Neovaginal cancer after sigmoid vaginoplasty: Implications for postoperative cancer surveillance.

Background: Intestinal vaginoplasty can be performed as vaginal reconstruction procedure. Aa pedicled intestinal segment is isolated and transferred to the (neo)vaginal cavity to form the neovaginal lining. Case: A 38-year old patient with Fanconi anemia and congenital vaginal absence, who underwent sigmoid vaginoplasty at the age of one, visited the outpatient clinic with a palpable neovaginal mass. At MRI examination, a neovaginal tumor was observed of approximately 25 × 10 mm without lymphadenopathy, which turned out to be a mucinous adenocarcinoma (T3N0M0). She underwent excision of the total mesocolon, including the sigmoid neovagina, coloanal anastomosis and anus. Summary and Conclusion: Postoperative cancer surveillance seems justified after sigmoid vaginoplasty, even more so in patients with a (genetically) high risk of developing cancer and/or with a history of malignancy.

Improving patient care by virtual case discussion between plastic surgeons and residents of Uganda and the Netherlands.

INTRODUCTION: Traditional on-site missions of plastic surgeons from "high-income countries" in "low- and middle-income countries" are often limited in time and lack proper follow-up. Regular digital collaboration could lead to a more impactful and durable exchange of knowledge for plastic surgeons and residents in both settings. AIMS: The aim of this study was to evaluate the satisfaction of the first twelve months of weekly digital meetings, explore advantages/disadvantages, and to provide tools for similar initiatives. METHODS: Weekly meetings started from August 2021. An encrypted digital connection allowed residents and plastic surgeons from Uganda and the Netherlands to discuss cases for educational purposes, where treatment options were considered. After twelve months, a survey was sent to participants from both countries to indicate the meetings' strengths, weaknesses, and possible improvements. RESULTS: A total of 18 participants responded to the questionnaire (ten plastic surgeons, six residents, and two researchers). The strengths of the meetings were the accessibility of the meetings, knowledge exchange and practice for residents' final exams. Possible improvements included having a clear format for patient discussion, a session moderator and better internet connectivity. Moreover, a database to assess the impact of the given intervention on the patient cases by evaluating postoperatively (e.g. three months), could further improve clinical care. CONCLUSIONS: Virtual patient discussions subjectively contributed to medical education at both locations. Improved digital infrastructure and a collaborative database could further maximize learning capacity. Furthermore, digital proctoring is a promising way to establish sustainable collaborations between high- and low-resource countries.

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men.

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.

HIV Prevalence and High-Risk Subgroup Identification in Transgender Women Who Undergo Primary Vaginoplasty in the Netherlands.

Purpose: Worldwide, transgender women (TGW) bear a high HIV burden. Limited data are available on HIV prevalence and risk factors among TGW in western European countries. Our aim is to assess the prevalence of TGW living with HIV who underwent primary vaginoplasty in an academic reference hospital and to identify high-risk subgroups. Methods: All TGW who underwent primary vaginoplasty between January 2000 and September 2019 at our institution were identified. A retrospective chart study was conducted, recording the medical history, age at vaginoplasty, region of birth, use of medication, injecting drug use, history of pubertal suppression, HIV status, and sexual preference at time of surgical intake. High-risk subgroups were identified using logistic regression analysis. Results: Between January 2000 and September 2019, a total of 950 TGW underwent primary vaginoplasty, of whom 31 (3.3%) individuals were known to live with HIV. Prevalence of HIV was higher in TGW born outside of Europe (20/145, 13.8%) than among those born in Europe (11/805, 1.4%), p<0.001. In addition, having a sexual preference toward men was significantly associated with HIV. None of the TGW living with HIV had a history of puberty suppression. Conclusion: The HIV prevalence in our study population is higher than the reported HIV prevalence in cisgender population in the Netherlands but lower than reported in previous studies in TGW. Further studies should investigate the need and feasibility of routine HIV testing of TGW in Western countries.

Triangular Flap Extension to Create a Meatal Appearance in Phalloplasty Without Urethral Lengthening.

