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Reconstructive Management Pearls for the Transgender Patient

Current Urology Reports volume 19, Article number: 36 (2018) Cite this article

Abstract

Purpose of Review

A growing number of transgender patients are seeking gender-affirming genital reconstructive surgery (GRS). These complex procedures have high complication rates. We describe common surgical pitfalls in GRS and approaches for minimizing complications.

Recent Findings

Penile inversion vaginoplasty has been associated with excellent cosmetic and functional outcomes. A robotic-assisted dissection may minimize risk of rectal injury. As a younger transgender population chooses pubertal suppression, alternative sources for lining the vaginal canal, such as enteric vaginoplasties, may be more widely utilized. Since adoption of microvascular techniques in phalloplasty, transmasculine individuals have potential for a sensate neophallus and penetrative intercourse. Urethral complications are common and challenging to manage; techniques using flap coverage may minimize ischemia-related strictures. Innovations in prosthesis placement require adaptations to neophallus anatomy.

Summary

A growing number of transgender individuals are seeking genital reconstruction. Ongoing innovation in surgical technique is needed to improve patient outcomes.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. •• Flores AR, Herman JL, Gates GJ, Brown TNT. How many adults identify as transgender in the United States? Los Angeles: The Williams Institute; 2016. Authors provide a contemporary estimate of the prevalance of transgender individuals in the U.S.

    Google Scholar 

  2. Karim RB, Hage JJ, Mulder JW. Neovaginoplasty in male transsexuals: review of surgical techniques and recommendations regarding eligibility. Ann Plast Surg. 1996;37(6):669–75.

    Article  PubMed  CAS  Google Scholar 

  3. Abbe R. New method of creating a vagina in a case of congenital absence. Med Rec. 1898;54:836.

    Google Scholar 

  4. Laub DR, Fisk N. A rehabilitation program for gender dysphoria syndrome by surgical sex change. Plast Reconstr Surg. 1974;53(4):388–403.

    Article  PubMed  CAS  Google Scholar 

  5. Huang TT. Twenty years of experience in managing gender dysphoric patients: I. Surgical management of male transsexuals. Plast Reconstr Surg. 1995;96(4):921–30. discussion 31-4.

    Article  PubMed  CAS  Google Scholar 

  6. Gillies HMR The principles and art of plastic surgery: Little, Brown and Company; 1957.

  7. Perovic S, Djinovic R. Genitoplasty in male-to-female transsexuals. Curr Opin Urol. 2009;19(6):571–6.

    Article  PubMed  Google Scholar 

  8. Amend B, Seibold J, Toomey P, Stenzl A, Sievert KD. Surgical reconstruction for male-to-female sex reassignment. Eur Urol. 2013;64(1):141–9.

    Article  PubMed  Google Scholar 

  9. Buncamper ME, van der Sluis WB, van der Pas RS, Ozer M, Smit JM, Witte BI, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg. 2016;138(5):999–1007.

    Article  PubMed  CAS  Google Scholar 

  10. • Horbach SE, Bouman MB, Smit JM, Ozer M, Buncamper ME, Mullender MG. Outcome of vaginoplasty in male-to-female transgenders: a systematic review of surgical techniques. J Sex Med. 2015;12(6):1499–512. A systematic review of studies describing outcomes of vaginoplasty techniques in a total of 1,461 penile skin inversion and 102 bowel vaginoplasties.

    Article  PubMed  Google Scholar 

  11. Perovic SV, Stanojevic DS, Djordjevic ML. Vaginoplasty in male transsexuals using penile skin and a urethral flap. BJU Int. 2000;86(7):843–50.

    Article  PubMed  CAS  Google Scholar 

  12. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. 2015;12(8):1837–45.

    Article  PubMed  Google Scholar 

  13. Rossi Neto R, Hintz F, Krege S, Rubben H, Vom Dorp F. Gender reassignment surgery—a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38(1):97–107.

    Article  PubMed  CAS  Google Scholar 

  14. Wroblewski P, Gustafsson J, Selvaggi G. Sex reassignment surgery for transsexuals. Curr Opin Endocrinol, Diabetes, Obes. 2013;20(6):570–4.

