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Claeys W, Weynants L, Jamaer C, Van der Jeugt J, Hoebeke P, Spinoit AF. Secondary phallic prosthesis placement in transgender patients postmetoidioplasty: a case report on technique and outcome. Sex Med 2023; 11:qfad056. [PMID: 38028733 PMCID: PMC10661292 DOI: 10.1093/sexmed/qfad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 09/19/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Gender affirming surgery is common among transgender and gender-nonconforming individuals. Genital gender-affirming surgery is a form of surgery that involves transformation and reconstruction of the genitalia while maintaining urologic and sexual function. Masculinizing genital gender-affirming surgery can involve the removal of the female genital and reproductive organs and the creation of a more masculine appearance by using phalloplasty or metoidioplasty techniques. While metoidioplasty has advantages such as limited scarring and preserved genital sensation and clitoral erection, it may not always guarantee the ability to void while standing or even penetrate a sexual partner. Aim To describe our method of secondary phallic enhancement after metoidioplasty with a phallic prosthesis. Methods Our case is based on a 39-year-old transgender male who underwent metoidioplasty with vaginectomy, scrotoplasty, and urethral lengthening. However, the original surgery was complicated by extensive hematoma formation in the suprapubic area and neoscrotum, leading to a buried position of the neophallus. Subsequent surgery was performed to reduce the prepubic fat pad and penoscrotal interposition, but it too was complicated by hematoma formation and wound dehiscence. To maximize phallic elongation, the tethering urethra was removed, and perineal urethrostomy was performed but could not sufficiently alleviate the buried phallus. As a further step to improve the outcome, we proposed the implantation of a specific phallic prosthesis designed for metoidioplasty with testicular prosthesis placement. Surgery was performed as a single procedure through a penoscrotal incision and greatly enhanced genital appearance. Results Three months after surgery, the patient had good sensation of the phallus and was able to have satisfactory sexual activity with his partner. However, he remained dissatisfied with the amount of prepubic tissue and opted to undergo further liposuction. Conclusion Phallic prosthesis implantation can be a procedure to improve the condition of multioperated cases of metoidioplasty with resistant phallic burying. Reconstruction with a phallic prosthesis was performed successfully in this case. However, long-term complications and functional outcomes, such as the ability to void while standing or penetrate a sexual partner, remain uncertain. Further experience is needed to determine the efficacy and safety of using a phallic prosthesis as a secondary procedure in patients undergoing metoidioplasty.
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Affiliation(s)
- Wietse Claeys
- Department of Urology, Ghent University Hospital, Ghent 9000 Belgium
| | | | - Caroline Jamaer
- Department of Urology, Jessa Ziekenhuis, 3500 Hasselt, Belgium
| | | | - Piet Hoebeke
- Department of Urology, Ghent University Hospital, Ghent 9000 Belgium
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Grupp K, Blessmann M, König HH, Hajek A. Are transgender people satisfied with their lives? BMC Public Health 2023; 23:1002. [PMID: 37254078 DOI: 10.1186/s12889-023-15831-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/06/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Our goal was to examine the proportion of transgender people satisfied with their lives (i.e., cognitive evaluation of life as a whole) and the determinants of life satisfaction level among transgender individuals. METHODS Data were taken from the HH-TPCHIGV study. Included were 104 transgender people who had joined self-help groups to get and share information about the gender-affirming surgeries performed at the Division of Plastic, Reconstructive and Aesthetic Surgery at the University Medical Center Hamburg-Eppendorf. The established Satisfaction with Life Scale was used to quantify life satisfaction. Sociodemographic-, lifestyle-related and health-related determinants were included in multiple linear regressions. In regression analysis, life satisfaction served as outcome measure and in a robustness check ordered probit regressions were used. RESULTS Among transgender people, 12.9% can be classified as "extremely dissatisfied", 18.3% can be classified as "dissatisfied", 12.9% can be classified as "slightly dissatisfied", 7.5% as "neutral", 30.1% as "slightly satisfied", 17.2% as "satisfied" and 1.1% as "extremely satisfied". Higher levels of life satisfaction were associated with higher age (β = .15, p < .05), higher school education (β = 5.54, p < .001), and favorable self-rated health (β = 2.20, p < .001). CONCLUSIONS Nearly half of the transgender people were at least "satisfied" with their lives. Knowledge about the correlates of life satisfaction may assist in addressing unsatisfied individuals.
