Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

Gender-affirming Clitoroplasty and Construction of the Clitoro-urethral Complex: An Anatomy Guided Selection of Two Techniques

OBJECTIVE

To present 2 clitoroplasty techniques-the preputial skin and urethral flap-and describe our rationale for using each technique to construct the clitoro-urethral complex in gender-affirming vaginoplasty.

METHODS

For uncircumcised patients or circumcised patients with greater than 2 cm of inner preputial skin and at least 8 cm of shaft skin proximal to the circumcision scar, we use the preputial skin clitoroplasty, a modification of the Ghent style clitoroplasty. The entire corona is used after medial glans and urethral mucosa is excised. The corona is brought together 1 cm from midline to create the visible ovoid clitoris; the remaining coronal tissue remains lateral to the clitoris for erogenous sensation as clitoral corpora. The clitoris is anchored to the proximal tunica, positioned at the level of the adductor longus tendon. The folded neurovascular bundle is fixed in the suprapubic area. The ventral urethral is spatulated and urethral flap approximated to the clitoris. Preputial skin is sutured proximally as tension allows. The clitoro-urethral complex is inset into an opening created in the penile skin flap. For patients with less skin, we use the urethral flap clitoroplasty. More corpus spongiosum is used, as the urethra creates the clitoral hood; this is described in the literature and attributed to Pierre Brassard. The clitoris is inset following a dorsal urethrotomy, with a small collar of preputial skin sewn to the spongiosum and urethral mucosa. The urethra is transected about 1 cm distally. The ventral urethra is then spatulated and the urethroplasty completed.

RESULTS

We prefer the preputial skin flap technique for its' greater coronal tissue volume for erogenous sensation and better esthetics, in our opinion. Circumcised patients should have at least 2 cm of skin distal to the circumcision scar. To avoid using skin graft for the introitus-a risk for introital stenosis-shaft skin proximal to the circumcision line should be at least 8 cm.

CONCLUSION

We present 2 technical options for clitoroplasty and construction of the clitoro-urethral complex in gender-affirming vaginoplasty.

Second-stage Scrotoplasty with Autologous Tissue Augmentation after Metoidioplasty

We present our technique for second-stage scrotoplasty with autologous tissue augmentation following gender-affirming metoidioplasty. This technique augments the scrotum while removing the upper labia majora and making the penis more visible and accessible. This procedure avoids the need for testicular prostheses and their potential for discomfort, displacement, extrusion, or infection. Our preliminary results show that the complication rate is low.

Incidence and Risk Factors for Postoperative Venous Thromboembolism After Gender Affirming Vaginoplasty: A Retrospective Analysis of a Large Insurance Claims Database

OBJECTIVES

To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty.

METHODS

We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities.

RESULTS

We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE.

CONCLUSION

In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

Management of Urologic Complications After Genital Gender-Affirming Surgery in Transgender and Nonbinary Patients

Transgender and nonbinary (TGNB) patients are a population with unique urologic needs that are often overlooked in urologic training. Most urology residents think that learning to take care of this population is important in their training; however, there is much variation in this educational content within urology residency programs. This review provides information on the current state of teaching regarding the unique needs of caring for TGNB patients as urologists and overviews some basic principles that every urologist should know.

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights

Background and Objective

Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy.

Methods

We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available.

Key Content and Findings

Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%.

Conclusions

Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.

"Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots"

BACKGROUND

Urologic complications in genital gender-affirming surgery (GGAS) are imperfectly measured, with existing evidence limited by "blind spots" which will not be resolved through implementation of patient-reported outcomes alone. Some blind spots are expected in a surgical field with rapidly expanding techniques, and may be exacerbated by factors related to transgender health.

METHODS

We provide a narrative review of systematic reviews published in the last decade to describe the current options for genital gender-affirming surgery and surgeon-reported complications, as well as contrasting peer-reviewed sources with data not reported by primary surgeon. In combination with expert opinion, these findings describe complication rates.

