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Genital Reconstructive Surgery for the Transmasculine Patient: An Overview for the OBGYN Practitioner

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Abstract

Purpose of Review

Transmasculine patients will often seek care with obstetrician-gynecologists before, during, or after genital gender-affirmation surgery. This review provides an overview of gynecologic and reconstructive surgical procedures related to masculinizing genital surgery and highlights essential considerations for the OBGYN provider.

Recent Findings

The field of gender-affirming surgery continues to evolve, with a return of care to academic medical centers and a refocus on pooling data and evidence-based care. Nevertheless, the establishment of standardized surgical outcome measures and patient-centered metrics remains a work in progress. Encouraging advancements in urethroplasty techniques demonstrate notable efficacy in mitigating urethral strictures and fistulas.

Summary

Obstetrician-gynecologists are essential members of the surgical care team and provide preoperative, postoperative, and surgical services desired by transmasculine patients. We recommend that all OBGYN providers be familiar with the surgical options for transmasculine patients and follow the most up-to-date care guidelines as outlined by the American College of Obstetricians and Gynecologists and the World Professional Association for Transgender Health.

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Fig. 1
Fig. 2

Source—Semin Plast Surg. Aug 2011; 25(3): 196–205 [32]

Fig. 3

Similar content being viewed by others

Data Availability

No datasets were generated or analysed during the current study.

References

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

  1. James SE, Herman JL, Rankin S, Keisling M, Mottet, L, Anafi M. The report of the 2015 U.S. transgender survey. Washington, DC: National Center for Transgender Equality; 2016. [Internet]. Available from: https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf.

  2. •• Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health. 2022;23(1):S1-259. https://doi.org/10.1080/26895269.2022.2100644. This clinical consensus document provided by WPATH includes the most up-to-date and comprehensive guidelines for providing quality and ethical care to TGD individuals.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Kinnear HM, Moravek MB. Reproductive capacity after gender-affirming testosterone therapy. Hum Reprod. 2023;31(10):1872–80. https://doi.org/10.1093/humrep/dead158.

    Article  Google Scholar 

  4. Barrero JA, Mockus I. Preservation of fertility in transgender men on long-term testosterone therapy: a systematic review of oocyte retrieval outcomes during and after exogenous androgen exposure. Transgend health. 2023;8(5):408–19. https://doi.org/10.1089/trgh.2022.0023.

    Article  PubMed  Google Scholar 

  5. Leung A, Sakkas D, Pang S, Thornton K, Resetkovia N. Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: a new frontier in reproductive medicine. Fertil Steril. 2019;112(5):858–65. https://doi.org/10.1016/j.fertnstert.2019.07.014.

    Article  CAS  PubMed  Google Scholar 

  6. Tollinche LE, Rosa WE, van Rooyen CD. Perioperative considerations for person-centered gender-affirming surgery. Adv Anesth. 2021;39:77–96. https://doi.org/10.1016/j.aan.2021.07.005.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Mishra P, Nath A, Kaushal A, Kain R. Gender reassignment surgery - a narrative overview of anaesthetic considerations and implications. Anaesthesiol Intensive Ther. 2021;53(4):343–9. https://doi.org/10.5114/ait.2021.109446.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sanchez KJ, Sanchez RA, Khallouq B, Bertha MA, Ellis DB. Perioperative care of transgender and gender-diverse patients: a biopsychosocial approach. Anesth Analg. 2023;137(1):234–46. https://doi.org/10.1213/ANE.0000000000006480.

    Article  PubMed  Google Scholar 

  9. Nance Y, Chung T, Ray EC, Sioni C, Jimenez-Eichelberger A, Garcia MM. Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: an unsanctioned barrier to care. Androl. 2021;9(6):1765–72. https://doi.org/10.1111/andr.13028.

    Article  Google Scholar 

  10. Obedin-Maliver J, Light A, de Haan G, Jackson RA. Feasibility of vaginal hysterectomy for female-to-male transgender men. Obstet Gynecol. 2017;129(3):457–63. https://doi.org/10.1097/AOG.0000000000001866.

    Article  PubMed  Google Scholar 

  11. Grant JMML, Tanis J, Harrison J, Herman JL, Keisling M. Injustice at every turn: a report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. [Internet]. Available from: https://transequality.org/sites/default/files/docs/resources/NTDS_Report.pdf.

  12. •• Health care for transgender and gender diverse individuals. ACOG committee opinion, Number 823. Obstet Gynecol. 2021;137(3):e75-88. https://doi.org/10.1097/AOG.0000000000004294. Clinical guidance document for OBGYNs who provide TGD care.

    Article  Google Scholar 

  13. Cao CD, Amero MA, Marcinkowski KA, Rosenblum NG, Chan JSY, Richard S. Clinical characteristics and histologic features of hysterectomy specimens from transmasculine individuals. Obstet Gynecol. 2021;138(1):51–7. https://doi.org/10.1097/AOG.0000000000004421.

