1
|
Wascher J, Hazra A, Fisher AR. Sexual Health for Transgender and Gender Diverse Individuals: Routine Examination, Sexually-Transmitted Infection Screening, and Prevention. Obstet Gynecol Clin North Am 2024; 51:405-424. [PMID: 38777492 DOI: 10.1016/j.ogc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
Gynecologists play a critical role in the office evaluation of transgender and gender diverse individuals. This includes the provision of essential healthcare services including the treatment and prevention of human immunodeficiency virus and sexually-transmitted infections and screening for human papillomavirus infection-related diseases and cancers. Caring for patients who identify as transgender or gender diverse (TGD) and who have undergone gender-affirming surgical treatments is challenging due in part to clinical gaps in knowledge resulting from insufficient training and educational resources. A patient-centered approach to the care of TGD individuals requires knowledge of the general principles of affirming, holistic care with attention to the risk factors, and anatomic considerations unique to this population. This review aims to provide basic knowledge needed for the successful gynecologic evaluation of a gender diverse patient.
Collapse
Affiliation(s)
- Jocelyn Wascher
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
| | - Aniruddha Hazra
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA; Pritzker School of Medicine, 924 E 57th Street #104, Chicago, IL 60637, USA
| | - Andrew R Fisher
- Department of Obstetrics and Gynecology, University of Chicago, 5841 S. Maryland Avenue, Chicago, IL 60637, USA; Pritzker School of Medicine, 924 E 57th Street #104, Chicago, IL 60637, USA.
| |
Collapse
|
2
|
Dickstein DR, Edwards CR, Rowan CR, Avanessian B, Chubak BM, Wheldon CW, Simoes PK, Buckstein MH, Keefer LA, Safer JD, Sigel K, Goodman KA, Rosser BRS, Goldstone SE, Wong SY, Marshall DC. Pleasurable and problematic receptive anal intercourse and diseases of the colon, rectum and anus. Nat Rev Gastroenterol Hepatol 2024; 21:377-405. [PMID: 38763974 DOI: 10.1038/s41575-024-00932-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2024] [Indexed: 05/21/2024]
Abstract
The ability to experience pleasurable sexual activity is important for human health. Receptive anal intercourse (RAI) is a common, though frequently stigmatized, pleasurable sexual activity. Little is known about how diseases of the colon, rectum, and anus and their treatments affect RAI. Engaging in RAI with gastrointestinal disease can be difficult due to the unpredictability of symptoms and treatment-related toxic effects. Patients might experience sphincter hypertonicity, gastrointestinal symptom-specific anxiety, altered pelvic blood flow from structural disorders, decreased sensation from cancer-directed therapies or body image issues from stoma creation. These can result in problematic RAI - encompassing anodyspareunia (painful RAI), arousal dysfunction, orgasm dysfunction and decreased sexual desire. Therapeutic strategies for problematic RAI in patients living with gastrointestinal diseases and/or treatment-related dysfunction include pelvic floor muscle strengthening and stretching, psychological interventions, and restorative devices. Providing health-care professionals with a framework to discuss pleasurable RAI and diagnose problematic RAI can help improve patient outcomes. Normalizing RAI, affirming pleasure from RAI and acknowledging that the gastrointestinal system is involved in sexual pleasure, sexual function and sexual health will help transform the scientific paradigm of sexual health to one that is more just and equitable.
Collapse
Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Collin R Edwards
- Department of Radiology, Vagelos College of Physicians and Surgeons of Columbia University, New York, NY, USA
| | - Catherine R Rowan
- Inflammatory Bowel Disease Unit, Division of Gastroenterology and Hepatology, University of Calgary, Calgary, Alberta, Canada
| | - Bella Avanessian
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Barbara M Chubak
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher W Wheldon
- Department of Social and Behavioral Sciences, College of Public Health at Temple University, Philadelphia, PA, USA
| | - Priya K Simoes
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael H Buckstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laurie A Keefer
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua D Safer
- Center for Transgender Medicine and Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Endocrinology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Keith Sigel
- Division of Infectious Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Karyn A Goodman
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - B R Simon Rosser
- Division of Epidemiology and Community Health, School of Public Health at University of Minnesota, Minneapolis, MN, USA
| | - Stephen E Goldstone
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Serre-Yu Wong
- The Dr. Henry D. Janowitz Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deborah C Marshall
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| |
Collapse
|
3
|
Hirpara MM, Amin L, Aloyan T, Shilleh N, Lewis P. Does the Internet Provide Quality Information on Metoidioplasty? Using the Modified Ensuring Quality Information for Patients Tool to Evaluate Artificial Intelligence-Generated and Online Information on Metoidioplasty. Ann Plast Surg 2024; 92:S361-S365. [PMID: 38689420 DOI: 10.1097/sap.0000000000003797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND Public interest in gender affirmation surgery has surged over the last decade. This spike in interest, combined with extensive free online medical knowledge, has led many to the Internet for more information on this complicated procedure. This study aimed to evaluate the quality of online information on metoidioplasty. METHODS Google Trends in searches on "metoidioplasty" from 2004 to present were assessed. "metoidioplasty" was searched on three popular search engines (Google, Yahoo, and Bing), and the first 100 websites from each search were extracted for inclusion (Fig. 1). Exclusion criteria included duplicates, websites requiring fees, photo libraries, and irrelevant