Management of the patient requesting transgender surgery
Urologist’s role may include orchiectomy, treatment of voiding dysfunction
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).
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.
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.