Perioperative risk predictors for gender affirming surgery in the NSQIP database

INTRODUCTION

Gender affirming surgeries (GAS), such as phalloplasty (PLPs) and vaginoplasty (VGPs), are important aspects of medical care for transgender patients. Here, we aim to better characterize patient demographics and surgical outcomes for PLPs and VGPs using the National Surgical Quality Improvement Program (NSQIP). We hypothesized that frailty indices would be predictive of perioperative PLP and VGP risk and outcomes for PLPs and VGPs.

MATERIALS AND METHODS

Primary GAS, specifically PLPs and VGPs performed from 2006-2020 were identified in NSQIP. Baseline frailty was based on NSQIP's modified frailty index (mFI) and preoperative morbidity probability (morbprob) variable.

RESULTS

Fifty-eight PLPs and 468 VGPs were identified. The overall 30-day complication rate for PLP was 26%, with 17% of total patients experiencing minor complications and 16% experiencing major complications. The overall, minor, and major complication rates for VGP were 14%, 7%, and 9% respectively. Readmissions and reoperations occurred in 7% PLP and 5% VGP patients. No deaths occurred in either group within 30 days. The mFI scores were not predictive of 30-day complications or LOS. NSQIP morbprob was predictive of 30-day complications for both PLP (OR 4.0, 95% CI 1.08-19.59, p = 0.038) and VGP (OR 2.39, 95% CI 1.46-3.97, p = 0.0005). NSQIP's morbprob was also predictive of extended LOS for PLP patients (6.3 ± 1.3 days, p = 0.03).

CONCLUSIONS

This study describes patient characteristics and complication rates of PLPs and VGPs. The NSQIP preoperative morbprob is an effective predictor of surgical complications and is better than the mFI.

Quantifying Nipple-Areolar Complex Shape and Location After Transmasculine Top Surgery: A Study of Postoperative Photographs Posted on Social Media and Surgeons' Professional Websites

Purpose

The transgender community utilizes online platforms to view and share postoperative masculinizing top surgery photographs. However, the quantitative and qualitative nature of these photographs is unknown. We aimed to conduct an analysis of postoperative online photographs for nipple-areolar complex (NAC) shape and location, and compare social media platforms to World Professional Association for Transgender Health (WPATH) surgeons' websites and published cis-male chest proportions.

Methods

In a cross-sectional analysis (April to May 2019), social media (Instagram and Reddit) and WPATH surgeon website postoperative top surgery photographs were analyzed. Areola height (AH):areola width (AW), NAC horizontal (inter-nipple distance [IND]:chest width [CW]) and vertical placement (sternal notch to nipple line [SN-NL]:sternal notch to umbilicus [SN-U]), and vertical scar placement (sternal notch to scar line [SN-SL]:SN-U) ratios were assessed on MATLAB. Data were compared to published cis-male proportions. Photograph skin color, soft tissue redundancy, and scar location were also analyzed.

Results

We analyzed 304 social media and 192 surgeons' website photographs qualitatively, and 139 social media and 189 surgeons' photographs quantitatively. Means (standard deviation) for postoperative photographs were AH:AW 1.12±0.24, IND:CW 0.68±0.07, SN-NL:SN-U 0.37±0.06. Most ratios significantly differed from published cis-male ratios (p<0.001). Photographs from WPATH surgeons' websites differed from social media platforms in SN-NL:SN-U and SN-SL:SN-U (p<0.001), and in scar location and soft tissue redundancy (p=0.012).

Conclusion

Postoperative top surgery photographs on online platforms showed more vertically oval, caudally positioned, and in many cases wider-spaced NACs than cis-male proportions. Our study highlights variability in results of masculinizing top surgery as it relates to an emerging source of information; online photographs.

Shallow-depth vaginoplasty: preoperative goals, postoperative satisfaction, and why shallow-depth vaginoplasty should be offered as a standard feminizing genital gender-affirming surgery option

BACKGROUND

Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV), or vaginoplasty with creation of a vaginal canal. SDV is associated with fewer short- and long-term risks and shorter recovery, and does not require a lifelong commitment to vaginal dilation and douching.

