Reassignment Surgery Research Articles

Patient-reported outcomes after one-stage neourethral reconstruction in transmen with phalloplasty-associated strictures and fistulas

IntroductionUrethral strictures and fistulas arising after gender-affirming surgery in transmen require meticulous management strategies. This study evaluates the safety and efficacy of urethral reconstruction and patient satisfaction post-surgery.MethodsA retrospective analysis examined peri- and postoperative data from transmen undergoing urethral reconstruction for urethral fistula and/or strictures at the distal urethral anastomosis between December 2017 and April 2023. Follow-up involved clinical examinations, uroflowmetry, and voiding cystourethrography. Patient satisfaction and quality of life were assessed using USS PROM and ICIQ-S questionnaires.ResultsAmong 25 patients, 88% (n = 23) had urethral fistulas, and 48% (n = 12) had urethral strictures. 41% of fistula patients also had strictures, while 75% of stricture patients had concurrent fistulas. Previous surgeries for fistula or stricture repair were noted in 26% of cases. Techniques for stricture included modified flap (50%), buccal oral mucosal grafting (33%), and primary anastomosis (17%). Post-operative urethrogram revealed urethral strictures in 15% (n = 3) and urinary extravasation in an equal number. Postoperative uroflow parameters showed improvement (Qmax 18 ml/s, Qave 7.9 ml, time 37 s, volume 332 ml). Perioperative complications were low (n = 6, 24%), all grade one (Clavien-Dindo). Follow-up revealed that 33% required another surgical intervention. The mean six-item LUTS score was 6.7 (SD 3.9). Mean ICIQ-S overall satisfaction score was 8.6 (SD 1.6) and outcome score was 20 (SD 2.8).DiscussionOur study found a significant recurrence rate of urethral strictures and fistulas post-surgery. Despite this, patient satisfaction remains high and complications are generally low-grade, highlighting the importance of expert surgical intervention.

Late Gender Re-Assignment in 46XY 17 Beta-Hydroxysteroid Dehydrogenase (Type 3) Deficiency: A Case Report Highlighting Challenges of Diagnosis and Management

A 12-year-old child, previously raised as a female, presented with phallic enlargement at puberty. The sexual maturity ratings were Stage 2 and 4 for breast and pubic hair, respectively, with a stretched phallic length of 3.2cm. The patient re-presented at 16 years with progressive masculinisation and regression of breast buds. A pelvic ultrasound scan, magnetic resonant imaging and laparoscopic examination showed intrabdominal left testis, intracanalicular right testis, vas deferens, and bilateral pampiniform plexus with no uterus or ovaries. Histology of gonadal biopsy showed germ cell aplasia, and the karyotype was 46XY. The surgeons fixed the gonads in the scrotal sacs after biopsy. The human chorionic gonadotrophin stimulation test showed low basal and stimulated testosterone/androstenedione ratios (0.22 and 0.17, respectively) which were strongly suggestive of 17 beta-hydroxysteroid dehydrogenase-3 (17β-HSD3) deficiency. The patient was evaluated by the mental health team and after sessions of therapy, the patient requested for gender reassignment, which necessitated orthoplasty and urethroplasty. It is to be noted that 17β-HSD3 deficiency is a frequent cause of gender change at puberty.

Impact of Hormone Therapy on Serum Lipids in Transgender People

The term “Transgender” is used to describe individuals whose gender identity is different from their external sexual anatomy at birth. The number of people identifying as transgender has increased in recent years, and consequently, the number of gender affirmation surgeries and the use of hormonal therapies has also increased. A wide range of hormonal therapies has emerged considering the target population, age, and final outcomes, and as such these are becoming increasingly developed and complex in order to be the most appropriate for each individual. However, the side effects of these therapies remain to be fully understood. Therefore, this review aims to assess the impact of hormone therapy, in both transgender men and women of different ages, on the lipid profile. From the studies analyzed, it is possible to conclude that there is a relationship between hormone therapy and the lipid profile, with different outcomes between transgender men and women. There is a reduction in cardiovascular risk for transgender women as opposed to transgender men, in whom cardiovascular risk seems to increase due to lipid changes. It is now necessary to understand the mechanisms involved in order to reduce the consequences of these therapies and promote positive health outcomes.

Trends in Revision Facial Feminization Surgery.

