Faculty Bibliography

Objective: The Preserve it And Turn it Inside Out (PATIO) technique has been used for repair of urethrocutaneous fistula (UCF) after hypospadias repair. We demonstrate this technique for the repair of UCF in the adult cisgender and transgender population. This technique preserves and inverts the fistula tract to prevent egress of urine. We present a video detailing our updated surgical technique and outcomes from our single-institution experience. Patients and surgical procedure: A retrospective review of adult patients who underwent PATIO repair for UCF between November 2017 and July 2021 by a single surgeon (LCZ) was performed. A circumferential incision is made around the fistula opening, a figure-of-8 or purse string suture with absorbable suture is placed across the opening, and the suture is pulled through the urethral meatus thereby inverting the fistula tract. The suture is secured to the meatus and the skin overlying the fistula is closed in two layers.
Result(s): Nine patients met criteria with a total of 10 PATIO procedures performed. Six patients were cisgender and three were transgender. Of the 6 cisgender patients, etiology of UCF included penile piercings (4/6) and prior hypospadias repair (2/6). All fistulas were distal. All three transgender patients developed UCF as a result of phalloplasty and fistula location was proximal. Median fistula size was 2.6mm (range 0.6-4.6), median operative time was 55 min (range 29-124), and median estimated blood loss was 5 ml (range 5-50). No intraoperative complications were reported. Three patients underwent adjunctive procedures the time of repair. Overall success rate was 70% with one patient undergoing successful repeat PATIO repair.
Conclusion(s): PATIO repair offers a safe and durable method of UCF repair in adult cisgender and transgender patients with a range of UCF presentations. We report a short operative time, minimal blood loss, minimal need for urethral catheterization, and a 70% success rate. Adjunctive maneuvers may be employed concurrently in complex or recurrent cases.
Funding(s): None.
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OBJECTIVE:1) To describe the authors' technique of anterolateral thigh (ALT) phalloplasty with staged skin graft urethroplasty and 2) to report the surgical outcomes and complications of this technique in a preliminary patient cohort. METHODS:Following IRB (Institutional Review Board) approval, retrospective chart review identified all patients undergoing primary three-stage ALT phalloplasty by the senior authors. Stage I involves single tube, pedicled ALT transfer. Stage II involves vaginectomy, pars fixa urethroplasty, scrotoplasty, and opening the ALT ventrally and construction of a urethral plate with split-thickness skin graft. Stage III involves tubularization of the urethral plate to create the penile urethra. Data collected included patient demographics, intraoperative details, postoperative courses, and complications. RESULTS:Twenty-four patients were identified. Twenty-two patients (91.7%) underwent ALT phalloplasty prior to vaginectomy. All patients underwent staged split-thickness skin grafting for the penile urethra reconstruction. Twenty-one patients (87.5%) achieved standing micturition at the time of data collection. Eleven patients (44.0%) experienced at least 1 urologic complication requiring additional operative intervention, most commonly urethrocutaneous fistulae (8 patients, 33.3%), and urethral strictures (5 patients, 20.8%). CONCLUSION/CONCLUSIONS:ALT phalloplasty with split-thickness skin grafting for urethral lengthening is an alternative technique to achieve standing micturition with an acceptable complication rate in gender-affirming phalloplasty.

