Management of the patient requesting transgender surgery

Transgender individuals make up an estimated 0.6% of the U.S. population (Flores et al. How Many Adults Identify as Transgender in the United States? Los Angeles: The Williams Institute, 2016) and have been the subject of increasing mainstream media attention in recent years. A growing number of insurance providers and health care systems, including Medicare and the Veterans Health Administration, now offer coverage for certain aspects of medical and surgical gender transition.

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As surgeons of the genitourinary tract, urologists are likely to see increased demand from transgender patients both for general urologic care and for needs specific to surgical transition.

Gender-confirming surgery, previously described as sex reassignment surgery, includes procedures that alter an individual’s body to resemble that of their identified gender. Urologists may be involved in providing surgical castration, genital reconstruction, or in managing complications of genital reconstruction. Beyond gender-confirming surgeries, transgender patients may have unique urologic needs as a result of hormonal therapy or prior reconstruction.

In this article, we will provide an overview of the urologist’s role in caring for patients undergoing gender transition as well as urologic concerns of transgender men and women.

Terminology

First, it is helpful to understand relevant terminology. “Transgender” is an umbrella term for individuals who do not identify with the physical sex to which they were assigned at birth. A transgender woman (male-to-female; MtF) is an individual who was assigned male at birth and has a female gender identity; a transgender man (female-to-male; FtM) is an individual who was assigned female at birth and has a male gender identity.

“Gender nonconforming” or “gender variant” individuals may identify with neither male nor female gender identity. Providers should ask gender nonconforming patients about their preferred pronoun (he, she, they) during the initial clinic visit and address them accordingly.

Gender identity development is thought to reflect a complex interplay of biologic, environmental, and cultural factors, with emerging evidence of a neurologic basis. A patient’s gender identity, biological sex, and sexual orientation or sexual preference may be distinct from one another. A subset of transgender patients develop “gender dysphoria,” or severe distress caused by a discrepancy between a person’s gender identity and their sex assigned at birth.

Next: Caring for patients undergoing transition

Caring for patients undergoing transition

The care of patients undergoing transition requires a multidisciplinary team of endocrinologists, primary care providers, psychologists, plastic surgeons, and reconstructive urologists, among others. Transition may involve a combination of psychotherapy, hormone therapy, and/or surgery, which are cited in the psychiatric literature as effective treatment options for gender dysphoria (Br J Psychiatry 2014; 204:96-7; Arch Sex Behav 2014; 43:1263-6; Arch Sex Behav 2012; 41:759-96).

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Not all transgender patients will choose to undergo all aspects of transition. Urologists require extensive specialty training in genital reconstruction prior to undertaking reconstructive procedures. However, a working knowledge of common approaches and complications of gender-confirming surgeries allows urologists to provide high-quality care and appropriate referrals.

Surgical castration (orchiectomy) may be requested by patients as an alternative to high-dose estrogen therapy, which may be supplemented by progestins and/or anti-androgens. Patients on exogenous estrogen are known to be at increased risk of thromboembolic and cardiovascular complications (Hematol Oncol Clin North Am 2000; 14:1045-59), with a lower rate of complications at lower doses (JAMA 1970; 214:1303-13).

Transgender patients are at a 20- to 45-fold increased risk of thromboembolic events compared to the expected rate for natal men in the same age range (J Clin Endocrinol Metab 2003; 88:5723-9; Clin Endocrinol [Oxf] 1997; 47:337-42). Spironolactone (Aldactone), also widely used among MtF patients in the United States as part of a feminizing hormonal regimen, confers risks of hyperkalemia and diuretic effects.

Prior to performing orchiectomy for transgender patients, the urologist may consult the World Professional Association for Transgender Health (WPATH) Standards of Care, which are flexible clinical guidelines designed to protect the transgender patient and the provider. WPATH recommends referrals from two qualified mental health professionals who have independently evaluated the patient prior to gonadectomy, and:

• persistent, well-documented gender dysphoria

• capacity to make a fully informed decision and to consent for treatment

• age of majority in a given country

• If significant medical or mental health concerns are present, they must be well controlled.

• 12 continuous months of hormone therapy as appropriate to the patient’s gender goals (unless hormones are not clinically indicated for the individual).

WPATH provides a separate set of guidelines regarding the care of gender nonconforming children and adolescents.

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Simple bilateral orchiectomy should be performed through a vertical midline scrotal incision, rather than a horizontal incision, to preserve vascular supply for possible future vaginoplasty.

Next: Urologic concerns of transgender women (MtF)

Urologic concerns of transgender women (MtF)

Transgender women (MtF) on feminizing hormones will experience body fat redistribution, decreased muscle mass, decreased libido and spontaneous erections, male sexual dysfunction, breast growth, decreased testicular volume and sperm production, and thinning of body and facial hair.

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In addition to orchiectomy, genital surgery relevant to urologists includes penectomy, vaginoplasty (figures 1A and 1B), clitoroplasty, and labiaplasty for MtF patients. The two most common approaches to vaginoplasty include penile inversion vaginoplasty, with a graft of scrotal skin, or enterovaginoplasty with pedicled flap from ileum, sigmoid, or right colon. Clitoroplasty utilizes the glans penis and involves preservation of the neurovascular bundle between Buck’s fascia and the corpora cavernosa for preserved genital sensation.

Approximately one-quarter of patients undergoing vaginoplasty experience complications (Nat Rev Urol 2011; 8:274-82), including venous thromboembolism, bleeding/hematoma formation, infection, acute urinary retention, wound breakdown or necrosis, granulation tissue, neuropathic pain, and in rare cases, recto-neovaginal fistulae or vesico-neovaginal fistulae. Longer-term risks include meatal stenosis with urinary retention, loss of vaginal depth and width, and vaginal hair growth. Patients undergoing penile inversion vaginoplasty must preserve vaginal depth and width with regular dilation.

Acute urinary retention requires catheterization often with a smaller (14F or less) catheter. Due to altered anatomy, the meatus may be difficult to find-the patient may be able to assist the provider in identifying the urethral meatus. For those with longer-term retention and voiding dysfunction, urodynamics may be helpful.

While benign prostatic hyperplasia and prostate adenocarcinoma are rare in the transgender population due to use of estrogen-based hormonal therapy, these are still concerns in the long-term care of an MtF patient. Prostatectomy is not generally performed at the time of genital reconstruction, and biological prostate activity persists in castrated MtF patients. When diagnosed in this population, prostate cancer appears to behave more aggressively (Andrologia 2014; 46:1156-60). Prostate monitoring using digital rectal exam or transvaginal exam (rather than PSA screening) should be considered in transgender women, though there are no clear guidelines on this practice.

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There are some special considerations regarding the surgical management of voiding dysfunction in these patients who have undergone vaginoplasty. As the urethra has been shortened, treatment of incontinence with urethral sling or artificial urinary sphincter may be difficult. Thus, care should be taken with any bladder outlet procedures where incontinence is a possible complication.

Next: Urologic concerns of transgender men (FtM)

Urologic concerns of transgender men (FtM)

Transgender men (FtM) on masculinizing hormones will experience facial and body hair growth, scalp hair loss, increased muscle mass, body fat redistribution, amenorrhea, clitoral enlargement (figure 2), vaginal atrophy, and voice deepening.

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FtM patients may undergo genital reconstructive procedures including metoidioplasty or phalloplasty (utilizing pedicled or free vascularized flap), vaginectomy, urethroplasty, scrotoplasty, penile prosthesis placement, and/or testicular implant placement, with oophorectomy and hysterectomy (figures 3 and 4).

Metoidioplasty involves construction of a microphallus from release of the suspensory ligaments of the clitoris, which requires hormonally induced clitoromegaly. Patients may choose to undergo urethral lengthening as well if they desire the ability to stand while voiding.

There is no phalloplasty technique considered to be the standard for penile reconstruction, and the choice of technique is dependent on the patient’s needs and requests, with each approach having benefits and drawbacks. Radial forearm free flap involves use of a free vascularized forearm flap, with a urethral tube made from cutaneous skin with an outer phallus tube. Other reconstructive options include anterolateral thigh flap, fibula, latissimus dorsi, and suprapubic flaps.

Erogenous sensation may be achieved via anastomosis of the dominant sensory nerve from the flap to the clitoral nerve, or transposition of the clitoris to the superficial aspect of the base of the phallus. Patients may also undergo scrotoplasty, immediate or delayed glans sculpturing, urethroplasty, and later placement of a penile prosthesis and/or testicular prosthesis.

The complication rates for FtM genital reconstruction are high, with immediate risks of partial phallus loss due to flap failure, wound breakdown, neo-urethral fistula and stricture, and donor site morbidity. Changes in urinary habits, including a post-void dribble, are common. Due to the surgical risks, many patients will choose not to undergo surgical reconstruction beyond hysterectomy and salpingo-oophorectomy.

Summary

Urologists in the United States may see a greater number of transgender or gender-variant patients in their practices due to changing legislation, insurance coverage, and greater social acceptance of transgender individuals. While gender-confirming surgeries should only be attempted by experienced reconstructive surgeons, patients may seek care from general urologists for orchiectomy and management of voiding dysfunction or other concerns that may be complicated by prior reconstructions.

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