Genital Gender-affirming Surgery Research Articles

Urinary symptoms after genital gender-affirming penile construction, urethral lengthening and vaginectomy.

Transgender and non-binary (TGNB) individuals are seeking penile reconstruction in greater numbers; many pursue urethral lengthening surgery with a goal of voiding while standing. Changes in urinary function and urologic complications-i.e., urethrocutaneous fistulae and urinary stricture-are common. Familiarity with presenting symptoms and management strategies for urinary complaints after genital gender-affirming surgery (GGAS) can improve patient counseling and outcomes. We will describe current gender-affirming penile construction options with urethral lengthening and review associated urinary complications that present as urinary incontinence. The incidence and impact of lower urinary tract symptoms after metoidioplasty and phalloplasty are poorly characterized due to limited post-operative follow-up. Post-phalloplasty, urethrocutaneous fistula is the most common urethral complication, ranging in incidence from 15-70%. Assessment of concomitant urethral stricture is necessary. No standard technique exists for management of these fistula or strictures. Metoidioplasty studies report lower rates of stricture and fistula, 2% and 9% respectively. Other common voiding complaints include dribbling, urethral diverticula and vaginal remnants. History and physical exam in the post-GGAS evaluation require understanding of prior surgeries and attempted reconstructive efforts; adjuncts to physical exam include uroflowmetry, retrograde urethrography, voiding cysto-urethrogram, cystoscopy, and MRI. Following gender-affirming penile construction, TGNB patients may experience a host of urinary symptoms and complications that impact quality of life. Due to anatomic differences, symptoms require tailored evaluation which can be done by urologists in an affirming environment.

Developing Gender-Affirming Surgery Curricula for Plastic Surgery Residency and Fellowship via Delphi Consensus.

Gender-affirming surgery (GAS) is a rapidly growing field within plastic surgery, and residents and fellows must receive appropriate training. However, there are no standardized surgical training curricula. The objective of this study was to identify core curricula within the field of GAS. Four GAS surgeons from different academic institutions identified initial curricular statements within six categories: (1) comprehensive GAS care, (2) gender-affirming facial surgery, (3) masculinizing chest surgery, (4) feminizing breast augmentation, (5) masculinizing genital GAS, and (6) feminizing genital GAS. Expert panelists consisting of plastic surgery residency program directors and GAS surgeons were recruited for three rounds of the Delphi-consensus process. The panelists decided whether each curriculum statement was appropriate for residency, fellowship, or neither. A statement was included in the final curriculum when Cronbach α value was greater than or equal to 0.8, meaning that 80% or more of the panel agreed on inclusion. A total of 34 panelists (14 plastic surgery residency program directors and 20 GAS surgeons representing 28 US institutions) participated. The response rate was 85% for the first round, 94% for the second, and 100% for the third. Out of 124 initial curriculum statements, 84 reached consensus for the final GAS curricula, 51 for residency, and 31 for fellowship. A national consensus on core GAS curriculum for plastic surgery residency and GAS fellowship was achieved by a modified Delphi method. Implementation of this curriculum will ensure that trainees in plastic surgery are adequately prepared in the field of GAS.

