Surgical outcomes and patients' satisfaction with suprapubic phalloplasty

Imaging the acute complications of gender-affirming surgeries: a primer for radiologists in the emergency setting

Gender-affirming surgery (GAS) is increasingly being performed. GAS is tailored to the patient leading to a diverse spectrum of radiologic post-operative findings. Radiologists who are unfamiliar with expected anatomic alterations after GAS may misdiagnose important complications leading to adverse patient outcomes. This collaborative multi-institutional review aims to: Describe relevant embryology and native anatomy. Describe relevant Gender-Affirming Surgery (GAS) techniques and expected neo-anatomy with associated complications, including common terminology. Review expected imaging appearance of neo-anatomy/postoperative findings. Review multi-modality [ultrasound, plain film, retrograde urethrogram, computed tomography] emergent imaging findings. Understand unique patient evaluation and imaging protocol considerations in the GAS population. Discuss pearls and pitfalls of imaging in the acute post-GAS setting.

Defining Preferred Esthetics of the Ideal Phallus via Crowdsource Survey

OBJECTIVE

To describe phalloplasty subunits and determine the preferred crowdsourced esthetics. Esthetic ideals are often used to guide reconstruction, and there has been an increase in the number of gender-affirming surgeries and reconstructive phalloplasties performed. However, there is a paucity of literature describing ideal phalloplasty esthetics.

METHODS

Phallus esthetic subunits were defined, and a split testing-based survey was used. Subjects were solicited via Craigslist, Amazon Mechanical Turk, and Reddit and distributed among health care co-workers. Computer-generated images with variable ratios of glans, corona, and shaft were provided and respondents were asked to select the most esthetically pleasing photo. Demographic information was gathered. Univariate and multivariate regression were performed.

RESULTS

A total of 1029 people responded to the survey request and 909 people (88.3%) completed the entire survey. There were 440 respondents who self-identified as male, 334 female, 92 transgender male, and 25 transgender female. The health care field was the profession for 55.4%. Health care providers had 65.3% higher odds of preferring the longer shaft length-to-width ratio, 30.3% less odds of preferring a bilateral taper of the glans, and 48.4% less odds of preferring an angulated shaft compared to non-health care providers (P = .006, P = .021, P <.001, respectively). When compared to males, transgender females were more than 13 times likely to prefer an angulated glans corona junction (P = .008).

CONCLUSION

The ideal phallic esthetic varies by individual, and there were statistically significant preferences across age, education, health care status, gender, and sexual orientation. This study can serve as a guide on phalloplasties for patients and gender-affirming surgeons.

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

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

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021

Introduction:  In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods:  We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results:  We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion:  In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Genital gender affirming surgery in trans men]

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

30 Years of Experience in Musculocutaneous Latissimus Dorsi Flap Phalloplasty with Reinnervation: Optimal Principles

The technique of urogenital plastic surgery continues to pose difficulties for surgeons due to physical features of the anatomical region, which complicates the correction of various severe male urogenital pathologies. The goal of the surgeon is to create a neophallus that allows for urination and intercourse with minimal damage to the donor site. This special topic provides a historical overview and principles for optimal phalloplasty. To improve results in latissimus dorsi free-flap phalloplasty, we share our approach, its benefits, and the lessons we have learned.

Methods

We performed a retrospective review of patients who underwent shaft-only, two-stage or one-stage latissimus dorsi flap phalloplasty with or without reinnervation at a single institution from 1991 through 2020. Patients with a minimum of 1 year of follow-up were included. Data on the patient's demographics, the procedure, and the results of the operation were maintained.

Results

In total, 592 latissimus dorsi flap phalloplasties were performed during the entire study period. Of the phalloplasties, 494 (83.5%) were performed for gender-affirming surgery, of which 470 were performed for transgender patients and 24 for intersex patients. Twenty-five patients (4.2%) had congenital malformations, 17 (2.9%) had oncologic resections, and 56 had posttraumatic loss (9.5%).

Conclusion

Latissimus dorsi flap total phalloplasty with reinnervation is currently one of the few methods that can solve not only an aesthetic problem, but also a functional one without the use of an endoprosthesis if the level of reinnervation and muscle contraction is sufficient.

