Genital Gender-affirming Surgery Research Articles

(043) Gender-Affirming Bilateral Orchiectomy Prior to Vaginoplasty versus with Vaginoplasty: A Comparison of Preoperative Goals and Postoperative Satisfaction

Abstract Introduction Gender-affirming bilateral orchiectomy (GA-BO), defined here as either a standalone procedure and/or precursor to vaginoplasty, is associated with a decrease in gender-affirming hormone therapy (GAHT) dosages. In comparison to bilateral orchiectomy at time of gender-affirming vaginoplasty (GA-V), GA-BO is associated with shorter waitlist times, procedure duration, and outpatient recovery. While objective benefits of GA-BO have been described, there is limited qualitative data that assesses the preoperative goals and postoperative satisfaction of patients who elect GA-BO. We aim to assess the decision-guiding factors that led patients to select GA-BO, and to compare measures of patient satisfaction between GA-BO and GA-V patients. Objective To assess the decision-guiding factors that led patients to select gender-affirming bilateral orchiectomy before vaginoplasty versus with vaginoplasty, and to compare measures of patient satisfaction between groups. Methods A retrospective chart review identified 170 patients who underwent GA-BO (n=106; 64%) or GA-V (n=64; 36%) between 4/2017 and 12/2020 at our institution. Patients were emailed a link to an anonymous, online questionnaire (QualtricsTM). Results 136/170 (80%) patients completed the questionnaire: 86/136 (63%) respondents were GA-BO patients and 50/136 GA-V (37%). 78/86 (91%) of GA-BO respondents had either subsequently undergone vaginoplasty, or, planned to do so in the future. For patients who later underwent vaginoplasty, the mean reported time interval between GA-BO and vaginoplasty was 15 months [Range: 1–34 months]. Respondents prioritized the following expectations in their decision to undergo GA-BO: potential to decrease GAHT medications and dosages (reported as important by 67%), low rates of complications (56.5%), short recovery time (51.6%), and low postoperative pain (46.2%). GA-BO and GA-V patients reported high postoperative improvement in various indices of gender dysphoria and body image, with only 1/4 indices of gender dysphoria differing significantly between the two groups (Figure 1). Unsurprisingly, GA-V patients reported a significantly greater improvement in 3/3 body image indices. Conclusions GA-BO is a low-risk procedure that provides a more immediate option to decrease gender dysphoria and improve QOL. All patients who were assigned male at birth and are interested in genital gender-affirming surgery should be made aware of the advantages of GA-BO and offered GA-BO alongside GA-V. Disclosure No.

(041) What Penis Size and Glans-Shape do Cis and Trans Men and Women Prefer?

Abstract Introduction The ideal length, circumference, and appearance of the penis are important to the self-confidence and body image of most men. To date, only 2 works have assessed preferred erect (but not flaccid) penis length, and only among cis-gender women. No study has evaluated preferred aesthetics--ideal erect and flaccid penile length, or, glans-shape and size preferences among cis-gender and transgender and non-binary individuals. These preference domains are especially important with genital gender-affirming surgery (gGAS) because length and glans-shape are entirely elective and technique-based, and help define neophallus appearance. Lastly, outlining the planned glans shape on a neophallus can be technically challenging, and, to date no publications have reported offering trans men input/choices. Objective 1) To query ideal for flaccid and erect penis length across all individuals, across cis- and transgender identities; 2) Determine specific likes/dislikes among all subjects for 7 different glans-shape examples; and 3) Among men undergoing phalloplasty, creation of glans-shape stencils for use in the OR, as a means to offer patients choice, and, to ensure that the final product aligns with patient’s choice. Methods An anonymous, online survey (QualtricsTM) evaluated glans preferences among 7 realistic prosthetic penis models shown. Participants were queried about their age, sex, gender, sexual orientation, and their ideal flaccid and erect penis length. Stencils were created based on 6 penis models. Subsequently, 7 transmen-subjects were able to choose the most-preferred glans shape and the stencil was applied before glansplasty surgery (Figure 1). Glansplasty results were assessed 12-weeks post-operatively (Figure 1c;E-F). Results 74 participants took the survey, (mean age of 35.3, Range: 23–59). 43/74 (58%) self-identified as men, and 28/74 (38%) identified as men, including 7 trans men (Table 1a). Men reported a mean ideal flaccid and erect length of 4.5 and 6.3-inches, respectively, while women reported a length of 5.2 inches and 6.16-inches, respectively. Women had a wider range of responses for both ideal flaccid and erect penile length (p>0.05) (Table 1b). For glans-shape preference, across all groups (independent of sex or sexuality), the “most-liked” options were A and E, and “most-disliked” were B and D (Figure 2). Among the 7 transmen undergoing glansplasty, 5/7 (71%) chose glans-shape C, and 1/7 (14%) each chose glans-shapes A and E, for their own phallus. Conclusions This is the first study to survey both men and women regarding ideal erect penile length, and the first regarding ideal flaccid penile length and glans-shape preferences. Our data suggests that the ideal erect and flaccid length are longer (within 2SD) than the mean values for cis-men of 5.16-inches and 3.61-inches respectively, (Miles et al., BJUI, 2014) but there is greater variability among women’s responses. Regarding glans-shape, most preferred a more tapered, bullet-like tip for the distal glans and a less prominent glans ridge. Finally, our glansplasty stencils are easy to use, yield excellent aesthetic results, and the option to choose their own glans shape is highly appreciated by patients. Disclosure No.