RESULTS

Eight systematic reviews describe complications in vaginoplasty patients, including 5%-16.3% mean incidence of meatal stenosis and 7%-14.3% mean incidence of vaginal stenosis. Compared to surgeon-reported cohorts, vaginoplasty and vulvoplasty patients in alternate settings report higher rates of voiding dysfunction (47%-66% vs 5.6%-33%), incontinence (23%-33% vs. 4%-19.3%) and misdirected urinary stream (33%-55% vs 9.5%-33%). Outcomes in six reviews of phalloplasty and metoidioplasty included urinary fistula (14%-25%), urethral stricture and/or meatal stenosis (8%-12.2%), and ability to stand to void (73%-99%). Higher rates of fistula (39.5%-56.4%) and stricture (31.8%-65.5%) were observed in alternate cohorts, along with previously unreported complications such as vaginal remnant requiring reoperation.

CONCLUSION

The extant literature does not completely describe urologic complications of GGAS. In addition to standardized, robustly validated patient-reported outcome measures, future research on surgeon-reported complications would benefit from using the IDEAL (Idea, Development, Exploration, Assessment, and Long-term Study) framework for surgical innovation.

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Skin Management During Robotic Peritoneal Flap Vaginoplasty for Penoscrotal Hypoplasia Secondary to Pubertal Suppression

OBJECTIVE

To demonstrate an approach to skin management in cases of gender-affirming vaginoplasty in the setting of penoscrotal hypoplasia. Gender-affirming penile inversion vaginoplasty is a procedure that has traditionally relied upon the use of local genital tissues to both construct the vulva and line the neovaginal canal. Improved and earlier access to pubertal suppression has resulted in an increasing number of individuals presenting for vaginoplasty with penoscrotal hypoplasia and significantly less skin available to accomplish the goals of vaginoplasty. Robotic-assisted gender-affirming peritoneal flap vaginoplasty is one solution that has emerged to help address the challenge of limited skin and provide an alternative source of neovaginal lining. Although this technique provides valuable peritoneal tissue that is used to line a large portion of the neovaginal canal, external vulvar construction remains a challenge. Amid a growing number of cases of penoscrotal hypoplasia secondary to pubertal suppression, there is a need for resources that illustrate strategies to deal with these challenging scenarios. In this video the authors demonstrate their approach to vulvar construction in the setting of penoscrotal hypoplasia secondary to pubertal suppression.

METHODS

This video demonstrates an approach to skin management during robotic peritoneal flap vaginoplasty in the setting of limited genital skin secondary to pubertal suppression at Tanner stage 2.

RESULTS

Penile inversion vaginoplasty typically relies upon the penile skin tube reaching and reconstructing the introitus, and forming the distal aspect of the neovaginal canal. However, in most cases of penoscrotal hypoplasia secondary to pubertal suppression, there will not be enough length of penile skin to reach or construct the introitus. In these cases, the inverted penile skin tube is also often also too narrow in caliber to accommodate passage of a dilator for neovaginal dilation. These clinical scenarios are challenging and often require construction of the introitus with skin graft, complete splitting of the ventral penile skin tube and optimization of remaining skin to form other critical vulvar structures (labia minora and clitoral hood).

CONCLUSION

As individuals with penoscrotal hypoplasia continue to present for gender-affirming vaginoplasty procedures, it is important to adjust traditional approaches to vulvar construction and optimize strategies to manage cases with limited genital skin. In this video the authors present their approach to skin management and vulvar construction in gender-affirming vaginoplasty with penoscrotal hypoplasia secondary to pubertal suppression.

Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US

Importance

Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level.

Objective

To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient's state of residence.

Design, Setting, and Participants

This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021.

Exposures

Vaginoplasty and phalloplasty.

Main Outcomes and Measures

The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models.

Results

The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence.

Conclusions and Relevance

In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.

