Requests for vulvoplasty as gender-affirming surgery: a cross-sectional study in Denmark.

BACKGROUND: Vulvoplasty, described as a promising procedure for transgender and gender diverse (TGD) persons who were assigned male at birth and who, for example, do not need a vagina or who have contraindications to vaginoplasty, is a procedure that in accordance with current guidelines is not offered as genital gender-affirming surgery in Denmark. AIM: In this study we sought to quantify the need for offering vulvoplasty in Denmark. MATERIALS AND METHODS: An online questionnaire was developed. The target group included TGD persons who were assigned male at birth and a minimum of 18 years old. Prior to data collection, the questionnaire was tested with stakeholders from the target group and was subsequently distributed exclusively in closed groups and online fora for TGD persons. Data collection took place from September 1 to October 31, 2022. OUTCOMES: Primary outcomes were type of bottom surgery respondents preferred, when vulvoplasty was chosen, the reason(s) for choosing it. RESULTS: A total of 152 responses were included for data analysis, and 134 records were complete responses. Out of 134 respondents, 35 (26.1%) preferred vulvoplasty. The reasons for preferring vulvoplasty were the belief that there is less risk with the procedure (71%), followed by not wanting to dilate (54%), no need for a vagina (48%), and no need for vaginal penetration (40%). Health issues or other reasons were infrequent (5%). Out of 122 respondents who had not had prior bottom surgery, 106 (86.9%) wanted it in the future. CLINICAL IMPLICATIONS: Some TGD individuals in Denmark could benefit from vulvoplasty and would choose it if offered. STRENGTHS AND LIMITATIONS: Strengths of this study were that the questionnaire was thoroughly tested prior to application and that the survey could only be accessed via closed fora and groups for TDG persons. Limitations were that the sample size was small, and that the response rate could not be estimated. CONCLUSION: The results of this study imply that there is an unmet need for vulvoplasty, and bottom surgery in general, in Denmark.

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients.

BACKGROUND: Current literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies. AIM: To use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes. METHODS: A peer-informed survey of transmasculine peoples' experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image. OUTCOMES: Of the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty. RESULTS: Patients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004). CLINICAL IMPLICATIONS: These results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males. STRENGTHS & LIMITATIONS: These results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire. CONCLUSION: Complication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction. Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800-811.

Imaging in Gender Affirmation Surgery.

PURPOSE OF REVIEW: This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation. RECENT FINDINGS: The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.

Transgender Surgery in Denmark From 1994 to 2015: 20-Year Follow-Up Study.

INTRODUCTION: Gender dysphoria is a mismatch between a person's biological sex and gender identity. The best treatment is believed to be hormonal therapy and gender-confirming surgery that will transition the individual toward the desired gender. Treatment in Denmark is covered by public health care, and gender-confirming surgery in Denmark is centralized at a single-center with few specialized plastic surgeons conducting top surgery (mastectomy or breast augmentation) and bottom surgery (vaginoplasty or phalloplasty and metoidioplasty). AIMS: To report the first nationwide single-center review on transsexual patients in Denmark undergoing gender-confirming surgery performed by a single surgical team and to assess whether age at time of gender-confirming surgery decreased during a 20-year period. METHODS: Electronic patient databases were used to identify patients diagnosed with gender identity disorders from January 1994 through March 2015. Patients were excluded from the study if they were pseudohermaphrodites or if their gender was not reported. MAIN OUTCOME MEASURES: Gender distribution, age trends, and surgeries performed for Danish patients who underwent gender-confirming surgery. RESULTS: One hundred fifty-eight patients referred for gender-confirming surgery were included. Fifty-five cases (35%) were male-to-female (MtF) and 103 (65%) were female-to-male (FtM). In total, 126 gender-confirming surgeries were performed. For FtM cases, top surgery (mastectomy) was conducted in 62 patients and bottom surgery (phalloplasty and metoidioplasty) was conducted in 17 patients. For MtF cases, 45 underwent bottom surgery (vaginoplasty), 2 of whom received breast augmentation. The FtM:MtF ratio of the referred patients was 1.9:1. The median age at the time of surgery decreased from 40 to 27 years during the 20-year period. CONCLUSION: Gender-confirming surgery was performed on 65 FtM and 40 MtF cases at our hospital, and 21 transsexuals underwent surgery abroad. Mastectomy was performed in 62 FtM and bottom surgery in 17 FtM cases. Vaginoplasty was performed in 45 MtF and breast augmentation in 2 MtF cases. There was a significant decrease in age at the time of gender-confirming surgery during the course of the study period.

