Faculty Bibliography

OBJECTIVE:To generate surgeon consensus on metoidioplasty and phalloplasty gender-affirming surgery (MaPGAS) outcomes statements using a modified Delphi method. MATERIALS AND METHODS/METHODS:We invited MaPGAS surgeons to anonymously participate in a two-round web-based Delphi survey to generate consensus on patient centered outcome statements generated from surgeon practice patterns, literature review, and patient input. Consensus was predefined as at least 70% agreement. Surgeons were asked to provide open ended feedback on statements which were thematically analyzed and used to revise statements not reaching consensus for a second-round survey. RESULTS:Twenty-one metoidioplasty and phalloplasty surgeons were invited and 16 (76%) reviewed 39 statements in round one and 17/20 (85%) reviewed 10 statements in round two. Following round two, nearly all statements reached consensus: 14/15 (93%) of statements on metoidioplasty, 11/12 (92%) of radial forearm phalloplasty statements and 12/12 (100%) of anterolateral thigh phalloplasty statements. We found that 12/12 (100%) statements on sexual health, 8/8 (100%) statements on non-urinary complications, and 16/18 (89%) statements on urinary outcomes met consensus. CONCLUSIONS:In a modified web-based Delphi survey, surgeons reached consensus on nearly all outcome statements. Variations in surgeon experience, length of follow up, and reporting of outcomes contribute to different definitions of urinary complications. Results from this study will help create decision making tools for individuals considering metoidioplasty and phalloplasty.

OBJECTIVES/UNASSIGNED:To compare the outcomes of open versus robotic ureteral reimplantation procedures at a single centre. MATERIAL AND METHODS/UNASSIGNED:The charts of all patients with ureteral strictures who underwent open ureteral reimplantation between 2005 and 2024, and those who underwent robotic reimplantation between 2013 and 2024, were retrospectively reviewed, and the outcomes of the two approaches were compared. RESULTS/UNASSIGNED:Eighty patients were included in the final analysis: 45 in the open surgery group and 35 in the robotic group. After a median follow-up duration of 16,5 months for the open group and 10 months for the robotic group, the stricture recurrence rate was similar in both groups (6,8% vs. 8.6%; p = 0.99). In terms of long-term complications, there were similar rates of symptomatic reflux (4.4% vs. 5.7%; p = 0.99) and flank pain (8.9% vs. 8.6%; p = 0.99) between both groups. There were more recurrent urinary tract infections in the open group (17.8% vs. 8.6%) and more de novo lower urinary tract symptoms in the robotic group (11.4% vs. 2.2%), but these differences were not statistically significant (p = 0.33 and p = 0.16, respectively). Overall, 30 patients (38%) had at least one long-term complication (35.6% vs 40%; p = 0.82). The only variable significantly associated with the risk of stricture recurrence was radiotherapy (OR = 11.2; p = 0.01). CONCLUSION/UNASSIGNED:The robotic approach appears to be non-inferior to the open approach in terms of stricture recurrence while being associated with a shorter length of hospital stay and lower estimated blood loss. More importantly, the present series raises questions regarding the long-term consequences of ureteral reimplantation and confirms the higher risk of failure in radiated patients.

PURPOSE/OBJECTIVE:To investigate outcomes of robotic ureteral reconstruction (RUR) in female patients with ureteral strictures caused by peri-ureteral endometriosis lesions. METHODS:We retrospectively reviewed our multi-institutional Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database to identify all consecutive patients undergoing RUR for surgical management of endometriosis-induced ureteral strictures between 2017 and 2022. Indications for surgery included female patients with radiographic evidence of ureteral strictures and/or decreasing renal function on renal scan. We performed a descriptives analysis of perioperative outcomes in patients who met inclusion criteria. Surgical success was defined as freedom from additional interventions for recurrent ureteral stenosis. RESULTS:Overall, 19 patients met the inclusion criteria. Median age was 39 (IQR 30-43) years. Ureteral strictures were located in the middle ureter in 4 (21.1%) patients and in the distal ureter in 15 (78.9%) patients. Fourteen (73.6%) patients had a known preoperative diagnosis of endometriosis. RUR techniques included refluxing reimplantation (47.4%), side-to-side reimplantation (21.1%), ureteroureterostomy (21.1%), and buccal mucosa graft ureteroplasty (10.5%). There was one (5.3%) major postoperative complication (Clavien > 2) in which a patient developed an intrabdominal abscess requiring drainage by interventional radiology. Five (26.3%) patients were ultimately diagnosed postoperatively with endometriosis based on surgical pathology. At a median follow-up of 22.5 (IQR 11.7-41.5) months, 18 (94.7%) patients were surgically successful. CONCLUSION/CONCLUSIONS:Clinicians should maintain a high index of suspicion for endometriosis in premenopausal women with ureteral stricture disease. RUR techniques may be effective for the management of patients with ureteral strictures secondary to endometriosis.

