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Urethral complications after gender reassignment surgery: a systematic review

Abstract

The aim of the present systematic review is to evaluate the impact of gender reassignment surgery on the development of urethral complication. A systematic search in accordance the Preferred Reporting Items for Systematic Review and Meta-Analyses statement for original articles published up until June 2019 was performed using the Pubmed, Scopus, Embase, and Web of Science databases. Pooled analyses were done when appropriate. The bibliographic search with the included terms ((“Transsexualism”[Mesh])) AND (“Sex Reassignment Surgery”[Mesh]) produced a literature of 879 articles altogether. After removing papers of not interest or articles in which the outcomes could not be deduced, 32 studies were examined for a total of 3463 patients screened. Thirty-two studies met our inclusion criteria and were evaluated, and references were manually reviewed in order to include additional relevant studies in this review. Female-to-male (FtM) surgery and male-to-female (MtF) surgery was discussed in 23 and 10 studies, respectively. One study discussed both. Varying patterns of complications were observed in FtM and MtF surgeries, with increased complications in the former because of the larger size of the neourethra. Meatal stenosis is a particular concern in MtF surgery, with complication rates ranging from 4 to 40%, and usually require meatotomy for repair. Stricture and fistulization are frequently reported complications following FtM surgery. In studies reporting on fistulae involving the urethra, 19–54% of fistulae resolved spontaneously without further surgical intervention. High rates of complications are reported in the current literature, which should be understood by patients and practitioners alike. Shared decision making with patients regarding incidence and management of urethral complications including stricture disease and fistulae, particularly after FtM surgery, is critical for setting expectations and managing postoperative outcomes.

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References

  1. Selvaggi G, Bellringer J. Gender reassignment surgery: an overview. Nat Rev Urol. 2011;8:274–82. https://doi.org/10.1038/nrurol.2011.46.

    Article  PubMed  Google Scholar 

  2. Santucci RA. Urethral complications after transgender phalloplasty: strategies to treat them and minimize their occurrence. Clin Anat 2018;31:187–90. https://doi.org/10.1002/ca.23021.

    Article  PubMed  Google Scholar 

  3. Moher D, Liberati A, Tetzlaff J, Altman DG, PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009;6:e1000097. https://doi.org/10.1371/journal.pmed.1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Oxford Center of Evidence-Based Medicine. Levels of Evidence. https://www.cebm.net/2016/05/ocebm-levels-of-evidence/. Published 2011. Accessed September 22, 2019.

  5. Hoebeke P, Selvaggi G, Ceulemans P, et al. Impact of sex reassignment surgery on lower urinary tract function. Eur Urol. 2005;47:398–402. https://doi.org/10.1016/j.eururo.2004.10.008.

    Article  PubMed  Google Scholar 

  6. Weyers S, Selvaggi G, Monstrey S, et al. Two-stage versus one-stage sex reassignment surgery in female-to-male transsexual individuals. Gynecol Surg. 2006;3:190–4. https://doi.org/10.1007/s10397-006-0203-3.

    Article  Google Scholar 

  7. Schaff J. Enlarged range of free flaps for phalloplasty in transsexual reassignment surgery. Int J Transgenderism. 2007;10:39–45. https://doi.org/10.1300/J485v10n01_06.

    Article  Google Scholar 

  8. Takamatsu A, Harashina T. Labial ring flap: a new flap for metaidoioplasty in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:318–25. https://doi.org/10.1016/j.bjps.2008.11.038.

    CAS  Article  PubMed  Google Scholar 

  9. Kim S-K, Lee K-C, Kwon Y-S, Cha B-H. Phalloplasty using radial forearm osteocutaneous free flaps in female-to-male transsexuals. J Plast Reconstr Aesthet Surg. 2009;62:309–17. https://doi.org/10.1016/j.bjps.2007.11.011.

    Article  PubMed  Google Scholar 

  10. Zhang Y-F, Liu C-Y, Qu C-Y, et al. Is vaginal mucosal graft the excellent substitute material for urethral reconstruction in female-to-male transsexuals? World J Urol. 2015;33:2115–23. https://doi.org/10.1007/s00345-015-1562-z.

    Article  PubMed  Google Scholar 

  11. Fang R-H, Kao Y-S, Ma S, Lin J-T. Phalloplasty in female-to-male transsexuals using free radial osteocutaneous flap: a series of 22 cases. Br J Plast Surg. 1999;52:217–22. https://doi.org/10.1054/bjps.1998.3027.

