Masculinizing Genital Gender Confirmation Surgery

Pelvic floor and sexual dysfunctions after genital gender-affirming surgery: a systematic review and meta-analysis

BACKGROUND

Genital gender-affirming surgery has become a crucial step in the transitioning process of numerous transgender people.

AIM

To highlight the consequences of genital gender-affirming surgery on pelvic floor function in transgender people.

METHODS

Medical databases (PubMed, EMBASE, and Cochrane Library) were consulted according to a combination of keywords. All papers published up to February 29, 2024 were considered. Two reviewers independently screened the abstracts of the selected studies and extracted data from the full-text articles included. Data were subsequently tabulated and compared for consistency. The bias associated with each included study was evaluated according to the Observational Study Quality Evaluation (OSQE) method. This study is registered on PROSPERO number CRD42024522580.

OUTCOMES

Pelvic floor dysfunctions in individuals who undergo gender-affirming surgery, factors that may be involved in the increased prevalence of these dysfunctions and perspectives of treatment of the complications through pelvic floor physical therapy.

RESULTS

Twenty-five papers were considered for systematic review, while 17 studies were included for meta-analysis. There was significant statistical heterogeneity across the included studies. Among transwomen who had undergone vaginoplasty, pelvic organ prolapse occurred in 1%-7.5% of patients, urinary incontinence affected up to 15% of patients, while urinary irritative symptoms up to 20%. Sexual dysfunctions were reported by 25%-75% of patients. Among transmen who underwent hysterectomy and phalloplasty, pelvic organ prolapse occurred in 3.8% of patients, urinary incontinence affected up to 50% of patients, while urinary irritative symptoms up to 37%. Finally, sexual dysfunctions were reported by 54% of patients.

CLINICAL IMPLICATIONS

The findings of this study could be helpful for transgender patients pre-operative counselling.

STRENGTHS AND LIMITATIONS

This is the first systematic review and meta-analysis about pelvic floor dysfunctions in transgender people undergoing genital gender-affirming surgery. The main limitations are the limited number of studies included and their heterogeneity.

CONCLUSION

Pelvic floor dysfunctions following genital gender-affirming surgery are an emerging issue. Adequate information for each surgical procedure, explicit postoperative instructions, continuity of care, communication with healthcare providers, and recommendation for tailored perioperative pelvic floor physiotherapy are necessary for a better surgical result.

Using a novel and validated survey tool to analyze sexual functioning following vaginoplasty in transgender individuals

Background In the healthcare setting, transgender patients are often marginalized, face discrimination and have limited access to high-quality gender-affirming care, such as gender-affirming surgery (GAS). As a result, the available data pertaining to GAS are often based on convenience samples, and the majority of published studies in the US are cross-sectional. Transgender people may undergo GAS to align their bodies with their gender identities. There has been little emphasis on the GAS self-evaluated experience. GAS may be associated with improved quality of life in transgender people. This study aimed to analyze the functionality of transgender patients' genitals following vaginoplasty. Methods A total of 306 transgender patients responded to a validated survey for patient-reported feminizing GAS outcomes. Surveys were given to patients prior to GAS, and then 2weeks, 6months and 12months postoperatively. Pre- and post-GAS responses were compared using McNemar and Wilcoxon signed-rank tests. Self-identified race/ethnicity was available for all survey participants. All participants voluntarily took the same survey by using the same survey platform to eliminate bias. Results Five questions showed significant improvement between the 2-week and 6-month responses. These questions assessed if respondents had sensation in their clitoris (P =0.031), the frequency that clitoral stimulation was pleasurable (P =0.018), the presence of sexual activity in the past 3months (P P =0.031) and if labial irritation while walking or exercising decreased (P =0.051). Significant differences were not detected between the 6-month and 12-month responses for any of the survey questions. Conclusions The results of five different metrics regarding sexual activity and vaginal functioning showed a significant improvement for transgender people following GAS. Findings also similarly demonstrate a high success rate of sexual activity after GAS. These are significant patient-reported outcomes using tools validated for the transgender population. Respondent outcomes significantly improved between the 2-week and 6-month time period, but did not differ between the 6-month and 12-month period, suggesting the ideal time to assess the above-described patient-perceived outcomes with vaginoplasty is 6months postoperatively.