websites. Websites were assigned a score (out of 36) using the modified Ensuring Quality Information for Patients (EQIP) instrument, which grades patient materials based on content (18), identification (6), and structure (12). ChatGPT was also queried for metoidioplasty-related information and responses were analyzed using EQIP. RESULTS Google Trends analysis indicated relative search interest in "metoidioplasty" has more than quadrupled since 2013(Fig. 2). Of the 93 websites included, only 2 received an EQIP score greater than 27 (6%). Website scores ranged from 7 to 33, with a mean of 18.6 ± 4.8. Mean scores were highest for websites made by health departments (22.3) and lowest for those made by encyclopedias and academic institutions (16.0). Websites with the highest frequency were research articles, web portals, hospital websites, and private practice sites, which averaged scores of 18.2, 19.7, 19.0, and 17.8, respectively. Health department sites averaged the highest content points (11.25), and academic institutions averaged the lowest (5.5). The average content point across all websites was 7.9 of 18. ChatGPT scored a total score of 29: 17 content, 2 identification, and 10 structures. The artificial intelligence chatbot scored the second highest score among all included online resources. CONCLUSIONS Despite the continued use of search engines, the quality of online information on metoidioplasty remains exceptionally poor across most website developers. This study demonstrates the need to improve these resources, especially as interest in gender-affirming surgery continues to grow. ChatGPT and other artificial intelligence chatbots may be efficient and reliable alternatives for those seeking to understand complex medical information.
Collapse
Affiliation(s)
- Milan M Hirpara
- From the California University of Science and Medicine School of Medicine, Colton, CA
| | | | | | | | | |
Collapse
|
4
|
Loria M, Van Dorn C, Bobrow A, Gautam A, Fraiman E, McNamara M, Gupta S, Mishra K. Are cisnormative surveys adequate to assess sexual well-being in trans men post-genital gender-affirming surgery? Sex Med Rev 2024:qeae023. [PMID: 38651588 DOI: 10.1093/sxmrev/qeae023] [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: 12/18/2023] [Revised: 02/29/2024] [Accepted: 03/25/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION For transmasculine spectrum individuals, there is a lack of validated surveys to assess sexual well-being (SWB) post-genital gender-affirming surgery. Currently, either providers are designing their own SWB surveys or surveys designed for cisgender men are being used. OBJECTIVE This study investigated the applicability of SWB surveys validated for cisgender men to transmasculine spectrum individuals post-genital gender-affirming surgery (TMSX). Recognizing the paucity of validated tools for assessing SWB in transmasculine individuals post-genital gender-affirming surgery (TMSX), we evaluated current surveys for their inclusiveness and relevance to this population. METHODS Our methodology involved analyzing surveys validated in English-speaking North American cisgender men. We conducted a systematic review, yielding 31 surveys, out of which 12 met our inclusion criteria. These were then assessed against the 10 domains of holistic SWB as identified by Özer et al. Each survey was scored based on its reflection of these domains, thus generating an SWB score. Additionally, we performed a thematic analysis to identify areas needing modification for better applicability to TMSX. RESULTS Our findings indicate an average SWB score of 5.17 out of 10 across the surveys. The surveys predominantly addressed sexual function, with a marked underrepresentation of domains like quality of life, sexuality, and sexual pleasure. This underscores the tendency of these surveys to focus more on the biological mechanisms of sex, rather than on a nuanced biopsychosocial understanding. Thematic analysis revealed significant gaps, such as the irrelevance of questions about erections and ejaculations for TMSX, and the need for greater emphasis on psychosocial factors. CONCLUSION Given these gaps and the inadequacy of most cisnormative surveys, we recommend the creation of a novel, validated SWB survey specifically for TMSX. This should be developed in collaboration with a multidisciplinary panel and TMSX community advisory board, ensuring a tool that truly reflects the unique SWB needs of this population.
Collapse
Affiliation(s)
- Matthew Loria
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
| | - Chloe Van Dorn
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
| | - Aidan Bobrow
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
- Ohio University Heritage College of Osteopathic Medicine, Athens, OH, 45701, United States
| | - Aishwarya Gautam
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
| | - Elad Fraiman
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
| | - Megan McNamara
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
- Department of Internal Medicine, Louis Stokes Cleveland Department of Veterans Affairs, Cleveland, OH, United States
| | - Shubham Gupta
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
| | - Kirtishri Mishra
- Case Western Reserve University School of Medicine, Cleveland, OH, 44106 United States
- University Hospitals, Urology Institute, Cleveland, OH, 44106, United States
- Department of Urology, Metro Health Medical Center, Cleveland, OH, 44109, United States
| |
Collapse
|
5
|
Maffucci F, Clark J, Jun M, Douglass L. A Urologist's Guide to Caring for Transgender and Gender Diverse Patients. Urol Clin North Am 2023; 50:577-585. [PMID: 37775216 DOI: 10.1016/j.ucl.2023.06.020] [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: 10/01/2023]
Abstract
Urologists are experts in the fields of genital and pelvic anatomy, sexual health and reproductive medicine. As such, a working understanding of urologic conditions relevant to transgender and gender diverse patients should be expected within their scope of practice. Herein, we describe an introductory framework for general urologists to grow their knowledge of the appropriate terminology, anatomy, and basic tenets of gender-affirming care to better manage the urologic needs of transgender and gender diverse patients.
