1
|
Hu W, Henry AS, Rouanet M, Pop A, Claudic Y, Vais B, Perrier A, Tehri I, Saraoui W, Perruisseau-Carrier A. [Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]. ANN CHIR PLAST ESTH 2023; 68:446-454. [PMID: 37652835 DOI: 10.1016/j.anplas.2023.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
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.
Collapse
Affiliation(s)
- W Hu
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmouqlins, 29238 Brest, France.
| | - A S Henry
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - M Rouanet
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmouqlins, 29238 Brest, France
| | - A Pop
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - Y Claudic
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - B Vais
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - A Perrier
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - I Tehri
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - W Saraoui
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France
| | - A Perruisseau-Carrier
- Service de chirurgie plastique, reconstructrice et esthétique, centre hospitalier universitaire de Brest, boulevard Tanguy-Prigent, 29200 Brest, France; Faculté de médecine, université de Brest, 22, rue Camille-Desmouqlins, 29238 Brest, France
| |
Collapse
|
2
|
Elyaguov J, Isakov R, Nikolavsky D. Evaluation and management of urologic complications following transmasculine genital reconstructive surgery. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/10/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Jason Elyaguov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Roman Isakov
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| | - Dmitriy Nikolavsky
- Department of Urology SUNY Upstate Medical University Syracuse New York USA
| |
Collapse
|
3
|
Li VY, Demzik A, Snyder L, Ogunleye AA, Wang A, Figler BD. Genital Gender Affirming Surgery. Am Surg 2022; 88:2817-2822. [PMID: 35762947 DOI: 10.1177/00031348221109479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Genital gender affirming surgery is an effective treatment for gender dysphoria in transgender individuals. Optimization of medical and mental health conditions, including coordination with a patient's entire care team, is essential. Feminizing procedures include vaginoplasty (creation of female genitalia with a vaginal canal) and vulvoplasty (creation of female genitalia with a short or absent vaginal canal). Masculinizing procedures include metoidioplasty (construction of male genitals via local tissue rearrangement) and phalloplasty (creation of a phallus from extra-genital tissue). We aim to provide an overview of genital gender affirming surgery for providers who are interested in learning more about genital gender affirming surgery.
Collapse
Affiliation(s)
- Virginia Y Li
- Department of Urology, 82579Kaiser Permanente Los Angeles, Los Angeles, CA, USA
| | - Alysen Demzik
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Liem Snyder
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Adeyemi A Ogunleye
- Department of Surgery, Division of Plastic Surgery, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Annmarie Wang
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| | - Bradley D Figler
- Department of Urology, 2331UNC School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
4
|
Bencic M, Stojanovic B, Bizic M, Djordjevic ML. Musculocutaneous Latissimus Dorsi Phalloplasty. Indian J Plast Surg 2022; 55:162-167. [PMID: 36017409 PMCID: PMC9398531 DOI: 10.1055/s-0041-1740382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The treatment of gender dysphoria consists of psychiatric evaluation, initiation of hormonal therapy, and the final step in an individual's transition, performing gender-affirming surgery. Construction of the neophallus is one of the most demanding tasks in genital affirming surgery of transgender men. The main objectives of phalloplasty are to achieve a cosmetically acceptable and functional phallus, with a neourethra that allows voiding in standing position, sufficient length and strength for possible penetrative intercourse, preserved tactile and orgasmic sensation, and acceptable donor site morbidity. The musculocutaneous latissimus dorsi flap has reliable and suitable anatomy (good size, volume, and length of neurovascular pedicle) to meet the esthetic and functional requirements of neophallus reconstruction. Despite many advantages, the main disadvantage of this flap is the lack of sensitivity. Although the radial free forearm flap technique is the most commonly performed procedure, musculus latissimus dorsi flap is an acceptable choice in gender-affirming surgery.
Collapse
Affiliation(s)
- Marko Bencic
- Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav L. Djordjevic
- Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
5
|
Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in Gender Affirmation: A Review. Indian J Plast Surg 2022; 55:156-161. [PMID: 36017403 PMCID: PMC9398530 DOI: 10.1055/s-0041-1740081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.