Functional and surgical outcomes after phalloplasty in cis men

PURPOSE

Evaluate the surgical outcomes along with a comprehensive assessment of functional outcomes in cis men (non-trans) who underwent phalloplasty.

METHODS

All consecutive cis men who underwent phalloplasty from 2008 to 2018 for penile insufficiency due to various causes were included. These underwent phalloplasty by either a radial forearm free flap (RFFF) or suprapubic phalloplasty (SPP). Data were collected from medical files. A questionnaire was sent a minimum of 1 year after surgery to each patient to evaluate sexual function and self-esteem, satisfaction with genitals, and urinary function.

RESULTS

Among the 19 patients included, 12 underwent RFFF and 7 SPP; 25% of those who had RFF and 14.3% of those with SPP had a Clavien-Dindo ≥ 2 complication. A total of 16 patients had a urethroplasty procedure, 50.0% of whom had a Clavien-Dindo ≥ 2 complication. Penile prostheses were implanted in 14 patients; 64.3% of whom had a complication. Seven patients answered the questionnaire (36.8%); the relationship satisfaction score was 89.5/100 and the confidence score was 100/100. Among the 5 patients who had a sexual relationship, all reported having a lot of pleasure during sexual intercourse and reached orgasm at least "regularly". At least 66.7% of the patients were "satisfied" or "very satisfied" about the size and the appearance of genitals. Among the 5 patients who answered questions regarding urinary function, 60.0% had standing micturition, and 80.0% reported being comfortable in public toilets.

CONCLUSION

Despite the high frequency of complications and the need for revision surgery, phalloplasty seems to allow a satisfying psychosexual and urinary functions for cis men suffering from penile insufficiency.

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

INTRODUCTION

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Primary Use of the Deep Inferior Epigastric Pedicle for Free-flap Phalloplasty: Rationale, Technique, and Outcomes

Most free-flap phalloplasty reports describe the femoral artery and great saphenous vein as recipient vessels, with the deep inferior epigastric artery and venae comitantes (DIEA/V) only rarely reported. We review our experience with preferentially using the DIEA/V as recipient vessels in gender-affirming free-flap phalloplasty, with DIEV as primary venous outflow.

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

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.

Preferences for and barriers to gender affirming surgeries in transgender and non-binary individuals

Background: The transgender/non-binary community continues to be an underserved population in medicine, and our understanding of their interests, disinterests, and barriers to transition-related healthcare is quite limited, especially among the diverse gender identities within the transgender/non-binary umbrella. Aim: To determine the interests, disinterests and barriers to gender affirming surgeries for transgender men, transgender women and non-binary individuals of any birth-assigned sex. Methods: An anonymous, online survey using REDcap was applied across all 50 states and advertised through social media, healthcare organization websites and flyers. The responses of individuals greater than 18 years of age who identified as transgender or non-binary were analyzed. Results: Compared to the 2015 US Transgender Survey, interest in gender affirming surgeries was higher across all gender identities surveyed and for all procedures, by an average of 38%. Interest overall in gender affirming procedures varied greatly among gender identity groups as well as with age differences. Barriers were found to be a mixture of lack of resources for recovery, financial, and a fear of complications. Discussion: Our results highlight that a desire for these procedures is unique for each individual and should never be assumed for transgender/non-binary patients. In order to better aid this underserved population, the medical community must further work to mitigate the barriers to gender affirming procedures by decreasing cost, investigating ways to increase access to resources for recovery, and improving outcomes for each of the gender affirming surgeries.

Total phallic construction techniques in transgender men: an updated narrative review

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

[Prosthetics after construction of the outer genitalia for transmen]

BACKGROUND

Growing awareness of gender identity issues and a rising prevalence of female-to-male transsexualism is increasing demand for surgical solutions that deliver both aesthetically and functionally satisfying outer genitalia for transmen.

OBJECTIVE

This article summarizes the available prosthetic options, describes different surgical approaches and reviews the outcome of prosthetics for transmen with a focus on penile prosthesis in phalloplasty.

METHODS

Current international standards of care, reviews and original publications are critically reviewed and correlated with our own experience with more than 400 transmen at two interdisciplinary referral centres in Frankfurt, Germany and London, UK.

