Faculty Bibliography

BACKGROUND:To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited. METHODS:A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion. RESULTS:Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low. CONCLUSIONS:Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

OBJECTIVES/OBJECTIVE:To present the technique and early outcomes of salvage neovaginal reconstruction using robotic dissection and peritoneal flap mobilization. METHODS:Twenty-four patients underwent robotic peritoneal flap revision vaginoplasty from 2017-2020. A canal is dissected between the bladder and rectum towards the stenosed vaginal cavity, which is incised and widened. Peritoneal flaps from the posterior bladder and pararectal fossa are advanced and sutured to edges of the stenosed cavity. Proximal peritoneal flap edges are approximated to form the neovaginal apex. Patient demographics, comorbidities, surgical indications, and operative details are described. Outcome measures include postoperative neovaginal dimensions and complications. RESULTS:Mean age at revision was 39 years (range 27-58). All patients had previously undergone PIV, with revision surgery occurring at a median 35.3 months (range 6-252) after primary vaginoplasty. Surgical indications included short or stenotic vagina or absent canal. Average procedure length was 5 hours. At mean follow up of 410 days (range 179-683), vaginal depth and width were 13.6 cm (range 10.9-14.5) and 3.6 cm (range 2.9-3.8), respectively. There were no immediate or intraoperative complications related to peritoneal flap harvest. No patient had rectal injury. One patient had post-operative canal bleeding requiring return to the operating room for hemostasis. CONCLUSIONS:Robotic peritoneal flap vaginoplasty is a safe, novel approach to canal revision after primary PIV with minimal donor site morbidity.

SUMMARY/CONCLUSIONS:There remain significant gaps in the evidence-based care of patients undergoing gender-affirming mastectomy with regard to implications for breast cancer development and screening. The current clinical evidence does not demonstrate an increased risk of breast cancer secondary to testosterone therapy in transgender patients. Gender-affirmation mastectomy techniques vary significantly with regard to the amount of residual breast tissue left behind, which has unknown implications for the incidence of postoperative breast cancer and need for screening. Subcutaneous mastectomy should aim to remove all gross breast parenchyma, although this is limited in certain techniques. Tissue specimens should also be routinely sent for pathologic analysis. Several cases of incidental breast cancer after subcutaneous mastectomy have been described. There is little evidence on the need for or types of postoperative cancer screening. Chest awareness is an important concept for patients that have undergone subcutaneous mastectomies, as clinical examination remains the most common reported method of postmastectomy malignancy detection. In patients with greater known retained breast tissue, such as those with circumareolar or pedicled techniques, consideration may be given to alternative imaging modalities, although the efficacy and cost-utility of these techniques must still be proven. Preoperative patient counseling on the risk of breast cancer after gender-affirming mastectomy in addition to the unknown implications of residual breast tissue and long-term androgen exposure is critical. Patient awareness and education play an important role in shared decision-making, as further research is needed to define standards of medical and oncologic care in this population.

OBJECTIVES/OBJECTIVE:To report our novel technique and mid-term follow up for robotic-assisted laparoscopic vaginectomy (RALV), a component procedure of staged gender-affirming penile reconstructive surgery (GAPRS). METHODS:The records of patients seeking GAPRS who underwent RALV, performed by a single surgeon at our institution, between May 2016 and January 2020 were reviewed retrospectively for demographic and perioperative data. Patients were included irrespective of history of previous phalloplasty. A subset of these patients elected to have urethral lengthening during second stage phalloplasty for which an anterior vaginal mucosa flap urethroplasty was performed. Postoperative complications and outcomes and most recent follow-up were obtained. RESULTS:A total of 42 patients were reviewed, of whom 19 (45%) patients ultimately had radial forearm free flap, 15 (41%) had anterolateral thigh flap, 5 (12%) had metoidioplasty, and 1 (2.4%) had abdominal phalloplasty. A vaginal mucosa and gracilis flap was used in all of 36 (86%) patients in whom a pars fixa was created. Average operative time was 299 minutes (range 153-506). Median estimated blood loss was 200 ml (range 100-400). Median length of stay was 3 days (range 1-7). Complications within 30 days from surgery occurred in 15 patients (36%), of whom 12/15 were Clavien-Dindo grade 1 or 2, and 11/15 had complications unrelated to vaginectomy. Of the 4 patients who had vaginectomy-related complications, all resolved with conservative management. Median overall follow-up was 15.8 months. CONCLUSIONS:RALV offers a safe and efficient approach during staged gender-affirming penile reconstruction and may mitigate the subsequent risk of urethral complications.