Collapse
Affiliation(s)
- Borko Stojanovic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marko Bencic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Miroslav L. Djordjevic
- Department of Urology, Belgrade Center for Urogenital Reconstructive Surgery, School of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
6
|
Callegari M, Pettigrew G, MacLean J, Mishra K, Khouri JS, Gupta S. Gender Affirmation Surgery for the Transmasculine Patient. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2022. [DOI: 10.1007/s13669-022-00330-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
7
|
de Rooij FPW, Falcone M, Waterschoot M, Pizzuto G, Bouman MB, Gontero P, Lumen N, Pigot GLS. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022; 19:377-384. [PMID: 34974989 DOI: 10.1016/j.jsxm.2021.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/02/2021] [Accepted: 12/06/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Several treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes. AIM The aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty. METHODS A multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers. OUTCOMES The primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively. RESULTS Of 96 transmen included in this study with a urethral complication, 44 (46%) experienced a urethral fistula, 31 (32%) a urethral stricture, and 21 (22%) both complications simultaneously. The recurrence-free rate for urethral strictures following endoscopic management (ie, urethral dilation or direct visual internal urethrotomy) was 61% after 1, 50% after 2, and 43% after 3 years, compared to 82% following open treatment options after 1, 2, and 3 years (P = .002). Open treatment options were Heineke-Mikulicz procedure (7/9, 78% success), excision and primary anastomosis (3/3, 100%), 2-stage without graft (9/9, 100%), pedicled flap urethroplasty (1/1, 100%), and buccal mucosa graft urethroplasty (2/4 [50%] single-stage, 1/1 [100%] 2-stage). The recurrence-free rate for small urethral fistulas located at the pendulous urethra was 79% after 1, and 72% after 2 and 3 years, compared to 45% after 1, and 41% after 2 and 3 years for large fistulas, generally located at the urethral anastomoses of the fixed urethra. Treatment options for urethral fistulas were fistulectomy (26/48, 54%), fistulectomy & (redo) colpectomy (7/11, 64%), buccal mucosa graft urethroplasty (1/1, 100%), and retubularization of the urethral plate (3/4, 75%). A colpectomy before or during reoperation of a urethral fistula at the proximal urethral anastomosis showed higher success rates compared to without a colpectomy (7/11 [64%] vs 2/13 [15%] respectively, P = .03). CLINICAL IMPLICATIONS This study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen. STRENGTHS & LIMITATIONS Strengths were the relatively large sample size and the overview of multiple treatment options available. Limitations were the heterogeneity of the cohort, underexposure of some surgical modalities, and absence of patient-reported outcomes. CONCLUSION Open surgical techniques show better long-term outcomes in the management of urethral strictures compared to endoscopic options, and a colpectomy is beneficial before or during urethral fistula repair at the proximal urethral anastomosis. de Rooij FPW, Falcone M, Waterschoot M, et al. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022;19:377-384.
Collapse
Affiliation(s)
- Freek P W de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands.
| | - Marco Falcone
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | | | - Giuseppe Pizzuto
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | - Mark-Bram Bouman
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Paolo Gontero
- Urology Department, Città della Salute e della Scienza, Torino, Italy
| | - Nicolaas Lumen
- Department of Urology, Ghent University Hospital, Ghent, Belgium
| | - Garry L S Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| |
Collapse
|
8
|
Wu M, Chen R, Xu Y, Shi X, Song R, Sun M, Xue C, Wang Y, Zhang W. At The Forefront of Penile Surgical Reconstruction: A Bibliometric Study of the 100 Most-Cited Articles. Aesthetic Plast Surg 2022; 46:480-488. [PMID: 34595594 DOI: 10.1007/s00266-021-02609-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/19/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE The citation count of a scientific article is considered as the recognition it received from this field. The purpose of this bibliometric analysis was to identify the top 100 most-cited scientific articles in penile surgical reconstruction. METHODS The Web of Science database was used to extract the top 100 most-cited articles. Individual articles were reviewed to identify the authorship, published journal, journal impact factor (IF), primary disease, article type, institution and country of origin, and year of publication. RESULTS The top 100 most-cited articles were published between 1947 and 2013. The number of citations ranged from 23 to 233. Journal of Urology contributed the most articles (n = 36). Articles with a high level of evidence like prospective analysis (n = 5), systematic review and meta-analysis (n = 2), and guideline (n = 1) were all published after 2000. The average citation per year of articles published in high-IF journals was significantly higher than that of other articles (p = 0.0129). There was a positive linear correlation between citation count per year and publication year (r2 = 0.26, p < 0.001). Among the top 100 articles, 74 articles were interlinked via citation of each other. The major topic of co-citation network was the application of flaps in penile reconstruction. CONCLUSIONS The analysis of top 100 most-cited articles facilitates the comprehensive recognition of current focus in the field of penile surgical reconstruction, which is the exploration of flaps and development of new techniques in penile reconstruction. In the future, more attention should be paid to evidence-based medicine to provide high-level evidence for research. LEVEL OF EVIDENCE III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Collapse
Affiliation(s)
- Minliang Wu
- Department of Plastic Surgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Rui Chen
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Yalong Xu
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
- Department of Urology, General Hospital of Central Theater Command, Wuhan, 430070, Hubei, China
| | - Xiaolei Shi
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Ruixiang Song
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Mengyan Sun
- Department of Plastic Surgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Chunyu Xue
- Department of Plastic Surgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China
| | - Yuchong Wang
- Department of Plastic Surgery, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China.
| | - Wei Zhang
- Department of Urology, Changhai Hospital, Naval Medical University, 168 Changhai Rd, Shanghai, 200433, China.
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Özer M, Toulabi SP, Fisher AD, T'Sjoen G, Buncamper ME, Monstrey S, Bizic MR, Djordjevic M, Falcone M, Christopher NA, Simon D, Capitán L, Motmans J. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2021; 10:100471. [PMID: 34971864 PMCID: PMC8847816 DOI: 10.1016/j.esxm.2021.100471] [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: 05/18/2021] [Revised: 10/06/2021] [Accepted: 11/09/2021] [Indexed: 01/09/2023] Open
Abstract
Introduction Much has been published on the surgical and functional results following Gender Affirming Surgery (‘GAS’) in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. Aim To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. Methods The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. Main Outcomes Measure The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. Results The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. Conclusion The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement “Sexual Wellbeing After Gender Affirming Surgery”. Sex Med 2022;10:100471.