OBJECTIVE:To address instances when there is insufficient remnant tissue to perform revision following canal-deepening gender affirming vaginoplasty revisions as indicated by insufficient depth. Options for lining of the vaginal canal include skin grafts, peritoneal flaps, or intestinal segment. Our center uses robotically harvested peritoneal flaps in vaginal canal revisions. When the peritoneal flap is insufficient for full canal coverage, we use AlloDerm, an acellular dermal matrix, for additional coverage. METHODS:Retrospective analysis of 9 patients who underwent revision RPV with AlloDerm was performed. Tubularized AlloDerm grafts were used to connect remnant vaginal lining to the peritoneal flaps. Revision indications, surgical and patient outcomes, and patient-reported post-op dilation were recorded. RESULTS:Nine patients underwent revision RPV using AlloDerm for canal deepening. Median follow-up was 368 days (Range 186-550). Following revision, median depth and width at last follow-up were 12.1 cm and 3.5 cm, and median increase in depth and width were 9.7 cm and 0.9 cm, respectively. There were no intraoperative complications. Two patients had focal areas of excess AlloDerm that were treated with in-office excision without compromise of the caliber or depth of the otherwise healed, epithelialized canal. CONCLUSION/CONCLUSIONS:AlloDerm is an off-the-shelf option that does not require a secondary donor site. The use of AlloDerm for a pilot cohort of patients lacking sufficient autologous tissue for revision RPV alone was demonstrated to be safe and effective at a median 1-year follow-up.

BACKGROUND:Insufficient genital tissue has been reported as a barrier to achieving depth in gender-affirming vaginoplasty. The authors sought to characterize vaginal depth and revision outcomes in patients with genital hypoplasia undergoing robotic peritoneal flap vaginoplasty. METHODS:Retrospective case-control analysis of patients undergoing robotic peritoneal vaginoplasty between September of 2017 and August of 2020 was used. All 43 patients identified as having genital hypoplasia (genital length <7 cm) were included with 49 random controls from the remaining patients with greater than 7 cm genital length. Baseline clinical characteristics and perioperative variables were recorded to identify potential confounders. Outcomes measured included vaginal size reported at last visit and undergoing revision surgery for depth or for vulvar appearance. RESULTS:Patients were well matched other than median body mass index at the time of surgery, which was greater in the hypoplasia cohort by 3.6 kg/m 2 ( P < 0.0001). Patients had a median of 1-year of follow-up, with a minimum follow-up of 90 days. No significant differences in outcomes were observed, with a median vaginal depth of 14.5 cm (interquartile range, 13.3 to 14.5 cm), and a median width of dilator used of 3.8 cm (interquartile range, 3.8 to 3.8 cm). No depth revisions were observed, and an 11% ( n = 10) rate of external revision occurred. CONCLUSIONS:Patients with genital hypoplasia had equivalent dilation outcomes in a case-control analysis with consistent follow-up past 90 days. The robotic peritoneal flap vaginoplasty technique provides vaginal depth of 14 cm or greater regardless of genital tissue before surgery. Further investigation with patient-reported outcome measures is warranted. CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.

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:The incidence of transgender adolescents seeking gender affirming surgery (GAS) in increasing. Surgical care of the adolescent transgender patient is associated with several unique technical, legal, and ethical factors. The authors present a review of the current literature on gender affirming surgery for individuals under the age of legal majority and propose directions for future research. METHODS:A scoping review of recent literature was performed to assess evidence on gender affirming surgery in individuals under the age of legal majority. Papers were included that examined either ethical or technical factors unique to pediatric GAS. Study characteristics and conclusions were analyzed in conjunction with expert opinion. RESULTS:Twelve papers were identified meeting inclusion criteria. Ten of these papers discussed ethical challenges in adolescent GAS, seven papers discussed legal challenges, and five papers discussed technical challenges. Ethical discussions focused on the principles of beneficence, nonmaleficence, and autonomy. Legal discussions centered on informed consent and insurance coverage. Technical discussions focused on the impact of puberty blockade on natal tissue. CONCLUSIONS:Surgical care of the adolescent transgender patient involves important ethical, legal, and technical considerations that must be addressed by the clinical team. As the population of individuals seeking GAS after puberty blockade increases, future research is needed describing functional and psychosocial outcomes in these individuals.

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.

BACKGROUND:Many patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints. AIM/OBJECTIVE:Our aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling. METHODS:A retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic. OUTCOMES/RESULTS:Orgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record. RESULTS:A total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy. CLINICAL IMPLICATIONS/CONCLUSIONS:Preoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery. STRENGTHS & LIMITATIONS/UNASSIGNED:This investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm. CONCLUSION/CONCLUSIONS:The majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery.