Hello, and welcome to our live webcast, Gender Affirmation Surgery, the Role of Urogynecologist. Thank you for joining us. My name is Tyler, and I will be the operator for the presentation today. Before we get started, I would like to take a moment to acquaint you with a few features of this web event technology. On the right-hand side of your screen, you will see the Q&A window. To send a question, click in the text box and type your text. When finished, click the Send button or press Enter. All questions that you submit are only seen by today's presenters. Your questions will be responded to in the order in which they were received and will be addressed throughout and at the end of the presentation. At the conclusion of today's program, we ask that you complete a brief post-event survey. Please take a moment to complete this survey, as it will help us plan future web events. We are joined today by our moderator, Christina Lewicki-Goop, and our speakers, Cecile Unger, Laumiel Lepetka, and Dmitriy Nikolovsky. At this time, I would like to turn the microphone over to Christina to begin the presentation. Christina? Hi, everyone. I wanted to thank everyone for participating in today's webinar. For Cecile, Dmitriy, and Luzmila, taking time out of your busy schedules to put this together, I think, is so wonderful. We are eternally grateful on behalf of the Education Committee from Augs. And let's get started on such an interesting and kind of pertinent topic, the Transgender Care Role of the Urogynecologist. So, I'm gonna start over with my part, and I will be followed by Cecile and Dmitriy in order. We orchestrated that as a panel presentation. So, the idea of this webinar was conceived last year. As some of you might remember, the 38th Augs meeting was scheduled to take place in North Carolina, but instead, it was moved to Rhode Island. It happened as our society responded to highly controversial House Bill 2, also known as Bathroom Law, which was passed in North Carolina and required that people in government-run facilities use bathrooms, which corresponds to gender listed on their birth certificates. At the same time, about March in 2016, the Department of Health and Human Services issued final regulation, which pressured health insurers to cover gender reassignment surgery. In the fact sheet on the portion of the rule regarding sex discrimination, the government explained that healthcare providers cannot refuse to cover all the services related to sex change as a matter of policy. As transgender patients gain better access to healthcare, we realize that healthcare providers need to become more educated about the specific patient population. The main goal of today's webinar is to introduce you to basics of gender affirmation surgery and provide you with some perspective in regards to the role of urogynecologists in transgender care. One of the challenges in transgender healthcare lies in the heterogeneity of population. Transgender-identified activists commonly refer to it as a transgender umbrella. There is an ever-growing list of gender identities. In 2014, Facebook released the mind-boggling list of 50 custom options. So to start this presentation with addressing definitions and terminology, it's very important to learn the proper language in the context of transgender healthcare. The gender identity is the personal internal sense of self and how they fit into the word from the perspective of the gender. Sex historically has referred to the sex assigned at birth based on assignment of external genitalia as well as chromosomes and gonads. In everyday language, it's often used interchangeably with gender, however, there are differences which become important in the context of transgender people. There's also gender expression, the outward manner in which an individual expresses or displays their gender. This may include choices of clothing and hairstyles, speech and mannerism. Gender identity and gender expression may differ. For example, a woman, transgender or non-transgender may have an unoriginal appearance. For men, transgender or non-transgender may have a feminine form of self-expression. Transgender is a person whose gender identity differs from the sex that was assigned at birth. It may be abbreviated to trans. A transgender man is someone with a male gender identity and a female birth assigned sex. A transgender woman is someone with a female gender identity and a male birth assigned sex. A non-transgender person may be referred as a cisgender. There's also gender non-conforming, a person whose gender identity differs from what was assigned at birth, but may be more complex, fluid, multi-faceted, otherwise less clearly defined than a transgender person. Gender creators are not a term used by some with this range of identities. There's also non-binary, which is transgender or gender non-conforming, a person who identifies as neither male or female. There's trans-masculine and trans-feminine, terms to describe gender non-conforming or non-binary persons based on the directionality of their gender identity. A trans-masculine person has a masculine spectrum gender identity with the sex of female listed on their original birth certificate. A trans-feminine person has a feminine spectrum gender identity with the sex of male listed on their