V09-04 REPAIR OF URINARY INCONTINENCE AND VENTRAL DEHISCENCE AFTER MASCULINIZING GENITAL GENDER AFFIRMATION SURGERY

You have accessJournal of UrologyCME1 Apr 2023V09-04 REPAIR OF URINARY INCONTINENCE AND VENTRAL DEHISCENCE AFTER MASCULINIZING GENITAL GENDER AFFIRMATION SURGERY Joshua Sterling and Dmitriy Nikolavsky Joshua SterlingJoshua Sterling More articles by this author and Dmitriy NikolavskyDmitriy Nikolavsky More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Stress urinary incontinence (SUI) is an infrequently reported complication following transmasculine genital gender affirming surgery (gGAS), thus far there are no reports to help with management of severe SUI post gGAS. In this video, we demonstrate a case of de novo SUI following vaginectomy and metoidioplasty. These were treated with autologous fascial sling and staged urethral repair. METHODS: Patient is a 22 year old transgender male who underwent vaginectomy and metoidioplasty and developed severe SUI. Three months of pelvic therapy improved incontinence to 168g daily. He was referred for treatment of SUI and correction of ventral shaft dehiscence. Stage-1 included placement of an autologous fascial retropubic sling, and stage 1 urethroplasty with buccal mucosa graft (BMG). In the time interval before the Stage 2, the patient was monitored for evidence of recurrent SUI or urinary retention. Stage 2 involved tubularization of the neourethra. The procedure was done in dorsal lithotomy position. Perineum (site of prior vaginectomy) and previously created pars fixa were opened ventrally. Using the balloon of the Foley at the bladder neck as a palpable landmark, the native urethra and the bladder neck were dissected to the inferior aspect of the pubic symphysis. A 1.5x8cm segment of rectus fascia was harvested for the autologous sling. Full length 2-0 polypropylene suture was secured to either end of the fascial sling and delivered retropubicly to the abdominal incision from the perineal incision using a fine tonsil clamp. The sling was appropriately tensioned and secured. Ventral penile chordee was released sharply and a stage 1 urethroplasty was performed with dorsal BMG inlay. After a 6-month delay the patient did not show any signs of recurrence of SUI or retention and the Stage 2 urethroplasty was performed. The patient's urethral plate was augmented with an additional BMG to achieve 3cm width. The neourethra was tubularized and the neophallus was closed in multiple layers with non-overlapping suture lines. RESULTS: The procedure resulted in the successful repair of the patient’s SUI and metoidioplasty shaft dehiscence. The patient achieved durable social continence (completely dry) with normal voiding patterns and low residuals after placement of autologous retropubic sling. CONCLUSIONS: SUI is a real and devastating complication following masculinizing gGAS. Here we show it can be safely and effectively treated using an established pelvic floor reconstructive technique for a new indication. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e837 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Sterling More articles by this author Dmitriy Nikolavsky More articles by this author Expand All Advertisement PDF downloadLoading ...

(De-)centralized health care delivery, surgical outcome, and psychosocial health of transgender and gender-diverse people undergoing vaginoplasty: results of a retrospective, single-center study

PurposePrevious research on genital gender-affirming surgery lacked to build a framework that took various surrounding factors into account. E.g., transgender health care services are delivered in both centralized (by one interdisciplinary institution) and decentralized settings (by different medical institutions spread over several locations). The present study investigated the effects of different structural and clinical aspects of gender-affirming genital surgery on psychosocial outcomes.MethodsWe surveyed former transgender and gender-diverse people who completed a vaginoplasty between 2014 and 2018. 45 participants were included in the study. We calculated hierarchical linear regression analyses to assess the relationship between psychosocial outcome measures (gender congruence, mental health, quality of life) and different aspects of gender-affirming genital surgery (e.g., setting of service delivery). To address shortcomings regarding the small sample size, we applied a rigorous statistical approach (e.g., Bonferroni correction) to ensure that we only identify predictors that are actually related to the outcomes.ResultsA non-responder analysis revealed no systematic bias in the recruitment procedure. Treatment satisfaction was a significant predictor for gender congruence. Moreover, we found the setting of service delivery (centralized, decentralized) to predict psychological health and the physical health dimension of quality of life. The effect sizes of our models were moderate to high, and models explained up to 26% of the total variance with a power up to 0.83.ConclusionThe present study is an exploratory attempt into the manifold relationships between treatment-related factors (e.g., aesthetic outcome), the setting of service delivery, and their effects on gender-affirming genital surgery.