Choice of vaginoplasty technique is guided by the patient's natal anatomy, patient goals, and surgeon preference. The biggest distinction among techniques is the choice of lining for the vaginal canal. This chapter provides an overview of current data on the most pertinent complications, both universal and specific to different techniques for gender-affirming vaginoplasty. Clinical pearls for the management of these complications and indications for revision will be reviewed.

The surgical approach of ureteral stricture has changed dramatically over the past 15 years with the rise of robotic upper urinary tract reconstruction. This study aimed to evaluate the outcomes of all robotic ureteral reconstructions performed at a single academic center for ureteral stricture and to assess the predictive factors of stricture recurrence. The charts of all patients who underwent robot-assisted ureteral reconstruction between 2013 and 2024 at a single academic center were retrospectively reviewed. Many different surgical techniques were used including non-refluxing reimplantation with or without psoas hitch, refluxing ureteral reimplantation (side-to-side), Boari flap, uretero-ureterostomy, ureterolysis and buccal mucosa graft (BMG) ureteroplasty. The primary outcome was the absence of stricture recurrence, defined as no need for repeat surgery, urinary drainage, or symptomatic upper urinary tract dilation at the last follow-up. Sixty patients, accounting for 63 ureteral reconstructions, were included in the final analysis. Twenty-five patients experienced early postoperative complications (40%), the majority being Clavien-Dindo grade 2. There were only three (5%) major complications (Clavien-Dindo grade 3b). Stricture recurrence occurred in six patients (10%), with a median time to recurrence of 2.5 months postoperatively. Radiotherapy was the only factor significantly associated with an increased risk of stricture recurrence. The present series confirm the overall low morbidity and low recurrence rate of robotic ureteral reconstruction using a variety of surgical techniques. Comparative studies with longer follow-up periods are necessary to evaluate outcomes in comparison to traditional surgical approaches.

CONTEXT.—/UNASSIGNED:The use of hormonal therapy and gender-affirming surgery in the transgender community has been rising during the last several years. Although it is generally safe, hormonal therapy's link to testicular cancer remains uncertain. OBJECTIVE.—/UNASSIGNED:To review the incidence of testicular cancer in specimens from gender-affirming orchiectomies at our institution and evaluate the tumors for histologic and genetic alterations. DESIGN.—/UNASSIGNED:Pathology reports for gender-affirming orchiectomies (January 1, 2018, to August 1, 2023) were reviewed for testicular neoplasms, with additional analysis for chromosome 12 abnormalities. Incidence and chromosome variations were compared with those in the general population. RESULTS.—/UNASSIGNED:Among 458 cases during 5.5 years, 5 germ cell neoplasms in 4 patients emerged. Our institution's annual incidence rate (159 per 100 000) is 26.5 times higher than the National Cancer Institute's previous report (6.0 per 100 000). Although they were morphologically no different from germ cell neoplasms in the general population, fluorescence in situ hybridization tests showed no i(12p) in 4 of 5 neoplasms (80%) in our cohort. CONCLUSIONS.—/UNASSIGNED:The cause behind this rise in incidence remains uncertain but may be due to long term pretreatment with hormones or blockers. The lower isochromosome 12p frequency suggests an alternative mechanism driving tumor development, which requires more detailed molecular studies.

Gender-affirming care has emerged as a critical component of healthcare, addressing the specific medical and psychosocial needs of transgender and non-binary individuals. In this review article, we address what we see as the most pressing evidence gaps in the gender health literature: long-term effects of pubertal blockers and gender-affirming hormone therapy and the lack of standardised outcome measures of gender-affirming care. Substantial uncertainties persist regarding long-term effects of hormone therapy and the implications of gender-affirming therapy on cancer risk. Though there is some uncertainty about the long-term effects of gender-affirming medical therapy, providers must also consider the potential negative consequences of prolonging a dysphoric experience. Additionally, there is a dearth of validated measures for patient-reported outcomes and a lack of standardisation in the reporting of data that is detrimental to the progress of understanding the impacts of gender-affirming care.

