Atlas of Operative Techniques in Gender Affirmation Surgery 9780323983778

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Atlas of Operative Techniques in Gender Affirmation Surgery

Atlas of Operative Techniques in Gender Affirmation Surgery

Editor Rajveer S. Purohit

Icahn School of Medicine at Mount Sinai, New York, NY, United States

Miroslav L. Djordjevic

Belgrade University School of Medicine, Belgrade, Serbia; Icahn School of Medicine at Mount Sinai, New York, NY, United States

Academic Press is an imprint of Elsevier 125 London Wall, London EC2Y 5AS, United Kingdom 525 B Street, Suite 1650, San Diego, CA 92101, United States 50 Hampshire Street, 5th Floor, Cambridge, MA 02139, United States The Boulevard, Langford Lane, Kidlington, Oxford OX5 1GB, United Kingdom Copyright © 2023 Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. ISBN 978-0-323-98377-8 For information on all Academic Press publications visit our website at https://www.elsevier.com/books-and-journals

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Dedication To our families who have made many sacrifices so that we can pursue our passions Rajveer S. Purohit Miroslav L. Djordjevic

Contributors Cori A. Agarwal  University of Utah, School of Medicine, Division of Plastic Surgery, Salt Lake City, UT, United States Brandon Alba  Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States Ashley Alford  NYU Langone Medical Center, New York, NY, United States Marko Bencic  Department of Urology, University Children’s Hospital; School of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia Marta R. Bizic  Department of Urology, University Children’s Hospital; School of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia Rachel Bluebond-Langner  NYU Langone Medical Center, New York, NY, United States Mark-Bram Bouman  Department of Plastic, Reconstructive and Hand Surgery; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands Marci L. Bowers  Mills-Peninsula Medical Center, Burlingame, CA; Mt. Sinai-Icahn School of Medicine, New York, NY, United States Marlon Buncamper  Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium Luis Capitán  The Facialteam Group, Marbella, Málaga, Spain Fermín Capitán-Cañadas  The Facialteam Group, Marbella, Málaga, Spain Amanda C. Chi  Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, United States Karel E.Y. Claes  Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium Wietse Claeys  Department of Urology, Ghent University Hospital, Ghent, Belgium Curtis Crane  Crane Center for Transgender Surgery, Austin, TX, United States Fionnuala Crowley  Internal Medicine, Mount Sinai Morningside West, Icahn School of Medicine at Mount Sinai, New York, NY, United States Ashley DeLeon  Crane Center for Transgender Surgery, Austin, TX, United States Krystal A. DePorto  Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, United States Wouter B. van der Sluis  Department of Plastic, Reconstructive and Hand Surgery; Center of Expertise on Gender Dysphoria, Amsterdam University Medical Center, Amsterdam, The Netherlands

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Contributors Marcelo Di Maggio  Cirugia Plastica Olivos, Plastic Surgery; Hospital Britanico, Plastic and Reconstructive Surgery; MDMsurgery, Plastic and Craniofacial Surgery, Buenos Aires, Argentina Miroslav L. Djordjevic  Department of Urology, University Children’s Hospital; School of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia; Icahn School of Medicine at Mount Sinai, New York, NY, United States Daniel D. Dugi III  Department of Urology, Plastic and Reconstructive Surgery, Transgender Health Program, Oregon Health and Science University, Portland, OR, United States Esteban Elena Scarafoni  Private Practice, Plastic and Reconstructive Surgery, Mar del Plata, Argentina Ross G. Everett  Oregon Health and Science University, Portland, OR, United States Daisy I. Gonzalez  Constructive Surgery Associates, Miami, FL, United States Aaron Grotas  Icahn School of Medicine, Mount Sinai Hospital, New York, NY, United States Alireza Hamidian Jahromi  Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States Dana Johns  University of Utah, School of Medicine, Division of Plastic Surgery, Salt Lake City, UT, United States Marissa Kent  Icahn School of Medicine at Mount Sinai, New York, NY, United States Anish Kumar  Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, United States Natasha Kyprianou  Department of Urology, Mount Sinai Hospital; Department of Pathology & Molecular and Cell Based Medicine; Department of Oncological Sciences; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States Dara J. Lundon  Department of Urology, Mount Sinai Hospital; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States Wilhelmus J.H.J. Meijerink  Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands Meredith Mihalopoulos  Icahn School of Medicine at Mount Sinai; Department of Urology, Mount Sinai Hospital, New York, NY, United States Kirtishri Mishra  NYU Langone Medical Center, New York, NY, United States Stan Monstrey  Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium Shane Morrison  Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium; Division of Plastic Surgery, Department of Surgery, University of Washington Medical Center and Seattle Children’s Hospital, Seattle, WA, United States Gerhard S. Mundinger  Crane Center for Transgender Surgery, Austin, TX, United States Dmitriy Nikolavsky  Department of Urology, SUNY Upstate Medical University, Syracuse, NY, United States Elizabeth O’Neill  Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States Melissa M. Poh  Department of Plastic Surgery, Kaiser Permanente Southern California, Los Angeles, CA, United States

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Contributors Rajveer S. Purohit  Icahn School of Medicine at Mount Sinai, New York, NY, United States Jorge Rey  Constructive Surgery Associates, Miami, FL, United States Polina Reyblat  Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, United States Zoe Isabel Rodriguez  Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science at Mount Sinai West & Mount Sinai Morningside, New York, NY, United States Paige De Rosa  Department of Urology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States Joshua D. Safer  Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, United States Christopher J. Salgado  Constructive Surgery Associates, Miami, FL, United States Jessica N. Schardein  Department of Urology, SUNY Upstate Medical University, Syracuse, NY; Division of Urology, Department of Surgery, University of Utah, Salt Lake City, UT, United States Loren Schechter  Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States Kaylee B. Scott  University of Utah, School of Medicine, Division of Plastic Surgery, Salt Lake City, UT, United States Gennaro Selvaggi  Department of Plastic Surgery, University of Gothenburg, The Sahlgrenska Academy, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden Michelle Seu  Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, United States Yair Shachar  Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium Tony Shao  Constructive Surgery Associates, Miami, FL, United States Alexandra R. Siegal  Icahn School of Medicine, Mount Sinai Hospital, New York, NY, United States Daniel Simon  The Facialteam Group, Marbella, Málaga, Spain Joshua Sterling  Department of Urology, SUNY Upstate Medical University, Syracuse, NY; Department of Urology, Yale School of Medicine, New Haven, CT, United States Borko Stojanovic  Department of Urology, University Children’s Hospital; School of Medicine, University of Belgrade; Belgrade Center for Urogenital Reconstructive Surgery, Belgrade, Serbia Lindsay M. Tanner  Constructive Surgery Associates, Miami, FL, United States Ann Tran  Icahn School of Medicine at Mount Sinai, Department of Obstetrics, Gynecology, and Reproductive Science at Mount Sinai West & Mount Sinai Morningside, New York, NY, United States Jurriaan B. Tuynman  Center of Expertise on Gender Dysphoria; Department of Surgery, Amsterdam University Medical Center, Amsterdam, The Netherlands Aran Yoo  Division of Plastic and Reconstructive Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, United States Lee C. Zhao  NYU Langone Medical Center, New York, NY, United States Ariel Zisman  Icahn School of Medicine at Mount Sinai, New York, NY, United States