A systematic review of surgical simulation in gender affirmation surgery.

The burgeoning field of gender affirmation surgery (GAS) has become increasingly complex, challenging plastic surgeons to meet high standards for their patients. During the COVID-19 pandemic, the emphasis on remote learning ushered in the increased use of surgical simulation training, offering residents the opportunity to trial challenging procedures before treating patients. This systematic review seeks to summarize current simulation training models used in GAS. A systematic review was conducted according to PRISMA-P guidelines using the following databases: PubMed, Medline, Scopus, Embase, Web of Science, and Cochrane. Inclusion criteria were English-language peer-reviewed articles on surgical simulation techniques or training related to the field of gender surgery. Skills and techniques taught and assessed, model type, equipment, and cost were abstracted from articles. Our search criteria identified 1650 articles, 10 of which met the inclusion criteria for data extraction. Simulation models included those that involved cadavers (n = 2), synthetic benchtop (n = 5), augmented/virtual reality (n = 2), and 3D-printed interfaces (n = 1). The most common procedure involved breast or pectoral reconstruction and/or augmentation (n = 5), followed by vaginal reconstruction (n = 3). One simulation model involved facial GAS. All models focused on surgical technique and anatomy, three on suture skills or knot-tying, and one on surgical decision-making. The evolving field of GAS requires that plastic surgery trainees be knowledgeable on surgical techniques surrounding this scope of practice. Surgical simulation not only teaches residents how to master techniques but also helps address the sensitive nature of GAS.

Emergency Medicine Considerations in the Transgender Patient.

Transgender patients are at high risk for poor health outcomes and many harbor fear of healthcare settings secondary to prior discrimination, perceived sensationalism, clinician unfamiliarity, and unwanted exams. It is essential to approach transgender patients without judgement and with empathy. Asking open ended questions with explanation as to why your questions are pertinent to their specific care will help create rapport and trust. Through a basic working knowledge of terminology, types of hormone therapy, non-surgical techniques, garments, and surgical procedures typically encountered by such patients, and their respective potential side effects and complications, clinicians can provide quality care to transgender patients.

What do patients want to know about gender-affirming surgery? Analysis of common patient concerns and online health materials.

PURPOSE: Patients considering gender-affirming surgery often utilize online health materials to obtain information about procedures. However, the distribution of patient concerns and content of online resources for gender-affirming surgery have not been examined. We aimed to quantify and comprehensively analyze the most searched questions of patients seeking gender-affirming surgery and to examine the quality and readability of associated websites providing the answers. METHODS: Questions were extracted from Google using the search phrases "gender-affirming surgery," "transgender surgery," "top surgery," and "bottom surgery." Questions were categorized by topic and average search volume per month was determined. Websites linked to questions were categorized by type, and quality of the health information was evaluated utilizing the DISCERN instrument (16-80). Readability was assessed with the Flesch Reading Ease Score and Flesch-Kincaid Grade Level. RESULTS: Ninety questions and associated websites were analyzed. Common questions were most frequently answered by academic websites (30%). Topics included cost (27%), technical details of surgery (23%), and preoperative considerations (11%). Median (interquartile range) DISCERN score across all website categories was 42 (18). The mean readability was of a 12th-grade level, well above the grade six reading level recommended by the American Medical Association. CONCLUSIONS: Online gender-affirming surgery materials are difficult to comprehend and of poor quality. To enhance patient knowledge, informed consent, and shared decision-making, there is a substantial need to create understandable and high-quality online health information for those seeking gender-affirming surgery.

Life-Threatening Bleeding Following Penile Inversion Vaginoplasty: Case Analysis and Practice Improvement.

