Perineal Cyst in Transgender Men: A Rare Complication Following Gender Affirming Surgery – A Case Series and Literature Overview (original) (raw)
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Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men
International urogynecology journal, 2017
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 wi...
The Journal of Sexual Medicine, 2019
Background: Colpectomy, removal of the vaginal epithelium, may be performed in transgender men because of a disturbed male self-image, to reduce vaginal discharge, or to reduce the risk of fistula formation at the urethraleneourethral junction in future phalloplasty or metaidoioplasty. Aim: To demonstrate that vaginal colpectomy in transgender men, either alone or in combination with, for example, laparoscopic hysterectomy, metaidoioplasty, scrotoplasty, or urethroplasty, is a feasible procedure. Methods: This single-center retrospective cohort study included 143 transgender men who underwent vaginal colpectomy between January 2006 and April 2018. Surgical details and clinical outcomes were collected from all patients. Outcomes: The primary outcome was the number of perioperative and postoperative complications, including intraoperative blood loss. Secondary outcomes were operating time, change in hemoglobin level, and duration of hospital stay. Results: In 109 patients (76%), the procedure consisted of colpectomy only, whereas in 34 patients (23%), colpectomy was combined with other procedures. In the whole group (combined procedures included), the median blood loss was 300 mL (interquartile range [IQR] ¼ 250 mL), the mean operating time was 132 ± 62 minutes, and the mean duration of hospital admission was 3.6 ± 1.9 days. In the colpectomy-only group, the median blood loss was 300 mL (IQR ¼ 250 mL), mean operating time was 112 ± 40 minutes, and mean duration of hospital admission was 3.2 ± 1.5 days. For the total group, 15 patients (10%) experienced a major perioperative complication (ie, bowel injury, ureter injury, urethra injury, bladder injury, hemorrhage requiring transfusion and/or intervention and conversion to laparoscopy), and 1 patient (0.7%) had a minor perioperative complication (hemorrhage). Major postoperative complications (hemorrhage, hematoma, fistula, wound infection and prolonged pain complaints) were reported in 17 patients (12%), and minor postoperative complications (urinary tract infection, urinary retention, hemorrhage, and hematoma) occurred in 50 patients (35%). Clinical Implications: This study provides a detailed description of our technique and comprehensive reporting on perioperative and postoperative complications and reintervention rate. Strengths & Limitations: Study strengths include the large number of patients included and the detailed reporting on the complications of vaginal colpectomy. The main limitation is the retrospective design, which can cause data to go missing during extraction and is prone to bias. Conclusion: Vaginal colpectomy is a procedure with a high complication rate, but its advantages seem to outweigh its disadvantages. In all but 1 case, no long-term sequelae were reported. However, the high complication rate and reintervention rate should be discussed with patients who are considering undergoing this
Bartholin gland cyst in a transgender male: case report of a rare occurrence
Translational Andrology and Urology
This case report highlights the importance of a wide differential diagnosis in transgender patients. A 77-year-old transgender (female-to-male) with recurrent urinary tract infections (UTI) and obstructive voiding difficulties presented with a perineal cyst. Further examinations, including computed tomography (CT) and puncture, revealed that the patient had a symptomatic Bartholin gland cyst, a phenomenon that normally only affects women. In his gender confirmation surgery (GCS) 30 years before, the patient's female labia minora and Bartholin glands were used to lengthen the urethra for the phalloplasty. This explains the unusual location and the prolonged time to the correct diagnose. We decided to perform an incision of the fluid collection from perineal. A follow-up sonography after one month revealed a remaining cyst size of 6 mL, which was assumed to be residual fluid or newly produced liquid; however, the patient has not had any UTIs since the incision of the cyst. Our case seems to be the first description of a symptomatic Bartholin gland cyst in a trans man. This stresses the importance of an expanded understanding of sex/ gender concepts, and underlines one of the many possible diagnostic pitfalls when treating trans people.
