The field of genital gender-affirming surgery (gGAS) is in an exciting phase. The last 3 decades have yielded several new surgical options and techniques that improved patient care. However, time has also shown us that some of these surgical options are associated with complications that have a significantly adverse effect on quality of life.^1,2 There is also a nationwide shortage of surgeons with expertise to manage gGAS complications,³ and there are large geographic areas of the U.S. that suffer from limited to no trans health care support.⁴

For all of these reasons it is especially important today to: 1) counsel patients thoroughly about potential complications of gGAS and 2) offer a net risk/benefits ratio that includes significantly lower risk of postoperative complications requiring additional surgeries.

A “one size fits all” approach to gGAS options is insufficient and will not serve many patients. Providers must consider that patients “don’t know what they don’t know” about short and long-term surgery risks and benefits, and surgeons “don’t know what they don’t know” about what each individual patient most wants to gain from surgery and what specific outcomes each wants to avoid. The surgeon should articulate the potential priority “gains” and “costs” of each surgery.

Here we present work by our group to develop: 1) gGAS options that reduce risk of postoperative complications and morbidity, 2) results from questionnaires aimed at better understanding patients’ priorities related to surgery selection and 3) our experience providing recordings of surgery discussion sessions to enhance their recall of risks and benefits we discuss and to improve satisfaction.

Masculinizing Surgery: “Modified Phalloplasty”

The vast majority of complications with phalloplasty (and metoidioplasty) come from the urethral lengthening (+UL) portion of the surgery, which allows the patient to urinate from the tip of his penis. Complications include strictures, fistulae, obstructive lower urinary tract symptoms and urinary tract infections. These often require urgent management, followed by single and multistage (and often repeat) repairs.^1,5

While it is possible to construct a phallus without UL (−UL),⁶ patients willing to forego standing to urinate are often not offered this option and/or choose to forego this option if the final result “looks different” from phalloplasty+UL (P+UL). For these reasons, and to include a “lower risk” option for all patients, we developed an almost identical-appearing alternative to P+UL which we term simply “modified phalloplasty” (fig. 1). We create a novel 2 cm long distal urethra and normal appearing urethral meatus (fig. 1, a), and we preserve a 1 cm cuff of periurethral mucosa with the native urethral opening (fig. 1, b). The scrotum is constructed to be longer in the center (opposite of the Ghent technique⁶) by anchoring the posterior ends of the labia majora to the anterior aspect of the native urethral meatus (fig. 1, c and d) so the posterior end of the scrotum hangs over and obscures the urethral opening (fig. 1, e). The final result is identical-appearing to P+UL. The same techniques can also be applied to metoidioplasty−UL (fig. 1, f).

Figure 1. a, At Stage I, the flap for the P-UL modified phallourethroplasty can be harvested from the forearm or anterior lateral thigh (ALT) using a similar template as for P+UL, except that only the distal 2–2.5 cm of the urethral portion is used. b, At Stage II surgery, all vulva, labia minora and clitoris epithelium are excised (purple hatch). A 1 cm wide cuff of periurethral mucosal epithelium (blue hatched line) is preserved. The clitoris disappears from view (but is accessible for stimulation) after it is placed into a subdartos space and is sutured to the skin at the right base of the shaft. The lateral edge of the labia majora (darker blue hatch) is incised, from the introitus (orange asterisk) anteriorly (yellow asterisk) to create the neoscrotum. c, We include all subcutaneous fat with the labia majora flaps (green arrows) to preserve skin viability and to optimize scrotal fullness. The ∼1 cm periurethral cuff can be trimmed as needed (red hatch). d, After vaginectomy, we begin by anchoring the posterior ends of the labia majora to the midline anterior aspect of the periurethral cuff (#1, orange asterisk). Next, the periurethral cuff is sutured to surrounding lateral edge of the labia majora and lateral perineal skin, in the order shown: #2 (green), #3 (yellow) and #4 (blue). e, Glansplasty is performed at Stage II (inset). After complete vulvectomy, the new urethral opening does not have a feminine appearance, and is visible only when the patient manually elevates his scrotum (upper). With gravity, the redundant midline scrotal skin hangs over and obscures the urethral opening (located at the green hatched line). f, This same technique can be used with metoidioplasty as well.