(126) Medicolegal Considerations for Patients Undergoing Urologic Surgical Interventions and the Development of an Audio-Recording Application for use During Genital Gender-Affirming Surgical Consultation

Abstract Introduction Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results A PubMed search yielded 921 results on "medical malpractice claims" from 2013–2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010–2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020–2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure No.

(272) Evidence-Based Strategies for Preventing Lower-Limb Complications Secondary to Prolonged use of the Dorsal Lithotomy Position

Abstract Introduction Patient positioning at the time of surgery plays a critical role in determining patient outcomes. Specific to patients undergoing genital gender-affirming surgery (gGAS), these patients are required to be placed in the lithotomy position to access the pelvis and perineum for their procedures. Lower-extremity injury due to prolonged surgical time in the lithotomy position can have significant post-operative morbidity affecting patient outcomes. This risk is increased in patients undergoing gGAS procedures due to high surgical complexity and especially long operative times as compared to other surgical procedures. Careful attention must be placed on the patient’s specific position perioperatively due to potential injury risk. Prolonged stasis can cause injuries ranging from mild soft-tissue injuries which rapidly resolve, such as mild pressure injuries to bony prominences, to severe injuries including pressure ulcers, nerve injuries, rhabdomyolysis, and compartment syndrome. These complications can have lasting impact on the patient, with associated morbidity and mortality risk, and can also impact healthcare systems through additional dollars spent caring for patients who suffer these complications and their associated rehabilitation, and legal recourse on behalf of the patient who suffered these severe complications. Objective Our study aimed to describe our technique for preventing lower extremity injuries in the dorsal lithotomy position, and to evaluate our positioning-related post-operative complications and rates. Methods We describe our technique for lower-limb positioning in the dorsal lithotomy position, with an emphasis on injury prevention for patients undergoing gGAS. We assessed positioning-related outcomes and complications among patients undergoing gGAS for prolonged periods (>300 minutes) in the lithotomy position between January 2017 to March 2023. Results A total of 227 patients underwent 310 gGAS procedures were included in our study (156 masculinizing: 154 feminizing gGAS procedures). Mean operative time was 495.5 minutes +/- 156.5 minutes (SD) (Range 300–1095 minutes) (Table 1a). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-operatively. No (0%) patients had major or chronic complications including chronic nerve injury, pressure ulcers, rhabdomyolysis or compartment syndrome (Table 1b). Our patient positioning employs the use of ½ inch foam placed to surround the lower extremity, ensuring that all at-risk areas of compression are adequately protected when placing the patient’s leg in the Allen stirrups whilst in the lithotomy position (Figure 1). In addition, a perioperative list is also utilized with regular leg checks every 1.5–2 hours with nursing documentation and also, ensuring patients are able to move their lower extremities without any pain post-operatively (Figure 2). Conclusions Our study is the first to describe a specific technique and outline strategies for protecting the lower extremities to prevent injuries in patients undergoing prolonged surgical procedures in the lithotomy position. The low complication rates associated with our technique warrants attention to further refine this technique, and, to integrate these strategies into operating-room programs across diverse specialties. Disclosure No.