Collapse
Affiliation(s)
- Fenizia Maffucci
- Department of Urology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Jessica Clark
- Department of Urology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - Min Jun
- Crane Center for Transgender Surgery, 575 Sir Francis Drake Boulevard, Suite 1, Greenbrae, CA 94904, USA
| | - Laura Douglass
- Department of Urology, Lewis Katz School of Medicine at Temple University, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| |
Collapse
|
6
|
Glick H, Tang M, Daignault-Newton S, Hadj-Moussa M. Assessment of neophallus length following metoidioplasty. Transl Androl Urol 2023; 12:1390-1396. [PMID: 37814700 PMCID: PMC10560337 DOI: 10.21037/tau-23-155] [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: 03/08/2023] [Accepted: 08/03/2023] [Indexed: 10/11/2023] Open
Abstract
Background An increasing number of gender diverse individuals are presenting for gender affirming care. An option for genital gender affirming surgery (gGAS) in transmasculine individuals is metoidioplasty, creating a small neophallus from enlarged clitoral tissue following prolonged testosterone exposure. The goal of this study is to understand factors which contribute to greater exposed neophallus length following metoidioplasty. Methods We performed a retrospective chart review on patients presenting to a single academic institution who underwent a metoidioplasty. All operations were performed using the Belgrade technique with or without urethral lengthening depending on patient preference. Results Twenty-seven patients underwent metoidioplasty from 2017-2022. Sixteen had recorded stretched clitoral length (pre-operatively) and exposed neophallus length (post-operatively). The median length of time on testosterone therapy was 4.6 years. The median stretched clitoral length was 5.8 cm, and exposed neophallus length was 6 cm. There was a strong correlation between pre-operative length and post-operative length (ρ=0.9; P<0.0001). There were no correlations between pre-operative length or exposed neophallus length and BMI (ρ=-0.02, P=0.93; ρ=0.05, P=0.83, respectively). Time on testosterone does not correlate with stretched clitoral length nor exposed neophallus length (ρ=-0.28, P=0.15; ρ=-0.35, P=0.18, respectively). Conclusions Patients considering metoidioplasty often wonder how large their neophallus will be. We found that patients can expect exposed neophallus length to be about 0.6 cm longer than their pre-operative stretched clitoral length. No evidence of association of time on testosterone nor BMI with exposed neophallus length was found. This information is crucial for gender diverse patients to make informed decisions about gGAS.
Collapse
Affiliation(s)
| | - Michael Tang
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | | | | |
Collapse
|
7
|
Reisner SL, Pletta DR, Pardee DJ, Deutsch MB, Peitzmeier SM, Hughto JM, Quint M, Potter J. Digital-Assisted Self-interview of HIV or Sexually Transmitted Infection Risk Behaviors in Transmasculine Adults: Development and Field Testing of the Transmasculine Sexual Health Assessment. JMIR Public Health Surveill 2023; 9:e40503. [PMID: 36930204 PMCID: PMC10131935 DOI: 10.2196/40503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/29/2022] [Accepted: 01/12/2023] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The sexual health of transmasculine (TM) people-those who identify as male, men, or nonbinary and were assigned a female sex at birth-is understudied. One barrier to conducting HIV- and sexually transmitted infection (STI)-related research with this population is how to best capture sexual risk data in an acceptable, gender-affirming, and accurate manner. OBJECTIVE This study aimed to report on the community-based process of developing, piloting, and refining a digitally deployed measure to assess self-reported sexual behaviors associated with HIV and STI transmission for research with TM adults. METHODS A multicomponent process was used to develop a digital-assisted self-interview to assess HIV and STI risk in TM people: gathering input from a Community Task Force; working with an interdisciplinary team of content experts in transgender medicine, epidemiology, and infectious diseases; conducting web-based focus groups; and iteratively refining the measure. We field-tested the measure with 141 TM people in the greater Boston, Massachusetts area to assess HIV and STI risk. Descriptive statistics characterized the distribution of sexual behaviors and HIV and STI transmission risk by the gender identity of sexual partners. RESULTS The Transmasculine Sexual Health Assessment (TM-SHA) measures the broad range of potential sexual behaviors TM people may engage in, including those which may confer risk for STIs and not just for HIV infection (ie, oral-genital contact); incorporates gender-affirming language (ie, genital or frontal vs vaginal); and asks sexual partnership characteristics (ie, partner gender). Among 141 individual participants (mean age 27, SD 5 years; range 21-29 years; n=21, 14.9% multiracial), 259 sexual partnerships and 15 sexual risk behaviors were reported. Participants engaged in a wide range of sexual behaviors, including fingering or fisting (receiving: n=170, 65.6%; performing: n=173, 66.8%), oral-genital sex (receiving: n=182, 70.3%; performing: n=216, 83.4%), anal-genital sex (receptive: n=31, 11.9%; insertive: n=9, 3.5%), frontal-genital sex (receptive: n=105, 40.5%; insertive: n=46, 17.8%), and sharing toys or prosthetics during insertive sex (n=62, 23.9%). Overall barrier use for each sexual behavior ranged from 10.9% (20/182) to 81% (25/31). Frontal receptive sex with genitals and no protective barrier was the highest (21/42, 50%) with cisgender male partners. In total, 14.9% (21/141) of participants reported a lifetime diagnosis of STI. The sexual history tool was highly acceptable to TM participants. CONCLUSIONS The TM-SHA is one of the first digital sexual health risk measures developed specifically with and exclusively for TM people. TM-SHA successfully integrates gender-affirming language and branching logic to capture a wide array of sexual behaviors. The measure elicits sexual behavior information needed to assess HIV and STI transmission risk behaviors. A strength of the tool is that detailed partner-by-partner data can be used to model partnership-level characteristics, not just individual-level participant data, to inform HIV and STI interventions.