RESULTS

Despite of a wide range of different phalloplasty techniques and prosthetic types, the currently most used technique is implantation of a three-piece, inflatable penile prosthesis in a radial-free-flap phalloplasty. There is still an ongoing debate about the number of implanted penile prosthesis cylinders, the use of customised corporoplasty-windsocks for the cylinder(s), and the location for the placement of the reservoir. At present there is only one penile prosthesis design for use in phalloplasties and long-term results are still pending.

CONCLUSION

There is still no ideal implant available for the use in phalloplasties. The current literature does not provide evidence-based treatment algorithms, which is also due to a lack of prospective randomised studies and validated measurement tools for the postoperative outcome. Initial data for the first transmen-specific penile prosthesis as well as an increase of transgender studies might lead to an improvement of treatment and the quality-of-life of the affected transmen.

Suprapubic phalloplasty in transmen: surgical results and critical review

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

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

Preexpansion in Phalloplasty Patients: Is It Effective?

BACKGROUND

Phalloplasty is performed as genital gender-affirming surgery in transmasculine persons. It requires the harvest of sizeable autologous fasciocutaneous flaps, which is associated with donor-site morbidity and extensive scarring. Flap preexpansion has been used to facilitate wound closure and reduce scarring, but the efficacy of flap preexpansion in phalloplasty is unclear. The objective of this study was to assess the safety and effectiveness of preexpansion before phalloplasty.

METHODS

Transmasculine persons who underwent phalloplasty between December 2006 and July 2014 at our institution were identified and invited to participate. A chart review was performed to obtain patient demographics and expander-related complications. Outcomes regarding the donor-site scar (Patient Observer Scar Assessment Scale, scar size, patient satisfaction) were measured at the outpatient clinic and compared between transmasculine persons treated with and transmasculine persons treated without preexpansion.

RESULTS

Of 33 transmasculine persons who underwent phalloplasty, 17 underwent preexpansion. Phalloplasty techniques included the use of the radial forearm free flap, the anterolateral thigh flap, or a combination of both. In total, 34 tissue expanders were placed in the forearm (n = 12) and/or thigh (n = 22). Complications occurred in 18 (52.9%) of 34 tissue expanders and in 13 (76.5%) of 17 transmasculine persons. Seven reoperations were performed because of extrusion (n = 2), infection (n = 2), port failure (n = 2), or leakage (n = 1). Sixteen transmasculine persons visited our clinic for scar assessment (8 with and 8 without preexpansion). Primary closure was achieved in 4 (31%) of 13 expanded donor sites. Relative scar size was reduced when the wound could be closed primarily, but overall scar size, quality, and satisfaction did not differ significantly between groups.

CONCLUSION

Donor-site expansion before phalloplasty was associated with high rates of expander-related complications and expander failure. Primary closure of the donor site was achieved in less than a third of the cases. Primary closure may potentially lead to smaller scars and greater satisfaction; however, we concluded that the potential advantages of preexpansion do not outweigh the high risk of complications and lack of success.

[Gender reassignment from female to male : Phalloplasty]

BACKGROUND

The increasing prevalence of gender dysphoria necessitates an evaluation of the literature of phalloplasty techniques for female to male transgender individuals.

OBJECTIVE

The following article provides an overview of the current surgical concepts and complications of phalloplasty, associated urethrogenitoplasty and the implantation of prostheses in phalloplasty.

MATERIAL AND METHODS

Current international reviews and original publications from 2010 to 2020 were reviewed and correlated with our referral center experience with more than 350 female to male transgender patients over the last 25 years.

RESULTS

Free radial forearm flap phalloplasty is the most widely used technique, followed by an anterolateral thigh flap (ALT flap) and pedicled or microsurgical transplantation. Hydraulic multicomponent prostheses are given preference and supplementary surgical techniques, such as scrotoplasty and glans sculpturing can make sense or be necessary. The complication rates after phalloplasty and after insertion of penile prostheses are substantial. Nevertheless, the overall patient reported satisfaction rate in the majority of studies is often over 80%.

CONCLUSION

Due to the increasing prevalence of gender dysphoria there is currently a need for interdisciplinary referral centers for gender reassignment surgery. A certain standardization of surgical techniques and timing would be desirable but a review of the current literature shows a high heterogeneity so that this cannot be derived from the currently available literature. It is hoped that the recently founded S2K guideline committee on operative treatment of gender dysphoria under the auspices of the German Society for Urology and the Society for Plastic and Reconstructive Surgery can report an initial collection of experiences in 2021.

