Prelamination of Neourethra with Uterine Mucosa in Radial Forearm Osteocutaneous Free Flap Phalloplasty in the Female-to-Male Transgender Patient

Radial forearm free flap phalloplasty is the most commonly performed flap for neophallus construction in the female-to-male (FtM) transgender patient. Urological complications, however, can arise quite frequently and can prevent the patient from urinating in the standing position, an important postsurgical goal for many. Using mucosa to construct the fixed urethra and to prelaminate the penile urethra has been successful in reducing urologic complications, particularly strictures and fistulas. Until now, only buccal, vaginal, colonic, and bladder sites have been described as sources for these mucosal grafts. We present the successful use of uterine mucosa for prelamination of the neourethra in an FtM patient who underwent hysterectomy and vaginectomy at the prelamination stage of a radial forearm phalloplasty. Three months postoperatively, the patient was able to void while standing and showed no evidence of stricture or fistula on retrograde cystogram. These results suggest that uterine mucosa may be used for prelamination of the penile neourethra in patients undergoing phalloplasty

Lateral Colporrhaphy

Lateral colporrhaphy is a surgical technique used to cosmetically tighten the vaginal mucosa and is indicated for vaginal laxity and decreased vaginal sensation, though data are limited regarding its effectiveness. The goal of lateral colporrhaphy is to excise redundant vaginal mucosa to improve appearance and enhance sensation during intercourse. Possible complications include localized infection, postoperative bleeding, wound breakdown, recurrent vaginal laxity or decreased sensation, overcorrection resulting in a very narrow vaginal canal, vaginal pain, dyspareunia, granulation tissue, cystotomy, proctotomy, and fistulae. This is considered a cosmetic procedure by most insurance companies and not covered

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men

For transgender men (TGM), gender-affirmation surgery (GAS) is often the final stage of their gender transition. GAS involves creating a neophallus, typically using tissue remote from the genital region, such as radial forearm free-flap phalloplasty. Essential to this process is vaginectomy. Complexity of vaginal fascial attachments, atrophy due to testosterone use, and need to preserve integrity of the vaginal epithelium for tissue rearrangement add to the intricacy of the procedure during GAS. We designed the technique presented here to minimize complications and contribute to overall success of the phalloplasty procedure. After obtaining approval from the Institutional Review Board, our transgender (TG) database at the University of Miami Hospital was reviewed to identify cases with vaginectomy and urethral elongation performed at the time of radial forearm free-flap phalloplasty prelamination. Surgical technique for posterior vaginectomy and anterior vaginal wall-flap harvest with subsequent urethral lengthening is detailed. Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. Mean estimated blood loss (EBL) was 290 ± 199.4 ml for the vaginectomy and urethral elongation, and no one required transfusion. There were no intraoperative complications (cystotomy, ureteral obstruction, enterotomy, proctotomy, or neurological injury). One patient had a urologic complication (urethral stricture) in the neobulbar urethra. Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term

Singapore Flap (Pudendal Thigh Fasciocutaneous Flap) for Vaginal Reconstruction

The Singapore flap, which is a pedicled pudendal fasciocutaneous flap from the thigh, is used for vaginal reconstruction in the case of vaginal agenesis, perineal wound closure, rectovaginal fistula repair, and disorders of sexual differentiation. It may also be used to reconstruct the vagina following pelvic exenteration in the case of gynecologic malignancy. Possible complications include flap loss or necrosis, wound dehiscence, neovaginal stenosis or prolapse, infection, hair growth, and dyspareunia

Applying concurrent multidisciplinary care to gender affirmation in transgender women: A case series

Gender affirmation surgeries, though important for many transgender persons, can be numerous. Combining surgeries, as presented in this case series, affords many benefits to patients without increasing risk or complications. Gender affirmation surgeries, though important for many transgender persons, can be numerous. Combining surgeries, as presented in this case series, affords many benefits to patients without increasing risk or complications

Risk Factors for Anal Dysplasia in Transgender Women: A Retrospective Chart Review

The aim of the study was to assess risk factors for anal human papillomavirus (HPV) infection and anal dysplasia among a cohort of transgender women (TGW). A retrospective chart review was conducted based on electronic medical records of TGW patients seen in the University of Miami Health System between 2010 and 2016. Outcome measures included risk factors of anal dysplasia, including HIV infection, receptive anal intercourse, and smoking history. Descriptive statistical analysis and χ testing were used. Sixty-nine TGW patients' charts were reviewed. Patients' ages ranged from 18 to 72 (mean = 38 [15]). Twenty-two (30%) were older than 50 years; 10 (15%) were black/African descent; 20 (29%) reported a smoking history; 6 (9%) were HIV positive, and 28 (72%) among those with known partner preference (n = 39) reported male partners. Male partner preference was significantly associated with being black/African descent (p = .009) and being single (p = .048). Older age was significantly associated with HIV-positive status (p = .023). The average number of risk factors per person was 2.10 (0.97). Sixty-one years or older had the highest average number of risk factors (2.90 [0.88]). Because rates of HIV, dangerous sexual behaviors, and other risk factors for anal dysplasia continue to persist among TGW, this study reinforces the need to increase the focus on anal health in the care of TGW and the need for further research to guide patient care and anal dysplasia screening strategies among those individuals

Supersonic Transporter Deformity in Transgender Men following Phalloplasty

Phalloplasty is often the final stage of gender-affirmation surgery for transgender men. Obtaining penile rigidity is important for sexual function, but may also bring complications, including supersonic transporter deformity, in which the glans becomes ventrally displaced and flaccid. Two cases of supersonic transporter deformity are presented here, one with a hydraulic penile implant and one with an autologous bone transplant. Attempt at surgical correction was performed in both. Careful attention must be paid to the unique anatomy of the neophallus and type of penile prosthesis to prevent or correct supersonic transporter deformity in transgender men. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V

Transitioning Transgender: Investigating the Important Aspects of the Transition: A Brief Report

The purpose of this study is to identify important aspects of the transition to facilitate decision-making and improved care for transgender patients by transition-care providers. A survey was used to identify transition aspects deemed significant by transgender persons. Among transgender women, the most important transition elements were legal gender change, hormone therapy, breast augmentation, frontal bone setback, and removal of body hair, and among transgender men, change of dress/clothing, name and legal gender change, speech therapy, hormone therapy, chest reconstruction and breast binding. This information is useful to physicians as they care for transgender patients to better offer transition-related counseling

Sexual Preferences and Partnerships of Transgender Persons Mid- or Post-Transition

The process of gender transition has varying effects on various aspects of sexuality. The purpose of this study was to investigate the effects of transitioning on transgender persons' sexual preferences and partnerships. Data were collected through an anonymous online survey. Questions focused on timing of gender transition in relation to change in sexual preference. Transgender individuals have a variety of sexual partners, predominantly cisgender, and may change sexual preference when they transition. Transitioning can be associated with having no primary sexual partner, despite past sexual partnerships. Length of time between identifying as transgender and starting the transition might be associated with changing sexual partner preference, particularly in transgender women. The emerging trends of sexual partnerships and changing sexual preferences related to the transition in this study warrant further investigation. These data provide more understanding of the relationship between transitioning and sexual preferences and partnerships