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Acknowledgments We have envisioned this textbook as a way of having leaders in gender affirmation surgery share practical surgical techniques with other surgeons to improve outcomes and to ultimately benefit patients. As with any endeavor, there are many without whose dedication this textbook would not have been possible, such as all our coauthors. All are leaders in the field with busy clinical practices, and the time taken to write the chapters often came at the expense of their personal lives. So, it is with profound gratitude that we appreciate their contributions and the time it took them to share their practical wisdom with us and others through writing. We thank the visionaries who set up the Icahn School of Medicine at Mount Sinai to be a clinical and academic leader in providing the highest level of care to transgender patients through its Center for Transgender Medicine and Surgery (CTMS). Dr. David Reich was instrumental in putting together all of the disparate pieces as were Dr. Ashutosh Tewari, Dr. Joshua Safer, and among many others at CTMS, who organized the resources and ideas for our practices and shared our passion for taking care of transgender and gender nonbinary patients. Above all, we thank our patients who have entrusted us with the solemn but joyful privilege of providing care to them. They have been a source of inspiration and ideas that drive us to improve, and without them, this book would not have been possible. Rajveer S. Purohit MD, MPH Miroslav L. Djordjevic MD, PhD

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CHAPTE R 1

Developing a transgender health center of excellence: The Mount Sinai model Anish Kumar and Joshua D. Safer Icahn School of Medicine at Mount Sinai, Mount Sinai Center for Transgender Medicine and Surgery, New York, NY, United States

Introduction According to estimates, 1.4 million people in the United States identify as transgender and gender diverse (TGD) [1]. These patients may have unique health needs compared to their cisgender counterparts, which may be related to several etiologies [2]. Minority stress connected to discrimination is associated with an elevated incidence of mental health morbidity, substance use, and sexually transmitted infection [3]. Other health needs often include expertise in the gender-affirming medical and surgical interventions typically used to better align the body with the gender identity of TGD people. Accessing high-quality, culturally sensitive health care can be difficult for TGD people, given the lack of training in transgender healthcare at both the medical school and residency levels [4,5]. Further, many TGD people may not feel comfortable seeking gender-affirming healthcare, based on negative previous experiences with clinicians. Additionally, TGD patients are more likely to face economic instability with corresponding lack of access to comprehensive insurance [6]. The unique health needs of TGD people, along with the relative difficulty in accessing quality gender-affirming healthcare, may be addressed in part with transgender health centers of excellence [6,7]. Centers of excellence are designed to be specialized department service lines within larger healthcare institutions that focus on providing high quality care in a certain clinical area or to a specific population. Such centers are generally designed with a multidisciplinary perspective in order to leverage high levels of expertise across different subject areas to deliver optimal care. The Mount Sinai Center for Transgender Medicine and Surgery (CTMS) in New York, NY, was established in 2016. The mission of CTMS includes both (1) the consolidation of care for TGD patients within the greater Mount Sinai Hospital System in one specific program Atlas of Operative Techniques in Gender Affirmation Surgery. https://doi.org/10.1016/B978-0-323-98377-8.00020-8 Copyright © 2023 Elsevier Inc. All rights reserved.

1

2  Chapter 1 and (2) the modeling of structure for a center of excellence for TGD health. In line with these goals, CTMS provides a unified point of contact for all patients seeking TGD-related care [8]. Given the wide range of clinical expertise required for TGD healthcare, navigating a large, complex health system can be challenging. The multidisciplinary nature of CTMS allows patients to access pediatric/adolescent, adult medical, behavioral, and genderaffirming surgical care through one contact point, instead of seeking care that is siloed across different teams, without a unifying center of operations. CTMS brings together resources from medicine, pediatrics, surgery, social work, chaplaincy/ spiritual care, and behavioral health to guide patients through care. Fig. 1 provides a high-level overview of how patients begin and navigate these services at CTMS. The interdisciplinary model begins from the onset of care, when a patient approaches CTMS for services and their needs are evaluated by a team of navigators who help direct them into one of three major clinical workflows: (1) gender-affirming medical care, (2) gender-affirming surgical procedures, and (3) gender-affirming pediatric services. After review of the model and operations in 2018, CTMS aimed to foster a more comprehensive, interdisciplinary care (IDC) approach to inpatient treatment of TGD patients, specifically those undergoing surgical procedures. This new framework was developed by adapting a model used in existing transplant and bariatric programs that had previously demonstrated successful approaches to providing IDC [8].

Overview of services Pediatric and adolescent health services Mount Sinai CTMS provides TGD-related care to pediatric and adolescent patients and their families. Minors and their guardians begin care with CTMS by completing an intake with a mental health provider who conducts an evaluation to determine the best course of action for their care. The provider ultimately provides the family with advice, connects them with ongoing mental health or family support, or refers them to the medical teams for puberty blocker or hormone therapy. Established patients who have been under longitudinal care at CTMS can have surgeries if they are old enough and meet all requirements for the operation. Typically, these patients are shifted to adult care teams, with the narrow exception of transmasculine patients who might get masculinizing chest surgeries as young as age 16 and remain with their pediatric/ adolescent health provider.

Adult medical services Mount Sinai CTMS provides comprehensive care with both services specifically related to TGD health as well as standard clinical care. CTMS maintains a network of primary care

Fig. 1 Overview of three major clinical workflows for patients starting care at Mount Sinai CTMS.