OBJECTIVE: To describe an easy-to-perform surgical refinement to create a meatal appearance in phalloplasty without urethral lengthening by using a triangular flap extension. METHODS: Transgender men undergoing phalloplasty without urethral lengthening are candidate for this flap extension. A triangular flap is drawn at the distal part of the flap. When the flap is raised, this triangle is raised with the flap and subsequently folded in the tip of the neophallus, thus creating a neomeatal appearance. RESULTS: We present this easy-to-perform technique, our experience and postoperative results. Two pitfalls of this technique are: (1) when it is insufficiently trimmed and thinned, it adds too much bulk to the phallic top and (2) when it is insufficiently vascularized, wound healing problems will occur; especially since the neophallus will swell in the immediate postoperative phase. CONCLUSION: Using a triangular flap extension is an easy method to create a neomeatal appearance.

Genital gender-affirming surgery for transgender women.

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.

Mastectomy is a safe procedure in transgender men with a history of breast reduction.

Little is known about the safety and surgical outcomes of mastectomy after breast reduction in the trans male population. Several concerns have been voiced that performing mastectomy with prior breast reduction surgery, increases the risk for complications and revision surgery. All transgender men with a history of breast reduction, who underwent a mastectomy at our center between 01-1990 and 01-2021 were identified from our hospital registry. A retrospective chart study was conducted recording surgical characteristics, surgical complications, revision surgery, and clinical follow-up. A total of 1362 subcutaneous mastectomies were performed between 01-1990 and 01-2021. A total of 36 (2.6%) individuals were included (35 bilateral and 1 unilateral breast reduction). The mean age at mastectomy was 37 ± 10 years, and the median time between breast reduction and mastectomy was 6.3 years (range 1.0-31.1). Most individuals underwent a Wise-pattern breast reduction (91%) and a double incision mastectomy with free nipple grafts (86%). Following mastectomy, one acute reoperation was performed because of hemorrhage (3%). Partial pedicled nipple necrosis was seen in 7% and (partial) non-take of nipple grafts in 4%. Scar revisions were performed in 9%, dogear corrections in 20%, and both nipple corrections, and contour corrections in 6%. When comparing the outcomes in literature for surgical complications, scar revision, contour correction or nipple areolar complex revision, no clear disadvantage seems to be present when performing mastectomy after breast reduction. Mastectomy is a safe procedure in transgender men with a history of breast reduction.

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.

Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men.

OBJECTIVES: To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS: A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS: The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION: The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.

Surgical outcomes of testicular prostheses implantation in transgender men with a history of prosthesis extrusion or infection.

Background: Testicular prostheses implantation may be used for neoscrotal augmentation in transgender men. In current literature, explantation rates range from 0.6% to 30% and most are a result of infection or extrusion. Information on the surgical path of individuals after prosthesis explantation is scarce. Aim: To assess the frequency and success rate of testicular prosthesis implantation after previous explantation due to infection or extrusion. Methods: All transgender men who underwent testicular prosthesis explantation between January 1991 and December 2018 were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording demographics, surgical and prosthesis characteristics, reoperations, and outcomes. Results: A total of 41 transgender men were included who underwent testicular prosthesis explantation in the study time period. Of these, 28 (68%) opted for new prosthesis implantation. Most explanted prosthesis had a volume ≥30cc and were replaced with an equally sized one. The postoperative course was uneventful in 19 out of 28 (68%) individuals. Explantation of one or both prostheses occurred in 7 out of 28 (25%) individuals, because of infection (n = 3, 11%) or extrusion (n = 4, 14%). Patients that experienced complications had more often a history of smoking (p = 0.049). The explantation rate was lower if a smaller or lighter prosthesis was reimplanted (p = 0.020). Discussion: Most patients opt for testicular prosthesis implantation after previous explantation due to extrusion or infection. Explantation rates are higher than after the primary implantation procedure. Results of current study can be used to inform individuals on postoperative outcomes.

Long-term Follow-up and Trends in Breast Augmentation in 527 Transgender Women and Nonbinary Individuals: A 30-year experience in Amsterdam.