Total Phallic Reconstruction in the Genetic Male

BACKGROUND

Total phallic reconstruction (TPR) is a reconstructive challenge.

OBJECTIVE

To report both surgical outcomes and patient-reported outcomes (PROs) of genetic male patients undergoing TPR utilising a radial artery forearm free flap (RAFFF).

DESIGN, SETTING, AND PARTICIPANTS

A retrospective tertiary referral centre analysis of a series of genetic male patients with penile insufficiency (PI) either due to congenital micropenis, or from traumatic or surgical amputation was conducted.

SURGICAL PROCEDURE

RAFFF phalloplasty was conducted as a multistaged procedure: (1) TPR, (2) glans sculpting with second-stage urethroplasty when indicated, and (3) penile prosthesis implantation.

MEASUREMENTS

A descriptive analysis of the patient's baseline features, surgical outcomes, and PROs was conducted.

RESULTS AND LIMITATIONS

A total of 108 patients were enrolled. The median age was 32.5 yr (interquartile range [IQR] 24-46) and median follow-up was 78.5 mo (IQR 30-129). A primary anastomotic urethroplasty was performed in 90 patients (83.4%) and a staged procedure in the remainder. Four patients experienced an acute arterial thrombosis, leading to complete loss of the phallus in two. Immediate surgical exploration saved the flap in two cases of venous thrombosis. Urethral complication occurred in 49.1% of patients. The multivariate logistic regression analysis showed an association (p=0.04) between the staged urethral reconstruction and the incidence of urethral complications. The limitations of our study are its retrospective nature and the lack of control.

CONCLUSIONS

Despite the high incidence of postoperative complications and the possible need for revisions, TPR in the genetic male with PI using a RAFFF yields satisfactory aesthetic and functional results. PATIENT SUMMARY: in this report, we looked at the outcomes from TPR in a large population of male patients with penile inadequacy either due to congenital micropenis, or from traumatic or surgical amputation. Our results support the idea that penile reconstruction with a forearm free flap leads to satisfactory outcomes.

Suprapubic pedicled phalloplasty in transgender men: a multicentric retrospective cohort analysis

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.

Prosthetic Placement After Phalloplasty

Significant developments have enabled the transformation of phalloplasty to a functional organ. Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle. Increased complications compared with nonphalloplasty cohorts remain one of the biggest challenges, including rates of infection, erosion, mechanical malfunction, and malposition. Nonetheless, the placement of penile prosthesis within a phalloplasty enables trans men to achieve a once near-impossible goal of penetrative sexual intercourse without an external device.

Gender Affirmation Surgery: A Synopsis Using American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample Databases

BACKGROUND

Gender affirmation surgery (GAS) is a heterogeneous group of body transformational procedures to match one's gender identity. There is a paucity of literature on the outcomes and safety profile of GAS. This study aims to examine trends and outcomes of GAS from 2010 to 2015 using the American College of Surgeons National Surgery Quality Improvement Program and National Inpatient Sample databases.

METHODS

Patients with a primary diagnosis of gender dysphoria at the time of surgery were identified in both databases. Thirty-day complication rates were determined using the National Surgery Quality Improvement Program database. Patient socioeconomic status and hospital characteristics were examined using the National Inpatient Sample database.

RESULTS

The number of cases per year increased from 5 in 2010 to 231 in 2015. The overall 30-day complication rate was 5.5%. Younger age was an independent risk factor for overall complications and reoperation. Total operating time was an independent risk factor for overall complications and infection. Black/African American race was associated with an increased risk of reoperation and readmission. Most patients (80%) had income at or above the national median income level; most were self-pay or had private insurance (90%). The typical hospitals providing GAS were large, urban, nonteaching, private nonprofit institutions in the US West Coast and Northeast.

CONCLUSIONS

Gender affirmation surgery has an acceptable safety profile. The marked increase in case numbers likely reflects recent improvements in social climate and access to care. However, there are socioeconomic disparities in utilization and surgical outcomes among this already vulnerable patient population.