Gender-affirming Vaginoplasty and Vulvoplasty: An Initial Experience

To describe the initial outcomes of a new multidisciplinary gender-affirming surgery (GAS) program comprised of plastic and urologic surgeons. We retrospectively examined consecutive patients who underwent gender-affirming vaginoplasty or vulvoplasty between April 2018 and May 2021. We used logistic regression modeling to analyze associations between preoperative risk factors and postoperative complications. Between April 2018 and May 2021, 77 genital GAS (gender-affirming surgery) procedures were performed at our institution (56 vaginoplasties, 21 vulvoplasties). All surgeries were performed in combination with urology and plastic surgery primarily using the perineal penile inversion technique. Mean patient age was 39.6 years, and mean BMI was 26.2 (Table 1a). The most common pre-existing conditions were hypertension and depression, with nearly 14% of patients reporting a previous suicide attempt. The complication rate for vaginoplasty was 53.7% within the first 30 days (Table 4). The most common complications were yeast infection (14.8%) and hematoma (9.3%). For vulvoplasty, the 30-day complication rate was 57.1%, with urinary tract infection (14.3%) and granulation tissue (9.5%) being the most common. 88.1% and 91.7% of the complications were Clavien-Dindo grade I or II for vaginoplasties and vulvoplasties, respectively. No association was found between preoperative patient factors and postoperative complications. Revision surgeries were performed for 38.9% of vaginoplasty patients during the study period, most commonly including urethral revision (29.6%), labia majoraplasty (20.4%), and labia minoraplasty (14.8%). Collaboration between urology and plastic surgery is a safe and effective means to establish a GAS program.

Impact of testosterone use on the vaginal microbiota of transgender men, including susceptibility to bacterial vaginosis: study protocol for a prospective, observational study

IntroductionThe effect of testosterone (T) therapy on the vaginal microbiota of transgender men (TGM) is not well characterised, although one cross-sectional study comparing the vaginal microbiota of cisgender women to...

Genital gender-affirming surgery for transgender women.

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database.

Gender-affirming orchiectomy may be performed in isolation, as a bridge to vaginoplasty, or concurrently with vaginoplasty for transgender and nonbinary persons, although there is a paucity of data on immediate postoperative outcomes on the various procedural approaches. The aim of the study is to compare 30-day surgical outcomes after gender-affirming orchiectomy and vaginoplasty as separate and isolated procedures. This was a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database to compare surgical outcomes of orchiectomy alone and vaginoplasty alone to concurrent orchiectomy with vaginoplasty using bivariate and adjusted multivariable regression statistics. Concurrent orchiectomy and vaginoplasty were associated with greater 30-day surgical complications compared with orchiectomy alone (15.4% vs 2.9%, P < 0.01) and similar odds of 30-day surgical complications compared with vaginoplasty alone (15.4% vs 11.1%, P = 0.15). On multivariable logistic regression analysis, compared with orchiectomy alone, concurrent orchiectomy and vaginoplasty were associated with higher increased odds of 30-day surgical complications (adjusted odds ratio, 6.48; 95% confidence interval, 2.83-14.86) as well as vaginoplasty alone (adjusted odds ratio 4.30; 95% confidence interval, 1.85-10.00). This study highlights the perioperative outcomes for isolated versus concurrent gender-affirming orchiectomy and vaginoplasty, demonstrating lower morbidity for orchiectomy alone and similar morbidity for vaginoplasty alone when compared with concurrent procedures. These data will aid health care providers in preoperative counseling and surgical planning for gender-affirming genital surgery, particularly for patients considering concurrent versus staged orchiectomy and vaginoplasty.

Principles and outcomes of gender-affirming vaginoplasty.

Vaginoplasty is the most frequently performed gender-affirming genital surgery for gender-diverse people with genital gender incongruence. The procedure is performed to create an aesthetic and functional vulva and vaginal canal that enables receptive intercourse, erogenous clitoral sensation and a downward-directed urine stream. Penile inversion vaginoplasty (PIV) is a single surgical procedure involving anatomical component rearrangement of the penis and scrotum that enables many patients to meet these anatomical goals. Other options include minimal-depth, peritoneal and intestinal vaginoplasty. Patient quality of life has been shown to improve drastically after vaginoplasty, but complication rates have been documented to be as high as 70%. Fortunately, most complications do not alter long-term postoperative clinical outcomes and can be managed without surgical intervention in the acute perioperative phase. However, major complications, such as rectal injury, rectovaginal fistula, and urethral or introital stenosis can substantially affect the patient experience. Innovations in surgical approaches and techniques have demonstrated promising early results for reducing complications and augmenting vaginal depth, but long-term data are scarce.