original birth certificate. Transsexual is a more clinical term which has historically been used to describe those transgender people who sought medical intervention or months of surgery for gender affirmation. Trans is less commonly used in the present day. However, some individuals and communities maintain a strong and very affirmative connection to this term. And finally, sexual orientation. It describes sexual attraction only and it's not directly related to gender identity. Next slide. So this picture provides a little bit better visual representation of the problem complexity in light of the definition we just went through. When you take care of transgender patients, several things needs to be taken into consideration. Of course, gender identity and biologic sex comes to mind first, but you should also be addressing sexual orientation. The sexual orientation of transgender people should be defined by the individual. It is often described based on belief gender. Transgender woman attracted to other woman would be a lesbian and transgender man attracted to other man would be a gay man. The next important definition I wanted to address is the difference between gender nonconformity and gender dysphoria. Discordance and noncongruency between the sex and identity is called gender nonconformity. Gender dysphoria is actually a medical term and it was defined in a sense with DSM and WHO in 2007. I need to mention WPATH, which is the Board of Professional Association for Transgender Health, which was founded in 1979, and largely responsible for publishing guidelines for transgender care. Since 1979, they published about six revisions of the guidelines. The current one is the seventh revision. And gender dysphoria is a medical term which basically identified that the condition of a nonconformity is causing distress to the person. I also wanted to touch base on some of epidemiologic considerations. The estimated rate of was it transgender identity range from a low bound of one in 2000 or about 0.05% in New Orleans and Belgium to 0.5% in Massachusetts and to 1.2% in New Zealand. And you can see that there is a large variation in the incidence and it is somewhat related to the research and also definitions because legality of the transgender fraud word is very different. But overall, it is estimated that about 0.005% of people assigned male at birth and 0.002% of people assigned female at birth would be diagnosed with gender dysphoria based on 2013 diagnostic criteria. So this is considered a modest underestimate. Again, it depends on how the research is conducted on epidemiology. Research indicates people who transition in adulthood up to three times more likely to be male assigned at birth. But among people transitioning in childhood, the sex ratio is close to one to one. Transitioning is a very important term in among transgender patient. It's a process of changing one's gender presentation and sex characteristics to accord with the internal sense of gender and identity. And it's complicated, multi-step process that can take years as transgender people align their anatomy, their gender identity and gender expression. So I wanted to start talking about gender affirmation. And you can see that it largely consists of several steps. But not all the patients go through all the steps. And typically, they start the changes in gender expression and role. The psychotherapy is one of the processes and it can be referred to not so much of the changing, mostly coping, the gender discongruency. And hormone therapy to feminize or masculinize the body would be considered to be somebody happening at the same time. And sometimes the psychotherapy is supportive of the hormone therapy, but they cannot be or can be interchangeably used by people. Surgery to change primary and secondary sex characteristics in one of the gender affirmation steps. And if you move to surgical intervention, they can be largely defined as specific to transgender population and non-specific to transgender population. If you look down at that box, then augmentation of mastoid, hysterectomy, norectomy, archectomy, and vaginectomy, also known as colpectomy, the procedures we're all familiar with. But certain procedures is very specific to transgender populations. And there are, some of them are pertinent to the appearance and some of them are pertinent to the genitalia. So generally, not all transgender people seek all intervention. Some may seek none at all. And contrast to past practices, then the pathway was pretty much described as going from changes in gender expression up to psychotherapy, up to hormones, up to genital surgery. The current, up to the top, bottom surgery, the current standard of care is to allow each transgender person to seek only those interventions which they desire to affirm their own gender identity. So with that, I wanna pass it to Cecile Amger, who's gonna talk about transgender care in male to female patients. Good evening, everybody. It's my pleasure to be on the line to talk about this topic. So I'm mostly going to talk about vaginoplasty surgery, which, one, I guess you can ask the role of a urogynecologist, but I'm a urogynecologist and I perform these surgeries, and I think that there's definitely an expanding role for our subspecialty to be doing this. So I