Trends of Medicare reimbursement rates for gender affirmation procedures.

BACKGROUND: While nearly 1 in 5 Americans receives health insurance coverage through Medicare, literature suggests that Medicare reimbursement is lagging behind inflation for many plastic surgery procedures. AIM: This article evaluates trends in Medicare reimbursement for gender affirmation procedures. METHODS: The most common gender affirmation procedures performed at an urban academic medical center were identified in this cross-sectional study (level 4 evidence). Five nongender surgery codes were evaluated for reference. A standardized formula utilizing relative value units (RVUs) was used to calculate monetary data. Differences in reimbursement between 2014 and 2021 were calculated for each procedure. OUTCOME: The main outcome was inflation-adjusted difference of charges from 2014 to 2021. RESULTS: Between 2014 and 2021, Medicare reimbursement for gender affirmation procedures had an inflation-unadjusted average change of -0.09% (vs +5.63% for the selected nongender codes) and an inflation-adjusted change of -10.03% (vs -5.54% for the selected nongender codes). Trends in reimbursement varied by category of gender-affirming procedure. The overall average compound annual growth rate had a change of -0.99% (vs -0.53% for the selected nongender codes). The average changes in work, facility, and malpractice RVUs were -1.05%, +9.52%, and -0.93%, respectively. CLINICAL IMPLICATIONS: Gender surgeons and patients should be aware that the decrease in reimbursement may affect access to gender-affirming care. STRENGTHS AND LIMITATIONS: Our study is one of the first evaluating the reimbursement rates associated with the full spectrum of gender affirmation surgery. However, our study is limited by its cross-sectional nature. CONCLUSIONS: From 2014 to 2021, Medicare reimbursement for gender affirmation procedures lagged inflation.

Mandibular Gender Dimorphism: The Utility of Artificial Intelligence and Statistical Shape Modeling in Skeletal Facial Analysis.

BACKGROUND: In gender-affirming surgery, facial skeletal dimorphism is an important topic for every craniofacial surgeon. Few cephalometric studies have assessed this topic; however, they fall short to provide skeletal contour insights that direct surgical planning. Herein, we propose statistical shape modeling (SSM) as a novel tool for investigating mandibular dimorphism for young white individuals. METHODS: A single-center, retrospective study was performed using computed tomography (CT) scans of white individuals, aged 20 to 39 years old. AI-assisted, three-dimensional (3D) mandibles were reconstructed in Materialise Mimics v25.0. We used SSM to generate average 3D models for both genders. Relevant manual anthropometric measurements were taken for the SSMs and individual mandibles. Contour disparities were then represented using 3D overlays and heatmaps. Statistical analyses were performed using unpaired student t testing or Wilcoxon signed rank testing with 95% confidence interval as deemed appropriate by population-level normality assessment. RESULTS: Ninety-eight patients (53 females, 45 males) were included. Male mandibles showed greater bigonial width, intercondylar width, ramus height, and body length [p<0.005]. There was no statistically significant difference in the gonial angle measurements [p=0.62]. All relevant manual individual measurements demonstrated excellent concordance to their SSM counterparts. The 3D overlays of SSMs revealed squarer male chins with more lateral but less anterior projection than their female counterparts. Also, the female mandibles showed smoother transition at the gonial angle. CONCLUSIONS: SSM provides a novel tool to objectively evaluate volumetric and contour dimorphisms between genders. Moreover, this method can be automated, allowing for expedited comparisons between populations of interest compared to manual assessment. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors   www.springer.com/00266 . Bullet points about the importance of this work: Advancing Anthropometric Assessment: Statistical shape modeling (SSM) offers a cutting-edge approach to visualizing gender-specific skeletal anatomic differences for aesthetic and gender-affirming facial surgery. Expediting Comparative Analysis: The workflow established in this paper streamlines the evaluative process, enabling rapid morphologic comparisons between populations. Patient-Centered Care: This study establishes a foundation for the development of SSMs in individualized operative planning.

Feminization Surgery of the Upper Face as the Crucial Factor in Gender Confirmation-Pearls and Pitfalls.

