Hi, my name is Bella Avanessian, and I'm a surgeon at Mount Sinai Center for Transgender Medicine and Surgery in association with Dr. Justin. My gender pronouns are she and her. Today, I will be talking to you about transmasculine genital surgery. Our learning objectives for today's session are to review the role of surgery in the care of the transgender patient, to look at the goals of surgery as treatment options, and review the surgical options for genital masculinization surgery including hysterectomy, oophorectomy, vaginectomy, metoidioplasty, phalloplasty, glansplasty, scrotoplasty, and implants. First, what should you know about surgery? Surgery is a proven therapy for patients who identify as transgender. It is medically necessary and should be covered by insurance. A multi-disciplinary team approach is best for optimal surgical outcomes. Our goals in surgery are to improve the patient's comfort with themselves and improve their personal experience, achieve results that are both good function and natural in appearance, and minimize complications throughout the process. What's possible in transmasculine surgery? Here, we will focus on surgery of the genitalia. These are the different surgical options. Hysterectomy is removal of the uterus. Oophorectomy is removal of the ovaries. This is sometimes called salpingo-oophorectomy when referring also to the fallopian tubes. Vaginectomy or removal of the vagina, metoidioplasty, which is creation of a microphallus. Phalloplasty, which is creation of a phallus, and can be done with or without a glansplasty, which is creation of a glans or the circumcised look. A phalloplasty is typically a big multistage procedure with a long recovery and common complications. Scrotoplasty is creation of the scrotum and implants, which can be either testicular or erectile. Hysterectomy and salpingo-oophorectomy. This is the removal of the female reproductive organs. After surgery, the benefit is that the patient will no longer need gynecologic exam. Also, future pathology of these organs is no longer possible. For example, you can't have cervical cancer if your cervix has been removed. Minimally invasive options exist and can be done laparoscopically with the assistance of a robot or through the vagina. This surgery can be paired with other reconstructive surgeries, including surgeries of the face, chest, or genitals. Vaginectomy is removal of the vagina. This can be done either by resecting or cutting away the vaginal lining or by fulgurating or cauterizing it. Either process makes the walls of the vagina less slippery and smooth, and able to heal together when stitched. Next, stitches are placed to close the vaginal canal, and once healed, this completely closes the vagina. It's important to note that patients often referred to the vagina as the front hole, and patients have a front hole preference. Meaning, not every patient wants a vaginectomy. It's important to listen to what the patient wants to be able to choose the right surgical option for them. We will now compare metoidioplasty and phalloplasty. Metoidioplasty is creation of a microphallus, which is typically less than nine centimeters. A phalloplasty creates a phallus, which is larger than this. After metoidioplasty, penetrative or insertive intercourse is usually not possible. After phalloplasty, after a healed erectile implant, penetrative intercourse can be possible. A metoidioplasty is typically a single stage procedure, more if there are complications. A phalloplasty usually involves at least two stages. Metoidioplasty happens at one surgical site, whereas phalloplasty involves a minimum of two surgical sites. Phalloplasty has much higher complication rates than metoidioplasty. It's important to note that both procedures allow for urination while standing, but only if urethral lengthening and hook-up is performed. It's also possible to convert from a metoidioplasty to a phalloplasty. In that sense, a metoidioplasty can be viewed as a first step to phalloplasty. Now we'll focus specifically on metoidioplasty or creation of the microphallus. There are two types of metoidioplasty: a simple and complex. In a simple metoidioplasty, the goal is to release the ligaments that secure the sensate organ, formerly the clitoris, to the pubic bone. This allows us to lengthen the microphallus slightly and rapid in skin, making it look more phallic. In a complex metoidioplasty, we again release these ligaments, but we also lengthen the urethra to extend to the tip of the microphallus. This whole construct is then wrapped in the surrounding skin, giving it the appearance of a microphallus. Once healed, this allows for urinating while standing. This procedure can be done with or without a vaginectomy and/or scrotoplasty. Again, patient preferences vary, and it's important to design the surgery based on the patient's goals. These are two images of preoperative genitalia after a prolonged testosterone effect. This is called virilization. As you can see, the sensory organ is enlarged, and after surgery, it will look slightly lengthened. In these postoperative photos, the photo on the left is an example of metoidioplasty, and the photo on the right is another example of metoidioplasty, but after testicular implants. Now we will look specifically at phalloplasty. Again, metoidioplasty can be viewed as a first step to phalloplasty, and conversion to a phalloplasty is always possible. First, what do we need when constructing a phallus? We need a glans if we're going for the circumcised look, a urethra that reaches to the tip of the phallus, phallus bulk, phallus skin envelope, a scrotum possibly, testes, the ability to have an erection, and we want to preserve the ability to have an orgasm. Now we'll look at what we have available. Locally available, we have a short urethra, a clitoris capable of orgasm, some skin and tissue likely to be used to form the scrotum. What we need from elsewhere is urethral length, phallus bulk, phallus skin envelope, testes, and an erection. The goals of phalloplasty for the patient are to be able to achieve orgasm, to be able to urinate either sitting or standing up depending on patient preference, to have a functional penis capable of erection and sex, again based on patient preference, and to have a natural appearance. The goal of the surgeon is to meet the patients goals and expectations for a surgery. This is the most critical aspect of taking care of patients undergoing these surgeries, also to minimize complications. Again as the surgeon, your goal is to preserve the ability to achieve orgasm, remove female genitalia, construct ideally a sensate phallus, lengthen the urethra to the tip of the phallus, create a glans if the patient would like a circumcised look, create a scrotum and testes, and allow for erectile function. There are many different types of phalloplasties, and each procedure is quite complex. The mainstay of treatment is with free flaps. Meaning we disconnect tissue from one part of the body, we move it to the genital region, and we reconnect its nerves and blood vessels at that site, so it can live in a new location. Pedicled flaps involve moving tissue while it stays connected to its blood supply. So they need to be near the genital area in order to qualify for this. Aside from different options for creation of the phallus, there are also different ways of creating the urethra within the phallus. We won't be discussing these differences today. The most common type of phalloplasty is radial forearm free flap phalloplasty. This is what the rest of this talk will focus on. In designing the radial forearm free flap, we've marked the planned flap design on the forearm, and then elevated the flap leaving it connected to the arm only based on its blood vessels, so it's artery and vein. Nerves are also harvested with this flap, and you see them as small filaments on either side of those vessels. In the photo on the left, we are wrapping the smaller rectangle portion of this flap around a urinary catheter to form the urethra. In the photo on the right, the urethral inner tube is complete. Next, we wrap the larger rectangle portion of the flap around this inner tube to form the outer tube of the tube-within-a-tube design. This creates the outside of the phallus. After transferring it to the groin and connecting it to blood vessels and nerves in the area, it can now live at this new site. Urethral hook-up is the connection of the urethra to the neo-urethra, which is the new urethra within the phallus. Usually, this surgery is done after complete healing of a urethral lengthening procedure, which thinking back is very similar to the complex metoidioplasty. It is sometimes also done during phalloplasty. Usually, at least three months need to have passed from phalloplasty if urethral lengthening as part of the first procedure. The criteria for doing a urethral hook-up or that the urethra within the phallus, the neo-urethra, is completely healed and open, and that the urethra at the urethra lengthening site or in the complex metoidioplasty is also fully healed and open without strictures which are tightness or fistulla, which are little holes to the outside skin. Postoperatively, a patient can expect to have a fully urinary catheter, which is a catheter that enters through the urethra and sits within the bladder. It is also possible that the patient will have a suprapubic tube, which is a urinary catheter that passes through the skin of the low pelvis directly into the bladder. Usually, there is a period of at least one day of bed rest, and a hospital stay which ranges from days to weeks. Overall recovery from this procedure is quite long. It can be weeks to months before the patient can return to normal activities. Complications are very common. Significant complications are less likely than smaller complications, but there is a high likelihood that a complication will occur. Typically, after one surgery, there is at least a three-month wait before the patient can have another genital surgery. This allows for normal healing, for swelling to resolve, and for the tissues to normalize. Glansplasty, again creation of the circumcised look. This is typically a much smaller procedure and can sometimes even be done as an in office procedure. It can be done at the time of the initial phalloplasty or in a delayed fashion. This is the phallus after having healed a glansplasty. Scrotoplasty or creation of the scrotum, can be done either during the phalloplasty, at a later time, or before the phalloplasty. It can be done with autologous tissue, meaning tissue from the patient's own body, or it can be achieved with testicular implants. Here is a photo of each. A penile prosthesis is needed for erectile function and for the possibility of penetrative or insertive intercourse. Typically a phallus needs to have at least six months of healing before a penile prosthesis can be safely introduced. This is because it needs to develop what's called protective sensation or the ability to feel something is painful, indicating that a problem might be happening. One common way to allow for erectile function is by using a hydraulic pump implant depicted here. The implant sits inside the phallus and is connected to a pump which sits in the scrotum. The system is also connected to a fluid reservoir in the lower part of the abdomen. By activating the pump in the scrotum manually, the implant fills with fluid from the reservoir and creates an erection. When the patient no longer needs an erection, they release the pump, and the fluid drains back into the reservoir softening the phallus. This is a photo of a phallus immediately after insertion of an erectile device. The erectile device here is partially filled. Conclusions, surgery is a proven therapy for patients who identify as transgender. Surgery is medically necessary and should be covered by insurance. A multi-disciplinary team approach is best for optimal outcomes. Most importantly, a patient's goals must govern the surgical plan. Surgery is individualized based on the goals of the patient. Here we will review the surgeries that we discussed today. Hysterectomy, oophorectomy, vaginectomy are removal of the female reproductive organs. Metoidioplasty is the creation of a micro phallus. It typically does not allow for penetrative or insertive sex. Single-stage surgery is a key advantage of this procedure. Phalloplasty is creation of a phallus. This can be done with or without creation of a glans or the circumcised look. Many techniques exist, but radial forearm free flap phalloplasty is the most common. Phalloplasty is a multi-stage complex surgery with long recovery. Complications are common. Peripheral lengthening and hookup, these are needed to allow the patient to urinate while standing. These can be paired either with metoidioplasty or phalloplasty. They can also not be done if the patient prefers to urinate sitting down. Scrotoplasty, creation of the scrotum. This can be done either with the body's own tissues or with testicular implants. Erectile implants allow for erection and sometimes for penetrative or insertive sex. Typically, an implant is placed six or more months after the initial phalloplasty. Thank you for joining me for this session. I hope this has increased your understanding of transmasculine genital surgery.
