Genital Gender-affirming Surgery Research Articles

Correcting gender dysphoria –the anatomical changes with male to female gender reassignment surgery

ABSTRACT Introduction & Objectives Increased Global acceptance of transgender communities, gender-affirming genital reconstructive surgery is becoming more prominent. Formalised education and training however has not quite entered the curriculum of many surgical training programs yet it remains imperative we have an understanding of modified anatomy in out patients. We demonstrate anatomical reconstruction during the transition between male to female anatomy. Methods Patient consent was obtained to take a series of photographs during gender affirming surgery from male to female. Results Contemporary patients receive both spinal and general anaesthesia prior to positioning in standard lithotomy. A perineal incision of approximately 10cm in the midline raphae exposes the corpora and spongiosum. A simple bilateral orchidectomy was performed at the level of the external inguinal ring. A neovaginal cavity was created by firstly dividing the bulbospongiosus attachments to the perineal body and the space is both blunt and sharply dissected. Further dissection is carried out in the avascular perirectal fat plant anterior to the Denonvilliers fascia. During this dissection a 18-22Fr urethral sound is used to apply downward traction on the rectum. A sterile ultrasound sleeve is placed in the rectum to allow bimanual palpation to confirm intact rectal mucosa. A circumferential incision proximal to the glans is performed to aide degloving of the penis. Bucks fasica is left intact and distal penile skin will later be used to form the clitoral hood. The dorsal neurvascular bundle is raised off the corporal bodies but an attachment to the glans remains. A triangular section of dorsal glans is preserved and dissected off the tips of corpora. The penile tissue is then disassembled separating the corpus spongiosum from the corporal bodies. The corpora are amputated at the level of the pubis, remaining erectile tissue destroyed and oversewn for haemostasis. The Urethra is shortened to an appropriate length to allow the dorsal aspect to align between the neoclitoris and neomeatus. The ventral aspect is spatulated to expose the neomeatus. The penile skin flap is invaginated within the neovaginal space and the skin incised to expose the neoclitoris and neomeatus. The penile skin is then anastomosed to the neoclitoris and neomeatus The distal end of the penile skin flaps is oversewn to create a blind ending tube and thus creating the neovagina. Labia Majora are formed by excising excess scrotal skin to create an appropriate contour. This form of neovagina is compared to methods that involve intestinal and peritoneal lining transfer. Conclusions We have outline the stepwise transition of male to female anatomy with a conventional contemporary technique. Creation of a neovagina with penile inversion has become common practice in gender affirming surgery. However there are other means of creating genitalia with alternative tissues, which subspecialised practitioners should be aware. Disclosure Work supported by industry: no.

Effectiveness of Pudendal Nerve Blocks on Postoperative Pain Control and Reduction in Opioid Usage after Gender-affirming Vaginoplasty

ABSTRACT Introduction Postoperative pain control in gender-affirming penile-inversion vaginoplasty (PIV) significantly affects patient experience and satisfaction. With the rise of opioid misuse and over-prescription, non-narcotic adjuncts for post-surgical analgesia are greatly needed. Currently, there is limited data on postoperative pain control after genital gender-affirming surgery (gGAS). Objective To evaluate the effects of preoperative pudendal nerve block on post-op patient-reported pain scores and opioid usage. Methods We retrospectively reviewed all trans-female patients undergoing PIV (+ creation of vaginal canal) at a single institution from August 2017 to July 2021. We recorded patient demographics, operative details, surgical-site pain (using a Likert scale 0-10; 0=no pain, 10=severe pain), and analgesic medication usage. Baseline demographics, pain scores and opioid usage were compared between patients who received pudendal nerve block preoperatively (immediately before the surgical procedure) and those who did not. Independent sample t-tests were used for all comparisons. Results Out of 36 consecutive patients (mean age 36.6 years, mean BMI 25.3 kg/m2) that underwent PIV, 25/36 patients did not have pre-op pudendal nerve block, while the most recent 11/36 patients did. Patient characteristics across cohorts were similar, though the 11 patients who had pudendal nerve block had higher rates of depression (54.5% vs. 28.0%, p=0.043) and hypertension (18.2% vs. 4.0%, p=0.041). Surgical-site pain scores on postop day 0 (POD0) were compared: patients who received pudendal nerve block had 35% lower pain scores than those who did not (3.09 vs. 4.74, p<0.001). Surgical-site pain scores on POD5 were 10% lower in those who received pudendal nerve block (4.16 vs. 4.63, p=0.046). Although patients experienced lower subjective pain scores, average total opioid usage was similar between patients who received pudendal block (MME= 224) versus those that did not (MME= 225). Conclusions Our preliminary data suggests that pudendal nerve blocks are safe and effective adjuncts to improve pain control after gender-affirming PIV, thus improving patients’ postoperative experience. This modality should be further investigated and considered for routine usage in vaginoplasty, and other gGAS perioperative pain regimens. Similar opioid usage despite improved pain scores suggests that in-hospital opioid pain regimens should be more closely tailored to patient-reported pain scores. Disclosure No