BACKGROUND: Transgender women and transfeminine spectrum nonbinary individuals may opt for breast augmentation. The aim of the study is to analyze the complications, surgical trends, and long-term follow-up of breast augmentations in this population over the past 30 years. METHODS: All transgender women and nonbinary individuals who underwent breast augmentation at our center between 01-1990 and 01-2020 were retrospectively identified. A retrospective chart study was conducted, recording individual demographics, implant characteristics, surgical timing, postoperative complications or other reasons requiring reoperation, and implant survival. A literature search was performed in MEDLINE on clinical outcomes and revision surgery of this procedure. RESULTS: A total of 527 individuals were identified. Median clinical follow-up time was 11.2 years (interquartile range 3.3-17.5). Median implant size increased significantly over the last years (1990-1990 median 275cc, 2000-2009 252cc, 2010-2019 375cc, p<0.01). Most individuals underwent breast augmentation and genital gender-affirming surgery in one-stage. Reoperations due to short-term complications were infrequent (hematoma (0.4%) or infection (0.4%)). Reoperations due to long-term complications comprised: implant rupture (5.7%), capsular contracture (4.9%), aesthetic problems (3.8%), low-grade infection (0.4%), or seroma (0.6%). In total, 2.5% of individuals requested larger implants. After performing the literature search and manuscript screening, 9 out of 115 identified studies were included for review. Follow-up time ranged from 30 days to 5.5 years. Reported complications requiring reoperation were capsular contraction (range 0.0-5.6%), asymmetry (3.6%), hematoma (range 0.0-2.9%), infection (range 0.0-0.9%) and implant rupture (0.7%), CONCLUSION: Implant-based breast augmentation is a safe procedure in transgender individuals.

Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men.

BACKGROUND: In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL). AIM: The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up. METHODS: A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. OUTCOMES: Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction. RESULTS: Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P < .001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P < .001) and with voiding (P = .02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P = .48 and P = .95 respectively). CLINICAL IMPLICATIONS: Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. STRENGTHS & LIMITATIONS: Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey. CONCLUSION: No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974-981.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

BACKGROUND: To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. METHODS: A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. RESULTS: Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. CONCLUSIONS: Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes.

Background: Different surgical procedures are available for transgender women wishing to undergo genital gender-affirming surgery. Aim: To assess preoperative motivations, the frequency of orchiectomy procedures, and postoperative outcomes of orchiectomy in transgender individuals. Methods: All transgender individuals who underwent orchiectomy in the period between January 2012 and January 2020 at our institution were retrospectively identified. A chart study was conducted, recording motivations, demographics, perioperative characteristics and surgical outcomes. The frequency of orchiectomy and vaginoplasty procedures during the study period were determined and compared. Results: During the study period, an increase of performed orchiectomy procedures was observed. The orchiectomy/vaginoplasty ratio was 0.01-0.07 in the period 2012-2018 and 0.24 in 2019. A total of 43 transgender individuals were retrospectively identified. Sixteen (37%) initially wished to undergo a vaginoplasty, but did not meet institutional requirements (nonsmoker, BMI < 30kg/m2) or were not eligible for vaginoplasty surgery because of interfering somatic or mental health issues. Fourteen (33%) individuals who underwent orchiectomy regarded it as a preceding step to a future vaginoplasty procedure. Out of these fourteen, one person is now on the waiting list for vaginoplasty surgery. Thirteen (30%) others did not report a desire to pursue vaginoplasty in the future. This was mostly motivated by the absence of genital dysphoria or motivations related to their gender identity, with a desire to discontinue anti-testosterone treatment. The postoperative course was uncomplicated in 39 (91%) individuals. Conclusion: In the Netherlands, especially in the last year, the frequency of orchiectomy procedures has increased. Reasons that people chose to undergo this procedure include: not being eligible for a vaginoplasty procedure, seeing it as a preceding step to a possible future vaginoplasty or other identity-related motivations (i.e., non-binary gender identification or absence of genital dysphoria).

Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men-A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction.