Sexual Function and Sexual Satisfaction Following Gender-Affirming Genital Surgery: A Scoping Review

Historically, outcome measures for gender-affirming genital surgery have focused on medical and surgical outcomes, with limited attention to patients’ reports of post-surgical sexual function and sexual satisfaction. The aim of this scoping review was to assess the published literature on patients’ sexual function and sexual satisfaction following gender affirming genital surgery, identifying gaps in the evidence base and potential areas of focus for future research efforts. Our sample included English-language studies published in the past 20 years addressing measures of sexual health, sexual function, and/or sexual well-being for individuals who underwent gender affirming genital surgery. Systematic reviews, meta-analyses, and other forms of reviews were excluded. The final sample consisted of ten articles. All studies addressed sexual function through assessment of ability to orgasm. Overall, transgender women who underwent vaginoplasty and were sexually active post-operatively described improved sexual function after surgery. In one study, transgender men showed moderate improvement of sexual function while another indicated reduced sexual function compared to transgender men treated with hormones only. Prospective research is needed to improve understanding of patients’ values, goals and expectations for sexual function and sexual satisfaction following surgery, and to inform the development of validated outcomes measures.

The effect of colpectomy on lower urinary tract function in transgender men

Background: In transgender men, effects of colpectomy on voiding function are unknown, except for the incidence rates of urinary tract infections and urinary retention. Aims: To provide insight into the effect of colpectomy on Lower Urinary Tract Function (LUTF) in transgender men. Methods: A retrospective chart review was conducted among transgender men who underwent colpectomy between January 2018 and October 2020. Primary outcomes were objective and subjective changes in voiding. Secondary outcomes were transurethral catheterization length and the need for clean intermittent self-catheterization (CISC). Results: Of 132 men, 89 (67%) underwent Robot-assisted Laparoscopic Colpectomy (RaLC) and 43 (33%) Vaginal Colpectomy (VC). Maximum flow rate on uroflowmetry decreased following RaLC (mean of 29.1 vs. 38.3 mL/s, p = 0.002) and VC (mean of 29.2 vs. 40.3 mL/s, p < 0.001) after a median of four months postoperatively. An increase in total International Prostate Symptom Score was seen more frequently following VC compared to RaLC. Subjective changes were indicated by 39%, more often by men who underwent VC, of which the majority improved during the first months postoperatively. Trial without catheter (TWOC) on the first postoperative day was more successful after RaLC (79/89, 89%) than VC (24/43, 56%). Secondary TWOC was successful in 22/132 (17%) patients after a median of eight days postoperatively. In 5/132 (4%) men (three VC and two RaLC), temporary CISC was necessary for a period ranging from 5 to 21 days. The last 2/132 (2%) men after RaLC were still performing CISC at end of follow-up. Eventually, 5% (two VC and four RaLC) had to refrain from genital gender-affirming surgery with urethral lengthening due to voiding dysfunction. Discussion: After colpectomy, most objective and subjective worsening in LUTF is of a temporary nature, however, 5% had to refrain from genital gender-affirming surgery with urethral lengthening due to persistent voiding dysfunction, despite the desire to void while standing.

Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients' Needs.