4  Chapter 1 providers across the Mount Sinai Health System network. Since the primary care clinicians at CTMS have experience working with TGD patients, they can provide expertly informed care. Further, providing services connected to a dedicated TGD health center may allay the concerns of patients who are reluctant to seek out health services for fear of discrimination or misinformed understanding of their healthcare needs. Endocrinology CTMS’s trained endocrinologists work with medical teams at CTMS to develop plans for gender-affirming hormone therapy (GAHT). GAHT is a medical intervention that is often used to help align a patient’s appearance with their gender identity. Feminizing hormone therapy aims to change the shape of a patient’s face and body as well as alter hair growth patterns. Masculinizing hormone therapy similarly alters body and face shape as well as hair growth in addition to stopping menstruation and deepening the pitch of the patient’s voice. Endocrinologists at CTMS are available for other endocrinology-related care (thyroid health, bone health, diabetes, etc.) and have expertise in managing such conditions in concordance with gender-affirming hormone replacement therapy. Gynecology Gynecology services are available at CTMS, with focus on providing care for transgender men as well as pre- and postoperative care for various genital modification procedures. Clinicians in this service are also well trained in a range of minimally invasive gynecological procedures, as well as vaginectomies and other gender-affirming surgeries.

Surgical services Gender-affirming surgical procedures can be categorized into transfeminine and transmasculine operations. For both categories, there are a wide range of surgical procedures that modify primary and secondary sex characteristics. It is important to remember that the experience of each TGD person is different so that care must be individualized. Patients seek varying levels of customization when considering surgical-based operations: some opt for genital based procedures over those that modify secondary sex characteristics and vice versa, while others may seek both. Some procedures, like phalloplasties, are commonly performed in conjunction with other procedures. The exact parameters of care are discussed in detail with the patient and surgery team during initial consultations and goal planning. Fig. 2 provides a detailed overview of the flow through the surgical process at CTMS. Transfeminine surgeries Table 1 lists commonly performed transfeminine surgical procedures. These procedures can be split into three broad categories: breast augmentation, facial feminization, and genital reconstruction. Breast augmentation involves the addition of implants (often fat or tissue

Fig. 2 Interdisciplinary approaches to care for TGD patients receiving gender-affirming surgical procedures at Mount Sinai CTMS. Table 1: Transfeminine surgical procedures. Surgical Category

Procedure

Description

Ambulatory or inpatient

Breast augmentation

Breast augmentation

Ambulatory

Facial feminization

Rhinoplasty Chondrolaryngoplasty

Breast implantations in chest Nose reshaping Reduction of the thyroid cartilage

Genital reconstruction

Forehead & brow recontouring Hairline advancement Jaw & chin contouring Orchiectomy Vaginoplasty

Vulvoplasty

Inpatient Ambulatory Inpatient

Removal of the testes Creation of a vagina, clitoris, labia majora/ minora Creation of a vulva, clitoris, shortened urethra without a vaginal canal

Inpatient Inpatient Ambulatory Inpatient

Inpatient

6  Chapter 1 from other parts of the body) to the chest to make it more typically feminine appearing. Facial feminization procedures include an array of different procedures that contour or shape different parts of the head and neck, depending on the patient’s goals and desires, as well as the recommendations of their surgeon. Transfeminine genital reconstruction procedures involve orchiectomy and/or surgical construction of a vagina, clitoris, and labia. Transmasculine surgeries Table 2 lists commonly performed transfeminine surgical procedures. Like transfeminine surgeries, these procedures can be split into three broad categories: chest reconstruction, reproductive organ removal, and genital reconstruction surgeries. Chest reconstruction surgeries involve the removal of breast and fat tissue as well as optional repositioning of the nipple to render a typically masculine appearing chest. Reproductive organ removal procedures include oophorectomies and hysterectomies, the removal of the ovaries and uterus, respectively. Transmasculine genital reconstruction includes two major options for procedures to reconstruct a penis. In a metoidioplasty procedure, surgeons construct a small phallus from clitoral tissue, as opposed to creating a phallus from skin grafted from other areas of the body in a phalloplasty. Both reconstructive surgeries can be conducted in conjunction with related procedures including vaginectomy, urethral lengthening, scrotoplasty, and/or penile prosthesis placement. Peri-operative services A robust preoperative assessment and care plan is essential to providing high quality care that minimizes risk of complications and negative outcomes. As part of this process, CTMS medical teams complete an assessment of patients before scheduled surgeries and address Table 2: Transmasculine surgical procedures. Surgical category

Procedure

Description

Ambulatory or inpatient

Chest reconstruction

Mastectomy

Ambulatory

Reproductive organ removal Genital reconstruction

Hysterectomy Oophorectomy Metoidioplasty

Removal of mammary fat and tissue Removal of uterus Removal of ovaries Creation of phallus using existing genital tissue Creation of a penis using tissue graft Closing of the vaginal opening Elongation of the urethra Creation of a scrotum Implantation of device to facilitate erection

Phalloplasty Procedures often conducted in conjunction with genital reconstruction

a

Vaginectomya Urethroplastya Scrotoplastya Penile implantationa

A procedure that is often conducted in conjunction with genital reconstruction surgeries.

Ambulatory Ambulatory Inpatient Inpatient

Developing a transgender health center of excellence: The Mount Sinai model  7 specific risks as well as plan postoperative care. Further, behavioral health specialists and spiritual care specialists engage with patients to conduct assessments regarding readiness for procedures and ensure that they have adequate access to resources they may need postoperatively. Concurrently, social work teams assess the paraclinical needs of the patient and ensure that there is an appropriate plan for resource access, transportation, and secondary care after the operation [8]. Such readiness evaluations that consider psychosocial criteria are rarely prioritized regarding gender-affirming surgeries, but have shown a high potential in predicting surgical outcomes [9]. For both transmasculine and transfeminine procedures, there are an array of operations that are ambulatory along with others that require inpatient stays ranging from 1 to 7 days. For the latter, patients recover in the hospital under the supervision of medicine and surgical teams who can manage postoperative complications. Daily interdisciplinary clinical rounds are conducted during a patient’s postoperative stay [8]. Rounds are led by the same medical teams that conducted the patients’ preoperative health and risk assessment. The goal of these rounds is to facilitate communication among members of all teams involved in direct and indirect clinical care, including social work, nursing, behavioral health, nutrition, surgery, and spiritual care teams. Robust postoperative care includes a detailed plan for discharge and transition of care to secondary support services. To ensure that quality care would continue outside of the hospital, CTMS selected a skilled care facility (SNF) and visiting nurse service as a primary location for continued care following discharge. Staff members at these services were given comprehensive training in postoperative management of patients following various gender-affirming surgical procedures to facilitate rehabilitation and minimize complications. Additionally, caregivers are provided with specific instructions and relevant resources for supporting patients during recovery periods until they can return to function. Following the immediate recovery period, long-term care becomes important, especially in terms of reducing risk for complications and managing any that arise. Primary care and medical teams at CTMS provide longitudinal care following surgical procedures and ensure that there is routine monitoring and screening of surgically modified anatomy. This is especially important in terms of prophylaxis, monitoring and treatment of sexually transmitted infections as well as screening for certain types of cancer (breast, cervical, prostate, etc.).