Promoting trans patient autonomy in surgical preparation for phalloplasty and metoidioplasty: results from a community-based cross-sectional survey and implications for preoperative assessments

BACKGROUND

Some transgender and nonbinary people undergo phalloplasty and/or metoidioplasty as part of their medical transition process. Across surgical disciplines, a variety of resources are used to assist patients who are preparing for surgeries, including educational materials, workshops, peer support, and lifestyle changes. For gender-affirming surgeries, patients undergoing assessments to discern whether they are ready to undergo the surgery, and to assist them in achieving preparedness when needed. Little research investigates what resources are useful in helping patients to feel prepared to undergo phalloplasty or metoidioplasty, and how assessments and resources can promote patient autonomy in the process. Respect for patient autonomy is one of the central tenets of ethical healthcare, yet historically, scholarship related to pre-surgical assessments for gender-affirming surgery has focused determining the ideal surgical candidate rather than respecting patient autonomy and ascertaining individual patient needs.

METHODS

This study sought to fill this gap by utilizing data from PROGRESS (Patient-Reported Outcomes of Genital Reconstruction and Experiences of Surgical Satisfaction), a cross-sectional, community-based survey of trans and nonbinary adults from the United States of America and Canada who had undergone one or more of these surgeries.

RESULTS

Results revealed most participants (86%, n = 186) felt prepared to undergo surgery, though the majority of our sample (53%, n = 105) did not find referral letter assessments to be helpful. Peer support such as online resources/blogs were rated as highly useful, along with surgical consults. In a multivariable logistic regression, higher perceived preparedness was associated with identifying as queer (inclusive of gay, bi and pansexual compared to being straight), and feeling that one's assessment process was useful (as opposed to not useful). Type of assessment was not significantly associated with preparedness; therefore, what is most useful when preparing for surgery may vary across individuals.

CONCLUSION

Healthcare professionals who interact with preparing patients should develop new or utilize existing resources to assist patients in identifying their preparation needs and achieving preparedness. Our data supports assessments that center surgical care planning rather than assessing level of gender dysphoria. Future longitudinal research could further refine which assessment processes are most effective in helping patients who are preparing for these surgeries. Assessments should ensure that patients are appropriately prepared to undergo and recover from surgery through a robust process of informed consent.

Staged Phalloplasty by Metoidioplasty First Does Not Appear to Lower Complication Rates

Purpose

Genital gender-affirming surgery in transmasculine patients encompasses both metoidioplasty and phalloplasty. Some patients opt to undergo staged phalloplasty by metoidioplasty first (SPMF). The aim of this study was to evaluate whether SPMF is associated with less surgical complications compared with immediate phalloplasty (IP).

Methods

Our institutional database was retrospectively evaluated to identify transmasculine patients who underwent SPMF between 2006 and 2020. These patients were matched based on the type of flap (radial forearm free flap vs. anterolateral thigh flap) and for the time period in regard to patients who underwent IP. Both groups were compared on patient characteristics, perioperative and postoperative outcomes.

Results

Twenty-seven patients with SPMF were matched with 27 IP patients. Median follow-up after phalloplasty was held, respectively, 32 and 33 months after the intervention for SPMF and IP (p=0.99). There were no significant differences in age, body mass index, and smoking habits between both groups. For SPMF, metoidioplasty required subsequent corrective surgery before phalloplasty in three patients (11%). For SPMF and IP, median operation time was 396 and 410 min (p=0.6), median hospital stay was 16 and 17 days (p=0.5), and median catheter stay was 19 and 20 days (p=0.9). In both groups, 16 patients (59%) needed at least one additional surgical procedure for postoperative complications, urethral complications (stricture, fistula), and/or flap-related complications.

Conclusion

In our cohort, complications were not reduced by SPMF. In case metoidioplasty is considered as a step toward phalloplasty, separate morbidity of metoidioplasty must be taken into account.

Functional outcomes after supra-pubic phalloplasty

BACKGROUND

A thorough evaluation of the functional outcomes resulting from supra-pubic phalloplasty (SPP) assessing different aspects of the phalloplasty technique has not been reported.

PURPOSE OF THE STUDY

To report the outcomes on sexuality, urinary function, satisfaction, and regrets following SPP performed at our centre.

SUBJECTS STUDIED

All consecutive patients who underwent the three-step technique of pre-expanded SPP between 2007 and 2018 and who had at least one year of follow-up.

METHODS

Questionnaires were sent to analyse several domains of penile reconstruction: sexuality, urinary function, perceived sensitivity, and satisfaction. Sexuality was evaluated using the Self-Esteem And Relationship (SEAR) questionnaire. Urinary function was analysed based on the urethral stricture surgery patient-reported outcome measures (USS-PROM) questionnaire.

MAIN FINDINGS

A total of 77 patients were included, 92.2% were transmen, and 33 (42.9%) responded to the questionnaire. Urethral lengthening (UL) was performed in 28 (36.4%) procedures, and erectile prosthesis was implanted in 42 patients (54.5%). The mean length of the neophallus was 15.3 cm (standard deviation [SD] 2.6), and the mean girth was 11.8 cm (SD 2.1). The mean total SEAR score (/100) was 73.8 (SD 26.7). The mean six-item lower urinary tract symptom score (/24) was 8.4 (SD 4.6). The standing position was the usual voiding position reported by 11 patients (73.3%).