Suspensory ligament release combined with acellular dermal matrix filler in infrapubic space: A new method for penile length augmentation

Until now, no reliable method is recognised in treating buried penis. This study explored a new method of penile length augmentation using acellular dermal matrix filler in infrapubic space combined with liposuction and penile suspensory release. Patients with "small-sized penis" received penile length augmentation procedure including suprapubic liposuction, penile suspensory ligament release and insertion of folded acellular dermal matrix between corpora cavernosa and pubis symphysis. Their penile length from tip to skin was measured pre-operatively and post-operatively. The post-operative complications and patients' satisfaction were also recorded. Fifteen adult male patients were included with the mean age of 33.2 ± 4.6 years old and BMI of 28.9 ± 5.3 kg/m² . The average amount of liposuction was 430 ± 90.0 ml. The average penile length measured pre-operatively and post-operatively (on table and 3 months afterwards) was 3.0 ± 1.3 cm, 7.3 ± 2.1 cm and 5.4 ± 1.8 cm. The penile length has significantly increased by 4.3 ± 1.6 cm (on table) and 2.4 ± 0.8 cm (3 months post-operatively; p < 0.05). The post-operative complications included oedema of penis, ecchymosis of lower abdomen and poor wound healing. No patient was dissatisfied with the appearance and function. The new method using acellular dermal matrix combined with liposuction and penile suspensory ligament release is safe and effective. The method could be applied to selected patients with buried penis.

Overview of surgical techniques in gender-affirming genital surgery

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.

How Gender Identity and Treatment Progress Impact Decision-Making, Psychotherapy and Aftercare Desires of Trans Persons

The gender identity of trans individuals influences their treatment preferences, and this in turn seems to affect their individual treatment progress. However, there has been no research which—next to the impact of gender identity on treatment desires—has also investigated the influence of treatment progress using a measure which assumes various possible transition pathways of trans persons.Therefore, an online community survey of trans people was conducted in Germany in 2015. Data were collected via an online survey from a non-clinical sample of n = 415 trans individuals (over half assigned female at birth), aged 16–76 (Mean (M) = 38.12). Almost one fifth of participants embraced non-binary or genderqueer (NBGQ) identities. Participants progressed 60.77% (standard deviation (SD) = 35.21) through treatment at point of data collection, as measured by the individual treatment progress score (ITPS). All participants, especially participants assigned male at birth, differed significantly in desire to participate in decision-making processes based on transition progress; individuals without treatment experience had less desire to decide treatment plans. NBGQ participants assigned male at birth in early stages of transition had significantly more desire for psychotherapy during transition than participants of the same identity in later transition stages. All participants, especially binary participants, significantly differed in desire for aftercare based on transition progress; individuals without treatment experience indicated more desire for aftercare. Results indicate health professionals should expect changing treatment desires in trans individuals at various stages of transition, particularly at treatment start, and based on gender identity.

Free Tissue Transfer Penile Reconstruction

Phalloplasty can be a challenging plastic surgery procedure associated with complications and unsatisfactory results. Phalloplasty has become an important procedure in the setting of trauma, partial or complete excision of the penis, and gender affirmation. Advances in microsurgery has expanded penile reconstruction through free tissue transfer techniques which include the radial forearm free flap, fibular osteocutaneous flap, anterolateral thigh flap, latissimus dorsi flap, scapular flap, and abdominal flaps. Each procedure has advantages and disadvantages; most of the procedures achieve adequate cosmetic results with high patient satisfaction. Most of the surgical complications are related to the reconstruction of the urethra or creating rigidity for intercourse. The main goals of reconstruction are to create a cosmetically appealing phallus with satisfactory sexual function.

Patient-Reported Outcome Measures Used in Gender Confirmation Surgery: A Systematic Review

BACKGROUND

The usefulness of patient-reported outcome measures is emphasized along with the development of patient-centered care. When implementing patient-reported outcome measures, evidence of the instrument's validity, reliability, and responsiveness in the target population is necessary to secure accurate reporting of the patient's experience. The aim of this study was to identify the literature in which structured patient-reported outcome measures have been used to evaluate the results of gender confirmation surgery, and to systematically evaluate the validity of these instruments.

METHODS

A systematic review of the current literature was performed to identify structured patient-reported outcome measures used to evaluate the outcome of gender confirmation surgery. The identified instruments' validity in the transgender population was assessed for adherence to international guidelines for development and validation of health outcomes instruments.

