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Ha B, Morrill MY, Salim AM, Stram D, Weiss E. Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients. Perm J 2022; 26:49-55. [PMID: 36245082 PMCID: PMC9761287 DOI: 10.7812/tpp/22.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background The authors sought to compare the perioperative morbidity of Stage 1 phalloplasty with asynchronous vs concurrent hysterectomy among transmasculine patients. Methods This retrospective study included transmasculine patients undergoing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy at Kaiser Permanente Northern California from January 1, 2017, to September 9, 2019. The primary outcome was differences in surgical site infection rates. Secondary outcomes included perioperative and other postoperative complications. Comparisons of demographics and outcomes were made by F-tests and Fisher's exact tests. A p value of < 0.05 was considered statistically significant. Results Of 66 transmasculine patients undergoing Stage 1 phalloplasty, 32 (48%) had an asynchronous hysterectomy and 34 (52%) had a concurrent hysterectomy. Overall, surgical site infection rates were low, and there were no significant differences between groups. Patients who had undergone asynchronous hysterectomy had more neourethral complications with Stage 1 phalloplasty than those undergoing concurrent procedures (28% vs 3%, p < 0.05). There were no significant differences in estimated blood loss, length of stay, urinary tract infection, overactive bladder or narcotic use between groups. Conclusion Overall, there were no differences between groups in most postoperative complication rates. Although more neourethral complications were found in those undergoing asynchronous hysterectomy prior to Stage I phalloplasty, this may be partially explained by increasing surgeon experience over time given this difference did not remain statistically significant after the first year of the study period. Gynecologists seeking to provide comprehensive and inclusive care to transmasculine patients should take these findings into consideration when counseling patients planning genital gender affirmation surgery.
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Affiliation(s)
- Barbara Ha
- 1Obstetrics & Gynecology, Kaiser Permanente, San Francisco, CA, USA,Barbara Ha, MD, MSPH
| | - Michelle Y Morrill
- 2Female Pelvic Medicine & Reconstructive Surgery, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Ali M Salim
- 3Plastic Surgery, Kaiser Permanente Northern California, San Francisco, CA, USA
| | - Douglas Stram
- 4Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Erica Weiss
- 5Obstetrics & Gynecology, Kaiser Permanente Northern California, San Francisco, CA, USA
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de Rooij FPW, van der Sluis WB, Ronkes BL, Steensma TD, Al-Tamimi M, van Moorselaar RJA, Bouman MB, Pigot GLS. Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men. Int J Transgend Health 2022; 24:487-498. [PMID: 37901060 PMCID: PMC10601502 DOI: 10.1080/26895269.2022.2110548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0-6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.
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Affiliation(s)
- Freek P. W. de Rooij
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Wouter B. van der Sluis
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Brechje L. Ronkes
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Thomas D. Steensma
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Medical Psychology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Muhammed Al-Tamimi
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | | | - Mark-Bram Bouman
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Department of Plastic, Reconstructive and Hand Surgery, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
| | - Garry L. S. Pigot
- Department of Urology, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam University Medical Center, Location VUmc, Amsterdam, The Netherlands
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Liu JL, Eisenbeis L, Preston S, Burnett AL, DiCarlo HN, Coon D. Postphalloplasty urinary function test: an observational study of novel outcome instrument to capture urinary dysfunction and quality of life after phalloplasty. Asian J Androl 2022; 24:570-574. [PMID: 35229758 PMCID: PMC9809483 DOI: 10.4103/aja2021110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Due to growing social acceptance, there has been an increasing number of gender-affirmation surgeries performed in North America. Most research in this patient population focuses on surgical outcomes and advancing techniques. However, little work has been done to study functional outcomes. To better evaluate urinary dysfunction in the postphalloplasty trans men patient population, our group developed a novel patient-reported outcome instrument - the postphalloplasty urinary function test (PP UFT) and protocol to measure postvoid urethral volume (PVUR), and we present our preliminary results. We conducted a cross-sectional pilot study in a cohort of 15 adult trans men who had undergone phalloplasty with urethral lengthening surgery between 2018 and 2021. Patients had stable urinary function via the neophallus at the time of survey. Patients filled out the PP UFT and were asked to record their PVUR as per our protocol. The average PP UFT score was 8.9 out of 40 and the average quality-of-life (QOL) score was 2.6. Postvoid dribbling constituted the major complaint and on average comprised 63.2% of the reported PP UFT score. The average PVUR was 2.2 ml (range: 0.5-5.6 ml). There was a positive correlation between higher PP UFT and worse-reported quality of life (P < 0.01; R2 = 0.4). Current questionnaires accepted in cis-male urology have limitations for accurately capturing urinary dysfunction in this specific patient group. The combination of PP UFT and PVUR measurement offers potential for quantifying urinary function and quality of life in patients who undergo phalloplasty. Future studies will validate these instruments.
