Transgender surgery: Videos demonstrate cutting-edge techniques

Transgender surgery is a burgeoning field in urology and, with nearly 700,000 people in the United States alone identifying as transgender, this represents a significant unmet patient need. Although the field is new and encompasses both plastic surgery and urology, urologists are more familiar with the anatomy (both male and female) than any other specialty. Thus, they are uniquely positioned to play a key role in the surgical management of transgender patients. It is very likely that there will soon be transgender surgical fellowships in the future. Work by these surgeons and others will, hopefully, ensure that these fellowships remain within the purview of urology. Commentary on each video is provided by Lee Zhao, MD, assistant professor of urology at New York University Langone Medical Center, New York, and by 'Y'tube Section Editor James M. Hotaling, MD, MS, assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Continue to the next page to watch the videos.

Vaginoplasty using penile and scrotal skin is performed for male-to-female transgender patients who desire genital reconstruction. However, short vaginal length, vaginal stenosis, or complications in the perineal dissection are limitations of current open techniques in vaginoplasty. We demonstrate our technique for the robot-assisted penile inversion vaginoplasty, for which the deep pelvic dissection is performed with robotic assistance, allowing for increased vaginal depth.

Dr. Hotaling: This video demonstrates how reconstructive surgeons trained in the robotic era are applying the tools and techniques of abdominal robotic surgery to gender confirmation surgery. Vaginal stenosis can be a devastating problem for patients undergoing male-to-female gender confirmation surgery. The approach described here, wherein Dr. Zhao performs a perineal dissection first and then uses the robot to ensure that the neovagina is appropriately developed, is a nice application of robotic surgery to reconstructive urology.

Lee Zhao, MD, is assistant professor of urology at New York University Langone Medical Center, New York.

Metoidioplasty is an operation to construct a phallus sufficient for voiding standing up in a transgender man. This operation is performed after a patient who was born female or intersex has undergone psychologic assessment and has decided to take male hormone (testosterone) to phenotypically match their identified gender male. Preoperative clitoral hypertrophy is essential to the success of achieving voiding while standing. This video reflects a variant of the operation because no laminectomy was performed at the patient's request. This technique would increase the risk of proximal fistula.

Dr. Zhao: This video describes how the hypertrophied clitoris can be transformed into a male-appearing phallic organ that allows for standing to void. For those in the audience that are unfamiliar with gender-affirming surgery, there are many similarities between metoidioplasty and proximal hypospadias repair. Division of the vaginal mucosa results in release of a “chordee,” and straightening of the clitoris. This division results in a gap between the native female urethra and the distal glans that is bridged by a tubularized flap of labia minora. The neourethral reconstruction is then buttressed by a flap of de-epithelialized labia minora. Reduction of mons pubis via monsplasty helps to accentuate the appearance of a prominent phallus.

Dr. Hotaling: Here, Dr. Grotas demonstrates how a hypertrophied clitoris can be reconstructed to allow a standing void. The most important take-home point of this video is how crucial the maintenance of proper anatomic planes is in reconstructive gender confirmation surgery. This allows the reconstruction of a neo-urethra from existing tissue.

David Shi, MD, is a urology resident and Aaron Grotas, MD, is clinical assistant professor of urology at the Icahn School of Medicine at Mount Sinai, New York. Dr. Grotas is also the urologist at the Center of Transgender Medicine and Surgery at Mount Sinai. Miroslav L. Djordjevic, MD, PhD, is professor of urology and surgery at the School of Medicine, University of Belgrade, Serbia.

In this video, we demonstrate our technique and special considerations for orchiectomy in transgender patients. Principles include use of a vertical midline scrotal incision and maximal preservation of underlying tissue to facilitate potential future genital reconstruction.

Dr. Zhao: There are several psychologic and medical benefits of orchiectomy for male-to-female transgender patients. This video elegantly demonstrates how orchiectomy for gender affirmation differs from orchiectomy for oncologic purposes. For transgender patients, preservation of scrotal skin and Dartos is important as some patients will eventually undergo penile inversion vaginoplasty, in which the scrotal skin is used to line the neovagina, and the Dartos is used to add volume to the labia majora.

Dr. Hotaling: Here, Dr. Walsh and colleagues from the University of Washington demonstrate meticulous tissue handling and preservation of the anatomic planes during an orchiectomy for a male-to-female transgender patient. They show how optimal exposure allows a relatively high orchiectomy through a scrotal approach while preserving tissue for future reconstruction.

Geolani W. Dy, MD, is a fifth-year urology resident and Thomas J. Walsh, MD, MS, is associate professor of urology at the University of Washington School of Medicine, Seattle.

Section Editor James M. Hotaling, MD, MS, is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.