    Article  Google Scholar 

  15. Gaither TW, Awad MA, Osterberg EC, Murphy GP, Romero A, Bowers ML, et al. Postoperative complications following primary penile inversion vaginoplasty among 330 male to female transgender patients. J Urol. 2017;197:e1258.

    Article  Google Scholar 

  16. Hage JJ, Karim RB. Abdominoplastic secondary full-thickness skin graft vaginoplasty for male-to-female transsexuals. Plast Reconstr Surg. 1998;101(6):1512–5.

    Article  PubMed  CAS  Google Scholar 

  17. Bouman MB, Buncamper ME, van der Sluis WB, Meijerink WJ. Total laparoscopic sigmoid vaginoplasty. Fertil Steril. 2016;106(7):e22-e3.

    Article  Google Scholar 

  18. Bouman MB, van der Sluis WB, Buncamper ME, Ozer M, Mullender MG, Meijerink WJ. Primary total laparoscopic sigmoid vaginoplasty in transgender women with penoscrotal hypoplasia: a prospective cohort study of surgical outcomes and follow-up of 42 patients. Plast Reconstr Surg. 2016;138(4):614e–23e.

    Article  PubMed  CAS  Google Scholar 

  19. Bouman MB, van Zeijl MC, Buncamper ME, Meijerink WJ, van Bodegraven AA, Mullender MG. Intestinal vaginoplasty revisited: a review of surgical techniques, complications, and sexual function. J Sex Med. 2014;11(7):1835–47.

    Article  PubMed  Google Scholar 

  20. Djordjevic ML, Stanojevic DS, Bizic MR. Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases. J Sex Med. 2011;8(12):3487–94.

    Article  PubMed  Google Scholar 

  21. Hage JJ, Karim RB, Asscheman H, Bloemena E, Cuesta MA. Unfavorable long-term results of rectosigmoid neocolpopoiesis. Plast Reconstr Surg. 1995;95(5):842–8. discussion 9-50

    Article  PubMed  CAS  Google Scholar 

  22. Kwun Kim S, Hoon Park J, Cheol Lee K, Min Park J, Tae Kim J, Chan Kim M. Long-term results in patients after rectosigmoid vaginoplasty. Plast Reconstr Surg. 2003;112(1):143–51.

    Article  PubMed  Google Scholar 

  23. Groenman F, Nikkels C, Huirne J, van Trotsenburg M, Trum H. Robot-assisted laparoscopic colpectomy in female-to-male transgender patients; technique and outcomes of a prospective cohort study. Surg Endosc. 2017;31(8):3363–9.

    Article  PubMed  Google Scholar 

  24. Gilbert DA, Horton CE, Terzis JK, Devine CJ Jr, Winslow BH, Devine PC. New concepts in phallic reconstruction. Ann Plast Surg. 1987;18(2):128–36.

    Article  PubMed  CAS  Google Scholar 

  25. Chang TS, Hwang WY. Forearm flap in one-stage reconstruction of the penis. Plast Reconstr Surg. 1984;74(2):251–8.

    Article  PubMed  CAS  Google Scholar 

  26. Garaffa G, Spilotros M, Christopher NA, Ralph DJ. Total phallic reconstruction using radial artery based forearm free flap phalloplasty in patients with epispadias-exstrophy complex. J Urol. 2014;192(3):814–20.

    Article  PubMed  Google Scholar 

  27. Monstrey S, Hoebeke P, Selvaggi G, Ceulemans P, Van Landuyt K, Blondeel P, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124(2):510–8.

    Article  PubMed  CAS  Google Scholar 

  28. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3):229–44.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Lee GK, Lim AF, Bird ET. A novel single-flap technique for total penile reconstruction: the pedicled anterolateral thigh flap. Plast Reconstr Surg. 2009;124(1):163–6.

    Article  PubMed  CAS  Google Scholar 

  30. Rubino C, Figus A, Dessy LA, Alei G, Mazzocchi M, Trignano E, et al. Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals. J Plastic, Reconstr Aesthet Surg: JPRAS. 2009;62(3):e45–9.

    Article  CAS  Google Scholar 

  31. Morrison SD, Son J, Song J, Berger A, Kirby J, Ahdoot M, et al. Modification of the tube-in-tube pedicled anterolateral thigh flap for total phalloplasty: the mushroom flap. Ann Plast Surg. 2014;72(Suppl 1):S22–6.

