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

OBJECTIVES: To investigate the incidence and associated risk factors of venous thromboembolism (VTE) after gender affirming vaginoplasty. METHODS: We searched International Business Machines Corporation (IBM) Marketscan, a commercial claims database, for Current Procedural Terminology and International Classification of Diseases (ICD) procedure codes to identify patients who underwent gender affirming vaginoplasty from 2011-2020. We quantified deep venous thrombosis and pulmonary embolism using ICD-9 and ICD-10 codes found within 90 days after surgery. Univariate and multivariate analyses were performed to establish association between VTE events and age, residency location, and comorbidities. RESULTS: We identified 1588 patients who underwent gender affirming vaginoplasty. Overall, 1.1% of patients experienced a VTE within 90 days following surgery. Patients who experienced postoperative VTE were older, more likely to have had a prior VTE, less likely to be from an urban area, and more likely to have a higher Charlson Comorbidity Index score. Among patients with postoperative VTE, 47.1% had previous VTE. Among patients without a postoperative VTE, 1.3% had previous VTE. CONCLUSION: In patients undergoing gender affirming vaginoplasty, the incidence of postoperative VTE was 1.1%. Older age, rurality, increased comorbidities, and prior VTE were associated with increased risk of postoperative VTE. Current guidelines do not recommend cessation of gender affirming hormone therapy (GAHT) prior to vaginoplasty. Further research is needed to evaluate if certain high-risk patients would benefit from perioperative adjustment of GAHT or perioperative VTE prophylaxis.

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.

Ring Flap Metoidioplasty.

OBJECTIVE: To describe our technique for performing ring flap metoidioplasty in transgender men. METHODS: In a ring flap metoidioplasty, the urethra is created from bilateral anteriorly based labia minora and vestibular flaps. This technique is combined with Ghent scrotoplasty, vaginectomy (distal mucosal excision and proximal mucosal fulguration followed by cavity closure) and perineal masculinization. Suprapubic tube is placed for urinary diversion. To avoid disrupting the anteriorly based urethral pedicles, we do not perform monsplasty, division of the suspensory ligament, or resection of the labial folds adjacent to the penis at the time of ring flap metoidioplasty. Typically, resection of labial folds adjacent to the penis and testicular prosthesis insertion are performed 4-6 months after metoidioplasty. RESULTS: From November 2017 to June 2021, 52 patients underwent metoidioplasty with urethroplasty and concomitant vaginectomy by two surgeons (BF, MC). Median age was 30 years, and median follow-up was 22 months. Urethrocutaneous fistula developed in 7 (13%) patients, 1 of whom had spontaneous closure of the fistula. Urethral stricture occurred in 4 (8%) patients. Fistula repair and/or urethroplasty was required in 8 (15%) patients. Non urethral complications included bacteremia (1 patient) and venous thromboembolism (1 patient). CONCLUSION: Ring flap metoidioplasty allows select patients to obtain masculine appearing genitals and the ability to void standing.