Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know.

OBJECTIVE: To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS: A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS: The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION: Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

Secondary phallic prosthesis placement in transgender patients postmetoidioplasty: a case report on technique and outcome.

Introduction: Gender affirming surgery is common among transgender and gender-nonconforming individuals. Genital gender-affirming surgery is a form of surgery that involves transformation and reconstruction of the genitalia while maintaining urologic and sexual function. Masculinizing genital gender-affirming surgery can involve the removal of the female genital and reproductive organs and the creation of a more masculine appearance by using phalloplasty or metoidioplasty techniques. While metoidioplasty has advantages such as limited scarring and preserved genital sensation and clitoral erection, it may not always guarantee the ability to void while standing or even penetrate a sexual partner. Aim: To describe our method of secondary phallic enhancement after metoidioplasty with a phallic prosthesis. Methods: Our case is based on a 39-year-old transgender male who underwent metoidioplasty with vaginectomy, scrotoplasty, and urethral lengthening. However, the original surgery was complicated by extensive hematoma formation in the suprapubic area and neoscrotum, leading to a buried position of the neophallus. Subsequent surgery was performed to reduce the prepubic fat pad and penoscrotal interposition, but it too was complicated by hematoma formation and wound dehiscence. To maximize phallic elongation, the tethering urethra was removed, and perineal urethrostomy was performed but could not sufficiently alleviate the buried phallus. As a further step to improve the outcome, we proposed the implantation of a specific phallic prosthesis designed for metoidioplasty with testicular prosthesis placement. Surgery was performed as a single procedure through a penoscrotal incision and greatly enhanced genital appearance. Results: Three months after surgery, the patient had good sensation of the phallus and was able to have satisfactory sexual activity with his partner. However, he remained dissatisfied with the amount of prepubic tissue and opted to undergo further liposuction. Conclusion: Phallic prosthesis implantation can be a procedure to improve the condition of multioperated cases of metoidioplasty with resistant phallic burying. Reconstruction with a phallic prosthesis was performed successfully in this case. However, long-term complications and functional outcomes, such as the ability to void while standing or penetrate a sexual partner, remain uncertain. Further experience is needed to determine the efficacy and safety of using a phallic prosthesis as a secondary procedure in patients undergoing metoidioplasty.

Assessment of neophallus length following metoidioplasty.

Background: An increasing number of gender diverse individuals are presenting for gender affirming care. An option for genital gender affirming surgery (gGAS) in transmasculine individuals is metoidioplasty, creating a small neophallus from enlarged clitoral tissue following prolonged testosterone exposure. The goal of this study is to understand factors which contribute to greater exposed neophallus length following metoidioplasty. Methods: We performed a retrospective chart review on patients presenting to a single academic institution who underwent a metoidioplasty. All operations were performed using the Belgrade technique with or without urethral lengthening depending on patient preference. Results: Twenty-seven patients underwent metoidioplasty from 2017-2022. Sixteen had recorded stretched clitoral length (pre-operatively) and exposed neophallus length (post-operatively). The median length of time on testosterone therapy was 4.6 years. The median stretched clitoral length was 5.8 cm, and exposed neophallus length was 6 cm. There was a strong correlation between pre-operative length and post-operative length (ρ=0.9; P<0.0001). There were no correlations between pre-operative length or exposed neophallus length and BMI (ρ=-0.02, P=0.93; ρ=0.05, P=0.83, respectively). Time on testosterone does not correlate with stretched clitoral length nor exposed neophallus length (ρ=-0.28, P=0.15; ρ=-0.35, P=0.18, respectively). Conclusions: Patients considering metoidioplasty often wonder how large their neophallus will be. We found that patients can expect exposed neophallus length to be about 0.6 cm longer than their pre-operative stretched clitoral length. No evidence of association of time on testosterone nor BMI with exposed neophallus length was found. This information is crucial for gender diverse patients to make informed decisions about gGAS.

[Genital gender affirming surgery in trans men]. / Chirurgie génitale de masculinisation des hommes trans.