CONCLUSION

Pre-expanded SPP is a robust technique that can achieve substantial flap dimensions, leading to high satisfaction with neophallus appearance and the choice of the phalloplasty technique. Overall, sexual outcomes are mostly favourable. UL is feasible and effective in terms of voiding in a standing position.

Pain mechanisms in the transgender individual: a review

Specific Aim

Provide an overview of the literature addressing major areas pertinent to pain in transgender persons and to identify areas of primary relevance for future research.

Methods

A team of scholars that have previously published on different areas of related research met periodically though zoom conferencing between April 2021 and February 2023 to discuss relevant literature with the goal of providing an overview on the incidence, phenotype, and mechanisms of pain in transgender patients. Review sections were written after gathering information from systematic literature searches of published or publicly available electronic literature to be compiled for publication as part of a topical series on gender and pain in the Frontiers in Pain Research.

Results

While transgender individuals represent a significant and increasingly visible component of the population, many researchers and clinicians are not well informed about the diversity in gender identity, physiology, hormonal status, and gender-affirming medical procedures utilized by transgender and other gender diverse patients. Transgender and cisgender people present with many of the same medical concerns, but research and treatment of these medical needs must reflect an appreciation of how differences in sex, gender, gender-affirming medical procedures, and minoritized status impact pain.

Conclusions

While significant advances have occurred in our appreciation of pain, the review indicates the need to support more targeted research on treatment and prevention of pain in transgender individuals. This is particularly relevant both for gender-affirming medical interventions and related medical care. Of particular importance is the need for large long-term follow-up studies to ascertain best practices for such procedures. A multi-disciplinary approach with personalized interventions is of particular importance to move forward.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

A History of Gender-Affirming Surgery at the University of Michigan: Lessons for Today

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.

Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know

OBJECTIVE

To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS).

METHODS

A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis.

RESULTS

The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure.

CONCLUSION

Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

Surgical outcomes, motivations, sexuality, and urinary function of metoidioplasty with semi-rigid prosthesis

Background

Preliminary results of a specific semi-rigid prosthesis for metoidioplasty (ZSI® 100D4; Zephyr Surgical Implants, Geneva) have been reported, suggesting a safe procedure that may enhance the metoidioplasty outcomes by stiffening and increasing protrusion of the constructed neo-phallus.

Aim

The objective of the present study was to report the updated surgical results of metoidioplasty with implantation of the ZSI®100D4, along with a comprehensive evaluation of the outcomes including, motivations, sexuality, and urinary function.

Methods

All individuals who underwent a metoidioplasty with implantation of the ZSI®100D4 between August 2017 and January 2021 with at least 1 year of follow-up were included and their data retrospectively collected. They were contacted by telephone between November 2020 and May 2022 and invited to answer a questionnaire exploring motivations, satisfaction with genitals and sexual life, as well as urinary and sexual function.

Results

Twenty-one individuals were included and followed-up during a median [IQR] period of 19.5 months [12.8-24.2]. Most individuals (n = 13; 62.0%) had a post-operative complication, the most frequent was wound dehiscence (n = 6; 28.6%). Three urinary fistula (14.3%) were reported, all managed conservatively (Clavien-Dindo grade 2) with a prolonged urinary diversion. Among the 18 individuals who answered the questionnaire, 16 (88.9%) were sexually active, and 11 (61.1%) were engaged in a sexual relationship. The total median [IQR] self-esteem and relationship questionnaire score was 92 [91-97]. The reported urinary symptoms of delay, intermittency, lagging drops and spraying were mostly never or rarely reported. The satisfaction regarding overall genital aspect was highly favorable as 15 (83.3%) individuals reporting being very satisfied or satisfied, although 5 (27.8%) reported being dissatisfied with the size of their genitals.

Conclusion

Implantation of a semi-rigid prosthesis in a metoidioplasty seems a safe procedure, with no reported complications related to the prosthesis. Overall, satisfaction regarding genitals, sexual and urinary function are favorable.

[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]

AIMS

The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications.

METHODS

In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery.

RESULTS

The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant.

CONCLUSION

Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

[Genital gender affirming surgery in trans men]

OBJECTIVE

Genital surgery for masculinisation in the context of gender incongruence is characterised by the reconstruction of male genitalia using multiple surgical techniques - free flap phalloplasty, pedicled flap phalloplasty or metaoidioplasty - which this article aims to describe.

MATERIAL AND METHODS

A narrative review of the literature on these trans surgeries was carried out.

