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Urethroplasty Methods for Stricture Repair After Gender Affirming Phalloplasty: High Failure Rates in a Hostile Surgical Field

We conducted a retrospective chart review of 85 urethroplasties performed for stricture repair in 71 patients with phalloplasty for gender affirmation between August 2017 and May 2020. Stricture location, urethroplasty type, complication rate, and recurrence rate were recorded.

Authors: Crane CN, Santucci RA, Reddy SA, Holdren C, Srikanth P

Published in: Urology, 2023 June 20

Facial gender surgery represents a complex array of craniofacial and soft-tissue procedures that require application of advanced skills and decision- making. Facial gender operations are not cosmetic, are medically necessary, and require development of new CPT codes specific to facial gender surgery. It is imperative to create educational programs and methods to define sufficient training for facial gender surgery surgeons. Research priorities include better procedural outcomes data, more quality-of-life studies, and insight into variation in both patient and procedural subgroups.

Authors: Coon DO, Berli JU, Oles N, Mundinger GS,  Thomas KH, Meltzer TR, Houssock CA, Satterwhite T, Morrison SD, Bailón C, Tenório T, Simon DJ, Capitán-Cañadas F, Capitán L

Published in: PRS Journal, 2021 May 20

Phalloplasty is a masculinizing genital gender affirmation surgery, requested by 91% of patients seeking surgical transition. Due to the complexity of reconstruction involved, phalloplasty has been associated with high complications, with all cause urinary complications being reported as high as 70%. The objective of our study is to observe the specific urinary, emergent, donor site, and aesthetic complications associated with this complex procedure.

Authors: Santucci RA, Crane CN, Safir MS, Briles LB, Gondran JG, Linder ER
Published in: Journal of Urology, 2022 May 1

Access to Gender-affirming surgeries (GAS) is an ongoing discussion and must balance operative risks, individual risk factors, and potential benefit. Many of those offering these procedures list an ideal or inflexible upper limit of body mass index (BMI). The objective of this work is to determine if there is a relationship between BMI and surgical outcomes for GAS, both chest and genital, both masculinizing and feminizing.

Authors: Carter EC, DeLeon ANCrane CN, Santucci RA, Safir MS
Published in: Journal of Urology, 2022 May 1

Female-to-male gender-affirming top surgery is growing in demand. We ventured to further improve double-incision free nipple graft bilateral mastectomy by utilizing a streamlined method of eliminating dead space and abandoning the practice of postoperative drain placement.

Authors: DeLeon ANCrane CN, Santucci RA, Knudson SA
Published: 2022, June 19

Penile prostheses may be used as a component of genital gender affirmation surgery for the purpose of achieving penile rigidity after phalloplasty, and transgender individuals experience higher complication rates than cisgender individuals. This study, observes complications with transmasculine penile prosthesis surgery over time and across surgical conditions.

Authors: Santucci RA, Crane CN, Safir MS, Briles LB, Middleton, RY, Celtik KE
Published in: The Journal of Sexual Medicine, 2022, March 1

A growing number of urologic, plastic, gynecologic and general surgeons are becoming specialty trained in gender-affirmation surgery. Now it is especially relevant to revisit the fascinating history of gender-affirming vaginoplasty (GAV) technique. To determine the historical accuracy and completeness of the current history that persists to this day, we utilized a rigorous re-review of the primary literature, historical research and historical discovery.

Authors: Santucci RA, Zilavy AJ, Gallegos MA
Published in: Journal of Urology, 2022, May 1

Gender-affirming top surgery can have a notable impact on the quality of life of gender dysphoric individuals transitioning to the masculine phenotype. These transitions are growing in demand because of wider societal acceptance of transgenderism, posing great responsibility on surgeons to ensure quality, efficacy, and best practice of emerging innovations in transgender surgical services.

Authors: DeLeon ANCrane CN, Santucci RA, Knudson SA
Published in: Plastic and Reconstructive Surgery – 2022 Jan 1

In addition to chest contour and incision placement, nipple-areola complex size, orientation, and position is a primary concern of patients undergoing masculinizing chest surgery with free nipple grafting for gender dysphoria or gynecomastia. The author has developed a double-sided nipple-areola complex harvest and inset marker that facilitates graft healing in an optimized masculine orientation.

Author: Mundinger GS
Published in: Plastic and Reconstructive Surgery – Global Open, 2021 September 

We present 2 cases in which intraoperative microvascular obstruction threatened the viability of the RFFF of transgender phalloplasty patients. In each patient, an AVF was created between the radial artery and cephalic vein in the distal flap either after being transferred out of the operating room, as has previously been described, or during initial operation.

Authors: Crane CN, Santucci RA, Wachtman GS, Newson KD
Published in: Plastic and Reconstructive Surgery – Global Open 2021 May 21

The records of patients seeking GAPRS who underwent RALV, performed by a single surgeon at the 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.