BACKGROUND: Genital gender-affirming surgery (gGAS) with urethral lengthening (UL) in transgender men is associated with high urological complication and reoperation rates. Since 2009, we offer gGAS without UL to avoid these complications. AIM: The aim of this study was to assess what portion of the transgender men opted for gGAS without UL and to assess functional, surgical outcomes, and patient satisfaction after gGAS without UL. MATERIAL AND METHODS: Retrospective data were collected from patients' charts. The International Prostate Symptom Score, uroflowmetry, and 24-hour frequency voiding chart were used to assess voiding, and a self-constructed semistructured questionnaire was used to assess patient-reported outcomes. Transgender men who underwent gGAS without UL between January 2009 and January 2018 were included, and 56 transgender men were approached to complete the patient-reported outcome measurement. The simple statistical analysis combined with the Mann-Whitney U test and the Wilcoxon signed-rank test was used. OUTCOMES: 68 transgender men were included. Median follow-up time was 24 (6-129) months. Uroflowmetry and the International Prostate Symptom Score were completed by 44 transgender men, whereas 13 completed the frequency voiding chart preoperatively and postoperatively, respectively. The patient-reported outcome measurement was completed by 40 of 56 (71%) transgender men. RESULT: Postoperative surgical and urological complications occurred in 9 of 68 (13%) and 8 of 68 (12%) patients, respectively. Storage and voiding function remained unchanged. The median quality of life because of urinary symptoms was scored as "pleased." Sexual functioning and voiding were scored satisfactory and very satisfactory in 18 of 40 (45%) and 21 of 40 (53%) patients, respectively. The number of patients satisfied with the penis and neoscrotum was 25 of 40 (63%) and 26 of 40 (65%), respectively. Increased self-esteem was reported by 32 of 40 (80%), 32 of 40 (80%) would undergo the surgery again, and 28 of 40 (70%) would recommend it to others. CLINICAL IMPLICATIONS: gGAS without UL should be part of the surgical armamentarium in centers performing gender-affirming surgery. STRENGTHS AND LIMITATIONS: Strengths of this study comprise the number of patients, the completeness of data, incorporation of patient-reported outcomes, and description of a relatively new surgical approach that may be well-suitable for a subgroup of transgender men. Limitations are the retrospective study design and the lack of validated questionnaires. CONCLUSION: gGAS without UL shows good surgical and urological outcomes. After extensive counseling, the majority of this selective group of patients shows favorable patient-reported outcomes. Pigot GLS, Al-Tamimi M, Nieuwenhuijzen JA, et al. Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men-A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction. J Sex Med 2020;17:2478-2487.

Scrotal Reconstruction in Transgender Men Undergoing Genital Gender Affirming Surgery Without Urethral Lenghtening: A Stepwise Approach.

BACKGROUND: Scrotal (re)construction, scrotoplasty, is performed as part of gender affirming surgery in transgender men. OBJECTIVE: To describe, step-by-step, our scrotal reconstruction technique in transgender men undergoing genital gender affirming surgery without urethral lengthening. MATERIAL AND METHODS: A 29-year-old transgender men underwent scrotal reconstruction and phalloplasty without urethral lengthening. For this purpose, the traditional scrotal reconstruction technique in patients that undergo urethral lengthening was modified. The patient is placed in lithotomy position. A pedicled horseshoe-shaped pubic flap, clitoral hood, and U-shaped labia majora flaps are used for scrotal reconstruction. The inner part of the labia minora (this is used to reconstruct the fixed part of the neourethra) is resected. The cranially pedicled U-shaped labia majora flaps are rotated 90 degrees medially to bring the neo-scrotum in front of the legs. Pedicled labia majora fat pads are released bilaterally and relocated in the neo-scrotum to achieve bulkiness. The meatus and vaginal orifice are diverted underneath the scrotum and a perineostomy is performed. RESULTS: We present our scrotoplasty technique as a step-by-step video guide. The technique results in the reconstruction of a perineostomy at the perineal scrotal transition, an augmented neo-scrotum, minimal visible scars, and proper neo-perineal length. CONCLUSION: Scrotal reconstruction using a horseshoe-shaped pedicled pubic flap, labia majora fat pads, and 2 cranially pedicled U-shaped labia majora flaps results in a neo-scrotum that resembles the biological scrotum closely in terms of bulkiness, size, shape, tactile sensation, and anatomical position.

Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes.