Collapse
Affiliation(s)
- Sari L Reisner
- Brigham and Women's Hospital, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Fenway Health, Boston, MA, United States
| | - David R Pletta
- Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | | | - Madeline B Deutsch
- University of California San Francisco, San Francisco, CA, United States
| | | | - Jaclyn Mw Hughto
- Brown University School of Public Health, Providence, RI, United States
| | - Meg Quint
- Brigham and Women's Hospital, Boston, MA, United States
| | - Jennifer Potter
- Harvard Medical School, Boston, MA, United States
- Fenway Health, Boston, MA, United States
- Beth Israel Deaconess Medical Center, Boston, MA, United States
| |
Collapse
|
8
|
Green R, Eckstrand KL, Faeder M, Tilstra S, Ufomata E. Affirming Care for Transgender Patients. Med Clin North Am 2023; 107:371-384. [PMID: 36759103 DOI: 10.1016/j.mcna.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Gender identity is a deeply felt internal sense of self, which may correspond (cisgender) or not correspond (transgender) with the person's assigned sex at birth. Transgender, nonbinary, and gender diverse people may choose to affirm their gender in any number of ways including medical gender affirmation. This is a primer on the medical care of transgender individuals which covers an introduction to understanding a common language, history of transgender medical care, creating a welcoming environment, hormone therapy, surgical therapies, fertility considerations, and cancer screening in transgender people.
Collapse
Affiliation(s)
- Rebecca Green
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
| | - Kristen L Eckstrand
- Department of Psychiatry, University of Pittsburgh School of Medicine, Loeffler Building #301, 121 Meyran Avenue, Pittsburgh, PA 15213, USA
| | - Morgan Faeder
- University of Pittsburgh School of Medicine, UPMC Psychiatry CL, 3600 Forbes Avenue, Suite 306, Pittsburgh, PA 15213, USA
| | - Sarah Tilstra
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Eloho Ufomata
- Department of Medicine, University of Pittsburgh School of Medicine, UPMC General Internal Medicine Clinic, Montefiore 9S, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| |
Collapse
|
9
|
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
|
10
|
Stojanovic B, Djordjevic ML. Updates on metoidioplasty. Neurourol Urodyn 2022. [DOI: 10.1002/nau.25102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/21/2022]
Affiliation(s)
- Borko Stojanovic
- Belgrade Center for Urogenital Reconstructive Surgery Belgrade Serbia
- School of Medicine University of Belgrade Beograd Serbia
| | - Miroslav L. Djordjevic
- Belgrade Center for Urogenital Reconstructive Surgery Belgrade Serbia
- School of Medicine University of Belgrade Beograd Serbia
- Icahn School of Medicine at Mount Sinai New York New York USA
| |
Collapse
|
11
|
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
|
12
|
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
|
13
|
Revels JW, Wang SS, Weaver JS, Foreman JR, Gallegos MA, Thompson WM, Katz D, Moshiri M. A multimodality review of male urethral imaging: pearls and pitfalls with an update on urethral stricture treatment. Br J Radiol 2022; 95:20211034. [PMID: 35001669 PMCID: PMC10996428 DOI: 10.1259/bjr.20211034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 11/18/2021] [Accepted: 12/09/2021] [Indexed: 11/05/2022] Open
Abstract
Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.