Anal Sex and Sexual Function Satisfaction: A Comprehensive (and Critical) Review of Current Medical Literature

ABSTRACT Introduction Anal sex is practiced by people of all sexualities, genders and bodies. Despite common practice, there is relatively little in the clinical literature about anal sex from a more sex-positive “sexual health” perspective. Objective To review the medical literature related to anal intercourse, with attention to the fraction that focuses on the sex positive aspects of anal sex to address and support the sex-based questions and concerns of adults who practice it. Methods A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of synonyms for anal intercourse and combined them with synonyms for sex positivity (sexual satisfaction, erogenous, pleasure, and orgasm). Results We identified a total of 149 articles from the search terms. Of these articles, 59 abstracts were relevant to include and were reviewed. Among these abstracts, 23 manuscripts were reviewed in full and only 20 of these were acceptable for inclusion in this review. Twelve of the twenty papers included in our review were primarily sexual health focused, while the other eight primarily pathology focused. Men who have sex with men (MSM) is the population most considered within the discussion of anal sex. There was a trend towards identifying the influence of external factors on the sexual outcomes of anal sex in MSM, such as condom use, lubricant use, prostate cancer, and drug use. Among women who have sex with men (WSM), 28.4% described the first experience as pleasant and 62.3% continued to practice anal sex. However, almost half of WSM found their first experience to be too painful to continue. Women who have sex with women (WSW) were missing from the discussion of anal sex and sexual health. Conclusions Though the medical literature contains an abundance of studies of “sexual pleasure” and “sexual function” these are commonly hetero-normative and focus on penile-vaginal intercourse, and very rarely include anal stimulation/sex. Given that anal sex is widely practiced, the dearth of sex-positive literature focused on anal sex suggests both that patient's practices of anal sex is less commonly queried by providers, and, that there is a need for medical literature to help inform providers and patients about how to make anal sex safer and more satisfactory. Second to the general U.S. population, other small but important subgroups for whom this is relevant include cancer survivors working to recover their sexual health, and transgender women awaiting gender affirming genital surgery. There is a need for more investigation into the sex positive nature of anal sex. Disclosure No

Requirement of Mental-health Referral Letters for Staged and Revision Genital Gender-Affirming Surgeries: An Unsanctioned Barrier to Care

ABSTRACT Introduction The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental-health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health-insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines. Objective This study investigates insurance requirements for referral letters and their negative impact on care. Methods We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral-letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed. Results Nearly all reviewed U.S. health-insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral-letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Conclusions Insurance companies’ requirements for referral letters impede care and contradict WPATH guidelines. We advocate that referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral-letter requirements for secondary surgeries provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients’ surgical readiness. Significant changes in mental-health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document. Disclosure No

'Modified Phallourethroplasty' as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes.

BackgroundMost complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL).AimTo describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL.MethodsWe describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date.OutcomesAmong patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries.ResultsAll patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57).Clinical ImplicationsThe significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system.Strengths and LimitationsStrengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time.ConclusionIt is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs.Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.

Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique

BackgroundPhalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. AimTo evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. MethodsBetween 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients’ demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. ResultsPatients’ demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. Clinical ImplicationOptimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. Strengths & LimitationThis retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. ConclusionThe Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty.Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661–668.

Weight stigma mitigating approaches to gender-affirming genital surgery

The use of body mass index (BMI) to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested. While BMI thresholds are often meant to be protective, restricting patients from access to surgery can also cause harm. There is a rationale for the continued use of BMI, but the inherent problems with it must also be recognized, including how weight stigma impacts patients’ access to gender-affirming surgery and influences clinical care. This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries, as well as analogous procedures, existing de facto BMI thresholds, and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss. BMI factors into surgical decision-making based on the existing literature, which demonstrates that high BMI is associated with increased surgical risk, including higher incidences of surgical site infections and poor wound healing, as well as the possibility of free flap complications, which are a component of certain genital procedures. This patient population is at higher risk for eating disorders, and it is prudent to find alternatives to requiring patient self-monitored weight management. The impacts of weight stigma should be considered when treating gender-affirming surgery patients, and further data and research are needed to augment shared decision-making and lead to practice change.

Use of Voice Recordings in the Consultation of Patients Seeking Genital Gender-Affirming Surgery: An Opportunity for Broader Application Throughout Surgery?

It has been demonstrated that patient memory for medical information is often poor and inaccurate. The use of audio recordings for patient consultation has been described; however, to our knowledge this is the first reported use of audio recordings in consultation for gender-affirming surgery. Our aim was to determine whether, and specifically how, audio recording the consultation of patients presenting for genital gender-affirming surgery would be of benefit to patients. We began to offer all new patients the opportunity to have their consultations recorded. At the end of the consultation the recording was uploaded to a USB, which was given to the patient to keep. We then surveyed all patients who had received a copy of their recorded consultation to query the utility of having access to an audio recording of their consultation. 71/72 (98.6%) patients who were given the option to have their consultation recorded chose to do so. 50/71 (70%) of patients who had their consultation recorded responded to our survey. Patients reported that having access to a voice recording of their consultation was beneficial and was viewed overwhelmingly positively. Routine audio recording of patient consultations is highly beneficial to patients, with little cost to providers, and should be considered as a valuable addition to the new patient consultation. This approach may have applications in broader clinical contexts where patients face numerous, complex, and nuanced management options. The study would benefit from continued application and a larger (multi-center, international) sample.

Histological study on the influence of puberty suppression and hormonal treatment on developing germ cells in transgender women.