Addressing urologic health disparities in sexual and gender minority communities through patient-centered outcomes research

Sexual and gender minority (SGM) communities face stigma and discrimination that impact all aspects of health. To better understand and improve their urologic health outcomes, we must study SGM patients as a distinct population and pursue research on outcomes identified as priorities to SGM communities. Patient-centered outcomes research (PCOR) is a methodology which is increasingly familiar to urologists and is crucial to adequately addressing SGM health in future urological research. We review existing literature focused on urologic outcomes of SGM populations and highlight specific PCOR initiatives built on SGM community engagement.

Erythrocytosis and thromboembolic events in transgender individuals receiving gender-affirming testosterone

Erythrocytosis is a well-recognized consequence of exogenous testosterone, however its prevalence and contributions to thrombosis remain unknown in the context of gender-affirming hormonal therapy. We undertook a retrospective study of transgender and non-binary (TGNB) adults receiving exogenous testosterone. In the retrospective sample, 923 transgender individuals receiving testosterone were identified with 519 having documented pre- and post-testosterone hemoglobin and hematocrit (Hgb/Hct). The mean peak Hgb/Hct was 15.7 g/dL, and 47.0%. Mean time-to-peak Hgb/Hct was 31.2 months; 7.8% developed a hemoglobin >17.5 g/dL, whereas 20% developed a hematocrit of >50%. Testosterone dose reduction occurred in 42% of patients with erythrocytosis and 4.8% underwent phlebotomy. Thromboembolic events occurred in 0.9%, of which 80% had developed erythrocytosis by either Hgb or Hct, including two cases each of superficial and calf vein thrombosis as well as one ischemic stroke. We then performed an analysis of 14,294,784 hospitalizations from the 2016-17 US National Inpatient Sample (NIS), which identified 4141 admissions involving transgender individuals. Of those, seven had erythrocytosis with one concurrent venous thromboembolic event. Hematocrit >50% occurs in up to 20% of transgender individuals receiving testosterone. Despite the high incidence of erythrocytosis, thromboembolic events and hospitalizations involving erythrocytosis were uncommon.

Clinical Outcomes of a Combined Robotic, Transabdominal, and Open Transperineal Approach for Anastomotic Posterior Urethroplasty

Background: Robotic pelvic surgery is being increasingly utilized for reconstruction proximal to the genitourinary diaphragm. We describe a combined robotic, transabdominal, and open transperineal approach for complex anastomotic posterior urethroplasty. Materials and Methods: We performed a multi-institutional retrospective study of patients who underwent anastomotic posterior urethroplasty by a combined robotic, transabdominal, and open transperineal approach between January 2012 and December 2018. Patient demographics; preoperative, intraoperative, and postoperative clinical data; and complications were reviewed. Urethroplasty success, de novo stress urinary incontinence (SUI), and de novo erectile dysfunction (ED) were evaluated. Results: Twelve patients were identified with a mean follow-up of 596 (range 73-1618) days. Mean patient age was 65.9 (range 53.4-76.8). Reconstruction required corporal splitting, prostatectomy, and gracilis muscle flap use in one (8.3%), eight (66.7%), and four (33.3%) patients, respectively. Postoperative urinary leak, thromboembolic event, and wound abscess occurred in one (8.3%), one (8.3%), and two (16.7%) patients, respectively. Stenosis recurrence occurred in two patients (16.7%) at a mean 187.5 (20-355) postoperative days. De novo ED and de novo SUI were reported in two (16.7%) and four (33.3%) patients, respectively. Nine patients (75.0%) underwent placement of an artificial urinary sphincter at a mean interval of 359.2 (111-1456) days after the index procedure, with no subsequent erosion. Conclusions: Complex posterior urethroplasty by a combined robotic, transabdominal and open transperineal approach is associated with success and complications rates that are comparable to open techniques and may allow for adjunctive procedures such as prostatectomy. This technique allows for the reconstruction of posterior urethral stenoses that would otherwise have been managed conservatively or with urinary diversion.

Robotic Peritoneal Flap Revision of Gender Affirming Vaginoplasty: a Novel Technique for Treating Neovaginal Stenosis

OBJECTIVES

To present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization.

METHODS

Twenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017 to 2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications.

