All right, so I think we can get started. Welcome to the AUG's webinar series. I'm Dr. Lauren Stewart, and I'll be moderating today's webinar. The title for today's webinar is Gender Affirmation Surgery, and Dr. Cecile Ferrando is presenting. Dr. Ferrando is going to present for 45 minutes, and then we'll have the last 15 minutes for question and answer period. During the webinar, you guys can feel free to type in questions in the Q&A or chat box. Dr. Cecile Ferrando is a board-certified female pelvic medicine and reconstructive surgery specialist at the Cleveland Clinic. She completed her OB-GYN residency training at the Combined Brigham and Women's Mass General Hospital Training Program and did her fellowship in FPMRS at Cleveland Clinic. She's been in practice for seven years. She has an academic appointment at Case Western Reserve University School of Medicine and is an active faculty member for the Cleveland Clinic Lerner College of Medicine. Dr. Ferrando was one of the founders of Cleveland Clinic's Transgender Surgery and Medicine Program, housed in their LGBT center. She's currently the director of surgical services there. Her clinical practice focuses on pelvic reconstruction, including gender affirmation surgery. She's performed over 300 gender affirmation surgeries in the last five years, and she's also the fellowship director for Cleveland Clinic's FPMRS fellowship, as well as the program director for the Transgender Surgery Fellowship. Dr. Ferrando's research is focused on the outcomes of pelvic reconstructive surgery, and she's published over 80 peer-reviewed papers and has authored 12 textbook chapters. She's the editor of the textbook Comprehensive Care of the Transgender Patient. She's committed to expanding research in the area of transgender health, and she continues to mentor students and trainees in this area. Before we begin, I'd like to just review some housekeeping items. This webinar is being recorded and live-streamed. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions and use the chat feature if you have any tech issues. The AUG staff will be monitoring the chat and can assist you. All right, Dr. Ferrando, I think you can take it away. Well, thanks, everybody, for having me. Lauren, thank you for that introduction. It's a pleasure to be here and to do this webinar. I can't see any attendees, but hello and good evening to everybody. So I'm going to do this talk on updates looking at gender affirmation surgery specifically for transfeminine patients. Transmasculine surgery is its own lecture, and I'm going to just be providing some background but also a few updates towards the end in terms of how we're innovating the field and what we're doing next. These are my disclosures. I do get authorship royalties specific to this topic from up to date. And then I guess one of the other disclosures I should have is that if you've heard me lecture in the last three to four weeks, I'm really sorry that this might be a little bit of a repeat of what you've heard. There haven't been any new updates in the last month, and I've given quite a few talks recently. But it's nice to have you here again with me if you're seeing a talk for the second or third time this month. So to give you a sense of what we're doing in Cleveland Clinic, just to give you a little bit of background of our center, for those of you currently training or practicing in a center that has a multidisciplinary practice for transgender care, I'm guessing what we are doing in Cleveland reflects what's happening in your institution. We opened our doors to our transgender patients in 2016. Our transgender surgery and medicine program falls under the purview of our Center for LGBT Care. We started with about 80 to 90 patients, and within just a few years have seen up to about 2,300 transmasculine and feminine patients to date. These are our numbers as of the end of 2021. We offer comprehensive care. Primary and preventative health services is actually our biggest service line. We have some specialty care that's meant specifically for LGBTQ plus patients. And then a handful of us providers do transition-specific care for transgender patients seeking transition services. In our own center, about one in three of our patients undergo some sort of gender-affirming surgery. We've performed about 800 gender-affirming procedures over the last five plus years. We offer a comprehensive surgical experience. So for a long time, we've been doing what we call top surgery, which is feminizing augmentation and mastectomy. Our plastic and reconstructive surgeons perform those surgeries. Facial feminization surgery is also performed by our craniofacial reconstructive surgeons. And we offer tracheal and laryngeal surgery offered by our ENT surgeons. And then our surgeons performing genital surgery is a bit of a mix. I am, as Lauren had explained, urogyne and fpamorous by training and do feminizing genitoplasty for patients. And a combination of us, including myself, urology and plastic surgery, just started our masculinizing genital program. For anybody who's curious, in the United States, about 9 out of 10 surgeries are covered by insurance. So most of our patients are getting the care that they need, either through their government subsidized care plans or through their employers or private insurance, which is actually a pretty phenomenal thing. I think a little bit of the history of gender-affirming care, we've been talking so much about it. And the real question is, why has this become so sensationalized? And why wasn't this as prevalent in this medical community for a really long time? It seems that in the last five to seven years, we're doing webinars, we're teaching, we're writing about this topic. There's been this real big stand and move in the medical community to add this in the types of services that we provide. Gender affirmation surgery has been around for a really long time. A lot of publications exist in the archives from the early 1950s and 60s and 70s. This is a fun picture that I always like to show in a lot of these talks of Dr. Georges Barou, who was a French surgeon. He had a clinic called La Clinique du Parc in Casablanca, where he operated on over 3,000 trans women who were seeking a genitoplasty surgery back then. And he was actually one of the first to publish on his outcomes. He published about his complications, cosmetic outcomes. And so he is really considered one of the