STUDY QUESTIONCan transgender women cryopreserve germ cells obtained from their orchiectomy specimen for fertility preservation, after having used puberty suppression and/or hormonal treatment?SUMMARY ANSWERIn the vast majority of transgender women, there were still immature germ cells present in the orchiectomy specimen, and in 4.7% of transgender women—who all initiated medical treatment in Tanner stage 4 or higher—mature spermatozoa were found, which would enable cryopreservation of spermatozoa or testicular tissue after having used puberty suppression and/or hormonal treatment.WHAT IS KNOWN ALREADYGender affirming treatment (i.e. puberty suppression, hormonal treatment, and subsequent orchiectomy) impairs reproductive function in transgender women. Although semen cryopreservation is generally offered during the transition process, this option is not feasible for all transgender women (e.g. due to incomplete spermatogenesis when initiating treatment in early puberty, in case of inability to masturbate, or when temporary cessation of hormonal treatment is too disruptive). Harvesting mature spermatozoa, or testicular tissue harboring immature germ cells, from orchiectomy specimens obtained during genital gender-affirming surgery (gGAS) might give this group a chance of having biological children later in life. Previous studies on spermatogenesis in orchiectomy specimens showed conflicting results, ranging from complete absence of germ cells to full spermatogenesis, and did not involve transgender women who initiated medical treatment in early- or late puberty.STUDY DESIGN, SIZE, DURATIONHistological and immunohistochemical analyses were performed on orchiectomy specimens from 214 transgender women who underwent gGAS between 2006 and 2018. Six subgroups were identified, depending on pubertal stage at initiation of medical treatment (Tanner stage 2-3, Tanner stage 4-5, adult), and whether hormonal treatment was continued or temporarily stopped prior to gGAS in each of these groups.PARTICIPANTS/MATERIALS, SETTING, METHODSAll transgender women used a combination of estrogens and testosterone suppressing therapy. Orchiectomy specimen sections were stained with Mayer’s hematoxylin and eosin and histologically analyzed to assess the Johnsen score and the ratio of most advanced germ cell types in at least 50 seminiferous tubular cross-sections. Subsequently, immunohistochemistry was used to validate these findings using spermatogonia, spermatocytes or spermatids markers (MAGE-A3/A4, γH2AX, Acrosin, respectively). Possibilities for fertility preservation were defined as: preservation of spermatozoa, preservation of spermatogonial stem cells or no possibilities (in case no germ cells were found). Outcomes were compared between subgroups and logistic regression analyses were used to assess the association between the duration of hormonal treatment and the possibilities for fertility preservation.MAIN RESULTS AND THE ROLE OF CHANCEMature spermatozoa were encountered in 4.7% of orchiectomy specimens, all from transgender women who had initiated medical treatment in Tanner stage 4 or higher. In 88.3% of the study sample orchiectomy specimens only contained immature germ cells (round spermatids, spermatocytes or spermatogonia, as most advanced germ cell type). In 7.0%, a complete absence of germ cells was observed, all these samples were from transgender women who had initiated medical treatment in adulthood. Cessation of hormonal treatment prior to gGAS did not affect the presence of germ cells or their maturation stage, nor was there an effect of the duration of hormonal treatment prior to gGAS.LIMITATIONS, REASONS FOR CAUTIONSince data on serum hormone levels on the day of gGAS were not available, we were unable to verify if the transgender women who were asked to temporarily stop hormonal treatment 4 weeks prior to surgery actually did so, and if people with full spermatogenesis were compliant to treatment.WIDER IMPLICATIONS OF THE FINDINGSThere may still be options for fertility preservation in orchiectomy specimens obtained during gGAS since a small percentage of transgender women had full spermatogenesis, which could enable cryopreservation of mature spermatozoa via a testicular sperm extraction procedure. Furthermore, the vast majority still had immature germ cells, which could enable cryopreservation of testicular tissue harboring spermatogonial stem cells. If maturation techniques like in vitro spermatogenesis become available in the future, harvesting germ cells from orchiectomy specimens might be a promising option for those who are otherwise unable to have biological children.STUDY FUNDING/COMPETING INTERESTNone.TRIAL REGISTRATION NUMBERN/A.

How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System.

IntroductionThe age at which transgender women (TW) and men (TM) first experience gender dysphoria (GD) has not been reported in a U.S. population of adults seeking genital gender-affirming surgery (gGAS). Because gender is an innate part of identity, we hypothesized that untreated GD would be a part of individuals’ earliest memories. Understanding GD onset can help guide providers with when and how to focus care to patients not yet identified as “transgenderAim(i) Determine the age at which transgender adults seeking gGAS first experience GD(ii) Determine the number of life-years that transgender adults spend living with untreated GDMethodsDuring initial consultation for gGAS, we asked patients the earliest age at which they experienced GD and the age at which they had their earliest episodic memory. We also queried history of anxiety, depression, and suicide attempt.Main Outcome MeasuresPatients self-reported their earliest recollections of experiencing GD, earliest memories in general, and history of anxiety, depression, and suicide attempt.ResultsData from 155 TW (mean age 41.3; SD 16.3) and 55 TM (mean age 35.4; SD 10.8) were collected. Most patients (TM: 78%; TW: 73%) reported experiencing GD for the first time between ages 3 and 7 years. For TM the mean age of onset was 6.17 years; for TW it was 6.71 years. A total of 81% of TW and 80% of TM described their first recollection of GD as one of their earliest memories. Mean years of persistent GD before the start of gender transition were 22.9 (TM) and 27.1 (TW). Rates of depression, anxiety, and suicide ideation decreased following gender transition.ConclusionOur findings suggest that GD typically manifests in early childhood and persists untreated for many years before individuals commence gender transition. Diagnosis and early management during childhood and adolescence can improve quality of life and survival.Zaliznyak M, Yuan N, Bresee C, et al. How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System. Sex Med 2021;9:100448.

Anatomical and sexual health considerations among transfeminine individuals who have undergone vaginoplasty: A review.

As acceptance of transgender and gender diverse individuals continues to increase, gender-affirming surgery, a cornerstone in the management of gender dysphoria, is becoming more readily available. HIV and sexually transmitted infections (STIs) disproportionately affect these populations, but there are limited epidemiologic and management data on STIs in people who have undergone gender-affirming genital surgery such as vaginoplasty. This review will provide clinicians with anatomical details about the various vaginoplasty procedures currently being performed, complications associated with these procedures, and an overview of the current literature describing HIV/STI epidemiology among transfeminine individuals who have undergone vaginoplasty.

Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions.

Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated. To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy. A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries). The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or "watershed" procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes. There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605-618.

Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

The World Professional Association for Transgender Health (WPATH) recommends referral lettersfrom two mental health providers within one year of gender-affirming genital surgery(gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirementsare not supported by WPATH guidelines. This study investigates insurancerequirements forreferral letters and their negative impact on care. We retrospectively reviewedallgGAScasesover a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented.The nation's largest insurance companies, including commercial, state-, and federally funded plans, werecontacted to confirm requirements.We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATHpublicationswere reviewed. Nearly all reviewed U.S. health insurance plans requiredannuallyupdated referral letters for each gGAS procedure, including staged and revision surgeries.No updated letters changed clinical management.Referral letter requirements delayed care.WPATH states that letters should not be needed for staged surgeries.Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines.We advocate that, at minimum,referral letters should not be required for surgical consultations or for staged or revision surgeriesafter a patient has already had first-stage primarygGAS. Universalreferral letterrequirementsprovide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition.As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness.Significant changes in mental health status or social situation should prompt surgeons to seek reassessment.WPATH recommendationsregardingreferral lettersshould be clarified and consolidated into a single document.