Background: Upper-face feminization is a frequently executed procedure in sexual reassignment surgery, owing to its ability to influence gender identity through adjustments to the hairline, forehead, and peri-orbital area. The procedure includes reducing the hairline, lifting the brows, shaving the orbital region, and applying specific techniques to reduce the frontal bone. This research aims to assess the outcomes, results, and potential complications associated with this surgery among transgender patients. Material and Method: Retrospective review of medical records of 20 patients who attended for facial feminization surgery of the upper face between June 2022 and June 2023, analyzing the previously performed procedures, complications and revision surgery outcomes, and first-time procedures. A literature review was performed for similar studies. Results: 20 patients were included in the study. Among the cohort treated elsewhere (n = 11), the primary complaint was insufficient browbone reduction and anterior frontal sinus table setback. They underwent poorly performed Type 1 reduction when full forehead reconstruction (Type 3/4) was indicated (n = 3), or no reduction was performed during hairline advancement (n = 4). Type 3 forehead reduction with orbital shaving and hairline advancement with simultaneous temporal browlift was most commonly performed in both revision and first-time surgical upper face feminization (n = 15) (75%). Type 1 osteoplasty was performed in four patients (10%), one Type 3 revision surgery was performed after insufficient Type 3 reduction, and one case of shock-induced alopecia was reported, treated with PRP/peptides and a FUE hair graft. Conclusions: The author's preferred technique, 'whole-in-one' upper face feminization by modified bi-coronal incision with frontal trichophytic hyper-beveled incision, provides sufficient insight into the frontal bone and orbital region, the desired forehead osteoplasty and the most efficient insight into the temporal area, enabling safe dissection between fasciae, ligamentous adhesion removal, and periosteal attachment, providing full soft and hard tissue feminization. Nevertheless, feminization procedures should be meticulously planned, and all concerning issues should be addressed during the first surgery in order to prevent revisions, complications, and patient dissatisfaction.

Esthetic Surgery of the Chin in Cis- and Transgender Patients-Application of T-Genioplasty vs. Single-Piece Segment Lateralization.

Background and Objectives: Correction of lower face asymmetry still remains challenging in maxillofacial surgery. This report describes techniques for the lateral transposition of the symphyseal segment to restore lower face symmetry while maintaining gender-related features in cis- and transgender patients. Materials and Methods: A retrospective review of medical records of 31 patients who attended for esthetic corrective surgery after orthodontic camouflage or orthognathic treatment, or during facial feminization of the lower face between June 2021 and June 2023 was performed. Result: All patients underwent lateralization genioplasty (with or without advancement or setback), either with or without narrowing T-osteotomy supplemented with necessary procedures in order to obtain proper facial balance and desired esthetical effects, such as bichectomy, liposuction, and face and neck lift. The mean asymmetry of the chin was 5.15 mm and was surgically corrected either by single segment lateralization or T-shape narrowing genioplasty depending on the gender and esthetical requirements. No complications were reported. Conclusions: Lateral shift genioplasty serves as a powerful tool in primary and secondary corrective surgery for lower face asymmetry that maintains gender-specific facial features. It may serve either as an additive to orthodontic camouflage or a way to correct previous orthognathic surgery pitfalls. The surgeon performing esthetic genioplasty associated with gender-specific expectations must be trained in facelift and facial liposculpting techniques in order to provide the best results and properly choose the right procedures for the right patients.

Thinking outside the box: Alternative techniques for gender affirming phalloplasty.

AIMS: The benefits of gender affirmation surgery have long been established, and with improved access to care, these operations are being performed with increased frequency. As these surgeries continue to be performed, the surgical techniques continue to evolve. Phalloplasty, or the creation of a phallus, remains one of the most complex surgical endeavors in which a variety of factors influence surgical decision making. This article aims to present the lesser known and less frequently performed means of phalloplasty in gender affirming genitourinary reconstruction. METHODS: A literature review of relevant articles, whether case series or more comprehensive, was performed to describe some of the more obscure and less frequently utilized flaps for phalloplasty. RESULTS: The most performed or widely accepted technique is that of the radial forearm free flap, but numerous other options decorate the surgical landscape. With limited and unreliable outcomes data, a standard of care is difficult to establish. CONCLUSIONS: Ultimately, phalloplasty reconstruction should aim to achieve standing micturition and penetrative intercourse, resolute tactile and erogenous sensation, desirable aesthetics of the phallus, and acceptable donor site morbidity. Although some procedures are more commonly performed, the standard for phalloplasty has not been established. Ultimately, approaching this reconstructive puzzle with persistent creativity will unearth more reliable options in the future.

