Faculty Bibliography

Background: Patient-reported outcomes regarding sexual health are lacking or have not been validated for transgender patients following vaginoplasty. The aim of this study is to further characterize the difference in sexual health, genital self-image, and the relationship between them for patients who were pre- and postvaginoplasty. Methods: A community advisory board informed an anonymous online survey utilizing patient-reported outcomes. Pre- and postvaginoplasty respondents were recruited online. Survey measures included the Female Genital Self-Image Scale (FGSIS) and the Patient-Reported Outcomes Measurement Information System sexual health measures. Welch approximation t tests were performed for FGSIS and Patient-Reported Outcomes Measurement Information System questions, using Bonferroni correction. Results: A total of 690 respondents prevaginoplasty (n = 525; 76%) and postvaginoplasty (n = 165; 24%) participated. The postoperative cohort, compared with the preoperative cohort, reported higher scores for orgasm (P = 0.0003), satisfaction (P = 0.001), and pleasure (P = 0.002). FGSIS total score was higher among postoperative respondents (79.4% ± 17.1%) than preoperative respondents (50.6% ± 15.1%) (P < 0.0001). Using Spearman rho, no significant correlation between FGSIS total score and any Patient-Reported Outcomes Measurement Information System subsectional measures was observed for the postoperative cohort, but a correlation (P <0.001) was observed for the preoperative cohort. Conclusions: Individuals who are contemplating vaginoplasty have worse sexual health and genital self-image than those who underwent vaginoplasty, yet genital self-image does not correlate directly with sexual health. Sexual health is multimodal for each person.

BACKGROUND:Gender-affirming mastectomy, or "top surgery," has become one of the most frequently performed procedures for transgender and nonbinary patients. However, management of perioperative testosterone therapy remains controversial. Despite a lack of supporting evidence, many surgeons require cessation of testosterone prior to top surgery. This represents the first study to compare complication rates in patients undergoing gender-affirming mastectomy with and without discontinuation of perioperative testosterone. METHODS:Retrospective review identified patients undergoing top surgery by the senior author between 2017 and 2020. Reflecting a change in the senior author's practice, prior to May 2019, all patients were required to discontinue testosterone prior to surgery, while all patients treated after this point continued their testosterone regimens throughout the perioperative period. Patients were stratified according to testosterone regimen and perioperative hormone management, with demographics and postoperative outcomes compared between groups. RESULTS:490 patients undergoing gender-affirming mastectomy during the study period were included. Testosterone was held perioperatively in 175 patients and continued in 211 patients, while 104 patients never received testosterone therapy. Demographics were similar between groups, and there was no difference in rates of hematoma (2.9% vs. 2.8% vs 2.9% respectively, p=0.99), seroma (1.1% vs. 0% vs 1%, p=0.31), venous thromboembolism (0% vs. 0.5% vs 0%, p=0.99), or overall complications (6.9% vs. 4.3% vs 5.8%, p=0.54). CONCLUSIONS:Our results demonstrate no difference in postoperative complication rates between groups. While further investigation is warranted, our data suggest that routine cessation of testosterone in the perioperative period is not necessary for patients undergoing gender-affirming mastectomy.

SUMMARY:The surgical treatment of gender incongruence with gender-affirming surgery requires a sophisticated understanding of the substantial diversity in patient expectations and desired outcomes. There are patients with gender incongruence who desire surgical intervention to achieve the conventional bodily configuration typical for cisgender men and women and those who desire surgery without the goal of typical cisgender presentation. Proper communication regarding diverse expectations poses a challenge to those unfamiliar with the nuances of this heterogeneous population; such difficulties have led to mistakes during patient care. Based on the lessons learned from these experiences, the authors provide conceptual recommendations with specific examples to account for cultural context and conceptions of gender within surgical practice and scientific research.

With the widespread dissemination of robotic surgical platforms, pathologies that were previously deemed challenging can now be treated more reliably with minimally invasive procedures via the robot. The advantages of precise articulation for dissection and suturing, tremor reduction, three-dimensional magnified visualization, and small incisions allow for the management of diverse lower urinary tract (LUT) disease. These may include recurrent or refractory bladder neck stenoses or intracorporeal urinary diversion with excellent perioperative and functional outcomes. Here, we review the recent literature comprising of developments in robotic-assisted LUT genitourinary reconstruction, with a view toward emerging technologies and future trends in techniques.

OBJECTIVE:To provide a summary of surgical technique and outcomes for Heineke-Mikulicz preputioplasty (HMP), a foreskin-preserving surgical treatment for phimosis in the adult population. METHODS:We retrospectively reviewed 7 patients who underwent HMP by a single surgeon from May 2017 to May 2021. Variables included patient demographics, intraoperative considerations, and post-operative course. HMP is performed using a 2-3 cm vertical incision over the phimotic band on the dorsal surface to just above Buck's fascia. Additional incisions are made on the ventral surface if phimosis remains persistent after dorsal release. The incision is closed horizontally in 2 layers. RESULTS:Seven patients underwent HMP. Median age was 47.3 and median BMI was 24.3. Five patients reported bothersome phimosis and 1 each reported paraphimosis and frenular tethering. Six patients requested foreskin sparing surgery as a personal preference and 1 patient was an intraoperative consult. Topical betamethasone was attempted in 3 of 7 patients. The median time from diagnosis to surgery was 2 months. Median operative time was 45.5 minutes and median estimated blood loss was 5 mL. Two patients required both dorsal and ventral incisions. No intraoperative complications were reported and all patients were discharged the same day. At median follow-up of 1.8 months, 1 patient reported bothersome phimosis secondary to scar formation treated successfully with triamcinolone. CONCLUSION/CONCLUSIONS:HMP is a safe and effective method of treating even very significant phimosis in patients trying to avoid circumcision or intraoperative consults where preferences may be unclear. Our method takes less time than traditional circumcision with a comparable recovery and complication profile.

