Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men

Rooij, Freek P. W. de; Grift, Tim C. van de; Veerman, Hans; Al-Tamimi, Muhammed; Sluis, Wouter B. van der; Ronkes, Brechje; Özer, Müjde; Mullender, Margriet G.; Bouman, Mark‐Bram; Pigot, Garry L.S.

doi:10.1016/j.jsxm.2021.03.002

Cited by 18 publications

(9 citation statements)

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“…The authors suggested that this may be due to increased erogenous sensation following metoidioplasty compared to phalloplasty, and patients’ acceptance that they are unlikely to acquire a phallus large enough for penetrative intercourse. 18 This finding further supports that erogenous sensation, the ability to orgasm, and erectile function appear to be more important than the ability to have penetrative intercourse for patients who have undergone metoidioplasty. These results can facilitate decision-making for patients who are exploring options in regard to bottom gender-affirmation surgery.…”

Section: Discussionsupporting

confidence: 62%

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

et al. 2022

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Background Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI). Aim We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids Methods All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA. Outcomes Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty. Results Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either “larger but not hard,” or “hard but not hard enough for penetration.” A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction. Clinical Translation The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery. Strengths & Limitations This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center. Conclusion Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i.

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Section: Discussionsupporting

confidence: 62%

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

et al. 2022

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“…We believe that a well-considered shared decision for or against UL will increase patient satisfaction postoperatively. In a previous study, comparable patient-reported outcomes were described after gGAS with and without UL, and satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall satisfaction at follow-up, in contrast to the complication and reoperation rate, and independently of UL (de Rooij et al., 2021 ).…”

Section: Introductionmentioning

confidence: 73%

“…This difference in the number of men choosing for or against UL may be explained by the paradigm shift toward a more patient-centered care approach, in which all surgical options and their associated benefits and risks are presented and a definitive choice of treatment is made after extensive preoperative counseling and through shared decision-making (Elfering et al., 2017 ). It is thought that achieving the most suitable choice of gGAS for each individual will lead to the highest rates of satisfaction, and in the current situation of transgender care from a patient’s point of view, the need to void while standing appears to be much more variable with in our institution more men opting for gGAS without UL (de Rooij et al., 2021 ; Jacobsson et al., 2017 ).…”

Section: Discussionmentioning

confidence: 95%

“…The choice for or against UL is a shared decision-making process through weighing of personal motives and the benefits and risks of different treatment options (Elfering et al., 2017 ). Mainly, this choice is based on the consideration of complication risk and burden, against the importance of being able to void from the tip of the phallus (and being able to void while standing) (de Rooij et al., 2021 ). Close involvement and multidisciplinary counseling by a team of plastic surgeons, urologists, and medical psychologists is of added value in that choice (de Rooij et al., 2021 ).…”

Section: Introductionmentioning

confidence: 99%

“…Mainly, this choice is based on the consideration of complication risk and burden, against the importance of being able to void from the tip of the phallus (and being able to void while standing) (de Rooij et al., 2021 ). Close involvement and multidisciplinary counseling by a team of plastic surgeons, urologists, and medical psychologists is of added value in that choice (de Rooij et al., 2021 ). Additionally, in our institution, a decision aid is used to further highlight all benefits and risks of the treatment options available (Ozer et al., 2018 ).…”

Section: Introductionmentioning

confidence: 99%

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Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men

Rooij

Sluis

Ronkes

et al. 2022

International Journal of Transgender Health

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Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL ( p = 0.02). Reoperation was needed in 81% with versus 27% without UL ( p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0–6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.

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Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide

et al. 2023

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ImportanceGender-affirming care is a key clinical area that can benefit from implementation of patient-reported outcome measures (PROMs). Identifying barriers to and enablers of PROM implementation is needed to develop an evidence-based implementation strategy.ObjectiveTo identify (1) PROMs previously implemented for gender-affirming care and constructs measured, (2) how patients completed PROMs and how results were reported and used, and (3) barriers to and enablers of PROM implementation.Evidence ReviewIn this systematic review, PubMed, Embase, MEDLINE, PsycINFO, CINAHL, and Web of Science were searched from inception to October 25, 2021, and updated on December 16, 2022. Gray literature was searched through gray literature database, online search engine, and targeted website searching. Inclusion criteria were (1) original articles of (2) a formally developed PROM or ad hoc instrument administered for gender-affirming care to (3) patients accessing gender-affirming care. The Critical Appraisal Skills Programme tool was used to evaluate quality of included studies. This review was registered on PROSPERO (CRD42021233080).FindingsIn total, 286 studies were included, representing 85 395 transgender and nonbinary patients from more than 30 countries. A total of 205 different PROMs were used in gender-affirming care. No studies described using an implementation science theory, model, or framework to support PROM deployment. Key barriers to PROM implementation included issues with evidence strength and quality of the PROM, engaging participants, and PROM complexity. Key enablers of PROM implementation included using PROMs validated for gender-affirming care, implementing PROMs able to be deployed online or in person, implementing PROMs that are shorter and reduce patient burden, engaging key stakeholders and participants as part of developing an implementation plan, and organizational climate.Conclusions and RelevanceIn this systematic review of barriers to and enablers of PROM implementation in gender-affirming care, PROM implementation was inconsistent and did not follow evidence-based approaches in implementation science. There was also a lack of patient input in creating implementation strategies, suggesting a need for patient-centered approaches to PROM implementation. Frameworks created from these results can be used to develop evidence-based PROM implementation initiatives for gender-affirming care and have potential generalizability for other clinical areas interested in implementing PROMs.

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Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men

Cited by 18 publications

References 18 publications

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men

Implementation of Patient-Reported Outcome Measures for Gender-Affirming Care Worldwide

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