal part being more sensitive than the distal part (median follow-up of 1.8 years, range 1.0-7.2)). Sensitivity of the neophallus was not significantly associated with the surgical flap used, yet increased significantly with follow-up time. The questionnaire was completed by 26 participants of which 24 (92.3%) experienced (some degree of) tactile sensitivity in their neophallus. Erogenous sensation was experienced by 23 (88.5%). Experienced and objectified tactile sensitivity were not significantly correlated (Spearmans's rho = 0.23, P = .26). Answers to open-ended questions showed that results often do not match expectations.

CONCLUSION

Tactile sensation of the neophallus was reduced in most transmasculine persons and improved slowly over time. A significant association between subjective and objective measures could not be detected. Although experienced sensitivity varied between individuals, the vast majority reported to have tactile and erotic sensitivity in the neophallus.Transmasculine persons should be informed that sensitivity of the neophallus will likely be reduced. Elfering L, van de Grift TC, Al-Tamimi M, et al. How Sensitive Is the Neophallus? Postphalloplasty Experienced and Objective Sensitivity in Transmasculine Persons. Sex Med 2021;9:100413.

Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index

INTRODUCTION

Feminizing gender-affirming surgery (GAS) has been an increasingly used procedure in the United States and worldwide for transgender women with gender dysphoria. Studies on patient-reported quality of life outcomes in those undergoing GAS remain limited.

OBJECTIVE

To provide recent insights from the literature on sexual metrics in the evaluation of the transgender women.

METHODS

We queried PubMed to identify studies assessing sexual function metrics in those undergoing feminizing GAS.

RESULTS

There is no single validated method to establish preoperative and postoperative sexual function. Assessment currently remains institutionally dependent. Evaluation can involve questionnaires including but not limited to the International Index of Erectile Function, the Female Sexual Function Index, and the Male to Female Sexual Function Index.

CONCLUSION

In this literature review, we discuss considerations for the evaluation of sexual function for patients considering feminizing GAS with vaginoplasty. Although we describe some of the major tools currently used in evaluating sexual function in this patient population, a need for a validated method remains. Syed JS, Honig S. Sexual Metrics in Transgender Women: Transitioning From International Index of Erectile Function to Female Sexual Function Index. Sex Med Rev 2021;9:236-243.