OBJECTIVE: Genital surgery for masculinisation in the context of gender incongruence is characterised by the reconstruction of male genitalia using multiple surgical techniques - free flap phalloplasty, pedicled flap phalloplasty or metaoidioplasty - which this article aims to describe. MATERIAL AND METHODS: A narrative review of the literature on these trans surgeries was carried out. RESULTS: Each technique has specific advantages and disadvantages, and does not produce the same results in terms of surgical risks, size of the reconstructed phallus, sensitivity, sexual function and urinary function. CONCLUSION: This surgical decision must therefore be shared with the person concerned, based on a clear understanding of their expectations and objectives. Long-term follow-up is recommended.

Decision making in metoidioplasty and phalloplasty gender-affirming surgery: a mixed methods study.

BACKGROUND: Gender-affirming surgical procedures, such as metoidioplasty and phalloplasty for those assigned female at birth, are complex and multistaged and involve risks. Individuals considering these procedures experience greater uncertainty or decisional conflict, compounded by difficulty finding trustworthy information. AIM: (1) To explore the factors contributing to decisional uncertainty and the needs of individuals considering metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) and (2) to inform development of a patient-centered decision aid. METHODS: This cross-sectional study was based on mixed methods. Adult transgender men and nonbinary individuals assigned female at birth at various stages of MaPGAS decision making were recruited from 2 study sites in the United States to participate in semistructured interviews and an online gender health survey, which included measures of gender congruence, decisional conflict, urinary health, and quality of life. Trained qualitative researchers conducted all interviews with questions to explore constructs from the Ottawa decision support framework. OUTCOMES: Outcomes included goals and priorities for MaPGAS, expectations, knowledge, and decisional needs, as well as variations in decisional conflict by surgical preference, surgical status, and sociodemographic variables. RESULTS: We interviewed 26 participants and collected survey data from 39 (24 interviewees, 92%) at various stages of MaPGAS decision making. In surveys and interviews, affirmation of gender identity, standing to urinate, sensation, and the ability to "pass" as male emerged as highly important factors for deciding to undergo MaPGAS. A third of survey respondents reported decisional conflict. Triangulation of data from all sources revealed that conflict emerged most when trying to balance the strong desire to resolve gender dysphoria through surgical transition against the risks and unknowns in urinary and sexual function, appearance, and preservation of sensation post-MaPGAS. Insurance coverage, age, access to surgeons, and health concerns further influenced surgery preferences and timing. CLINICAL IMPLICATIONS: The findings add to the understanding of decisional needs and priorities of those considering MaPGAS while revealing new complexities among knowledge, personal factors, and decisional uncertainty. STRENGTHS AND LIMITATIONS: This mixed methods study was codeveloped by members of the transgender and nonbinary community and yielded important guidance for providers and individuals considering MaPGAS. The results provide rich qualitative insights for MaPGAS decision making in US contexts. Limitations include low diversity and sample size; both are being addressed in work underway. CONCLUSIONS: This study increases understanding of the factors important to MaPGAS decision making, and results are being used to guide development of a patient-centered surgical decision aid and informed survey revision for national distribution.

A comprehensive analysis of YouTube videos on gender affirmation surgery.

INTRODUCTION AND HYPOTHESIS: The objective was to comprehensively analyze YouTube™ videos focusing on genital gender-affirmation surgery (GAS) from the perspective of urologists and gynecologists and to utilize results to create educational videos for transgender individuals with accurate and engaging content. METHODS: A YouTube search was performed using the keywords "Metoidioplasty," "Phalloplasty," "Gender affirmation surgery," "Transgender surgery," "Vaginoplasty," and "Male-to-female surgery." Video results that were duplicated, non-English, of low relevance, non-audio, and/or short duration (under 2 min) were excluded. The upload source was classified as university/nonprofit physician or organization, health information websites, medical advertisement/for-profit organizations, or individual patient experience. Viewer engagement metrics were obtained for each video. Each video was evaluated using the DISCERN, Global Quality Score (GQS), and Patient Education Materials Assessment Tool for audio-visual content (PEMAT A-V) tools. RESULTS: A total of 273 videos were evaluated. Viewer engagement metrics of videos from the patient experience group were higher than those of both universities/nonprofit physicians and medical advertisement/for-profit groups. DISCERN and GQS scores were significantly lower in videos uploaded by the patient experience group than in each of the other upload sources. More videos covered female-to-male (FtM) transition (168, 61.5%) than covered male-to-female (MtF; 71, 26.0%), and both (34, 12.5%). MtF transition videos had significantly higher total view counts than videos from the other groups (p<0.001). The like counts of videos were significantly higher in both MtF transition and FtM transition groups than for videos explaining both types of transition within the same video. The total DISCERN score was significantly lower in FtM transition videos than in the other content groups. Two educational videos were prepared, informed by the tools and results of this study, and hosted on YouTube. CONCLUSIONS: The findings suggest that genital GAS videos with less technical content have higher audience engagement. This information should be used to aid medical organizations when creating YouTube content to provide accurate information to larger audiences in the transgender community.

