Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions

Complication and Explantation Rates of Penile Prostheses in Transmasculine Patients: A Meta-analysis

OBJECTIVE

To synthesize current literature on penile prosthesis implantation post-gender affirming phalloplasty to correlate implant types and complication rates.

METHODS

A meta-analysis of penile prosthesis in transmasculine patients was initiated in December 2022. Inclusion criteria encompassed randomized clinical trials, cohort studies, and cross-sectional studies reporting on penile prosthesis complications post-gender-affirming phalloplasty. Exclusion criteria were review articles, meta-analyses, studies that exclusively reported on cisgender patients or surgeries other than penile prosthesis implantation. An initial search of 5 databases yielded a total of 1593 articles. Upon screening, 15 full-text articles were eligible for inclusion. Nine studies were included in the analysis.

RESULTS

The overall complication rate for the inflatable prosthesis group was 38% (95% CI: 21, 59) and for the malleable prosthesis group was 37% (95% CI: 18, 62). The most probable complications in the inflatable group were infection (14.5%), dysfunction (12.9%), dislocation (5.7%), and leakage (5.4%). The most probable complications in the malleable group were dislocation (14.9%), infection (11.2%), dysfunction (9.1%), and extrusion (7.6%). There was no significant difference in the probability of any complications between the malleable and inflatable prosthesis groups. The best estimate of explantation rates for any reason for the inflatable group was 19% (95% CI: 9, 38) and for the malleable group 13% (95% CI: 4, 33). There was no significant difference in the probability of any reason for explantation between the malleable and inflatable prosthesis groups.

Metoidioplasty in Norway: A 13-year Experience from a National Center

Background

Genital surgery is often considered the final step in surgical gender-affirming treatment. Metoidioplasty is a variant where the enlarged clitoris is lengthened and straightened. The technique has several advantages but is not without complications. We evaluated the surgical outcomes after metoidioplasty from our national center from 2007 to 2020.

Methods

All patients who had undergone the metoidioplasty procedure at Oslo University Hospital from January 1, 2007, to December 31, 2020, were identified by the Local Quality Register of Gender Incongruence. Demographic, clinical, and surgical variables were recorded. Statistical analysis was carried out with SPSS.

Results

A total of 84 patients were identified. The median age at the time of surgery was 27.5 years. Of 84 patients, 48 (57.1%) experienced some kind of complication after the surgery, with an average of 1.7 complications. Complications related to the urethroplasty were the most common, with strictures occurring in 19 (22.6%) patients and urethral fistulas occurring in 11 (13.1%) patients. Forty-one patients (48.8%) needed 1 or more secondary procedures. After the management of strictures and fistulas, a secondary testis implant correction was the most frequent revision procedure performed in 38.1% (32) of patients. With increasing body mass index, the risk of complications and of undergoing secondary procedures also increased significantly (P = 0.045 and 0.019, respectively).

Conclusions

Metoidioplasty is an operation with a relatively high complication rate, mainly related to urethroplasty. There is an urgent need for future research with a focus on quality of life and long-term follow-up.

Spectrum, Procedural Feasibility, and the Value of a Surgeon's Opinion in Varying Gender-Affirming Surgeries

The understanding of gender has expanded contributing to gaps in gender-affirming care. Traditional gender-affirming surgeries focus on binary results, diminishing room for affirmation of other identities. Surgeons are faced with the challenge of deciding whether a variation of gender-affirming surgery can be safely performed per request. The ethical question of when a surgeon may say yes or no to these varying requests comes after the consideration of premorbid conditions, body habitus, age, social and family support, individuals' goals, and risk assessment. Preoperative evaluations must take into account surgical experience, barriers to care, increased risk profile, and the surgeon's personal biases.

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.

A Comparative Study of Urinary Complication Rates before and after the Incorporation of a Urethral Lengthening Technique during Masculinizing Genital Gender Affirmation Surgery

Objectives  Masculinizing genital gender affirmation surgery (MgGAS) consists of operative procedures designed to help the transition of transmen in their journey toward male gender role. Phalloplasty and urethral lengthening remain the most challenging of these surgeries, as the female urethra (4 cm long) must be lengthened to male dimensions (15–29 cm) with anastomosis at two sites, the native urethra/pars fixa urethra and the pars fixa urethra-penile urethra. As a result, there is a high incidence of urinary complications such as strictures and fistulae. Authors incorporated a urethral lengthening technique to reduce urinary complications in MgGAS. They compare the rates of urinary complications rates in cohorts before and after the introduction of this technique.

Materials and Methods  Authors have been performing phalloplasty since past 27 years, utilizing mainly free radial artery forearm flap (fRAFFp 431 cases) and pedicled anterolateral thigh flap (pALTp 120 cases). A retrospective review and comparison of urinary complications were performed before and after the introduction of their new technique since March 2017.

Results  There was a statistically significant reduction in the incidence of stricture with and without fistulae (25.94% with conventional and 4.17% with urethral lengthening technique p  = 0.001) and fistulae alone (12.81% with conventional and 2.78% with urethral lengthening technique p  = 0.011) in fRAFFp cases. In pALTp cases, the respective reductions were 43.08 to 17.07%, p  = 0.006 (significant), and 13.85 to 4.88%, p  = 0.197 (not statistically significant).

Conclusion  Over years, the rates of urinary complications in MgGAS have remained constant, varying from 25 to 58% for strictures and 17 to 75% for fistulae as noted by many authors. Authors noted that in most of their cases, strictures occurred at distal pars fixa urethra (DPFU)-penile urethra anastomosis and incorporated a urethral lengthening technique, which lengthens the DPFU by 3 to 5 cm at this anastomotic site, thus significantly reducing the anastomotic tension and the rate of urinary complications.