IntroductionMedical providers may not be familiar with the genitourinary and sexual symptoms of transgender and non-binary (TGNB) individuals. This lack of familiarity may hinder a provider's ability to address these issues as patients may hesitate to report symptoms due to fear of stigma, misgendering, and being treated disrespectfully.AimTo describe the array of genitourinary and sexual symptoms in transfeminine individuals.MethodsUpon institutional review board approval, researchers used semi-structured interviews with 25 transfeminine individuals assigned male at birth to explore urinary and sexual symptoms on a sample of convenience. Participants were recruited and interviews were conducted until saturation was achieved. Two research assistants independently coded all de-identified transcripts and resolved discrepancies.OutcomesThematic codes pertaining to genitourinary and sexual symptoms were defined and assessed in this study.ResultsSome genitourinary symptoms unrelated to hormone therapy or genital gender-affirming surgery (GGAS) included frequency, urgency, nocturia, and incontinence, while those attributed to GGAS included slow stream, spraying, and retention. Sexual symptoms unrelated to hormone therapy or GGAS included sexually transmitted infections, erectile dysfunction, and low libido. Sexual symptoms related to GGAS included delayed ejaculation, penile pain, scar tissue pain, and pain with receptive vaginal penetration.Clinical ImplicationsIncreased provider awareness of and accountability for the treatment of genital and sexual symptoms of transfeminine individuals.Strengths and LimitationsOpen-ended questions were used to generate a range of responses and perspectives through conversation instead of quantifiable data. Findings are not applicable to all TGNB people since participants were limited to transfeminine adults assigned male at birth only. Recruitment was limited by the sensitive nature of the topic and hard-to-reach populations and relied on convenience through flyers and a chain-referral sampling approach.ConclusionTransfeminine individuals experience a wide array of genitourinary and sexual symptoms both similar and different to their cis gender counterparts.Chung PH, Swaminathan V, Spigner S, et al. Genitourinary and Sexual Symptoms and Treatments in Transfeminine Individuals: A Qualitative Exploration of Patients’ Needs. Sex Med 2022;10:100566.

Cosmetic Revision Surgeries after Transfeminine Vaginoplasty

BackgroundVaginoplasty is the most frequent genital gender-affirming surgery. Although both functional and aesthetic outcomes after transfeminine vaginoplasty have improved over the years, cosmetic revision surgeries demand after transfeminine vaginoplasty appears to be increasing and requires updated knowledge.MethodsAll patients who underwent vulvar cosmetic revision surgeries at our institution following transfeminine vaginoplasty from January 2014 to April 2022 were studied. The prevalence, topography and surgical techniques of cosmetic revision surgeries after transfeminine genital gender-affirming surgery were examined using clinical charts review and statistical analysis.ResultsDuring the study period, 354 patients underwent gender-affirming vaginoplasty at our single institution (212 penile inversion vaginoplasty, 122 colovaginoplasty and 20 penile inversion vaginoplasty with scrotal skin graft patients). Forty out of these 354 patients (11.29%) required cosmetic revision surgery after transfeminine vaginoplasty; additionally, 44 patients with vaginoplasty performed at other centres also underwent vulvar cosmetic revision surgery at our clinic during the study period. From all performed cosmetic revision surgeries, most of them (31.42%) were labia corrections, followed by clitoris (23.26%) repair surgeries. Mons Venus (10.20%), urethral meatus (9.38%), spongiosus tissue remnants (8.57%) and introitus (6.53%) revisions followed in frequency. Corrections of peri-inguinal scars (5.30%), anterior commissure (2.84%) and inferior fourchette (2.42%) were less prevalent. No differences were found among the different studied vaginoplasty techniques regarding cosmetic revision surgery prevalence or topography following transfeminine vaginoplasty (p < 0.05).ConclusionsCosmetic revision surgeries after transfeminine vaginoplasty are frequent. In our large and long-term cohort study, labiaplasty followed by clitoroplasty were found as the most required cosmetic revision surgical procedures. Further multicentre, prospective and controlled studies are necessary to improve cosmetic outcomes and scientific evidence after transfeminine vaginoplasty.Level of evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Desire for Genital Surgery in Trans Masculine Individuals: The Role of Internalized Transphobia, Transnormativity and Trans Positive Identity.

Some trans people experience gender dysphoria, which refers to psychological distress that results from an incongruence between one’s gender assigned at birth and one’s gender identity. People who are trans masculine or nonbinary assigned-female-at-birth may pursue multiple domains of gender affirmation, including surgical affirmation (e.g., masculine chest reconstruction, penile reconstruction, etc.). The present study aimed to investigate the possible factors involved in trans people’s desire to undergo gender-affirming genital surgery. Trans masculine and nonbinary participants (N = 127; mean age = 26.90) were recruited through a web-based survey and completed self-report instruments (i.e., the Internalized Transphobia subscale of the Gender Minority Stress and Resilience Measure, the Trans Positive Identity Measure, the Gender Congruence and Life Satisfaction Scale, an ad hoc scale on transnormativity, and a single-item on desire to undergo genital affirmation surgery). A path analysis showed that higher levels of internalized transphobia led to more significant genital discomfort via a dual parallel mediation of transnormativity and positive identity. Moreover, this genital discomfort fueling pattern was the most significant predictor of the desire to undergo genital surgery as the effect of internalized transphobia was fully mediated by increased genital discomfort. Findings are discussed in the light of the recent strand of research on gender dysphoria as a multifaceted construct, with social components.