Collapse
Affiliation(s)
- Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands.
| | - Sahaand Poor Toulabi
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Department of Experimental Clinical and Biomedical Sciences, University of Florence, Florence, Italy
| | - Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marlon E Buncamper
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University Hospital, Ghent, Belgium
| | - Stan Monstrey
- Department of Plastic, Reconstructive and Hand Surgery, Ghent University and Ghent University Hospital, Ghent, Belgium
| | - Marta R Bizic
- Department of Pediatric Urology, University of Belgrade, Belgrade, Serbia
| | | | - Marco Falcone
- Department of Urology, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Nim A Christopher
- Department of Urology, St Peter's Andrology Centre and The Institute of Urology, London, UK
| | - Daniel Simon
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Luis Capitán
- Facialteam Surgical Group, HC Marbella International Hospital, Marbella, Málaga, Spain
| | - Joz Motmans
- Center for Sexology and Gender, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
El-Arabi AM, Barrera EP, McLaren HE, Gray M, Grimstad FW. Masculinizing Gender Affirming Surgery. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2021.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Ahmad M. El-Arabi
- Department of Urology, University of Kansas Health System, Kansas City, Kansas, USA
| | - Ellis P. Barrera
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Hillary E. McLaren
- Department of Obstetrics and Gynecology, The University of Chicago, Chicago, Illinois, USA
| | - Meredith Gray
- Department of Obstetrics and Gynecology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Frances W. Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Obstetrics, Gynecology and Reproductive Biology, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
13
|
Waterschoot M, Hoebeke P, Verla W, Spinoit AF, Waterloos M, Sinatti C, Buncamper M, Lumen N. Urethral Complications After Metoidioplasty for Genital Gender Affirming Surgery. J Sex Med 2021; 18:1271-1279. [PMID: 37057418 DOI: 10.1016/j.jsxm.2020.06.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
| | - Piet Hoebeke
- Department of urology, Ghent University Hospital, Belgium
| | - Wesley Verla
- Department of urology, Ghent University Hospital, Belgium
| | | | | | - Céline Sinatti
- Department of urology, Ghent University Hospital, Belgium
| | - Marlon Buncamper
- Department of plastic and reconstructive surgery, Ghent University Hospital, Belgium
| | - Nicolaas Lumen
- Department of urology, Ghent University Hospital, Belgium
| |
Collapse
|
14
|
Odeluga N, Reddy SA, Safir MH, Crane CN, Santucci RA. Optimization of Second-stage Metoidioplasty. Urology 2021; 156:303-307. [PMID: 34087313 DOI: 10.1016/j.urology.2021.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To describe a planned 2-staged metoidioplasty. Metoidioplasty is a genital gender-affirmation surgery aimed at creating a neophallus, scrotum (if desired), and flat male-type perineum (if desired) from natal tissues. It generally requires a planned second-stage to place testes prostheses, address complications, and perform additional surgical steps to maximally lengthen the phallus. The details of this procedure are sparsely mentioned in the literature. We found that phallus length can be optimized in the second-stage by applying surgical principles already established in the surgical treatment of adult acquired buried penis. MATERIAL AND METHODS We conducted a retrospective chart review of patients after metoidioplasty between August 2015 and June 2020, and isolated those that underwent second-stage metoidioplasty. Each procedure was done by 1 of 4 surgeons in a single practice in 2 locations, San Francisco, CA, and Austin, TX. Details of procedures required, complications, and demographic information were recorded. RESULTS Out of the 75 patients that had undergone metoidioplasty, 37 (37 of 75, 49%) underwent a second-stage metoidioplasty. Reduction of upper scrotal blocking tissue was the most common procedure performed during a second-stage metoidioplasty (31 of 37, 84%), followed by escutcheonectomy/penile lift (30 of 37, 81%), bilateral implant placement (20 of 37, 54%), chordee repair (13 of 37, 35%), and unilateral implant placement (1 of 37, 3%). 6 of the 37 patients (16%) developed major complications. 5 of the 37 (5 of 37, 15%) second-stage patients required a redo second-stage metoidioplasty. CONCLUSION Second-stage metoidioplasties are commonly performed on patients to optimize results of phallic lengthening and release, and to repair complications that arise after single-stage metoidioplasty. Escutcheonectomy/penile lift, placement of scrotal implants, repair of chordee, and upper scrotal blocking tissue reduction are procedures that are often performed during a second-stage metoidioplasty.
Collapse
Affiliation(s)
| | - Soumya A Reddy
- Texas Tech Health Sciences Center School of Medicine, Lubbock, TX
| | | | | | | |
Collapse
|
15
|
Gender-Affirming Genitourinary Surgery. PHYSICIAN ASSISTANT CLINICS 2021. [DOI: 10.1016/j.cpha.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
16
|
Robinson IS, Blasdel G, Cohen O, Zhao LC, Bluebond-Langner R. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021; 18:800-811. [PMID: 33663938 DOI: 10.1016/j.jsxm.2021.01.183] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/07/2021] [Accepted: 01/25/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.
Collapse
Affiliation(s)
- Isabel S Robinson
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Oriana Cohen
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Rachel Bluebond-Langner
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.
| |
Collapse
|
17
|
Jolly D, Wu CA, Boskey ER, Taghinia AH, Diamond DA, Ganor O. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021; 9:100294. [PMID: 33429241 PMCID: PMC7930881 DOI: 10.1016/j.esxm.2020.100294] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/18/2020] [Accepted: 11/21/2020] [Indexed: 12/21/2022] Open
Abstract
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
Collapse
Affiliation(s)
- Divya Jolly
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA.
| | | | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - Amir H Taghinia
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| | - David A Diamond
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA; Department of Urology, Boston Children's Hospital, Boston, MA
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, Boston, MA; Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, MA; Department of Surgery, Harvard Medical School, Boston, MA
| |
Collapse
|
18
|
Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: Surgical Options and Outcomes in 813 Cases. Front Endocrinol (Lausanne) 2021; 12:760284. [PMID: 34721306 PMCID: PMC8548780 DOI: 10.3389/fendo.2021.760284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 09/22/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements. METHODS During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction. RESULTS Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus. CONCLUSION Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.