Background: Gender-affirming surgery is a medically necessary treatment for transgender and gender diverse patients experiencing gender dysphoria. Preliminary data demonstrate an association between gender-affirming surgery and improved mental health outcomes. Penile inversion vaginoplasty is the most frequently performed feminizing bottom surgery in transwomen. Importantly, complications associated with penile inversion vaginoplasty are not uncommon and can be life-threatening. Surgeons and other members of the health care team must be aware of these potential harms. However, there is a paucity of high-quality evidence reported in the literature about the management and breadth of complications regarding feminizing bottom surgery. Case: A healthy 37-year-old woman who was assigned male at birth underwent gender-affirming orchiectomy, penile inversion vaginoplasty, and vulvar reconstruction. During routine vaginal packing removal in the postoperative period, there was an acute arterial bleed in the neovaginal canal, and hemostasis was achieved in the operating room. Conclusions: We review the associated periprostatic anatomy and describe several practice improvements to mitigate postoperative complications.

Anterolateral Thigh Phalloplasty With Staged Skin Graft Urethroplasty: Technique and Outcomes.

OBJECTIVE: 1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS: Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS: Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION: ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

Robotics in Gender Affirming Surgery: Current Applications and Future Directions.

Genital surgery for the treatment of gender dysphoria has undergone significant evolution since its inception in the first half of the 20th century. Robotic approaches to the pelvis allow for improved visualization and reduced abdominal wall morbidity, making the robotic surgical system a very useful tool in the gender affirming genital surgeon's armamentarium. In penile inversion vaginoplasty, robotically harvested peritoneal flaps can be used to augment the vaginal canal, thereby leading to improved vaginal depth, as well as improve operative efficiency by facilitating a two-surgeon approach. In transgender men, the robotic approach to vaginectomy assists with visualization to confirm complete obliteration of the vaginal canal. Robotic surgery will play a central role in the continued evolution of the field of gender affirming surgery.

Examination of current available methods for pain management after vaginoplasty procedures.

Tweetable abstract As vaginoplasties become increasingly prevalent, it is imperative to develop efficient techniques to achieve adequate postoperative pain control. Currently available pain management methods following vaginoplasties are briefly discussed.

Piloting a Genital Affirmation Surgical Priorities Scale for Trans Masculine Patients.

Purpose: Many transgender men seek surgical interventions to create male genitalia. Currently, there is no standardized tool to assess individual goals and expectations for such reconstructive genital surgery. The purpose of this study was to develop and pilot a genital affirmation surgical priorities scale (GASPS) in transgender men seeking metoidioplasty and/or phalloplasty. Methods: The research team developed the GASPS and piloted it with 63 patients seeking reconstructive genital surgery. The scale was constructed after a comprehensive literature review identified key areas of importance, including size, erogenous and tactile sensation, interest in penetrative sex, ability to urinate standing up, and maintenance of orgasmic function. Results were then tabulated and analyzed to look for trends. Results: Sixty three consecutive patients, mean age 24.98 years (standard deviation [SD]=5.87), were administered the assessment. On the 5 point Likert scale, patients were most concerned about being able to stand to urinate (mean=4.38, SD=1.06) and erotic sensation (mean=4.21, SD=0.8). The ability to engage in penetrative intercourse (mean=3.98, SD=1.34), tactile sensation (mean=3.93, SD=1.01), and penis length (mean=3.37, SD=1.18), and girth (mean=3.09, SD=1.20) were not universally considered to be important and responses varied widely. Most patients (86%) stated they had a history of being able to orgasm, and 8% did not know. Feedback suggested that scale use helped patients clarify goals for surgery. Conclusion: GASPS use confirmed the diversity of patient priorities and the importance of individualized goal assessment. It also confirmed previous reports that standing to urinate is a major genital affirmation motivation for many transgender men.

Considerations in Gender-Affirming Surgery: Demographic Trends.

The transgender and nonbinary (TGNB) population is a significant minority, comprising at least 0.6% of the population. Visibility is growing rapidly, especially in younger generations. Gender affirming health care must adapt to this population's needs. Demographic data regarding TGNB health care are limited, but several disparities are clear, stemming from sociopolitical factors, such as external discrimination and insensitive and/or uninformed care. Most self-identifying TGNB patients receive some type of nonsurgical care, including hormonal and/or mental health. Gender-affirming surgery is highly prevalent as well, with at least one-quarter of TGNB people having had some combination of the procedures in this category.