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.

A randomized trial comparing perioperative pelvic FLOor physical therapy to current standard of care in transgender Women undergoing vaginoplasty for gendER affirmation: the FLOWER Trial.

INTRODUCTION AND HYPOTHESIS: There are sparse data on the use of postoperative pelvic floor physical therapy (PFPT) in patients undergoing vaginoplasty. The primary objective of this study was to compare the impact of PFPT on the ease of vaginal dilation after vaginoplasty in transgender women. We hypothesized that patients undergoing PFPT would report better ease of vaginal dilation following surgery. METHODS: This was a randomized trial of transgender women undergoing vaginoplasty. Patients were randomized to either no PFPT or PFPT 3 and 6 weeks following surgery. Subjects completed the Pelvic Floor Disorders Inventory and the Pelvic Floor Impact Questionnaire at baseline and at 12 weeks. At 12 weeks, subjects underwent vaginal length measurement and completed the Patient Global Impression of Improvement and a visual analogue scale (0-10) for ease of vaginal dilation and pain with dilation. A total of 17 subjects in each arm were needed to detect a significant difference in ease of dilation between the two groups. RESULTS: Forty-one subjects were enrolled and 12-week data were available for 37 subjects (20 PFPT, 17 no PFPT). Mean age and BMI were 31 ± 13 years and 24.9 (± 4.0) kg/m2. Subjects were on hormone therapy for a median of 39 (20-240) months and 5 (13.5%) patients had undergone previous orchiectomy. At 12 weeks, the median vaginal length was 12.5 (10-16) cm, reported mean ease of dilation was 7.3 (± 1.6), and pain with dilation was 2.4 (± 1.7). There were no differences in these outcomes or in pelvic floor symptoms between the groups. CONCLUSIONS: In this study, routine postoperative PFPT did not improve outcomes in patients undergoing vaginoplasty.

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.

Mental Health Parity Arguments for Accessing Gender Affirmation Surgery.

Many insurers exclude coverage for transgender individuals. Litigation challenging these exclusions has increased. Most of these cases successfully advance equality claims by arguing that trans exclusions discriminate based on sex. That is, procedures performed on patients for reasons unrelated to gender affirming care are being denied to transgender individuals. There are, however, limitations to this argument. First, some courts may construe care narrowly and hold that some procedures are unique to gender affirming care that have no analog in other contexts. Second, a court that is hostile to the sex discrimination argument might hold that the denial does not arise from sex discrimination, but rather, because of the kind of diagnosis at issue. Further, the sex discrimination argument might force transgender individuals into making claims based on a binarized gender identity which may not conform with their lived experience.Claims based on the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) can address these shortcomings. This Act prohibits insurers from discriminating against mental health diagnoses-for example, procedures that insurers cover because of medical or surgical diagnoses should also be covered if indicated for mental health diagnoses. Gender dysphoria is a recognized mental health diagnosis. Transgender individuals seeking gender affirming care arising from gender dysphoria can thus claim that exclusions of coverage violate the MHPAEA. Some transgender individuals might raise concerns that such an approach would lead to increased medicalization of trans identity. However, an MHPAEA claim would only appear in cases where a transgender individual is voluntarily submitting themselves to medical assistance in order to advance their own autonomy.

[Genital gender affirming surgery in trans women: Vulvo-vaginoplasty review]. / Chirurgie génitale d'affirmation de genre pour les femmes trans : revue des vulvo-vaginoplasties.

INTRODUCTION: A trans woman is a woman who was assigned male at birth, and who has a female gender identity. The majority are requesting a gender affirming genital surgery by vulvo-vaginoplasty. The objective is to review this surgery based on its history, then by presenting the different surgical techniques and their success and complication rates. MATERIAL AND METHODS: A narrative review was performed, based on a bibliography search with keywords from 2000 to 2022 on Pubmed. RESULTS: Vulvo-vaginoplasty for trans women began in 1931, and the first case series date from 1969. The procedure includes excision of scrotal skin, orchiectomy, clitoroplasty, urethroplasty, labioplasty, recto-vesico-prostatic dissection and creation of a vaginal cavity (performed by penile skin inversion and graft, intestine, or peritoneum). Vulvo-vaginoplasty by penile skin inversion (VPPI) is today the reference surgical technique. It represents the vast majority of surgeries performed with the longest follow-up. The majority of trans women are satisfied with the procedure aesthetically (90%) and functionally (80%), with an active sexuality. Major complications are rare (< 5%), they correspond to fistulas or vaginal stenosis. CONCLUSION: VPPI is the gold standard technique with satisfactory overall results, but long-term follow-up is requested.

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.

Gender Affirmation in India-The Current State of Knowledge, Management, Legal and Legislative Situation.

A mismatch between the birth sex of a person and psychological recognition of self (gender) leads to a gender expression, which is at variance with the societal norms, and thus gives rise to gender incongruence (GI). In the past few years, there has been a significant change in demographics, understanding of etiology, management, laws and legislations in the field of GI. The authors, who have been performing gender affirmative surgeries (GAS) since the past 27 years, present their experience in gender affirmation together with the current state of knowledge. Recent studies report a significant rise in prevalence of GI, which is similar to the experience of author and other large volume Gender identity clinics in India and worldwide. This article endeavors to provide the medical professional with the current state of knowledge in the field of GI, so that they are better equipped to optimally manage these patients.

Achieving Correct Axis and Good Depth in Gender Affirming Vaginoplasties by Penile-Perineoscrotal Flap Vaginoplasty.

Objectives Vaginoplasty as a part of feminizing genitoplasty (FG) in transwomen helps alleviate gender dysphoria and improves mental health, sexual and psychosocial functioning, and quality of life in these individuals. Penile inversion technique (PSFV) remains the gold standard procedure for FG with least morbidity but has inherent limitations often resulting in inadequate depth and incorrect (posteroinferior) vaginal axis, precluding sexual intercourse. Material and Methods Over the past 27 years, the senior author has refined his technique considerably incorporating several modifications penile perineo-scrotal flap vaginoplasty (PPSFV) to overcome the limitations in PSFV. Most of these modifications were in place by March 2015. Out of 630 primary FGs, retrospective review of all PPSFV with minimum 6 months follow-up operated during the period March 2015 to July 2020 was done for intra and postoperative complications. Results There were 183 patients who underwent PPSFV during the study period. Average follow-up was 31 (6-62) months. There were no cases of injury to bladder, rectum, urethral stenosis, or neovaginal prolapse. Average operative time was 4 hours and eight (4.37%) patients required blood transfusion. The vaginal depth was 13 to 14 cm or more in 159 (86.88%), 10 to 12 cm in 17 (9.29%), and 7.5 to 9 cm in seven (3.82%) patients. Ten (5.46%) patients complained of intravaginal hair growth. Touch up procedures in the form of anterior commissure and labia plasty were required in 13 (7.10%) patients. All (100%) patients had good clitoral sensitivity and preserved posterosuperior vaginal axis. One-hundred thirty nine (75.96%) patients were able to have satisfactory penetrative sexual intercourse, while 39 (21.31%) had not attempted intercourse and five (2.73%) complained of poor sexual experience on account of inadequate vaginal dimensions. Conclusion PPSFV addresses the limitations in PSFV and results in good vaginal depth and posterosuperior axis, which facilitates penetrative sexual intercourse, at the same time, avoiding potential complications of procedures such as intestinal vaginoplasties.

Male-to-Female Gender Affirmation Vaginoplasty via Laparoscopic Pedicled Peritoneal Flap-An Initial Experience.

Objective The objective of this study was to describe our early experience with laparoscopic pedicled peritoneal flap in patients undergoing male-to-female gender affirmation vaginoplasty. Methods This is a case series of five patients who underwent laparoscopic pedicled peritoneal flap vaginoplasty for gender reaffirmation from October 2020 to July 2021. The clinical and functional outcomes were recorded. Results Two patients underwent the surgery as a primary procedure, and three patients underwent surgery as a secondary deepening procedure after failed penile skin inversion. There were no complications after surgery, and the median length of hospital stay was 3 days. No patient developed vaginal stenosis in 6-month follow-up period, and the median vaginal depth was 6 inches with a healthy vaginal surface. Conclusion Laparoscopic pedicled peritoneal flap can be considered as a first choice in gender affirmation surgeries for patients with inadequate penoscrotal skin or failed penile skin inversion.