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

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

(345) Sexual Health Outcomes After Gender Affirming Metoidioplasty: A Systematic Review

Abstract Introduction Previous studies have evaluated surgical outcomes and aesthetic results of Genital Gender Affirming Surgery (GGAS) while few studies have examined sexual outcomes after GGAS. Objective We sought to systematically review the literature on sexual health outcomes of metoidioplasty in the transmasculine population. Methods PubMed, Embase, and Web of Science was used to identify studies through April 29, 2022 based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Figure 1 shows search terms, inclusion, and exclusion criteria. Results Fourteen papers were included. Findings on arousal/desire ranged from 86% (n=48) reporting desire for sex to 100% (n=1455) reporting no difficulty in arousal. Preserved erogenous sensation and no issues with masturbation was reported in 100% of people across studies (n=1164;1455). Orgasm ability ranged from 66-70% (n=115) who were able to orgasm during sexual activity or masturbation to 100% (n=1455) who had no problems with orgasm. Orgasm satisfaction was found to be 100% (n=48). A study found that 80% (n=15) had challenges with erections, with 83% (n=18) of Erection Hardness Scores were ‘larger but not hard’ or ‘hard but not hard enough for penetration.’ Earlier studies reported 100% of people had an erection (n=1599), and ratings of ‘satisfied’ or ‘partially satisfied’ in 94% (n=145). Across studies, 87-100% were unable to have penetrative sex (87% unable, n=15; 100% unable, n=737). For some, the inability to penetrate was the most dissatisfactory aspect of the metoidioplasty for 39% of patients (n=28). Conclusions Current literature on transmasculine people undergoing GGAS shows high ratings of arousal/desire, preservation of erogenous sensation, masturbation, and ability to orgasm following metoidioplasty. Data on the ability and adequacy of erection is less definitive. Overall ratings of sexual health appear high, but inability to have penetrative sex remains a source of persistent dissatisfaction for some. Further studies using surveys validated in transmasculine populations are needed to definitively describe sexual function after GGAS. Disclosure No.

(348) Gender-Affirming Bilateral Orchiectomy Prior to Vaginoplasty versus with Vaginoplasty: A Comparison of Preoperative Goals and Postoperative Satisfaction

Abstract Introduction Gender-affirming bilateral orchiectomy (GA-BO), defined here as either a standalone procedure and/or precursor to vaginoplasty, is associated with a decrease in dosage of gender-affirming hormone therapy (GAHT). In comparison to bilateral orchiectomy at time of gender-affirming vaginoplasty (GA-V), GA-BO is associated with shorter waitlist times, procedure duration, and outpatient recovery. While objective benefits of GA-BO have been described, there is limited qualitative data that assesses the preoperative goals and postoperative satisfaction of patients who elect GA-BO. We aim to assess the decision-guiding factors that led patients to select GA-BO, and to compare measures of patient satisfaction between GA-BO and GA-V patients. Objective We aim to assess the decision-guiding factors that led patients to select GA-BO, and to compare measures of patient satisfaction between GA-BO and GA-V patients. Methods A retrospective chart review identified 170 patients who underwent GA-BO (n=106; 64%) or GA-V (n=64; 36%) at our institution between 4/2017 and 12/2020. Patients were emailed a link to an anonymous, online questionnaire (QualtricsTM). Results The questionnaire was completed by 136/170 (80%) patients: 86/136 (63%) respondents were GA-BO patients and 50/136 GA-V (37%). 78/86 (91%) of GA-BO respondents had either subsequently undergone vaginoplasty, or, planned to do so in the future. For patients who later underwent vaginoplasty, the mean reported time interval between GA-BO and vaginoplasty was 15 months [Range: 1-34 months]. Respondents prioritized the following expectations in their decision to undergo GA-BO: potential to decrease GAHT medications and dosages (reported as important by 67%), low rates of complications (56.5%), short recovery time (51.6%), and low postoperative pain (46.2%). GA-BO and GA-V patients reported high postoperative improvement in various indices of gender dysphoria and body image, with only 1/4 indices of gender dysphoria differing significantly between the two groups (Figure 1). Unsurprisingly, GA-V patients reported a significantly greater improvement in 3/3 body image indices. Conclusions GA-BO is a low-risk procedure that provides a more immediate option to decrease gender dysphoria and improve QOL. All patients who were assigned male at birth and are interested in genital gender-affirming surgery should be made aware of the advantages of GA-BO and offered GA-BO alongside GA-V. Disclosure No.