Behavioral health services Mount Sinai CTMS includes a behavioral health team staffed by psychiatrists, clinical psychologists and social workers who provide a range of services related to mental health. These clinicians have expertise in mood disorders, schizophrenia, eating disorders, posttraumatic stress disorder, and substance use disorders as well as experience managing the unique mental health needs of TGD patients.

8  Chapter 1 By integrating behavioral health support within CTMS, patients have ready access to mental healthcare at any point in their healthcare relationship with the institution. Behavioral health specialists can perform presurgical evaluations as well as intake assessments for pediatric and adolescent patients for select services enumerated by practice guidelines, including the WPATH Standards of Care. The team also periodically facilitates support groups for patients who may benefit from engaging with other patients in moderated discussion and peer support. Clinicians also serve as a triage point to connect patients and caregivers with longitudinal behavioral health support both within the Mount Sinai health system and elsewhere.

Ancillary support A comprehensive, interdisciplinary approach to TGD care should include a robust ancillary support service. The socio-political context has a significant impact on the burden of health disparities faced by TGD people, a situation that is exacerbated by consistent patterns of marginalization and reduced access to social resources [5,10]. Consequently, addressing the social determinants of health of TGD patients is inextricable to direct clinical care. For these reasons, Mount Sinai CTMS tightly integrates social workers into the clinical care workflows. Team members sort through insurance protocols and provide patients with an overview of services and serve as navigators through their care at CTMS. As part of the transition to an IDC approach to inpatient care for surgical patients in 2018, CTMS examined the surgical preoperative criteria evaluation schema typically used to assess whether patients are ready for gender-affirming operations. The CTMS team modified the eligibility criteria delineated in the SOC 7 to be more patient-centered to reduce barriers to eligibility for gender-affirming surgeries. As part of this modification, they also augmented the criteria to consider access to social resources, given its importance to long-term outcome of many surgeries. Table 3 lists the criteria that used by the social work team to evaluate readiness for surgery [9]. In addition to guiding patients through their care process, the CTMS team also connects patients with community organizations and resources, including those offering legal support. Coordination with the Mount Sinai Medical-Legal Partnership allows patients to access free, on-site services that assist with any issues pertaining to discriminatory denial of healthcare or other social benefits as well as guidance with legal name, pronoun, or other gender marker changes. Table 3: Preoperative criteria for gender-affirming surgery evaluated by CTMS social work teams. Stable housing with adequate bathroom facilities Ability to stay within 90-min drive of postoperative care offices for 2 to 4 weeks following surgery Ability to arrange for a caretaker for 2 to 4 weeks postoperatively

Developing a transgender health center of excellence: The Mount Sinai model  9 Though precise measurements are difficult to estimate, it is known that TGD people experience disproportionate rates of interpersonal violence and trauma. While behavioral health services can be effective for coping with the effects of these experiences, such issues play a central role in the well-being and health of TGD patients. In partnership with the New York-based nonprofit organization Crime Victims Treatment Center (CVTC), Mount Sinai CTMS offers the Transgender Healing and Resilience Initiative for Survivors of Violence (THRIV) to offer dedicated support for TGD individuals ages 13 and older who have faced interpersonal violence or trauma. Services, which include individual and group therapy, are tailored to meet the needs of each patient, and include both psychological education to process past traumas as well as skills training to protect oneself from future threats of violence, abuse, and trafficking.

Education An important component of supporting access to high quality care for transgender patients includes investing in the education and training of clinicians to help them foster the skills to carry such work forward. CTMS also holds regular, live surgery courses to promote education of transgender-specific surgeries and to share expertise and best practices with other surgeons. Faculty also coordinate a freely accessible, online course regarding transgender healthcare for primary care physicians. CTMS is connected to the Mount Sinai Health System and the Icahn School of Medicine at Mount Sinai, making it a popular choice through which Mount Sinai trainees rotate and gain valuable experience regarding transgender healthcare and gender-affirming procedures as well as pursue formal fellowships in specific areas of care. Placements at CTMS are core, mandatory rotations for residents of the Mount Sinai Plastic Surgery Residency and for the Mount Sinai Endocrinology Fellowship Program. Rotations are also core components of the training programs for fellows in both the Mount Sinai LGBTQ Medicine and the Mount Sinai Urology residency programs. CTMS developed a Transgender Psychiatry Fellowship Program for physicians who have completed an Adult General Psychiatry residency and are licensed to practice in New York state. Through this program, fellows hone their skills in managing the mental health and behavioral health of transgender patients in both outpatient and inpatient settings through comprehensive curriculum encompassing psychotherapy, psychopharmacology, and the support of patients as they navigate gender-affirming procedures. A gender-affirming surgical fellowship is also available to board eligible plastic surgeons, allowing trainees to learn how to perform various gender-affirming surgical procedures and refine their surgical care for gender diverse patients. In addition, a one year reconstructive and transgender fellowship accredited through the Society of Genitourinary Reconstructive Surgeons (GURS) has been developed for the training of board eligible urologists to learn feminizing and masculinizing

10  Chapter 1 genital reconstructive surgery including vaginoplasty, metoidioplasty, phalloplasty, and management of urological complications of transgender surgery.