A Comparative Study of Urinary Complication Rates before and after the Incorporation of a Urethral Lengthening Technique during Masculinizing Genital Gender Affirmation Surgery.

Objectives Masculinizing genital gender affirmation surgery (MgGAS) consists of operative procedures designed to help the transition of transmen in their journey toward male gender role. Phalloplasty and urethral lengthening remain the most challenging of these surgeries, as the female urethra (4 cm long) must be lengthened to male dimensions (15-29 cm) with anastomosis at two sites, the native urethra/pars fixa urethra and the pars fixa urethra-penile urethra. As a result, there is a high incidence of urinary complications such as strictures and fistulae. Authors incorporated a urethral lengthening technique to reduce urinary complications in MgGAS. They compare the rates of urinary complications rates in cohorts before and after the introduction of this technique. Materials and Methods Authors have been performing phalloplasty since past 27 years, utilizing mainly free radial artery forearm flap (fRAFFp 431 cases) and pedicled anterolateral thigh flap (pALTp 120 cases). A retrospective review and comparison of urinary complications were performed before and after the introduction of their new technique since March 2017. Results There was a statistically significant reduction in the incidence of stricture with and without fistulae (25.94% with conventional and 4.17% with urethral lengthening technique p = 0.001) and fistulae alone (12.81% with conventional and 2.78% with urethral lengthening technique p = 0.011) in fRAFFp cases. In pALTp cases, the respective reductions were 43.08 to 17.07%, p = 0.006 (significant), and 13.85 to 4.88%, p = 0.197 (not statistically significant). Conclusion Over years, the rates of urinary complications in MgGAS have remained constant, varying from 25 to 58% for strictures and 17 to 75% for fistulae as noted by many authors. Authors noted that in most of their cases, strictures occurred at distal pars fixa urethra (DPFU)-penile urethra anastomosis and incorporated a urethral lengthening technique, which lengthens the DPFU by 3 to 5 cm at this anastomotic site, thus significantly reducing the anastomotic tension and the rate of urinary complications.

The gynecologic examination of the transfeminine person after penile inversion vaginoplasty.

As more transfeminine patients (transgender and gender-diverse persons, sex assigned male at birth, who identify on the feminine spectrum of gender) are undergoing gender-affirming penile inversion vaginoplasty, gynecologists, as providers of vaginal care for both native and neovaginas, should be prepared to welcome these patients into their practice and offer long-term pelvic healthcare. Many parts of the anatomy, clinical examination, and aftercare differ from both native vaginas and other neovaginal surgical techniques. Transgender and gender-diverse patients cite a lack of clinician knowledge as a barrier to accessing affirming and competent healthcare. Although publications are emerging regarding this procedure, most focus on intraoperative and postoperative complications. These studies are not positioned to provide long-term pelvic health guidance or robust instruction on typical examination findings. This clinical opinion aims to address that knowledge gap by describing the gynecologic examination in the transfeminine person who has undergone a penile inversion vaginoplasty. We review the anatomic changes with surgery and the neovagina's physiology. We describe the examination of the vulva, vagina, and urethra and discuss special considerations for performing pelvic examinations on patients with a penile inversion vaginoplasty neovagina. We will also address common pathologic findings and their initial management. This clinical opinion originates from the expertise of gynecologists who have cared for high volumes of transfeminine patients who have undergone penile inversion vaginoplasties at tertiary care centers performing gender-affirming genital surgery, along with existing research on postpenile inversion vaginoplasty outcomes. Gynecologists should be familiar with the anatomic changes that occur with penile inversion vaginoplasty gender-affirming surgery and how those changes affect care. Providing transgender patients with comprehensive care including this sensitive examination can and should be part of the gynecologist's scope of practice.

Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty.