thought I would talk about the procedure and at the end, briefly discuss the complications that are related to it. So I'm gonna provide an overview of the steps of vaginoplasty surgery and then briefly discuss its associated complications. So the goals of vaginoplasty surgery are to create a natural-appearing vagina, mons pubis, labia minora and majora, a functional vagina or neovagina, so to speak, a sensate neoclitoris that in itself is functional as well, moist appearance so that it looks as natural as possible, clitoral hoodings, also making the surgery and the reconstruction anatomic, and then some form of lubrication. This is essentially the list that a lot of patients come in when they're looking to have surgery. I tell patients preoperatively that outcomes vary. It all depends upon patient's body type. I take certain requests in terms of labia, but some patients, like the one on the left, specifically required large labia minora. The middle patient is sort of a heavier patient and has sort of a more anatomic outcome that's consistent with somebody who has a lot of sort of lower abdominal and groin weight. The person on the right is a bit thinner. And so I review, I have pictures that I show patients. The patient on the left is somebody who had requested sort of a more exposed clitoris with less hooding, whereas the patient on the right had wanted sort of very small labia minora and had made that special request. And so I provide pictures to patients to sort of show them what to expect, but I think the important take-home message is that outcomes really vary depending upon what we have to work with. When we do the surgery, some patients, we have this sort of surge in individuals who have undergone pubertal suppression and their genitalia is much smaller. So we're seeing 20-year-olds who don't have as much skin to work with. And so we talk about expectations and outcomes with regard to that sort of thing. So the technique itself, I'm gonna show a few video clips in order to allow everybody to have a better understanding of the surgery as well, some illustrations, but I'm gonna take the surgery step-by-step to make it a little bit more clear in terms of what we do. The surgery that we do is the penile inversion vaginoplasty. Everyone sort of has their own modification of it, but this is a surgery that's pretty much been described for over the last 75 to 85 years, and it's the one that's just been modified over time. Essentially, we start with a scrotal skin flap. Some people take the entire skin paddle off, like I do, others sort of keep it on a skin pedicle. But we essentially mark the skin flap about two centimeters medial from the groin crease, and then about four to five centimeters above the anus, depending upon how long the patient's perineum is. And we go along the scrotal margins and take off that flap and eventually make it into a split-thickness skin graft, which I'll show a little bit later in the presentation. So here, we have a video taking off the skin flap. So if we play the video, hopefully everybody can see it. We take our scrotal markings, and we essentially, a technique that we're all very common with, the epithelial is the entire skin paddle, in order to remove this full flap. Again, there are some people who keep it on its pedicle, but I like to take the entire skin flap off. All right, we'll go to the next slide and get rid of the video. Perfect. We then perform orchiectomy. So we remove the testes and the spermatic cord all the way down to the inguinal ligament, and transect, double clamp, and remove the testes, very similar to the way that we would remove the ovaries when we're doing that intra-abdominally or transvaginally. The next part is skeletonizing the underlying penile structure. So we remove a lot of the subcutaneous fat and expose the penile structures down to bucc fascia, and then undergo a degloving procedure where we essentially remove the penile structures from the penile skin tube in order to use the skin tube later on to line the neovagina, which is anastomose to the scrotal flap, which, again, we'll show a little bit later so that this is a little bit more clear. We then skeletonize the structures even further. So this is an illustration that we created on the left showing sort of this degloving process. I don't think I have a video here. I'm gonna keep going, but this is our video. So we're gonna show the last few steps that I just described. Essentially, this first part is removing a lot of the subcutaneous tissue. This patient had a lot of excess fat that we removed. We have to achieve really good hemostasis. We remove bucc fascia all the way down to the penile structures. This is more skeletonizing because you really want to expose the underlying penile anatomy in order to deconstruct it to eventually reconstruct it. This is a picture showing the carora and the cavernosus tissue. We're very careful here in dissecting. The dorsal neurovascular bundle runs dorsal, obviously, and you want to be careful to not transect the blood supply. So here we are degloving the penile structures. The suspensory ligament of the penis is also transected in order to free the entire penile anatomy. We can remove the video. The next part is where we create the neovagina. This is sometimes the most tenuous part, but I think