Facial feminization surgery (FFS) can be an important part of an individual's transition; however, outcomes have not been well explored in the literature. This study aims to elucidate trends in FFS with a focus on drivers of secondary FFS to further improve care for TGNB patients. A manual chart review was conducted on patients from a single institution from 2012 to 2023 with a diagnosis of transsexualism (F64) who had undergone one or more surgeries associated with any 1 or more of 95 CPT codes related to gender-affirming surgery. Patients who underwent >1 FFS procedure were separated into staged, unplanned, and revision FFS. Three hundred twenty-seven patients were included in the analysis, with 111 of these patients undergoing FFS. Those who underwent FFS were significantly older (P<0.001), had a lower BMI (P<0.001), and began socially transitioning and hormone therapy at an older age (P<0.001 and P=0.001) than those who did not undergo FFS. 44.1% of patients who underwent FFS also underwent secondary FFS, with 26.1% of FFS patients undergoing unplanned secondary FFS. Patient factors, including BMI, age at first FFS, smoking status, race, ethnicity, and order of FFS in relation to other gender-affirming surgeries, were not significantly associated with differences in rates of unplanned secondary FFS. These findings highlight the importance of tailoring the surgical approach to a patient's transition to their unique situation, as well as the need for future studies to identify factors influencing the need for revision FFS and to enhance surgical outcomes for patients undergoing gender-affirming procedures.

The Type I+ Forehead in Facial Feminization Surgery.

Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft. Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques. In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002). The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Genital gender-affirming surgery trends in Germany: Total population data with 19,600 cases from 2006 to 2022.

To delineate the current trends regarding gender-affirming surgeries (GAS) in Germany. Analysis of German hospital quality reports from 2006 to 2022 was conducted using the reimbursement.info tool. The German procedure classification (OPS) codes 5-646.0 for masculinizing- and 5-646.1 for feminizing surgery were assessed to identify GAS. Linear regression models were utilized for the analysis and depiction of current trends. A total of 19,632 gender-affirming procedures were performed during the study period with an exponential increase over the years. Masculinizing surgeries increased from 246 in 2006 to 1291 cases in 2022 (increase by 424%; p<0.001). The highest annual increase of 37.2% in numbers was from 2018 to 2019 (from 1235 to 1694 cases). Feminizing surgeries increased from 180 cases in 2006 to 799 procedures in 2022 (increase by 343%; p<0.001). The cases increased most between 2015 and 2016 from 277 to 502 cases (81.2%). The number of hospitals offering these surgeries expanded from 24 in 2006 to 29 in 2022 (21% increase; p<0.001). This study demonstrates an exponential growth in numbers feminizing and masculinizing of GAS performed each year in Germany. Furthermore, a discernible trend emerges with a propensity for concentration of procedures within selected high-caseload centers across Germany.

Gender-affirming Robotic Tubularized Peritoneal Vaginoplasty: Feasibility and Outcomes

ObjectivesTo evaluate the outcomes of robot-assisted tubularized peritoneal vaginoplasty (RATPV) for trans-feminine patients desiring genital gender-affirming surgery (gGAS). MethodsWe retrospectively reviewed all patients (adults ≥ 18 years old) who underwent RATPV for gGAS at our institution (July 2020-July 2022). Initial technique involved anastomosing the peritoneal flap to the introitus. The updated technique anastomosed the flap intraperitoneally to inverted penile shaft skin. Patient demographics, intraoperative details, and postoperative outcomes are described. ResultsIn 33 patients, the median age was 26 years old (IQR:24-37) and BMI 26 (IQR:23-32). Median operative time was 406 minutes (IQR: 370-434) and robotic console time 177 minutes (IQR:154-220). Intraoperatively, the median vaginal depth was 17cm and diameter 3+cm. Median length of stay was 7 days. One-third (n=11) of patients had a complication within 30 days postoperatively (40% Clavien Dindo I and 60% Clavien II). No patient had a Clavien III+ complication.At a median follow up of 499 days (range: 137-835), some degree of vaginal stenosis occurred in 48% (11/23) of patients with the original approach versus 10% (1/10) of those with the newer approach (p=0.05). Median vaginal depth was 11.3cm. Three patients (9%) required revision vaginoplasty, all of whom had the original approach and had difficulty dilating postoperatively. All had clitoral sensation. ConclusionsRATPV is a safe and effective option for individuals seeking gender affirming vaginoplasty that obviates the need for laser hair removal prior to surgery. More research is needed into long term outcomes of this technique.