Collapse
Affiliation(s)
- Noemi Bordas
- Department of Urology, Semmelweis Hospital, Kiskunhalas, Hungary
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Arpad Szanto
- Urology Clinic, University of Pecs, Pecs, Hungary
| | - Miroslav L. Djordjevic
- Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- *Correspondence: Miroslav L. Djordjevic,
| |
Collapse
|
19
|
Liedl B, Kogler T, Witczak M, Himmler M, Wallmichrath J. [Gender affirmation female to male-metaidoioplasty]. Urologe A 2020; 59:1331-1339. [PMID: 32975590 DOI: 10.1007/s00120-020-01335-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Description of an improved technique of metaidoioplasty (clitoris penoid) and presentation of the follow-up of our own patients in comparison to results in the literature. PATIENTS AND METHODS To reduce the complication rate of urethral strictures and urethrocutaneous fistula, the technique of metaidoioplasty was modified: After elongation of clitoris by incision of chorda the urethra-including the clitoral hood-was reconstructed by distally, broadly based flap of labia minora. In a retrospective follow-up study over 4 years, 75 patients completed questionnaires to assess complications and satisfaction/quality of life and urinary symptoms (ICIQ-FLUTS questionnaire). The same questionnaires were completed by 25 patients pre- and 3 months postoperatively. RESULTS In the retrospective study, urethral strictures were detected in 1.4% of patients and urethrocutaneous fistulas in 9.4% of patients, which could be repaired in all cases. Furthermore, 39.5% of patients did not decide for phalloplasty and were satisfied with the appearance of the clitoris penoid in 85% and with their function in 88%. A small proportion of the patients developed urinary symptoms, which were mainly of minor severity and significantly dependent on age. In the prospective study, postoperative-versus preoperative-symptoms of urinary incontinence, nocturia, and obstructive micturition were slightly elevated, but mainly of minor severity. CONCLUSIONS The improved technique of metaidoioplasty using distally broadly based labia-minora flaps resulted in high satisfaction with low urethral complication rates.
Collapse
Affiliation(s)
- B Liedl
- Zentrum für Rekonstruktive Urogenitalchirurgie, Urologische Klinik München-Planegg, Germeringer Straße 32, 82152, Planegg, Deutschland.
| | - T Kogler
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - M Witczak
- Zentrum für Rekonstruktive Urogenitalchirurgie, Urologische Klinik München-Planegg, Germeringer Straße 32, 82152, Planegg, Deutschland.,Beckenbodenzentrum Planegg, Urologische Klinik München-Planegg, Planegg, Deutschland
| | - M Himmler
- Klinik für Urologie und Urochirurgie, Universitätsmedizin Mannheim, Mannheim, Deutschland
| | - J Wallmichrath
- Zentrum für Rekonstruktive Urogenitalchirurgie, Urologische Klinik München-Planegg, Germeringer Straße 32, 82152, Planegg, Deutschland.,Abteilung für Plastische Chirurgie, Urologische Klinik München-Planegg, Planegg, Deutschland
| |
Collapse
|
20
|
Kelling JA, Erickson CR, Pin JA, Pin PG. Additional Comments on the Anatomical Dissection of the Dorsal Nerve of the Clitoris. Aesthet Surg J 2020; 40:NP611-NP612. [PMID: 32761150 DOI: 10.1093/asj/sjaa186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Joseph A Kelling
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Cameron R Erickson
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Paul G Pin
- Baylor University Medical Center, Dallas, TX
| |
Collapse
|
21
|
Bizic M, Stojanovic B, Bencic M, Bordás N, Djordjevic M. Overview on metoidioplasty: variants of the technique. Int J Impot Res 2020; 33:762-770. [PMID: 32826970 DOI: 10.1038/s41443-020-00346-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/28/2020] [Accepted: 08/13/2020] [Indexed: 11/09/2022]
Abstract
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.
Collapse
Affiliation(s)
- Marta Bizic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia. .,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.
| | - Borko Stojanovic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Marko Bencic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| | - Noémi Bordás
- Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia.,Department of Urology, Kiskunhalasi Semmelweis Kórház, Kiskunhalas, Hungary
| | - Miroslav Djordjevic
- Department of Urology, University Children's Hospital, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia
| |
Collapse
|
22
|
Surgical repair of urethral complications after metoidioplasty for genital gender affirming surgery. Int J Impot Res 2020; 33:771-778. [DOI: 10.1038/s41443-020-0328-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/22/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
|
23
|
Reply to Comment on "Suprapubic Pedicled Phalloplasty in Transgender Men: a Multicentric Retrospective Cohort Analysis". Int J Impot Res 2020; 33:862-863. [PMID: 32376882 DOI: 10.1038/s41443-020-0274-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 11/08/2022]
|
24
|
Turin SY, Placik OJ. Commentary on: Anatomical Dissection of the Dorsal Nerve of the Clitoris. Aesthet Surg J 2020; 40:548-550. [PMID: 32053155 DOI: 10.1093/asj/sjz367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Sergey Y Turin
- Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
| | - Otto J Placik
- Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
| |
Collapse
|
25
|
T'Sjoen G, Arcelus J, De Vries ALC, Fisher AD, Nieder TO, Özer M, Motmans J. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020; 17:570-584. [PMID: 32111534 DOI: 10.1016/j.jsxm.2020.01.012] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 01/07/2020] [Accepted: 01/15/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND There is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice. AIM We present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction. METHODS The task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available. OUTCOMES The foci of the study are assessment and hormonal aspects of trans health care. RESULTS As the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment. CLINICAL IMPLICATIONS This is an up-to-date ESSM position statement. STRENGTHS & LIMITATIONS These statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited. CONCLUSION This ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people. T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement "Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction". J Sex Med 2020;17:570-584.