fathers of gender-affirming surgery when it comes to somebody who shared his work. There are certainly a handful of other surgeons who are also very prominent during that time. In the United States in the 1970s, prominent academic centers like Johns Hopkins and Stanford started their own what they call gender centers with surgeons who were willing and able to perform some of these surgeries. Unfortunately, in the late 1970s, early 1980s, there were several white papers published looking at the regret of gender-affirming surgery. Back then, it was called sex reassignment surgery. That really ended up creating this movement that led to a moratorium on the surgical care of these patients and academics. And so a lot of in the 1980s and 90s and even the early 2000s, a lot of this was in the private sector. This is why some of us never even learned about this in medical school or talked about transgender care. And we're only talking about 20 years ago. Patients were having to pay for their services. Everything was in private practice. And there really weren't many academic surgeons performing these surgeries. And certainly, they weren't covered by insurance. During the Obama administration, with the advent of Obamacare and the Affordable Care Act, a lot of things changed. The Department of Health and Human Services in 2014 put out a mandate essentially saying that health care for trans individuals and all LGBTQ plus individuals should be covered. And there was a huge movement to cover health care services for this patient population, including surgery. I've shown this before in several talks. But I remember seeing this on Time magazine. In 2014, I was a fellow. And I was getting ready to start my practice in 2015 at Cleveland Clinic with the intention of starting a gender affirming surgical program. And there were only a few of us in academics. And 2014 is only about seven, eight years ago, wanting to do this. And I remember seeing this. And you can't see it on the title. But it says transgender care, the next civil rights frontier, which was really interesting. We've taken a lot of steps back. We're regressing in how we're actually taking care of sex and gender minority patients. There's a lot of fear in terms of what's going to happen in the future. But we, as academicians interested in this topic, have really been riding the social and political wave that's happened in the last 10 years. And we've been really given a lot of leeway and ability to care for this patient population, which has really been able to advance the field. Because as there was this political shift and the social shift in demanding basic services for trans people, a lot of academic centers started opening up multidisciplinary care teams for these patients. And these are just examples of a few of the prominent ones that really paved the way for other centers to have multidisciplinary care teams. And so we've been able to bring trans health back into academics, which has been fantastic for the surgical innovation. And I'm going to spend time at the end of this webinar talking about where we are today and what we're working on to help better the care that we're actually rendering to patients right now. We built this program in 2016. And now we've tenfold increased the number of providers. This is a slide I always show when I explain how do you actually create a transgender surgical program and a multidisciplinary program. You start out with the basics and that left-hand corner of what you need to take care of trans patients. You eventually build your program to that green egg on the right-hand side of the screen. Those are all the things that you really need to have a comprehensive program. And in the middle is all the things and all the work that you need to do in order to get institutional support and all of the things that you need to achieve in order to have a successful program. And all of these things are very achievable as long as there are stakeholders who are interested in actually making them happen. So I think that was a really, I somehow, I'm keeping clock. Also in seven minutes was able to talk about the history of gender affirmation surgery and how to build a successful program. Those two things are lectures within themselves. But I wanted to give a brief background. So I'm going to move now to the surgical aspect of gender affirmation, what I do in my practice. I've been saying this now for the last five, six, seven years that this type of surgery really belongs in FPRMS. Those of us who are training in it or have trained in it are excellent at it. And I hope to be able to propagate that thought process. So feminizing genital surgery, for those of you who are in the know, is often called vaginoplasty. So patients will often call and say, I'm looking for vaginoplasty surgery for gender affirmation. So this is trans-feminine patients, so individuals assigned male at birth who identify as female. Vaginoplasty is really a misnomer. It's not really a vaginoplasty in terms of what the whole procedure is. Vaginoplasty is really only one component of the surgery. But it's what is just commonly known by patients. And it's what surgeons refer to the surgery as. And it's even in the literature published as vaginoplasty. So the technique that's most commonly used is the penile inversion vaginoplasty. It is what has been published on the most. There are other alternative ways of doing the surgery, such as intestinal vaginoplasty, using bowel to create the neovagina. But the most common procedure is actually the penile inversion vaginoplasty. And we're not actually doing a penile inversion. We're just using a lot of the skin from the penile structure to be able to do the procedure. And I'll show you what I mean by that in a little bit. But the surgery entails an orchiectomy if a patient hasn't already had one preceding the surgery. Deconstruction of the penile anatomy with preservation of the neurovascular components. There's a vulvoplasty labioplasty, which is essentially reconstruction using the penile skin in order to create the important vulvar structures that are important for not just function, but also cosmesis and appearance. For creation of the female urethra from the male urethra, which is a urethroplasty. And then also using portions of the urethra to create the female vestibule. Vaginoplasty with skin grafting. So we essentially take genital or extra genital, depending upon how much skin