Authors:  Jun MS, Shakir NA, Blasdel G, Cohen O, Bluebond-Langner R, Levine JP, Zhao LC
Published in: Urology 2021 Jan 21

Vaginoplasty is a commonly performed surgery for the transfeminine patient. In this review, we discuss how to achieve satisfactory surgical outcomes, and highlight solutions to common complications involved with the surgery, including: wound separation, vaginal stenosis, hematoma, and rectovaginal fistula. Pre-operative evaluation and standard technique are outlined. Goal outcomes regarding aesthetics, creation of a neocavity, urethral management, labial appearance, vaginal packing and clitoral sizing are all described. Peritoneal vaginoplasty technique and visceral interposition technique are detailed as alternatives to the penile inversion technique in case they are needed to be used. Post-operative patient satisfaction, patient care plans, and solutions to common complications are reviewed.

Authors: Li JS, Crane CNSantucci RA.
Published in: Int. Braz J Urol. 2020 Aug 20.

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. A total of 145 transgender women underwent RPGAV between September 2017 and December 2019. Data was retrospectively reviewed for patients with a minimum 6 month of follow-up.

Authors: Dy GW, Jun MS, Blasdel G, Bluebond-Langner R, Zhao LC.
Published in: Eur Urol. 2020 Jul 2.

An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria. Phalloplasty is the most complex of these surgeries, and this complexity creates a wide range of potential complications. Some of the most common complications and therefore, targets for improvement in outcomes, concern neourethral fistula/stricture, efficacy of reinnervation of the phalloplasty flap, postoperative flap monitoring, and donor site morbidity. In the setting of no established “gold standard”, this review seeks to describe the components and staging of phalloplasty, with an emphasis on established and experimental solutions to the most common and vexing problems.

Authors: Carter EE, Crane CNSantucci RA.
Published in: Plast Aesthet Res. 2020 Jun 30.

A Systematic Review of Penile Prosthetic Outcomes and Complications in Gender-Affirming Surgery

Penile Prostheses are commonly used to achieve erectile rigidity after Phalloplasty in trans masculine patients. Implantation poses significant challenges because of the delicate nature of the neophallus and lack of native erectile tissue. This is the first study to aggregate all reported Penile Prosthesis characteristics and outcomes in trans masculine patients. Prosthesis implantation in gender-affirming operations poses significant risk of complication, but it is still a reasonable and useful method to achieve rigidity necessary for sexual intercourse.
Authors: Rooker SA, Vyas KS, DiFilippo EC, Nolan IT, Morrison SD, Santucci RA.
Published in: J Sex Med. 2019 May.

Phalloplasty is a critical step for many transgender men who seek relief from gender dysphoria; however, phalloplasty is a difficult and complex surgery with many potential complications. The most common complications are urinary, mostly comprised of urethrocutaneous (UC) fistulas and urethral strictures. Improvements in surgical technique have driven down complication rates over the past few decades. Despite these innovations, complication rates remain high, and transgender surgeons must be well versed in their diagnosis and treatment. Over the same time period, gender affirming surgery has seen unprecedented growth in the United States. Transgender surgeons are few, and their patients often travel great distances for their index surgery. As such, locally available reconstructive urologists will be called upon to treat these complications with greater frequency and must be proficient in diagnosis and treatment to help these patients achieve a good outcome.

Authors: Jun MS, Santucci RA.
Published in: Transl Androl Urol 2019 May 20.

Gender-affirming procedures for transgender women include Breast Augmentation using implants and genital reconstruction with Vaginoplasty. MRI is preferred over CT for post-Vaginoplasty evaluation given its superior tissue contrast resolution. Procedures for transgender men include chest masculinization (mastectomy) and genital reconstruction (Phalloplasty or Metoidioplasty, Scrotoplasty, and Erectile Device Implantation). Urethrography is the standard imaging modality performed to evaluate neourethral patency and other complications, such as fistulas and strictures. Radiologists must be aware of the wide variety of anatomic and pathologic changes unique to patients who undergo gender-affirming surgeries to ensure accurate imaging interpretation.
Authors: Stowell JT, Grimstad FW, Kirkpatrick DL, Brown ER, Santucci RA, Crane CN, Patel AK, Phillips J, Ferreira MA, Ferreira FR, Ban AH, Baroni RH, Wu CC, Swan KA, Scott SA, Andresen KJ.
Published in: Radiographics. 2019 Sep-Oct.