RESULTS

Each technique has specific advantages and disadvantages, and does not produce the same results in terms of surgical risks, size of the reconstructed phallus, sensitivity, sexual function and urinary function.

CONCLUSION

This surgical decision must therefore be shared with the person concerned, based on a clear understanding of their expectations and objectives. Long-term follow-up is recommended.

[The tube in tube thoracodorsal perforator flap phalloplasty]

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

Principles and outcomes of gender-affirming vaginoplasty

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

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.

Gender Dysphoria and Its Non-Surgical and Surgical Treatments

Gender dysphoria is defined by severe or persistent distress associated with an incongruence between one's gender identity and biological sex. It is estimated that 1.4 million Americans and 25 million people worldwide identify as transgender and that 0.6% of Americans experience gender dysphoria. The pathophysiology of gender dysphoria is multifactorial and incompletely understood. Genetics, androgen exposure, neuroanatomy, brain connectivity, history of trauma, parents with psychological disorders, and being raised by less than two parents are associated with gender dysphoria. Gender dysphoria most frequently presents in early teenage years but can present earlier or later. Anxiety and depression are the two most common comorbid diagnoses and may be the reason for presentation to medical care. Diagnosis is established through history and or validated questionnaires. Treatment includes psychosocial therapy, pharmacotherapy for underlying depression and/or anxiety, hormonal therapy, non-genital and/or genital feminization or masculinization operations. The frequency and severity of treatment related morbidity increases progressively as treatments go from conservative to more invasive. Gender dysphoria and its treatment is individualized and not completely understood.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men

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.

Th17 cells-linked mechanisms mediate vascular dysfunction induced by testosterone in a mouse model of gender-affirming hormone therapy

Clinical data point to adverse cardiovascular events elicited by testosterone replacement therapy. Testosterone is the main hormone used in gender-affirming hormone therapy (GAHT) by transmasculine people. However, the cardiovascular impact of testosterone in experimental models of GAHT remains unknown. Sex hormones modulate T cells activation, and immune mechanisms contribute to cardiovascular risk. The present study evaluated whether testosterone negatively impacts female cardiovascular function by enhancing Th17 cells-linked effector mechanisms. Female (8 weeks-old) C57BL/6J mice received testosterone (48 mg.Kg^-1.week^-1) for 8 weeks. Male mice were used for phenotypical comparisons. The hormone-treatment in female mice increased circulating testosterone to levels observed in male mice. Testosterone increased lean body mass and body mass index, and decreased perigonadal fat mass, mimicking clinical findings. After 8 weeks, testosterone decreased endothelium-dependent vasodilation and increased circulating Th17 cells. After 24 weeks, testosterone increased blood pressure in female mice. Ovariectomy did not intensify phenotypical or cardiovascular effects by testosterone. Female mice lacking T and B cells [Rag1 knockout (^-/-)], as well as female mice lacking IL-17 receptor (IL-17Ra^-/-), did not exhibit vascular dysfunction induced by testosterone. Testosterone impaired endothelium-dependent vasodilation in female mice lacking γδ T cells, similarly to the observed in wild type female mice. Adoptive transfer of CD4⁺ T cells restored testosterone-induced vascular dysfunction in Rag1^-/- female mice. Together, these data suggest that CD4⁺ T cells, most likely Th17 cells, are central to vascular dysfunction induced by testosterone in female mice, indicating that changes in immune cells balance are important in the GAHT in transmasculine people.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery

BACKGROUND

Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care.

AIM

The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement.

METHODS

Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations.

OUTCOMES

Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes.

RESULTS

Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235).

CLINICAL IMPLICATIONS

This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions.

STRENGTHS & LIMITATIONS

This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality.

CONCLUSION

Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

A Systematic Review of Staging and Flap Choice in Gender-Affirming Phalloplasty

Background As phalloplasty becomes more routinely performed, there is a growing need for an evidence base to guide surgical decision-making. Recent reviews have suggested that flap type and number of stages may affect the high rates of urethral complications seen with phalloplasty, but no rigorous comparison of both has been performed.

Methods A systematic review was conducted across PubMed, Google Scholar, and ScienceDirect (PROSPERO #158722). All included studies examined urethral complications following gender-affirming phalloplasty in transgender men. Data were extracted in line with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Quality of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. All searches, extractions, and grading were completed by two authors.

Results Twenty-five studies were included with a total of 1,674 patients. Identified flap types included radial forearm, anterolateral thigh, abdominal, and fibular flaps. Surgical techniques varied widely within the flap types. Number of stages ranged from one to four. Stricture and fistula were the most frequently reported complications with considerable variation in the reported rates between studies, even within singular flap types. Data extraction indicated serious quality issues with the published literature, with the majority of studies at high risk of bias due to short follow-up times, inconsistent and incomplete reporting of outcomes, and inconsistent reporting of surgical technique.