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Affiliation(s)
- Katharina Grupp
- Division of Plastic, Reconstructive and Aesthetic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Marco Blessmann
- Division of Plastic, Reconstructive and Aesthetic Surgery, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistr. 52, 20246, Hamburg, Germany
| | - André Hajek
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg Center for Health Economics, Martinistr. 52, 20246, Hamburg, Germany
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Marano AA, Noyes M, Eisenbeis L, Hedian HF, Segna K, Neira PM, Thomas K, Lee WPA, Redett RJ, Coon D. Building an Academic Transgender Medicine Center of Excellence: The 5-Year Johns Hopkins Experience. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2023; 98:569-576. [PMID: 36608643 DOI: 10.1097/acm.0000000000005135] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
Gender-affirming care for transgender and gender diverse (TGD) individuals is a multidisciplinary endeavor that requires organized efforts of many specialized practitioners. TGD individuals experience many health care barriers, including the scarcity of multidisciplinary teams formed to coordinate and deliver complex care in an efficient and affirming way. The Johns Hopkins Center for Transgender Health was founded in 2017 with the mission of decreasing health disparities and improving the health of the TGD community. The authors present their experience building the center around a service line model in which patients have 1 point of contact, they are tracked throughout the care process, and the multidepartmental practitioners involved in their care are aligned. This model allowed for a patient-centered experience in which all involved disciplines were seamlessly integrated and the patient could navigate easily among them. With the structure and mission in place, the next challenge was to develop an infrastructure for culturally competent care. Through competency training and adjustment of systems-based logistics, measures were put in place to prevent traumatic experiences, such as misgendering, use of culturally inappropriate vocabulary, and use of incorrect names. Partnerships among colleagues in the fields of plastic surgery, urology, gynecology, otolaryngology, anesthesia, psychiatry/mental health, internal medicine, endocrinology, fertility, nursing, social work, speech therapy, and pediatrics/adolescent care were necessary to provide the appropriate breadth of services to care for TGD patients. Since its inception, the center has seen steady and continual growth, with more than 2,800 patients in its first 5 years. By sharing their experience in creating and developing a center of excellence, the authors hope to provide a blueprint for others to expand health care quality and access for TGD individuals.
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Affiliation(s)
- Andrew A Marano
- A.A. Marano is a gender and microsurgery fellow, Brigham Center for Transgender Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Melissa Noyes
- M. Noyes is program manager, Brigham and Women's Center for Transgender Health, Brigham and Women's Hospital, Boston, Massachusetts. At the beginning of this work, the author was program coordinator, Center for Transgender Health, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lauren Eisenbeis
- L. Eisenbeis is lead physician assistant, Luminis Health, Anne Arundel Medical Center Plastic and Reconstructive Surgery Group, Annapolis, Maryland. At the beginning of this work, the author was a physician assistant, Johns Hopkins Center for Transgender Health, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Helene F Hedian
- H.F. Hedian is assistant professor of medicine, Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kara Segna
- K. Segna is assistant professor of anesthesiology and critical care medicine, Department of Anesthesiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paula M Neira
- P.M. Neira is clinical program director and founder, Johns Hopkins Center for Transgender Health, program director, LGBTQ+ Equity and Education, Office of Diversity, Inclusion and Health Equity, Johns Hopkins Medicineassistant professor, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kate Thomas
- K. Thomas is director of clinical services, Sex and Gender Clinic, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - W P Andrew Lee
- W.P.A. Lee is professor, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas. At the beginning of this work, the author was professor and director, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Redett
- R.J. Redett is professor and chair, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Devin Coon
- D. Coon is clinical director, Brigham Center for Transgender Health, Brigham and Women's Hospitalassociate professor, Harvard Medical School, Boston, Massachusetts. At the beginning of this work, the author was chief medical director and founder, Johns Hopkins Center for Transgender Healthassociate professor, Departments of Plastic and Reconstructive Surgery and Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Saxena N, Jolly D, Wu CA, Boskey ER, Ganor O. Comparing Scrotoplasty Complication Rates in Transgender and Cisgender Men: An ACS NSQIP Study. JPRAS Open 2023; 36:55-61. [PMID: 37139354 PMCID: PMC10149324 DOI: 10.1016/j.jpra.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/26/2023] [Indexed: 04/05/2023] Open
