Sexual health in transgender and gender diverse people.

PURPOSE OF REVIEW: Sexual health and sexual function are critical to the wellbeing of cisgender, transgender, and gender diverse populations. To date, there has been only limited patient-focused evaluation of sexual function in transgender and gender diverse patients at several stages in their gender-affirming medical care. There remains a need to better understand the impact of gender affirming medical and surgical therapy on sexual health, and to develop evidence-based treatments to address sexual dysfunction when present. RECENT FINDINGS: The impact of gender-affirming hormone therapy on sexual health is complex and evolves over time on treatment. Despite high incidences of complications, major genital gender-affirming surgeries such as vulvovaginoplasty and penile implant placement after phalloplasty yield high patient satisfaction. While treatments to preserve or restore erections and to improve vaginal lubrication have been trialed based upon literature in cisgender populations, there remains minimal evidence to guide medical treatment of sexual dysfunction ranging from erectile dysfunction to dyspareunia. SUMMARY: There is a continued need for ongoing efforts to develop patient-reported outcome measures and rigorous investigation of sexual health preservation and restoration treatments in transgender and gender diverse populations.

Ulcerative colitis in a transgender woman with a sigmoid neovagina: a case report.

BACKGROUND: Sex reassignment surgery (SRS) is a necessary step in transitioning into the desired gender for male-to-female transgender individuals. This study focuses on a rare complication developed following SRS, aiming to highlight potential complications associated with this procedure. CASE PRESENTATION: This report describes a 49-year-old transgender woman with a history of SRS who developed bloody diarrhea and neovaginal bleeding 10 years later. A colonoscopy revealed features compatible with ulcerative colitis, which was confirmed by a biopsy. CONCLUSIONS: The unpredictable clinical course of this phenomenon may prompt surgeons to reconsider the use of a rectosigmoid colon to create a neovagina. This case report underscores the necessity of long-term monitoring for gastrointestinal complications in transgender women post-SRS when a rectosigmoid colon segment is utilized for neovaginal construction.

Management of vaginoplasty canal complications.

PURPOSE OF REVIEW: Increasing uptake of gender affirming surgery has allowed for a wider breadth of publication examining complications associated with vaginoplasty. This review aims to provide a comprehensive overview of complications associated with vaginoplasty procedures, focusing on intraoperative, early postoperative, and delayed postoperative complications across different surgical techniques. RECENT FINDINGS: Intraoperative complications such as bleeding, injury of the rectum, urethra and prostate, and intra-abdominal injury are discussed, with insights into their incidence rates and management strategies. Early postoperative complications, including wound dehiscence, infection, and voiding dysfunction, are highlighted alongside their respective treatment approaches. Moreover, delayed postoperative complications such as neovaginal stenosis, vaginal depth reduction, vaginal prolapse, rectovaginal fistula, and urinary tract fistulas are assessed, with a focus on their etiology, incidence rates, and management options. SUMMARY: Vaginoplasty complications range from minor wound issues to severe functional problems, necessitating a nuanced understanding of their management. Patient counseling, surgical approach, and postoperative care optimization emerge as crucial strategies in mitigating the impact of complications. Standardizing complication reporting and further research are emphasized to develop evidence-based strategies for complication prevention and management in vaginoplasty procedures.

Phantom sensation in genital gender-affirming surgery: a narrative review.

PURPOSE OF REVIEW: To review findings related to phantom genital sensation, emphasizing phantom sensation in the transgender and gender diverse (TGD) population. We discuss prevalence, presentation and potential implications for sensory outcomes in genital gender-affirming surgery. RECENT FINDINGS: There is a high prevalence of phantom genital sensations in the TGD population. The prevalence varies by body part, approaching 50% in the most frequently reported transgender phantom - the phantom penis. Unlike genital phantoms that occur after trauma or surgery which are often painful, transgender phantoms are typically neutral and often erogenous in experience. Phantom sensation in the TGD population can be an affirming experience and important part of sexual well being and embodiment. SUMMARY: Recent studies have begun to characterize the prevalence and presentations of phantom genital sensations in TGD people, informing our evolving understanding of the sensory experiences of the transgender and gender diverse population. Targeting integration of these centrally-mediated phantom genital sensations with the peripherally generated sensation from genital stimulation may represent one potential avenue to improve sensation and embodiment following genital gender-affirming surgical procedures. Additionally, emerging techniques in modern peripheral nerve surgery targeting phantom pain may offer potential treatment options for painful phantom sensation seen after cases of genital surgery or trauma.