Research Traditionally, there has been a dearth of biomedical and clinical research focused on the healthcare and health outcomes of transgender patients and much of the existing literature is focused on elucidating disparities in disease burden. However, the ability to offer a wide range of gender-affirming clinical interventions, both hormone therapy and surgery, is possible only with important research in the field. CTMS continues to invest in similar research to both optimize existing care as well as develop novel therapies and interventions for transgender patients. There is a wide range of research at CTMS, spanning clinical outcomes of various procedures, social analyses of access and gaps in care, as well as studies examining or advocating for changes in curricular development and professional training of clinicians regarding transgender health and patients. As quality analysis and patient satisfaction with procedures is such an important area of research, CTMS created a database which allows patients to consent to provide de-identified data from their services to be used in prospective research projects. Researchers within the center have utilized quality surveys of patients who underwent transfeminine surgeries to identify prospective areas of improvements, with the goal of disseminating these findings and supporting recommendations to clinicians for integration into their medical and surgical care.

References [1] Safer JD, Tangpricha V. Care of transgender persons. N Engl J Med 2019;381:2451–60. https://doi. org/10.1056/NEJMcp1903650. [2] Tollinche LE, Walters CB, Radix A, Long M, Galante L, Goldstein ZG, Kapinos Y, Yeoh C. The perioperative care of the transgender patient. Anesth Anal 2018;127:359–66. https://doi.org/10.1213/ ANE.0000000000003371. [3] Safer JD. Research gaps in medical treatment of transgender/nonbinary people. J Clin Invest 2021;131:142029. https://doi.org/10.1172/JCI142029. [4] Korpaisarn S, Safer JD. Gaps in transgender medical education among healthcare providers: a major barrier to care for transgender persons. Rev Endocr Metab Disord 2018;19:271–5. https://doi.org/10.1007/ s11154-018-9452-5. [5] Safer JD, Coleman E, Feldman J, Garofalo R, Hembree W, Radix A, Sevelius J. Barriers to healthcare for transgender individuals. Curr Opin Endocrinol Diabetes Obes 2016;23:168–71. https://doi.org/10.1097/ MED.0000000000000227. [6] Wolf-Gould C. From margins to mainstream: creating a rural-based center of excellence in transgender health for upstate, New York. In: S P Fernandez C, Corbie-Smith G, editors. Leading community based changes in the culture of health in the US—experiences in developing the team and impacting the community. IntechOpen; 2021. https://doi.org/10.5772/intechopen.98453. [7] Klein P, Narasimhan S, Safer JD. The Boston Medical Center experience: an achievable model for the delivery of transgender medical care at an academic medical center. Transgender Health 2018;3:136–40. https://doi.org/10.1089/trgh.2017.0054.

Developing a transgender health center of excellence: The Mount Sinai model  11 [8] Shin SJ, Pang JH, Tiersten L, Jorge N, Hirschmann J, Kutsy P, Ashley K, Stein L, Safer JD, Barnett B. The Mount Sinai interdisciplinary approach to perioperative care improved the patient experience for transgender individuals. Transgender Health 2021. https://doi.org/10.1089/trgh.2020.0134. [9] Lichtenstein M, Stein L, Connolly E, Goldstein ZG, Martinson T, Tiersten L, Shin SJ, Pang JH, Safer JD. The Mount Sinai patient-centered preoperative criteria meant to optimize outcomes are less of a barrier to care than WPATH SOC 7 criteria before transgender-specific surgery. Transgender Health 2020;5:166–72. https://doi.org/10.1089/trgh.2019.0066. [10] Hardacker C, Ducheny K, Houlberg M, editors. Transgender and gender nonconfirming health and aging. 1st ed. Berlin Heidelberg, New York, NY: Springer; 2018.

CHAPTE R 2

Satisfaction and outcomes after genitourinary gender affirmation surgery Krystal A. DePortoa, Melissa M. Pohb, Polina Reyblata, and Amanda C. Chia a

Department of Urology, Kaiser Permanente Southern California, Los Angeles, CA, United States Department of Plastic Surgery, Kaiser Permanente Southern California, Los Angeles, CA, United States b

Introduction Approximately 25 million people identify as transgender worldwide, including more than 1 million individuals in the United States [1–7]. Gender dysphoria often motivates transgender individuals to seek gender-affirming procedures. One option is genitourinary genderaffirming surgery (GAS), with the goals of better aligning one’s genitourinary anatomy with that of their gender identity and improving quality of life [5–11]. GAS encompasses a heterogeneous group of surgical procedures and techniques. Recognition of the lack of standardization is imperative when assessing surgical, functional, aesthetic, sexual, and psychosocial outcomes in addition to complications [5,12]. Objective, physicianreported outcomes are limited to physical examinations, measurements of anatomical and physiological parameters, and calculations of complication rates [13]. In order to develop best practice techniques, these objective measures need to be linked to patient-reported outcomes. Unfortunately, there is a paucity of validated questionnaires for use in transgender individuals after undergoing GAS [11,13,14]. In this chapter, we will review the reported objective and subjective outcome measures for genitourinary GAS. For feminizing surgeries, this can include orchiectomy, penectomy, partial urethrectomy, zero- or shallow-depth vaginoplasty (also termed “vulvoplasty”), or full-depth vaginoplasty. Masculinizing surgery can include hysterectomy with or without oophorectomy, vaginectomy, metoidioplasty, phalloplasty, glansplasty, scrotoplasty, perineal reconstruction, testicular prosthesis insertion, and penile prosthesis insertion.

Atlas of Operative Techniques in Gender Affirmation Surgery. https://doi.org/10.1016/B978-0-323-98377-8.00017-8 Copyright © 2023 Elsevier Inc. All rights reserved.

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14  Chapter 2

Feminizing surgery Orchiectomy Gender-affirming orchiectomy was historically the first step in the surgical transition process; however, it is now more commonly performed on individuals not interested in vaginoplasty or as a staged approach to transition [15,16]. The relative simplicity of the procedure, low complication rates, and increased awareness and acceptance by the surgical community all make orchiectomy more accessible to patients. In addition to the visual and physical relief that patients may experience after orchiectomy, it also has a direct physiological impact on reducing the need for antiandrogen therapy [15–17]. In their series of 43 patients who underwent orchiectomy, van der Sluis et al. reported a 9% complication rate at an average follow-up of 7.6 (0.4–77.6) months. In our experience, complication rates after simple bilateral orchiectomy seem lower than those reported in the literature. Overall, the procedure is well-tolerated and followed by an expeditious recovery [15].