We surveyed our patients who underwent P−UL and asked them to rank what factors are most important to them to achieve (and to avoid) with surgery (fig. 2). Elimination of native female anatomy was always #1, but the next highest were “having a normal appearing phallus,” “preservation of erogenous sensation” and “desire to minimize complications.” The proportion who choose P−UL over P+UL in our practice today has increased to 35%, which is significantly higher than other reports.⁶ Never reported, about half can stand to urinate over a toilet in a closed stall, though for most this is not a priority.

Figure 2. Bar graph of some of the results of our surgery questionnaire regarding decision making factors among trans women and trans men. These illustrate the relative importance that transfeminine patients (who elected SDV over FDV) and transmasculine patients (who elected P-UL over P+UL) ascribe to a subset of surgery decision making domains.

Feminizing Surgery

The Tubularized Urachus-Peritoneal Hinge-Flap: Patients who suffer partial loss of vaginal depth after full-depth vaginoplasty (FDV) face limited options to augment depth. Our work developing a salvage technique for complete loss of depth using right colon vaginoplasty led us to develop a robot-assisted laparoscopic salvage technique utilizing peritoneum for patients who have residual satisfactory vaginal depth of 7–8 cm (fig. 3).⁷ Our technique is an alternative to other innovative techniques utilizing peritoneum.⁸ In contrast, however, ours does not incorporate the rectum. The vaginal canal-vault is incised and its anterior half is sutured to surrounding vesicorectal fold peritoneum, while the cephalad end of the flap is sutured to the posterior half of the opened residual vaginal canal.

Figure 3. Outline of our 3-layer (see inset) urachus-based peritoneal hinge-flap (red hatched line). The cephalad (periumbilical) end is sutured to the posterior edge of the residual vaginal canal epithelium (blue arrow). Mean immediate postoperative increase in vaginal depth was 7.9 cm, but at long-term followup, this gain in depth was reduced to 4 cm and nonetheless resulted in patient satisfaction and improved sexual function.

For well-selected patients this technique offers modest increased depth (fig. 3) but helps avoid more complex and potentially morbid salvage techniques, such as with intestinal vaginoplasty.⁷

Shallow-Depth Vaginoplasty: Vaginoplasty that includes vaginal canal construction requires a lifelong commitment to dilation/douching, which many patients find especially challenging. The vast majority of complications after vaginoplasty are associated with the vaginal canal. For select patients (eg unable to regularly perform dilation/douching, do not desire penetrative vaginal intercourse) vaginoplasty without creation of a vaginal canal deep to the introitus area (commonly referred to as “shallow-depth vaginoplasty” [SDV]⁹ or “vulvoplasty”¹⁰) is an excellent option. Considering that the vaginal canal is normally not visible, external appearance is identical to FDV.⁹ Erogenous sensation, orgasm and urinary function are also identical to FDV.

At our center, approximately 30% of patients choose SDV over FDV. Similar to others who have also reported positive outcomes with this surgery,¹⁰ satisfaction is high and regret rare. We surveyed patients regarding what priorities drove their decision making to select SDV over FDV, and results were similar to what trans men reported when choosing between P−UL vs P+UL (see table).

Audio Recordings of Surgery Planning Discussion

In an effort to optimize patient recall of the details of our extended (∼45–60 minutes) discussion with each regarding the risks and benefits associated with each surgery option, we offered to audio record the discussion and provide a copy on a USB drive that could be listened to at home. We then queried patients to understand whether, and how, being provided with this recording was useful to them (see table).

Conclusion

It is important to consider the complex and highly personal factors that contribute to patients’ decision making for specific gGAS procedures. Our experience suggests that the manner in which surgery options are presented (nuanced to convey that the patient is the decision maker, that most options are not perfect but a balance of pros/cons, and that all options are gender affirming) is essential to helping patients choose surgeries that best balance risks, expectations and achieving individual care goals.