Abstract
While masculinizing gender-affirming genital surgeries may include scrotoplasty, there has been limited research on the safety and outcomes of scrotoplasty among transgender men. We compared scrotoplasty complication rates between cisgender and transgender patients using data from the American College of Surgeon's National Surgical Quality Improvement Program (NSQIP) database. Data was queried between 2013 and 2019 for all patients with procedure codes for scrotoplasty. Transgender patients were identified through a gender dysphoria diagnosis code. T-tests and Fisher's exact test were used to identify any differences in demographics, operative characteristics, and outcomes. The primary outcomes of interest were demographic factors, operative details, and surgical outcomes. A total of 234 patients were identified between 2013 and 2019. Fifty were transgender and 184 were cisgender. Age and BMI were significantly different between the two cohorts, such that the cisgender cohort was older (M trans = 38 years (SD:14), M cis = 53 years (SD: 15)) and had higher BMI than the transgender cohort (M trans = 26.9 (SD: 5.5), M cis = 35.2 (SD: 11.2)). Cisgender patients also had poorer overall health (p = 0.001), and were more likely to have hypertension (p = 0.001) and diabetes (p = 0.001). Race and ethnicity did not vary significantly between the cohorts. Operative details differed significantly between cohorts, such that transgender patients had a longer operating time (M trans = 303 min (SD: 155), M cis = 147 min (SD: 107)) and fewer transgender patients had a simple scrotoplasty (p = 0.02). The majority of gender-affirming scrotoplasties were performed by plastic surgeons (62%) whereas the majority of cisgender scrotoplasties were performed by urologists (76%). Despite these demographic and pre-operative differences, the number of patients who underwent complex scrotoplasty experiencing any of the tested complications did not differ by gender. Our results support scrotoplasty as a safe procedure for transgender patients, with no significant differences in outcomes between transgender and cisgender patients.
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Preston S, Liu J, Eisenbeis L, Cohen A, Fishman EK, Coon D. 3D CT Urethrography With Cinematic Rendering (3DUG): A New Modality for Evaluation of Complex Urethral Anatomy and Assessment of the Postoperative Phalloplasty Urethra. Urology 2023; 174:212-217. [PMID: 36708932 DOI: 10.1016/j.urology.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 01/01/2023] [Accepted: 01/08/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To develop an imaging modality for the postoperative phalloplasty urethra. Despite high urologic complication rates after masculinizing genital surgery, existing methods for postsurgical evaluation after phalloplasty have drawbacks. Fluoroscopic studies like the retrograde urethrogram have limitations like user-dependence and need for meticulous positioning but also are inadequate for the evaluation of the anatomically complex postphalloplasty urethra. We developed a novel protocol utilizing CT urethrography with 3D reconstruction using cinematic rendering (3DUG) for neo-urethral imaging. MATERIALS AND METHODS Patients who underwent 3DUG after either phalloplasty, metoidioplasty, or prior to revision surgery were included. Low-dose imaging protocols were used to avoid any increases in radiation exposure. The first iteration of our protocol utilized retrograde contrast administration via the penile urethra, whereas the second iteration of our protocol utilized an antegrade technique with contrast instillation via the suprapubic catheter and a voiding scan. Imaging was initially obtained according to symptoms and then per protocol at 3 weeks after urethral lengthening. RESULTS Twenty-six patients were included in the series. Among postoperative phalloplasty patients imaged for symptoms, contrast extravasation/fistula was identified in 5 (63%), vaginal remnant in 3 (38%), and stricture in 2 (25%) compared to 5 (45%), 1 (9%), and zero respectively for patients imaged routinely. When intervention was required, operative findings correlated to anatomy on imaging. CONCLUSION We present a new protocol for the use of 3D CT urethrography with cinematic rendering for neo-urethral reconstruction. This technique has the potential to improve surgical planning and surveillance of urologic complications in postphalloplasty patients.
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Affiliation(s)
- Stephanie Preston
- Department of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - James Liu
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | - Lauren Eisenbeis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD
| | - Andrew Cohen
- Department of Urology, James Buchanan Brady Urological Institute, Johns Hopkins University, Baltimore, MD
| | - Elliot K Fishman
- Department of Radiology, Johns Hopkins University, Baltimore, MD
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD; Division of Plastic and Reconstructive Surgery, Brigham & Women's Hospital and Harvard Medical School, Boston, MA.