Phalloplasty And Metoidioplasty: Techniques, Complications, and How To Deal With Them

Transmasculine gender-affirming surgery is technically challenging, and in the past associated with a high but improving complication rate. Few surgical centers are performing this surgery, which can include Metoidioplasty and Phalloplasty, and patients often travel great distances for their surgery. While many will continue care with their original surgeons, others cannot due to social/geographic factors, or because emergencies arise. Thus, patients may seek care with their local urologist for relief of delayed complications, the most common of which include urethral stricture, penile prosthesis issues and urethrocutaneous fistula. This review discusses the surgical elements behind Metoidioplasty and Phalloplasty, and the diagnosis and treatment for the most common postoperative issues.
Authors: Jun MS, Crane CN, Santucci RA.
Published in: Minerva Urol Nefrol. 2019 Nov 4.

Disadvantages of Metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary Phalloplasty after Metoidioplasty. This is the first study to report on secondary Phalloplasty in collaboration with 8 specialized gender clinics. Transgender men who underwent secondary Phalloplasty after Metoidioplasty indicated reasons to undergo secondary Phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had Metoidioplasty performed as a first step toward Phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). In high-volume centers specialized in gender affirming surgery, a secondary Phalloplasty can be performed after Metoidioplasty with complication rates similar to primary Phalloplasty.
Authors include: Santucci RA, Crane CN
Published in: J Sex Med. 2019 Nov.

This article highlights one of the greatest challenges in female-to-male gender-affirming surgery: offering a reliable means of penetrative intercourse after phalloplasty. Various types of penile prostheses for a variety of phalloplasty are covered in this study. The results are sobering. Of the 32 initially placed penile prostheses, 50% were removed at a median of 1.1 years, which is concordant with our experience and that of the literature. Despite numerous variations in technique and device used, the success rate of penile prosthesis placement after phalloplasty remains discouragingly low. It is a testament to importance of penetrative intercourse and the lack of reasonable alternative treatment that, despite the known risks, trans men continue to opt for prosthesis placement. Clearly, a solution to allow for penetrative intercourse after phalloplasty remains an area for scientific investigation.

Author: Jun MS, Zhao LC
Published in: Practice Update. 2019 Nov 6

Musculocutaneous latissimus dorsi (MLD) free-flap total phalloplasty is technically demanding female-to-male gender reassignment surgery, which consists of creating a neophallus from extragenital tissue. Total MLD flap phalloplasty with urethral lengthening is a challenging and complex surgical procedure. This technique presents good variant for female transgenders with acceptable cosmetic outcome and enables good volume of neophallus, sexual arousal, and voiding while standing.

Author: Jun MS, Pušica S, Kojovic V, Bizic M, Stojanovic B, Krstic Z, Korac G and Djordjevic ML.
Published in: Urology. 2018 Aug 2

Strategies to Treat Them and Minimize Their Occurrence

Radial Forearm Free Flap Phalloplasty is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. In cases of urethral stricture, Urethroplasty is required in 94-96% of patients. Surgery should be delayed until all acute inflammation has subsided. Urethroplasty is technically challenging and fails in up to 50% of cases. Repeated surgery or salvage urethral exteriorization procedures, which can leave the patient with lifelong perineal urethrostomy, are often required. Patient and physician knowledge regarding the high burden and poor treatment options for urethral stricture after phalloplasty is incomplete, and patient acceptance of this reality is crucial for honest understanding of the potential complications of this increasingly common but extremely complex surgery.
Author: Santucci RA
Published in: Clin Anat. 2018 Mar.

Pedicled Anterolateral Thigh Flap Versus Radial Forearm Free Flap in Gender Confirming Surgery

The overall urethral complication rate for Radial Forearm Free Flap and Anterolateral Thigh Pedicled Flap Phalloplasty was 31.5% and 32.8%, and the rate of partial or total neophallus loss was 3.4% and 7.8%, respectively. Anterolateral Thigh Pedicled Flap Phalloplasty was associated with overall greater odds of urethral and other complications at 6 months of followup.
Authors: Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML.
Published in: J Urol. 2018 Jan.

Addition of a Vascularized Bulbospongiosus Flap from Vaginectomy Reduces Postoperative Urethral Complications

Vaginectomy is associated with a significant decrease in urethral stricture and fistula formation, most likely because Vaginectomy affords additional horizontal Urethroplasty suture line coverage of labia minora flaps with vascularized vestibular tissue. However, Vaginectomy is not a requisite step in phalloplasty, and some individuals may choose to retain their vagina. In these cases, extra layers of vascularized vestibular tissue are not used for horizontal urethra coverage. This study examined the effects of vaginectomy and the addition of extra layers of vascularized vestibular tissue on Phalloplasty complication rates.
Authors: Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML.
Published in: Plast Reconstr Surg. 2017 Oct.

Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that Phalloplasty is highly efficacious and beneficial to patients.
Authors: Morrison SD1, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK.
Published in: Plast Reconstr Surg. 2016 Sep.

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