Little is known regarding the incidence of symptomatic, de novo vesicoureteral reflux (VUR) after ureteral reimplantation in adults. We sought to characterize this phenomenon in a contemporary cohort. We conducted a retrospective review of a multi-institutional database of robotic ureteral reconstruction (CORRUS, or Collaborative of Reconstructive Robotic Ureteral Surgery). Inclusion criteria were adult patients undergoing robotic ureteral reimplantation with at least 6 months of follow-up. Patients who had no evidence of recurrent ureteral stenosis were asked to complete a questionnaire characterizing their symptoms. The primary outcome was symptoms suggestive of VUR (SS-VUR), defined as flank pain of at least moderate severity that occurred at least weekly and worsened with voiding or a full bladder. We identified 257 patients who underwent robotic reimplantation, of which 97 (37.7%) were free from recurrent ureteral stenosis and responded to the questionnaire. At a median follow-up duration of 35.0 months (IQR 22.0-59.0), 26 patients (27.4%) reported flank pain of any severity on the same side as reimplantation. Nine patients (9.5%) met criteria for SS-VUR. Four patients underwent additional surgical intervention (two endoscopic, two robotic) after radiographic and functional workup confirmed VUR. On multivariable logistic regression, younger age was an independent predictor of SS-VUR (p = 0.041). In our contemporary series of robotic ureteral reimplantation in adults, over one-quarter of patients reported flank pain postoperatively in the absence of ureteral obstruction. A small proportion of patients had more bothersome symptoms particularly suggestive of VUR.

IMPORTANCE/UNASSIGNED:There is an urgent need for a validated gender-affirming care-specific patient-reported outcome measure (PROM). OBJECTIVE/UNASSIGNED:To field test the GENDER-Q, a new PROM for gender-affirming care, in a large, international sample of transgender and gender diverse (TGD) adults and evaluate its psychometric properties. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This international cross-sectional study was conducted among TGD adults aged 18 years and older who were seeking or had received gender-affirming care within the past 5 years at 21 clinical sites across Canada, the United States, the Netherlands, and Spain; participants were also recruited through community groups (eg, crowdsourcing platform, social media). The study was conducted between February 2022 and March 2024. Participants had to be capable of completing the instrument in English, Danish, Dutch, or French-Canadian. Eligible participants accessed an online REDCap survey to complete sociodemographic questions and questions about gender-affirming care they had received or sought (ie, to look, function, or feel masculine, feminine, gender fluid, or another way). MAIN OUTCOME AND MEASURES/UNASSIGNED:Branching logic was used to assign relevant instrument scales. Rasch measurement theory (RMT) analysis was used to examine the fit of the observed data to the Rasch model for each scale. Test-retest reliability and hypothesis-based construct validity of instrument scales were examined. The hypothesis was that instrument scale scores would increase with better outcomes on corresponding categorical questions. RESULTS/UNASSIGNED:A total of 5497 participants (mean [SD] age, 32.8 [12.3] years; 1837 [33.4%] men; 1307 [23.8%] nonbinary individuals; and 2036 [37.0%] women) completed the field test survey. Participants sought or had the following types of gender-affirming care: 2674 (48.6%) masculinizing, 2271 (41.3%) femininizing, and 552 (10.0%) other. RMT analysis led to the development of 54 unidimensional scales and 2 checklists covering domains of health-related quality of life, sexual, urination, gender practices, voice, hair, face and neck, body, breasts, genital feminization, chest, genital masculinization, and experience of care. Test-retest reliability of the scales (intraclass correlation coefficient [average] >0.70) was demonstrated. Only 1 item (phalloplasty donor flap) had an ICC less than 0.70. As hypothesized, scores increased incrementally with better associated self-reported categorical responses. For example, among 661 participants who reported poor psychological well-being, the mean (SD) scale score was 45 (18) points; for those who reported excellent psychological well-being, the mean (SD) scale score was 85 (16) points (P < .001). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study of 5497 TGD adults, the instrument demonstrated reliability and validity. The instrument was validated in an international sample and is designed to collect and compare evidence-based outcome data for gender-affirming care from the patients' perspective.