Vulvoplasty/zero- or shallow-depth vaginoplasty The decision to undergo creation of a neovagina is a critical branch point for individuals perusing feminizing GAS. Vulvoplasty, which is also referred to as zero-depth or shallowdepth vaginoplasty, is an excellent option for individuals who do not wish to have vaginal penetrative intercourse or commit to long-term neovaginal dilation [18–21]. Vulvoplasty typically involves penectomy, orchiectomy, clitoroplasty, creation of the labia majora and the labia minora, and a shortened urethra that allows for voiding in a seated position. In addition to personal preference, indications for vulvoplasty may include prior pelvic radiation, radical prostatectomy, rectal surgery, and physical limitations such as the lack of hand dexterity required for neovaginal dilation [20–24]. In a series of 17 patients who underwent this type of reconstruction, the overall postoperative complication rate was 35% [19]. Complications consisted of three cases of minor wound dehiscence that resolved with conservative measures, two cases of urethral meatal stenosis, one case of remnant corpus spongiosum that required additional resection, and one case of postoperative urinary tract infection (UTI) [19]. Regarding sexual outcomes, Jiang et al. surveyed 16 patients after vulvoplasty at a mean follow-up of 8.7 months. They found that 58% of sexually active patients were able to achieve orgasms [21]. The overall patient satisfaction with vulvoplasty is reported to be 93% in the literature [21].

Full-depth vaginoplasty Feminizing genitoplasty was first reported in the medical literature in 1930 when Dr. Kurt Warnekros operated on Lili Elbe [25,26]. Full-depth vaginoplasty typically includes penectomy, orchiectomy, partial urethrectomy, clitoroplasty, vulvoplasty, and creation of

Satisfaction and outcomes after genitourinary gender affirmation surgery  15 a neovaginal canal [27,28]. The goal of feminizing genitoplasty is to create a perigenital complex that is cosmetically appealing and sensate, with a neovaginal canal capable of receptive penetration [5,27,28]. There are several surgical techniques that can be used to line the neovagina, including genital skin flaps and grafts, nongenital skin grafts, pedicled intestinal flaps, and peritoneal flaps [5,28–30]. The most common approach is penile inversion vaginoplasty, which involves the use of a penile skin flap in conjunction with scrotal skin graft to line the neovagina [27,29,31–33]. Penile inversion vaginoplasty involves removal of the testicles if prior orchiectomy has not been performed, degloving of the penile shaft at the level of Buck’s fascia, excision of the corpora with preservation of the neurovascular bundle to the glans, formation of a neovaginal cavity between the rectum and urethra/bladder, shortening of the urethra, and inversion of the penile skin with a scrotal skin graft into the neovagina [24,28,34,35]. Outcomes Neovaginal dimensions Anatomical measurements following vaginoplasty are one of the few objective outcome measures reported in the medical literature outside of surgical complication rates. Despite this, relatively few studies report neovaginal depth or width. In their 2021 systemic review, Bustos et al. reviewed 109 publications encompassing 3930 patients who underwent penile inversion vaginoplasty. Of those 109 publications, only 15 reported vaginal cavity dimensions. Overall, the average neovaginal depth was 9.4 (7.9–10.9) cm [36]. Reporting slightly deeper neovaginal canals were Horbach et al. in their review of 1461 patients who underwent penile inversion vaginoplasty with or without use of additional scrotal flaps; the mean neovaginal depth was found to be 10–13.5 (2.5–18) cm [33]. Blanchard et al. reported in their series of 22 patients who underwent penile inversion vaginoplasty, a mean neovaginal depth of 8.3 (4–13) cm at an average follow-up of 4.4 years. The reported frequency of neovaginal dilation was found to be significantly correlated to neovaginal depth (P = .01) [37]. Goddard et al. aimed at identifying changes in neovaginal depth over time; 82.2% of patients had an adequate vaginal depth of 5–15 cm at an early follow-up (mean of 52 days), as judged by a clinician and the patient’s personal observation. That number decreased to 61% at a late follow-up 36 months later. Neovaginal width is even less frequently reported. In a systematic review, only a single article was identified for mentioning quantitative neovaginal width with an average of 3–4 cm in 22 patients [33,38]. Less commonly, nongenital skin grafts and flaps are utilized for full-depth vaginoplasty. In a series of six patients for whom full-thickness skin grafts from the lower abdomen were used, a mean neovaginal depth of 12 cm and a mean width of 3 cm were reported at 7 months postoperatively [30]. Huang et al. combined penile inversion vaginoplasty with the addition of an extended inguinopudendal neurovascular island pedicle flap that included the inferolateral

16  Chapter 2 portion of the scrotal sac and the medial skin of the inguinal crease in 109 patients. Neovaginal depth was consistent with other previously mentioned techniques, ranging from 8 to 10 cm [33,39]. Surgical complications

The overall surgical complication rates following vaginoplasty range from 20% to 70% in the published medical literature [5,12,14]. The significant variation in complication rates highlights differences in surgical techniques, procedures performed, mechanisms for reporting complications, and small sample sizes. Despite the aforementioned heterogeneity, most complications tend to be minor and self-limiting in nature or are managed nonoperatively [5,33]. Several studies have shown that complication rates are associated with age, increased body mass index, diabetes, smoking status, and poor adherence to a postoperative neovaginal dilation regimen [27,40]. In a series of 240 patients who underwent penile inversion vaginoplasty, the postoperative complication rates at 30, 60, and 90 days were 23.8%, 31.8%, and 32.1%, respectively [12]. Bleeding  Neovaginal bleeding in the postoperative period is reported to occur at a rate of 1.6%–21% [5,12,14,27,33,38,41–47]. Potential etiologies include, but are not limited to, periurethral bleeding from the spongiosal tissue, clitoral bleeding, subcutaneous hematoma formation, dilation injuries, necrosis of the neovaginal graft or flap, infection, formation of the granulation tissue, or development of a fistula [5,48]. Most cases of neovaginal bleeding are self-limiting and resolve with a pressure dressing [5,26,42]. Studies show that the overall return to operating room rate for bleeding ranges from 0.3% to 5% [5,29]. Wound disruption and tissue loss

Mild wound-healing complications are commonly encountered following vaginoplasty with reported ranges from 3.3% to 33% [5,12,25,41–46,48–50]. Wound dehiscence is more common in areas of tissue tension, such as at the introitus and labial suture lines [5,12,48]. The reported incidence of tissue necrosis ranges from 0.6% to 24.6%. A 17% incidence of tissue necrosis along the inferior wound edge has been reported, which was the most common complication in a series of 117 patients [14]. Reoperation rates for wound dehiscence and/or tissue loss range from 0.6% to 50% [27–48]. Granulation tissue

The formation of the granulation tissue is often the result of delayed wound healing or infection and has an incidence of 2.5%–26% following vaginoplasty. Patients with comorbid hypertension, diabetes, and elevated body mass index appear to be at a higher risk [12,14,46]. Treatment with silver nitrate or a topical steroid cream can be carried out.