(139) What Penis Size and Glans-shape do Cis and Trans Men and Women Prefer?

Abstract Introduction The ideal length, circumference, and appearance of the penis are important to the self-confidence and body image of most men. To date, only 2 works have assessed preferred erect (but not flaccid) penis length, and only among cis-gender women. No study has evaluated preferred aesthetics--ideal erect and flaccid penile length, or, glans-shape and size preferences among cis-gender and transgender and non-binary individuals. These preference domains are especially important with genital gender-affirming surgery (gGAS) because length and glans-shape are entirely elective and technique-based, and help define neophallus appearance. Lastly, outlining the planned glans shape on a neophallus can be technically challenging, and, to date no publications have reported offering trans men input/choices. Objective 1) To query ideal for flaccid and erect penis length across all individuals, across cis- and transgender identities; 2) Determine specific likes/dislikes among all subjects for 7 different glans-shape examples; and 3) Among men undergoing phalloplasty, creation of glans-shape stencils for use in the OR, as a means to offer patients choice, and, to ensure that the final product aligns with patient’s choice. Methods An anonymous, online survey (QualtricsTM) evaluated glans preferences among 7 realistic prosthetic penis models shown. Participants were queried about their age, sex, gender, sexual orientation, and their ideal flaccid and erect penis length. Stencils were created based on 6 penis models. Subsequently, 7 transmen-subjects were able to choose the most-preferred glans shape and the stencil was applied before glansplasty surgery (Figure 1). Glansplasty results were assessed 12-weeks post-operatively (Figure 1c; E-F). Results 74 participants took the survey, (mean age of 35.3, Range: 23–59). 43/74 (58%) self-identified as men, and 28/74 (38%) identified as men, including 7 trans men (Table 1a). Men reported a mean ideal flaccid and erect length of 4.5 and 6.3-inches, respectively, while women reported a length of 5.2 inches and 6.16-inches, respectively. Women had a wider range of responses for both ideal flaccid and erect penile length (p>0.05) (Table 1b). For glans-shape preference, across all groups (independent of sex or sexuality), the “most-liked” options were A and E, and “most-disliked” were B and D (Figure 2). Among the 7 transmen undergoing glansplasty, 5/7 (71%) chose glans-shape C, and 1/7 (14%) each chose glans-shapes A and E, for their own phallus. Conclusions This is the first study to survey both men and women regarding ideal erect penile length, and the first regarding ideal flaccid penile length and glans-shape preferences. Our data suggests that the ideal erect and flaccid length are longer (within 2SD) than the mean values for cis-men of 5.16-inches and 3.61-inches respectively, (Miles et al., BJUI, 2014) but there is greater variability among women’s responses. Regarding glans-shape, most preferred a more tapered, bullet-like tip for the distal glans and a less prominent glans ridge. Finally, our glansplasty stencils are easy to use, yield excellent aesthetic results, and the option to choose their own glans shape is highly appreciated by patients. Disclosure No.