RESULTS

A total of 110 instruments were identified: 64 ad hoc; six generic; 24 evaluating psychiatric, social, or psychosocial aspects; nine evaluating function but only valid in other patient groups; five ad hoc with some formal development/validation; and two specific for gender dysphoria.

CONCLUSIONS

There is a lack of patient-reported outcome measures that are valid for the transgender population and concurrently sensitive enough to evaluate gender confirmation surgery without the influence of other gender confirming interventions. Basing research on instruments without confirmed validity decreases the validity of the study itself; thus, previous research using patient-reported outcome measures to evaluate gender confirmation surgery can be considered to have a low level of evidence. To obtain valid patient-reported outcome measures, specific for evaluating the results of gender confirmation surgery, development of new instruments or adaptation of existing instruments is needed.

Outcomes after Phalloplasty: Do Transgender Patients and Multiple Urethral Procedures Carry a Higher Rate of Complication?

BACKGROUND

Phalloplasty is associated with improved quality-of-life in those with penile defects, and in female-to-male transgender (transmale) patients seeking gender-confirming surgery. However, aggregate complication and outcome data are sparse. This study compares phalloplasty outcomes between transmale and cismale patients and between those with primary versus staged urethroplasty.

METHODS

A comprehensive literature search of PubMed, MEDLINE, and Google Scholar databases was conducted for studies relating to phalloplasty. Data on techniques, complications, outcomes, and patient demographics were collected. Analysis using the random-effects model with subgroup analyses was performed.

RESULTS

A total of 50 studies (1351 patients) were included: 19 studies (869 patients) for transmale patients and 31 studies (482 patients) for cismale patients. The urethral complication rate in the transmale group was 39.4 percent (95 percent CI, 30.6 to 48.9 percent; p = 0.028) compared to 24.8 percent (95 percent CI, 16.5 to 35.4 percent; p < 0.001) in the cismale group. The overall flap complication rates for transmale and cismale patients were 10.8 percent (95 percent CI, 7.0 to 16.2 percent; p < 0.001) and 8.1 percent (95 percent CI, 5.5 to 11.7 percent; p < 0.001), respectively. Twenty-three studies (723 patients) used primary urethroplasty and 13 studies (210 patients) performed staged urethroplasty procedures. Flap complication rates of primary and staged urethroplasty were 8.6 percent (95 percent CI, 5.3 to 13.8 percent; p < 0.001) and 16.7 percent (95 percent CI, 10.7 to 24.9 percent; p < 0.001), respectively. Primary urethroplasty had superior outcomes of voiding while standing, sexual function, and patient satisfaction compared with staged urethroplasty.

CONCLUSIONS

Cismale patients undergoing phalloplasty had lower urethral and flap complication rates compared with transmale patients. Staged urethroplasty had more flap complications, and worse outcomes and patient satisfaction compared with primary urethroplasty.

Total penile reconstruction: A systematic review

BACKGROUND

Phalloplasty poses a unique challenge to the plastic and reconstructive surgeon. The development of advanced microsurgical techniques has greatly augmented the range of surgical approaches available.

METHODS

A systematic review of the MEDLINE and Cochrane databases was performed to identify clinical studies of total penile reconstruction published within the last 10 years using the search algorithm: "(phallus or penis or penile) and (reconstruction or phalloplasty or transplant)".

RESULTS

The primary literature search retrieved 1400 articles. After applying inclusion and exclusion criteria, 30 studies were selected for review. The radial forearm free flap is the preferred technique for total phalloplasty; however, other techniques including the fibular osteocutaneous flap, anterolateral thigh flap, latissimus dorsi flap, scapular free flap, and abdominal flap are described. Background, indications, and preoperative and postoperative care are also discussed.

CONCLUSIONS

Total penile reconstruction can provide functional, aesthetic, and psychosocial benefits to the patient. Use of the radial forearm free flap has been proposed as the gold standard; however, the wide range of potential complications associated with phalloplasty warrants an individualized approach to each patient.

Mystery and realities of phalloplasty: a systematic review

The neophallus creation is still a mystery and it remains challenging even today. In this article, we performed a comprehensive review of the literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016. In this review, we have included 15 research articles and the results of 276 patients were examined. Studies revealed several indications and when indications were reviewed, 191 patients were female-to-male transgender, 9 patients had disorder of sex development/micropenis, 16 had penile amputation/trauma, 9 had ambiguus genitalia, 40 had exstrophy and/or epispadias, 11 had other problems. As a result of this review, phalloplasty is a reliable and useful operation with good functional and aesthetical results.