    Article  PubMed  CAS  Google Scholar 

  32. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol. 2017;

  33. Bettocchi C, Ralph DJ, Pryor JP. Pedicled pubic phalloplasty in females with gender dysphoria. BJU Int. 2005;95(1):120–4.

    Article  PubMed  Google Scholar 

  34. Terrier JE, Courtois F, Ruffion A, Morel Journel N. Surgical outcomes and patients’ satisfaction with suprapubic phalloplasty. J Sex Med. 2014;11(1):288–98.

    Article  PubMed  Google Scholar 

  35. Perovic SV, Djinovic R, Bumbasirevic M, Djordjevic M, Vukovic P. Total phalloplasty using a musculocutaneous latissimus dorsi flap. BJU international. 2007;100(4):899–905; discussion.

  36. Djordjevic ML, Bumbasirevic MZ, Vukovic PM, Sansalone S, Perovic SV. Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children. J Pediatr Urol. 2006;2(4):333–9.

    Article  PubMed  Google Scholar 

  37. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8(5):274–82.

    Article  PubMed  Google Scholar 

  38. Papadopulos NA, Schaff J, Biemer E. The use of free prelaminated and sensate osteofasciocutaneous fibular flap in phalloplasty. Injury. 2008;39(Suppl 3):S62–7.

    Article  PubMed  Google Scholar 

  39. Morrison SD, Shakir A, Vyas KS, Kirby J, Crane CN, Lee GK. Phalloplasty: a review of techniques and outcomes. Plast Reconstr Surg. 2016;138(3):594–615.

    Article  PubMed  CAS  Google Scholar 

  40. Morrison SD, Chen ML, Crane CN. An overview of female-to-male gender-confirming surgery. Nat Rev Urol. 2017;14(8):486–500.

    Article  PubMed  Google Scholar 

  41. Frey JD, Poudrier G, Chiodo MV, Hazen A. An update on genital reconstruction options for the female-to-male transgender patient: a review of the literature. Plast Reconstr Surg. 2017;139(3):728–37.

    Article  PubMed  CAS  Google Scholar 

  42. Hage JJ, Bloem JJ. Review of the literature on construction of a neourethra in female-to-male transsexuals. Ann Plast Surg. 1993;30(3):278–86.

    Article  PubMed  CAS  Google Scholar 

  43. Lumen N, Monstrey S, Goessaert AS, Oosterlinck W, Hoebeke P. Urethroplasty for strictures after phallic reconstruction: a single-institution experience. Eur Urol. 2011;60(1):150–8.

    Article  PubMed  Google Scholar 

  44. Rashid M, Tamimy MS. Phalloplasty: the dream and the reality. Indian J Plast Surg. 2013;46(2):283–93.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Fang RH, Kao YS, Ma S, Lin JT. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52(3):217–22.

    Article  PubMed  CAS  Google Scholar 

  46. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44(5):611–4.

    Article  PubMed  Google Scholar 

  47. Levine LA, Elterman L. Urethroplasty following total phallic reconstruction. J Urol. 1998;160(2):378–82.

    Article  PubMed  CAS  Google Scholar 

  48. Leriche A, Timsit MO, Morel-Journel N, Bouillot A, Dembele D, Ruffion A. Long-term outcome of forearm flee-flap phalloplasty in the treatment of transsexualism. BJU Int. 2008;101(10):1297–300.

    Article  PubMed  Google Scholar 

  49. Kim SK, Moon JB, Heo J, Kwon YS, Lee KC. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64(6):759–64.

    Article  PubMed  CAS  Google Scholar 

  50. Doornaert M, Hoebeke P, Ceulemans P, T'Sjoen G, Heylens G, Monstrey S. Penile reconstruction with the radial forearm flap: an update. Handchirurgie, Mikrochirurgie, plastische Chirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Handchirurgie : Organ der Deutschsprachigen Arbeitsgemeinschaft fur Mikrochirurgie der Peripheren Nerven und Gefasse 2011;43(4):208–14.

  51. Pariser JJ, Cohn JA, Gottlieb LJ, Bales GT. Buccal mucosal graft urethroplasty for the treatment of urethral stricture in the neophallus. Urology. 2015;85(4):927–31.