Kedudukan Ahli Waris Yang Berkelamin Ganda (Khuntsa)Menurut Hukum Waris Islam

The occurrence of someone who has dual genitalia in general in society has various impacts. Many cases have emerged that require handling. The purpose of this study is to determine the legal status of the heirs of Indonesian citizens who have dual genitalia (khuntsa) and how the rights to inherit the inheritance of heirs who have dual genitalia (khuntsa) or whose status is in doubt according to Islamic law. This type of research uses normative legal research which is based on the formulation of the problem and the purpose of the research. With the method of legislative approach and conceptual approach. The results of the study explain that the inheritance rights of khuntsa have not been explicitly regulated in the KHI, and in the Qur'an there has been no inheritance law for khuntsa. In determining the legal status of this khuntsa, it can be seen from the signs of maturity and where it urinates as mentioned in the hadith narrated by HR. Ibn 'Abbas, and can perform sex change operations. The heirs agree in calculating the level of the khuntsa musykil part by estimating and calculating it as a man then as a woman. Khuntsa and other heirs receive the smallest estimated share, while the rest that is still in doubt is withheld until the legal status of the khuntsa is clear. Keywords: Heirs, khuntsa, Islamic law

Impact of Gender-Affirming Surgery on Craniofacial Exposure for Plastic and Reconstructive Surgery Training: A Preliminary, Single-Institution Study

Objective: Current available plastic surgery positions in craniofacial surgery are not commensurate with the growing number of trained plastic surgery residents and fellows interested in the field. Despite this, there is growing demand for surgery in other areas of the craniofacial field, such as facial gender-affirming surgery (GAS), in which academic plastic surgery programs can increase resident and fellow case exposure. The present study sought to characterize the increase in craniofacial surgery exposure with the introduction of a GAS rotation among plastic surgery residents at one academic medical center. Methods: A single-center retrospective review of ten plastic surgery resident case logs between 2013 and 2021 was carried out. Case logs were evaluated for case frequency per year in craniofacial surgery and breast reconstruction surgery, which was used as a control. Case frequency was compared before and after the introduction of the GAS rotation in 2017. Results: Craniofacial surgery exposure increased from an average of 26 to 45 cases per resident per year after the introduction of a GAS rotation and overall increased from 17 to 29 cases per year. The average breast reconstruction caseload remained similar at the same time, from an average of 37 to 36 cases per year per resident. Conclusions: The introduction of a GAS rotation at one institution increased craniofacial surgery exposure for plastic surgery residents. Increasing craniofacial surgery exposure is crucial in the competitive landscape for job opportunities, further increasing resident exposure to the transgender and gender-diverse population, and expanding care for this patient population.

EP360 - Pitfalls in the management of transgender patients: a case report and discussion

Abstract Introduction There has been an increase in the number of transgender individuals in the population. In a clinical setting, this introduces potential patient safety issues from misidentification of biological sex, particularly in emergency scenarios. We report one such patient. Case report A 21-year-old ‘male’ patient presented with right iliac fossa pain. No surgical history was reported by the patient or GP records. Repeat medication included Testosterone gel. Bloods showed raised amylase though the clinical picture suggested appendicitis so a CT scan was done. This was reported normal but also identified normal sized uterus/ovaries! Following a sensitive discussion with the patient, ‘they’ revealed that ‘they’ were born biologically female and were on gender-affirming hormone-therapy. The patient was successfully managed conservatively. Discussion Our case report highlights the potential risks of misidentification of biological sex in an acute-abdomen scenario. Misdiagnosis is most critical - all gynaecological causes of abdominal pain (e.g. PID/ life- threatening ectopic-pregnancy) were missed. Due to the risk of ionizing radiation to unborn children, CT require the pregnancy status of patients with childbearing capacity, prior to the scan: this therefore should include transgender ‘males’ who have not undergone sex-reassignment surgery. There are also patient safety/ comfort issues with admission in single- sex wards. Conclusion It is important to identify transgender patients in order to avoid misdiagnosis and hence mismanagement. Taking detailed history including medication will help with this, as some transgender individuals may not volunteer details regarding their biological sex. Sensitive communication is vital to avoid any feeling of discrimination/stigmatisation.

Penile Inversion Vaginoplasty: An Evolving Technique.

Penile inversion vaginoplasty (PIV) is the most common surgical technique used in "gender-affirming bottom surgery." During this process, penile tissue is used to create a functional neo-vagina, allowing the individual to experience a more aligned physical manifestation of their "gender" identity. In this technical note, we describe the steps and nuances used by the senior author to ensure reliable aesthetic and functional outcomes, contributing to the overall well-being and satisfaction of transgender patients.