Conclusion To date, there is insufficient data to support a preferred flap type to minimize the urethral complication rates of phalloplasty. Further high-quality literature is required to determine the impact of potential factors affecting complications of gender-affirming phalloplasty. Improved literature quality may be facilitated by a standardized set of reporting guidelines.

"Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?"

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.

Creating Breast and Gynecologic Cancer Guidelines for Transgender Patients With BRCA Mutations

More than 1.5 million individuals in the United States identify as transgender. Transgender individuals have lower rates of health care utilization and higher rates of health care discrimination than cisgender patients. With a growing interest in providing comprehensive and compassionate care to the transgender community, there has been a concurrent increase in research on transgender health. However, lack of long-term data limits understanding the effects of hormone therapy on cancer risk factors in this population. This is particularly relevant for patients with hormonally mediated cancers and those at elevated risk from hereditary breast and ovarian cancer syndromes. Few cancer-screening and management guidelines currently exist for this population. Specific practices guided by the nuances of gender identity and gender-affirming care are essential to improve clinical management and to avoid further alienating a population that is already marginalized from the health care system. This commentary summarizes screening, management, and surveillance strategies devised for cisgender patients to offer corresponding recommendations tailored for transgender BRCA mutation carriers. In doing so, it highlights critical unanswered questions pertaining to the care of these patients. To address these questions, we must prioritize this population and adopt more inclusive frameworks in medicine and research.

Genital Self-Image and Aesthetic Genital Surgeries: Novel Perspectives Across the Cisgender and Transgender Spectrum

Genital-focused body image concerns or negative genital self-image are a common experience across the gender spectrum, including among cisgender and transgender populations. Such concerns can result in lower psychological and sexual well-being. In this article, it is proposed that the development of genital self-image concerns may be partly explained by the theoretical framework of cisgenderism. This theory proposes that there are only 2 genders-men and women-and these are dictated solely by the appearance of the genitals. Any deviation from these 2 categories can result in discrimination, which particularly impacts transgender individuals. An increasing number of cisgender and transgender people are seeking out aesthetic genital procedures to alleviate genital self-image concerns (and gender dysphoria in transgender populations). The growing body of research suggests that cisgender and transgender men and women are relatively satisfied with the results of their genital procedures. However, this research is limited by a lack of standardized and validated patient-reported measures to evaluate surgical outcomes. Furthermore, despite negative genital self-image being a key motivator for surgery, it is often not included as an outcome measure. In this article, recommendations are proposed for conducting higher-quality evaluation studies of aesthetic genital procedures in cisgender and transgender populations. Moreover, future research and clinical directions are suggested to assist transgender men and women who choose not to undergo genital gender-confirming surgery. The vast majority of transgender individuals do not have this surgery and so are in great need of support in managing their gender dysphoria and negative genital self-image.

Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study

BACKGROUND

While much emphasis has been put on the evaluation of gender-affirming surgery (GAS) approaches and their effectiveness, little is known about the health care needs after completion of these interventions.

AIM

To assess post-GAS aftercare needs using a mixed-method approach and relate these to participant characteristics.

METHODS

As part of the ENIGI follow-up study, data was collected 5 years after first contact for gender-affirming treatments in 3 large European clinics. For the current analyses, only participants that had received GAS were included. Data on sociodemographic and clinical characteristics was collected. Standard aftercare protocols were followed. The study focused on participants' aftercare experiences. Participants rated whether they (had) experienced (predefined) aftercare needs and further elaborated in 2 open-ended questions. Frequencies of aftercare needs were analyzed and associated with participant characteristics via binary logistic regression. Answers to the open-ended questions were categorized through thematic analysis.

OUTCOMES

Aftercare needs transgender individuals (had) experienced after receiving GAS and the relation to sociodemographic and clinical characteristics.

RESULTS

Of the 543 individuals that were invited for the ENIGI follow-up study, a total of 260 individuals were included (122 (trans) masculine, 119 (trans) feminine, 16 other, 3 missing). The most frequently mentioned aftercare need was (additional) assistance in surgical recovery (47%), followed by consultations with a mental health professional (36%) and physiotherapy for the pelvic floor (20%). The need for assistance in surgical recovery was associated with more psychological symptoms (OR=1.65), having undergone genital surgery (OR=2.55) and lower surgical satisfaction (OR=0.61). The need for consultation with a mental health professional was associated with more psychological symptoms and lower surgical satisfaction. The need for pelvic floor therapy was associated with more psychological symptoms as well as with having undergone genital surgery. Thematic analysis revealed 4 domains regarding aftercare optimization: provision of care, additional mental health care, improvement of organization of care and surgical technical care.