Rectal Injury During Penile Inversion Vaginoplasty.

OBJECTIVE: To evaluate the incidence, management, and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. METHODS: We performed a retrospective review of preoperative, intraoperative and post-operative findings of all patients with RI during GAV from January 2016 to September 2022. Descriptive statistics were calculated using Microsoft Excel. RESULTS: RI occurred in 9 of 1011 primary GAV and colorectal surgery (CRS) consulted in 5 cases, which included sigmoidoscopy with an air leak test in 4 and with temporary bowel diversion in 2. Of the 9, 6 proceeded with full-depth GAV, and 3 were converted to minimal-depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 patients with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full-depth GAV developed vaginal stenosis postoperatively. CONCLUSIONS: RI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full-depth GAV. It is reasonable to complete the full-depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Urethral Outcomes of the Labia Minora Ring Flap for Metoidioplasty and Phalloplasty.

OBJECTIVE: To determine urethral outcomes of single-stage metoidioplasty and radial forearm free flap (RFFF) phalloplasty using the labia minora ring flap for urethral lengthening (UL). METHODS: A retrospective review was performed of patients undergoing single-stage metoidioplasty and RFFF phalloplasty utilizing the labia minora ring flap technique. The ring flap consists of endodermal labia minora tissue ventral to the clitoris and surrounding the vaginal introitus. During metoidioplasty, the ring flap accounts for the entirety of UL. During RFFF phalloplasty, the ring flap becomes the pars fixa (PF) urethra. The primary outcomes measured were rates of fistula, stricture, and surgical revision. RESULTS: Between November 2017 and August 2023, 311 patients underwent metoidioplasty or RFFF phalloplasty (mean follow-up 37 months). Of the 69 metoidioplasties, urethrocutaneous fistulas developed in 11 patients (16%); strictures occurred in 4 (6%). Of the 242 phalloplasty patients, there were 71 fistulas (29%), 56 of which resolved spontaneously. Strictures developed in 44 patients (18%). Twenty-five patients (10%) developed both a stricture and fistula. Surgical repair was required in 8/69 (12%) metoidioplasty patients and in 46/242 (19%) RFFF phalloplasty patients for an overall revision rate of 17%. CONCLUSION: UL during metoidioplasty or RFFF phalloplasty can be accomplished in a single stage using the labia minora ring flap with comparable surgical revision rates to previously described techniques. This approach can also be applied to other phalloplasty techniques. Many fistulas of the PF urethra resolve spontaneously. Higher urethral revision rates were seen in phalloplasty compared to metoidioplasty.

Preoperative hypocoagulative state is an independent risk factor for wound complications and infection in gender-affirming bottom surgeries.

