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.

Variant genital gender-affirming surgery: a systematic review.

OBJECTIVE: To review the available literature on variant genital gender-affirming surgery (GGAS), including the reasons for performing it, the surgeries themselves and their outcomes. METHODS: A systematic review on the performance of variant GGAS was conducted (International Prospective Register of Systematic Reviews [PROSPERO] identifier: CRD42022306684) researching PubMed, Embase, Web of Science and Cochrane databases from inception up to 31 December 2023. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and risk of bias was assessed for each study using the five-criteria quality assessment checklist. RESULTS: In total 23 case series were included, of which 17 on masculinising and six on feminising surgeries. Patients mainly choose these surgical procedures out of personal desire to avoid risk of complication or because they do not have dysphoria about certain parts of their genitalia. Complications in masculinising surgeries primarily arose from the extended urethra, which could be mitigated through primary perineal urethrostomy. Both phalloplasty and metoidioplasty carried a higher risk of urethral complications when the vagina was preserved. In feminising surgeries, risk of visceral damage and requirement for lifelong self-dilation could be avoided when vulvoplasty was performed without vaginal canal creation. All studies had a high risk of bias. CONCLUSION: This review highlights the importance of variant GGAS and acknowledges the preferences of transgender and gender-diverse individuals. Patients should be informed about the risks and benefits of each step in these procedures.

Patient-reported outcome measures for assessing urinary dysfunction following gender-affirming genital surgery: A narrative review of the literature.

INTRODUCTION: Gender-affirming genital surgery is one of several surgical procedures available to transgender and nonbinary (TGNB) individuals to improve congruence between their gender identity and sex assigned at birth. Despite increasing utilization of these procedures, patient-reported outcome measures (PROMs) to assess subjective outcomes following gender-affirming genital surgery remain limited. Our aim was to provide a synopsis of PROMs currently being used to evaluate urinary outcomes among TGNB patients following gender-affirming genital surgery and to assess each PROM for content that is relevant to TGNB patients. METHODS: A multidatabase search was performed (Embase and PubMed) using search terms that included transgender, patient-reported outcome measures, questionnaire, and gender-affirming surgery. Studies that assessed subjective outcomes related to urinary outcomes and pelvic floor dysfunction following gender-affirming genital surgery were reviewed. Gender-affirming genital surgery included vaginal reconstruction (vaginoplasty) and penile reconstruction (phalloplasty and metoidioplasty). Included studies were evaluated for relevant content items and summarized in table. RESULTS: Our literature search identified 820 unique articles. Twenty-seven full articles were included in the final review. Until recently, measurement tools have been limited to unvalidated ad hoc questionnaires or PROMs developed for other conditions, such as urinary incontinence or vaginal prolapse, that are validated among the predominantly cisgender general population. Of the selected studies, PROMs used to evaluate urinary and pelvic floor dysfunction following gender-affirming genital surgery included self-construced ad hoc questionnaires (10 studies), Amsterdam Overactive Pelvic Floor Scale (four studies), King's Health Questionnaire (two studies), Pelvic Floor Distress Inventory (PFDI)-20 (two studies), Sheffield Pelvic Organ Prolapse (one study), International Consultation on Incontinence Questionnaire-Urinary Incontinence (ICIQ-UI) (one study), and ICIQ-Female Lower Urinary Tract Symptoms (one study). The PFDI-20 asked about the most relevant symptoms to TGNB patients following genital surgery; however, not all cisgender validated questionnaires included important questions about voiding position, splayed or misdirected stream. The Affirming Surgery Form and Function Individual Reporting Measure (AFFIRM) questionnaire is the first PROM for assessing subjective urinary outcomes that are validated for TGNB individuals, and the GENDER-Q is a promising new PROM with the aim of evaluating outcomes following surgical and other gender-affirming treatments. CONCLUSION: Despite recent advancements, a need remains for standardized assessment tools to evaluate pelvic floor dysfunction and urinary symptoms following gender-affirming genital surgery. Questionnaires developed for the general population to assess symptoms of pelvic organ prolapse and other urinary dysfunction do not fully capture the experiences unique to TGNB individuals undergoing this type of surgery. Nonetheless, PROMs validated specifically for TGNB individuals are necessary to more accurately evaluate outcomes of gender-affirming genital surgery, allow for informed patient counseling, and create evidence-based changes to improve these interventions.

Perioperative risk predictors for gender affirming surgery in the NSQIP database.

