Orchiectomy as Bridge or Alternative to Vaginoplasty

Hehemann, Marah; Walsh, Thomas J.

doi:10.1016/j.ucl.2019.07.005

Cited by 15 publications

(13 citation statements)

References 25 publications

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“…Based on an individual patient's gender journey and plan for transition, gender-affirming orchiectomy can be performed in isolation, as a bridge to vaginoplasty, or concurrently with vaginoplasty. [9][10][11][12][13] Understanding the surgical risk of these procedures as well as the various approaches is critical for preoperative risk counseling, especially among TGNB patients desiring orchiectomy and considering concurrent versus staged vaginoplasty. The decision to proceed with an isolated orchiectomy, staged procedure, or concurrent O&V is ultimately the decision of the patient after informed counseling in conjunction with their surgeon.…”

Section: Discussionmentioning

confidence: 99%

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database

Russell¹,

Hong²,

Fairchild³

et al. 2023

UROGC

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Importance Gender-affirming orchiectomy may be performed in isolation, as a bridge to vaginoplasty, or concurrently with vaginoplasty for transgender and nonbinary persons, although there is a paucity of data on immediate postoperative outcomes on the various procedural approaches.Objective The aim of the study is to compare 30-day surgical outcomes after gender-affirming orchiectomy and vaginoplasty as separate and isolated procedures. Study Design This was a retrospective cohort study of patients in the American College of Surgeons National Surgical Quality Improvement Program database to compare surgical outcomes of orchiectomy alone and vaginoplasty alone to concurrent orchiectomy with vaginoplasty using bivariate and adjusted multivariable regression statistics. Results Concurrent orchiectomy and vaginoplasty were associated with greater 30-day surgical complications compared with orchiectomy alone (15.4% vs 2.9%, P < 0.01) and similar odds of 30-day surgical complications compared with vaginoplasty alone (15.4% vs 11.1%, P = 0.15). On multivariable logistic regression analysis, compared with orchiectomy alone, concurrent orchiectomy and vaginoplasty were associated with higher increased odds of 30-day surgical complications (adjusted odds ratio, 6.48; 95% confidence interval, 2.83-14.86) as well as vaginoplasty alone (adjusted odds ratio 4.30; 95% confidence interval, 1.85-10.00). Conclusions This study highlights the perioperative outcomes for isolated versus concurrent gender-affirming orchiectomy and vaginoplasty, demonstrating lower morbidity for orchiectomy alone and similar morbidity for vaginoplasty alone when compared with concurrent procedures. These data will aid health care providers in preoperative counseling and surgical planning for gender-affirming genital surgery, particularly for patients considering concurrent versus staged orchiectomy and vaginoplasty.

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Section: Discussionmentioning

confidence: 99%

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database

Russell¹,

Hong²,

Fairchild³

et al. 2023

UROGC

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“…For primary vaginoplasty, we generally recommend single‐stage penile‐inversion vaginoplasty. However, although orchiectomy is part of vaginoplasty, 22 many women elect to undergo orchiectomy as a separate procedure before vaginoplasty 23‐25 for the anticipated benefits of orchiectomy including cessation of anti‐androgen agents such as spironolactone, decreased estrogen requirements (with decrease in associated side effects), 24 partial improvement of gender dysphoria, and improved ease of “tucking” the penis and scrotum, all with no compromise of the future planned vaginoplasty 25 11 we perform vaginoplasty in two stages selectively for the rare case where a patient elects primary colon vaginoplasty based on patient preference 26 .…”

Section: Methodsmentioning

confidence: 99%

“…However, although orchiectomy is part of vaginoplasty, 22 many women elect to undergo orchiectomy as a separate procedure before vaginoplasty [23][24][25] for the anticipated benefits of orchiectomy including cessation of anti-androgen agents such as spironolactone, decreased estrogen requirements (with decrease in associated side effects), 24 partial improvement of gender dysphoria, and improved ease of "tucking" the penis and scrotum, all with no compromise of the future planned vaginoplasty. 25 While two-stage vaginoplasty is rare (but performed by some surgeons), 11 we perform vaginoplasty in two stages selectively for the rare case where a patient elects primary colon vaginoplasty based on patient preference. 26 In such cases, vaginoplasty without creation of a vaginal canal ("shallow-depth vaginoplasty") is performed at the first stage; 4 months later, the right-colon neovagina segment is harvested laparoscopically and inset via a transperineal approach.…”