is available from the patient. And we line a cavity that's created surgically with the skin graft. It's very similar to the concept of the McIndoe. So for those of you who learn the McIndoe or have learned the McIndoe, the concept is exactly the same. And then it's important to note that some patients choose to have a vulvoplasty only meaning that they don't have a vaginal canal. And again, this is where this concept of this misnomer of vaginoplasty comes up. So patients can have either what we call zero depth or no depth procedure. So what we do is we create the vulva and we create a very small sort of dimple indentation for the introitus so that from a cosmetic perspective, it looks like the patient has an introital opening and vagina, but there is actually no depth to it. It's almost like they've had a copolysis. It's preferable to do it that way. If you don't do that actual extra part, the patients will just look like they have the vulva, but then it looks like they almost have like a perineal urethral opening, urostomy. If you don't actually do this sort of pseudo introitus. So that's an important part of that procedure. And I'll talk a little bit about considerations for zero depth. It's either recommended by the surgical team or patients request it specifically. So at Cleveland Clinic, we have specific vaginoplasty guidelines. So what are the things patients need to do in order to be able to have surgery? So there is a professional organization called the World Professional Association for Transgender Health. It is an international society that is made up of many different types of disciplines. It's super interesting. Most of us all belong, you know, we belong to OGGS and most of us are urologists or gynecologists who have female urologic or reconstructive surgery training. If you're an oncologist, you belong to SGO, et cetera. This society is really interesting because it's made up of medical doctors, surgical doctors, mental health specialists, not just physicians. And so it's a lot of different types of people coming together to share ideas about the care of transgender patients. And what's important is that WPATH has a framework or criteria that we use to assess patients for readiness from surgery. Some of those assessments include having letters of referral from a mental health care provider who recommends surgery for patients. And that's an important part of the process. Health insurance has actually now created guidelines to deny or accept cases and to cover them based upon the WPATH criteria. So they are actually really important. But at Cleveland Clinic, our patients need to meet these criteria. They also have to have good continuity of care with a mental health care provider who has to have an appointment with them following surgery. We document their family and or friend support that's going to be in Cleveland with us for the week that they're having surgery. Patients can't smoke. There's a BMI criteria. Patients have to have good management of their HIV if they're HIV positive. We have a hemoglobin A1C requirements. And then we give considerations for a history of prostatic disease. So patients who have a history of prostate cancer and have had radiation or prostatectomy have a tremendous amount of fibrosis in the area where we would be creating the vagina and their risk of GU or rectal injury is significantly high. And in order to avoid a terrible fistula problem following a potential injury, we recommend those patients not have an actual, what we call full depth vaginoplasty in those cases. We lower estrogen dosing perioperatively and patients also need to have genital hair removal in order to have a vaginoplasty procedure if they're having the vaginal canal only because we don't want to line the canal with a hair bearing skin graft that hasn't been where the follicles haven't been either cauterized and or the hairs removed. So those are our criteria. The question people ask is about how long all this takes. So minimum it's a year long process. Per WPATH guidelines, patients are recommended to be on hormone management for at least 12 months leading up to surgery. So in general, we tell patients that the fastest they really can start transition and end up with surgery is about 12 months. I would say most patients with logistics and finding a surgeon, it's often a little bit more than 12 months and can be several years for some patients depending upon their resources. So the procedure itself, I'm obviously biased. It's what I spend half of my time doing in my practice and I'm a bit of a nerd. And so I love the concept of the surgery. Again, some of you have either seen this or seen the video that I'm going to show you in a little bit but the beauty of the surgery really is that it's we're repurposing homologous embryologic structures. So what would have been female is turned into the female parts from the male parts. And so there's a bit of a beauty and like there's like a bit of a poetic theme when it comes to how the surgery is done which I hope some of you who are watching this can appreciate. The patients certainly like to hear about it in that we're really just reusing what became male and to make it female and knowing that it would have been female had there been two X chromosomes is somewhat of a sort of a comforting notion or concept. So I'm gonna show you a video that one of my fellows, she may even be on this webinar because I know she likes to follow along on this stuff, Livvy Chang created for me a couple of years ago when she was either a first or second year fellow. It was shown at Augs a few years ago. But it gives you a sense of this concept of the homologous embryologic structures. It gives you a sense of how we do the surgery. And I hope that some of you when you're watching this can say, oh yeah, as an FPMS provider with some formal training, this definitely could be in my or our wheelhouse. The objective of this video is to review the development of the external genitalia and to describe our technique for performing male to female vaginalplasty for the transgender woman. Our technique uses homologous embryologic structures of the external genitalia to retain sensation of the neoclitoris and function of the neovestibule. The external genitalia of both sexes originate from the proliferation of steroidogenic mesoderm around the cloacal membrane as a pair of cloacal folds. Interior to the cloacal membrane, the folds meet to create