Satisfaction and outcomes after genitourinary gender affirmation surgery  17 Infection  The incidence of local postoperative wound infection after feminizing genitoplasty ranges from 0% to 27% [5,14,25,27,29,42,44,48,50]. Most of these infections are treated with oral antibiotics, and surgical debridement is rarely necessary [27]. In their series of 475 patients who underwent penile inversion vaginoplasty, Buncamper et al. reported a return to operating room rate of 0.6% for surgical debridement related to postoperative infections. Comorbid diabetes (OR 9.8; P = .003), anticoagulation use (OR 5.8; P = .027), and a history of illicit drug use are all associated with an increased risk of postoperative wound infection [27]. The development of local abscesses occurs in 3.6%–5% of patients, is often in the labia, and is associated with the suture material [5,27,41,44]. Neovaginal canal

Neovaginal stenosis, which may refer to introital stenosis or canal stenosis, is often secondary to poor adherence to a dilation protocol, poor graft take leading to scar contracture, infection, development of the granulation tissue, or some combination thereof [5,27,50,51]. Introital stenosis often leads to canal stenosis, given the impedance to penetration and incomplete dilation [5,51]. The reported rates of introital stenosis and canal stenosis are 2.5%–15% and 0%–55%, respectively [5,27,41]. In 2012, Rossi Neto et al. reviewed canal stenosis rates across various flaps and grafts with the following findings: 6%–15% using penoscrotal skin flaps, 5%–55% using only the penile inversion skin, and 8%–45% using only free skin grafts [41]. In their series of 11 patients, Simessen et al. reported an overall canal stenosis rate of 45% with use of full-thickness penile skin, split-thickness skin graft, or a combination of both; however, this number increased to a 100% canal stenosis rate when looking at split-thickness skin grafts alone [52]. Similarly, Huang et al. noted a high canal stenosis rate of 33% when constructing the neovagina out of a penile skin flap and split-thickness skin graft [39]. The use of nongenital splitthickness skin grafts has largely been abandoned as first-line therapy given the significant risk of neovaginal stenosis [33]. Vaginal prolapse may occur as an early or late complication following full-depth vaginoplasty. An early vaginal prolapse is concerning for flap or graft nonadherence, which may lead to eventual graft loss. A late vaginal prolapse is more classically described as a bulge in the periurethral area or neovaginal canal [5]. The overall reported incidence of vaginal prolapse is 0–6% following penile inversion vaginoplasty [5,12,14,25– 27,29,33,38,41,42,46–48]. An elevated body mass index is associated with an increased incidence of neovaginal prolapse [5]. In a few reports, patients who experience an early postoperative neovaginal prolapse may be candidates for replacement of the prolapsed skin graft/flap with use of fibrin glue and neovaginal canal packing [27,38]. Some surgeons will fixate the apex of the neovagina to the sacrospinous ligament or to Denonvilliers’ fascia in an attempt to reduce the incidence of vaginal prolapse [38,43,53].

18  Chapter 2 Neoclitoris

The pedicled glans neoclitoris has been reported to be insensate in up to 2.7% of patients, whereas 1%–14% of patients report neoclitoral hypersensititivity [25,41]. Clitoral hypersensitivity is postulated to occur secondary to neural irritation from localized inflammation and can often be successfully managed with topical anesthetics [41]. Complete necrosis and loss of the neoclitoris is reported to occur in 0.5%–3% of patients [26,29,33,41,44,47]. Voiding function

Patients may report changes in their voiding function following feminizing genitoplasty. In their series of 31 patients who underwent penile inversion vaginoplasty, Hoebeke et al. reported that up to 32.2% experienced changes in their voiding, with 19.3% reporting a worsening of symptoms. The most commonly reported complaint was nocturia in 41.2% of patients [10]. The incidence of postoperative UTIs ranges from 4.4% to 32%, with an average of 1.7 UTIs per year [10,15,27]. Patients with comorbid hypertension (OR 3.7; P = .024), cardiovascular disease (OR 3.9; P = .009), and anticoagulation use (OR 6.1; P = .024) have been found to be at an increased risk for UTIs following vaginoplasty [27]. Although reasons for the changes in voiding are unclear, factors such as a shortened urethra, prostatic urethra colonization, vaginal dilation, and underlying pelvic floor dysfunction could be contributory [5]. Urinary stream divergence has been reported in 5.6%–33% of patients in the literature, often attributed to an asymmetric labia, scaring, adhesive bands, or residual corporal tissue [5,10,25,27,42,47,48]. Urinary incontinence after vaginoplasty has been reported to occur in 4%–6% of patients and is often transient and self-limited [5]. Damage to neural innervation of the bladder or sphincter is unlikely though possible. Injury to the external urethral sphincter has a reported incidence of 0.6% [29]. Postoperative urinary retention following Foley catheter removal ranges from 0% to 16.9%. Identified risk factors for urinary retention include use of anticoagulant or anticholinergic medications, comorbid hypertension and/or cardiovascular disease, and a history of bleeding disorders [14,27]. The incidence of urethral stenosis has been reported to be as high as 40% with the more modern literature reporting a 0%–4% risk of urethral stricture and a 1%–6% risk of meatal stenosis [5,25,41]. Urethral stricture is often treated with dilation alone; however, most patients will ultimately require a formal urethroplasty [50]. Meatal stenosis may be repaired with meatotomy or V-Y plasty [27,33]. Levy et al. reported a 2.9% rate of metal stenosis and attributed their lower incidence to an improved surgical technique, including special attention to wide spatulation of the urethra [12]. The incidence of intraoperative urethral injuries is reported to be 0%–3.6% [5,27,41]. If recognized, these can be primarily closed. If unrecognized, urethral injuries can lead to the