RESULTS

Mean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis.

CONCLUSIONS

Robotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.

Metoidioplasty With Urethral Lengthening: A Stepwise Approach

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Outcomes of Gender Affirming Peritoneal Flap Vaginoplasty Using the Da Vinci Single Port Versus Xi Robotic Systems

BACKGROUND

Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved.

OBJECTIVE

To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems.

DESIGN, SETTING, AND PARTICIPANTS

A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up.

SURGICAL PROCEDURE

Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex.

MEASUREMENTS

Demographics, perioperative data, and clinical outcomes were evaluated.

RESULTS AND LIMITATIONS

A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%).

CONCLUSIONS

RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches.

PATIENT SUMMARY

We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.

Ureteral Reimplantation via Robotic Nontransecting Side-to-Side Anastomosis for Distal Ureteral Stricture

Objective: To describe a novel technique of ureteral reimplantation through robotic nontransecting side-to-side anastomosis. Although the standard approach to ureteroneocystostomy has a high rate of success, it involves transection of the ureter that may impair vascularity and contribute to recurrent strictures. Our method seeks to maximally preserve distal ureteral blood flow that may reduce this risk. Materials and Methods: We retrospectively reviewed a multi-institutional ureteral reconstruction database to identify patients who underwent this operation between 2014 and 2018, analyzing perioperative and postoperative outcomes. Results: Our technique was utilized in 16 patients across three U.S. academic institutions. Median operative time and estimated blood loss were 178 minutes (interquartile range [IQR] 150-204) and 50 mL (IQR 38-100), respectively. The median length of stay was 1 day (IQR 1-2). No intraoperative complications or postoperative complications with Clavien score ≥3 were reported. Postoperatively, 15 of 16 (93.8%) patients reported clinical improvement in flank pain, and all patients who underwent follow-up imaging had radiographic improvement with decrease in hydronephrosis at a median follow-up of 12.5 months. Conclusions: Ureteral reimplantation through a robotic nontransecting side-to-side anastomosis is a feasible and effective operation for distal ureteral stricture that may have advantages over the standard of care transecting ureteroneocystostomy.

The development and comparative effectiveness of a patient-centered prostate biopsy report: a prospective, randomized study

PURPOSE

The prostate biopsy pathology report represents a critical document used for decision-making in patients diagnosed with prostate cancer, yet the content exceeds the health literacy of most patients. We sought to create and compare the effectiveness of a patient-centered prostate biopsy report compared with standard reports.

MATERIALS AND METHODS

Using a modified Delphi approach, prostate cancer experts identified critical components of a prostate biopsy report. Patient focus groups provided input for syntax and formatting of patient-centered pathology reports. Ninety-four patients with recent prostate biopsies were block randomized to the standard report with or without the patient-centered report. We evaluated patient activation, self-efficacy, provider communication skills, and prostate cancer knowledge.

RESULTS

Experts selected primary and secondary Gleason score and the number of positive scores as the most important elements of the report. Patients prioritized a narrative design, non-threatening language and information on risk classification. Initial assessments were completed by 87% (40/46) in the standard report group and 81% (39/48) in the patient-centered report group. There were no differences in patient activation, self-efficacy, or provider communication skills between groups. Patients who received the patient-centered report had significantly improved ability to recall their Gleason score (100% vs. 85%, p = 0.026) and number of positive cores (90% vs. 65%, p = 0.014). In total, 86% of patients who received the patient-centered report felt that it helped them better understand their results and should always be provided.

CONCLUSIONS

Patient-centered pathology reports are associated with significantly higher knowledge about a prostate cancer diagnosis. These important health information documents may improve patient-provider communication and help facilitate shared decision-making among patients diagnosed with prostate cancer.

Robotic Excision of Vaginal Remnant/Urethral Diverticulum for Relief of Urinary Symptoms Following Phalloplasty in Transgender Men

OBJECTIVE

To describe the technique of robotic remnant vaginectomy/excision of urethral diverticulum in transmen and report postoperative outcomes.