INTRODUCTION: Gender affirming surgeries (GAS), such as phalloplasty (PLPs) and vaginoplasty (VGPs), are important aspects of medical care for transgender patients. Here, we aim to better characterize patient demographics and surgical outcomes for PLPs and VGPs using the National Surgical Quality Improvement Program (NSQIP). We hypothesized that frailty indices would be predictive of perioperative PLP and VGP risk and outcomes for PLPs and VGPs. MATERIALS AND METHODS: Primary GAS, specifically PLPs and VGPs performed from 2006-2020 were identified in NSQIP. Baseline frailty was based on NSQIP's modified frailty index (mFI) and preoperative morbidity probability (morbprob) variable. RESULTS: Fifty-eight PLPs and 468 VGPs were identified. The overall 30-day complication rate for PLP was 26%, with 17% of total patients experiencing minor complications and 16% experiencing major complications. The overall, minor, and major complication rates for VGP were 14%, 7%, and 9% respectively. Readmissions and reoperations occurred in 7% PLP and 5% VGP patients. No deaths occurred in either group within 30 days. The mFI scores were not predictive of 30-day complications or LOS. NSQIP morbprob was predictive of 30-day complications for both PLP (OR 4.0, 95% CI 1.08-19.59, p = 0.038) and VGP (OR 2.39, 95% CI 1.46-3.97, p = 0.0005). NSQIP's morbprob was also predictive of extended LOS for PLP patients (6.3 ± 1.3 days, p = 0.03). CONCLUSIONS: This study describes patient characteristics and complication rates of PLPs and VGPs. The NSQIP preoperative morbprob is an effective predictor of surgical complications and is better than the mFI.

Determining the outcomes of urethral construction in phalloplasty.

OBJECTIVE: To evaluate the surgical and functional outcomes of urethral reconstruction associated with phalloplasty, depending on the surgical techniques and patient history. MATERIALS AND METHODS: We conducted a single-centre retrospective study including 89 patients who underwent phalloplasty with urethral reconstruction between 2007 and 2018. Patients included were trans-male patients undergoing gender-affirming surgery and cis-male patients undergoing penile reconstruction after trauma, congenital malformation, or cancer. Urethral reconstructions were performed by free flap or skin graft (total or thin). Secondary urethroplasty may include direct vision urethrotomy, excision-anastomosis, or augmentation urethroplasty (skin graft, buccal mucosa graft). Patient demographics, medical history, peri- and postoperative data were collected from patient files. Functional results were evaluated using individual questionnaires. RESULTS: The mean (±sd) follow-up duration was 5.5 (±3.7) years. No significant difference was found for total urethral complication rate (fistula and/or stricture) according to type of urethral construction (70.9% for free flap urethra vs 73.5% for skin graft urethra; P = 0.911), nor according to the patient's grounds for surgery (72.7% for cis-male vs 71.8% for trans-male patients; P = 1). A total of 36 patients (40.5%) answered the functional questionnaire, of whom 80.5% reported usually voiding while standing and 47.5% were comfortable with urinating in public. CONCLUSIONS: Urethral construction in phalloplasty is associated with a high complication and revision rate regardless of the type of urethral reconstruction. Voiding in a standing position is generally possible but should not conceal feeble functional results.

The pedicled gracilis muscle combined with the fascia lata: a preliminary clinical study of a new biomimetic dynamic phalloplasty method.

