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