Collapse
Affiliation(s)
- Guy T'Sjoen
- Department of Endocrinology and Center for Sexology and Gender, Ghent University and Ghent University Hospital, Gent, Belgium.
| | - Jon Arcelus
- Institute of Mental Health, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Annelou L C De Vries
- Department of Child and Adolescent Psychiatry, Center of Expertise on Gender Dysphoria, VU University Medical Center, Amsterdam, The Netherlands
| | - Alessandra D Fisher
- Andrology, Women's Endocrinology, Gender Incongruence Unit, Careggi University Hospital, Florence, Italy
| | - Timo O Nieder
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, Interdisciplinary Transgender Health Care Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Müjde Özer
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Joz Motmans
- Transgender Infopunt, Ghent University Hospital, Ghent, Belgium
| |
Collapse
|
26
|
Kocjancic E, Acar O, Talamini S, Schechter L. Masculinizing genital gender-affirming surgery: metoidioplasty and urethral lengthening. Int J Impot Res 2020; 34:120-127. [PMID: 32203431 DOI: 10.1038/s41443-020-0259-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 02/27/2020] [Accepted: 03/06/2020] [Indexed: 11/09/2022]
Abstract
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.
Collapse
Affiliation(s)
- Ervin Kocjancic
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA
| | - Omer Acar
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA.
| | - Susan Talamini
- University of Illinois at Chicago, College of Medicine, Department of Urology, Chicago, IL, USA
| | - Loren Schechter
- Weiss Memorial Hospital, Center for Gender Confirmation Surgery, Division of Plastic and Reconstructive Surgery, Chicago, IL, USA
| |
Collapse
|
27
|
Falcone M, Timpano M, Oderda M, Cocci A, Morelli G, Preto M, Polito C, Giorgio IR, Gideon B, Gontero P. Suprapubic pedicled phalloplasty in transgender men: a multicentric retrospective cohort analysis. Int J Impot Res 2020; 33:808-814. [PMID: 32034312 DOI: 10.1038/s41443-020-0238-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 11/09/2022]
Abstract
A variety of approaches are available to address a genital gender affirming surgery (GGAS) in transgender men. The aim of the present study is to report surgical and functional outcomes after a suprapubic pedicled phalloplasty (SPP). From November 2008 to August 2018, a consecutive series of 34 patients underwent an SPP in two tertiary referral centers. GGAS was conducted as a multistaged procedure, consisting (1) SPP with subsequent radial artery-based forearm free-flap urethroplasty, (2) glans sculpting, urethral anastomosis, and scrotoplasty, and (3) penile prosthesis implantation. The duration of surgery, intra and postoperative complications, and hospital stay were selected as variables for surgical outcomes. Functional outcomes were extrapolated from a four-item questionnaire.A partial necrosis of phallus was detected in two cases (5.8 %). Two cases of seroma formation with wound dehiscence (5.8%) were detected. Overall, 89% of patients declared to be fully satisfied of the SPP, 83% would recommend the procedure to someone else, and 89% would undergo the same procedure again. Overall, 66% of patients could achieve an orgasm during sexual penetrative intercourses. The retrospective design, the lack of randomization and validated questionnaire for outcomes reporting, and the limited follow-up represent the main drawbacks of our study. Our evidences suggest that SPP represents as an acceptable option for GGAS.
Collapse
Affiliation(s)
- Marco Falcone
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy.
| | - Massimiliano Timpano
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Marco Oderda
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | - Andrea Cocci
- Urology department, Careggi Hospital, University of Florence, Florence, Italy
| | | | - Mirko Preto
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| | | | | | - Blecher Gideon
- Urology Department, University of Melbourne, Melbourne, VIC, Australia
| | - Paolo Gontero
- Urology department, Città della Salute e della Scienza-Molinette Hospital, University of Turin, Turin, Italy
| |
Collapse
|
28
|
Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018. Plast Reconstr Surg 2020; 145:153e-161e. [DOI: 10.1097/prs.0000000000006385] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
29
|
Gender Affirmation Surgery: A Primer on Imaging Correlates for the Radiologist. AJR Am J Roentgenol 2019; 213:1194-1203. [PMID: 31414889 DOI: 10.2214/ajr.19.21686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
30
|
Jun MS, Crane CN, Santucci RA. What urologists need to know about female-to-male genital confirmation surgery (phalloplasty and metoidioplasty): techniques, complications, and how to deal with them. MINERVA UROL NEFROL 2019; 72:38-48. [PMID: 31692307 DOI: 10.23736/s0393-2249.19.03611-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Transmasculine gender-affirming surgery (GAS) is technically challenging, and in the past associated with a high but improving complication rate. Few surgical centers are performing this surgery, which can include metoidioplasty and phalloplasty, and patients often travel great distances for their surgery. While many will continue care with their original surgeons, others cannot due to social/geographic factors, or because emergencies arise. Thus, patients may seek care with their local urologist for relief of delayed complications, the most common of which include urethral stricture, penile prosthesis issues and urethrocutaneous fistula. This review will discuss the surgical elements behind metoidioplasty and phalloplasty, and the diagnosis and treatment for the most common postoperative issues.