    Article  PubMed  Google Scholar 

  14. Reilly ZP, Fruhauf TF, Martin SJ. Barriers to evidence-based transgender care: knowledge gaps in gender-affirming hysterectomy and oophorectomy. Obstet Gynecol. 2019;134(4):714–7. https://doi.org/10.1097/AOG.0000000000003472.

    Article  PubMed  Google Scholar 

  15. Broulik PD, Urbanek V, Libansky P. Eighteen-year effect of androgen therapy on bone mineral density in trans(gender) men. Horm Metab Res. 2018;50(2):133–7. https://doi.org/10.1055/s-0043-118747.

    Article  CAS  PubMed  Google Scholar 

  16. Coulter M, Diamond DA, Estrada C, Grimstad F, Yu R, Doyle P. Vaginectomy in transmasculine patients: a review of techniques in an emerging field. Female Pelvic Med Reconstr Surg. 2022;28(6):222–30. https://doi.org/10.1097/SPV.0000000000001132.

    Article  Google Scholar 

  17. Jun MS, Shakir NA, Blasdel G, Cohen O, Levine JP, Bluebond-Langner R, et al. Robotic-assisted vaginectomy during staged gender-affirming penile reconstruction surgery: technique and outcomes. Urol. 2021;152:74–8. https://doi.org/10.1016/j.urology.2021.01.024.

    Article  PubMed  Google Scholar 

  18. Weyers S, Selvaggi G, Monstrey S, Dhont M, Van den Broecke R, De Sutter P, et al. Two-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals. Gynecol Surg. 2006;3:190–4. https://doi.org/10.1007/s10397-006-0203-3.

    Article  Google Scholar 

  19. Djordjevic ML, Stojanovic B, Bizic M. Metoidioplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):248–53. https://doi.org/10.21037/tau.2019.06.12.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Stojanovic B, Bencic M, Bizic M, Djordjevic ML. Metoidioplasty in gender affirmation: a review. Indian J Plast Surgery Off Pub Assoc Plast Surg India. 2022;55(2):156–61. https://doi.org/10.1055/s-0041-1740081.

    Article  Google Scholar 

  21. •• Bordas N, Stojanovic B, Bizic M, Szanto A, Djordjevic ML. Metoidioplasty: surgical options and outcomes in 813 cases. Front Endocrinol. 2021. https://doi.org/10.3389/fendo.2021.760284. One of the largest, longitudinal, cohort studies on metoidioplasty to date. After long-term follow-up, the study revealed a 10.5% complication rate with urethroplasty, and 99% of patients expressed high satisfaction.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Glick H, Tang M, Daignault-Newton S, Hadj-Moussa M. Assessment of neophallus length following metoidioplasty. Transl Androl Urol. 2023;12(9):1390–6. https://doi.org/10.21037/tau-23-155.

    Article  PubMed  PubMed Central  Google Scholar 

  23. • Al-Tamimi M, Pigot GL, van der Sluis WB, van de Grift TC, Mullender MG, Groenman F, et al. Colpectomy significantly reduces the risk of urethral fistula formation after urethral lengthening in transgender men undergoing genital gender affirming surgery. J Urol. 2018;200(6):1315–22. https://doi.org/10.1016/j.juro.2018.07.037. This study provides data to support vaginal obliteration at the time of urethral lengthening to reduce the risk of urethral fistula.

    Article  PubMed  Google Scholar 

  24. Jolly D, Wu CA, Boskey ER, Taghinia AH, Diamond DA, Ganor O. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294. https://doi.org/10.1016/j.esxm.2020.100294.

    Article  PubMed  PubMed Central  Google Scholar 

  25. • Stojanovic B, Djordjevic ML. Updates on metoidioplasty. Neurourol Urodyn. 2023;42(5):956–62. https://doi.org/10.1002/nau.25102. This study adds to the outcomes reported by Bordas et al. and includes surgical insights from this high-volume surgical center.

    Article  PubMed  Google Scholar 

  26. Akhavan AA, Sandhu S, Ndem I, Ogunleye AA. A review of gender affirmation surgery: what we know, and what we need to know. Surgery. 2021;170(1):336–40. https://doi.org/10.1016/j.surg.2021.02.013.

    Article  PubMed  Google Scholar 

  27. Khorrami A, Kumar S, Bertin E, Wassersug R, O’Dwyer C, Mukherjee S, et al. The sexual goals of metoidioplasty patients and their attitudes toward using PDE5 inhibitors and intracavernosal injections as erectile aids. Sexual medicine. 2022;10(3):100505. https://doi.org/10.1016/j.esxm.2022.100505.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Heston AL, Esmonde NO, Dugi DD III, Berli JU. Phalloplasty: techniques and outcomes. Transl Androl Urol. 2019;8(3):254–65. https://doi.org/10.21037/tau.2019.05.05.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kovar A, Choi S, Iorio M. Donor site morbidity in phalloplasty reconstructions: outcomes of the radial forearm free flap. Plast Reconstr Surg. 2019;9:2442. https://doi.org/10.1097/GOX.0000000000002442.