CLINICAL IMPLICATIONS

Deeper understanding of post-GAS aftercare needs and associated individual characteristics informs health care providers which gaps are experienced and therefore should be addressed in aftercare.

STRENGTHS & LIMITATIONS

We provided first evidence on aftercare needs of transgender individuals after receiving GAS and associated these with participant characteristics in a large multicenter clinical cohort. No standardized data on aftercare received was collected, therefore the expressed aftercare needs cannot be compared with received aftercare.

CONCLUSION

These results underline a widely experienced desire for aftercare and specify the personalized needs it should entail. IJ de Brouwer, E Elaut, I Becker-Hebly et al. Aftercare Needs Following Gender-Affirming Surgeries: Findings From the ENIGI Multicenter European Follow-Up Study. J Sex Med 2021;18:1921-1932.

Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery

BACKGROUND

Possible options of genital gender affirming surgery in transmasculine are metoidioplasty or phalloplasty. As opposed to phalloplasty, no flapbased neophallic reconstruction is needed in metoidioplasty. Urethral lengthening is needed in metoidioplasty if the patient desires voiding at the tip of the neophallus. This urethral lengthening poses the patient at risk for urethral complications.

AIM

Our primary goal was to describe the morbidity and specific the urethral complications related to metoidioplasty. Second, we sought for predictors of these urethral complications.

METHODS

Our institutional database was retrospectively analyzed to identify transmasculine who underwent metoidioplasty between 2006 and 2020. This cohort was further evaluated for surgical morbidity, urethral complications and potential predictors for urethral complications.

OUTCOMES

The rate of surgical morbidity and urethral complications (temporary/permanent fistula, stricture or fistula and stricture) was calculated. Potential predictors evaluated herein were BMI, concomitant vaginectomy, active smoking and additional urethral lengthening (AUL). They were tested with logistic regression analysis with calculation of Odds Ratio (OR).

RESULTS

Seventy-four patients underwent metoidioplasty with a median follow-up of 44 months. Median age was 26 years. AUL was done in 36 (48.6%) patients and established by a transverse preputial skin island and labium minus flap in respectively 34 and 2 patients. Within 30 days after metoidioplasty, 3 (4.1%) high-grade complications were noted. Urethral complications of any kind were noted in 42 (56.8%) patients. All fistulas, permanent fistulas and strictures were seen in resp. 34 (45.9%), 27 (36.5%) and 14 (18.9%) patients. AUL is a significant predictor for all urethral complications (OR 15.5), strictures (OR 24.5), all fistula's (OR 6.07) and permanent fistulas (OR 3.83). In contrast, smoking is only a predictor for all fistulas (OR 6.54) and permanent fistulas (OR 3.76).

CLINICAL IMPLICATIONS

Obtaining information about the risk of complications is important in preoperative patient counselling. Patient who desires AUL are at higher risk to develop urethral complications and patients who continue to smoke at the period of metoidioplasty have a higher risk of fistula formation.

STRENGTH & LIMITATIONS

Sufficient events to calculate predictors for urethral complications. However, this is a retrospective study with still a small number of patients with a relative short follow-up.

CONCLUSION

Urethral complications are frequent after metoidioplasty and approximately 50% needs corrective surgery. AUL is an independent risk factor for fistula and stricture formation, whereas smoking is a risk factor for fistula formation. Waterschoot M, Hoebeke P, Verla W, et al. Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery. J Sex Med 2021;18:1271-1279.

An Option for Shaft-Only Gender-Affirming Phalloplasty: Vaginal Preservation and Vulvoscrotoplasty. A Technical Description

SUMMARY

Genital masculinizing gender-affirming surgery is a growing field. Because of a spectrum of gender identity, gender expression, sexual expression, patient desires, and patient tolerance for complications, options for surgery vary accordingly. Shaft-only phalloplasty avoids urethral lengthening, but may still be accompanied by hysterectomy, vaginectomy, scrotoplasty, clitoroplasty (burying of the clitoris), glansplasty, and placement of erectile devices and testicular implants. Patients who desire retention of vaginal canal patency are candidates for vaginal preservation vulvoscrotoplasty; however, there is a paucity of literature describing the procedure and its outcomes. In this article, the authors review the technique used by the senior author at Oregon Health and Science University and report surgical outcomes for four patients. Future studies regarding patient-recorded outcome measures, aesthetics, sexual function, urologic function, patient satisfaction, and conversion to other options will help surgeons better understand patients pursuing gender-affirming surgery through shaft-only phalloplasty.

