Transgender and Non-Binary Surgery Registry: Building a Patient-Focused Registry for Genital Gender Affirming Surgery.

Purpose: High quality data regarding long-term clinical and patient-reported outcomes (PROs) of genital gender-affirming surgery (GGAS) are lacking, and transgender and non-binary (TGNB) community voices have not historically been included in research development. These factors limit the utility of current research for guiding patients, clinicians, payers, and other GGAS stakeholders in decision-making. The Transgender and Non-Binary Surgery (TRANS) Registry has been developed to meet the needs of GGAS stakeholders and address limitations of traditional GGAS research. Methods: Development of the TRANS Registry occurred over several developmental phases beginning in May 2019 to present. Stakeholder engagement was performed throughout these phases, including: determination of key clinical outcomes and PROs, creation and implementation of data collection tools within the electronic health record (EHR), and development of centralized registry infrastructure. Results: The TRANS Registry is a prospective observational registry of individuals seeking vaginoplasty and vulvoplasty. The EHR-enabled infrastructure allows patients and clinicians to contribute longitudinal outcomes data to the TRANS Registry. We describe our community engaged approach to designing the TRANS Registry, including lessons learned, challenges, and future directions. Conclusions: The TRANS Registry is the first multicenter initiative to prospectively track the health of individuals seeking vaginoplasty and vulvoplasty using EHR-enabled methods, engaging TGNB community members and clinicians as partners in the process. This process may be used as a model for registry development in other emerging fields where high-quality longitudinal outcomes data are needed.

Preoperative Factors for Success of Robotic Ureteral Reconstruction for Distal Ureteral Strictures.

Introduction: To investigate preoperative predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for management of distal ureteral strictures. Methods: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for surgical repair of distal ureteral strictures between 04/2012 and 12/2022. Procedures included refluxing reimplant (58.5%), side to side reimplant (18.0%), ureteroureterostomy (12.7%), non-refluxing reimplant (6.3%), buccal mucosa ureteroplasty (2.8%), and appendiceal bypass ureteroplasty (1.7%). Patients were grouped according to whether they were surgically successful. Preoperative variables between both groups were compared using chi-square tests. All variables with associations of p < 0.2 underwent a binary logistic regression analysis to determine predictive variables of success for RUR (p ≤ 0.05 considered statistically significant). Results: Overall, 284 patients met inclusion criteria. Univariate analysis showed obesity (p = 0.03), smoking history (p = 0.10), abdominopelvic radiation history (p = 0.14), immunocompromised state (p = 0.12), and ureteral rest (p = 0.01) were notable preoperative factors (p < 0.2). Binary logistic regression analysis further revealed the odds of surgical success in patients with obesity was 0.32 times (CI: 0.12-0.83, p = 0.02) the odds of success for patients without obesity. The odds of surgical success in patients who underwent preoperative ureteral rest was 4.2 times (CI: 1.51-11.77, p < 0.01) the odds of success for patients who did not undergo preoperative ureteral rest. Conclusion: Preoperative factors including obesity and ureteral rest may affect surgical success of RUR for management of distal ureteral strictures.

The Impact of Social Deprivation on Anterior Urethral Stricture Recurrence After Urethroplasty - A Trauma and Urologic Reconstructive Network of Surgeons (TURNS) Analysis.

INTRODUCTION AND OBJECTIVES: Several factors influence recurrence after urethral stricture repair. The impact of socioeconomic factors on stricture recurrence after urethroplasty is poorly understood. This study aims to assess the impact that social deprivation, an area-level measure of disadvantage, has on urethral stricture recurrence after urethroplasty. METHODS: We performed a retrospective review of patients undergoing urethral reconstruction by surgeons participating in a collaborative research group. Home zip code was used to calculate Social Deprivation Indices (SDI; 0-100), which quantifies the level of disadvantage across several sociodemographic domains collected in the American Community Survey. Patients without zip code data were excluded from the analysis. The Cox Proportional Hazards model was used to study the association between SDI and the hazard of functional recurrence, adjusting for stricture characteristics as well as age and body mass index. RESULTS: Median age was 46.0 years with a median follow up of 367 days for the 1452 men included in the study. Patients in the fourth SDI quartile (worst social deprivation) were more likely to be active smokers with traumatic and infectious strictures compared to the first SDI quartile. Patients in the fourth SDI quartile had 1.64 times the unadjusted hazard of functional stricture recurrence vs patients in the first SDI quartile (95% CI 1.04-2.59). Compared to anastomotic ± excision, substitution only repair had 1.90 times the unadjusted hazard of recurrence. The adjusted hazard of recurrence was 1.08 per 10-point increase in SDI (95% CI 1.01-1.15, P = .027). CONCLUSIONS: Patient social deprivation identifies those at higher risk for functional recurrence after anterior urethral stricture repair, offering an opportunity for preoperative counseling and postoperative surveillance. Addressing these social determinants of health can potentially improve outcomes in reconstructive surgery.