Satisfaction and outcomes after genitourinary gender affirmation surgery  19 formation of urethroneovaginal fistulas, which occur at a rate of 0%–4% [5,27,29]. Krege et al. reported on a single patient who developed a urethroneovaginal fistula secondary to a hemostatic suture that was placed while resecting the corpus spongiosum [29]. Urethroneovaginal fistulas can also be associated with distal urethral necrosis, a relatively rare complication reported in only 0.6%–1.1% of patients after vaginoplasty [5,14,27,48]. Rectal injuries  Rectal injuries during full-depth vaginoplasty are reported to occur at an incidence of 0%–6.7% [5,27,41]. When identified intraoperatively, the rectum is primarily closed in layers. Rectal injuries can evolve into rectoneovaginal fistulas, which may also be caused by vascular injuries, cautery injuries, dilation injuries, infection, seromas, hematomas, neovaginal malignancy, or rectal malignancy. The incidence of rectoneovaginal fistula formation in the literature ranges from 0% to 17% [5,27,34,44]. Patients may require diverting colostomy with eventual fistula repair and may be at a risk of neovaginal loss. According to Hontscharuk et al., approximately half of these fistulas close spontaneously, whereas the other half are closed transneovaginally with tissue interposition. One must take special care to conduct a thorough digital rectal examination following neovaginal canal dissection to identify potential rectal injuries [25]. Pain

Perigenital pain following feminizing genitoplasty is often multifactorial in nature and is experienced by up to 20% of patients [5,47]. Dyspareunia, to be discussed further in the section on sexual outcomes, has been reported to occur in 2%–8% of patients following vaginoplasty. This can be due to the residual corpus spongiosum that engorges during sexual stimulation, ultimately impairing penetration and causing significant discomfort [5,29]. The redundant corpus spongiosum tissue can also be referred to as a urethral bulge. Up to 3% of patients undergo additional resection of the redundant corpus spongiosum [29]. Pain at the distal portion of the neovaginal canal can also be due to pelvic floor dysfunction, which could be more pronounced when the bulbospongiosus muscles are not adequately incised. Patients may also experience discomfort and neuropraxia secondary to positioning, particularly when surgical time in the lithotomy position exceeds 5 h [26]. Venous thromboembolism

Transgender female patients are often on long-term hormone replacement therapy, which may carry a risk of venous thromboembolism. Prior to feminizing genitoplasty, patients may be counseled to discontinue hormone replacement therapy perioperatively if they have other risk factors that increase the risk of venous thromboembolic disease. There is no suggested or standardized protocol for discontinuation of hormone replacement therapy, making cases surgeon-specific. The available medical literature reports less than 1% risk of venous

20  Chapter 2 thromboembolism in patients undergoing vaginoplasty. The risk of venous thromboembolism increases with greater than 5 h spent in high lithotomy/stirrups [26]. Overall, studies show that minor complications correlate more with patient dissatisfaction than a major complication. Predictors of patient dissatisfaction include intravaginal scarring, excessive external scarring, prolonged pain, loss of sensation, and excessive bleeding [14]. It is postulated that the chronicity of many complications that are labeled as “minor” interferes with quality of life more so than that of an acute “major” complication [14]. Aesthetic outcomes

The aesthetic appearance and the overall cosmesis following vaginoplasty is of undeniable importance to patients. Secondary procedures for unsatisfactory cosmetic results are the primary reason for returning to the operating room following vaginoplasty. Data show that 20%–54.2% of patients pursue revision surgery, predominantly labiaplasty (80%), followed by clitoral hood reduction (10%) and clitoral repositioning (10%) [5,14,27,33,38,43,46,53]. Despite the high rate of revision surgery, patients are overwhelmingly satisfied with their aesthetic outcome, with an average satisfaction rate of 92% (57%.1–100%) [13,14,25,28,29,33,36,54,55]. In a series of 49 patients who underwent penile inversion vaginoplasty, the mean overall aesthetic satisfaction score using a 0–10 Likert scale was 8.38 [13]. Buncamper et al. administered the Female Genital Self-Imaging Scale (FGSIS) questionnaire to patients following feminizing vaginoplasty. The scale uses seven questions and a four-point scoring scale, with a higher score being more positive, to assess self-image; the lowest mean score was a 3 for “I think my genitals smell fine” and the highest mean score was a 3.4 for “I am positive about my genitals” and “I am not embarrassed about my genitals” [28]. It is important to note that current questionnaires like FGSIS are not GAS-specific. Gender surgery-specific patient-reported outcome metrics are being developed and validated. Functional outcomes

Patient-reported outcomes following feminizing genitoplasty are limited by a lack of validated questionnaires in this population and significant long-term study attrition rates. Studies evaluating patient satisfaction with functional outcomes yielded a 72%– 100% overall satisfaction rate, regardless of which vaginoplasty technique was utilized [13,29,35,36,38,55,56]. Using a 0–10 Likert scale, Buncamper et al. reported an average score of 7.7 for functional outcomes as reported by patients following penile inversion vaginoplasty [28]. Qualitative studies looking at the binary outcome of yes/no satisfaction with neovaginal depth show that 76%–100% of patients are satisfied with the depth of their neovagina [29,33,38,47]. Patients must be appropriately counseled on realistic expectations for neovaginal depth [37].

Satisfaction and outcomes after genitourinary gender affirmation surgery  21 Sexual outcomes

On average, 75% of transgender females report having vaginal intercourse after GAS [33]. In a series of 40 patients, higher rates of engagement in sexual activity were reported postoperatively [13]. Sexual satisfaction following GAS has consistently been reported as improved by transgender women throughout the available literature [5,13,22,33,57,58]. Hormone replacement therapy, vaginal depth, clitoral sensation, overall cosmesis, general surgical satisfaction, natural lubrication, and having a partner are all associated with improved sexual satisfaction following feminizing genitoplasty [5]. The mean happiness with sexual function after GAS was 7.8 using a 0–10 Likert scale [33]. The Female Sexual Function Index (FSFI) has classically been one of the most commonly used questionnaires to assess sexual satisfaction following GAS. Patients expressed a 64%–98% satisfaction rate with their general sexual function using the FSFI [59]. The Amsterdam Hyperactive Pelvic Floor Scale-Women (AHPFS-W) uses a series of questions to assess pelvic floor function hypertonicity and resultant sexual dysfunction. Scores