the genital tubercle flanked by genital folds and genital swellings. These structures remain undifferentiated up to 12 weeks. In males, the genital tubercle elongates under the influence of dihydrotestosterone to develop the corpus cavernosum, corpus spongiosum body and glands of the penis. In females, it becomes the body and glands of the clitoris. The genital folds become the ventral aspect of the penis and the penile raphe in males. In females, they become the labia minora. In males, the genital swellings become the scrotum and scrotal raphe. In females, the genital swellings become the labia majora and mons pubis. The entire length of the male urethra is made from the endodermal lining of the urogenital sinus. In females, the urogenital sinus remains open as the vestibule. The procedure begins by marking and harvesting the scrotal flap. The flap is outlined superiorly by the base of the penile shaft, laterally by the edges of the scrotum, and inferiorly by the perineum roughly five centimeters above the anus. Once the flap is incised with a scalpel, the flap is grasped with allous clamps and it is removed from the underlying subcutaneous tissue using electrosurgery. The flap is handed off and kept moist with saline-soaked sponges to be used later to create the neovagina. To perform a bilateral orchiectomy, the testicle is grasped with a towel clamp and placed on traction. The spermatic cord is skeletonized. The genital vessels are then double clamped and sutured ligated at the level of the external inguinal ring to prevent a palpable bulge in the groin. The inguinal ring is closed with permanent suture to prevent small bowel herniation. This is performed bilaterally. Excess subcutaneous tissue is removed and the penis is skeletonized down to Buck's fascia. Next, a circumferential incision is made proximal to the gland's penis. The penile epithelium is degloved, leaving a penile skin flap which will be used to create the distal portion of the neovagina. The suspensory ligament of the penis is released. A space is created for the neovagina between the rectum and the prostatic urethra. A natural avascular plane exists proximal to denonvillus fascia which is found between the prostate and the rectum. A transverse incision is made at the level of the perineum and the central perineal tendon is transected below the bulbous urethra. To avoid injury to the rectum, one finger is placed inside the rectum during the dissection to ensure that the proper space is being dissected. Chemostasis is achieved as the dissection progresses. This is especially important when the prostate and its capsule are encountered as this is a very vascular space. Once dissection past the prostatic urethra is achieved, a combination of sharp and blunt dissection is used until a depth of 15 centimeters is obtained, which is usually where the vesicoperitoneal fold is encountered. Once the length and caliber of the neovagina is determined to be adequate, meticulous hemostasis is achieved and temporary packing is placed. The spongiosum and underlying urethra are separated from the carpus cavernosum. Often spongiosum is dissected off the urethra to avoid leaving a significant amount of erectile tissue on the urethra, which can be bothersome to some patients. Next, the clitoral flap is created by separating the dorsal neurovascular structures within the tunica abuginea sheath from the underlying cavernosal tissue. This is done by demarcating the dorsal structures with alice clamps and then using a penrose strain to further the dissection. Distally, the neoclitoris is marked out on the glans penis in the shape of a triangle. The clitoral flap is then separated completely from its underlying structures. The cura of the corpus cavernosa are suture ligated and then the cavernosa tissue is excised. These tissues can be very vascular and a vessel sealing device is helpful for part of this procedure. Next, the reconstructive portion of the procedure is undertaken. The clitoral flap is folded on itself and the neoclitoris is at the level of the insertion of the adductor longus tendon in the groin creases, which is similar to where their transclitoral line exists in a natal female. The flap is secured to the underlying fascia with placement of absorbable sutures on the lateral edges of the clitoris to create a naturally shaped clitoris. While unsetting this flap, care must be taken to avoid kinking its blood supply as this could lead to necrosis of the neoclitoris. The distal urethra and remaining corpus spongiosum are incised in the midline. The incision is carried down to the level of the pubic bone and the urethra is then spatulated and secured to the underlying fascia. The neourethral meatus should be flush against the bony pelvis. The remaining urethral flap is trimmed and then secured, creating the neovestibule, a mucosal surface between the urethral meatus and the neoclitoris. A small incision is made on the neovestibule to expose the neoclitoris. Attention is turned to the scrotal flap. The subcutaneous tissue and dartus muscle is removed sharply, creating a split thickness skin graft. The flap is sewn onto a vaginal stent, creating a neovaginal tube. Electrosurgical coagulation of the hair follicles is performed. The stent is then passed through the penile skin flap, which is then anastomosed to the scrotal flap with sutures. The vaginal tube and stent are placed into the neovaginal cavity. Mattress sutures are placed at the neoenteritis to take tension off the entroidal incision. The neovagina is tightly packed. A vertical incision is made through the anterior vulvar flap, exposing the neoclitoris, neovestibule, and neourethral meatus. The edges of the flap are secured. Labia minora and a clitoral hood are created. We perform male to female vaginoplasty, accounting for homologous embryologic structures of the male and female external genitalia. With our technique, the neoclitoris is created from the glands of the penis, which developed from the genital tubercle and would otherwise have developed into a clitoris in a biologic female. This ensures a sensate neoclitoris. The neovestibule in our technique is created from the urethra. Both the female vestibule and the male urethra develop from the endodermal lining of the urogenital sinus. The result is a functional neovestibule that provides moisture to the neovagina. Our technique results in a sensate neoclitoris and functional neovestibule and