Summarizing the evidence for robotic-assisted bladder neck reconstruction: Systematic review of patency and incontinence outcomes.

Objective: Bladder neck contracture and vesicourethral anastomotic stenosis are difficult to manage endoscopically, and open repair is associated with high rates of incontinence. In recent years, there have been increasing reports of robotic-assisted bladder neck reconstruction in the literature. However, existing studies are small, heterogeneous case series. The objective of this study was to perform a systematic review of robotic-assisted bladder neck reconstruction to better evaluate patency and incontinence outcomes. Methods: We performed a systematic review of PubMed from first available date to May 2023 for all studies evaluating robotic-assisted reconstructive surgery of the bladder neck in adult men. Articles in non-English, author replies, editorials, pediatric-based studies, and reviews were excluded. Outcomes of interest were patency and incontinence rates, which were pooled when appropriate. Results: After identifying 158 articles on initial search, we included only ten studies that fit all aforementioned criteria for robotic-assisted bladder neck reconstruction. All were case series published from March 2018 to March 2022 ranging from six to 32 men, with the median follow-up of 5-23 months. A total of 119 patients were included in our analysis. A variety of etiologies and surgical techniques were described. Patency rates ranged from 50% to 100%, and pooled patency was 80% (95/119). De novo incontinence rates ranged from 0% to 33%, and pooled incontinence was 17% (8/47). Our findings were limited by small sample sizes, relatively short follow-ups, and heterogeneity between studies. Conclusion: Despite limitations, current available evidence suggests comparable patency outcomes and improved incontinence outcomes for robotic bladder neck reconstruction compared to open repair. Additional prospective studies with longer-term follow-ups are needed to confirm these findings.

Technical Considerations and Outcomes for Panniculectomy in the Setting of Buried Penis Patients: A Systematic Review and Database Analysis.

BACKGROUND: Often secondary to obesity, adult-acquired buried penis (AABP) is an increasingly common condition. AABP is often detrimental to urinary and sexual function, psychological well-being, and quality of life. Surgical treatment involves resection of excess soft tissue, with adjunct procedures, including a panniculectomy. However, few studies have been conducted investigating the risks of panniculectomy in the context of AABP surgical repair. METHODS: A systematic review of PubMed, Embase, and Cochrane databases was performed, following the PRISMA 2020 guidelines. Descriptive statistics regarding patient demographics, complications, and surgical technique were conducted. After this, an analysis of AABP patients within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was conducted. RESULTS: Four studies including 57 patients reported panniculectomy as part of buried penis repair (PBPR). Surgical approaches included a modified trapezoid and traditional transverse incision. All authors utilized postoperative drains. Dehiscence and wound infection were the most frequent complications. Univariate NSQIP analysis revealed that PBPR patients had higher body mass index, more comorbidities, and greater wound complication rates. Multivariate analysis revealed that PBPR did not significantly increase 30-day complications compared to isolated BPR ( P > 0.05), while body mass index remained a significant predictor. CONCLUSIONS: Surgical repair of AABP can greatly improve patient quality of life. The available literature and NSQIP-based analysis reveal that concurrent panniculectomy in AABP repair has a comparable complication profile. Future studies are necessary to better characterize the long-term outcomes of this PBPR.

Pilot Test of A Gender-conscious Sexual Health Intake Questionnaire: Increasing Inclusivity and Mitigating Bias in Sexual History Taking.

