Eight-year follow-up on postoperative improvement protocol in extensive metoidioplasty transgenders:A case series

Background:This study aimed to evaluate the long-term penile size among patients who underwent extensive metoidioplasty.Methods:An evaluation was conducted on 7 out of 14 patients(mean age:29.71±13.76 years)who participated in a 2015 study that introduced a postoperative protocol to improve penile size after extensive metoidioplasty.Five transsexual females(46XX karyotype)and two patients with 5-alpha reductase deficiency were retrospectively followed up in 2023 to assess the long-term efficacy of the protocol at a specialized clinic in a general hospital in Tehran,Iran.All participants were informed about the study and consented to participate.Results:Five patients achieved increased penile size from their 2015 measurements(mean,29.00±13.34 mm).Five patients requested a larger sized penile traction device to continue the protocol.Conclusion:The long-term implementation of this protocol can result in increased penile size.We advise highly motivated patients to continue practicing the protocol to achieve better results.

A narrative review of outcomes following metoidioplasty:complications and satisfaction

Metoidioplasty consists of lengthening and straightening the hormonally hypertrophied clitoris.The goals of the procedure include masculinizing the external genitalia and enabling standing micturition.Metoidioplasty may be performed as a stand-alone procedure or an interval procedure prior to phalloplasty.While most often performed with urethral lengthening,metoidioplasty may also be performed as a“simple release”(i.e.,without urethral lengthening).Secondary procedures typically include scrotoplasty and placement of testicular implants.While satisfaction with this procedure is high,complications can occur.Complications are commonly categorized as either urologic(i.e.,strictures and fistula)or wound healing(i.e.,wound disruption,infection,bleeding,etc.).This narrative review discusses postoperative outcomes,including both satisfaction and complications.Published data on complications include fistula and stricture rates from 0%-50% and 0%-63%,respectively.Overall satisfaction with appearance ranges from 48%-100%,and patient ability to void while standing ranges from 67%-100%.Metoidioplasty is a safe and effective procedure for transgender men.Further research regarding surgical techniques and outcomes will help reduce complications and improve overall patient satisfaction.

Robotics in genital gender-affirming surgery

Gender-affirming genital surgery includes a constellation of pelvic procedures that can help feminize or masculinize the genitalia.Technological advances in robotic surgery can aid surgical access to and visualization of the pelvis,thereby facilitating certain procedures.In this scoping review,we will discuss the developing role of the robot in genital affirming genital surgery.Indications,techniques,and outcomes using the robot in both feminizing and masculinizing genital procedures will be reviewed.

Weight stigma mitigating approaches to gender-affirming genital surgery

The use of body mass index(BMI)to determine eligibility for gender-affirming surgery in transgender and nonbinary individuals has been contested.While BMI thresholds are often meant to be protective,restricting patients from access to surgery can also cause harm.There is a rationale for the continued use of BMI,but the inherent problems with it must also be recognized,including how weight stigma impacts patients’access to gender-affirming surgery and influences clinical care.This article uses a narrative review of current literature to discuss how high BMI affects surgical outcomes in gender-affirming genital surgeries,as well as analogous procedures,existing de facto BMI thresholds,and how to both minimize the harms of proceeding with surgery in patients with a high BMI or the harms of delaying for weight loss.BMI factors into surgical decision-making based on the existing literature,which demonstrates that high BMI is associated with increased surgical risk,including higher incidences of surgical site infections and poor wound healing,as well as the possibility of free flap complications,which are a component of certain genital procedures.This patient population is at higher risk for eating disorders,and it is prudent to find alternatives to requiring patient self-monitored weight management.The impacts of weight stigma should be considered when treating gender-affirming surgery patients,and further data and research are needed to augment shared decision-making and lead to practice change.

Management of urethral strictures after masculinizing genital surgery in transgender men

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.