MATERIALS AND METHODS

Between 2015 and 2018, 4 patients underwent robotic remnant vaginectomy/excision of urethral diverticulum for relief of urinary symptoms. Patients were of mean age 36 ± 10.1 years (range 26-50) at time of vaginal remnant excision, and were 26 ± 9.1 months (range 20-39) post-op following their primary vaginectomy and radial forearm free flap (n = 3) or anterolateral thigh (n = 1) phalloplasty. All had multiple urologic complications after primary phalloplasty, most commonly urinary retention (n = 4), urethral stricture (n = 3), fistula (n = 3), dribbling (n = 2), and obstruction (n = 2). Indication for revision was obstruction and retention (n =3 ) and/or dribbling (n = 2). In each case, the robotic transabdominal dissection freed remnant vaginal tissue from the adjacent bladder and rectum without injury to these structures. Concurrent first- or second-stage urethroplasty was performed in all cases at a more distal portion of the urethra using buccal mucosa, vaginal, or skin grafts. Intraoperative cystoscopy was used in each case to confirm complete resection and closure of the diverticulum.

RESULTS

At mean follow-up of 294 ± 125.6 days (range 106-412), no patients had persistence or recurrence of vaginal cavity/urethral diverticulum on cystoscopic follow-up. Of 3 patients who wished to ultimately stand to void, 2 were able to do so at follow-up.

CONCLUSION

Robotic transabdominal approach to remnant vaginectomy/excision of urethral diverticulum allows for excision without opening the perineal closure for management of symptomatic remnant/diverticulum in transgender men after vaginectomy.

Demographic and temporal trends in transgender identities and gender confirming surgery

Transgender and gender non-binary (TGNB) individuals are a growing demographic with unique healthcare needs. Amid changes in public and private insurance coverage of gender confirming surgeries (GCS), utilization of these procedures is increasing. Meanwhile, systemic barriers continue to limit access to gender confirming care and perpetuate health disparities among TGNB individuals. Studies on the prevalence of TGNB identities and utilization of GCS are limited by a lack of gender identity data in population-based surveys and electronic medical records. However, data collection on gender identity is improving, and will be essential for characterizing the healthcare practices and needs of TGNB individuals.

Patient reported outcome measures and quality of life assessment in genital gender confirming surgery

Transgender and gender nonbinary (TGNB) individuals may seek genital gender confirming surgery (GCS) as part of their transition. Outcomes of genital GCS may include gender congruence, sexual functioning and satisfaction, urinary symptoms, aesthetic satisfaction, and overall quality of life, among others. Despite a wide number of studies on results of vaginoplasty, metoidioplasty, phalloplasty, and other genital GCS, data regarding patient reported outcomes are limited. To date, there is no patient reported outcome measure (PROM) validated within the TGNB population to assess subjective outcomes of GCS. In this review, we aim to describe existing tools being utilized to report outcomes following GCS, assessing the merits and limitations of each.

Neonatal Circumcision and Urinary Tract Infections in Infants With Hydronephrosis

BACKGROUND

Boys with urinary tract abnormalities may derive a greater benefit from newborn circumcision for prevention of urinary tract infection (UTI) than the general population. However, the effect of newborn circumcision on UTI is not well characterized across the etiological spectrum of hydronephrosis. We hypothesized that boys with an early diagnosis of hydronephrosis who undergo newborn circumcision will have reduced rates of UTI.

METHODS

The MarketScan data set, an employer-based claims database, was used to identify boys with hydronephrosis or hydronephrosis-related diagnoses within the first 30 days of life. The primary outcome was the rate of UTIs within the first year of life, comparing circumcised boys with uncircumcised boys and adjusting for region, insurance type, year of birth, and infant comorbidity.