Background: Sexual health is critical to overall health, yet sexual history taking is challenging. LGBTQ+ patients face additional barriers due to cis/heteronormativity from the medical system. We aimed to develop and pilot test a novel sexual history questionnaire called the Sexual Health Intake (SHI) form for patients of diverse genders and sexualities. Methods: The SHI comprises four pictogram-based questions about sexual contact at the mouth, anus, vaginal canal, and penis. We enrolled 100 sexually active, English-speaking adults from a gender-affirming surgery clinic and urology clinic from November 2022 to April 2023. All surveys were completed in the office. Patients also answered five feedback questions and 15 questions from the Patient-Reported Outcomes Measurement Information System Sexual Function and Satisfaction (PROMIS-SexFS) survey as a validated comparator. Results: One hundred patients aged 19-86 years representing an array of racial/ethnic groups, gender identities, and sexuality completed the study. Forms of sexual contact varied widely and included all possible combinations asked by the SHI. Feedback questions were answered favorably in domains of clinical utility, inclusiveness of identity and anatomy, and comprehensiveness of forms of sexual behavior. The SHI captured more positive responses than PROMIS-SexFS in corresponding questions about specific types of sexual activity. The SHI also asks about forms of sexual contact that are not addressed by PROMIS-SexFS, such as penis-to-clitoris. Conclusions: SHI is an inclusive, patient-directed tool to aid sexual history taking without cisnormative or heteronormative biases. The form was well received by a diverse group of participants and can be considered for use in the clinical setting.

Robotic YV plasty outcomes for bladder neck contracture vs. vesico-urethral anastomotic stricture.

PURPOSE: To compare the outcomes of patients undergoing robotic YV plasty for bladder neck contracture (BNC) vs. vesico-urethral anastomotic stricture (VUAS). METHODS: A retrospective study included male patients who underwent robotic YV plasty for BNC after endoscopic treatment of BPH or VUAS between August 2019 and March 2023 at a single academic center. The primary assessed was the patency rate at 1 month post-YV plasty and during the last follow-up visit. RESULTS: A total of 21 patients were analyzed, comprising 6 in the VUAS group and 15 in the BNC group. Patients with VUAS had significantly longer operative times (277.5 vs. 146.7 min; p = 0.008) and hospital stay (3.2 vs. 1.7 days; p = 0.03). Postoperative complications were more common in the VUAS group (66.7% vs. 26.7%; p = 0.14). All patients resumed spontaneous voiding postoperatively. Five patients (23.8%) who developed de novo stress urinary incontinence had already an AUS (n = 1) or required concomitant AUS implantation (n = 3), all of whom were in the VUAS group (83.3% vs. 0%; p < 0.0001). The proportion of patients improved was similar in both groups (PGII = 1 or 2: 83.3% vs. 80%; p = 0.31). Stricture recurrence occurred in 9.5% of patients in the whole cohort, with no significant difference between the groups (p = 0.50). Long-term reoperation was required in three VUAS patients, showing a statistically significant difference between the groups (p = 0.05). CONCLUSION: Robotic YV plasty is feasible for both VUAS and BNC. While functional outcomes and stricture-free survival may be similar for both conditions, the perioperative outcomes were less favorable for VUAS patients.

Incidence, Complications, and Long-term Outcomes of Gender-affirming Phalloplasty: Analysis of a Large Statewide Population-based Dataset.

OBJECTIVE: To evaluate the incidence of gender-affirming phalloplasty and postoperative complications in a large population-based dataset. METHODS: Retrospective cohort study was done using the California Department of Health Care Access and Information datasets which include patient-level data from all licensed hospitals, emergency departments, and ambulatory surgery facilities in California. Adult patients 18 years or older undergoing gender-affirming phalloplasty in California from January 1, 2009 to December 31, 2019 were included. We examined phalloplasty-related complications using International Classification of Disease diagnosis and procedure codes and Current Procedural Terminology codes. Unique record linkage number identifiers were used to follow patients longitudinally. Statistical analysis included Kaplan-Meier survival analysis and Cox proportional hazards analysis. RESULTS: We identified 766 patients who underwent gender-affirming phalloplasty in 23 facilities. Of 475 patients with record linkage numbers, 253 (55.3%) had subsequent re-presentations to the inpatient, emergency department, and ambulatory surgery settings related to phalloplasty complications. Survival analysis indicated that 50% of patients re-presented by 1year post-phalloplasty. Asian/Pacific Islander patients had lower risk of complications, and California residents had higher risk of complications. CONCLUSION: This population-based study confirms that gender-affirming phalloplasty has a high complication rate, and demonstrates for the first time an association with high rates of return to hospitals, emergency departments, and ambulatory surgery centers. These findings provide additional higher-level evidence that may aid patient counseling, shared surgical decision-making, and institutional and government policy.