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Gao H, Wu D, Kong X, Zhu L, Jie X, Zhang W, Hu Z, Zhu X. A Novel Technique of Urethroplasty Could Reduce Urethra-Related Complications in Phalloplasty With Urethral Lengthening. Sex Med 2022; 10:100571. [PMID: 36182727 PMCID: PMC9780771 DOI: 10.1016/j.esxm.2022.100571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 08/26/2022] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION Urethral lengthening in phalloplasty could bring many postoperative complications, such as urethra fistula and stricture, which greatly affects the patient's mental health and quality of life. AIM To describe a novel technique of vaginal mucosal graft for prelamination urethra (VMGPU) combined with modified urethral anastomosis (MUA) for the reconstruction of a neourethra. METHODS A retrospective study of transgender men between January 2006 and March 2021 was conducted. Patients were divided into three groups according to the surgical methods : traditional group(TG,VMGPU group(VG) and VMGPU+MUA group (VMG). MAIN OUTCOME MEASURE The main outcomes measures were demographics, surgical characteristics, complications, International Prostate Symptom Score(IPSS,Quality of Life(QOL) score,and voiding frequency conditions. RESULTS Of 80 eligible transgender men(TG:n = 39,VG:n = 31, VMG:n = 10), the urethral fistula developed in 19/39 (49%) patients in TG, 8/31 (26%) in VG, and 1/10 (10%) in VMG (P = 0.034). The urethral stricture formed in 15/39 (38%) patients in TG, 4/31 (13%) in VG, and 1/10 (10%) in VMG (P = 0.028). Compared with TG, the VG got more favorable IPSS. The QOL scores showed that patients in VG or VMG were more satisfied with their postoperative status. CLINICAL IMPLICATIONS VMGPU combined with MUA may help reduce urethral complications for transgender men who wish to undergo phalloplasty with urethral lengthening. STRENGTH & LIMITATIONS VMGPU combined with MUA focuses on reducing the urethra-related complications in the anastomotic stoma between the fixed and the penile urethra, which has not been noticed in the past. The limitations of this study are that the retrospective study design is prone to bias; the study using VMGPU+MUA technique is only in the preliminary stage, and more cases are needed to prove its effectiveness; the median follow-up in VMG was only 2 years, and longer-term follow-up results are inconclusive; the IPSS, QOL, and the voiding frequency chart were not validated in transgender men. CONCLUSION Our pilot study suggests that VMGPU combined with MUA may reduce the urethra-related complications, especially the urethral fistula in the anastomosis stoma between the fixed and the penile urethra. Gao H, Wu D, Kong X, et al. A Novel Technique of Urethroplasty Could Reduce Urethra-Related Complications in Phalloplasty With Urethral Lengthening. Sex Med 2022;10:100571.
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Affiliation(s)
| | | | | | | | | | | | - Zheyuan Hu
- Corresponding Authors: Xiaohai Zhu, MD, Zheyuan Hu, MD, Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital (Chang Zheng Hospital) of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, China
| | - Xiaohai Zhu
- Corresponding Authors: Xiaohai Zhu, MD, Zheyuan Hu, MD, Department of Plastic and Reconstructive Surgery, Second Affiliated Hospital (Chang Zheng Hospital) of Naval Medical University, 415 Fengyang Road, Huangpu District, Shanghai, 200003, China
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de Rooij FPW, van der Sluis WB, Ronkes BL, Steensma TD, Al-Tamimi M, van Moorselaar RJA, Bouman MB, Pigot GLS. Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 24:487-498. [PMID: 37901060 PMCID: PMC10601502 DOI: 10.1080/26895269.2022.2110548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0-6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.