neovagina. Vaginoplasty remains an important part of the affirmation process for some transgender women. Okay, so that's how the procedure is performed. It's a bit of an older video, but in general the technique is the same. I sort of, I do the vulva a little bit differently now, but outcomes good are very good and they vary. And so this is what we show patients. When patients come, one of the biggest things they want to know is what is it going to look like? And this is a reconstructive surgery concept that as urogynecologists, we're not really used to showing before and after pictures and showing patients how others have healed and what to expect. But this is part of the practice and that patients will actually choose their surgeon based upon some of the photos that they show them. So again, it's a little bit strange for us, but people who do reconstructive surgery are really used to this. So just showing outcomes, these are all patients who've had surgery in our center and pretty favorable cosmetic, functional outcomes. Patients are sexually functional once they've healed, report good sensation. But as you can see, everybody sort of varies. But overall, feminized and structures that are really well-defined and certainly look like female genitalia. And so this is what we aim to do for our patients. And you can tell the scarring is a little bit different depending upon how patients heal, how much hair they've removed preoperatively, et cetera. So patients dilate about three times a day for the first 12 weeks. They dilate twice a day for the next three months. And then again, daily, usually for the rest of their lives or a regimen that is good enough to keep things open. This is a video of a patient who's dilating during on post-op day seven. When we teach them how to dilate, you can sort of see that dilator is quite large, but this is essentially what it looks like. And patients are usually able to dilate quite easily as long as the canal has been constructed properly. So that's what that looks like on day seven. So patients return to work and daily activities at six weeks. Some need up to 12 weeks. There's usually complete sensation of the flaps by the end of the 12 week healing period, although there can be some patchy neuropathy up to 12 months. We allow patients to either start or resume sexual activity at 12 weeks. With good dilation compliance, patients can maintain a full depth vagina of 12 to 15 centimeters, which is a little bit obviously longer than the physiologic anatomic natal vagina. But we do sort of add extra length in order to account for contracture of the skin graft in case that happens. You don't want to create a 10 or 12 centimeter vagina and end up with a 7 to 9 centimeter vagina. So the majority of patients are able to report the ability to orgasm by six months. And that's something that we've been able to assess with our patients. We ask all of our patients at the six month visit if they've been able to do this. So in terms of complications, I will say complications is an entire lecture in itself and how to manage them and how to approach them. In the box on the right is the list of the most common complications. So there's vaginal bleeding and pain, incision, dehiscence, abnormal urinary stream, introidal stenosis. That stenosis happens where the anastomosis between the penile tube and the scrotal flap are sewn together often. And it often ends up at the introitus, which is sort of the point where there's tension. And then cosmetic concerns. These are the most common. They're all very easily fixable with very minor either office intervention or revision surgery, which is usually outpatient and doesn't really require a lot of downtime for the patient. The last three complications in each of these complications can have its own lecture, are more severe and require a lot of intervention. So there can be complete flap necrosis. This certainly has happened at our center. Vaginal stenosis specifically in patients who don't dilate and then fistula. And so GU specifically urethrovaginal fistulas, vesicovaginal are really rare, but and urethrovaginal also rare, but a little bit more common than vesico. And then rectovaginal fistula also uncommon. If you look at the data in large databases, the quoted prevalence is about 1%. I would say that at our center, it's much lower than that. We do believe that in the hands of an experienced surgeon, these major complications are super rare, but the minor ones in blue are really common. I would say that about one in 20 patients have a quote complication that requires some sort of minor revision surgery. And about one in five have something that requires something in the office. And then we think based upon looking at our data, that the threshold to avoid complications is probably about 50 cases, which is when we designed our fellowship. And I'm going to talk about that in a second. We really felt on the threshold should be about 50 vaginoplasty cases during a training period in order to become really good at avoiding some of those complications. So what's next? So this is really, again, I feel like every topic I'm hitting is a lecture in itself, but, and this too is its own free standing topic, but what's next? What are the updates? Where are we going with this field? We've gotten to a point where there are a, I don't want to say a significant number of surgeons performing these surgeries, and there certainly aren't enough, but there are so many more than there used to be in patients really have better, much better access to care. We've perfected the way that primary vaginoplasty is done. I think surgeons who do this often enough do a really good job at achieving good cosmetic outcomes. And, but that's in the ideal patient. And clearly not every patient is ideal. So there are certainly ways for us to innovate and do better for the patient. That's not the standard patient. So first one of the big innovations is doing training providers in doing these surgeries and basically expanding our network. And I've worked in the last few years to try to expand our network in gynecology. For too many years, it was really plastic surgeons and urologists only, and it didn't exist in gynecology with only a couple of people, two gynecologists in academic practice, and then myself. And so we've trained fellows over the last two years. We had Kavitha Mishra come from Stanford as a urogynecologist and train. Frances Grimstad is