as urogynecologists, we're sort of more familiar with this kind of dissection. In order to create the neovagina, the perineal tendon, I think I have aerocapacity here, which is right here, is transected. The landmark is right underneath the bulbous urethra, and essentially, we transect the perineal tendon, and then I use a finger inside of the rectum in order to prevent rectal injury, but dissecting through the tendon and transecting the very distal levator anti-muscles and eventually being able to bluntly dissect. And what we want to do is find this plane, which isn't as natural in the biologic male as it is in the biologic female, but there's this fascia called denodilized fascia, which the female has as well, that runs between the rectum and the prostate, and as long as you stay above that area, you can avoid a rectal injury, but it can be a little tough, especially in patients who have a history of prostatitis or who've had a prostatectomy, and so you have to just be careful and be mindful in order to avoid injury below and above. These are more surgical pictures. Eventually, you can dissect through and end up with about a 12 to 16 centimeter vaginal canal, which is ideal. This is where we place our split-thickness skin graft, and so you want, these grafts can contract, and so you want as much space as possible so that when the patient dilates postoperatively, they can maintain vaginal length. Once the neovagina is done, we separate the spongiosis tissue and urethra from the overlying cavernosa tissue in order to create the neourethra and then also continue deconstructing the penile anatomy in order to further reconstruct it. So we mark out, once we've separated the urethra from the overlying cavernosa tissue, we create the clitoral flap. We mark out, here you can see the gland's penis attached to its blood supply in the cavernosa tissue. We mark out the clitoral flap, essentially with a marking pen, and then sort of wedge out this little piece of gland tissue, which will end up being the neoclitoris. That's what it ends up looking like. Everyone always thinks it's real cute, but that little portion of the glands that's left over essentially is still in the dorsal neurovascular bundle so that it maintains both sensation and blood supply for good sexual functioning. In patients that have enough skin, we will maintain a little bit of the penile skin on its blood supply so that we can create labia minora if the patient desires that, which is how, like I mentioned before, what we discussed during the preoperative visit. We can show this video. I think it's gonna recap some of the steps that I talked about. So here, I'm taking down some of the axis spongiosis tissue. That has some erectile function and can be very painful, and so we remove a lot of it. This is separation of the spongiosis from the overlying cavernosa. Here, we're tying off the cura of the cavernosa in order to achieve a little bit of hemostasis. The deep penile vessels run in this area, and so I usually tie them off to get hemostasis. Here, we've marked out where the dorsal neurovascular bundle is and separate it, mostly using sharp dissection, but we use cautery to achieve hemostasis as well. The neurovascular bundle is then, you can see the Penrose drain is around it. That's where the veins, artery, and nerve supply run, and so we essentially separate it from the underlying cavernosa tissue, which you really don't need. Those are really sort of serve just erectile purpose, and leaving too much of the cavernosa tissue behind can actually be very painful. Patients who come in postoperatively from having had their surgery from an outside facility with a lot of pain, the reason is often because too much cavernosa tissue was left behind during the dissection. So I'm just marking out where we're gonna continue removing the underlying cavernosa. You want the flap to be contiguous with the neoclitoris, which we're wedging out here from the glands because you don't need that entire gland. So it would clearly be a clitoris that would be, I guess, considered by most to be unsightly if you left that entire gland's penis there. All right, we can remove the video. So next, when we're left with just the thin clitoral flap, again, the illustration on the left shows its blood supply. It's then turned over on itself. So you can see in the surgical picture on the right where we've sort of turned the flap on itself. You want to be very careful. This is where in setting the flap, you want to secure it to the underlying fascia of the bony pelvis so that it's fixed. And you want to be careful to not kink the flap too much because if you lose that blood supply, the clitoris can necrose. After we do that, we spatulate the urethra. We open up the ventral surface in order to create a neourethra. And then we use the dorsal surface of the urethra to create a nice mucosal flap between the urethra and the clitoris. So this is an illustration on the left showing the spatulation and opening up of the urethra. What's nice about maintaining this ventral surface of the urethra is that we are able to create this sort of mucosal lining between the urethra and the clitoris, which sort of gives the reconstruction a more natural appearance once it heals completely. You can see the surgical picture on the right