BACKGROUND: Estrogen therapy and penile inversion vaginoplasty (PIV) are necessary, life-saving interventions for many transfeminine patients. Patients undergoing PIV are generally at low baseline risk for venous thromboembolism (VTE) based on Caprini Score. Estrogen therapy may increase VTE risk in surgical patients, but its cessation may be psychiatrically dysphoric for transfeminine patients. AIM: This study examines whether perioperative estrogen cessation impacts VTE risk in patients undergoing PIV. METHODS: This was a pre-post study of patients undergoing PIV. From 2014 through 2018, all patients stopped estrogen therapy for 2 weeks before surgery and resumed 1 week postoperatively (group 1). Starting in 2019, all patients continued estrogen therapy perioperatively, with dose reductions for those whose dose was >6 mg/day (group 2). OUTCOMES: The primary outcome was 90-day VTE rate. RESULTS: 178 patients were included in the study, with 117 in group 1 and 61 in group 2. Median Caprini Score was 4 in group 1 (interquartile range: 3-6) and 3 in group 2 (interquartile range: 3-4) (P = .011). Complications per patient were higher in group 1 (2.2 vs 0.9, P < .001), with a longer follow-up (14.1 vs 10.2 months, P < .001). Rates of 90-day VTE were not different between groups (0.0% vs 1.6%, P = .166). CLINICAL IMPLICATIONS: Patients undergoing PIV are generally at low risk for VTE, based on 2005 Caprini Scores. This study provides preliminary evidence that perioperative estrogen therapy continuation does not appear to substantially increase VTE risk in transfeminine patients undergoing PIV with low Caprini Scores, although more investigation is needed to establish true safety. STRENGTHS & LIMITATIONS: Strengths include the pre-post design and single-surgeon experience, high proportion of patients with 90-day follow-up, and relatively large series to understand baseline VTE risk by Caprini Score in a PIV population. The main weakness of this study is its limited power to measure true differences in VTE risk based on estrogen continuation. CONCLUSIONS: This study suggests that perioperative estrogen continuation may be safe for patients undergoing PIV, the overwhelming majority of whom are at low baseline VTE risk. However, clinicians should weigh the magnitude of the risks and benefits of estrogen cessation on a case-by-case basis. Nolan IT, Haley C, Morrison SD, et al. Estrogen Continuation and Venous Thromboembolism in Penile Inversion Vaginoplasty. J Sex Med 2021;18:193-200.

Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review.

BACKGROUND: Feminizing and masculinizing hormone treatments are established components of management in transgender patients. Exogenous hormones have been associated with hemostatic effects, which are well-studied in cis-gender individuals on hormone replacement therapy (HRT). Unfortunately, comprehensive understanding of their effects on venous thromboembolism (VTE) risk in the transgender population is lacking. AIM: This manuscript aims to identify the risk of VTE among transgender individuals undergoing cross-sex hormone therapy. METHODS: A Systematic review of the literature was performed in March 2020 for studies reporting VTE rates in transgender patients undergoing hormone treatment and rates in cis-gender patients on HRT. Data regarding demographics, hormone therapy, and VTE incidence were collected and pooled for analysis. OUTCOME: The primary outcome of interest was the development of a VTE event in association with concurrent hormone administration. RESULTS: Overall, 22 studies were included with 11 reporting VTE rates among transgender patients, 6 in cis-female patients, and 5 in cis-male patients. Data from 9,180 transgender patients (6,068 assigned male at birth [AMAB] and 3,112 assigned female at birth [AFAB]) undergoing hormone treatment and 103,713 cis-gender patients (18,748 female and 84,965 male) undergoing HRT were pooled. The incidence of VTE was higher in AMAB patients compared to AFAB patients (42.8 vs 10.8 VTE per 10,000 patient years; P = .02). The rate of VTE incidences in AMAB patients appears similar or higher than the rate demonstrated in cis-females on HRT. VTE incidence in AFAB patients, however, is similar to the published rates in cis-males on HRT. CLINICAL IMPLICATIONS: AMAB patients on hormone therapy have higher VTE rates than AFAB patients. AMAB and AFAB patients may have similar VTE incidence to cis-female and cis-male patients on hormone replacement therapy, respectively. STRENGTHS & LIMITATIONS: This is the first study to aggregate and quantify the development of VTE events in association with hormone therapy in transgender patients. It places these values in the context of rates published in more widely studied populations. It is limited by its retrospective data and heterogenic data. CONCLUSION: Surgical planning regarding perioperative and postoperative VTE prophylaxis or cessation of hormone therapy should take into account each patient's Caprini risk assessment and the nature of each intervention. Kotamarti VS, Greige N, Heiman AJ, et al. Risk for Venous Thromboembolism in Transgender Patients Undergoing Cross-Sex Hormone Treatment: A Systematic Review. J Sex Med 2021;18:1280-1291.

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.