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Affiliation(s)
- Freek P. W. de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Wouter B. van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Brechje L. Ronkes
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Thomas D. Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Muhammed Al-Tamimi
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | | | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Garry L. S. Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
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Scott KB, Thuman J, Jain A, Gregoski M, Herrera F. Gender-Affirming Surgeries: A National Surgical Quality Improvement Project Database Analyzing Demographics, Trends, and Outcomes. Ann Plast Surg 2022; 88:S501-S507. [PMID: 35690947 DOI: 10.1097/sap.0000000000003157] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Gender affirmation surgery is an exponentially growing field within plastic surgery. The aim of our study is to analyze demographics, procedure type, trends, and outcomes in the surgical management of gender identity disorder in the past few years. METHODS The American College of Surgeons NSQIP database was queried for the years 2015 to 2019. International Classification of Diseases codes were used to identify all gender-affirming cases. Patients were categorized by procedure type using Current Procedural Terminology codes for feminizing/masculinizing top, bottom and head/neck procedures. Patient demographics, comorbidities, and postoperative complications were analyzed using SPSS statistics software. A comparative analysis was performed among the procedure type. RESULTS From 2015 to 2019, 4114 patients underwent a gender-affirming surgery (GAS) increasing the number of surgeries by over 400%, according to the NSQIP database. Demographics include age (mean = 32 years), body mass index (mean = 28 kg/m2), race (60% White, 22% unknown, 13% African American, 4% Asian, 1% other). Female to male procedures represented the most commonly performed (n = 2647; 64%), followed by male to female (n = 1278; 31%) with head/neck procedures representing 5% (n = 189) of all procedures. Top surgeries were also the most common (n = 2347, 57%), followed by bottom surgeries (n = 1578, 38%). The overall complication rate was 6% (n = 247), 2.1% (n = 4) for head/neck procedures, 8% (n = 134) for bottom procedures, and 3.5% (n = 84) for top surgeries.A reoperation within 30 days and related to the initial GAS occurred for 52 patients. Postoperative complication rates were statistically different between bottom surgeries compared with the top and head/neck procedure groups (P < 0.001). Increasing age and body mass index showed a significantly higher odds of having a complication. CONCLUSIONS Gender-affirming procedures have significantly increased over the past 5 years. Increased exposure through literature and research, as well as an improvement in social climates, including increasing insurance coverage have contributed to the expansion of these procedures. Low serious complication rates within 30 days prove GAS to be safe.
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Affiliation(s)
- Kiandra B Scott
- From the Medical University of South Carolina, Division of Plastics and Reconstructive Surgery
| | - Jenna Thuman
- From the Medical University of South Carolina, Division of Plastics and Reconstructive Surgery
| | - Abhishek Jain
- Medical University of South Carolina, College of Medicine
| | | | - Fernando Herrera
- From the Medical University of South Carolina, Division of Plastics and Reconstructive Surgery
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Smith SM, Yuan N, Lee G, Stelmar J, Ray E, Garcia MM. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022; 10:100495. [PMID: 35255460 PMCID: PMC9023249 DOI: 10.1016/j.esxm.2022.100495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL). Aim To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL. Methods We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date. Outcomes Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries. Results All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57). Clinical Implications The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system. Strengths and Limitations Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time. Conclusion It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs. Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.
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Affiliation(s)
- Shannon M Smith
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute, Pasadena, CA, USA
| | - Grace Lee
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA
| | - Edward Ray
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; Cedars-Sinai Medical Center, Los Angeles, Division of Plastic Surgery, Los Angeles, CA, USA
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; University of California San Francisco, Department of Urology and Department of Anatomy, San Francisco, CA, USA.
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10
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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. CURRENT SEXUAL HEALTH REPORTS 2022. [DOI: 10.1007/s11930-021-00323-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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11
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Javier C, Crimston CR, Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. INTERNATIONAL JOURNAL OF TRANSGENDER HEALTH 2022; 23:255-273. [PMID: 35799954 PMCID: PMC9255096 DOI: 10.1080/26895269.2022.2038334] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Many transgender women and men undergo gender-affirming surgeries. Existing work shows that early surgery outcomes are generally positive, suggesting high surgical satisfaction and positive quality of life outcomes. Less work, however, examines these outcomes in the longer-term. AIMS To conduct a systematic literature review into the longer-term (i.e., ≥ 1 year) surgical satisfaction and quality of outcomes following various forms of gender-affirming surgery in transgender populations. Specifically, we aim to examine research on such outcomes at least one-year post gender-affirming chest, genital, facial, vocal cord, and Adam's apple removal surgeries. METHODS Studies were identified through Google Scholar, PsycINFO, Scopus, and PubMed databases, as well as through Google Scholar search alerts. We considered all studies published until October 2021. Two reviewers extracted data from suitable studies using Covidence. Both reviewers also independently assessed the identified studies' risk of bias and strength of evidence. RESULTS Seventy-nine low quality (e.g., small sample sizes, lack of control/comparison groups) studies suggest that most transgender patients are satisfied with surgical outcomes when assessed at least one-year post-surgery. Low quality research also indicates that transgender women and men typically report positive psychological and sexual wellbeing post-surgery, and similar wellbeing outcomes as those who have not had surgery. DISCUSSION To the best of our knowledge, this literature review is the first to critically summarize and evaluate all published studies on the longer-term quality of life outcomes following chest, genital, facial, voice and Adam's apple removal surgeries for transgender women and men. While the results suggest promising surgical satisfaction and quality of life outcomes following surgery, many studies only draw on small samples, and most studies do not allow for causal conclusions. Further, few studies have compared surgical outcomes between transgender women and men. We conclude by offering concrete suggestions for future research.