RESULTS

A total of 5561 boys met inclusion criteria, including 2386 (42.9%) undergoing newborn circumcision and 3175 (57.1%) uncircumcised boys. On multivariate analysis, circumcision was associated with a decreased risk of UTI in both boys with hydronephrosis and healthy cohorts: odds ratio (OR) 0.36 (95% confidence interval [CI] 0.29-0.44) and OR 0.32 (95% CI 0.21-0.48), respectively. To prevent 1 UTI, 10 patients with hydronephrosis would have to undergo circumcision compared with 83 healthy boys. Among specific hydronephrosis diagnoses, circumcision was associated with a reduced risk of UTI for those with isolated hydronephrosis (OR 0.35 [95% CI 0.26-0.46]), vesicoureteral reflux (OR 0.35 [95% CI 0.23-0.54]), and ureteropelvic junction obstruction (OR 0.35 [95% CI 0.20-0.61]).

CONCLUSIONS

Newborn circumcision is associated with a significantly lower rate of UTI among infant boys with hydronephrosis.

Comparative effectiveness of a pilot patient-centered ultrasound report in the management of hydronephrosis

PURPOSE

Hydronephrosis is a common pediatric abnormality and can be associated with substantial parental anxiety, especially in the prenatal period. Radiology reports contain complex content that can be difficult for lay audiences to comprehend, potentially contributing to parental distress.

MATERIALS AND METHODS

We developed and piloted a patient-centered radiology report (PCRR) for renal ultrasounds (US) in children with hydronephrosis (Figure). We obtained consensus from a multidisciplinary panel of experts regarding critical US report components. A parent focus group provided input regarding syntax and formatting of a PCRR, incorporating elements deemed valuable by the expert panel. We prospectively recruited parents of children who underwent US for hydronephrosis and randomized parents to receive either the PCRR + standard report (SR) or SR alone. Web-based surveys assessed self-efficacy and knowledge of US elements.

RESULTS

Our pilot study included 20 SR patients and 24 PCRR patients, with no difference in demographic or disease characteristics between groups. Self-efficacy scores were uniformly high in both groups (p = 0.79). PCRR parents trended towards increased accuracy in identifying presence of severity (88% vs. 70%; p = 0.15) and bilaterality (67% vs. 45%; p = 0.15), with minimal difference in identifying parenchymal pathology (75% vs. 70%; p = 0.71) and bladder abnormalities (88% vs. 85%; p = 0.81). Parents were more confident in their ability to understand the PCRR (92% vs. 60%; p = 0.01).

CONCLUSIONS

A PCRR was associated with significantly higher confidence in US report interpretation, but was underpowered to demonstrate increased accuracy in identifying US findings. These findings justify future studies of PCRRs for hydronephrosis care.

Variable Resource Utilization in the Prenatal and Postnatal Management of Isolated Hydronephrosis

OBJECTIVE

To characterize contemporary resource utilization and medical outcomes for infants with antenatal hydronephrosis and their mothers from a national claims database. We hypothesize that management of isolated hydronephrosis (IHN) varies widely, with decreased imaging following the 2010 Society for Fetal Urology Consensus Statement.

MATERIALS AND METHODS

Using MarketScan claims from 2007 to 2013, we identified infants 0-12 months of age with hydronephrosis and linked mothers. Those with urologic diagnoses more specific than hydronephrosis, additional urologic comorbidities, or postnatal surgeries were excluded. Resource utilization including prenatal and postnatal imaging, laboratory studies, hospital admissions, and medical outcomes within the first year was captured. Demographics, maternal characteristics, utilization measures, and outcomes were compared across imaging intensity groups based on number of postnatal ultrasounds received using bivariate analysis.

RESULTS

Among 801,919 mother-child pairs, 8610 infants (1.1%) had hydronephrosis or a related diagnosis. A total of 5876 (68.2%) met inclusion criteria for IHN. Patients underwent a mean 5.3 ± 3.5 prenatal and 2.1 ± 1.3 postnatal ultrasounds before age 1. Imaging practices were unchanged following the Society for Fetal Urology consensus statement.

CONCLUSION

Antenatal hydronephrosis prevalence in an insured population is consistent with published ranges. Prenatal imaging in IHN is variable and potentially excessive. Future study into the efficacy of evidence-based pathways in reducing excess utilization is warranted.