Collapse
Affiliation(s)
- Min S Jun
- Department of Reconstructive Urology and Trauma, NYU Langone Health, New York, NY, USA -
| | | | | |
Collapse
|
31
|
Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, van Moorselaar RJA, Mullender MG, Weigert R, Buncamper ME, Özer M, de Haseth KB, Djordjevic ML, Salgado CJ, Belanger M, Suominen S, Kolehmainen M, Santucci RA, Crane CN, Claes KE, Monstrey S, Bouman MB. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019; 16:1849-1859. [DOI: 10.1016/j.jsxm.2019.07.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 07/19/2019] [Accepted: 07/31/2019] [Indexed: 10/26/2022]
|
32
|
Dy GW, Granieri MA, Fu BC, Vanni AJ, Voelzke B, Rourke KF, Elliott SP, Nikolavsky D, Zhao LC. Presenting Complications to a Reconstructive Urologist After Masculinizing Genital Reconstructive Surgery. Urology 2019; 132:202-206. [DOI: 10.1016/j.urology.2019.04.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/23/2019] [Accepted: 04/27/2019] [Indexed: 11/29/2022]
|
33
|
Agana MG, Greydanus DE, Indyk JA, Calles JL, Kushner J, Leibowitz S, Chelvakumar G, Cabral MD. Caring for the transgender adolescent and young adult: Current concepts of an evolving process in the 21st century. Dis Mon 2019; 65:303-356. [DOI: 10.1016/j.disamonth.2019.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
34
|
Abstract
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.
Collapse
Affiliation(s)
- Marta R Bizic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Department of Urology, Faculty of Medicine, University of Belgrade, Tirsova 10, Belgrade 11000, Serbia.
| | - Borko Stojanovic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ivana Joksic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Clinic for Gynecology and Obstetrics "Narodni Front", Kraljice Natalije 62, Belgrade 11000, Serbia
| | - Miroslav L Djordjevic
- Belgrade Center for Genitourinary Reconstructive Surgery, Kumodraska 241v, Belgrade 11000, Serbia; Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| |
Collapse
|
35
|
Narayan SK, Morrison T, Dugi DD, Mosser S, Berli JU. Gender Confirmation Surgery for the Endocrinologist. Endocrinol Metab Clin North Am 2019; 48:403-420. [PMID: 31027548 DOI: 10.1016/j.ecl.2019.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Endocrinologists are at the front line for providing gender-affirming care for transgender patients by managing hormone regiments before and after surgery. This article provides the endocrinologist with an overview of the surgical options for transgender and nonbinary patients considering gender confirmation surgery, including feminizing and masculinizing facial, chest, and genital reconstruction. Discussions of the impact of hormones on surgery, and vice versa, as well as information on surgical decision making are provided to help inform patient education via the endocrinologist.
Collapse
Affiliation(s)
- Sasha K Narayan
- School of Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code: L352A, Portland, OR 97239, USA
| | - Tessalyn Morrison
- School of Medicine, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code: L352A, Portland, OR 97239, USA
| | - Daniel D Dugi
- Department of Urology, Oregon Health & Science University, 3303 Southwest Bond Avenue, Mail Code: CH10U, Portland, OR 97239, USA
| | - Scott Mosser
- Saint Francis Memorial Hospital, San Francisco, CA, USA
| | - Jens U Berli
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, 3181 Southwest Sam Jackson Park Road, Mail Code: L352A, Portland, OR 97239, USA.
| |
Collapse
|
36
|
Heston AL, Esmonde NO, Dugi DD, Berli JU. Phalloplasty: techniques and outcomes. Transl Androl Urol 2019; 8:254-265. [PMID: 31380232 DOI: 10.21037/tau.2019.05.05] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Phalloplasty is an exceptionally complicated reconstructive procedure that attempts to create a structure that is penis-like. As patient goals vary widely, it is helpful to think about phalloplasty as a modular set of procedures that can be combined, mixed and matched to meet the needs of each individual patient while also taking into account their anatomy. Each module-but particularly the shaft and penile urethra-can be performed using a variety of techniques. To date, there is no consensus among surgeons regarding the optimum staging of the reconstructive steps. Our primary goal is to outline the most frequently performed and reported options in phallic reconstruction and outline the various considerations that go into choosing a given sequence of procedures for the specific patient. The secondary goal of this article is to describe the complications common to each of those modules and how they interact when combined.