a PAG specialist at Boston Children's who's currently in the program. And we're excited to welcome Renee Rolston, who's a urogynecologist will be joining us this coming year to learn and then to go off and hopefully train other individuals. And what I'm hoping is to create the small army of GYN trained surgeons who are performing these surgeries in the United States and who will hopefully do research, study outcomes, and collaborate on the innovations that are happening. So that in itself has been an innovation is really training more people to do these surgeries who are competent, who are getting a full year of a really intensive experience. And so creating the fellowship, it was conceptualized in 2018. We based it on the same way we would base any fellowship that's ACGME approved. The goals are the same. There are milestones. There's a research component. There's competencies. So it's a real formalized program that is meant to have an evolution over a 12-month period. I mentioned this before, the majority of surgeons performing this have historically been PRS surgeons. Urologists entered the picture also about 10 years ago. And urologists were like uniquely positioned to be doing these geo-reconstructive surgeries. But then sort of the onus when creating a gynecology-based program was really to figure out how do you translate laparoscopic hysterectomies and cesarean sections to sort of doing these procedures that really need to focus on the mobilization of flaps and preparation of skin grafts, preserving blood supply, learning how to do tension-free closures, balancing cosmetic results with function. And that's been the really big challenge, but I think we've been doing it successfully, especially with the help of our plastic surgeons who helped design the program that we created for our fellows. So I envision I envision the future in gynecology as it relates to gender-affirming care. Because honestly, GYNs and GU surgeons are really uniquely qualified. This sort of, this got lost on me a little when I was worrying about choosing candidates to join us and to do these surgeries. But I soon learned through my fellows and through the residents and urogynecology fellows who currently work with me that the skillset that we learn as OBGYNs in residency, and for those of us who choose to go into fellowship, we make us actually super uniquely positioned to be really good surgical care providers to this patient population. So what we're working on now as a community is the innovations for challenging clinical scenarios. So what are those? So certainly taking care of kids has become a big challenge for us. These are pictures of two trans young women. Both patients have had surgery with me. They've given me permission to post their pictures for educational purposes. These are patients who most of them undergo puberty blockade at the age of 10, 11, and 12. They have very little genital skin and growth of some of the structures needed to create the female genitals that we're aiming to create. And so we're left with these sort of surgical challenges. And how do we achieve good cosmetic results that are also functional without actually having big wound complications or vascular supply issues? And so we're really trying to innovate how we do these procedures because these are individuals who need to live decades and decades, right? Some of them are presenting for surgery at age 18. They have their whole lives ahead of them. And they're also not positioned to be having to undergo major complication-related surgeries to manage things like wound issues. And so we really have to do our best to take care of this patient population. And these patients are similar to the patients who need revision surgery. So there certainly are patients who have vaginal stenosis, women who've had fistulas. I'm sure some of the uroguide specialists in this webinar have seen trans women who have rectoneal vaginal fistulas who weren't able to dilate while those fistulas were closing or were being surgically repaired who end up with vaginal stenosis. There are patients who just neglected to dilate or could not dilate because of life circumstances who have vaginal stenosis. Those are patients who need what we call redo vaginoplasties. And what are really our options for those patients? So one of the innovations, and I'll show a video of this, but again, I think is 100% within the gynecologist's wheelhouse, is doing neovaginal surgery. And one option is to employ either conventional laparoscopy or robotics to start modifying what we know about Davidoff or peritoneal pull-through procedures to redo the neovagina in trans individuals. And this wasn't being done until a few years ago when a couple of the centers, including NYU, started like thinking outside of the box. Some of the reconstructive urologists were thinking about the ways that they approach certain challenging cases in their own field. And so modifications on this Davidoff procedure started being published, and we'll show you an example of how this procedure is done. But certainly it doesn't require a team that does primary vaginoplasty to be able to do this. It would be really great to have urogynecologic centers be centers of referral for patients who need management of redo vaginoplasties or complications that happened in their primary surgeries. And then regenerative medicine is going to be, it has been an important field, but it's going to play an important role in how we actually create neovaginal tissue for vaginal eugenicists, but also trans women needing either extra tissue, different tissue to do the vaginal canal. And I know there are people in our field who are now leading and paving the way with some of their grants and some of their funding, and I've been in touch with these individuals. But I think in the next 10 years, we're going to see some amazing work as it relates to the way we create vaginal tissue and how we actually use it in patients who need neovaginal surgery. And this will translate to not just transgender patients, but all of our female patients needing that kind of work. So I'm going to show you a video. My fellow James Ross put this together, and just to give you a sense of what we mean by this Davidoff procedure. And then I think I've been able to fit everything I wanted to talk about in this talk tonight, and I'll take some questions. So let's see if this one will play. Great, the female external genitalia, and in