An Updated Overview of Gender Dysphoria and Gender Affirmation Surgery: What Every Plastic Surgeon Should Know

Gender dysphoria refers to the medical condition experienced by individuals whose physical anatomy is not consistent with their gender identity. Surgery is a safe and effective treatment for many individuals, yet the current demand for surgery exceeds the number of trained surgeons. This article reviews gender-affirming surgical procedures and emphasizes an individualized approach within the context of a multidisciplinary team. We review pre-, intra-, and postoperative care including the preoperative requirements for surgery.

Complications and Patient-reported Outcomes in Transfemale Vaginoplasty: An Updated Systematic Review and Meta-analysis

Supplemental Digital Content is available in the text.

Background:

Vaginoplasty aims to create a functional feminine vagina, sensate clitoris, and labia minora and majora with acceptable cosmesis. The upward trend in the number of transfemale vaginoplasties has impacted the number of published articles on this topic. Herein, we conducted an updated systematic review on complications and patient-reported outcomes.

Methods:

A update on our previous systematic review was conducted. Several databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus were assessed. Random effects meta-analysis and subgroup analyses were performed.

Results:

After compiling the results of the update with the previous systematic review, a total of 57 studies pooling 4680 cases were included in the systematic review, and 52 studies were used in the meta-analysis. Overall pooled data including any surgical technique showed rates of 1% [95% confidence interval (CI) <0.1%–2%] of fistula, 11% (95% CI 8%–14%) of stenosis and/or strictures, 4% (95% CI 1%–9%) of tissue necrosis, and 3% (95% CI 1%–4%) of prolapse. Overall satisfaction was 91% (81%–98%). Regret rate was 2% (95% CI <1%–3%). Average neovaginal depth was 9.4 cm (7.9–10.9 cm) for the penile skin inversion and 15.3 cm (13.8–16.7 cm) for the intestinal vaginoplasty.

Conclusions:

Transfemale vaginoplasty is a key component of the comprehensive surgical treatment of transfemale patients with gender dysphoria. Over time, we will see an increased demand for these procedures, so adequate surgical training, clinical/surgical experience, and research outcomes are required, as we continue to strive to provide the best care possible for a population in need.

Metoidioplasty With Implantation of a Specific Semirigid Prosthesis

BACKGROUND

Metoidioplasty is a possibility for penis reconstruction in transmen that could be enhanced by a semi-rigid prosthesis support.

AIM

Describe the surgical technique of metoidioplasty with implantation of a specifically designed semi-rigid prosthesis -the ZSI100D4- and analyze preliminary results.

METHODS

Implantation of semi-rigid prosthesis was proposed to transmen who chose metoidioplasty for genital gender affirming surgery in a specialized university hospital.

OUTCOMES

Surgical outcomes were collected from medical files. Functional outcomes and satisfaction were collected post-operatively with a questionnaire.

RESULTS

A total of 15 patients were operated; the mean length of followup was 22 months (SD = 8.7). Median prosthesis size was 8.5 cm (range: 8.5-10). Seven (46.7%) minor complications (Clavien-Dindo grade 2; 5 wound dehiscence and 2 fistula, managed conservatively) and 1 severe (Clavien-Dindo grade 3b) complication (Hematoma that need surgical revision) occurred. Thirteen patients (86.6%) answered the questionnaire; 11 (84.6%) reported being either "very satisfied" or "satisfied" with the appearance of the new genitalia; 10 (76.9%) could void while standing; and 12 patients (92.3%) answered "not at all" to the question "do you have regrets about this surgery ?".

CONCLUSION

Implantation of a semi-rigid prosthesis in an enlarged clitoris seems to be a valuable option and can be proposed as another possibility for the complex surgical answer to neophallus reconstruction in transmen. Neuville P, Carnicelli D, Paparel P, et al. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021;18:830-836.

A review of gender affirmation surgery: What we know, and what we need to know

BACKGROUND

Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature.

METHODS

PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized.

RESULTS

Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery.

CONCLUSION

Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.

Suprapubic phalloplasty in transmen: surgical results and critical review

This article presents the surgical outcomes of a consecutive series of 71 transmen undergoing pre-expanded suprapubic phalloplasty (SPP) in a specialized center. The median [IQR] duration to finalize this three-stage phalloplasty procedure was 7 months [6-7]. Median [IQR] follow-up was 39.4 months [19.7-81.2]. Among those included, 25 (35.2%) had a urethroplasty, and 40 (56.3%) a penile prosthesis as additional procedures. Complications were the result of disorders of wound healing (dehiscence, infection, partial necrosis) or tissue expander (migration, infection). Sixty patients (84.5%) experienced at least one complication during the phalloplasty procedure, mostly minor complications Clavien < IIIa (81.8%). Among these, 16 (22.5%) underwent at least one reintervention, 2 of whom underwent two reinterventions (18 reinterventions in total for Clavien ≥ IIIa complication). There was no loss of phalloplasty. Among the wide variety of techniques developed for phalloplasty, the suprapubic technique seems to be a valuable option for transmen on the path to genital gender affirming surgery.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients

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.

Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes

Introduction

There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men’s equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty.

Aim

To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction.

Methods

We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors.

Main Outcome Measures

Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula.

Results and Conclusion

A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique.

Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294

Metoidioplasty With Urethral Lengthening: A Stepwise Approach

BACKGROUND

Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate.

OBJECTIVE

To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes.

METHODS

We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique.

RESULTS

For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2).

CONCLUSION

We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.

Overview on metoidioplasty: variants of the technique

Number of gender dysphoric people increased over the last few decades with positive social acceptance of transpopulation. Genital gender affirming surgeries are of utmost importance in order to adjust body to the mind of these individuals. Creation of the phallus is usually the last step in transmen transition, which remains demanding and challenging for surgeons, with different options for phalloplasty available. The ideal phallus is esthetically appealing, with preserved tactile and erogenous sensation, enables standing micturition and sexual function with minimal donor-site morbidity. Metoidioplasty, as a variant of phalloplasty, uses the hormonally hypertrophied clitoris to create the neophallus. Metoidioplasty can be considered as a method of choice for thin-built individuals looking for male genitalia with preserved erogeneity, in one-stage genital gender affirming surgery. It can be combined together with removal of reproductive organs and vaginectomy. Preoperative consultation with patients and postoperative follow-up as well as multidisciplinary approach are essential for successful treatment.This literature review aims to assess and discuss different metoidioplasty approaches with a special reference to authors' current metoidioplasty technique.

Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening

Metoidioplasty denotes the creation of a neophallus out of the hormonally hypertrophied clitoris. Construction of an esthetically acceptable male-like genitalia while enabling micturition in standing position are the primary goals. Herein, we aim to review the literature regarding masculinizing gender-affirming genital surgery in the form of metoidioplasty, focusing on the steps related to urethral lengthening and reconstruction, and describe the authors' preferred surgical technique. Clitoral release, division of the urethral plate, native urethral lengthening with anterior vaginal wall flap, and neourethral tubularization using a combination of buccal mucosa graft and labia minora flap(s) seem to provide the best result in terms of urinary outcomes. This is reflected in a greater urethral length, higher probability of standing micturition, and lower incidence of fistula. Urethral complications, which can be encountered in up to 15% of the patients, may necessitate additional procedures. Some of the studies have reported successful penetrative intercourse following metoidioplasty. Case series about different metoidioplasty techniques do not allow head-to-head comparison due to non-standardized reporting and outcome assessment. Metoidioplasty can be offered to transgender men with sufficiently hypertrophied clitoris who wish to avoid a complicated, multistage, flap-based total phalloplasty, or for those individuals considering phalloplasty at a later date.

Urethrographic Evaluation of Anatomic Findings and Complications after Perineal Masculinization and Phalloplasty in Transgender Patients

Transgender patients seeking gender-affirming surgery are a growing population with unique health care needs. The radiologist must understand the challenges these patients face to facilitate a positive patient-physician interaction during the series of postoperative fluoroscopic evaluations. The authors present a standard two-stage surgical approach and common postoperative fluoroscopic findings after perineal masculinization and phalloplasty procedures. Perineal masculinization including urethral lengthening is performed first, followed by skin-flap-based phalloplasty. Patients undergo voiding cystourethrography (VCUG) after intravesical administration of contrast media by way of an indwelling suprapubic catheter after each stage. Retrograde urethrography plays a complementary role to supplement the limitations of VCUG after the second stage. The article reviews the expected postoperative anatomy and explains standardized terminology developed at the authors' institution. Imaging features of common and rare complications are discussed, including contained leak, stenosis, occlusion, and fistula. The successful postoperative imaging study in a transmasculine patient relies on open communication among the interdisciplinary team of specialized surgeons, radiologists, and medical providers, as well as special modifications to existing imaging techniques. ^©RSNA, 2020.

Metoidioplasty

Gender affirmation surgery for transmale patients is still challenging, as creation of the neophallus is one of the most demanding steps in surgical treatment. Metoidioplasty, as a one-stage procedure, can be considered in patients who desire gender affirmation surgery without undergoing a complex, multistage procedure with creation of an adult-sized neophallus. Metoidioplasty presents one of the variants of phalloplasty for patients in whom the clitoris is large enough under testosterone treatment. Advanced urethral reconstruction provides low complication rates with satisfying results of standing micturition.