(145) Utilization of Crowdfunding for Genital Gender Affirmation Surgery

Abstract Introduction Though the incidence of gender-affirming surgery (GAS) is increasing within the United States (US), many transgender and gender diverse individuals are denied insurance coverage for these procedures. Some turn to crowdfunding for financial assistance. Objective We aimed to determine characteristics of fundraisers for genital GAS within the US and factors associated with greater funding. Methods GoFundMe is the largest individual crowdfunding platform in the US and was queried in January 2023 using search terms related to genital GAS such as “bottom surgery”, “gender affirming surgery”, and “transgender surgery”. Duplicate, outside the US, non-English, and non-relevant campaigns were excluded. For each campaign, organizer’s state, fundraising goal, amount raised, number of donors, and campaign description were retrieved. Generalized additive models were created to determine the relationship of predictors with achieving full funding. An additional Bayesian estimation approach model was created to determine the relationship of predictors with overall campaign progress. Results From 4,921 viewable campaigns, 1,497 met inclusion criteria for analysis. All states were represented with the greatest number in California (n = 155, 10.4%). The median amount raised was $195 (IQR 0-2,270) of a goal of $12,000 (IQR 5,000-30,000); 87 (5.8%) campaigns were fully funded, while 555 (37.1%) had no funding. Three-quarters of campaigns were less than one-third funded. Of 1,315 campaigns where transition type was indicated, 76.6% (n = 1,007) were for FGS and 22.7% (n=298) were for MGS. Though the average marginal effect of increasing the goal was to decrease funding progress (FGS -0.329, 95% CI -0.445 to -0.0248, MGS -0.589, 95% CI -1.071 to -0.347), an increase in funding progress was seen with increasing the goal from $1,000 to $10,000 for FGS. The average marginal effect of increasing word count was +0.26 (95% CI 0.18 to 0.36) with the greatest effect between 100 to 500 words. The average marginal effect of increasing campaign age on progress was +0.35 (95% CI 0.27 to 0.47), with the greatest effect between 500 to 1000 days. Conclusions Crowdfunding is an attractive option for TGD individuals who need financial support for genital GAS and related expenses, but the majority of individual fundraisers on GoFundMe will only raise one-third or less of their goal. Specific windows of funding goal, word count, and campaign age are associated with greater odds of campaign progress. Such information can be used to counsel patients who are seeking financial assistance for genital GAS. Disclosure No.

(138) Evidence-based Strategies for Preventing Lower-limb Complications Secondary to Prolonged Use of the Dorsal Lithotomy Position

Abstract Introduction Patient positioning at the time of surgery plays a critical role in determining patient outcomes. Specific to patients undergoing genital gender-affirming surgery (gGAS), these patients are required to be placed in the lithotomy position to access the pelvis and perineum for their procedures. Lower-extremity injury due to prolonged surgical time in the lithotomy position can have significant post-operative morbidity affecting patient outcomes. This risk is increased in patients undergoing gGAS procedures due to high surgical complexity and especially long operative times as compared to other surgical procedures. Careful attention must be directed to the patient’s specific position intraoperatively due to significant risk of potential injury with prolonged surgeries. Prolonged stasis can cause injuries ranging from mild soft-tissue injuries which rapidly resolve, such as mild pressure injuries to bony prominences, to severe injuries including pressure ulcers, nerve injuries, rhabdomyolysis, and compartment syndrome. These complications can have lasting impact on the patient, with associated morbidity and mortality risk, and can also impact healthcare systems through additional dollars spent caring for patients who suffer these complications and their associated rehabilitation, and legal recourse on behalf of the patient who suffered these severe complications. Objective Our study aimed to describe our technique for preventing lower extremity injuries in the dorsal lithotomy position, and to evaluate our positioning-related post-operative complications and rates. Methods We describe our technique for lower-limb positioning in the dorsal lithotomy position, with an emphasis on injury prevention for patients undergoing gGAS. We assessed positioning-related outcomes and complications among patients undergoing gGAS for prolonged periods (>300 minutes) in the lithotomy position between January 2017 to March 2023. Results A total of 227 patients underwent 310 gGAS procedures were included in our study (156 masculinizing:154 feminizing gGAS procedures). Mean operative time was 495.5 minutes +/- 156.5 minutes (SD) (Range 300–1095 minutes) (Table 1a). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-operatively. No (0%) patients had major or chronic complications including chronic nerve injury, pressure ulcers, rhabdomyolysis or compartment syndrome (Table 1b). Our patient positioning employs the use of ½ inch foam placed to surround the lower extremity, ensuring that all at-risk areas of compression are adequately protected when placing the patient’s leg in the Allen stirrups whilst in the lithotomy position (Figure 1). In addition, a perioperative list is also utilized with regular leg checks every 2 hours with nursing documentation and also, ensuring patients are able to move their lower extremities without any pain post-operatively (Figure 2). Conclusions Our study is the first to describe and illustrate specific techniques, and outline strategies, for protecting the lower extremities to prevent injuries in patients undergoing prolonged surgical procedures in the lithotomy position. The low complication rates associated with our technique warrants attention to further refine this technique, and, to integrate these strategies into operating-room programs across diverse specialties. Disclosure No.