BACKGROUND: Phalloplasty is a challenging procedure in the field of repair and reconstruction. Traditional skin flap methods with prostheses or autologous tissue implantation are still common; however, with this method the reconstructed phallus is static and has a high risk of complications. AIM: We aimed to use novel methods for phalloplasty to mimic the normal structure of the phallus while maintaining the patient's ability to obtain sufficient hardness and subjective controllability. METHODS: The neophallus comprised the bilateral pedicled neurovascular gracilis muscle, which provided neophallus volitional control; the pedicled fascia lata, which mimicked the tunica albuginea; the pedicled anterolateral thigh flap, which was used to reconstruct the neourethra and neoglans; and the thin split-thickness skin grafted on the surface of the fascia lata. The urethral anastomosis was performed simultaneously. The appearance and function of the neophallus, as well as patient satisfaction, were evaluated postoperatively. OUTCOMES: The biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata was successfully performed in 4 patients. RESULTS: During follow-up at 10-21 months after the procedure, all 4 patients could complete sexual intercourse and were satisfied with the appearance and self-controllability of the neophallus. The size of the neophallus stabilized within 6 months. The tactile, deep touch sensation, and pain sensations of the neophallus partially recovered. All of the patients could stand to urinate. CLINICAL IMPLICATIONS: We used the gracilis muscle combined with the fascia lata to mimic the basic structure of the corpus cavernosum and tunica albuginea and successfully reconstructed the biomimetic dynamic neophallus. STRENGTHS AND LIMITATIONS: This is to our knowledge the first report of biomimetic dynamic phalloplasty using the bilateral pedicled gracilis muscle combined with the fascia lata to mimic the complex structure of the phallus and enable the achievement of erection. However, due to the small number of patients included in this study, the data have no statistical significance. More cases are needed to obtain conclusive data and examine the long-term clinical effects of this procedure. CONCLUSION: Using novel methods for phalloplasty, we successfully maintained the patient's ability to obtain sufficient hardness and subjective controllability without the use of implants, and the preliminary clinical results are encouraging.

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.

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.

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

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

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.

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.

Microsurgical phalloplasty: Anatomical study evaluating the use of the external pudendal vessels as recipients.

The inferior epigastric artery (IEA) is commonly used as a recipient vessel in microsurgical phalloplasty but its use can be associated with abdominal parietal complications (hernia, bulging). To preclude such complications and avoid involvement of the femoral artery, we assessed an external pudendal artery (EPA) as a recipient vessel. We studied the disposition of the external pudendal system and its general anatomy. Then we compared the external diameter of the EPA to that of the first branches of the femoral artery. The most important point was to determine the location of the EPA through a reference line to facilitate a surgical approach. We then illustrated this preliminary study with a clinical case to check the reliability of the identified landmarks. Ten adult cadavers were dissected. The arteries of interest were part of a system consisting of either a common trunk or a duplicated system. The branches of the pudendal system arose from either the femoral artery or the deep femoral artery. On a horizontal reference line passing through the two pubic tubercles, we observed that 83% of EPAs arose between the reference line and 3 cm below it, at the level of a vertical axis centered on the femoral artery. The EPA could be suitable as recipient vessel in phalloplasty owing to its location, size, and ease of dissection. Using it instead of the IEA precludes abdominal parietal complications and reduces scarring in the recipient area.

[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.

[The tube in tube thoracodorsal perforator flap phalloplasty]. / Phalloplastie par Lambeau perforant thoracodorsal « tube in tube ¼.

This article deals with a clinical case of a tube in a tube TDAP phalloplasty in a 38 years old trans-man. While penis reconstruction surgery aroused an efflorescence of different operative techniques, the resulting female to male surgery sees these procedures boil down to two or three flaps. If we usually discuss before surgery about the way to lengthen the urinary tract, as the way to implant later for intercourse; the choice of the donor site remains too systematized. Surgeons commonly focus on the reconstructed site prior to the donor site. In this case, laxity in the back and reliability of direct closure make us harvest the thoracodorsal perforator flap. Dissection of perforators saves muscular function and direct closure afford an aesthetic result less visible than a graft on the forearm. The thin flap we harvest allows tube in tube phalloplasty so that phallus and urethra are being built in the same time. One case has been reported in the literature of thoracodorsal perforator flap phalloplasty with grafted urethra, but no case of tube within a tube TDAP phalloplasty.

[Phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery]. / Phallopoièse par lambeau antébrachial radial libre dans la chirurgie de réassignation sexuelle femme à homme.

AIMS: The aims of this article are to provide an overview of the technique of phalloplasty by radial forearm free flap in the context of female-to-male gender reassignment surgery, with a specific focus on surgical technical details and the prevention of postoperative complications. METHODS: In the light of our 30 years of experience in caring for female-to-male transgender individuals and conducting a critical review of the literature, we exhaustively present our technique of radial forearm free flap phalloplasty in female-to-male gender reassignment surgery. RESULTS: The technique of radial forearm free flap phalloplasty, utilizing a one-stage approach for neourethral and neophallus construction based on the "tube within a tube" principle, not only achieves an aesthetically pleasing appearance of the neophallus resembling a normal penis with tactile and erogenous sensitivities but also yields a functional neourethra and satisfactory penile rigidity using implants for standing voiding and sexual intercourse. This intricate surgical procedure demands not only meticulous execution of all surgical maneuvers but also high-level postoperative care. Despite refinements in technique over recent decades, aesthetic sequelae at the donor site of the flap remain subject to criticism, and postoperative complications, particularly of vascular and urological nature, remain significant. CONCLUSION: Future optimization of the surgical technique for this procedure will be imperative to minimize postoperative complications and establish a true technical "gold standard" for phalloplasty in female-to-male transgender individuals.