AIM

To describe a surgical technique for SDV that creates a dimpled introitus, together with clinical outcomes, decision-making prioritization, and satisfaction data. We hypothesize that SDV patients prioritize comparable appearance and sexual function to FDV over shorter-term risk factors, and experience high satisfaction.

METHODS

We describe (1) a surgical technique for SDV; (2) the proportion of patients who underwent SDV vs. FDV, with SDV complication rates; and (3) the results of an anonymous, electronic questionnaire administered via Qualtrics that assessed SDV patient demographics, terminology preferences, prioritization of decision-guiding factors for choosing SDV over FDV, and postoperative satisfaction across various domains.

OUTCOMES

A total of 110 patients underwent primary feminizing genital gender-affirming surgery at a single institution between April 2017 and July 2022: 35 (32%) of 110 underwent SDV and 75 (68%) underwent FDV. The 35 SDV patients were invited to answer the study questionnaire, of which 29 (83%) completed it (mean age 51.9 ± 16.7 years, mean body mass index 27.3 ± 5.3 kg/m2).

RESULTS

All but one survey respondent met one or more of the following characteristics: (1) ≥40 years of age, (2) exclusively feminine-identifying sexual partners, and/or (3) significant aversion to performing long-term vaginal dilation and douching. Ranking of 8 decision-guiding factors revealed prioritization of long-term over short-term outcomes. Postoperatively, patients reported high satisfaction across all 3 domains. When asked if they had to choose between SDV and FDV over again, 86% reported that they would choose SDV. While 14% would choose FDV, all but one reported new interest in receptive vaginal intercourse due to finding masculine-identifying partners post-SDV surgery. A total of 27% of SDV patients experienced complications that required additional surgeries; 82% of complications were related to urinary spraying.

CLINICAL IMPLICATIONS

SDV is a lower-risk alternative to FDV and is associated with reduced postoperative maintenance and high postoperative satisfaction.

STRENGTHS AND LIMITATIONS

This study describes the clinical outcomes of the largest documented cohort of patients to undergo SDV to date. Limitations include recall bias due to the retrospective survey and use of nonvalidated questions attributed to the paucity of validated gender-affirming surgery questionnaires.

CONCLUSION

SDV's appeal to a large subset of patients (32% in this study), low complication rate, high satisfaction, and low decisional regret suggests that this surgical option should be offered to all patients seeking feminizing genital gender-affirming surgery.

Bilateral Urinary Stones in a Transgender Woman: A Case Report in Lebanon

This case report presents a 38-year-old transgender woman, assigned male at birth, who presented with severe right flank pain associated with nausea and hematuria. After previously undergoing gender-affirming surgeries, including abdominoplasty, liposuction, breast augmentation, and reconstructive vaginal surgery, the patient developed bilateral ureteral and kidney stones leading to significant hydronephrosis. Bilateral double J insertion was performed following a computed tomography (CT) Uroscan. This was followed by flexible ureteroscopy and laser fragmentation of the stone bilaterally. The patient's anatomy was remarkable for the presence of neovagina and prostate. This case highlights the unique challenges and considerations in managing genitourinary complications in transgender individuals. The literature is limited in the Middle East concerning transgender individuals, hence the need to conduct further research and compile comprehensive case reports on transgender individuals in the Middle East in order to establish a robust database and draw meaningful epidemiological conclusions.