MP36-06 EFFECTS OF GENDER-AFFIRMING HORMONE THERAPY ON SEXUAL FUNCTION OF TRANSGENDER MEN AND WOMEN

You have accessJournal of UrologySexual Function/Dysfunction: Medical, Hormonal & Non-surgical Therapy II (MP36)1 Sep 2021MP36-06 EFFECTS OF GENDER-AFFIRMING HORMONE THERAPY ON SEXUAL FUNCTION OF TRANSGENDER MEN AND WOMEN Michael Zaliznyak, Marie Lauzon, Jenna Stelmar, Nance Yuan, and Maurice Garcia Michael ZaliznyakMichael Zaliznyak More articles by this author , Marie LauzonMarie Lauzon More articles by this author , Jenna StelmarJenna Stelmar More articles by this author , Nance YuanNance Yuan More articles by this author , and Maurice GarciaMaurice Garcia More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002045.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Transgender patients who present for medical and surgical care are treated with hormone medications and genital surgeries that affect, and often significantly change, sexual function. Although patients rely on providers to counsel them about what effects they might expect, the effects of such treatments on sexual function are not well described or understood. We sought to assess the impact of gender affirming hormone therapy (GAHT) on patients’ sexual function. METHODS: We queried potential changes in orgasm function before and after commencing GAHT (minimum 1 year) among 130 consecutive transgender women (TW) and 33 transgender men (TM). TW presented to either undergo initial vaginoplasty surgery (N=96), or who had previously had vaginoplasty (N=34), and all TM had no prior history of gender affirming genital surgery (n=33). We queried the following specific domains under a uniform condition (masturbation): 1. Lead-time to achieve orgasm, 2. Duration of orgasm, 3. Body location of orgasm sensation; 4. Description of orgasm as either a single or multiple-peak event, 5. Duration of post-orgasm refractory period, and 6. Overall satisfaction with orgasm quality. RESULTS: Within groups by gender, TW and TM cohorts reported similar responses to our inventory before starting GAHT. After GAHT, TW in both pre- and post-vaginoplasty surgery groups reported similar changes in orgasm function: increase in lead-time necessary to achieve orgasm, orgasm duration, and overall orgasm satisfaction; and decrease in post-orgasm refractory period. Similarly, TM reported an increase in duration of orgasm and overall satisfaction with orgasm quality; and a decrease in post-orgasm refractory period. Over half of the TW and TM patients reported experiencing orgasms in additional body locations. Additionally, prior to commencing GAHT, the majority of TM and TW patients reported their orgasms as a short, single-peak event but following GAHT these same patients reported longer and multiple-peak orgasms. Reported dissatisfaction was driven by longer time to orgasm. CONCLUSIONS: Our findings suggest that, with GAHT, TW and TM experience considerable change in several sexual function domains- but also improved overall orgasm quality and satisfaction. Interestingly, among TW, GAHT results in orgasm function and quality that more closely resembles what cis-women describe- something that has not been reported to date. It is important to share such data with patients prospectively before treatments. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e637-e638 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Michael Zaliznyak More articles by this author Marie Lauzon More articles by this author Jenna Stelmar More articles by this author Nance Yuan More articles by this author Maurice Garcia More articles by this author Expand All Advertisement Loading ...

Treatment of Urethral Strictures in Transmasculine Patients.

Background: Urethral strictures are a common complication after genital gender-affirming surgery (GGAS) in transmasculine patients. Studies that specifically focus on the management of urethral strictures are scarce. The aim of this systematic review is to collect all available evidence on the management of urethral strictures in transmasculine patients who underwent urethral lengthening. Methods: We performed a systematic review of the management of urethral strictures in transmasculine patients after phalloplasty or metoidioplasty (PROSPERO, CRD42021215811) with literature from PubMed, Embase, Web of Science and Cochrane. Preferred Reporting Items for Systematic reviews and Meta-Analysis-(PRISMA) guidelines were followed, and risk of bias was assessed for every individual study using the 5-criterion quality appraisal checklist. Results: Eight case series were included with a total of 179 transmasculine patients. Only one study discussed the management of urethral strictures after metoidioplasty. Urethral strictures were most often seen at the anastomosis between the fixed and pendulous urethra. For each stricture location, different techniques have been reported. All studies were at a high risk of bias. The current evidence is insufficient to favor one technique over another. Conclusions: Different techniques have been described for the different clinical scenarios of urethral stricture disease after GGAS. In the absence of comparative studies, however, it is impossible to advocate for one technique over another. This calls for additional research, ideally well-designed prospective randomized controlled trials (RCTs), focusing on both surgical and functional outcome parameters.

Surgical and demographic trends in genital gender-affirming surgery in transgender women: 40 years of experience in Amsterdam.

This was a single-centre, retrospective study of transgender women undergoing genital gender-affirming surgery. A chart study was conducted, recording individual demographics, all genital surgical procedures, and surgical techniques. Procedure incidence, techniques employed, and demographic variations over the years were analysed.

Shaft-only Phalloplasty: Technical Modifications to Optimize Aesthetics.