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Affiliation(s)
- James L Liu
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Lauren Eisenbeis
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA,Johns Hopkins Center for Transgender Health, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Stephanie Preston
- Department of Surgery, University of Texas Southwestern, Dallas, TX 75370, USA
| | - Arthur L Burnett
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | - Heather N DiCarlo
- The James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA,Johns Hopkins Center for Transgender Health, Johns Hopkins Medicine, Baltimore, MD 21287, USA
| | - Devin Coon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA,Johns Hopkins Center for Transgender Health, Johns Hopkins Medicine, Baltimore, MD 21287, USA,
Correspondence: Dr. D Coon ()
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Bowen DK, Cheng EY, Hirsch J, Huang J, Meyer T, Rosoklija I, Chu DI, Yerkes EB. A fresh "slant" on modified Mitchell bladder neck reconstruction: A contemporary single-institution experience. Front Pediatr 2022; 10:933481. [PMID: 36120660 PMCID: PMC9478545 DOI: 10.3389/fped.2022.933481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 07/27/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Patients with neurogenic urinary incontinence due to an incompetent outlet may be offered bladder neck reconstruction, but the quest for the perfect surgical-outlet procedure continues. Our aim was to characterize continence and complications after modified Mitchell urethral lengthening/bladder neck reconstruction (MMBNR) with sling and to introduce a modification of exposure that facilitates subsequent steps of MMBNR. METHODS A single-institution, retrospective cohort study of patients who underwent primary MMBNR between May 2011 and July 2019 was performed. Data on demographics, urodynamic testing, operative details, unanticipated events, continence, bladder changes, and additional procedures were collected. A 2013 modification that permits identification of the incompetent bladder neck prior to urethral unroofing was applied to the last 17 patients. The trigone and bladder neck are exposed via an oblique low anterolateral incision on the bladder. Ureteral reimplantation is not routinely performed. Focal incision of the endopelvic fascia after posterior plate creation limits breadth of blunt dissection for sling placement. Descriptive statistics were utilized. RESULTS A total of 25 patients (13 females) had MMBNR with sling at a median age of 10 years [interquartile range (IQR) 8-11]. Bladder augmentation was performed concurrently in 14/25 (56%) patients. At a median of 5.0 (IQR 3.9-7.5) years follow-up after MMBNR, 9/11 (82%) without bladder augmentation and 13/14 (93%) with bladder augmentation had no leakage per urethra during the day without further continence procedures. Of the three patients with persistent incontinence, two achieved continence with bladder wall Botox injection (overall continence 24/25, 96%). New and recurrent vesicoureteral reflux was noted in five patients and one patient, respectively. Two patients required subsequent bladder augmentation for pressures and one other will likely require it. None have required bladder neck closure or revision. CONCLUSION MMBNR with sling provides promising continence per urethra in neurogenic bladder with low need for secondary continence procedures. Ongoing modifications may achieve elusive total continence.
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Affiliation(s)
- Diana K Bowen
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Earl Y Cheng
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Josephine Hirsch
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Jason Huang
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Theresa Meyer
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Ilina Rosoklija
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - David I Chu
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Elizabeth B Yerkes
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Hochstätter R, Bertholin y Galvez MC, Hartleb R, Laback C, Aigmüller T, Tamussino K, Gold D. Voiding dysfunction after colpectomy and urethral lengthening in transgender men. Int J Transgend Health 2021; 24:108-112. [PMID: 36713147 PMCID: PMC9879163 DOI: 10.1080/26895269.2021.1924916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
BACKGROUND Colpectomy is a frequent part of gender-affirming surgery in transgender men. Urologic complications with these procedures can complicate and delay further management. Aim: We reviewed the rate of postoperative voiding dysfunction after colpectomy with urethral lengthening in transgender men. METHODS We reviewed postoperative voiding in 47 transgender men (age, 19-50 years) who underwent colpectomy with urethral lengthening. Thirty-eight patients (81%) had undergone hysterectomy (36 total, 2 subtotal/supracervical) previously and 11 (23%) underwent concomitant hysterectomy or removal of the residual cervix (4 abdominal, 6 laparoscopic, 1 transvaginal). Colpectomy was done transvaginally by opening and developing laterally the vesicovaginal and rectovaginal spaces and then transecting the lateral vaginal attachments with bipolar vessel sealing. Urethral lengthening with an anterior vaginal flap was performed in the same procedure as colpectomy. A transurethral catheter was left in situ for 14 days postoperatively. Voiding dysfunction was defined as failure of spontaneous micturition after removal of the catheter at 14 days. RESULTS 40/47 (85%) patients were able to void after catheter removal, 7 (15%) were not. Voiding dysfunction occurred in 3/11 (27%) patients undergoing concomitant hysterectomy or removal of a residual cervix and in 4/36 patients (11%) status post total hysterectomy. Voiding dysfunction persisted for a median of 3 months (2 days - 46 months). CONCLUSIONS In this series voiding dysfunction developed in 15% of transgender men undergoing colpectomy with urethral lengthening and appeared to be more common in patients undergoing concomitant hysterectomy or removal of a residual cervix than in those status post hysterectomy. Patients should be counseled accordingly.
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Affiliation(s)
- Rüdiger Hochstätter
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | | | - Riccarda Hartleb
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Christian Laback
- Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Graz, Austria
| | - Thomas Aigmüller
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Karl Tamussino
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Daniela Gold
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
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