Collapse
Affiliation(s)
- Jonathan Wesley Revels
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Sherry S Wang
- Department of Radiology and Imaging Sciences, University of
Utah, Salt Lake City, Utah,
United States
| | - Jennifer S Weaver
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Jordan R Foreman
- Department of Urology, University of New Mexico,
Albuquerque, New Mexico, United
States
| | - Maxx A Gallegos
- Department of Urology, University of New Mexico,
Albuquerque, New Mexico, United
States
| | - William M Thompson
- Department of Radiology, University of New
Mexico, Albuquerque, New Mexico,
United States
| | - Douglas Katz
- Department of Radiology, NYU Langone Hospital - Long
Island, Mineola, New York,
United States
| | - Mariam Moshiri
- Department of Radiology, Vanderbilt University,
Nashville, Tennessee, United
States
| |
Collapse
|
14
|
Khorrami A, Kumar S, Bertin E, Wassersug R, O'Dwyer C, Mukherjee S, Witherspoon L, Mankowski P, Genoway K, Kavanagh AG. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022; 10:100505. [PMID: 35405363 PMCID: PMC9177887 DOI: 10.1016/j.esxm.2022.100505] [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: 11/18/2021] [Revised: 01/22/2022] [Accepted: 02/17/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI). AIM We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA. OUTCOMES Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty. RESULTS Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction. CLINICAL TRANSLATION The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery. STRENGTHS & LIMITATIONS This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center. CONCLUSION Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.
Collapse
Affiliation(s)
- Amir Khorrami
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Sahil Kumar
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Elise Bertin
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Richard Wassersug
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Cormac O'Dwyer
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada
| | - Smita Mukherjee
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luke Witherspoon
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Mankowski
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krista Genoway
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Division of Plastic and Reconstructive Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex G Kavanagh
- Gender Surgery Program, Vancouver Coastal Health, Vancouver, British Columbia, Canada; Department of Urologic Sciences, University of British Columbia, Vancouver, British Columbia, Canada.
| |
Collapse
|
15
|
Smith SM, Yuan N, Lee G, Stelmar J, Ray E, Garcia MM. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022; 10:100495. [PMID: 35255460 PMCID: PMC9023249 DOI: 10.1016/j.esxm.2022.100495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/12/2022] [Accepted: 01/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL). Aim To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL. Methods We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date. Outcomes Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries. Results All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57). Clinical Implications The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system. Strengths and Limitations Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time. Conclusion It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs. Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.
Collapse
Affiliation(s)
- Shannon M Smith
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Nance Yuan
- Huntington Plastic Surgery Institute, Pasadena, CA, USA
| | - Grace Lee
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA
| | - Jenna Stelmar
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA
| | - Edward Ray
- Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; Cedars-Sinai Medical Center, Los Angeles, Division of Plastic Surgery, Los Angeles, CA, USA
| | - Maurice M Garcia
- Cedars-Sinai Medical Center, Los Angeles, Division of Urology, Los Angeles, CA, USA; Cedars-Sinai Transgender Surgery and Health Program, Los Angeles, CA, USA; University of California San Francisco, Department of Urology and Department of Anatomy, San Francisco, CA, USA.
| |
Collapse
|
16
|
Parker A, Blasdel G, Kloer C, Kimberly L, Shakir N, Robinson I, Bluebond-Langner R, Zhao LC. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022; 19:385-393. [PMID: 34920952 DOI: 10.1016/j.jsxm.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/15/2021] [Accepted: 10/10/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The limitations of metoidioplasty and phalloplasty have been reported as deterrents for transgender and other gender expansive individuals (T/GE) desiring gender affirming surgery, and thus penile transplantation, epithesis, and composite tissue engineering (CTE) are being explored as alternative interventions. AIM We aim to understand the acceptability of novel techniques and factors that may influence patient preferences in surgery to best treat this diverse population. METHODS Descriptions of metoidioplasty, phalloplasty, epithesis, CTE, and penile transplant were delivered via online survey from January 2020 to May 2020. Respondents provided ordinal ranking of interest in each intervention from 1 to 5, with 1 representing greatest personal interest. Demographics found to be significant on univariable analysis underwent multivariable ordinal logistic regression to determine independent predictors of interest. OUTCOMES Sexual orientation, gender, and age were independent predictors of interest in interventions. RESULTS There were 965 qualifying respondents. Gay respondents were less likely to be interested in epithesis (OR: 2.282; P = .001) compared to other sexual orientations. Straight individuals were the least likely to be interested in metoidioplasty (OR 3.251; P = .001), and most interested in penile transplantation (OR 0.382; P = .005) and phalloplasty (OR 0.288, P < .001) as potential interventions. Gay and queer respondents showed a significant interest in phalloplasty (Gay: OR 0.472; P = .004; Queer: OR 0.594; P = .017). Those who identify as men were more interested in phalloplasty (OR 0.552; P < .001) than those with differing gender identities. Older age was the only variable associated with a decreased interest in phalloplasty (OR 1.033; P = .001). No demographic analyzed was an independent predictor of interest in CTE. CLINICAL IMPLICATIONS A thorough understanding of patient gender identity, sexual orientation, and sexual behavior should be obtained during consultation for gender affirming penile reconstruction, as these factors influence patient preferences for surgical interventions. STRENGTHS AND LIMITATIONS This study used an anonymous online survey that was distributed through community channels and allowed for the collection of a high quantity of responses throughout the T/GE population that would otherwise be impossible through single-center or in-person means. The community-based methodology minimized barriers to honesty, such as courtesy bias. The survey was only available in English and respondents skewed young and White. CONCLUSION Despite previously reported concerns about the limitations of metoidioplasty, participants ranked it highly, along with CTE, in terms of personal interest, with sexual orientation, gender, and age independently influencing patient preferences, emphasizing their relevance in patient-surgeon consultations. A. Parker, G. Blasdel, C. Kloer et al. "Postulating Penis: What Influences the Interest of Transmasculine Patients in Gender Affirming Penile Reconstruction Techniques?". J Sex Med 2022;19:385-393.