Journal of Urology, 2018
Purpose: We assessed the effect of performing colpectomy before (primary) or after (secondary) gender affirming surgery with single stage urethral lengthening on the incidence of urethral fistula in transgender men. Materials and Methods: We retrospectively reviewed the charts of all transgender men who underwent gender affirming surgery with urethral lengthening between January 1989 and November 2016 at VU University Medical Center. Patient demographics, surgical characteristics, fistulas and fistula management, and primary and secondary colpectomy were recorded. Descriptive statistics were calculated and incidence rates were compared. Results: A total of 294 transgender men underwent gender affirming surgery with urethral lengthening. A urethral fistula developed in 111 of the 232 patients (48%) without colpectomy and in 13 of the 62 (21%) who underwent primary colpectomy (p <0.01). Secondary colpectomy resulted in 100% fistula closure when performed in 17 patients with recurrent urethral fistula at the proximal urethral anastomosis and the fixed part of the neourethra. Conclusions: Primary colpectomy decreases the incidence rate of urethral fistulas. Secondary colpectomy is also an effective treatment of fistulas at the proximal urethral anastomosis and the fixed part of the neourethra.
Management of urethral strictures after masculinizing genital surgery in transgender men
Plastic and Aesthetic Research, 2022
Transgender men undergoing phalloplasty and metoidioplasty have a high rate of urethral stricture. Evaluation of stricture includes evaluation of symptoms and uroflow, cystoscopy, and retrograde urethrogram. Important anatomic differences between the phallus of cis-gender and transgender men increase the likelihood and complexity of treating urethral strictures in transgender men after surgery. Urethral strictures after masculinizing procedures are more likely to require open surgical treatment and recur after treatment. There is a paucity of data, but less invasive options such as dilation and urethrotomy have had minimal success. Open surgical options with a variety of techniques, including one-stage and two-stage techniques, have higher success rates in treating strictures, but there is minimal comparative data on outcomes. We present a review on management options for urethral reconstruction in transgender men and our data on urethroplasty for these patients.
Indian Journal of Plastic Surgery
Objectives Masculinizing genital gender affirmation surgery (MgGAS) consists of operative procedures designed to help the transition of transmen in their journey toward male gender role. Phalloplasty and urethral lengthening remain the most challenging of these surgeries, as the female urethra (4 cm long) must be lengthened to male dimensions (15–29 cm) with anastomosis at two sites, the native urethra/pars fixa urethra and the pars fixa urethra-penile urethra. As a result, there is a high incidence of urinary complications such as strictures and fistulae. Authors incorporated a urethral lengthening technique to reduce urinary complications in MgGAS. They compare the rates of urinary complications rates in cohorts before and after the introduction of this technique. Materials and Methods Authors have been performing phalloplasty since past 27 years, utilizing mainly free radial artery forearm flap (fRAFFp 431 cases) and pedicled anterolateral thigh flap (pALTp 120 cases). A retrospe...
Urologic management of the transgender patient
Translational Andrology and Urology, 2019
With growing social acceptance and increasing access, transgender care is at the forefront of medicine. Urologists, especially those of us dedicated to genitourinary reconstruction, stand to play a major role in the delivery of surgical care. The challenges of primary gender-affirming surgery include the lack of formal urologic training, the historically siloed method of delivery of care, and the relative lack of comparative research regarding optimal techniques. Understanding gender-affirming surgery (genital and non-genital) is critical even to those reconstructive urologists who do not perform primary gender-affirming surgery because they may be faced with addressing the complications of primary surgery. In performing revision surgery, one needs a broad understanding of the multiple techniques for primary gender-affirming surgery to identify pitfalls and potential complications. Regardless, complication rates are high, and revisions may not be successful. We seek to provide a review of the urologic management of the transgender patient, drawing from an international set of experts with varying experiences. We begin with a broad review of epidemiology, trends and surgical principles in the gender affirming surgery. In an effort to be comprehensive, non-urologic procedures, such as chest and craniofacial surgery, are presented along with fertility concerns. Individual surgical procedures of vaginoplasty, metoidioplasty, and phalloplasty are then discussed. Finally, urologic consequences of phalloplasty, such as urethroplasty and penile prosthesis placement, are reviewed. Respectfully, we