BACKGROUND:Sexually transmitted infections (STIs) following penile reconstruction in transgender, nonbinary, and other gender expansive (T/GE) populations has not previously been described, despite known risk factors in the population. Following T/GE penile reconstruction, care providers may underdiagnose STI without anatomically appropriate guidelines. METHODS:A detailed anonymous online survey of experiences of T/GE penile reconstruction patients was constructed with community input. Respondents were recruited from online support groups. RESULTS:128 T/GE people with experience of penile reconstruction responded to an anonymous survey posted in online support groups January to May 2020. Seven respondents (5.5%) self-reported one or more of the listed STIs at any point after penile reconstruction. All respondents with neourethras were diagnosed with localized STIs in nonurethral (extrapenile) locations only, and lack of vaginectomy was correlated with STI (p = 0.002). STIs were correlated with reporting sex with cisgender men (p = 0.001), transgender men (p = 0.009), and transgender women (p = 0.012). Of healthcare access variables, only receiving healthcare at a Community Health Center was correlated with STI history (p = 0.003). CONCLUSION/CONCLUSIONS:This exploratory survey indicates STI occurs after penile reconstruction in T/GE patients. Clinical confirmation is needed to identify specific risk factors and relative susceptibility of post-reconstruction anatomy to STIs. Given no previous surveillance recommendations for this population and the correlation of healthcare provider location with STI prevalence, underdiagnoses are likely. Based on the authors' clinical experience, we describe a urogenital screening algorithm following gender affirming penile reconstruction.

BACKGROUND:Following gender-affirming penile inversion vaginoplasty or vulvoplasty, patients may seek vulvar revision procedures for a variety of common aesthetic and functional concerns. These indications for revision and accompanying techniques are not well-described in the literature. METHODS:Patients who underwent vulvar revision surgery at the authors' institution were identified, and patient demographics, surgical indications, operative details, and complications were described. Common complaints requiring external genital revision were sorted into four categories: clitoral, labial, introital, and urethral. RESULTS:Thirty-five patients with a history of vaginoplasty underwent vulvar revision between May of 2017 and December of 2019. The mean age at surgical correction was 38.9 years. Ten patients (28.6 percent) had undergone prior secondary procedures (range, 1 to 3). Mean follow-up after revision surgery was 10.7 ± 8.7 months (range, 0 to 30.6 months). The majority of patients underwent concurrent revisions in multiple "categories". Labial aesthetic concerns were most common (n = 27, 77.1 percent), followed by clitoral (n = 20, 57.1 percent), urologic (n = 17, 48.6 percent), and introital complaints (n = 12, 34.3 percent). Twelve patients (34.3 percent) had canal stenosis requiring concurrent robot-assisted canal revision with peritoneal flaps. Complications included labial abscess (n = 1) and deep vein thrombosis (n = 1). Three patients (8.6 percent) underwent subsequent external genital revisions. Management approaches and surgical techniques for each of these common revision categories are provided. CONCLUSION/CONCLUSIONS:As more individuals seek vaginoplasty and vulvoplasty, surgeons must be prepared to address a range of common aesthetic and functional complaints requiring vulvar revision. CLINICAL QUESTION/LEVEL OF EVIDENCE/METHODS:Therapeutic, IV.

OBJECTIVE:To describe the authors' experience diagnosing and managing intra-abdominal complications following robotic peritoneal flap vaginoplasty. The peritoneal flap vaginoplasty is a technique used to achieve consistent vaginal depth regardless of available natal tissue. Intra-abdominal complications following robotic peritoneal flap creation are rare but prompt diagnosis and management is critical to preventing patient harm. Given the infancy of the technique there is limited data on associated complications and their management. METHODS:Retrospective chart review identified patients undergoing robotically assisted peritoneal flap vaginoplasty by the senior authors between 2017 and 2020 who subsequently developed intra-abdominal complications requiring readmission and/or return to the operating room. Patient charts were analyzed for preoperative demographics, medical comorbidities, intraoperative details, postoperative complication presentation, diagnosis, management, and long-term outcomes. RESULTS:Out of 274 patients undergoing peritoneal flap vaginoplasty during the study period, six patients were identified who developed intra-abdominal complications (2.2%). One patient developed a postoperative hematoma requiring return to the operating room for diagnostic laparoscopy and hematoma evacuation. Two patients developed intraabdominal abscesses requiring diagnostic laparoscopy and abscess drainage. One patient developed recurrent episodes of small bowel obstructions that resolved with bowel rest. Two patients developed incarcerated internal hernias requiring diagnostic laparoscopy and internal hernia reduction. In one case, the hernia occurred at the peritoneal flap closure site, and in the other case the hernia occurred at the peritoneal flap donor site. CONCLUSIONS:Intra-abdominal complications following robot assisted peritoneal flap vaginoplasty are rare.  In addition to hematoma and abscess, small bowel incarceration and internal hernias are potential complications of peritoneal flap vaginoplasty that require prompt attention.

Increased access to care and insurance coverage has led to an increase in gender-affirming surgeries performed in the United States. Gender-affirming phalloplasty has a variety of donor sites and surgical techniques including both pedicled and free flaps. Although surgical techniques and patient outcomes are well-described, no reports in the literature specifically discuss postoperative management, which plays a crucial role in the success of these operations. Here, we present a postoperative protocol based on our institution's experience with gender-affirming phalloplasty with the hope it will serve as a standardized, reproducible reference for centers looking to offer these procedures.