Updates on metoidioplasty.

AIMS: Metoidioplasty presents a variant of phalloplasty in transmen who require simple and safe genital gender affirmation surgery (GAS). The aim is to evaluate updates on the technique, as well as personal experience. METHODS: The surgical steps of metoidioplasty are removal of the vagina, clitoral straightening and lengthening, urethral lengthening using available flaps and grafts, and creation of the scrotum with testicular prostheses implantation. The surgical goal is to achieve appearance of male genitalia, voiding in standing position, and full erogenous sensitivity. Modifications of the technique have developed due to recent advances in anatomy and new requests from transmen. Besides full metoidioplasty, other variants include metoidioplasty before, after or simultaneously with total phalloplasty. Each variant has its' own advantages, which must be discussed with the candidate preoperatively. RESULTS: A total of 938 transmen with the mean age of 29 years underwent one-stage metoidioplasty between January 2004 and January 2022. In majority of cases (65%) metoidioplasty was performed as a final option, and the length of the neophallus ranged between 4 and 10 cm. Urethral complications occurred in 143 cases, dislocation and rejection of testicular implant in 55 and vaginal remnant in 92 cases. Voiding in standing position was reported in almost all cases (99%), and 12.5% of transmen requested phalloplasty after metoidioplasty. CONCLUSION: Metoidioplasty is a safe, one-stage procedure with good esthetic and functional outcomes. It includes a wide spectrum of variants that can be offered to transmen as a part of genital reconstruction, with goal of achieving patients' satisfaction.

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.

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.

Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients.

Background The authors sought to compare the perioperative morbidity of Stage 1 phalloplasty with asynchronous vs concurrent hysterectomy among transmasculine patients. Methods This retrospective study included transmasculine patients undergoing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy at Kaiser Permanente Northern California from January 1, 2017, to September 9, 2019. The primary outcome was differences in surgical site infection rates. Secondary outcomes included perioperative and other postoperative complications. Comparisons of demographics and outcomes were made by F-tests and Fisher's exact tests. A p value of < 0.05 was considered statistically significant. Results Of 66 transmasculine patients undergoing Stage 1 phalloplasty, 32 (48%) had an asynchronous hysterectomy and 34 (52%) had a concurrent hysterectomy. Overall, surgical site infection rates were low, and there were no significant differences between groups. Patients who had undergone asynchronous hysterectomy had more neourethral complications with Stage 1 phalloplasty than those undergoing concurrent procedures (28% vs 3%, p < 0.05). There were no significant differences in estimated blood loss, length of stay, urinary tract infection, overactive bladder or narcotic use between groups. Conclusion Overall, there were no differences between groups in most postoperative complication rates. Although more neourethral complications were found in those undergoing asynchronous hysterectomy prior to Stage I phalloplasty, this may be partially explained by increasing surgeon experience over time given this difference did not remain statistically significant after the first year of the study period. Gynecologists seeking to provide comprehensive and inclusive care to transmasculine patients should take these findings into consideration when counseling patients planning genital gender affirmation surgery.

Metoidioplasty in Gender Affirmation: A Review.

Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.

Gender Affirmation Surgery, Transmasculine.

Transmasculine genital gender affirmation surgery (GAS) is evolving rapidly due to social and surgical advances over recent decades. Important innovations include the use of free or pedicled sensate tissue flaps with integrated urethra coupled with an improved understanding of how best to offer inclusive care. Disappointingly, most publications have thus far failed to address standardization, classification systems, and prospective trials to help guide shared decision making. This narrative review highlights contemporary techniques, controversies, and innovations while addressing gaps in the literature and future directions for research.