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

BACKGROUND: Urologic complications in genital gender-affirming surgery are imperfectly measured, with existing evidence limited by "blind spots" that 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 they may be exacerbated by factors related to transgender health. METHODS: The authors provide a narrative review of systematic reviews published in the past 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 the primary surgeon. In combination with expert opinion, these findings help estimate complication rates. RESULTS: Eight systematic reviews describe complications in patients undergoing vaginoplasty, including 5% to 16.3% mean incidence of meatal stenosis and 7% to 14.3% mean incidence of vaginal stenosis. Compared with surgeon-reported cohorts, patients undergoing vaginoplasty or vulvoplasty in other reports had higher rates of voiding dysfunction (47% to 66% versus 5.6% to 33%), incontinence (23% to 33% versus 4% to 19.3%), or misdirected urinary stream (33% to 55% versus 9.5% to 33%). Outcomes in six reviews of phalloplasty and metoidioplasty included urinary fistula (14% to 25%), urethral stricture or meatal stenosis (8% to 12.2%), and ability to stand to void (73% to 99%). Higher rates of fistula (39.5% to 56.4%) and stricture (31.8% to 65.5%) were observed in alternate cohorts, along with previously unreported complications such as vaginal remnant requiring reoperation. CONCLUSIONS: The literature does not completely describe urologic complications of genital gender-affirming surgery. 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.

Preoperative Predictors of Surgical Success for Robotic Ureteral Reconstruction of Proximal and Middle Ureteral Strictures.

OBJECTIVE: To investigate predictors of surgical success for patients undergoing robotic ureteral reconstruction (RUR) for ureteropelvic junction obstruction (UPJO), proximal, and middle ureteral stricture disease. METHODS: We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery database to identify all consecutive patients undergoing RUR for UPJO, proximal and/or middle ureteral stricture disease between April 2012 and December 2020. The specific reconstruction technique was determined by the primary surgeon based on clinical history and intraoperative findings. Patients were grouped according to whether they were surgical successful. Preoperative variables between both groups were compared using chi-square tests. All independent variables with associations of P <.2 then underwent a binary logistic regression analysis to determine predictive variables of success for RUR (P ≤.05 was considered statistically significant). RESULTS: Overall, 338 patients met inclusion criteria. Surgical success rates of RUR are shown in Table 1. Univariate analysis (Table 2) showed that there were a lower proportion of patients with diabetes (8.9% vs 25.7%, P <.01) and a higher proportion of patients who underwent ureteral rest (74.3% vs 48.6%, P <.01) in the surgical success group. Multivariate logistic regression analysis (Table 3) further revealed the odds of surgical success in patients without diabetes was 3.08 times ((confidence interval) CI 1.26-7.54, P = .01) the odds of success for patients with diabetes. The odds of surgical success in patients who underwent preoperative ureteral rest were 2.8 times (CI 1.35-5.83, P = .01) the odds of success for patients who did not undergo preoperative ureteral rest. CONCLUSION: Surgical success of RUR for management of UPJO, proximal, and middle ureteral strictures may be influenced by factors including preoperative ureteral rest and presence of diabetes.

Outcomes of Urethroplasty for Synchronous Anterior Urethral Stricture Utilizing the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System.