BACKGROUND: Penile inversion vaginoplasty is the surgical gold standard for genital gender-affirmative surgery in transgender women. However, there is an increase of attention for gender-confirming vulvoplasty (GCV), in which no neovaginal cavity is created. AIM: To describe underlying motives and surgical outcomes of GCV in transgender women. METHODS: All transgender women who underwent GCV were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording underlying motives, demographics, perioperative complications, and reoperations. OUTCOMES: Underlying motives and perioperative complication rate. RESULTS: In the period January 1990 to January 2020, 17 transgender women underwent GCV at our center. Most women reported that their motivation to undergo GCV was because they had no wish for postoperative neovaginal penetration (n = 10, 59%). This was due to a sexual preference toward women without the wish for neovaginal penetrative intercourse (n = 6, 35%) or due to a negative sexual experience in the past (n = 4, 24%). Some women desired vaginoplasty with neovaginal cavity creation but were ineligible for this because of their medical history (n = 4, 24%), for example, due to locoregional radiotherapy. The median clinical follow-up was 34 months (range 3-190). The postoperative course was uncomplicated in 11 (65%) women. Postoperative complications comprised the following: meatal stenosis (n = 2, for which surgical correction), remnant corpus spongiosum tissue (n = 1, for which surgical correction), minor wound dehiscence (n = 3, for which conservative management), and postoperative urinary tract infection (n = 1, successfully treated with oral antibiotics). One woman, who developed meatal stenosis, had a history of radiotherapy because of rectal carcinoma and needed 2 surgical procedures under general anesthesia to correct this. Information on self-reported satisfaction was available for 12 women. All were satisfied with the postoperative result and they graded their neovagina an 8.2 ± 0.9 out of 10. CLINICAL IMPLICATIONS: GCV may be added to the surgical repertoire of the gender surgeon. Transgender women with a desire for genital gender-affirmative surgery should be counseled on surgical options and its (dis)advantages. STRENGTHS & LIMITATIONS: Strengths of this study comprise that it is from a high-volume center. A weakness of this study is the retrospective design. The absence of a self-reported outcome measure validated for the transgender persons is a well-known problem. CONCLUSION: An increase is observed in transgender women who opt for GCV; however, the absolute number undergoing this surgery remains small in our center. Postoperative complications do occur but are generally minor and treatable. van der Sluis WB, Steensma TD, Timmermans FW, et al. Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes. J Sex Med 2020;17:1566-1573.

The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty.

BACKGROUND: Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon. AIM: To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty. METHODS: Perioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes). OUTCOMES: The main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications. RESULTS: A total of 42 transgender women were included (median age: 28 years (range 18-66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%). CLINICAL IMPLICATIONS: The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery. STRENGTHS & LIMITATIONS: Strenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time. CONCLUSION: The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;17:1033-1040.

The First Experience of Using the Pedicled Labia Minora Flap for Urethral Lengthening in Transgender Men Undergoing Anterolateral Thigh and Superficial Circumflex Iliac Artery Perforator Flap Phalloplasty: A Multicenter Study on Clinical Outcomes.

OBJECTIVE: To describe the novel surgical technique of urethral lengthening in anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty with a pedicled labia minora flap (PLMF) and report on the clinical outcomes. METHODS: Between March 2014 and August 2018, 16 transgender men underwent phalloplasty with a PLMF for urethral lengthening at the Amsterdam UMC (VU university), the Netherlands and the Belgrade University Hospital, Serbia. Patient demographics, surgical characteristics, neourethra characteristics, intra- and postoperative complications, pre-and postoperative voiding evaluation, and the length of hospital stay were retrospectively identified from chart reviews. RESULTS: The mean neourethral length was 16.8 ± 2.3 cm, and the pars pendulans 11.7 ± 2.2 cm. The neomeatus was localized on top of the neophallus in 12 (75%) patients. No intraoperative complications occurred. Urethral fistula formation occurred in 4 (25%) patients and strictures in 6 (37.5%) patients. In 3 (18.7%) patients a (temporary) perineostomy had to be performed. Voiding from a standing position was possible in 9 (56.3%) patients. CONCLUSION: The PLMF for urethral reconstruction, both pars fixa and pars pendulans, in phalloplasty is a feasible surgical technique in transgender men undergoing anterolateral thigh or superficial circumflex iliac artery perforator flap phalloplasty with sufficient labia minora tissue.