    CAS  Article  PubMed  Google Scholar 

  12. Dabernig J, Chan LKW, Schaff J. Phalloplasty with free (septocutaneous) fibular flap sine fibula. J Urol 2006;176:2085–8. https://doi.org/10.1016/j.juro.2006.07.036.

    CAS  Article  PubMed  Google Scholar 

  13. Djordjevic ML, Stanojevic D, Bizic M, et al. Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience. J Sex Med. 2009;6:1306–13. https://doi.org/10.1111/j.1743-6109.2008.01065.x.

    Article  PubMed  Google Scholar 

  14. Garaffa G, Christopher NA, Ralph DJ. Total phallic construction in female to male transsexuals. Curr Urol 2009;3:146–55. https://doi.org/10.1159/000253373.

    Article  Google Scholar 

  15. Kim S-K, Moon J-B, Heo J, Kwon Y-S, Lee K-C. A new method of urethroplasty for prevention of fistula in female-to-male gender reassignment surgery. Ann Plast Surg. 2010;64:759–64. https://doi.org/10.1097/SAP.0b013e3181a5b719.

    CAS  Article  PubMed  Google Scholar 

  16. Wierckx K, Van Caenegem E, Elaut E, et al. Quality of life and sexual health after sex reassignment surgery in transsexual men. J Sex Med. 2011;8:3379–88. https://doi.org/10.1111/j.1743-6109.2011.02348.x.

    Article  PubMed  Google Scholar 

  17. Djordjevic ML, Bizic MR. Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery. J Sex Med. 2013;10:1431–8. https://doi.org/10.1111/jsm.12108.

    Article  PubMed  Google Scholar 

  18. van der Sluis WB, Smit JM, Pigot GLS, et al. Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction. Microsurgery 2017;37:917–23. https://doi.org/10.1002/micr.30190.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Stojanovic B, Bizic M, Bencic M, et al. One-stage gender-confirmation surgery as a viable surgical procedure for female-to-male transsexuals. J Sex Med. 2017;14:741–6. https://doi.org/10.1016/j.jsxm.2017.03.256.

    Article  PubMed  Google Scholar 

  20. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. Colpectomy significantly reduces the risk of urethral fistula formation after urethral lengthening in transgender men undergoing genital gender affirming surgery. J Urol 2018;200:1315–21. https://doi.org/10.1016/j.juro.2018.07.037.

    Article  PubMed  Google Scholar 

  21. Ascha M, Massie JP, Morrison SD, Crane CN, Chen ML. Outcomes of single stage phalloplasty by pedicled anterolateral thigh flap versus radial forearm free flap in gender confirming surgery. J Urol 2018;199:206–14. https://doi.org/10.1016/j.juro.2017.07.084.

    Article  PubMed  Google Scholar 

  22. Wirthmann AE, Majenka P, Kaufmann MC, et al. Phalloplasty in female-to-male transsexuals by Gottlieb and Levine’s free radial forearm flap technique-A long-term single-center experience over more than two decades. J Reconstr Microsurg. 2018;34:235–41. https://doi.org/10.1055/s-0037-1608656.

    Article  PubMed  Google Scholar 

  23. Namba Y, Watanabe T, Kimata Y. Flap combination phalloplasty in female-to-male transsexuals. J Sex Med. 2019;16:934–41. https://doi.org/10.1016/j.jsxm.2019.02.010.

    Article  PubMed  Google Scholar 

  24. D’Arpa S, Claes K, Lumen N, et al. Urethral reconstruction in anterolateral thigh flap phalloplasty: a 93-case experience. Plast Reconstr Surg. 2019;143:382e–392e. https://doi.org/10.1097/PRS.0000000000005278.

    CAS  Article  PubMed  Google Scholar 

  25. Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal colpectomy in transgender men: a retrospective cohort study on surgical procedure and outcomes. J Sex Med. 2019. https://doi.org/10.1016/j.jsxm.2019.03.263.

    Article  PubMed  Google Scholar 

  26. Rohrmann D, Jakse G. Urethroplasty in female-to-male transsexuals. Eur Urol. 2003;44:611–4. https://doi.org/10.1016/S0302-2838(03)00356-7.

    Article  PubMed  Google Scholar 

  27. Garaffa G, Christopher NA, Ralph DJ. Total phallic reconstruction in female-to-male transsexuals. Eur Urol 2010;57:715–22. https://doi.org/10.1016/j.eururo.2009.05.018.

    Article  PubMed  Google Scholar 

  28. Lawrence AA. Patient-reported complications and functional outcomes of male-to-female sex reassignment surgery. Arch Sex Behav. 2006;35:717–27. https://doi.org/10.1007/s10508-006-9104-9.