Genital gender-affirming surgery for transmasculine & nonbinary patients: Impact of a resident educational course

Background Despite a high national demand for genital gender-affirming surgery, training within United States obstetrics and gynecology (OB/GYN) residencies is limited. Method OB/GYN residents from eight programs, including two programs in each geographic area of the United States, participated in a standardized, clinical scenario-based educational module on genital gender-affirming surgery for transmasculine and nonbinary patients from August 2022 to July 2023. Residents completed pre- and post-surveys associated with this educational module. Results Eighty-three residents participated in the course, including thirty-two (38.6%) from the Midwest, thirty (36.1%) from the Northeast, thirteen (15.7%) from the South, and eight (9.6%) from the West. Pre-intervention comfort counseling on genital gender-affirming surgery differed by residency region (p = 0.04), with residents in the West demonstrating the most comfort. Residents in the Midwest, Northeast, and South demonstrated increased comfort with counseling after the module (p < 0.01, p < 0.01, p = 0.01 respectively), while no change was observed in the West (p > 0.99). Residents in all regions had increased comfort with preoperative requirements for genital gender-affirming surgery after the module (p < 0.01, p < 0.01, p = 0.04, p = 0.03). A majority (81.9%) of residents felt that incorporation of this module would be beneficial to their OB/GYN training (99%). Conclusion OB/GYN resident competence with counseling on genital gender-affirming surgery for transmasculine and nonbinary patients improved in the Midwest, Northeast, and South following a five-part clinical scenario-based educational module. Absence of a change in comfort counseling in the West suggest a decreased utility in this region.

Insights into the assembly of the neovaginal microbiota in Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome patients

Neovaginas are surgically constructed to correct uterovaginal agenesis in women with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome or as part of gender-affirming surgery for transfeminine individuals. Understanding the assembly of the neovaginal microbiota is crucial for guiding its management. To address this, we conducted a longitudinal study on MRKH patients following laparoscopic peritoneal vaginoplasty. Our findings reveal that the early microbial assemblage exhibited stochastic characteristics, accompanied with a notable bloom of Enterococcus faecalis and genital Mycoplasmas. While both the pre-surgery dimple microbiota and the fecal microbiota constituted the primary species pool, the neovaginal microbiota developed into a microbiota that resembled that of a normal vagina at 6–12 months post-surgery, albeit with a bacterial vaginosis (BV)-like structure. By 2–4 years post-surgery, the neovaginal microbiota had further evolved into a structure closely resembling with the homeostatic pre-surgery dimple microbiota. This concords with the development of the squamous epithelium in the neovagina and highlights the pivotal roles of progressive selective forces imposed by the evolving neovaginal environment and the colonization tropism of vaginal species. Notably, we observed that strains of Lactobacillus crispatus colonizing the neovagina primarily originated from the dimple. Since L. crispatus is generally associated with vaginal health, this finding suggests potential avenues for future research to promote its colonization.

Thirty-Day Complication Rates After Gender-Affirming Bottom Surgery: An Analysis of the NSQIP Database From 2010 to 2020.

Gender-affirming bottom surgeries (GABS) play a central role in treating gender dysphoria to improve quality of life for transgender and nonbinary (TGNB) patients. However, there exists limited data on operative risks and outcomes for patient populations undergoing GABS. The goal of this study is to identify sociodemographic and clinical risk factors for determining 30-day postoperative complications in patients undergoing GABS. The ACS-NSQIP database from 2010 to 2020 was used to identify patients undergoing gender affirmation surgery (GAS) using Current Procedural Terminology (CPT) codes included in transfeminine and transmasculine bottom surgery. IBS-SPSS software was used to perform a multivariate analysis to determine risk factors for increased 30-day postoperative complications including unplanned reoperation and readmission rates. A total of 1809 GABS were performed in the NSQIP database from 2010 to 2020. There was an upward trend in GABS procedures throughout the years, with 2017 having the most GABS (n = 629). Transmasculine patients with a BMI of 29 and over were at a greater risk for wound complications (P < 0.05). Diabetic transfeminine patients were also at a greater risk for wound complications (P < 0.05). This study identified that several sociodemographic and clinical risk factors, such as BMI and diabetes mellitus type 2, had increased postoperative complications for patients undergoing gender-affirming bottom surgeries. Wound care management and patient education are essential in GABS to prevent long-term complications. Physician awareness of risk factors and social determinants of health can help prevent and improve postoperative care education and patient compliance.

Individually customized gender affirming genital procedures: techniques and considerations.