Section: Review Of Wpath Standards Of Care Guidelines and Policy Docu...mentioning

confidence: 99%

“…However, the results are controversial. For example, some researchers have reported that SARS-CoV-2 was not detected in the male reproductive tract, [25][26][27][28][29][30][31][32][33][34] while others reported that SARS-CoV-2 RNA was found in the semen or testes of COVID-19 patients. 35,36 There are also unknown factors regarding COVID-19 and male reproduction.…”

Section: Introductionmentioning

confidence: 99%

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Requirement of mental health referral letters for staged and revision genital gender‐affirming surgeries: An unsanctioned barrier to care

et al. 2021

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Background:The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health insurance plans will not authorize second-and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines.Objectives: This study investigates insurance requirements for referral letters and their negative impact on care. Materials and methods:We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed.Results: Nearly all reviewed U.S. health insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH. Discussion and Conclusion:Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental health status or social situation should prompt How to cite this article: Yuan N, Chung T, Ray EC, Sioni C, Jimenez-Eichelberger A, Garcia MM. Requirement of mental health referral letters for staged and revision genital gender-affirming surgeries: An unsanctioned barrier to care.

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“…20,21 Despite this, we do not discourage patients from undergoing orchiectomy prior to vaginoplasty, because orchiectomy may be a critical treatment for their gender dysphoria. 22 The importance of limited scrotal skin at the time of vaginoplasty will vary based on the surgeon's vaginoplasty technique. This finding is likely important for surgeons who perform vaginoplasty with high utilization of scrotal skin graft, 23 compared with centers that less frequently rely on skin grafts 24 or utilize other tissue, such as robotic-assisted peritoneal flap vaginoplasty or intestinal vaginoplasty.…”

Section: Impact Of Orchiectomymentioning

confidence: 99%

Genital Hypoplasia in Gender-affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning

Sineath

Butler

et al. 2022

Journal of Urology

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Purpose:Penile inversion vaginoplasty uses genital skin to construct the neovaginal canal. When genital skin is insufficient, extragenital tissue is needed. The purpose of this study is to evaluate which demographic factors and intraoperative anatomical measurements are associated with skin availability and the need for extragenital tissue.Materials and Methods:This was a prospective cohort study of patients undergoing penile inversion vaginoplasty from May 2016 through January 2021. Preoperative variables included patient demographics, orchiectomy and circumcision status, and stretched penile and scrotal skin lengths. Outcomes included measurements of available scrotal skin surface area and need for extragenital skin graft.Results:A total of 235 patients were included. Patients with prior orchiectomy and shorter stretched scrotal and penile lengths had less scrotal skin available (P < .002) and were more likely to require extragenital skin grafts (P < .001). Patients with prior orchiectomy had 3 times greater odds of needing additional skin grafts. Length of time exposed to gender-affirming hormones did not predict scrotal skin availability (P = .8).Conclusions:Factors associated with need for extragenital skin grafting with penile inversion vaginoplasty were prior orchiectomy and stretched penile skin length <8 cm. Scrotal skin length >10 cm was associated with low risk for needing additional graft. Considering these factors can help with preoperative planning and patient counseling.

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Orchiectomy as Bridge or Alternative to Vaginoplasty

Cited by 15 publications

References 25 publications

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database

Complications After Orchiectomy and Vaginoplasty for Gender Affirmation: An Analysis of Concurrent Versus Separate Procedures Using a National Database

Requirement of mental health referral letters for staged and revision genital gender‐affirming surgeries: An unsanctioned barrier to care

Genital Hypoplasia in Gender-affirming Vaginoplasty: Prior Orchiectomy, Penile Length, and Other Factors to Guide Surgical Planning

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