    Article  PubMed  Google Scholar 

  52. Hage JJ, Bouman FG, Bloem JJ. Construction of the fixed part of the neourethra in female-to-male transsexuals: experience in 53 patients. Plast Reconstr Surg 1993;91(5):904–910; discussion 11-3.

  53. • Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg. 2017;140(4):551e-8e. Retrospective single center analysis of 224 phalloplasty patients; concurrent vaginectomy allows for a vascularized bulbospongiosus flap and additional suture line coverage, decreasing urethral complications.

    Article  CAS  Google Scholar 

  54. Salgado CJ, Fein LA, Chim J, Medina CA, Demaso S, Gomez C. Prelamination of neourethra with uterine mucosa in radial forearm osteocutaneous free flap phalloplasty in the female-to-male transgender patient. Case Rep Urol. 2016;2016:8742531.

    PubMed  PubMed Central  Google Scholar 

  55. Zhang YF, Liu CY, Qu CY, Lu LX, Liu AT, Zhu L, et al. Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals? World J Urol. 2015;33(12):2115–23.

    Article  PubMed  Google Scholar 

  56. Salgado CJ, Nugent AG, Moody AM, Chim H, Paz AM, Chen HC. Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula. J Plast, Reconstr Aesthet Surg: JPRAS. 2016;69(11):1551–7.

    Article  Google Scholar 

  57. Biemer E. Penile construction by the radial arm flap. Clin Plast Surg. 1988;15(3):425–30.

    PubMed  CAS  Google Scholar 

  58. Kim SK, Lee KC, Kwon YS, Cha BH. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast, Reconstr Aesthet Surg: JPRAS. 2009;62(3):309–17.

    Article  Google Scholar 

  59. Kim SK, Kim TH, Yang JI, Kim MH, Kim MS, Lee KC. The etiology and treatment of the softened phallus after the radial forearm osteocutaneous free flap phalloplasty. Arch Plast Surg. 2012;39(4):390–6.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Schaff J, Papadopulos NA. A new protocol for complete phalloplasty with free sensate and prelaminated osteofasciocutaneous flaps: experience in 37 patients. Microsurgery. 2009;29(5):413–9.

    Article  PubMed  Google Scholar 

  61. Noe JM, Birdsell D, Laub DR. The surgical construction of male genitalia for the female-to-male transsexual. Plast Reconstr Surg. 1974;53(5):511–6.

    Article  PubMed  CAS  Google Scholar 

  62. Selvaggi G, Branemark R, Elander A, Liden M, Stalfors J. Titanium-bone-anchored penile epithesis: preoperative planning and immediate postoperative results. J Plast Surg Hand Surg. 2015;49(1):40–4.

    Article  PubMed  Google Scholar 

  63. Selvaggi G, Elander A, Branemark R. Penile epithesis: preliminary study. Plast Reconstr Surg. 2010;126(5):265e–6e.

    Article  PubMed  Google Scholar 

  64. Callens N, De Cuypere G, T'Sjoen G, Monstrey S, Lumen N, Van Laecke E, et al. Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study. World J Urol 2015;33(1):137–143.

  65. Hage JJ. Dynaflex prosthesis in total phalloplasty. Plast Reconstr Surg. 1997;99(2):479–85.

    Article  PubMed  CAS  Google Scholar 

  66. Hoebeke PB, Decaestecker K, Beysens M, Opdenakker Y, Lumen N, Monstrey SM. Erectile implants in female-to-male transsexuals: our experience in 129 patients. Eur Urol. 2010;57(2):334–40.

    Article  PubMed  Google Scholar 

  67. Zuckerman JM, Smentkowski K, Gilbert D, Storme O, Jordan G, Virasoro R, et al. Penile prosthesis implantation in patients with a history of total phallic construction. J Sex Med. 2015;12(12):2485–91.

    Article  PubMed  Google Scholar 

  68. Jordan GH, Alter GJ, Gilbert DA, Horton CE, Devine CJ Jr. Penile prosthesis implantation in total phalloplasty. J Urol. 1994;152(2 Pt 1):410–4.