    Article  Google Scholar 

  30. 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-e558. https://doi.org/10.1097/PRS.0000000000003697.

    Article  CAS  PubMed  Google Scholar 

  31. Danker S, Esmonde N, Berli JU. ‘Staging’ in phalloplasty. Urol Clinics N Am. 2019;46(4):581–90. https://doi.org/10.1016/j.ucl.2019.07.011.

    Article  Google Scholar 

  32. Bluebond-Langner R, Redett RJ. Phalloplasty in complete aphallia and ambiguous genitalia. Semin Plast Surg. 2011;25(3):196–205. https://doi.org/10.1055/s-0031-1281489.PMID:22851911;PMCID:PMC3312182.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Jun MS, Santucci RA. Urethral stricture after phalloplasty. Transl Androl Urol. 2019;8(3):266–72. https://doi.org/10.21037/tau.2019.05.08.

    Article  PubMed  PubMed Central  Google Scholar 

  34. • Ortengren CD, Blasdel G, Damiano EA, Scalia PD, Morgan TS, Bagley P, et al. Urethral outcomes in metoidioplasty and phalloplasty gender affirming surgery (MaPGAS) and vaginectomy: a systematic review. Transl Androl Urol. 2022;11(12):1762–70. https://doi.org/10.21037/tau-22-174. This meta-analysis examined data published since 2000 to observe urethral-related complications with transmasculine gender-affirming surgery.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Hu CH, Chang CJ, Wang SW, Chang KV. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10–24. https://doi.org/10.1016/j.bjps.2021.08.006.

    Article  PubMed  Google Scholar 

  36. 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. 2018;199(1):206–14. https://doi.org/10.1016/j.juro.2017.07.084.

    Article  PubMed  Google Scholar 

  37. 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. https://doi.org/10.1054/bjps.1998.3027.

    Article  CAS  PubMed  Google Scholar 

  38. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44(5):611–4. https://doi.org/10.1016/s0302-2838(03)00356-7.

    Article  PubMed  Google Scholar 

  39. Monstrey SJ, Ceulemans P, Hoebeke P. Sex reassignment surgery in the female-to-male transsexual. Semin Plast Surg. 2011;25(3):229–44. https://doi.org/10.1055/s-0031-1281493.

    Article  PubMed  PubMed Central  Google Scholar 

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

    Article  CAS  PubMed  Google Scholar 

  41. Remington AC, Morrison SD, Massie JP, Crowe CS, Shakir A, Wilson SC, et al. Outcomes after phalloplasty: do transgender patients and multiple urethral procedures carry a higher rate of complication? Plast Reconstr Surg. 2018;141(2):220e-e229. https://doi.org/10.1097/PRS.0000000000004061.

    Article  CAS  PubMed  Google Scholar 

  42. 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. https://doi.org/10.1097/PRS.0b013e3181aeeb06.

    Article  CAS  PubMed  Google Scholar 

  43. 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 Int. 2018;121(1):139–44. https://doi.org/10.1111/bju.14027.

    Article  CAS  PubMed  Google Scholar 

  44. van der Sluis WB, Pigot GLS, Al-Tamimi M, Ronkes BL, de Haseth KB, Ozer M, et al. A retrospective cohort study on surgical outcomes of penile prosthesis implantation surgery in transgender men after phalloplasty. Urol. 2019;132:195–201. https://doi.org/10.1016/j.urology.2019.06.010.

    Article  PubMed  Google Scholar 

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Acknowledgements

Dr. Loren Schechter, MD for providing photos contributing to Figs. 1 and 3.

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Author notes

  1. Brianna C. Sohl and Skiey Hardin contributed equally to this work.

Authors and Affiliations

  1. Department of Obstetrics & Gynecology, Rush University Medical Center, 600 S Paulina St, 403 AAC, Chicago, IL 60612, USA

    Brianna C. Sohl, Skiey Hardin & Kristin M. Jacobs

  2. Department of General Surgery, Division of Plastic & Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA

    Kristin M. Jacobs

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Contributions

B.C.S and S.H contributed equally and wrote the main manuscript text. K.M.J provided significant edits to the manuscript and provided Figs. 1 and 3. B.C.S prepared Table 1 and S.H. prepared Table 2. All authors reviewed the manuscript.

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Correspondence to Brianna C. Sohl or Skiey Hardin.

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Sohl, B.C., Hardin, S. & Jacobs, K.M. Genital Reconstructive Surgery for the Transmasculine Patient: An Overview for the OBGYN Practitioner. Curr Obstet Gynecol Rep (2024). https://doi.org/10.1007/s13669-024-00385-y

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