(037) Medicolegal Considerations for Patients Undergoing Urologic Surgical Interventions and the Development of an Audio-Recording Application for Use During Genital Gender-affirming Surgical Consultation

Abstract Introduction Patient recollection of details discussed during medical consultation is often limited (Figure 1a). For genital gender-affirming surgery (gGAS) consultations, lengthy discussions and deep contemplation surrounding surgical options are critical. Inadequate communication can result in patient complaints and medico-legal action, whereupon issues such as a lack of discussion or poor documentation can lead to medico-legal liability against the care provider and hospital system. As a result, strategies must be developed to ensure that information discussed during complex medical consultations are made available so patients can properly weigh out the care options presented. Objective 1) Assess medico-legal incidents in Urologic and surgical specialties in the UK, US, and a Californian quaternary care center, 2) evaluate the advantages and feasibility of offering audio-recordings of patient consultations, and 3) create a user-friendly smartphone app for recording healthcare consultations. Methods A literature review evaluated current evidence on medical liability claims in the UK and US was conducted. Additionally, our center's Department of Risk Management provided information pertaining to medico-legal cases against our institution. Separately, gGAS patients consented to audio-record their consultation. Copies were provided to patients and kept in their medical records. A follow-up survey assessed its usefulness, and based upon patient feedback, a smartphone application was developed. Results A PubMed search yielded 921 results on "medical malpractice claims" from 2013-2023. In Urologic Surgery, 32 papers addressed medical malpractice, with 2 providing data over the last 15 years. In the UK, 660 claims were made from 2010-2020, of which 8.2% were due to poor communication (37 = informed consent; 17 = lack of follow-up). In the US, from 2020-2022, 38.3% of Urologists faced at least one legal proceeding in their career, and 5.3% were sued within 1 year for any reason. Our institution's Department of Risk Management reported 32% of lawsuits were related to surgical care. Informed consent involved 8% of cases and had a component in 32%. The average financial settlement for medical malpractice was $125,000.00 USD, and trial costs averaged $75,000.00 USD. 50/71 patients completed an anonymized, online survey post-audio recording. Positive results were noted regarding recording quality, comfort whilst being recorded, and wishes for future consultation recordings (Figure 1b). In addition, most patients felt less anxiety, and had greater confidence in their treatment choice (Figure 1c) Based upon patient responses, we developed a smartphone App which records 90 minutes of audio, allows for file and hyperlink attachments to be sent to patients before immediately deleting all information (Figure 1d). Routine use of audio-recordings led to a reduction in patient queries to our office. Conclusions Routine audio recording of patient consultations provides significant benefits with minimal cost to providers. As per our institution's Office of Risk Management, it offers protection against medico-legal risks. Adequate discussion, good documentation and providing adjuncts for patients can help prevent a large proportion of medicolegal complaints in addition to optimizing patient care. Considering that patients face similar challenges across different disciplines and regions, a larger study (multi-center, international, multi-language) is warranted. Disclosure No.

Geographic Variability of Genital Gender-Affirming Surgery Centers and Costs of Hospitalization.