Collapse
Affiliation(s)
- Augustus Parker
- NYU Grossman School of Medicine, NYU Langone Health Systems, New York, NY, USA
| | - Gaines Blasdel
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Carmen Kloer
- Duke University School of Medicine, Duke Health Systems, Durham, NC, USA; Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Laura Kimberly
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA
| | - Nabeel Shakir
- Department of Urology, New York University Langone Health, New York, NY, USA
| | - Isabel Robinson
- Hansjörg Wyss Department of Plastic Surgery, 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
| | - Lee C Zhao
- Department of Urology, New York University Langone Health, New York, NY, USA.
| |
Collapse
|
17
|
Gender Affirming Surgery: A Comprehensive, Systematic Review of All Peer-reviewed Literature and Methods of Assessing Patient-centered Outcomes (Part 2: Genital Reconstruction). Ann Surg 2022; 275:e67-e74. [PMID: 34914663 DOI: 10.1097/sla.0000000000004717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To perform the first systematic review of all available GAS publications across all procedures to assess outcomes reported in the literature and the methods used for outcome assessment. SUMMARY OF BACKGROUND DATA Assessment of GAS results is complex and multidimensional, involving not only complication rates but also anatomic (eg, vaginal depth), functional (eg, urinary), and psychosocial outcomes. A fully comprehensive aggregation of all prior research would offer an essential cornerstone for continued progress. METHODS A systematic review was performed after PRISMA guidelines to identify all outcomes measures in GAS cohorts, including patient-centered outcomes, complications, and functional outcomes. Data were aggregated to assess pooled rates of complications, satisfaction, and other outcomes. RESULTS Overall, 15,186 references were identified, 4162 papers advanced to abstract review, and 1826 underwent full-text review. After review, there were 406 GAS cohort publications, including 171 vaginoplasty, 82 phalloplasty, 16 metoidioplasty, 23 oophorectomy/vaginectomy, and 21 with multiple procedures.Although 68.7% of genitoplasty papers addressed patient-centered outcomes, only 1.0% used metrics validated in the transgender population. Forty-three different outcome instruments were used. No instrument was used in more than 15% of published series and 38 were used in only 1 or 2 publications. CONCLUSIONS Our review found high patient satisfaction for genital procedures but little concordance between study methods, with almost 90% of patient-focused outcome metrics appearing only once or twice. Standardization of outcome instruments and measurement methods through patient-inclusive, multidisciplinary consensus efforts is the essential next step for quality improvement. As GAS continues to mature, building on current foundations with the goal of improving both surgical and patient-reported outcomes is essential.
Collapse
|
18
|
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
|
19
|
Wilde M, Huguelet P, Alaniz VI. Transgender Medicine and Hormone Therapy: What the Gynecologist Needs to Know. Clin Obstet Gynecol 2021; 64:739-756. [PMID: 34292172 DOI: 10.1097/grf.0000000000000646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The transgender community comprises individuals with diverse identities in both gender and sexual orientation. Unfortunately, many face discrimination and harassment within our society-including within the medical system. There is an overall lack of provider training in transgender specific health which has led to health disparities and inequities within this population. This chapter aims to elucidate the medical needs unique to transgender and gender nonconforming individuals and thus enable medical providers to meet those needs with competency and compassion.
Collapse
Affiliation(s)
- Melyssa Wilde
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| | | | | |
Collapse
|
20
|
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
|
21
|
Treatment of Urethral Strictures in Transmasculine Patients. J Clin Med 2021; 10:jcm10173912. [PMID: 34501359 PMCID: PMC8432136 DOI: 10.3390/jcm10173912] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/02/2021] [Accepted: 08/22/2021] [Indexed: 12/27/2022] Open
Abstract
Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.
Collapse
|
22
|
Grimstad F, Boskey ER, Taghinia A, Ganor O. Gender-Affirming Surgeries in Transgender and Gender Diverse Adolescent and Young Adults: A Pediatric and Adolescent Gynecology Primer. J Pediatr Adolesc Gynecol 2021; 34:442-448. [PMID: 33852937 DOI: 10.1016/j.jpag.2021.03.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/28/2021] [Accepted: 03/31/2021] [Indexed: 12/12/2022]
Abstract
Transgender and gender diverse adolescent and young adults (AYA) may seek gender-affirming surgeries (GAS) as part of their gender affirmation. A number of GAS are related to reproductive and sexual health, and pediatric and adolescent gynecology (PAG) clinicians are well positioned as sexual and reproductive health experts to provide care in this area. PAG clinicians may encounter patients presenting for preoperative counseling (including discussions regarding fertility, family building, future sexual function, and choice of oophorectomy at time of hysterectomy), requesting referrals to GAS clinicians, or requiring GAS aftercare, or those seeking general sexual and reproductive health care who have a history of GAS. This article reviews presurgical considerations for AYA seeking GAS, types of GAS, their impact on pelvic, sexual, and reproductive health, and aftercare that may involve PAG providers, with the goal of helping PAG clinicians to better understand these procedures and to empower them to engage collaboratively with GAS teams. With this knowledge, reproductive health clinicians can have an integral role as skilled collaborators in the world of AYA GAS in partnership with GAS surgeons.