Collapse
Affiliation(s)
- Aaron L Heston
- Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Nick O Esmonde
- Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Daniel D Dugi
- Division of Urology, Oregon Health & Science University, Portland, Oregon, USA
| | - Jens Urs Berli
- Division of Plastic and Reconstructive Surgery, Oregon Health & Science University, Portland, Oregon, USA
| |
Collapse
|
37
|
Abstract
Phalloplasty represents the latest step in female-to-male transitioning and still remains a great challenge for transgender surgeons. Since we have two options in this transitioning-metoidioplasty and total phalloplasty-the transgender surgeon has to fully inform the individual about all aspects such as surgical steps, outcomes, advantages and disadvantages, possible complications, and expectations. Total phalloplasty with the creation of a neophallus of a similar volume to that in genetic males, is a complex and multi-staged procedure. Many different tissues (i.e., flaps) can be used, and the ideal procedure is still not established. In contrast to the above complexities involved in total phalloplasty, metoidioplasty presents a simple and one-stage procedure for the creation of a neophallus from a hormonally enlarged clitoris. This technique is very promising for individuals who desire gender-affirmation surgery without having to undergo the difficult and multistage creation of a male-sized neophallus. Also, this technique prevents scarring to the extragenital region, making the final results more acceptable for transgender individuals. Our goal is to objectively present the techniques for metoidioplasty and to define their value based on postoperative results.
Collapse
Affiliation(s)
- Miroslav L Djordjevic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Centre for Genitourinary Reconstructive Surgery, School of Medicine, Belgrade, Serbia
| |
Collapse
|
38
|
Chen ML, Reyblat P, Poh MM, Chi AC. Overview of surgical techniques in gender-affirming genital surgery. Transl Androl Urol 2019; 8:191-208. [PMID: 31380226 DOI: 10.21037/tau.2019.06.19] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.
Collapse
Affiliation(s)
| | - Polina Reyblat
- Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Melissa M Poh
- Southern California Permanente Medical Group, Los Angeles, CA, USA
| | - Amanda C Chi
- Southern California Permanente Medical Group, Los Angeles, CA, USA
| |
Collapse
|
39
|
Djordjevic ML, Bencic M, Kojovic V, Stojanovic B, Bizic M, Kojic S, Krstic Z, Korac G. Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery. World J Urol 2019; 37:631-637. [PMID: 30673829 DOI: 10.1007/s00345-019-02641-w] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. METHODS Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. RESULTS The mean follow-up period was 43 months (ranged from 13 to 137 months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6 cm in length and 12.4 cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7 cm (mean 15.8 cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. CONCLUSION Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.
Collapse
Affiliation(s)
- Miroslav L Djordjevic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia.
- University Children's Hospital, Belgrade, Serbia.
- School of Medicine, University of Belgrade, Belgrade, Serbia.
| | - Marko Bencic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- University Children's Hospital, Belgrade, Serbia
| | - Vladimir Kojovic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Borko Stojanovic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- University Children's Hospital, Belgrade, Serbia
| | - Marta Bizic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- University Children's Hospital, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Sinisa Kojic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
| | - Zoran Krstic
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Gradimir Korac
- Belgrade Center for Genital Reconstructive Surgery, Belgrade, Serbia
- University Children's Hospital, Belgrade, Serbia
| |
Collapse
|
40
|
Nikolavsky D, Hughes M, Zhao LC. Urologic Complications After Phalloplasty or Metoidioplasty. Clin Plast Surg 2018; 45:425-435. [PMID: 29908632 DOI: 10.1016/j.cps.2018.03.013] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In the past decade, issues facing transgender individuals have come to the forefront of popular culture, political discourse, and medical study. The evaluating physician should have knowledge of the reconstructed anatomy, as well as potential postoperative complications. This knowledge will aid in providing appropriate care and recognizing issues that may require specialized urologic care. Transgender anatomic definitions and a synopsis of common urologic complications specific to transmen, including urethrocutaneous fistulae, neourethral strictures, and persistent vaginal cavities are discussed.
Collapse
Affiliation(s)
- Dmitriy Nikolavsky
- Department of Urology, SUNY Upstate Medical University, Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Michael Hughes
- Department of Urology, SUNY Upstate Medical University, Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA
| | - Lee C Zhao
- Department of Urology, New York University School of Medicine, 50 East 32nd, Street, 2nd Floor, New York, NY 10016, USA
| |
Collapse
|
41
|
Hadj-Moussa M, Agarwal S, Ohl DA, Kuzon WM. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2018; 7:141-155. [PMID: 30122339 DOI: 10.1016/j.sxmr.2018.06.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 06/22/2018] [Accepted: 06/23/2018] [Indexed: 12/18/2022]
Abstract
INTRODUCTION This article is the third in a 3-part series focused on the comprehensive treatment of gender dysphoria. Multidisciplinary gender dysphoria care may involve a combination of counseling, social gender transition, hormone therapy, and gender confirmation surgery (GCS) to maximize physical characteristics congruent with a patient's gender identity. Nonoperative management of gender dysphoria was covered in part 1. The focus of part 2 was feminizing GCS. In part 3, surgical considerations for masculinizing GCS are summarized, including a review of different phalloplasty techniques. This installment also includes information about adjunctive procedures, therapies, and products used by transgender men and women to express their gender identity. AIM To provide an overview of both genital and nongenital masculinizing gender confirmation procedures. To review phalloplasty techniques, preoperative considerations, complications, and outcomes. To summarize ancillary services and procedures available to transgender patients to facilitate their gender presentation. METHODS A review of relevant literature through May 2017 was performed via PubMed. MAIN OUTCOME MEASURES To summarize ancillary products and services used by transgender patients and to review surgical considerations for masculinizing genitoplasty. RESULTS A variety of nonsurgical ancillary services exist for transgender patients to aid their transition. A variety of phalloplasty procedures have been developed for transgender men who seek genital GCS. Most surgeons prefer radial forearm phalloplasty, including the authors whose surgical technique is described. Each phalloplasty approach is associated with its own benefits, drawbacks, and complications. CONCLUSION A variety of ancillary services and procedures that help transgender men and women communicate their gender identity in society is available and is an important adjunct to medical or surgical treatment of gender dysphoria. Pre-operative, intra-operative, and post-operative considerations of masculinizing genital gender confirmation procedures were reviewed. Hadj-Moussa M, Agarwal S, Ohl DA, et al. Masculinizing Genital Gender Confirmation Surgery. Sex Med Rev 2019;7:141-155.