BACKGROUND:Gender-affirming surgery is becoming increasingly more common. Procedures including chest masculinization, breast augmentation, vaginoplasty, metoidioplasty, and phalloplasty routinely generate discarded tissue. The incidence of finding an occult malignancy or premalignant lesion in specimens from gender-affirming surgery is unknown. The authors therefore conducted a retrospective review of all transgender patients at their institution who underwent gender-affirming surgery to determine the incidence of precancerous and malignant lesions found incidentally. METHODS:A retrospective review of transgender patients who underwent gender-affirming surgery at the authors' institution between 2017 and 2018 performed by a single plastic surgeon and a single reconstructive urologic surgeon was conducted. Only transgender patients who underwent gender-affirming surgery that led to routine pathologic review of discarded tissue (mastectomy, vaginoplasty, vaginectomy as part of phalloplasty) were included. Charts were reviewed and patient demographics, duration of hormonal therapy, medical comorbidities, genetic risk factors for cancer, medications (including steroids or other immunosuppressants), pathology reports, and cancer management were recorded. RESULTS:Between 2017 and 2018, 295 transgender patients underwent gender-affirming surgery that generated discarded tissue sent for pathologic evaluation. During this period, 193 bilateral mastectomies, 94 vaginoplasties with orchiectomies, and eight vaginectomies were performed; 6.4 percent of all patients had an atypical lesion found on routine pathologic evaluation. CONCLUSIONS:Gender-affirming surgery is increasingly more common given the increase in access to care. The authors' review of routine pathologic specimens generated from gender-affirming surgery yielded a 6.4 percent rate of finding atypical lesions requiring further evaluation. The authors advocate that all specimens be sent for pathologic evaluation.

BACKGROUND:Robotic-assisted peritoneal flap gender-affirming vaginoplasty (RPGAV) with the da Vinci Xi system has been reported to be a safe alternative to traditional penile inversion vaginoplasty. Utilizing the Single Port (SP) robot system, our surgical approach has evolved. OBJECTIVE:To describe a step-by-step technique for RPGAV using the SP robot and to compare outcomes between Xi and SP systems. DESIGN, SETTING, AND PARTICIPANTS/METHODS:A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. We retrospectively reviewed data for patients with a minimum 6 mo of follow-up. SURGICAL PROCEDURE/METHODS:Peritoneal flaps are harvested from the posterior bladder and pararectal fossa. The vaginal space is dissected transabdominally. Inverted penile flap with or without scrotal graft is sutured to the peritoneal flaps, which form the neovaginal apex. MEASUREMENTS/METHODS:Demographics, perioperative data, and clinical outcomes were evaluated. RESULTS AND LIMITATIONS/CONCLUSIONS:A total of 100 (Xi = 47; SP = 53) patients had a minimum 6 mo of follow-up. The mean age was 36.2 (range 16.1-71.4) yr. Average procedure times were 4.2 and 3.7 h in Xi and SP cohorts, respectively (p <0.001). At the mean follow-up of 11.9 (range 6.0-25.4) mo, vaginal depth and width were 13.6 (range 9.7-14.5) and 3.7 (range 2.9-3.8) cm in the Xi group, and 14.1 (range 9.7-14.5) and 3.7 (range 3.5-3.8) cm in the SP group (p =0.07 and 0.04, respectively). Complications included transfusion (6%), rectovaginal fistula (1%), bowel obstruction (2%), pelvic abscess (1%), and vaginal stenosis (7%). CONCLUSIONS:RPGAV using the SP robot reduces operative time by facilitating a dual-surgeon abdominal-perineal approach. There is no difference in complication rates between the two approaches. PATIENT SUMMARY/UNASSIGNED:We studied the outcomes of robotic peritoneal flap vaginoplasty with two robot systems. With both systems, patients had good vaginal depth and width at an average follow-up of 1 yr. Surgery time was shorter with the Single Port (SP) robot.