Collapse
Affiliation(s)
- Frances Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, 02115 Boston, Massachusetts; Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts.
| | - Elizabeth R Boskey
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts; Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 02115 Boston, Massachusetts
| | - Amir Taghinia
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
| | - Oren Ganor
- Center for Gender Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Plastic and Oral Surgery, Boston Children's Hospital, 02115 Boston, Massachusetts; Department of Surgery, Harvard Medical School, 02115 Boston, Massachusetts
| |
Collapse
|
23
|
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
|
24
|
Feasibility, Safety, and Satisfaction of Combined Hysterectomy with Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18137133. [PMID: 34281069 PMCID: PMC8297260 DOI: 10.3390/ijerph18137133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/28/2021] [Accepted: 06/29/2021] [Indexed: 11/29/2022]
Abstract
The demand for masculinizing breast surgery and hysterectomy with bilateral salpingo-oophorectomy (HBSO) from transmen has increased. With a multidisciplinary approach, these surgeries can be performed in a single session. The objective of this study was to retrospectively evaluate the feasibility, safety, and satisfaction of HBSO and chest surgery in transmen. A cohort of 142 subjects who underwent HBSO alone or combined with chest surgery at Sant’Orsola Hospital was analyzed. Intra and post operation events were evaluated. Subjective post-intervention satisfaction, acceptability, and impact of intervention were assessed via a semi-structured interview. Nineteen transmen underwent HBSO alone and 123 underwent combined surgery. HBSO was performed laparoscopically in 96.5% of transmen (137/142). As expected, length of hospital stay and blood loss were significantly higher in the combined surgery group. A total of 13 intra or post-operative complications occurred in the combined surgery group (10.5%) with thoracic hematoma being the most frequent complication (7.6%). Only one rare complication occurred in the HBSO group (omental herniation through a laparoscopic breach). The overall subjective satisfaction score was 9.9 out of 10 for both groups. Positive changes in all areas of life were reported, with no significant differences. We found that the combined surgery appears to be well tolerated, safe, and feasible in transmen and satisfaction with the combined procedure was high in all subjects.
Collapse
|
25
|
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
|
26
|
Morgenstern SC, Sohn M. [Prosthetics after construction of the outer genitalia for transmen]. Urologe A 2021; 60:722-731. [PMID: 33938977 DOI: 10.1007/s00120-021-01532-6] [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] [Accepted: 04/08/2021] [Indexed: 11/30/2022]
Abstract
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.
Collapse
Affiliation(s)
- S C Morgenstern
- Sektion für rekonstruktive Urologie und geschlechtsangleichende Operationen, Klinik für Urologie und Klinik für roboterassistierte Urologie und Uroonkologie, AGAPLESION Markus-Krankenhaus Frankfurt, Wilhelm-Epstein-Str. 4, 60431, Frankfurt, Deutschland.
| | - M Sohn
- Sektion für rekonstruktive Urologie und geschlechtsangleichende Operationen, Klinik für Urologie und Klinik für roboterassistierte Urologie und Uroonkologie, AGAPLESION Markus-Krankenhaus Frankfurt, Wilhelm-Epstein-Str. 4, 60431, Frankfurt, Deutschland
| |
Collapse
|
27
|
Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging. Plast Reconstr Surg 2021; 147:801e-811e. [PMID: 33890903 DOI: 10.1097/prs.0000000000007898] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
SUMMARY The creation of a sensate, aesthetic, and functional phallus for transmasculine individuals has high reported complication rates. Neourethra reconstruction is the most challenging aspect of this surgery, with widely varying techniques and staging between providers. In an operation of this complexity, surgeons should not be expected to offer all the options, but rather the specific variation that works in their given setting. For some, it is single-stage phalloplasty with full-length urethroplasty. For others, staged phalloplasty with separation of perineal masculinization from phallus reconstruction works better. In this expert opinion article, the authors strive to give an overview of the principles behind, and a detailed explanation of, the technical details of creating the penile and bulbar urethra during phalloplasty. The authors focus on the three most common strategies: single-stage phalloplasty; two-stage phalloplasty with a metoidioplasty-first approach; and two-stage phalloplasty with a phalloplasty-first (Big Ben method) approach. It is not the authors' intent to establish the "best" or "only" way, but rather to compile different options with their respective pros and cons.