Collapse
Affiliation(s)
| | - Shailesh Agarwal
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Dana A Ohl
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - William M Kuzon
- Section of Plastic Surgery, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
42
|
Djordjevic ML. Novel surgical techniques in female to male gender confirming surgery. Transl Androl Urol 2018; 7:628-638. [PMID: 30211052 PMCID: PMC6127556 DOI: 10.21037/tau.2018.03.17] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The current management of female to male (FTM) gender confirmation surgery is based on the advances in neo phalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Reconstruction of the neophallus is one of the most difficult elements in surgical treatment of female transsexuals. While there is a variety of available surgical techniques, their results are not equally acceptable to all patients. The preference for a particular surgical technique mostly depends on the patient's desires and expectations. Nevertheless, the surgeon's duty is to fully inform the patient about all the advantages and disadvantages, as well as all complications that might occur after surgical procedure-and even to talk them out of a desired surgical technique if there are contraindications. Metoidioplasty is a technically demanding surgical procedure used in FTM transsexuals who desire a gender reassignment surgery (GRS) without undergoing a complex, multi-staged surgical creation of an adult-sized phallus. Metoidioplasty is viable in cases where the clitoris seems large enough after androgen hormonal treatment. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome of FTM transgender surgery is predictable. Various free flaps have been reported for total phalloplasty, such as radial forearm flap, latissimus dorsi flap, anterolateral tight flap, different abdominal wall flaps, free deltoid flap, scapular free flap, sensate osteocutaneous free fibula flap, tensor fasciae latae, deep epigastric artery perforator flap and dorsalis pedis flap. The fact that there are so many techniques for penile reconstruction in cases of penis absence, proves that none of the above mentioned techniques succeeded in achieving the ideal goals of penis reconstruction. We will emphasize the most commonly used surgical techniques in genital confirmation in FTM transsexuals with reference to respective eligibility criteria for each procedure.
Collapse
|
43
|
|
44
|
|
45
|
Autologous Rectus Fascia Graft Interposition Repair of Urethrocutaneous Fistulae in Female-to-Male Metoidioplasty Patients. Urology 2018; 116:208-212. [DOI: 10.1016/j.urology.2018.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/04/2018] [Accepted: 03/08/2018] [Indexed: 12/14/2022]
|
46
|
Middleton I, Holden FA. Urological issues following gender reassignment surgery. ACTA ACUST UNITED AC 2017; 26:S28-S33. [DOI: 10.12968/bjon.2017.26.18.s28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Iffy Middleton
- Lead Nurse Genital Reconstruction, Parkside Hospital, Wimbledon
| | - Fiona Ann Holden
- Clinical Nurse Practitioner, University College London Hospitals NHS Foundation Trust and St Peter's Andrology Centre, London
| |
Collapse
|
47
|
Bizic MR, Stojanovic B, Djordjevic ML. Genital reconstruction for the transgendered individual. J Pediatr Urol 2017; 13:446-452. [PMID: 28943352 DOI: 10.1016/j.jpurol.2017.07.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 07/12/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Gender dysphoria is defined as one's belief that his/her body does not reflect his/her true "inner" identification of physical sex and requires medical and/or surgical treatment that will alter his/her body to better reflect what he/she believes is his/her true gender. OBJECTIVE The aim was to describe current surgical techniques available in genital reconstruction for female-to-male (FTM) and male-to-female (MTF) transgender patients. STUDY DESIGN We reviewed recently published papers concerning the most common procedures in genital reconstruction in FTM transgenders and in MTF transgenders. RESULTS There is a wealth of available surgical procedures for FTM transgenders that will adjust their body and genitals toward the male gender. Chest masculinization combined with either metoidioplasty or phalloplasty are the most common procedures resulting in high patient satisfaction. Standardization of the procedures for vaginoplasty in MTF transgenders led to the penile inversion skin technique becoming a "gold standard" for vaginal lining in MTF patients, providing satisfying functional and esthetical outcome of the surgery. In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from hairless skin grafts, or a section of intestine may be used (bowel vaginoplasty). CONCLUSION A multidisciplinary approach including psychiatrists, psychologists, plastic surgeons, urologists, and gynecologists is the only effective treatment in transgenders. The surgeons' familiarity with the surgical procedure and the patients' desired body images should meet at the same level to guarantee a successful outcome.
Collapse
Affiliation(s)
- Marta R Bizic
- School of Medicine, University of Belgrade, Belgrade, Serbia; University Children's Hospital, Belgrade, Serbia
| | | | - Miroslav L Djordjevic
- School of Medicine, University of Belgrade, Belgrade, Serbia; University Children's Hospital, Belgrade, Serbia.
| |
Collapse
|
48
|
Abstract
BACKGROUND Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes. METHODS A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. CONCLUSIONS Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.
Collapse
|
49
|
|
50
|
An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient. Plast Reconstr Surg 2017; 139:728-737. [DOI: 10.1097/prs.0000000000003062] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|