offer some words of caution. It is important for those surgeons who wish to get involved in transgender care to become trans-competent and immerse themselves in the field. The procedures are technically demanding, and patients' individual desires and anatomy add constant challenges to a set of procedures with high complication rates. Even in the portions of each surgery that overlap with existing urologic procedures (e.g., orchiectomy and penectomy during vaginoplasty), there are nuances specific to the transgender patient, which are realized with training and experience. Thus, we would warn readers to avoid "dabbling" in gender-affirming surgery. Additionally, the surgical care of transgender patients is multidisciplinary. It is important for the urologist to work within a team of other specialties (plastics, colorectal, etc.) capable of handling the various surgical complications and the non-surgical workload (dilation, letters of support, insurance issues, etc.) that come with delivery of care to the transgender patient. Regardless, our goal was to provide a timely and salient set of articles for urologists either delving into transgender care or those well-entrenched in the field. Acknowledgments None. Footnote Conflicts of Interest: SP Elliott: Consultant to Boston Scientific. Investment interest in Percuvision. Paid investigator for Urotronic. The other authors have no conflicts of interest to declare. Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Masculinizing Genitoplasty in Intersex Patients
The Journal of Urology, 2005
Purpose: We reviewed cosmetic and functional outcome of masculinizing genitoplasty (MPG) in intersex patients assigned as a male performed in our service for more than 12 years. Materials and Methods: A total of 57 patients underwent MPG in our department during a 20-year period. Of these cases MPG was performed using modern 1-stage surgical techniques from 1991 to 2003 in 39 (68%). Of the 39 children 8 (21%) had 17-hydroxysteroid dehydrogenase deficiency, 2 (5%) had 3-hydroxysteroid dehydrogenase deficiency, 8 (21%) had 5␣-reductase deficiency, 2 (5%) had mixed gonadal dysgenesis, 1 (2.6%) was a true hermaphrodite, 1 (2.6%) had Klinefelter's syndrome, 1 (2.6%) had partially androgen insensitivity syndrome and 16 (41%) had idiopathic male pseudohermaphroditism. The presenting disease was severe proximal penoscrotal hypospadias in 30 cases (77%), perineal hypospadias in 9 (23%) and mü llerian duct opening in the perineum along with the urethral meatus in 16 (28%). Median patient age at surgery was 1.8 years. MPG was performed with a transverse pedicled preputial island flap as an onlay in 29 cases (74%). The remaining 10 patients (26%) underwent tubularization of the mucosa in the perineal area and end-to-end anastomosis to a tube made from the pedicled prepuce. Scrotal transposition as well as orchiopexy was performed in some patients as an independent operation so as not to jeopardize the perineal and preputial flaps. Results: In 23 (59%) of the 39 children 1 operation achieved satisfactory cosmetic and functional results in terms of good urinary stream and straight phallus during erection. Three (7%) children presented with various degrees of breakdown of the urethroplasty and required a repeat operation. In 5 patients (12.8%) a small urethral fistula developed and closure was performed. Conclusions: A 1-stage male genitoplasty for male pseudohermaphroditism is accompanied by a reasonable incidence of major complications. It should be performed in early childhood to avoid psychological and social anxiety by the child and parents.
Overview of surgical techniques in gender-affirming genital surgery
Translational Andrology and Urology, 2019
Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Perioperative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.
Techniques and considerations of prosthetic surgery after phalloplasty in the transgender male
Translational Andrology and Urology, 2019
For many transgender males, "lower" or "bottom" surgery (the construction of a phallus and scrotum) is the definitive step in their surgical journey for gender affirmation. The implantation of penile and testicular prostheses is often the final anatomic addition and serves to add both functionality and aesthetics to the reconstruction. However, with markedly distinctive anatomy from cis-gender men, the implantation of prostheses designed for cis-male genitalia poses a significant surgical challenge for the reconstructive urologist. The surgical techniques for these procedures remain in their infancy. Implantation of devices originally engineered for cis-men is an imperfect solution but not insurmountable if approached with ingenuity, patience, and persistence. Urologists and patients undergoing implantation should be aware of the high complication rates associated with these procedures as well as the current uncertainty of long-term outcomes. This review provides a comprehensive overview of the perioperative considerations, adaptive surgical techniques, and unique complications of penile and testicular prosthetic implantation in transgender men.