OBJECTIVE: To describe the characteristics, management, and functional outcomes of patients with synchronous urethral stricture disease (SUSD) utilizing a multi-institutional cohort. METHODS: Data were collected and assessed from a prospectively maintained, multi-institutional database. Patients who underwent anterior urethroplasty for urethral stricture disease (USD) were included and stratified by the presence or absence of SUSD. USD location and etiology were classified according to the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System. Anterior urethroplasty techniques were recorded for both strictures. Functional failure was compared between groups. RESULTS: One thousand nine hundred eighty-three patients were identified, of whom, 137/1983 (6.9%) had SUSD. The mean primary stricture length for patients with SUSD was 3.5 and 2.6 cm for the secondary stricture. Twelve anterior urethroplasty technique combinations were utilized in treating the 27 different combinations of SUSD. Functional failure was noted in 18/137 (13.1%) patients with SUSD vs 192/1846 (10.4%) patients with solitary USD, P = .3. SUSD was not associated with increased odds of functional failure. S classifications: S1b, P = .003, S2a, P = .001, S2b, P = .01 and S2c, P = .02 and E classifications: E3a, P = .004 and E6, P = .03, were associated with increased odds of functional failure. CONCLUSION: Repair of SUSD in a single setting does not increase the risk of functional failure compared to patients with solitary USD. Increasing S classification, S1b through S2c and E classifications E3a and E6 were associated with increased functional failure. This reinforces the importance of the Trauma and Urologic Reconstruction Network of Surgeons Length, Segment and Etiology Anterior Urethral Stricture Classification System as a necessary tool in large-scale multi-institutional analysis when assessing highly heterogenous patient populations.

Nipple-Preserving Inferior Ellipse Mastectomy: A New Technique for Gender-Affirming Top Surgery.

SUMMARY: The two most common techniques for gender affirming mastectomy are the double incision free nipple graft and peri areolar. There are however patients that are not well suited for either technique. When the nipples are high and on the pectoralis muscle yet there is marked breast tissue and skin redundancy, a double incision free nipple graft would land the incision above the pec shadow but a peri-areolar approach would not adequately remove the excess skin. In these patients, a nipple-preserving inferior ellipse incision allows for appropriate chest contouring leaving the nipple position unchanged and placing the incision in the pectoralis muscle shadow. Retrospective review identified all consecutive patients undergoing nipple-preserving inferior ellipse mastectomy by the senior author. Indications were patients with moderate glandular tissue, skin excess and a high nipple areolar complex (NAC) above the inferior border of the pectoralis major. Sixteen patients underwent inferior ellipse mastectomy and were included. Mean follow-up was 203 days. Two patients (14%) required revision of the NAC. There was no partial or complete NAC loss. One patient (7%) developed postoperative seroma which resolved with aspiration. In summary, for patients with moderate glandular tissue, excess skin in the inferior pole and NAC position above the inferior border of the pectoralis major, the nipple-preserving inferior ellipse mastectomy technique achieves excellent chest contour.

Robotic-assisted Posterior Urethroplasty: Outcomes From 105 Men in a Single-center Experience.

OBJECTIVE: To determine surgical outcomes in a large of cohort men undergoing robotic-assisted posterior urethroplasty (RPU), which has been described in small series as a viable option. MATERIALS AND METHODS: We performed a retrospective review of all 105 men who underwent RPU from October 2014 to August 2022 at a single institution. We evaluated postoperative outcomes, including complications; surgical success defined as no need for reintervention; and incontinence requiring artificial urinary sphincter placement. We performed descriptive statistics and chi-square testing to determine if outcomes were associated with certain posterior urethral disease etiologies. RESULTS: Mean follow-up time was 18.7months. Over half of patients (57.1%) received prior pelvic radiation. The most common reconstructive techniques were excision and primary anastomosis (n = 45, 30.0%), resitting of the bladder neck (n = 26, 24.8%), Y-V plasty (n = 21, 20.0%), and buccal mucosal graft urethroplasty (n = 14, 13.3%). Forty-one patients (39.0%) required a combined abdominoperineal approach. Seven patients (6.7%) had ≥CD grade 3 complications within 30days. Thirty patients (28.6%) developed incontinence with subsequent artificial urinary sphincter placement. One-quarter (24.8%) of patients required at least one subsequent surgical reintervention. CONCLUSION: In the largest RPU cohort to date, surgical success rates were similar and continence rates were improved compared to open surgery and align with existing robotic series, adding to the growing body of evidence demonstrating advantages of RPU.