Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men—A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction

Garry L.S. Pigot MD; Muhammed Al-Tamimi MD; Jakko A. Nieuwenhuijzen PhD; Wouter B. van der Sluis PhD; R.Jeroen A. van Moorselaar MD, PhD; Margriet G. Mullender PhD; Tim C. van de Grift PhD; Mark-Bram Bouman MD, PhD

FIRST PUBLISHED: October 15, 2020 – The Journal of Sexual Medicine

DOI: https://doi.org/10.1016/j.jsxm.2020.08.004

Introduction

Typical approaches to genital gender-affirming surgery (gGAS) in transgender men includes urethral lengthening. However, complications, such as urethral stricture and urethral fistulae, are common, affecting an estimated 50% to 70% of patients. For many, these complications require further surgical treatment and can cause psychological and socioeconomic distress.

The Centre of Expertise on Gender Dysphoria at the Amsterdam UMC has offered gGAS without urethral lengthening since 2009. The current study examined what portion of transgender men chose this option and assessed patients’ urological and surgical outcomes.

Methods

Patient Selection 

The study included transgender men who had at least one year of follow-up history after undergoing gGAS without urethral lengthening between 2009 and 2018.

Urinary Function (Storage and Voiding) Assessment

The International Prostate Symptoms Score (IPSS) and a 24-hour frequency voiding chart were used to assess storage and voiding function. A uroflowmetry was also conducted. These assessments were taken before and after gGAS. Outpatient follow-up visits were scheduled for 3 weeks, 3 months, and 12 months after surgery.

Patient-Reported Outcome Measurement

Researchers from various related medical specialties developed a patient-reported outcome measure (PROM) to evaluate satisfaction with surgical outcomes and function and feelings of masculinity and sexuality at least one year after gGAS.

Preoperative Workup

Before surgery, all aspects of gGAS with and without urethral lengthening were discussed with the patients so that they would know what to expect. A psychologist consulted with each patient as well.

Surgical Technique

The surgery was described as follows:

The scrotoplasty is based on the scrotoplasty as developed by Hoebeke and Monstrey. The labia minora and a large part of its inner lining are resected leaving about 1 cm mucosa surrounding the urethral meatus. As a result, a wide urogenital opening at the perineal scrotal junction is created. The anatomic position of the urethral meatus remains unchanged. If the vaginal canal is preserved, the perineal orifice is referred to as the urogenital opening that allows voiding and drainage of vaginal discharge. In case the vaginal canal is removed, the orifice is referred to as a perineal urethrostomy that allows voiding. The clitoral skin is incorporated in the ventral part of the neoscrotum. The perineum is lengthened by the closing part of the perineal skin, making it more masculine. A 16 French transurethral catheter is placed. The flaps used for the phalloplasty were the anterolateral thigh flap from the upper leg or the superficial circumflex iliac perforator flap from the groin. Both are pedicled flaps with an easy-to-conceal and less conspicous donor site. Because the flap sensory nerves must be spared, these flaps cannot be thinned out too rigorously. The appropriate thickness of these fasciocutaneous flaps is therefore important because this determines the final girth of the neophallus. The transurethral catheter is removed at day 4 or 5 (during hospital stay) so the transgender men leave the hospital without a catheter. In comparison, our transgender men who undergo gGAS with UL have a hospital stay of approximately 7 days and both a suprapubic and transurethral catheter for at least 3 weeks postoperatively. Postoperative outpatient visits are scheduled after 3 weeks, 3 months, and 12 months. Urinary storage and voiding assessment using the IPSS, 24-hour FVC, and uroflowmetry is performed at 12 months postoperatively unless otherwise indicated.

Results

The study results are based on 68 men who underwent gGAS without urethral lengthening, with a median follow-up of 24 (6-129) months. Sixty-six of the men opted for this procedure, as “having no complications after surgery outweighed the urge to void while standing.” Two men preferred to have gGAS with urethral lengthening, but were advised against it.

Thirty-five patients (51.5%) underwent metoidioplasty, and 33 (48.5%) underwent phalloplasty.

No patients regretted having gGAS without urethral lengthening.

Surgical Complications 

There were no intraoperative complications. Postoperative complications were reported as follows:

Urinary Complications and Storage and Voiding Outcomes

Eight of the men (12%) experienced urinary complications: stenosis of the urogenital opening (5 men) and perineal urethrostomy stenosis (3 men). Minor surgical revisions were performed.

Storage and voiding function were assessed pre- and post-operatively. No changes were seen with uroflowmetry (44 men), IPSS (44 men), and frequency voiding chart (13 men) assessments.

On the IPSS, a quality of life item changed from “delighted” to “pleased” and was considered a statistically significant decline.

No urethra fistulas or strictures occurred after surgery.

Patient-Reported Outcome Measurement 

Forty men completed the PROM. Of these, 63% and 65% were satisfied or very satisfied with the esthetic results of their penis and neoscrotum, respectively. About half were satisfied or very satisfied with their functional outcomes (voiding and sexual functioning).

Eighty percent agreed or strongly agreed that surgery increased their self-esteem, 70% said they would recommend the surgery to others, 77% said they would have the surgery again, and 78% said the outcomes met their expectations. There were no associations between complications and PROM results.

Discussion 

This study of gGAS without urethral lengthening “shows favorable surgical and urinary outcomes.” The urinary complication rate was around 10%, which is “significantly lower” than the reported rate for gGAS with urethral lengthening.

Some men who underwent phalloplasty expressed dissatisfaction because they had not yet received a penile implant. Some men who underwent metoidioplasty were dissatisfied with lack of length and inability to have sexual intercourse.

While some of the men expressed dissatisfaction, none said they regretted having the procedure.

Because gGAS without urethral lengthening has fewer complications, it may involve fewer secondary operations and outpatient hospital visits, which might reduce healthcare costs.

Preoperative counseling is an important part of the patient experience. In this study, a decision aid also guided patients.

Strengths of the study included the number of patients, completeness of data, and the use of patient-reported outcomes.

However, not all participants completed all assessments, the IPSS is not validated for use in transgender populations, and the PROM was not validated. These factors were considered limitations.

“Favorable results with concern to patient’s satisfaction are reported after surgery emphasizing the importance of thorough patient counseling and shared decision-making. gGAS without UL is a valuable option that should be included in the preoperative counseling and should be incorporated in the surgical armamentarium of surgeons in centers specialized in masculinizing gGAS.”