demonstrates this. So you can see this inner mucosa that's turned outwards creates this nice mucosal lining. We can play the video. So here I'm insetting the flap in its place to the underlying fascia. You want to make sure that this is anatomic. I tend to try to go, the transclitoral line is thought to be along the same place that the adductor longus inserts at the level of the groin. We know this from learning how to place transopterator slings, so I try to use that as the anatomic landmark. I also just go a few centimeters below the pubic symphysis. You don't want your clitoris to be too high or too low, otherwise it won't look very good. And then this is spatulation of the urethra. So there's the neourethra with a urethra that was opened and it's basically inset in itself and secured in place. Here's securement of the ventral, or sorry, the dorsal inner surface of the urethra to create that nice mucosal lining between the clitoris and the neourethra. And we can remove the video. We then, once we've done all that, usually I have an assistant, it's usually either a resident or a fellow preparing our split thickness skin graft. So we use a stent and sew inside out the scrotal flap that was removed, and then place that stent through the penile tube and then anastomose the scrotal flap to the penile flap and then invert it. Again, it's inside out, so it's an inversion technique so that the inner portion of the vagina is essentially skin-lined. And so these illustrations show just that. This is what it looks like intraoperatively. So this is a picture of a pretty full-length neovaginal flap that's then inserted into the cavity. We can show this video. This is what it looks like. It's then, that scrotal flap that was placed on the stent is then anastomosed to the penile tube that was left behind. And depending upon the amount of skin that you have to work with, preoperatively can be long or it could be a little shorter, so you have to sort of make adjustments with your scrotal flap. It's then inverted inside out and then secured in place with the stent. And then eventually we remove the stent and we pack the neovagina with a packing that I leave in place for about a week as the graft takes. And once I take the packing out, the graft is set in place. So this is very similar to the McIndoe technique and this is what we do here for our McIndoes except we use split-thickness skin graft from obviously a different donor site or a biologic graft material. But we pack and you have to pack it very tightly in order for the graft to take. And you want to make sure that the neovaginal cavity is very hemostatic. If there's any bleeding in this cavity, it can create a hematoma and lead to the graft not taking, which is a challenging thing to take care of postoperatively. We do the vulvoplasty last. So once the neovagina is placed in, we open up the penile flap in order to expose the underlying clitoral structures that had been inset previously. So we do that. And so the illustration essentially shows us opening it up with a scalpel, allowing us to expose the underlying structures. And then we spend a lot of time cosmetically placing the labial flap and the clitoral flap in the right position so that it looks cosmetically appealing and anatomically correct once everything has healed. Postoperatively, right in the operating room, this is what it looks like once it scars in. There's usually a very nice cosmetic component as long as we don't have any flap loss or necrosis of any of our flaps. And so we can show this video. And so this is the opening of the penile flap. So that we can expose our underlying clitoral structures. And then we sew them into place, eventually exposing the labia minora so that we can also sew them into the right proper location. This is a different patient than the one that I had shown earlier. This patient didn't have a lot of penile skin, so we created sort of this rippling effect to get the appearance of labia minora rather than using leftover penile skin, which is sometimes what you have to do when the phallus isn't very big preoperatively. We placed drains in the labia majora. You can easily get a hematoma in this area and wound problems, so we make sure that we drain them for about three days or until the output is quite low, which usually takes about two to three days. We then get rid of these unsightly dog ears in order to create a really nice appearance to the labia majora. This sometimes can be pretty challenging when there's large dog ears, but we've gotten pretty good at repairing these. We then close the suture lines over the drains, and you want to close everything in a tension-free manner. You don't want there to be a lot of tension on your incisions, because then they'll open. You also want to make sure your drains are placed in such a way that they drain properly. Okay, we can remove this video. So complications related to vaginoplasty surgery. The obvious ones are bleeding and hematoma, needing continuous drainage or opening up of the incision lines in order to drain the hematoma. Seroma formation is also common. Delayed wound healing. The incisions, especially near the neoenteritis, can sometimes separate, requiring careful management of granulation tissue and just applying normal wound healing principles. Fistulas can occur