BACKGROUND: Bottom gender affirmation surgery (GAS) involves the risks of bleeding and associated complications. Effective preoperative blood management is paramount across surgical disciplines with international normalized ratio (INR)≤1.5 advised prior to certain surgeries. This study aimed to examine the proportion of patients who were hypocoagulative before they underwent bottom GAS and assess the influence of hypocoagulability on their 30-day post-operative outcomes. METHOD: A retrospective study on female-to-male (FtM) and male-to-female (MtF) bottom GAS was performed based on American college of surgeons national surgical quality improvement program (ACS-NSQIP) database from 2005 to 2021. Patients with hypocoagulation were identified when PTT> 60 s, PT > 30 s, and/or INR> 2. Multivariable logistic regression was used to compare the 30-day perioperative outcomes between patients with hypocoagulation and controls. RESULTS: In this study, 380 patients (182 FtM, 198 MtF) with hypocoagulation and 1176 controls (886 FtM, 310 MtF) were included. Mortality and organ system complications were infrequent in both groups. Patients with hypocoagulation had higher wound complication rates (13.68% vs. 2.64%, aOR 2.858, p < 0.01), especially wound dehiscence (10.00% vs. 0.60%, aOR 4.424, p < 0.01) and organ space infection rates (2.11% vs. 0.26%, aOR 12.77, p < 0.01). Additionally, patients with hypocoagulation had higher sepsis (0.79% vs. 0.09%, aOR 15.508, p = 0.04) and readmission rates (4.74% vs. 2.47%, aOR 1.919, p = 0.03), but lower rates of discharge not to home (7.92% vs. 25.38%, aOR 0.324, p < 0.01). CONCLUSION: Preoperative hypocoagulative state is observed in approximately a quarter of the patients undergoing bottom GAS and is an independent risk factor for increased risks of 30-day wound complications and infections. Therefore, meticulous monitoring of preoperative hemostasis and implementing hemostasis control before surgery may be necessary. Thus, it may be advisable to discontinue oral anticoagulants before the surgery.

Complications and management of excessive phallic turgor following gender-affirming phalloplasty.

Gender-affirming phalloplasty involves flap tubularization, placing unique stresses on the vascularity of the flap. Tubularization renders the flap susceptible to postoperative edema that can lead to excessive turgor that, if left untreated, can compromise perfusion and threaten the viability of the phallic reconstruction. This phenomenon has not been formally described in our literature. We aim to define this entity, described here as "Excessive Phallic Turgor" (EPT), and to outline its incidence, frequency of its underlying etiologies, and sequelae. We conducted a single-center, retrospective review of all phalloplasty operations involving flap transfer performed from December 2016 to May 2023. All patients requiring emergent intervention (bedside suture release, reoperation, or both) due to excessive phallic swelling and impending flap compromise were considered to have EPT. Variables compared between groups included underlying etiology (categorized as congestion, hematoma or swelling), patient demographics, flap type and size, management, length of stay, and postoperative outcomes. Over the study period, 147 phalloplasty operations involving flap transfer for shaft creation were performed. Of those, 15% developed EPT. Age, BMI, flap length, flap circumference, flap surface area, single vs multistage operation, flap tubularization (shaft-only vs tube-within-tube), and flap donor site were not significantly different between the cohort that developed EPT and that which did not. Development of EPT was associated with higher rates of phallic hematoma, surgical site infection, shaft fistula requiring repair, and longer inpatient stays. When EPT develops, prompt diagnosis and alleviation of intraphallic pressure are paramount for mitigating short- and long-term morbidity.

Vaginal Stenosis After Gender-affirming Vaginoplasty: A Systematic Review.

OBJECTIVE: To review the literature and report the incidence of vaginal stenosis (VS) after vaginoplasty and compare the incidence rates by surgical technique and follow-up duration. METHODS: We performed a systematic literature review according to PRISMA guidelines. Original research on primary vaginoplasty was included. Exclusion criteria included non-English studies, mixed cohorts without subgroup analysis, revision vaginoplasty, and papers without stenosis rates. The search was ran in Pubmed, Embase, Scopus, and Cochrane on September 9, 2022. Stenosis rates were compared with descriptive statistics using SPSS. RESULTS: Fifty-nine studies with a cumulative 7338 subjects were included. The overall incidence of VS was 5.83% (range 0%-34.2%). Combining VS with introital stenosis (IS) and contracture results in a cumulative incidence of 9.68%. The rate of VS in the penile inversion vaginoplasty subgroup (PIV) was 5.70%, compared to 0.20% in primary intestinal vaginoplasty. The rate of IS in the PIV group was 3.13% and 4.7% in the intestinal vaginoplasty subgroup. CONCLUSION: The overall rate of VS was 5.83%, which is lower than previously documented. This may be related to the inclusion of more recent studies and analysis limited to primary vaginoplasty. The similar rate of IS in PIV and intestinal vaginoplasty subgroups may be secondary to multiple suture lines and the need for dilation through this anastomosis. Our research demonstrates a need for a standardized definition of VS.

