Faculty Bibliography

BACKGROUND:Despite the medical necessity, legislative mandates, and economic benefits of gender-affirming surgery, access to treatment remains limited. The World Professional Association for Transgender Health (WPATH) has proposed guidelines for transition-related surgery in conjunction with criteria to delineate medical necessity. The authors assessed insurance coverage of "top" gender-affirming surgery and evaluated the differences between insurance policy criteria and WPATH recommendations. METHODS:The authors conducted a cross-sectional analysis of insurance policies for coverage of top gender-affirming surgery. Insurance companies were selected based on their state enrollment data and market share. A Web-based search and individual telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from publicly available policies. RESULTS:Of the 57 insurers evaluated, bilateral mastectomy (transmasculine) was covered by significantly more insurers than breast augmentation (transfeminine) (96 percent versus 68 percent; p < 0.0001). Only 4 percent of companies used WPATH-consistent criteria. No criterion was universally required by insurers. Additional prerequisites for coverage that extended beyond WPATH guidelines for top surgery were continuous living in congruent gender role, two referring mental health professionals, and hormone therapy before surgery. Hormone therapy was required in a significantly higher proportion of transfeminine policies compared with transmasculine policies (90 percent versus 21 percent; p < 0.0001). CONCLUSIONS:In addition to the marked intercompany variation in criteria for insurance coverage that often deviated from WPATH recommendations, there are health care insurers who categorically deny access to top gender-affirming surgery. A greater evidence base is needed to provide further support for the medical necessity criteria in current use.

Introduction & Objective: We describe a novel skin incision used when performing surgery with the da Vinci Single Port Robotic Surgical System.
Method(s): A 2.7cm diameter circumferential skin incision is made around the umbilicus and carried down through the subcutaneous tissue while leaving the umbilical stalk intact. The fascia adjacent to the umbilicus is exposed by retracting the skin incision in a direction determined by the operative field. The fascia and peritoneum are entered, and the Single Port robotic trocar is inserted in the standard fashion. This technique allows for a cosmetic incision partially hidden within the umbilicus and places less tension on the skin than a standard linear incision.
Result(s): This technique was utilized in approximately 70 patients at a single institution between October 2018 and May 2019. This method of skin incision has been used for a wide variety of robotic reconstructive urologic procedures including penile inversion vaginoplasty, vaginectomy, pyeloplasty, ureteral reimplant, Boari flap, cystectomy and intracorporeal ileal conduit, bladder neck reconstruction, and posterior urethroplasty. No patients have yet to experience complications related to the incision.
Conclusion(s): A circumferential periumbilical skin incision is a versatile skin incision that can be used for a wide array of cases using the Single Port Robotic Surgical System. Moreover, it may have benefits compared to a standard linear incision

BACKGROUND:Penile inversion vaginoplasty (PIV) is the most common procedure for genital reconstruction in transwomen. While PIV usually provides an excellent aesthetic result, the technique may be complicated by vaginal stenosis and inadequate depth, especially in transwomen with limited penile and scrotal tissue. Here, we describe a technique of using peritoneal flaps to augment the neovaginal apex and canal in penile inversion vaginoplasty for transwomen. METHODS:Between 2017 and 2018, 41 female-to-male patients were identified who underwent primary penile inversion and peritoneal flap vaginoplasty. Two approximately 6cm wide by 8cm long peritoneal flaps are raised from the anterior aspect of the rectum and sigmoid colon, and the posterior aspect of the bladder to create the apex of the neovagina. RESULTS:The 41 patients had an average age of 34 +/- 14 years. Average length of procedure was 262 +/- 35 minutes and the average length of stay was 5 days. Average length of follow up was 114 +/- 79 days and at most recent follow up, vaginal depth and width were measured to be 14.2 +/- 0.7 cm and 3.6+/- 0.2 cm respectively. The peritoneal flap added an additional 5 cm of depth beyond the length of the skin graft, forming the vaginal canal in patients with limited scrotal skin. CONCLUSION/CONCLUSIONS:Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a well-vascularized apex with acceptable anticipated complications.

In conjunction with social transition, hormones, and counseling, gender-affirming surgery (GAS) is a key component in the treatment gender dysphoria. Gender affirming surgeries can be divided into genital surgery (phalloplasty, metoidioplasty, oophorectomy, vaginoplasty, and orchiectomy) and non-genital surgeries. The non-genital surgeries for transmasculine individuals include chest masculinization and body contouring. For transfeminine individuals, they include breast augmentation, and facial feminization. Chest masculinization eliminates the need for binding and improves overall confidence and quality of life. Choice of technique depends on body habitus and patient preference. For transfeminine individuals, some breast growth can be achieved with the use of estrogen over the course of 1-2 years, but many still require breast augmentation for breasts that are proportionate to their frame. Facial surgery for transfeminine patients is highly effective in changing classic masculine anatomic features to feminine norms. The most common of these procedures include forehead contouring, rhinoplasty, lip lift, mandible angle reduction, genioplasty and chondrolaryngoplasty. These non-genital surgeries are critical to treating gender dysphoria in transgender and gender non-binary individuals. Further research with standardized and validated assessments of patient reported outcomes is needed to fully understand long term effects on quality of life and gender dysphoria.