Phalloplasty: A Review of Techniques and Outcomes

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.

[Phalloplasty: Microsurgical options and management algorithm]

The free radial forearm flap is considered as the gold standard in penile reconstruction for good functional and aesthetic results. The scar on donor site could be considered as pathognomonic of their situation by transsexual patients. The development of microsurgical flaps provides new therapeutic options. This options are discussed and a therapeutic algorithm is presented. The main techniques used are the pedicled anterolateral thigh perforator flap and free muscle sparing latissimus dorsi flap. Principal criteria are listed, the choice of patient and the local anatomical conditions are the most important. Antebrachial flap stay the first choice. In case of non-feasibility of this flap, phalloplasty with pedicle ALT flap or free MSLD flap will be proposed. Urethral reconstruction will be done by a narrow free forearm flap or by a delayed thin skin graft or buccal mucosa graft. Microsurgical phalloplasty options are not limited to the forearm flap. Satisfactory results can be obtained using alternative procedure. The use of a therapeutic algorithm allows to choose the most optimal solution for each patient.

Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?

Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.

Fertility and sexual dysfunction issues in adults with genitourinary congenital anomalies

PURPOSE OF REVIEW

As growing numbers of adolescents with a history of congenital genitourinary anomalies successfully enter adulthood, their spectrum of urologic concerns broadens to include sexual function and reproduction.

RECENT FINDINGS

In hypospadias repair, preoperative testosterone was found to reduce rates of postoperative complications of urethrocutaneous fistula formation and meatal stenosis. Following hypospadias correction, dissatisfaction with surgical outcomes has been observed to correlate with psychological outcomes, rather than objective measurements such as location of meatus degree of curvature. In women with a congenital absence of a vagina, sigmoid vaginoplasty and dilation yield similar sexual outcomes, however, vaginoplasty was associated with a 20% rate of reoperation. Ilioinguinal-to-dorsal neurorrhaphy for restoration of penile sensation in myelomeningocele has shown success in a small pilot study. Both sexual activity and paternity rates are higher in women, compared with men who are born with bladder exstrophy.

SUMMARY

The extent and complexity of issues related to sexual function and fertility in the population of patients with a history of genitourinary malformation requires a thoughtful approach to timely surgical management and consistent care through their transition from childhood to adulthood.

Neophalloplasty in boys with aphallia: A systematic review

OBJECTIVE

Aphallia is a rare penile congenital abnormality. The aim of this systematic review was to assess all available literature on neophalloplasty in infancy with an interest in technical alternatives and clinical outcome.

MATERIALS AND METHODS

We performed a Pubmed search using the terms: neophalloplasty, neophallus, and phalloplasty, and selected articles that presented technical alternatives for penile construction in cases of penile dysgenesis, especially aphallia in children and/or adolescents.

RESULTS

A total of 319 articles were identified in the initial search. Among the different techniques presented in 19 papers collected, we categorized reconstructive procedures into two groups: microsurgical and non-microsurgical techniques. Among the microsurgical techniques, procedures such as the osteocutaneous fibular flap (n = 18), the myocutaneous latissimus dorsi flap (n = 24), and the radial forearm free flap (n = 293) were reported. Among the non-microsurgical techniques, we found a wider range of technical options (6 in total). Most were based on groin, abdominal, and scrotal flaps. Long-term reports on the functionability of the neophallus and psychological aspects of the patients are lacking.

CONCLUSION

In assessing recent literature, it seems rational that neophalloplasty should be regarded as the preferred strategy for boys born with aphallia, in opposition to female gender assignment.

Postoperative imaging of phalloplasties and their complications

OBJECTIVE

In this article, we summarize the common phalloplasty indications, surgical techniques, and relevant anatomy. We review the appropriate imaging techniques used in postoperative evaluation of the neophallus and illustrate the postoperative appearance and complications associated with phalloplasty.

CONCLUSION

Phalloplasty is an infrequently encountered yet complex procedure requiring careful postoperative imaging assessment. Modern microsurgical techniques have made free flaps the reference standard in phalloplasty, and the radiologist must be aware of the expected postoperative appearance and complications to appropriately manage these patients.