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.

Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty.

BACKGROUND: Transgender men who undergo gender-affirming phalloplasty have limited options for attaining sufficient rigidity for sexual penetration. AIM: The goal of this study was to understand interest in and concerns about internal erectile prostheses among transgender men who had undergone phalloplasty. METHODS: As part of a pilot study of an external erectile device, transgender men (n = 15) were surveyed about their interest in, and concerns about, getting an internal prosthesis. Descriptive analyses were performed for structured questions and content analysis was used to analyze open responses. OUTCOMES: Measured outcomes included closed- and open-ended questions assessing patient attitudes about internal erectile prostheses. RESULTS: Before starting the study, approximately half the men stated they were interested in getting an internal device, 20% said they weren't, and 33% said they didn't know. More than half of this postphalloplasty population stated they were somewhat or very concerned about the need for additional surgery (73%), side effects (pain, damage to the phallus; 100%), and the risk of device failure (100%). An additional 47% stated they were somewhat or very concerned about cost and 33% stated they were somewhat or very concerned about finding a surgeon. CLINICAL IMPLICATIONS: There is a need to develop appropriate alternatives to current internal prostheses for penetrative function after phalloplasty. STRENGTHS & LIMITATIONS: Generalizability of results is limited by the fact that data are from men who had enrolled in a pilot study to test an external erectile prosthesis, and as such were explicitly interested in exploring nonsurgical alternatives to attain an erection. The combination of quantitative and qualitative data demonstrates that transgender men's concerns about internal prostheses are grounded in the current evidence. CONCLUSION: Transgender men who have undergone phalloplasty have substantial concerns about the risks of getting an internal prosthesis and there is significant interest in alternatives to current devices. Boskey ER, Mehra G, Jolly D, et al. Concerns About Internal Erectile Prostheses Among Transgender Men Who Have Undergone Phalloplasty. J Sex Med 2022;19:1055-1059.

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.

Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications.

BACKGROUND: Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. AIM: To observe complications with transmasculine penile prosthesis surgery over time and across surgical conditions. METHODS: Retrospective chart review of all transmasculine patients with phalloplasty undergoing penile prosthesis placement between 4/14/2017 and 2/11/2020 (80 patients). OUTCOMES: Independent variables include implant type, previous genital surgeries, and simultaneous genital surgeries. Dependent variables include prosthesis infection and mechanical complication (device malfunction, dislodgement, erosion). RESULTS: There was an overall complication requiring surgery rate of 36% and infection rate of 20% (15/67 for inflatable prostheses and 1/13 for semirigid), with 14% (11/80) experiencing infection requiring removal. Differences in infection rates appeared insignificant across categories of previous surgery or with simultaneous surgery, but we did notice a markedly lower rate for semirigid prostheses compared to inflatable. There was a significant relationship between infection and case number, with the probability of infection decreasing over time. Device loss at 9 months was 21% overall. Preoperative conditions of the neophallus such as prior stricture correction and perioperative factors such as simultaneous clean and clean-contaminated procedures seemed to pose no additional increase in complication rates. CLINICAL IMPLICATIONS: Type and number of prior and simultaneous non-prosthetic surgeries should not be considered as a risk factor for penile prosthesis after phalloplasty for transmasculine patients, even those that are clean-contaminated STRENGTHS & LIMITATIONS: Our cohort size is large compared to currently available studies, although not large enough to generate sufficient power for group comparisons. We have reported every genital surgical step between phalloplasty and penile prosthesis placement and recorded complications with subsequent devices after failure. Patient-reported outcomes were not collected. CONCLUSION: We demonstrate that preoperative conditions of the neophallus, such as prior stricture correction, and perioperative factors, such as simultaneous clean and clean-contaminated procedures, seem to pose no additional increase in complication rates. Our data suggest that surgical experience may further decrease complications over time. B. L. Briles, R. Y. Middleton, K. E. Celtik, et al. Penile Prosthesis Placement by a Dedicated Transgender Surgery Unit: A Retrospective Analysis of Complications. J Sex Med 2022;19:641-649.