Patient reported outcomes in genital gender-affirming surgery: the time is now.

Transgender and non-binary (TGNB) individuals often experience gender dysphoria. TGNB individuals with gender dysphoria may undergo genital gender-affirming surgery including vaginoplasty, phalloplasty, or metoidioplasty so that their genitourinary anatomy is congruent with their experienced gender. Given decreasing social stigma and increasing coverage from private and public payers, there has been a rapid increase in genital gender-affirming surgery in the past few years. As the incidence of genital gender-affirming surgery increases, a concurrent increase in the development and utilization of patient reported outcome measurement tools is critical. To date, there is no systematic way to assess and measure patients' perspectives on their surgeries nor is there a validated measure to capture patient reported outcomes for TGNB individuals undergoing genital gender-affirming surgery. Without a systematic way to assess and measure patients' perspectives on their care, there may be fragmentation of care. This fragmentation may result in challenges to ensure patients' goals are at the forefront of shared- decision making. As we aim to increase access to surgical care for TGNB individuals, it is important to ensure this care is patient-centered and high-quality. The development of patient-reported outcomes for patients undergoing genital gender-affirming surgery is the first step in ensuring high quality patient-centered care. Herein, we discuss the critical need for development of validated patient reported outcome measures for transgender and non-binary patients undergoing genital reconstruction. We also propose a model of patient-engaged patient reported outcome measure development.

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids.

BACKGROUND: Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI). AIM: We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA. OUTCOMES: Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty. RESULTS: Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction. CLINICAL TRANSLATION: The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery. STRENGTHS & LIMITATIONS: This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center. CONCLUSION: Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.

Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery.

BACKGROUND: Despite high rates of online misinformation, transgender and gender diverse (TGD) patients frequently utilize online resources to identify suitable providers of gender-affirming surgical care. AIM: The objective of this study was to analyze the webpages of United States academic plastic surgery programs for the types of gender-affirming surgery (GAS) procedures offered and to determine how this correlates with the presence of an institutional transgender health program and geographic region in order to identify potential gaps for improvement. METHODS: Online institutional webpages of 82 accredited academic plastic surgery programs were analyzed for the presence of the following: GAS services, specification of type of GAS by facial, chest, body and genital surgery, and presence of a concomitant institutional transgender health program. This data was analyzed for correlations with geographic region and assessed for any significant associations. OUTCOMES: Frequencies of GAS services, specification of the type of GAS by facial, chest, body and genital surgery, presence of a concomitant institutional transgender health program, and statistical correlations between these items are the primary outcomes. RESULTS: Overall, 43 of 82 (52%) academic institutions offered GAS. Whether an institution offered GAS varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .329). Whether institutions that offer GAS specified which anatomic category of GAS procedures were offered varied significantly with the presence of an institutional transgender health program (P < .001) but not with geographic region (P = .235). CLINICAL IMPLICATIONS: This identifies gaps for improved transparency in the practice of communication around GAS for both physicians and academic medical institutions. STRENGTHS & LIMITATIONS: This is the first study analyzing the quality, content, and accessibility of online information pertaining to GAS in academic institutions. The primary limitation of this study is the nature and accuracy of online information, as current data may be outdated and not reflect actuality. CONCLUSION: Based on our analysis of online information, many gaps currently exist in information pertaining to GAS in academic settings, and with a clear and expanding need, increased representation and online availability of information regarding all GAS procedure types, as well as coordination with comprehensive transgender healthcare programs, is ideal. Aryanpour Z, Nguyen CT, Blunck CK, et al., Comprehensiveness of Online Information in Gender-Affirming Surgery: Current Trends and Future Directions in Academic Plastic Surgery. J Sex Med 2022;19:846-851.

Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men.