Gender-affirming surgery is being increasingly performed for transgender and gender-diverse individuals diagnosed with gender dysphoria. However, there is a group of patients who may seek outcomes that are either a combination of or altogether different from those of binary procedures such as penile inversion vaginoplasty or phalloplasty. We describe surgical techniques for less commonly performed gender-affirming genital procedures, in order to introduce these procedures to the medical and surgical community. Operative techniques for phallus-preserving vaginoplasty, vagina-preserving phalloplasty, and removal of genitalia with creation of perineal urethrostomy are described. Demographic characteristics and complications of these procedures in 16 patients are reported. Individually customized gender-affirming genital procedures, such as phallus-preserving vaginoplasty, vaginal-preserving phalloplasty, and removal of genitalia and creation of perineal urethrostomy, may better affirm the identities of some gender-diverse patients, and may also preserve desired sexual function of natal genitalia.

Review of Gender Affirming Mastectomy Surgery: Comparing Drains Versus No Drains.

Gender-affirming mastectomy can improve mental health and gender expression. However, there is no consensus on routine drain usage in gender-affirming surgeries. The purpose of this study is to compare gender-affirming mastectomies with and without drains and review complications. An institutional review board-approved, retrospective review was performed to identify patients between 2017-2021 who had double-incision mastectomy, with or without nipple graft, and separated into drain and no-drain cohorts. Patient demographics, outcomes, and postoperative complications were analyzed, including unplanned return to the operating room, seromas, hematomas, postoperative infection, and postoperative antibiotic use. Univariate and multivariate analysis was performed. There were 359 patients that had a gender-affirming mastectomy surgery between 2017 and 2021. The mean age was 26.1 years old, and mean body mass index was 27.4. There were 144 patients (40.1%) who had a drain, and 215 patients (59.9%) without a drain. For postoperative complications of all patients, there were 12 (3.3%) unplanned returns to the operating room, 18 seromas (5.0%), 26 hematomas (7.2%), 50 (13.9%) postoperative antibiotic use, and 4 postoperative infections (1.1%). There were no significant differences found between drain use for all postoperative complications, but no-drain use was significantly associated with less prescribed postoperative antibiotics compared to drain use (3.7% and 29.0%, respectively; P < 0.001). Gender-affirming mastectomy surgeries are safe and effective treatment options. No-drain placement was not associated with increased postoperative complications. Surgeons may consider not prescribing routine postoperative antibiotics if using drains, and avoiding drains for gender-affirming mastectomies may be considered in selected individuals based on clinical judgment.

Postoperative Opioid Use in Staged Gender-Affirming Facial Surgery.

Postoperative Opioid Use in Staged Gender-Affirming Facial Surgery.

Along the Spectrum from Reduction to Mastectomy: Comparing the Opinions of the Transmasculine and Gender-diverse Community on an Algorithmic Approach to Gender-Affirming Top Surgery

Along the Spectrum from Reduction to Mastectomy: Comparing the Opinions of the Transmasculine and Gender-diverse Community on an Algorithmic Approach to Gender-Affirming Top Surgery

Temporal Trends and Outcomes of Gender-Affirming Gynecologic Surgery

We performed a population-based analysis to examine the trends in utilization and outcomes of gynecologic surgical procedures performed for gender-affirming care using the National Inpatient and Ambulatory Surgery Samples. Overall, 3,344,186 (95% CI, 3,281,163–3,407,209) unique individuals who underwent gynecologic surgery were identified. Transgender and gender-diverse (TGD) individuals accounted for 19.7% (345/1,748) of the labiaplasty–clitoroplasty procedures, 15.0% (3,355/22,433) of vaginoplasties, 2.0% (212/10,679) of vaginectomies, 0.2% (5,369/2,346,748) of hysterectomies, and 0.1% (515/962,578) of oophorectomies. The percentage of cases performed in TGD individuals increased substantially from 2016 to 2020 for vaginoplasty (6.2–24.1%) and clitoroplasty–labiaplasty (8.0–35.1%). Among patients who underwent vaginoplasty, the complication rate was significantly higher among TGD individuals (16.5% vs 11.1%) (adjusted odds ratio 1.85, 95% CI, 1.22–2.81). For the other procedures, the complication rate was not higher.

Toward informed consent: Canadian providers’ perspectives on presurgical mental health assessments for gender-affirming surgeries.

Toward informed consent: Canadian providers’ perspectives on presurgical mental health assessments for gender-affirming surgeries.