    Article  PubMed  CAS  Google Scholar 

  69. Cohen AJ, Bhanvadia RR, Pariser JJ, Hatcher DM, Gottlieb LJ, Bales GT. Novel technique for proximal bone anchoring of penile prosthesis after radial forearm free flap neophallus. Urology. 2017;

  70. • Falcone M, Garaffa G, Gillo A, Dente D, Christopher AN, Ralph DJ. Outcomes of inflatable penile prosthesis insertion in 247 patients completing female to male gender reassignment surgery. BJU international. 2017. Retrospective single-center analysis of 247 neophallus patients undergoing inflatable penile prosthesis placement; patients report high satisfaction despite high complication and revision rates.

  71. Neuville P, Morel-Journel N, Maucourt-Boulch D, Ruffion A, Paparel P, Terrier JE. Surgical outcomes of erectile implants after phalloplasty: retrospective analysis of 95 procedures. J Sex Med. 2016;13(11):1758–64.

    Article  PubMed  Google Scholar 

  72. Levine LA, Zachary LS, Gottlieb LJ. Prosthesis placement after total phallic reconstruction. J Urol. 1993;149(3):593–8.

    Article  PubMed  CAS  Google Scholar 

  73. Hoebeke P, de Cuypere G, Ceulemans P, Monstrey S. Obtaining rigidity in total phalloplasty: experience with 35 patients. J Urol. 2003;169(1):221–3.

    Article  PubMed  CAS  Google Scholar 

  74. Hage JJ, Bloem JJ, Bouman FG. Obtaining rigidity in the neophallus of female-to-male transsexuals: a review of the literature. Ann Plast Surg. 1993;30(4):327–33.

    Article  PubMed  CAS  Google Scholar 

  75. Puckett CL, Montie JE. Construction of male genitalia in the transsexual, using a tubed groin flap for the penis and a hydraulic inflation device. Plast Reconstr Surg. 1978;61(4):523–30.

    Article  PubMed  CAS  Google Scholar 

  76. Segal RL, Massanyi EZ, Gupta AD, Gearhart JP, Redett RJ, Bivalacqua TJ, et al. Inflatable penile prosthesis technique and outcomes after radial forearm free flap neophalloplasty. Int J Impot Res. 2015;27(2):49–53.

    Article  PubMed  CAS  Google Scholar 

  77. Large MC, Gottlieb LJ, Wille MA, DeWolfe M, Bales GT. Novel technique for proximal anchoring of penile prostheses in female-to-male transsexual. Urology. 2009;74(2):419–21.

    Article  PubMed  Google Scholar 

  78. Sengezer M, Sadove RC. Scrotal construction by expansion of labia majora in biological female transsexuals. Ann Plast Surg. 1993;31(4):372–6.

    Article  PubMed  CAS  Google Scholar 

  79. Hage JJ, Bouman FG, Bloem JJ. Constructing a scrotum in female-to-male transsexuals. Plast Reconstr Surg. 1993;91(5):914–21.

    Article  PubMed  CAS  Google Scholar 

  80. Millard DR Jr. Scrotal construction and reconstruction. Plast Reconstr Surg. 1966;38(1):10–5.

    Article  PubMed  Google Scholar 

  81. Selvaggi G, Hoebeke P, Ceulemans P, Hamdi M, Van Landuyt K, Blondeel P, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009;123(6):1710–8.

    Article  PubMed  CAS  Google Scholar 

  82. Wilson SC, Stranix JT, Khurana K, Morrison SD, Levine JP, Zhao LC. Fasciocutaneous flap reinforcement of ventral onlay buccal mucosa grafts enables neophallus revision urethroplasty. Ther Adv Urol. 2016;8(6):331–7.

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Urology, University of Washington School of Medicine, Seattle, WA, USA

    Geolani W. Dy

  2. Department of Urology, New York University, 150 East 32nd Street, 2nd Floor, New York, NY, 10016, USA

    Jeff Sun, Michael A. Granieri & Lee C. Zhao

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  1. Geolani W. Dy
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  2. Jeff Sun
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Correspondence to Lee C. Zhao.

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Geolani W. Dy, Jeff Sun, Michael A. Granieri, and Lee C. Zhao each declare no potential conflicts of interest.

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Dy, G.W., Sun, J., Granieri, M.A. et al. Reconstructive Management Pearls for the Transgender Patient. Curr Urol Rep 19, 36 (2018). https://doi.org/10.1007/s11934-018-0795-y

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Keywords

  • Transgender
  • Vaginoplasty
  • Phalloplasty
  • Urethral stricture
  • Penile prosthesis