Transgender-Related Education in Plastic Surgery and Urology Residency Programs

BACKGROUND

With increasing public awareness of and greater coverage for gender-confirming surgery by insurers, more transgender patients are likely to seek surgical transition. The degree to which plastic surgery and urology trainees are prepared to treat transgender patients is unknown.

OBJECTIVE

We assessed the number of hours dedicated to transgender-oriented education in plastic surgery and urology residencies, and the impact of program director (PD) attitudes on provision of such training.

METHODS

PDs of all Accreditation Council for Graduate Medical Education-accredited plastic surgery (91) and urology (128) programs were invited to participate. Surveys were completed between November 2015 and March 2016; responses were collected and analyzed.

RESULTS

In total, 154 PDs (70%) responded, and 145 (66%) completed the survey, reporting a yearly median of 1 didactic hour and 2 clinical hours of transgender content. Eighteen percent (13 of 71) of plastic surgery and 42% (31 of 74) of urology programs offered no didactic education, and 34% (24 of 71) and 30% (22 of 74) provided no clinical exposure, respectively. PDs of programs located in the southern United States were more likely to rate transgender education as unimportant or neutral (23 of 37 [62%] versus 39 of 105 [37%]; P = .017). PDs who rated transgender education as important provided more hours of didactic content (median, 1 versus 0.75 hours; P = .001) and clinical content (median, 5 versus 0 hours; P < .001).

CONCLUSIONS

A substantial proportion of plastic surgery and urology residencies provide no education on transgender health topics, and those that do, provide variable content. PD attitudes toward transgender-specific education appear to influence provision of training.

National Trends in Secondary Procedures Following Pediatric Pyeloplasty

PURPOSE

Although reported success rates after pediatric pyeloplasty to correct ureteropelvic junction are high, failure may require intervention. We sought to characterize the incidence and timing of secondary procedures after pediatric pyeloplasty using a national employer based insurance database.

MATERIALS AND METHODS

Using the MarketScan® database we identified patients 0 to 18 years old who underwent pyeloplasty from 2007 to 2013 with greater than 3 months of postoperative enrollment. Secondary procedures following the index pyeloplasty were identified by CPT codes and classified as stent/drain, endoscopic, pyeloplasty, nephrectomy or transplant. The risk of undergoing a secondary procedure was ascertained using Cox proportional hazards models adjusting for demographic and clinical characteristics.

RESULTS

We identified 1,976 patients with a mean ± SD followup of 23.9 ± 19.8 months. Overall 226 children (11.4%) had undergone at least 1 post-pyeloplasty procedure. The first procedure was done within 1 year in 87.2% of patients with a mean postoperative interval of 5.9 ± 11.1 months. Stents/drains, endoscopic procedures and pyeloplasties were noted in 116 (5.9%), 34 (1.7%) and 71 patients (3.1%), respectively. Length of stay was associated with undergoing a secondary procedure. Compared with 2 days or less the HR of 3 to 5 and 6 days or greater was 1.65 and 3.94 (p = 0.001 and <0.001, respectively).

CONCLUSIONS

Following pediatric pyeloplasty 1 of 9 patients undergoes at least 1 secondary procedure with the majority performed within the first year. One of 11 patients undergoes intervention more extensive than placement of a single stent or drain, requiring management strategies that generally signify recurrent or persistent obstruction. Estimates of pyeloplasty success in this national data set are lower than in other published series.

Successful pregnancy in patients with exstrophy-epispadias complex: A University of Washington experience

INTRODUCTION

With advances in genitourinary reconstructive surgery, women with exstrophy-epispadias complex (EEC) have improved health and quality of life, and may reach reproductive age and consider pregnancy. Despite literature suggesting impaired fertility and higher risk with pregnancy, childbirth is possible. Medical comorbidities, including müllerian anomalies, contribute to increased risk of obstetric and urologic complications during pregnancy.

