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    Management of the patient requesting transgender surgery

    Urologist’s role may include orchiectomy, treatment of voiding dysfunction


    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.

    Figures 2, 3, and 4Approximately 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.

    Read - Prostate Ca: Novel model predicts ‘true cancer state’

    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)


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