The cost of gender-affirming surgery (GAS) is an important component of healthcare accessibility for transgender patients. However, GAS is often prohibitively expensive, particularly as there are inconsistencies in insurance coverages. Variability in hospital costs has been documented for other types of nonplastic surgery procedures; however, this analysis has not been done for GAS. To better understand the financial barriers impairing access to equitable transgender care, this study analyzes the distribution of hospitals that perform genital GAS and the associated costs of inpatient genital GAS. This is a study of the 2016-2019 National Inpatient Sample database. Transgender patients undergoing genital GAS were identified using International Classification of Diseases, Tenth Revision, diagnosis and procedure codes, and patients undergoing concurrent chest wall GAS were excluded. Descriptive statistics were done on patient sociodemographic variables, hospital characteristics, and hospitalization costs. χ2 test was used to assess for differences between categorical variables and Mood's median test was used to assess for differences between continuous variable medians. A total of 3590 weighted genital GAS encounters were identified. The Western region (50.8%) and Northeast (32.3%) performed the greatest proportion of GAS, compared with the Midwest (9.1%) and the South (8.0%) (P < 0.0001). The most common payment source was private insurance (62.8%), followed by public insurance (27.3%). There were significant differences in the variability of median hospital costs across regions (P < 0.0001). The South and Midwest had the greatest median cost for vaginoplasty ($19,935; interquartile range [IQR], $16,162-$23,561; P = 0.0009), while the West had the greatest median cost for phalloplasty ($26,799; IQR, $19,667-$30,826; P = 0.0152). Across both procedures, the Northeast had the lowest median cost ($11,421; IQR, $9155-$13,165 and $10,055; IQR, $9,013-$10,377, respectively). There is significant regional variability in the number of GAS procedures performed and their associated hospitalization costs. The identified disparities in insurance coverage present an area of possible future improvement to alleviate the financial burden GAS presents to gender-discordant individuals. The variability in cost suggests a need to evaluate variations in care, leading to cost standardization.

Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine.

Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited. To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth. There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model. We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW). TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models. When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety. To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions. Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

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

To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). 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. 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. 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.

The Use of Acellular Tissue Matrices in Gender-Affirming Surgery: Review of the Literature and Institutional Experience.

Wound healing complications are not uncommon after genital gender-affirming surgery and can pose significant challenges for the reconstructive surgeon. Acellulartissue matrices are products that contain extracellular matrix compounds without living cells and are used to expedite and improve wound healing.Some of these products have been described for a variety of different indicationsin gender-affirming surgery. In this paper, the authors present a review of the current literature on the use of acellular tissue matrices in gender-affirming surgeryas well as the authors' institutionalexperience in using these products.

Strategies to Prevent Lower-Extremity Positioning Injuries During Long-Duration Surgery in the Lithotomy Position: Our Techniques and Clinical Outcomes Following Genital Gender-Affirming Surgeries

Purpose: Lower-extremity (LE) injuries due to prolonged surgery duration in the dorsal lithotomy (DL) position are often morbid and can significantly affect the patient’s short and long-term quality of life. These include the development of lower extremity pressure ulcers, neuropathies, rhabdomyolysis, and compartment syndromes. As compared to other surgeries, this risk is increased in patients undergoing genital gender-affirming surgery (gGAS) due to the relatively long operative time of these surgeries related to their high complexity. Our study aimed to describe our technique for preventing LE injuries in the DL position, and to evaluate our positioning-related post-operative complications and rates. Materials and Methods: We describe our technique for positioning in the dorsal lithotomy position, with an emphasis on injury prevention. We ensure a specific padding technique of the LE, we alert surgical assistants to not lean/rest on the LE, and we schedule LE checks and repositioning throughout the case to prevent and mitigate occult injuries. Herein, we report our clinical positioning-related outcomes and complications among all patients undergoing gGAS procedures lasting &gt;300 minutes between January 2017 to March 2023. Results: A total of 227 patients underwent 310 surgical procedures (156 masculinizing, 154 feminizing gGAS procedures). Mean operative time was 495.5 minutes+/-156.5 minutes (SD) (Range 300–1095 minutes). A total of 6/227 (2.6%) patients (2 masculinizing and 4 feminizing surgical patients) had transient, self-limited LE pain post-op. No (0%) patients had major complications including chronic nerve injury, pressure ulcers, rhabdomyolysis, or compartment syndrome. Conclusions: Our study is the first to describe a replicable technique, and specifically which integrates the OR team and nursing staff, to prevent LE injuries during DL. We show that it is possible to achieve a 0%-to-rare incidence of major LE injury during long-duration surgeries.

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State.

Impact of Medicaid Expansion on Genital Gender-Affirming Surgery in New York State.

Robotics in genital gender-affirming surgery

Gender-affirming genital surgery includes a constellation of pelvic procedures that can help feminize or masculinize the genitalia. Technological advances in robotic surgery can aid surgical access to and visualization of the pelvis, thereby facilitating certain procedures. In this scoping review, we will discuss the developing role of the robot in genital affirming genital surgery. Indications, techniques, and outcomes using the robot in both feminizing and masculinizing genital procedures will be reviewed.