OBJECTIVES

We reviewed our experience with EEC patients who achieved pregnancy to investigate (1) urological characteristics of women who achieved pregnancy; (2) pregnancy management, complications, and delivery; and (3) neonatal outcomes. We developed recommendations for managing pregnancy in women with EEC.

STUDY DESIGN/RESULTS

This was a retrospective chart review of 36 female patients with EEC seen at our institution between 1996 and 2013. Female patients less than 18 years, and patients who did not have documented pregnancy were excluded. This resulted in a total of 12 patients with 22 pregnancies. All women with successful pregnancy had bladder exstrophy. The majority had undergone prior bladder augmentation (75%) and were on self-catheterization programs (92%). Thirty-six percent had symptomatic urinary tract infections (UTIs) during pregnancy. Five women had more than one pregnancy. There were four terminations of pregnancy. Of 18 desired pregnancies, there were four spontaneous abortions (SABs) (22%) and 16 live births (78%). The cesarean delivery (CD) rate was 100% (14/14), of which the majority were vertical (classical) uterine incisions with a paramedian skin incision. With the exception of one patient, there were no CD surgical complications. The mean gestational age at delivery was 36 weeks (Range 25 4/7 to 39 4/7 weeks) among eight pregnancies with known gestational age. There were no stillbirths, one neonatal death and no birth defects.

DISCUSSION

Women with EEC can have successful pregnancies, though at increased risk for preterm delivery and SABs. In our cohort, the rate of SAB is similar to that described in prior studies. Symptomatic UTIs likely due to self-catheterization were common. Cesarean delivery using a paramedian skin incision and classical uterine incision were not associated with major complications in this cohort. Limitations include reliance on retrospective data and small sample size. The strength of this study is the longitudinal detailed management of pregnancies in EEC women by a single team over time. A multidisciplinary approach to providing a continuum of care from pediatrics through adolescence to adulthood optimizes successful transitions, reproductive health, and successful pregnancies. Based on our experience, an algorithm providing guidance for pregnancy management was developed.

Impact of graft position on failure of single-stage bulbar urethroplasties with buccal mucosa graft

OBJECTIVE

To determine whether patency rates after bulbar urethroplasty with buccal mucosa graft onlay differ on the basis of whether the graft is placed ventrally or dorsally.

METHODS

This was a retrospective single-center study of all single-stage bulbar urethroplasties performed from 2001 to 2011 by 2 surgeons in which buccal mucosa was used as an onlay graft. Failure was defined as the need for endoscopic or open revision of the reconstruction or the placement of a suprapubic catheter for urinary retention.

RESULTS

A total of 103 patients were reviewed; 41 underwent dorsal onlay, and 62 underwent ventral onlay. Mean age was 40.8 years. Most patients (84%) underwent a previous procedure, which consisted of direct vision internal urethrotomy in 69%, dilation in 53%, and urethroplasty in 14%. Mean stricture length was 3.9 cm. At a mean follow-up of 36 months, failure occurred in 19 patients (12 ventral and 7 dorsal). The vast majority of these patients (79%) were successfully treated with a single dilation or direct vision internal urethrotomy. There was no difference in failure rate or time to failure according to whether graft position was ventral or dorsal. In multivariate analysis, diabetes was predictive of failure (odds ratio 8.7; 95% confidence interval 1.6-46.5; P = .01).

CONCLUSION

Single-stage bulbar urethroplasty with buccal mucosa graft is an effective procedure for patients with a bulbar urethral stricture that is not amenable to primary anastomosis. From our experience, we cannot conclude that dorsal or ventral graft position is inherently superior. Patients with diabetes may be more likely to require additional procedures after bulbar urethroplasty with buccal grafting.

Detection and management of pediatric conditions that may affect male fertility

Conditions affecting male fertility may be detected in childhood. Affected children and adolescents and their parents are often anxious and concerned when infertility is discussed. Urology nurses and midlevel providers play a key role in the education and counseling of the patient and family An awareness of the more common conditions, including presentation, evaluation, and management, is critical.