Spending and Out-of-Pocket Costs for Genital Gender-Affirming Surgery in the US

Genital gender-affirming surgery (GAS) is safe and offers substantial benefits to patients. Geographic accessibility and high out-of-pocket (OOP) costs reportedly hinder access; however, to date, this has not been thoroughly investigated at the national level. To estimate OOP and total costs for GAS among commercially insured beneficiaries and assess whether costs differed between surgical procedures conducted in and outside the patient's state of residence. This cross-sectional study used previously collected insurance data from the MarketScan Commercial Database (129 million patients) from January 1, 2007, to December 31, 2019. Vaginoplasties and phalloplasties were identified using diagnosis and procedure codes among patients aged 18 to 64 years. Out-of-state surgical procedures were identified based on residence at enrollment and place of service of the surgery. Data analysis took place from July 1 to September 31, 2021. Vaginoplasty and phalloplasty. The main outcomes were differences in OOP and total costs by out-of-state designation, census region, age, and insurance type for surgical procedures, estimated using multivariable linear regression models. The study included 771 patients who underwent GAS. A total of 609 underwent vaginoplasty, of whom 249 (41%) underwent surgery in their state of residence (mean [SD] age, 38.7 [13.1] years) and 340 (56%) underwent surgery outside their state (mean [SD] age, 38.1 [13.0] years), and 162 underwent phalloplasty, of whom 66 (41%) underwent surgery in their state of residence (mean [SD] age, of 39.7 [11.6] years) and 81 (50%) underwent surgery outside their state (mean [SD] age, 35.8 [10.9] years); 20 vaginoplasties (3%) and 15 phalloplasties (9%) could not be classified as in or out of state owing to missing data about the facility or residence. Procedures outside the state were associated with 49% (95% CI, 19%-85%) higher OOP costs compared with procedures done in the state of residence. In this cross-sectional study, 56% of patients who underwent vaginoplasty and 50% of patients who underwent phalloplasty underwent the procedure outside their state of residence. Patients who underwent these procedures outside their state also experienced higher OOP costs than did those who underwent these procedures in their state. Improving geographic access and understanding patient preferences for surgical care may help reduce the cost burden for those planning to undergo GAS.

Improving Access to Genital Gender-Affirming Surgery—The Need for Comprehensive Gender Health Centers of Excellence

Improving Access to Genital Gender-Affirming Surgery—The Need for Comprehensive Gender Health Centers of Excellence

Risk of transfusion-related acute lung injury and human immunodeficiency virus associated with donations from trans donors in Quebec, Canada.

Blood operator must establish selection criteria according to the populations at risk of blood-related infections and complications. Therefore, this study aimed to assess the risks of transfusion-related acute lung injury (TRALI) and human immunodeficiency virus (HIV) associated with donations from trans persons. Donor screening data from Héma-Québec were used. The risks of TRALI and HIV were estimated based on internal data and assumptions derived from the literature. The risk was assessed under four scenarios: a most likely scenario, an optimistic scenario and two pessimistic scenarios. All scenarios assumed no prior screening for trans donors. The trans population comprised 134 donors, including 94 (70.1%) trans men. Of the 134 donors, 58 (43.3%) were deferred from donating a blood-derived product because of an ongoing gender-affirming genital surgery, and the remaining 76 (56.7%) were eligible donors. The risk of having a TRALI-causing donation, given that it comes from a trans man, was estimated at one every 115-999 years for all scenarios. The risk of having an HIV-contaminated donation, given that it comes from a trans woman, was estimated at one every 1881-37,600 years for all scenarios. This study suggests that donations from trans persons are associated with a negligible risk of TRALI and HIV.

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

ABSTRACT Introduction &amp; 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&amp;lt;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