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Affiliation(s)
- Christienne Javier
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
- CONTACT Christienne Javier School of Psychology, The University of Queensland, St Lucia, Queensland4072, Australia
| | - Charlie R. Crimston
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
| | - Fiona Kate Barlow
- School of Psychology, The University of Queensland, St Lucia, Queensland, Australia
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12
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Melancon DM, Walton AB, Mundinger G, Benson C. Surgical Outcomes and Complications of Genital Gender Affirmation Surgery. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00318-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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13
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Neophallus Construction and Penile Prosthesis Implantation: Techniques and Complications. CURRENT SEXUAL HEALTH REPORTS 2021. [DOI: 10.1007/s11930-021-00316-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Walton AB, Hellstrom WJG, Garcia MM. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021; 9:605-618. [PMID: 34493480 DOI: 10.1016/j.sxmr.2021.07.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/29/2021] [Accepted: 07/06/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated. OBJECTIVES To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy. METHODS A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries). RESULTS The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or "watershed" procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes. CONCLUSION There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605-618.
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Affiliation(s)
- Alice B Walton
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Tulane University School of Medicine, Department of Urology, New Orleans, LA, USA.
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Department of Urology, Los Angeles, CA, USA
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15
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Shaft-only Phalloplasty: Technical Modifications to Optimize Aesthetics. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3645. [PMID: 34168941 PMCID: PMC8219247 DOI: 10.1097/gox.0000000000003645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/21/2021] [Indexed: 11/26/2022]
Abstract
Shaft-only phalloplasty (SOP) has been described as an alternative option for phalloplasty. Although traditional phalloplasty represents the most complete form of genital gender-affirming surgery, this variation also carries the greatest surgical risk. Patients may opt for a lower risk SOP for reasons including gender identity, gender expression, sexual function, desire for future childbearing, or minimal gender dysphoria associated with sedentary urination. Further, some patients may, due to associated co-morbidities, not be a candidate for neourethral reconstruction. Forgoing urethral reconstruction also means forgoing the presence of a distal urethral meatus and thereby compromising on one of the basic tenets of phalloplasty surgery—the aesthetic appearance. In an SOP, the flap is usually a simple tube with a purse-string suture placed at the distal end. Another concern can be the insufficient bulk of the phallus due to the absence of the volume added by the inner tube. The purpose of this article is to review our technical modifications that allow for creation of a phallic meatus as well as increasing phallic girth when needed. The most frequently described technique to create a neo-urethra is the tube-within-tube concept. We expanded on this and apply it as a short segment for distal meatal creation in an SOP. Improved aesthetics are achieved by creating the appearance of a phallic meatus and when desired, utilizing a lateral de-epithelialized strip to increase phallic bulk and girth. We hope these technical refinements can assist the surgeon in better meeting the goal of creating an aesthetically pleasing phallus.
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16
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de Rooij FPW, Peters FRM, Ronkes BL, van der Sluis WB, Al-Tamimi M, van Moorselaar RJA, Bouman MB, Pigot GLS. Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men. BJU Int 2021; 129:63-71. [PMID: 34046987 PMCID: PMC9291467 DOI: 10.1111/bju.15500] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/30/2021] [Accepted: 05/23/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.
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Affiliation(s)
- Freek P W de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Femke R M Peters
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Brechje L Ronkes
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Wouter B van der Sluis
- Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Muhammed Al-Tamimi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - R Jeroen A van Moorselaar
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands.,Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
| | - Garry L S Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands.,Center of Expertise on Gender Dysphoria at the Amsterdam University Medical Center, Location VUmc, Amsterdam, the Netherlands
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Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2021; 18:974-981. [PMID: 33896759 DOI: 10.1016/j.jsxm.2021.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/02/2021] [Accepted: 03/07/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL). AIM The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up. METHODS A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. OUTCOMES Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction. RESULTS Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P < .001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P < .001) and with voiding (P = .02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P = .48 and P = .95 respectively). CLINICAL IMPLICATIONS Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. STRENGTHS & LIMITATIONS Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey. CONCLUSION No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974-981.
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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] [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
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