Histoire de la vaginoplastie : évolution technique et sociologique

Technical advances in gender-affirming genital surgery have allowed the modern surgeon to create a vagina, vulva and clitoris from a male sex. This surgery, commonly known as vaginoplasty, should in fact be identified as aidopoiesis, since it is not a question of improving an already existing vagina but of creating a female sex. Numerous technical advances made since 1930 throughout the world now offer a safe and proven surgical strategy for female genital gender affirmation. Most of these techniques are derived from advances in intersex genital surgery. The first vaginoplasties described in the context of gender affirmation were performed in Berlin in the 1930s. After the Second World War, the greatest advances in vaginoplasty were made in Denmark. It was not until Geroges Burou in Casablanca and Harold Gillies, aided by Ralph Millard in England, in the mid-fifties that the modern technique of invagination of the penile skin took over from neo-vaginal grafting techniques. The creation of the clitoris from the glans penis and a more aesthetic vulva were the major advances from the 1970s. Other flap or intestinal transplant techniques were also developed, often to correct the failure of penile skin invagination. Some of the patients who benefited from these early technical advances, such as Lili Elbe and Christine Jorgensen later on, helped to make this surgery, which had long remained taboo, popular with the general public. Pioneers such as the gynaecologist Georges Burou in Casablanca have contributed, with the greatest discretion, to the well-being of gender-affirmed people by improving these techniques. Today, this hard-won heritage cannot be ignored by surgeons interested in vaginoplasty.

Shallow-depth vaginoplasty: preoperative goals, postoperative satisfaction, and why shallow-depth vaginoplasty should be offered as a standard feminizing genital gender-affirming surgery option.

Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV), or vaginoplasty with creation of a vaginal canal. SDV is associated with fewer short- and long-term risks and shorter recovery, and does not require a lifelong commitment to vaginal dilation and douching. To describe a surgical technique for SDV that creates a dimpled introitus, together with clinical outcomes, decision-making prioritization, and satisfaction data. We hypothesize that SDV patients prioritize comparable appearance and sexual function to FDV over shorter-term risk factors, and experience high satisfaction. We describe (1) a surgical technique for SDV; (2) the proportion of patients who underwent SDV vs. FDV, with SDV complication rates; and (3) the results of an anonymous, electronic questionnaire administered via Qualtrics that assessed SDV patient demographics, terminology preferences, prioritization of decision-guiding factors for choosing SDV over FDV, and postoperative satisfaction across various domains. A total of 110 patients underwent primary feminizing genital gender-affirming surgery at a single institution between April 2017 and July 2022: 35 (32%) of 110 underwent SDV and 75 (68%) underwent FDV. The 35 SDV patients were invited to answer the study questionnaire, of which 29 (83%) completed it (mean age 51.9 ± 16.7 years, mean body mass index 27.3 ± 5.3 kg/m2). All but one survey respondent met one or more of the following characteristics: (1) ≥40years of age, (2) exclusively feminine-identifying sexual partners, and/or (3) significant aversion to performing long-term vaginal dilation and douching. Ranking of 8 decision-guiding factors revealed prioritization of long-term over short-term outcomes. Postoperatively, patients reported high satisfaction across all 3 domains. When asked if they had to choose between SDV and FDV over again, 86% reported that they would choose SDV. While 14% would choose FDV, all but one reported new interest in receptive vaginal intercourse due to finding masculine-identifying partners post-SDV surgery. A total of 27% of SDV patients experienced complications that required additional surgeries; 82% of complications were related to urinary spraying. SDV is a lower-risk alternative to FDV and is associated with reduced postoperative maintenance and high postoperative satisfaction. This study describes the clinical outcomes of the largest documented cohort of patients to undergo SDV to date. Limitations include recall bias due to the retrospective survey and use of nonvalidated questions attributed to the paucity of validated gender-affirming surgery questionnaires. SDV's appeal to a large subset of patients (32% in this study), low complication rate, high satisfaction, and low decisional regret suggests that this surgical option should be offered to all patients seeking feminizing genital gender-affirming surgery.