BACKGROUND: Several treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes. AIM: The aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty. METHODS: A multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers. OUTCOMES: The primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively. RESULTS: Of 96 transmen included in this study with a urethral complication, 44 (46%) experienced a urethral fistula, 31 (32%) a urethral stricture, and 21 (22%) both complications simultaneously. The recurrence-free rate for urethral strictures following endoscopic management (ie, urethral dilation or direct visual internal urethrotomy) was 61% after 1, 50% after 2, and 43% after 3 years, compared to 82% following open treatment options after 1, 2, and 3 years (P = .002). Open treatment options were Heineke-Mikulicz procedure (7/9, 78% success), excision and primary anastomosis (3/3, 100%), 2-stage without graft (9/9, 100%), pedicled flap urethroplasty (1/1, 100%), and buccal mucosa graft urethroplasty (2/4 [50%] single-stage, 1/1 [100%] 2-stage). The recurrence-free rate for small urethral fistulas located at the pendulous urethra was 79% after 1, and 72% after 2 and 3 years, compared to 45% after 1, and 41% after 2 and 3 years for large fistulas, generally located at the urethral anastomoses of the fixed urethra. Treatment options for urethral fistulas were fistulectomy (26/48, 54%), fistulectomy & (redo) colpectomy (7/11, 64%), buccal mucosa graft urethroplasty (1/1, 100%), and retubularization of the urethral plate (3/4, 75%). A colpectomy before or during reoperation of a urethral fistula at the proximal urethral anastomosis showed higher success rates compared to without a colpectomy (7/11 [64%] vs 2/13 [15%] respectively, P = .03). CLINICAL IMPLICATIONS: This study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen. STRENGTHS & LIMITATIONS: Strengths were the relatively large sample size and the overview of multiple treatment options available. Limitations were the heterogeneity of the cohort, underexposure of some surgical modalities, and absence of patient-reported outcomes. CONCLUSION: Open surgical techniques show better long-term outcomes in the management of urethral strictures compared to endoscopic options, and a colpectomy is beneficial before or during urethral fistula repair at the proximal urethral anastomosis. de Rooij FPW, Falcone M, Waterschoot M, et al. Surgical Outcomes After Treatment of Urethral Complications Following Metoidioplasty in Transgender Men. J Sex Med 2022;19:377-384.

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.

Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review.

Background: There is currently a paucity of data on urethral-related outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) with urethral lengthening (UL)and vaginectomy. Methods: A systematic review was performed utilizing MEDLINE, Web of Science, Cochrane Library, Europe PMC, OSF Preprints, and EMBASE. Methodologic quality was scored using Methodological Index for Non-Randomized Studies (MINORS) criteria. Four independent reviewers performed the article evaluation, data extraction, and methodologic quality assessment. Primary outcomes included standing to urinate/pee (STP), penile length, glanular meatus, urethral stricture, fistula, and flap necrosis. Results were summarized qualitatively with descriptive statistics. Results: A total of 2,881 articles of which 11 retrospective reviews of 13 cohorts met criteria; 4.3/16 average (avg) MINORS score. Six metoidioplasty cohorts had an average penile length of 6 cm, 74% reported successful STP, and a quarter developed stricture or fistula. Phalloplasty cohorts included radial forearm flap (RF) and Anterolateral Thigh flap (ALT). Of the 4 RF studies nearly a third developed a stricture or fistula and only one study reported 99% STP with a glanular meatus. Three ALT studies reported no length but had 80-90% STP with a glanular meatus and a quarter with stricture or fistula. Conclusions: Urethral complications in MaPGAS-UL in a cohort with prior vaginectomy are common and variably reported. Patient centered outcome measures as well as clearly defined outcome metrics created in partnership with community members are needed.

Metoidioplasty: Surgical Options and Outcomes in 813 Cases.

Introduction: Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements. Methods: During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction. Results: Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus. Conclusion: Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.

Masculinizing gender-affirming surgery for trans men and non-binary individuals: what you should know.

Gender dysphoria, the discordance between one's gender identity and anatomy, affects nearly 25 million people worldwide, and the prevalence of transgender and non-binary identities is increasing because of greater acceptance and awareness. Because of the improved accessibility to gender-affirming surgery (GAS), many providers will care for patients during and after gender transition. For trans men (female-to-male), GAS represents a combination of procedures rather than a single surgery. The particular combination of masculinizing procedures is chosen on the basis of informed patient-provider discussions regarding the patient's goals and anatomy and implemented through a multidisciplinary team approach. In this review, we describe the common procedures comprising masculinizing GAS to improve delivery of specialized care for this patient population.