some patients, construction of a skin grafted vaginal canal between the rectum and the prosthetic urethra and bladder. This illustration depicts the dissection that is usually performed in this anatomic space and the inverted penile skin that is often anastomosed to a scrotal skin graft in order to line the dissected cavity. Most operatively, patients are required to perform regular vaginal dilation to avoid graft contracture and eventual vaginal stenosis. Vaginal stenosis occurs in patients who cannot dilate or fail to comply with the dilation plan post-operatively. We present a case of a 54-year-old transgender woman who presented with vaginal stenosis. She underwent her primary surgery in May, 2017, and underwent a penile inversion vaginoplasty, which was complicated by post-operative bleeding, requiring two re-operations to control the bleeding. She underwent re-operation for management of granulation tissue and was told she had graft necrosis in the neovagina. In February, 2019, she underwent a perineal neovagina revision with skin grafting. She had subsequent difficulty with dilation due to pain and bleeding. On examination, she had normal vulvar anatomy and was noted to have a 1.5-centimeter scarred neovagina with hyperkeratinization and friable granulation tissue. She desired another revision surgery to attempt creation of a functional neovagina. The options for revision include transperineal revision with skin grafting, which she had already undergone and was not recommended for her case. She was also a candidate for intestinal vaginoplasty and peritoneal pull-through vaginoplasty. After reviewing the risks and benefits of each, she opted to have a peritoneal vaginoplasty, also commonly referred to as a Davidoff procedure. Based on Surge's skillset and experience, the decision was made to perform the surgery in a minimally invasive fashion using robotic assistance. Once the points are placed, the robot is docked and the anatomy is inspected and restored. The posterior peritoneum is then incised. The vas deferens and the seminal vesicles are identified and used as landmarks for this dissection. Dissection is carried down inferior to these structures and the plane is developed towards denonvilliers fascia. The fascia is incised and the posterior plane is further developed until the scarred neovagina is encountered. This dissection can be challenging as there can be significant scarring from the previous neovaginal surgery and the tissue can be friable. To identify the neovaginal apex, a lighted cystoscope is placed in the canal. This is used as a guide to continue the dissection. The apex of the vagina is opened sharply and then incised laterally until adequate width and depth are sufficient. When passage of a vaginal dilator or stent is possible, the caliber is determined to be adequate. Peritoneum from the posterior dissection is then pulled through to the vaginal incision and is sutured to the posterior cuff using 2-O capresin. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. This is followed by the incision of the peritoneal incision and the incision of the peritoneal incision. The same thing is performed along the anterior neovaginal cuff. This is done until there is approximation of the peritoneum to the vaginal cuff circumferentially. This is done until there is approximation of the peritoneum to the vaginal cuff circumferentially. This is done until there is approximation of the peritoneum to the vaginal cuff circumferentially. The peritoneal flaps are then created. First, the vesicoperitoneal flap is made. The lateral peritoneal flaps are then created. The lateral peritoneal flaps are then created. In this case, we start on the patient's left. The ureter is identified and visualized during the entire dissection as it is carried down caudally. The same procedure is done on the right side, with care taken to visualize the large vasculature and the ureter on that side as the flap is raised. After the dissection is complete, the flaps are sutured together to create a peritoneal pouch that will serve as the neovagina. to create a peritoneal pouch that will serve as the neovagina. to create a peritoneal pouch that will serve as the neovagina. Closure is done using a 2-0 V-lock suture. Closure is done using a 2-0 V-lock suture. Closure is done using a 2-0 V-lock suture. The stent is placed to ensure that the caliber and depth is appropriate. The stent is placed to ensure that the caliber and depth is appropriate. At the end of the procedure, At the end of the procedure, At the end of the procedure, At the end of the procedure, the neovagina is packed under direct visualization. The patient will be required to perform regular vaginal dilation postoperatively to maintain neovaginal length, but also to ensure that the caliber of the neovagina, where the peritonea meets the vaginal opening, remains adequate. We also perform cystoscopy at the end of the procedure We also perform cystoscopy at the end of the procedure to ensure ureteral patency exhibited by bilateral efflux. to ensure ureteral patency exhibited by bilateral efflux. Again, just a modification of the traditional Davidoff, which for some practices has fallen by the wayside, others still perform it for individuals with vaginal agenesis, or patients who have had radiation surgery, or patients who have had radiation, so we are applying these gynecologic reconstructive concepts to our transfeminine patients as well. This is becoming a popular way to do the neovagina, or a portion of the neovagina for some of our puberty-blocked adolescents who don't have a lot of skin to invert so we may keep the scrotum to work on the vulva. It is definitely an option and continuing to be innovated on and certainly will continue to evolve over time. In the interest of time, I think I was able to fit all of that in 50 minutes. I would be happy to take some questions if there are any in the Q&A. I would be happy to take some questions if there are any in the Q&A. Perfect. Thank you so much, Dr. Ferrando. We have about 10 minutes, like you said, for questions. Anyone who has questions can feel free to put them in the Q&A. We have a couple waiting for you. Can you describe the urethral reconstruction that is done during the penile inversion vaginoplasty? There is not much actual reconstruction. The urethra, all the way to the level of the pubic bone, they said during a vaginoplasty, not during a masculinizing