Collapse
|
28
|
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]
|
29
|
Neuville P, Carnicelli D, Paparel P, Ruffion A, Morel-Journel N. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021; 18:830-836. [PMID: 33741289 DOI: 10.1016/j.jsxm.2021.01.177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/23/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Metoidioplasty is a possibility for penis reconstruction in transmen that could be enhanced by a semi-rigid prosthesis support. AIM Describe the surgical technique of metoidioplasty with implantation of a specifically designed semi-rigid prosthesis -the ZSI100D4- and analyze preliminary results. METHODS Implantation of semi-rigid prosthesis was proposed to transmen who chose metoidioplasty for genital gender affirming surgery in a specialized university hospital. OUTCOMES Surgical outcomes were collected from medical files. Functional outcomes and satisfaction were collected post-operatively with a questionnaire. RESULTS A total of 15 patients were operated; the mean length of followup was 22 months (SD = 8.7). Median prosthesis size was 8.5 cm (range: 8.5-10). Seven (46.7%) minor complications (Clavien-Dindo grade 2; 5 wound dehiscence and 2 fistula, managed conservatively) and 1 severe (Clavien-Dindo grade 3b) complication (Hematoma that need surgical revision) occurred. Thirteen patients (86.6%) answered the questionnaire; 11 (84.6%) reported being either "very satisfied" or "satisfied" with the appearance of the new genitalia; 10 (76.9%) could void while standing; and 12 patients (92.3%) answered "not at all" to the question "do you have regrets about this surgery ?". CONCLUSION Implantation of a semi-rigid prosthesis in an enlarged clitoris seems to be a valuable option and can be proposed as another possibility for the complex surgical answer to neophallus reconstruction in transmen. Neuville P, Carnicelli D, Paparel P, et al. Metoidioplasty With Implantation of a Specific Semirigid Prosthesis. J Sex Med 2021;18:830-836.
Collapse
Affiliation(s)
- Paul Neuville
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France.
| | - Damien Carnicelli
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Philippe Paparel
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Alain Ruffion
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| | - Nicolas Morel-Journel
- Hospices Civils de Lyon, Hôpital Lyon Sud, Service d'urologie, Chemin du Grand Revoyet, 69310 Pierre-Benite, France
| |
Collapse
|
30
|
Akhavan AA, Sandhu S, Ndem I, Ogunleye AA. A review of gender affirmation surgery: What we know, and what we need to know. Surgery 2021; 170:336-340. [PMID: 33741180 DOI: 10.1016/j.surg.2021.02.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/02/2021] [Accepted: 02/05/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Gender-affirmation surgery is a rapidly growing field in plastic surgery, urologic surgery, and gynecologic surgery. These procedures offer significant benefit to patients in reducing gender dysphoria and improving well-being. However, the details of gender-affirmation surgery are less well-known to other surgical subspecialties and other medical subspecialties. The data behind gender-affirmation surgery are comparatively sparse, and due to the recency of the field, large gaps exist in the literature. METHODS PubMed searches were carried out specific to gender-affirming mastectomies, vaginoplasty, vulvaplasty, mastectomy, metoidioplasty, and phalloplasty. Combinations and variants of "gender affirming," "gender confirming," "transgender," and other variants were used to ensure broad capture. Historical articles were also reviewed. The data gathered were collated and summarized. RESULTS Gender-affirmation surgery is generally safe. Complication rates for gender-affirming mastectomy and breast augmentation are very low, and complication rates for genital surgeries are also reasonably low. Gender-affirmation surgery decreases rates of gender dysphoria, depression, and suicidality, and significantly improves quality-of-life measures. Data regarding facial gender-affirming surgery are limited. There are very few patient-reported outcome measures specific to gender-affirmation surgery. CONCLUSION Although the data behind male-to-female gender-affirming surgery are more robust, there are significant gaps in the literature with respect to female-to-male surgery, surgical complication rates for genital surgery, facial masculinization and feminization, and patient-reported outcomes. We therefore present recommendations for further study.
Collapse
Affiliation(s)
- Arya Andre Akhavan
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Shabaaz Sandhu
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Idorenyin Ndem
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC
| | - Adeyemi A Ogunleye
- Division of Plastic Surgery, University of North Carolina-Chapel Hill, Chapel Hill, NC.
| |
Collapse
|
31
|
Hassan O, Sun D, Jha P. Imaging in Gender Affirmation Surgery. Curr Urol Rep 2021; 22:14. [PMID: 33515366 PMCID: PMC7847456 DOI: 10.1007/s11934-020-01029-3] [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] [Accepted: 12/16/2020] [Indexed: 11/29/2022]
Abstract
Purpose of Review This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation. Recent Findings The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Summary Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.
Collapse
Affiliation(s)
- Omar Hassan
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA.
| | - Derek Sun
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| | - Priyanka Jha
- Department of Radiology, Abdominal Imaging and Ultrasound Section, University of California, San Francisco, 505 Parnassus Ave, box 0628, San Francisco, CA, 94143-0628, USA
| |
Collapse
|
32
|
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
|
33
|
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
|
34
|
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
|
35
|
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
|
36
|
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]
|
37
|
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
|