Summary:Shaft-only phalloplasty (SOP) has been described as an alternative option for phalloplasty. Although traditional phalloplasty represents the most complete form of genital gender-affirming surgery, this variation also carries the greatest surgical risk. Patients may opt for a lower risk SOP for reasons including gender identity, gender expression, sexual function, desire for future childbearing, or minimal gender dysphoria associated with sedentary urination. Further, some patients may, due to associated co-morbidities, not be a candidate for neourethral reconstruction. Forgoing urethral reconstruction also means forgoing the presence of a distal urethral meatus and thereby compromising on one of the basic tenets of phalloplasty surgery—the aesthetic appearance. In an SOP, the flap is usually a simple tube with a purse-string suture placed at the distal end. Another concern can be the insufficient bulk of the phallus due to the absence of the volume added by the inner tube. The purpose of this article is to review our technical modifications that allow for creation of a phallic meatus as well as increasing phallic girth when needed. The most frequently described technique to create a neo-urethra is the tube-within-tube concept. We expanded on this and apply it as a short segment for distal meatal creation in an SOP. Improved aesthetics are achieved by creating the appearance of a phallic meatus and when desired, utilizing a lateral de-epithelialized strip to increase phallic bulk and girth. We hope these technical refinements can assist the surgeon in better meeting the goal of creating an aesthetically pleasing phallus.

Total phallic construction techniques in transgender men: an updated narrative review.

From 2012, the World Professional Association Transgender Health defined a structured therapeutic path and standards of care for transgender patients undergoing genital gender affirming surgery (GGAS). The main goal of GGAS in transgender males is to provide patients with an aesthetically appealing appearance of the neophallus that should allow standing micturition and enabling penetrative intercourse along with erogenous and tactile sensitivity. The optimal procedure should be safe, reproducible and performed in the fewest number of surgical stages. The ideal technique for total phallic construction (TPC) has not yet been demonstrated; TPC remains challenging and, from a functional point of view, it is also make more demanding as yet there are no perfect replacement materials for erectile and urethral tissues. Several procedures and different type of flaps (pedicled and free-flaps) have been proposed and investigated over time to address TPC with significant advances over the years especially after microsurgical procedures introduction. Due to its high complexity TPC is not free from complications. Local tissue ischaemic complications, complete and partial flap loss, donor site morbidity and urethral complications (fistulae and strictures) are reported. This narrative review aims to provide the readers with a contemporary overview of surgical procedures for TPC in transgender males focusing on key surgical steps, as well as surgical and functional outcomes.

P1119 - Patient-reported outcomes after genital gender-affirming surgery with versus without urethral lengthening in transgender men

P1119 - Patient-reported outcomes after genital gender-affirming surgery with versus without urethral lengthening in transgender men

A systematic review of decision aids for gender affirming therapy.

BackgroundTransgender and gender diverse (TGD) persons considering gender affirming therapy have to make many complex medical decisions, potentially without understanding the associated harms or benefits of hormonal and surgical interventions. Further, clinicians are often unaware of how best to communicate information to persons seeking gender affirming therapy. Patient decision aids have been developed to provide evidence-based information as a way to help people make decisions in collaboration with their clinicians. It is unclear whether such tools exist for persons seeking gender affirming therapy. The objective of our systematic review is to search for and determine the quality of any existing patient decision aids developed for TGD persons considering gender affirming therapy, and the outcomes associated with their use.MethodsWe adapted a search strategy for databases using two key concepts “decision support intervention/patient decision aid” and “transgender”. We also conducted a brief online search of Google and abstracts from relevant conferences to identify any tools not published in the academic literature. Following study selection and data extraction, we used the International Patient Decision Aid Standards instrument (IPDASi) to assess the quality of patient decision aids, and the Standards for UNiversal reporting of patient Decision Aid Evaluations (SUNDAE) checklist to assess the quality of evaluations.ResultsWe identified 762 studies; none were identified from Google or conference content. One tool met our inclusion criteria: an online, pre-encounter patient decision aid for transmasculine genital gender-affirming surgery developed in Amsterdam, translated in English and Dutch. The tool met all the IPDASi qualifying criteria, and scored a 17/28 on the certification criteria, and 57/112 on the quality criteria. The efficacy of the patient decision aid has not been evaluated.ConclusionsDespite multiple decisions required for gender affirming therapies, only one patient decision aid has been developed for transmasculine genital reconstruction. Further research is required to develop patient decision aids for the multiple decision points along the gender affirming journey.