The male upper lip has a distinctly longer cutaneous height from the nasal base to the upper vermilion border than its female counterpart. The subnasal indirect lip lift using the bullhorn technique or its modifications allows for shortening of this height to feminize the lower face, creating a more aesthetically pleasing upper lip secondary to increased vermilion height and lip pout. Patient selection is critical, taking into account lip height, vermilion height, alar base width, skin type, upper incisal show, and maxillary height. Precise measurements, controlled excision of the planned resection, and meticulous reapproximation of skin provide an aesthetic result, while minimizing visible scarring.

Transgender and gender-nonconforming (TGNC) youth who suffer from gender dysphoria are at a substantially elevated risk of numerous adverse physical and psychosocial outcomes compared with their cisgender peers. Innovative treatment options used to support and affirm an individual's preferred gender identity can help resolve gender dysphoria and avoid many negative sequelae of nontreatment. Yet, despite advances in these relatively novel treatment options, which appear to be highly effective in addressing gender dysphoria and mitigating associated adverse outcomes, ethical challenges abound in ensuring that young patients receive appropriate, safe, affordable treatment and that access to this treatment is fair and equitable. Ethical considerations in gender-affirming care for TGNC youth span concerns about meeting the obligations to maximize treatment benefit to patients (beneficence), minimizing harm (nonmaleficence), supporting autonomy for pediatric patients during a time of rapid development, and addressing justice, including equitable access to care for TGNC youth. Moreover, although available data describing the use of gender-affirming treatment options are encouraging, and the risks of not treating TGNC youth with gender dysphoria are evident, little is known about the long-term effects of both hormonal and surgical interventions in this population. To support ethical decision-making about treatment options, we encourage the development of a comprehensive registry in the United States to track long-term patient outcomes. In the meantime, providers who work with TGNC youth and their families should endeavor to offer ethically sound, patient-centered, gender-affirming care based on the best currently available evidence.

Introduction& Objective: Penile inversion vaginoplasty (PIV) is the standard operation for genital reconstruction in transwomen. Despite usually providing an excellent aesthetic result, the technique can be complicated by vaginal stenosis and inadequate depth, particularly in transwomen with limited penile and scrotal tissue. Vascularized peritoneal flaps have been used to augment vaginal depth in neovaginal creation in patients with congenital vaginal agenesis.Here, we review our experience with the novel application of peritoneal flaps in penile inversion vaginoplasty in transwomen, to augment the neovaginal apex with well-vascularized tissue.
Method(s): Between 2017 and 2018, 20 female-to-male patients were identified who underwent a robotically assisted PIV using peritoneal flaps. In brief, approximately 5cm by 5cm peritoneal flaps are raised from the anterior rectum and posterior bladder to create the apex of the neovagina and serve as an attachment for inverted penile skin and scrotal skin graft. Patient demographics, medical comorbidities, intra-operative details, peri-operative complications, and neovagina measurements served as primary outcome measures.
Result(s): In our cohort of 20 patients, average age at time of surgery was 33.5+/-11.2 years. Average length of procedure was 319.3+/-41.6 minutes and the average inpatient stay was 5 days. Average length of follow up was 54.6+/-42.1 days and at most recent follow up, vaginal depth and width were measured to be 12.83+/-1.1 cm and 2.85+/-.3 cm respectively. The peritoneal flap added an additional 5 cm of depth. There were no complications related to peritoneal flap harvest.
Conclusion(s): Penile inversion vaginoplasty remains the gold standard for primary genital reconstruction in transwomen. Neovaginal depth can be limited by available donor tissue. With increased use of puberty blockade, we believe that there will be an increase in women presenting with limited natal tissue. While intestinal flaps or extragenital skin grafts have been used when there is inadequate penile and scrotal skin, there can be considerable donor site morbidity. Peritoneal flaps provide an alternative technique for increased neovaginal depth, creating a wellvascularized apex without additional donor morbidity

This article focuses on flap-related complications after creation of a neophallus for transgender individuals. It outlines the most frequently used flaps for this procedure and how flap-related complications can affect the overall outcome of the phalloplasty. With surgeons staging the procedure in different stages, it is important to understand the different strategies and the implication a flap-related complication can have on the end result and how it may be prevented.