A pilot study of inflatable penile prosthesis placement in transgender neophallus using Tutoplast® pericardium graft sock technique

Placement of an inflatable penile prosthesis (IPP) in a transgender patient's neophallus carries unique considerations versus cis-gender IPP placement in mitigating infection, erosion, and overall complication rates. An example of this includes the lack of an anatomical corpus cavernosum and crura for cylinder placement and anchoring. Multiple grafting approaches and materials have been utilized to mitigate possible cylinder instability and improve anchoring. Here we describe our experience and surgical technique in IPP neophallus placement utilizing a single cylinder with distal and proximal cylinder human cadaver pericardium (Tutoplast®, IOP Ophthalmics, Costa Mesa, CA, USA) grafts. Our goals were to determine postoperative satisfaction and device functionality in patients undergoing transgender neophallus IPP placement using our technique. Both patients report satisfaction and no complications at last follow-up (currently up to 14 and 23 months post-operatively, respectively) with satisfactory erectile function and ability to perform penetrative intercourse. In neophallus IPP placement, the anatomical differences compared to cis-gender IPP operations require unique considerations such as cylinder grafting material selection for proximal cylinder fixation and mitigation of device erosion rates. Optimization of grafting material in neophallus IPP placement in an effort to reduce erosion rates has become increasingly important as frequency of this operation increases. Utilizing human cadaver pericardium graft in distal and proximal cylinder coverage shows beneficial preliminary outcomes in our patients.

Occupational Therapy's Role for Gender Affirming Surgeries: Vaginoplasty and Vulvoplasty

This article explores the new surgical population of gender affirming surgery, specifically vaginal surgeries for transgender and gender diverse people. There are established perioperative rehabilitation guidelines for nearly all other surgeries. A growing population of people is seeking gender affirming healthcare which includes vaginal surgery. This article reviews the guidelines set forth by the World Professional Association for Transgender Health Standards of Care (Version 8), explores the occupational needs of this population, as well as provides suggestions for future versions of official documents of the American Occupational Therapy Association to provide more inclusive language for the unique needs of this population following surgery.

Robotics in Gender Affirming Surgery: Current Applications and Future Directions

Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.

Transgender and Alagille Syndrome: A Rare Case of a Trans Woman with Alagille Syndrome

Alagille syndrome is a rare autosomal dominant disorder with variable expression. Liver damage, especially cholestatic, is the most common feature of the syndrome. Transgender patients may suffer from a great distress due to the discrepancy between assigned sex at birth and unaffirmed gender identity. Gender affirmation treatment options for these patients include hormone therapy (HT) to induce secondary sexual characteristics and various surgical procedures. Estrogen-based hormonal treatments have been linked to an increased risk of liver enzyme elevation and disruption of bilirubin metabolism, especially in those with a genetic susceptibility. The case presented here is the first described Alagille syndrome transgender patient to undergo gender affirmation treatment, including (HT) and vulvo-vaginoplasty surgery.

Genital Gender Affirming Surgery

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.

Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women

BACKGROUND

Penile inversion vaginoplasty still remains the gold standard in genital gender affirming surgeries in transwomen. However, insufficiency of the penile skin due to either radical circumcision or puberty blockers presents great challenge in vaginal reconstruction.¹ Peritoneal pull-through vaginoplasty is well known technique for the treatment of vaginal absence in cis-woman due to vaginal agenesis or trauma.² OBJECTIVE: We describe our laparoscopy assisted technique of using peritoneal flaps for neovaginal construction in male to female gender affirming surgery METHODS: In period from March 2016 to June 2021, 52 transwomen, aged from 19 to 52 years (mean 27) underwent laparoscopy assisted peritoneal pull-through vaginoplasty. Indications were genital skin insufficiency (radical circumcision in 16, scrotal skin insufficiency in 3 and lichen sclerosis in 3 cases) and prepubertal blockers in 22 and 17 cases, respectively. In remaining 13 candidates, peritoneal pull-through vaginoplasty was preferable method of choice. Two peritoneal flaps are harvested from posterior bladder wall and anterior rectosigmoid peritoneum, using laparoscopy approach. Vaginal channel is created by combined perineal and laparoscopy approaches. Good vascularized peritoneal flaps are maximally mobilized and pulled-through to be joined with inverted penile skin. Peritoneal flaps are joined laterally to create neovagina. Gender affirming surgery is completed with reconstruction of external female genitalia, clitoris, labia minora and majora, and urethra. Vaginal packing is placed for 7 days postoperatively and followed by proper vaginal dilation for the first 12 months postoperatively.

RESULTS

Follow-up ranged from 6 to 69 months (mean 29 months). Complications occurred in 7 cases: 3 had prolonged hematoma of the labia majora, one had neovaginal introitus dehiscence and one had superficial necrosis of the left labia majora. None of the complications required additional surgeries. The depth of the neovagina at the control check-up in 6 months after surgery was 14.7 ± 0.5cm, while width was about 3.4 ± 0.4cm. Majority of patients (≈96%) were satisfied with the new genitalia, sensitivity, lubrication and possibility of engaging in sexual intercourse according to self-reports. One patient required reduction of the size of her clitoris because of hypersensitivity and the other one requested laser treatment of the incisional scars.

CONCLUSIONS

Although known for quite a long time in vaginal reconstruction for cis-women with vaginal agenesis and different forms of vaginal absence, peritoneal pull-through vaginoplasty offers promising outcomes in transgender women, as an option that will give self-lubricating neovagina, with insignificant scarring and complications and high degree of patient's satisfaction.

Recognizing Racial Disparities in Postoperative Outcomes of Gender Affirming Surgery

Purpose: Given the increasing frequency with which gender affirming surgery (GAS) is performed, understanding risk factors for poor outcomes is imperative. Recent investigations highlight inferior health outcomes experienced by Black transgender and gender expansive (TGE) individuals. Herein, we evaluate the relationship between race and postoperative outcomes in TGE patients undergoing GAS, utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Methods: We conducted a retrospective review of ACS NSQIP from 2010 to 2018. Patients with a primary diagnosis of gender dysphoria undergoing GAS were identified and grouped by race. Patient characteristics and 30-day postoperative outcomes were recorded. Univariate analysis was used to compare patient characteristics and postoperative outcomes across groups. Multivariate logistic regression was used to determine independent predictors of complications. Results: We included 2308 patients (1780 White, 419 Black, 109 Asian). Gender, body mass index, smoking status, and type of surgery performed differed significantly between groups (p < 0.001). Univariate analysis revealed significant differences in 30-day readmission and organ space surgical site infection (SSI) across groups (p = 0.03). Multivariate logistic regression, adjusted for confounders, revealed that Black patients had higher odds of reoperation (odds ratio [OR] 1.82, p = 0.047), 30-day readmission (OR 2.46, p = 0.003), and organ space SSI (OR 4.65, p = 0.024) than White patients. Conclusion: We found that race was an independent predictor of important short-term postoperative outcomes in GAS. Inclusive clinical research, effective engagement with the TGE community, and surgery-specific enhanced recovery after surgery protocols may help address disparities, but we must acknowledge race as a social determinant of health.

Sexual Function of Transgender Women After Gender Affirming Surgery: A Mini Review

BACKGROUND

A transgender person has a gender identity opposite to the sex assigned at birth. Transgender individuals may have altered sexual function (SF) due to psychosocial factors related to body image distortion, shame, and dissatisfaction with genital appearance, and these conditions can increase the risk of sexual dysfunction. This study aimed to characterize the SF of trans-women after gender affirming surgery.

METHODS

We reviewed the Pubmed database for studies published between January 2008 to December 2021.

RESULTS

17 studies were included, 4 were cross-sectional studies, 1 prospective study, 4 prospective cohort studies, five retrospective studies. The instruments used to evaluate the SF were Female Sexual Index (FSFI), semi-structured questionnaires, patients' opinion, Sexual Desire Inventory (SDI), Maudsley Marital Questionnaire-S, WHOQOL-100. The results of our review indicate there is weak evidence that gender affirming surgery improves the SF of trans-women.

CONCLUSION

We thus recommend that future studies use questionnaires that are validated for the assessment of the SF of trans-women to better determine the impact of genital surgery in this population. This article is protected by copyright. All rights reserved.

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

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

Feasibility, Safety, and Satisfaction of Combined Hysterectomy with Bilateral Salpingo-Oophorectomy and Chest Surgery in Transgender and Gender Non-Conforming Individuals

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.

Gender-affirmation surgery and bariatric surgery in transgender individuals in The Netherlands: Considerations, surgical techniques and outcomes

INTRODUCTION

The number of transgender individuals seeking medical and surgical care has increased over the last years. Within the transgender population overweight and obesity is more frequently observed when compared to the general population. Little is known on the prevalence of bariatric surgery in the transgender population and the effects on the surgical gender transition path of the individual transgender with overweight or obesity.

MATERIAL AND METHODS

All transgender individuals who underwent gender-affirming surgery (GAS) between 1980 and 2020 were retrospectively identified from our hospital registry. Those with a history of bariatric surgery were selected. A retrospective chart study was conducted, recording gender identity, bariatric surgery specifications, gender surgery specifications, complications, reoperations and clinical follow-up time.

RESULTS

A total of 15 transgender individuals (11 transgender men, 4 transgender women) who underwent bariatric surgery were identified. All individuals underwent bariatric surgery before any GAS procedure, except for one transgender man. At the first GAS procedure, all individuals experienced significant weight loss when compared to their weight at bariatric surgery (mean 13.1 ± 3.8 BMI points lost for transgender men, mean BMI points lost 14.3 ± 2.8 for transgender women, p < 0.01). Obesity was still frequently prevalent in transgender men after bariatric surgery. All included transgender men underwent mastectomy via the double incision with free nipple grafting technique. Only one transgender man underwent genital GAS. All transgender women underwent penile-inversion vaginoplasty, one in combination with prosthesis-based augmentation mammoplasty.

CONCLUSION

Surgical gender transition is possible after massive weight loss after bariatric surgery. Specific surgical subtechniques will be more prevalent in this population.

[CLINICAL OUTCOMES OF GENDER AFFIRMING SURGERY FOR GENDER DYSPHORIA/INCONGRUENCE: A SINGLE-INSTITUTE EXPERIENCE]

(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence. (Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes. (Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m² or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery. (Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.

Combining total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with subcutaneous mastectomy in trans men: The effect on safety outcomes

Background: Masculinizing mastectomy is the most requested gender affirming surgery (GAS) in trans men, followed by genital GAS. Mastectomy and total laparoscopic hysterectomy, with or without bilateral salpingo-oophorectomy (TLH ± BSO), can both be performed in one single operation session. However, data on complication rates of the combined procedure is scarce and no consensus exists on the preferred order of procedures. Aims: To compare safety outcomes between mastectomy performed in a single procedure with those when performed in a combined procedure and assess whether the order of procedures matters when they are combined. Methods: A retrospective chart review was performed of trans men who underwent masculinizing mastectomy with or without TLH ± BSO in a combined session. The effects of the surgical procedure on complication and reoperation rate of the chest were assessed using logistic regression. Results: In total, 480 trans men were included in the study. Of these, 212 patients underwent the combined procedure. The gynecological procedure was performed first in 152 (71.7%) patients. In the total sample, postoperative hematoma of the chest occurred in 11.3%; 16% in the combined versus 7.5% in the single mastectomy group (p = 0.001). Reoperations due to hematoma of the chest were performed in 7.5% of all patients; 10.8% in the combined versus 4.9% in the single mastectomy group (p = 0.017). The order of procedures in the combined group had no significant effect on postoperative hematoma of the chest (p = 0.856), and reoperations (p = 0.689). Conclusion: Combining masculinizing mastectomy with TLH ± BSO in one session was associated with significantly more hematoma and reoperations compared with separately performing mastectomy. This increased risk of complications after a combined procedure should be considered when deciding on surgical options. The order of procedures in a combined procedure did not have an effect on safety outcomes.