    Article  PubMed  Google Scholar 

  29. Rossi Neto R, Hintz F, Krege S, Rübben H, vom Dorp F. Gender reassignment surgery - a 13 year review of surgical outcomes. Int Braz J Urol. 2012;38:97–107. https://doi.org/10.1590/S1677-55382012000100014.

    CAS  Article  PubMed  Google Scholar 

  30. Amend B, Seibold J, Toomey P, Stenzl A, Sievert K-D. Surgical reconstruction for male-to-female sex reassignment. Eur Urol 2013;64:141–9. https://doi.org/10.1016/j.eururo.2012.12.030.

    Article  PubMed  Google Scholar 

  31. Raigosa M, Avvedimento S, Yoon TS, Cruz-Gimeno J, Rodriguez G, Fontdevila J. Male-to-female genital reassignment surgery: a retrospective review of surgical technique and complications in 60 patients. J Sex Med. 2015;12:1837–45. https://doi.org/10.1111/jsm.12936.

    Article  PubMed  Google Scholar 

  32. van der Sluis WB, Bouman M-B, de Boer NKH, et al. Long-term follow-up of transgender women after secondary intestinal vaginoplasty. J Sex Med. 2016;13:702–10. https://doi.org/10.1016/j.jsxm.2016.01.008.

    Article  PubMed  Google Scholar 

  33. Kuzon WMJ, Gast KM, Buncamper ME, et al. Surgical outcome after penile inversion vaginoplasty: a retrospective study of 475 transgender women. Plast Reconstr Surg. 2016;138:999–1007. https://doi.org/10.1097/PRS.0000000000002684.

    CAS  Article  Google Scholar 

  34. Ives GC, Fein LA, Finch L, et al. Evaluation of BMI as a risk factor for complications following gender-affirming penile inversion vaginoplasty. Plast Reconstr Surg Glob Open. 2019;7:e2097 https://doi.org/10.1097/GOX.0000000000002097.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Goddard JC, Vickery RM, Qureshi A, Summerton DJ, Khoosal D, Terry TR. Feminizing genitoplasty in adult transsexuals: early and long-term surgical results. BJU Int. 2007;100:607–13. https://doi.org/10.1111/j.1464-410X.2007.07017.x.

    Article  PubMed  Google Scholar 

  36. Krege S, Bex A, Lümmen G, Rübben H. Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients. BJU Int. 2001;88:396–402. https://doi.org/10.1046/j.1464-410X.2001.02323.x.

    CAS  Article  PubMed  Google Scholar 

  37. World Professional Association for Transgender Health. Standards of Care—WPATH. https://www.wpath.org/publications/soc. Accessed September 25, 2019.

  38. Morrison SD, Chen ML, Crane CN. An overview of female-to-male gender-confirming surgery. Nat Rev Urol. 2017;14:486–500. https://doi.org/10.1038/nrurol.2017.64.

    Article  PubMed  Google Scholar 

  39. Jun MS, Santucci RA. Urethral stricture after phalloplasty. Transl Androl Urol. 2019;8:266–72. https://doi.org/10.21037/tau.2019.05.08.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Massie JP, Morrison SD, Wilson SC, Crane CN, Chen ML. Phalloplasty with urethral lengthening: addition of a vascularized bulbospongiosus flap from vaginectomy reduces postoperative urethral complications. Plast Reconstr Surg. 2017;140:551e–558e. https://doi.org/10.1097/PRS.0000000000003697.

    CAS  Article  PubMed  Google Scholar 

  41. Salgado CJ, Nugent AG, Moody AM, Chim H, Paz AM, Chen H-C. Immediate pedicled gracilis flap in radial forearm flap phalloplasty for transgender male patients to reduce urinary fistula. J Plast Reconstr Aesthet Surg. 2016;69:1551–7. https://doi.org/10.1016/j.bjps.2016.05.011.

    Article  PubMed  Google Scholar 

  42. Cocci A, Frediani D, Cacciamani GE, et al. Systematic review of studies reporting perioperative and functional outcomes following male-to- female gender assignment surgery (MtoF GAS): a call for standardization in data reporting. Minerva Urol Nefrol. 2019. https://doi.org/10.23736/S0393-2249.19.03407-6.

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Nassiri, N., Maas, M., Basin, M. et al. Urethral complications after gender reassignment surgery: a systematic review. Int J Impot Res 33, 793–800 (2021). https://doi.org/10.1038/s41443-020-0304-y

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