Masculinizing Gender-Affirming Surgery for the General Urologist

Educational Objectives

The goal of this program is to improve management of patients undergoing gender-affirming surgery. After hearing and assimilating this program, the clinician will be better able to:

1. Determine eligibility for gender-affirming surgery.
2. Select a procedure for gender-affirming surgery to match patient preferences and expectations.

Summary

Criteria for surgery: patients with mental illness (eg, depression) may undergo surgery; however, mental illness must be well-controlled and not interfere with the ability to make decisions; patients must have ≥2 letters from mental health professionals, one of which must be an MD or PhD; a third letter from the hormone provider which attests that the patient has been taking hormones for ≥1 yr is required; most patients present for genital surgery late in their transition and have already had other procedures (eg, mastectomy, hysterectomy)

Incidence of gender-affirming surgery: ≈1.6 million adults in the United States are transgender; ≈25% of transgender men desire genital surgery; surgery for transgender women is less complicated, and ≤50% desire the procedure; the expression of transgenderism is increasing; the decision to operate is based on the subjective feelings of the patient; procedures are performed according to the preferences of the patient

Forearm phalloplasty: the gold standard operation for female-to-male gender-affirming surgery; tissue from the forearm is harvested; the tissue is formed into one tube to create a urethra, and a second tube is formed to create the phallus; the first step is the removal of the vagina; the second step is the preparation of the pars fixa (ie, the urethra between the native urethra and the base of the scrotum, which may extend to the tip of phallus); tendons, arteries, and veins are exposed in the forearm; the entire flap is served by 1 artery and 1 to 4 veins; the urethra and phallus are constructed while the flaps are on the forearm; the skin graft for the forearm is commonly taken from the leg; the clitoris, which is a downward-facing structure, becomes an upward facing structure; the vagina is absent; the urethra is lengthened; the labia majora is used to construct the scrotum; a clitoral nerve should be marked for attachment to the major sensory nerve of the donor by the plastic surgeon; the labia majora are fused across the midline to create a scrotum (similar to the formation of the scrotum in a fetus); drains are no longer commonly used; a microsurgeon requires ≈4 hr to prepare the forearm, and ≈45 min for anastomosing the arteries and veins

Anterior lateral thigh flap: the second method for formation of a phallus; the flap is brought under the muscles and placed in the groin; microsurgery is not required; native veins and arteries remain intact; however, the fat in the tissue of the thigh may create a phallus that is too thick; excess thickness may be treated with liposuction 4 month after the procedure; patients with very large thigh flaps may require multiple procedures to achieve the desired size

Metoidioplasty: may be preferred by patients who do not want a phalloplasty or are not prepared for a lengthy surgery with a 100% complication rate; patients receive a vaginectomy, a scrotum, and a small penis; the end organ is lengthened in patients who are on high doses of testosterone; the result is a large clitoris which resembles a phallus; the procedure does not require manipulation of the nerves, arteries, or veins; patients are able to achieve an erection; no large scars are visible on the arm; the operation is less severe than phalloplasty; ≈20% of patients who underwent metoidioplasty may eventually undergo phalloplasty; phalloplasty is a less complicated procedure in patients who underwent a metoidioplasty

Metoidioplasty procedure: similar to repairing hypospadias; the downward-facing clitoris becomes upward-facing; the urethra is lengthened; the surrounding tissue can be removed to increase the apparent length; a penile lift raises the entire genital unit ≤2 inches; tissue at the top of the scrotum is reduced; testicle implants are placed through the same incision; complications may be addressed during the planned second surgery; testes implants — saline-filled implants and solid implants are available; solid implants are often preferred because of their superior durability

Complications of metoidioplasty: the rate of strictures is ≤5%; fistulas — occur at a rate of ≤10%; small fistulas may form in the ventral phallus; the occurrence of wound separation may precipitate a pseudomonas infection in the native urethra; the resulting fistula is larger and may become the passage through which urine is voided; wound healing — may be delayed; patients may be concerned by delayed healing, but it commonly resolves through secondary intention; most patients do not have loss of sensation; testes implants — lost in 2% of cases; caused by the failure of the fragile flaps composing the scrotum to survive surgical dissection; the implant is removed and may be reimplanted 6 mo later; the main concern with fistula repairs is blood flow; urination — a superpubic catheter may be inserted in cases of blockage of the urethra

Readings

Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(Suppl 1):S1-S259. Published 2022 Sep 6. doi:10.1080/26895269.2022.2100644; Cylinder I, Heston A, Carboy J, et al. Partial flap loss in gender affirming phalloplasty. J Reconstruct Microsurg. 2022;38(4):276-283. doi: 10.1055/s-0041-1732428; Kim S, Dennis M, Holland J, Terrell M, Loukas M, Schober J. The anatomy of forearm free flap phalloplasty for transgender surgery. Clin Anat. 2018;31(2):145-151. doi:10.1002/ca.23014; Lin-Brande M, Clennon E, Sajadi KP, Djordjevic ML, Dy GW, Dugi D. Metoidioplasty with urethral lengthening: a stepwise approach. Urology. 2021;147:319-322. doi:10.1016/j.urology.2020.09.013; Massanyi EZ, Gupta A, Goel S, et al. Radial forearm free flap phalloplasty for penile inadequacy in patients with exstrophy. J Urol. 2013;190:1577-1582. doi: 10.1016/j.juro.2012.12.050; Remington A, Morrison S, Massie J, et al. Outcomes after phalloplasty: do transgender patients and multiple urethral procedures carry a higher rate of complication? Plastic Reconstruct Surg. 2018;141(2):220e-229e. doi: 10.1097/PRS.0000000000004061; Rifkin W, Daar D, Cripps C, et al. Gender-affirming phalloplasty: a postoperative protocol for success. Plastic Reconstruct Surg – Global Open. 2022;10 (6):e4394. doi: 10.1097/GOX.0000000000004394; Santucci R, Linder E, Wachtman G, et al. Planned and unplanned delayed anterolateral thigh flap phalloplasty. Plastic Reconstruct Surg - Global Open. 2021;9(6):e3654. doi: 10.1097/GOX.0000000000003654.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Santucci reported nothing relevant to disclose. Members of the planning committee reported nothing relevant to disclose. Dr. Santucci's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Santucci was recorded at the 2022 Annual Fall Meeting, held September 8 to 11, 2022, in Sea Island, GA, and presented by the Georgia Urological Association. For information on future CME activities from this presenter, please visit meetings.association-service.org/gua. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

UR452202

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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