Surgical techniques and outcomes of thyroid chondroplasty in transfeminine individuals: A systematic review.

Thyroid chondroplasty (TC) in facial gender-affirming surgery (FGAS) is aimed at modifying the thyroid cartilage to achieve a more feminine laryngeal appearance. This study evaluated open versus endoscopic techniques to TC and associated outcomes and complications. A systematic review (SR) of articles pertaining to TC was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Twelve articles representing 368 patients were included for analysis. Nine articles described open approaches, and three articles described endoscopic techniques. The rate of total complications was 4.3% (n = 12) in the open approach compared to 15% (n = 13) in the endoscopic approach. Positive esthetic results were reported in 92% of cases performed with the open approach and 90% with the endoscopic approach. In the open approach, seven (2.5%) patients requested additional removal of cartilage, and three (1.1%) requested scar revision. In the endoscopic approach, three (3.7%) patients requested additional cartilage removal. In addition, data of individuals who underwent "cervical tracheoplasty" for gender dysphoria from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was reviewed, and there was no incidence of wound or major complications among patients who underwent tracheoplasty alone. Although the advantage of the endoscopic approach is a scarless neck incision, the rate of complications is higher with the open approach. Endoscopic approaches are still not widely used, and continued investigations are warranted to improve familiarity with this approach and reduce postoperative complications.

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.

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database.

IMPORTANCE: Gender-affirming orchiectomy may be performed in isolation, as a bridge to vaginoplasty, or concurrently with vaginoplasty for transgender and nonbinary persons, although there is a paucity of data on immediate postoperative outcomes on the various procedural approaches. OBJECTIVE: The aim of the study is to compare 30-day surgical outcomes after gender-affirming orchiectomy and vaginoplasty as separate and isolated procedures. STUDY DESIGN: This was a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database to compare surgical outcomes of orchiectomy alone and vaginoplasty alone to concurrent orchiectomy with vaginoplasty using bivariate and adjusted multivariable regression statistics. RESULTS: Concurrent orchiectomy and vaginoplasty were associated with greater 30-day surgical complications compared with orchiectomy alone (15.4% vs 2.9%, P < 0.01) and similar odds of 30-day surgical complications compared with vaginoplasty alone (15.4% vs 11.1%, P = 0.15). On multivariable logistic regression analysis, compared with orchiectomy alone, concurrent orchiectomy and vaginoplasty were associated with higher increased odds of 30-day surgical complications (adjusted odds ratio, 6.48; 95% confidence interval, 2.83-14.86) as well as vaginoplasty alone (adjusted odds ratio 4.30; 95% confidence interval, 1.85-10.00). CONCLUSIONS: This study highlights the perioperative outcomes for isolated versus concurrent gender-affirming orchiectomy and vaginoplasty, demonstrating lower morbidity for orchiectomy alone and similar morbidity for vaginoplasty alone when compared with concurrent procedures. These data will aid health care providers in preoperative counseling and surgical planning for gender-affirming genital surgery, particularly for patients considering concurrent versus staged orchiectomy and vaginoplasty.

Skin Management During Robotic Peritoneal Flap Vaginoplasty for Penoscrotal Hypoplasia Secondary to Pubertal Suppression.

OBJECTIVE: To demonstrate an approach to skin management in cases of gender-affirming vaginoplasty in the setting of penoscrotal hypoplasia. Gender-affirming penile inversion vaginoplasty is a procedure that has traditionally relied upon the use of local genital tissues to both construct the vulva and line the neovaginal canal. Improved and earlier access to pubertal suppression has resulted in an increasing number of individuals presenting for vaginoplasty with penoscrotal hypoplasia and significantly less skin available to accomplish the goals of vaginoplasty. Robotic-assisted gender-affirming peritoneal flap vaginoplasty is one solution that has emerged to help address the challenge of limited skin and provide an alternative source of neovaginal lining. Although this technique provides valuable peritoneal tissue that is used to line a large portion of the neovaginal canal, external vulvar construction remains a challenge. Amid a growing number of cases of penoscrotal hypoplasia secondary to pubertal suppression, there is a need for resources that illustrate strategies to deal with these challenging scenarios. In this video the authors demonstrate their approach to vulvar construction in the setting of penoscrotal hypoplasia secondary to pubertal suppression. METHODS: This video demonstrates an approach to skin management during robotic peritoneal flap vaginoplasty in the setting of limited genital skin secondary to pubertal suppression at Tanner stage 2. RESULTS: Penile inversion vaginoplasty typically relies upon the penile skin tube reaching and reconstructing the introitus, and forming the distal aspect of the neovaginal canal. However, in most cases of penoscrotal hypoplasia secondary to pubertal suppression, there will not be enough length of penile skin to reach or construct the introitus. In these cases, the inverted penile skin tube is also often also too narrow in caliber to accommodate passage of a dilator for neovaginal dilation. These clinical scenarios are challenging and often require construction of the introitus with skin graft, complete splitting of the ventral penile skin tube and optimization of remaining skin to form other critical vulvar structures (labia minora and clitoral hood). CONCLUSION: As individuals with penoscrotal hypoplasia continue to present for gender-affirming vaginoplasty procedures, it is important to adjust traditional approaches to vulvar construction and optimize strategies to manage cases with limited genital skin. In this video the authors present their approach to skin management and vulvar construction in gender-affirming vaginoplasty with penoscrotal hypoplasia secondary to pubertal suppression.

Gender-affirming vaginoplasty: Technical considerations in patients with genital skin deficiency.

INTRODUCTION: Gender dysphoria affects over 1 million American adults. Vaginoplasty is a critical step in gender affirmation, and many patients have insufficient genital skin for full-depth penile inversion vaginoplasty (PIV). We reviewed the literature for technical considerations addressing this and present our data supporting the use of peritoneal flaps (Davydov technique). MATERIALS AND METHODS: A comprehensive review of modern literature was conducted. Second, we present a retrospective case review of our experience with PIV, including data from procedures utilizing peritoneal flaps. RESULTS: We identified 20 original articles, including retrospective and prospective case and cohort studies. Approaches included the application of local soft tissue grafts and flaps, peritoneal flaps, and intestinal segments. Between June 2018 and February 2021, 47 patients at our institution, underwent PIV for the treatment of gender dysphoria. Nineteen of those patients underwent robotic-assisted peritoneal flap procedure in addition to PIV. In this cohort, the mean follow-up was 200.6 ± 124.8 days. Mean neovaginal depth was 13.1 ± 3.0 cm intra-operatively and 11.0 cm at the last follow-up. Twenty-six percent of complications were Clavien Grade 1 or 2; others included wound dehiscence (30.4%), perianal and urethral fistula (13.0%), and neovaginal stenosis (8.7%). The majority of patients reported satisfactory results in terms of sexual function with intact tactile and erogenous sensation. Almost half were able to have penetrative vaginal intercourse at the last follow-up. We did not aim to perform statistical calculations to compare the outcomes of PIV with and without robotic-assisted peritoneal flap augmentation, as the groups were not constructed in that manner. However, it is evident that anatomical and functional results as well as the distribution of postoperative complications seem similar. CONCLUSION: Vaginoplasty is indicated in a growing population of patients with a wide range of medical histories and anatomic variations. Genitourinary reconstructive surgeons must have several methods to achieve full-depth vaginoplasty in cases of inadequate genital skin. Peritoneal flaps serve as a versatile, safe, and functionally advantageous solution.

Evaluation and management of urologic complications following transmasculine genital reconstructive surgery.

AIMS: Transmasculine genital reconstructive surgery involves the creation of a neourethra by way of metoidioplasty or phalloplasty. We aim to describe approaches in identifying complications associated with these procedures as well as the various reparative techniques that can be utilized to reestablish the neourethral tract. METHODS: We prepared a guide to diagnostic and procedural interventions for urologic complications following transmasculine genital reconstructive surgery based on our clinical experience as well as those of our colleagues. We reviewed all current peer-reviewed publications based on this topic. RESULTS: These procedures have a considerable revision rate for urologic complications, which include urethrocutaneous fistulae, persistent vaginal remnant, and urethral strictures. These complications often present simultaneously and require appropriate workup and treatment. CONCLUSIONS: Several reconstructive techniques can be employed to restore the neourethral tract, as we describe in detail.

Outcomes of penile inversion vaginoplasty and robotic-assisted peritoneal flap vaginoplasty in obese and nonobese patients.

AIM: To explore the impact of body mass index (BMI) on the outcomes of gender-affirming vaginoplasty. METHODS: A cohort consisting of all gender-affirming vaginoplasties in our practice between September 27th, 2018, and September 1st, 2022 were identified, and data were retrospectively collected. Patients were classified as obese if their BMI was ≥30 kg/m2 at the time of surgery and nonobese if their BMI was <30 kg/m2 . Complications were assigned a Clavien-Dindo grade and grouped as Grade ≥2 versus Grade ≤1. Patient-reported functional outcomes of intact erogenous sensation, tactile sensation, ability to achieve penetrative vaginal intercourse, and cosmetic satisfaction were assessed. RESULTS: A total of 58 patients with a mean follow-up time of 6.9 months were included. Seventeen patients (mean BMI = 36.8 kg/m2 ) were classified as obese and 41 patients (mean BMI = 25.1 kg/m2 ) were classified as nonobese. No significant differences in outcomes were identified in the obese versus nonobese groups in terms of the incidence of complications. Patient-reported functional outcomes did not differ significantly between the two groups. CONCLUSIONS: Similar results can be achieved with gender-affirming vaginoplasty in obese patients when compared to their nonobese counterparts. Eligibility for this procedure should not be restricted based on BMI alone.

An update on gender-affirming phallus construction using the radial forearm free-flap.

AIMS: The history of phallus construction parallels the advances made in plastic and reconstructive surgery whereby the era of microsurgery revolutionized numerous techniques. In 1993, we reported our early experience in phalloplasty. While the originally presented technique was a modification of the original design reported by Chang and Hwang, we now present further modifications of the past 30 years. METHODS: Through critical review of our technical modifications, as well as others', we present a comprehensive review of elements of the radial forearm free flap phallus construction. RESULTS: A radial forearm free flap is harvested and tubed to form the following components: urethra, shaft, and glans of the neophallus. When excess adipose tissue exists, the excess thickness is accommodated by increasing the proximal width of the flap. To optimize the venous drainage, the radial and ulnar superficial veins as well as the radial deep veins are included within the flap; however, venous flow is optimized through creation of an arteriovenous fistula within neo-glans. To lengthen the native urethra, labia minora and vaginal mucosal flaps are employed at a preliminary stage during vaginectomy. New coronoplasty modifications offer esthetic refinements. Updates in scrotal reconstruction and implantation of erectile devices complete the total genitourinary reconstruction. CONCLUSIONS: Phallus construction has evolved significantly over time. While numerous techniques exist, no standard of care has been identified. Continue surgical evolution will provide modern solutions for problems most often encountered to improve overall outcomes for transgender and gender-diverse patients pursuing masculinizing genitourinary reconstruction.

Wound healing complications in gender-affirming surgery.

AIMS: Gender-affirming surgery consists of a group of surgical procedures for patients presenting with gender incongruence. Patients may seek treatment of anatomic areas including the face, chest, breast, and genitalia. The aim of this scoping review is to provide a general understanding of wound healing to optimize outcomes and manage complications. METHODS: A scoping review was performed to include wound healing principles, outcomes related to gender-affirming surgery, and management of postsurgical wounds. RESULTS: Based on the review performed and clinical experience, strategies to manage complications are recommended. These include an understanding of wound healing principles, patient optimization, and postoperative management. CONCLUSIONS: A comprehensive understanding of wound healing principles, perioperative optimization, and postoperative management of wounds assists the provider in mitigating and managing complications.