procedure. They didn't actually specify, but the question was submitted during the video presentation . The urethra and the overlying spongiosus is completely separated from the cavernosa. The spongiosus is excised. What is left is the urethra. The ventral aspect of the urethra is essentially opened, either with cold or with cautery, and the urethra is opened right distal to the sphincter mechanism of the urethra. Continence is maintained in these procedures. Once you open right distal to the bulbous urethra, the urethra is spatulated and sutured in place. You end up with a flushed urethral meatus. The dorsal portion of the urethra is flipped upwards and used to create the vestibule. It has a pink mucosal tissue between the clitoris and the urethral meatus, which mimics the female vestibule. Awesome. Another question we had is , do you have any data about post-op infection right after the vaginoplasty? I would say we have looked at this in our own cohort. We published on this a couple of years ago. Depending on whether you ask me or my nurse practitioner, I would say our real infection rate is 0%. We have one patient who had a wound infection following the surgery. It is incredibly rare. It is either 0% or 0.3%. That is incredible. Another question we had is pertaining to the more bread and butter complaints in trans women. Have you encountered neovaginal prolapse or stress incontinence in these patients who have had penile inversion vaginoplasty? What considerations are there for management? How are you managing that? There are very rare instances where there is a neovaginal prolapse as a consequence of vaginoplasty surgery. The sphincter mechanism is maintained during the surgery. It is unusual to disturb that and cause that kind of problem. Male stress incontinence is a thing. There are male slings placed by reconstructive urologists. It requires consultation with somebody who does these male slings because they are anchored differently. The bony part of the pelvis is different. Patients are candidates for bulking procedures. This is not based on a lot of evidence. I would start with a bulking procedure. You can do your dynamics on patients and ensure it is stress incontinence. There is a possibility that they don't have a urethroneovaginal fistula and are leaking from the vagina. If you are confident it is urethral leaking and coming from poor supports to the urethra, bulking is a possibility. We have colleagues who know how to do slings in those patients. Prolapse is a different thing. There are a lot of people in our field who have reported seeing one patient with prolapse. It is not really prolapse. I will specify two things. There are patients with the penile inversion and vaginoplasty. They don't get prolapse because there are poor supports like level 2 and level 1 supports to the actual tissues. There is a risk of skin graft meaning it will pop out. That often happens if the cavity wasn't created long enough or there was too much skin graft to cavity ratio. Eventually there is no fibrosis and the skin graft doesn't take. There are a couple of options. Removing the averted skin and redoing the skin graft. You can do sacrocopalpexy using fascial or cadaveric grafting. If anybody has ever felt these neovaginas, they are quite thin so doing a mesh graft is precarious. You can do a sacrospinous suspension but the male pelvis is different so you have to know your anatomy and go through skin graft . In women who have had intestinal vaginoplasty, there is a little bit more prolapse and it is almost like having a rectal prolapse and those patients do well with a trans neovaginal pexy like a modified Delorme or Altmyer procedure. Interesting. Another comment is a fantastic presentation. We have a lot of questions about neovaginal maintenance, things like douching, screening, routine health maintenance, screening after vaginoplasty and things like that. Our patients are given a douche regimen. It is safe to have them douche in this case. They are neovaginal skin grafts. Starting at about six weeks sooner if the patient has a baby soap, generic baby soap, we have them dilute a few drops in warm water and douche with that. The other option is you can dilute a little bit of vinegar inside of a warm water douche prep and douche with that. There is a degree of skin sloughing that can happen so it can create odor. If the patient has hair removal, they can get a lot of discharge. Hair removal either with cautery in the office or application of a hair removal ointment or cream on a tampon or just an applicator can sometimes get rid of hair. If patients have chronic discharge, it is probably that they may have, if they are within a year of surgery, they may have a lot of discharge. That is the most common stuff that a gynecology practice might see. It is not unusual to have somebody with discharge. There have been small studies of the microbiome of the neovagina. It is not similar to the natal female which I don't think should surprise you. There is another question about regret and if you have studied that in your patient population. It is incredibly rare. We are actually in the midst of submitting a very large grant with one of the aims looking at qualitative aspects of the surgical experience. There are small data that show that when patients do feel regret, it is not about transitioning or having had surgery. It is often about either the time in their life when they chose to have surgery or the surgeon or it is usually associated with complications. It is a little muddled there but the concept of regret and everything that we have seen in the last decade, late 1970s and early 80s that led to people not doing the surgeries anymore, nobody thinks that regret is a major issue. It is also because we have improved how we get patients ready for surgery. The mental health component and the support that we require for our patients is much different than 40 or 50 years ago. It is not that we don't want to do surgery. We do our due diligence because we want to do right by this patient population. Thank you so much. I think we are out of time at this point. On behalf of AUGS, I would like to thank you, Dr. Farando and everyone for joining us today. Thank you for having me. Have a good night, everyone.

gender affirmation surgery

transfeminine patients

penile inversion vaginoplasty

orchiectomy

vulvoplasty labioplasty

female urethra

vestibule

complications

regenerative medicine