mostly in the setting of intraoperative injuries, so injury to the rectum, to the urethra, to the bladder. Looking at the data, we think that any patient who has any type of injury, especially to the rectum, probably has about a 30% chance of developing a postoperative fistula, and so care has to be taken in managing these patients if there is an intraoperative rectal injury. The picture of the patient to the right is a patient that had been operated on in an outside facility and ended up with a rectofaginal fistula, which we closed with a buccal mucosal flap. And you can sort of see this little tongue right here. This is the flap that we closed it with, and she did fine. But often you can't get away with that kind of flap. You need a much bigger repair. So a fistula and intraoperative rectal injury are not to be taken lightly in this patient population. Patients can have urinary stream issues, which are very common, which can be usually revised with small outpatient procedures. Vaginal stenosis is very common. It's actually reported to be one of the most common complications after this procedure for obvious reasons. There's contracture of the neovaginal skin graft and can be managed with revision surgery, but those are much more complicated than the initial surgery. So patients are really encouraged to dilate properly after surgery. Necrosis and flap loss, loss of sensation can occur, and also unsatisfactory cosmesis if the wounds don't heal properly, necessitating revision surgery. So I think that's all that I have. I'm going to turn it over to Dimitri, who's going to talk about the trans male. Thank you so much for this opportunity. I'll be talking about female-to-male transition and a disclosure that I don't do these primary procedures, but I specialize in repair and complications, and basically I had to find the original anatomy and steps of the original surgery kind of hard way. I have no other disclosures, and today we'll be talking about background, genitourinary anatomy after gender confirmation, postoperative care and complications, including radiographic findings, treatment options, and outcomes of the revisions from literature. As we already discussed, but I remind that before patients see us in a bottom surgery or in the urology department, reconstructive department, they already went through many steps that start with documented gender dysphoria, hormonal treatment, life in new gender for more than 12 months. They need to obtain letters of recommendations from mental health professionals. By that time, they probably already had mastectomy, hysterectomy, oophorectomy, and finally they come for vaginectomy, phalloplasty, possibly in the same setting. So what I learned by talking to others and discovering in texts is the following, that there are actually two types of bottom surgery for female-to-male transition. One is called metoidioplasty, and this is a procedure that is very similar to our urological procedures for hypospadias repair, and it's creating a phallus that is only suitable for voiding upright, but not for sexual function. And it consists of local flaps, only clitoral dissection and elongation. And then there is phalloplasty, which is a much more advanced and invasive procedure, and it's suitable for sexual function and voiding function. And this kind of neophallus consists of two parts. One is neobulbar urethra, or pars fixa, and penile urethra created with free flaps, and this is called pars pendulans. So these are a couple of examples of metoidioplasty. You can see how clitoris is elongated and urethral plate is created to reach the tip of this neophallus. And then at the end you tubularize all this local tissue around the foley catheter, and you create this actually up to 10-centimeter phallus that is suitable for urinating upright. On the other hand, phalloplasty kind of also starts with the same idea. You start with dissecting bulbar urethra and create local flaps around the foley catheter. Labia majora is becoming here scrotum. And then at that point you stop and you start creating a neophallus. So this is a typical idea of a tube within a tube lined outside and inside with the skin, and this example is radial forearm flap. This is an example of thigh flap. You can see that this marking, the narrow marking here identifies the future urethra, and the thicker part will be rotated in opposite direction to create skin of the phallus. So these pictures are produced by Dr. Curtis Crane, who does these procedures routinely, and with his permission I use it here. So you can see that this flap is rotated and two minor pedicles are identified with arrows. Then you create a tunnel under the muscles and deliver this rotated flap into the perineum. This is how you fix the defect and cover it with a split thickness skin graft. And at the end you can see the final product with the foley catheter in the inner tube and the neophallus in place in the perineum. This is another example, radial forearm flap. You can see the template, the same idea, tube within the tube. At this point it's still attached to the forearm with arteries and nerves. The urethra is rotated around the foley catheter and nearly finished product here right before transplantation to the perineum. Now here is perineal area prepared and proton is created. The foley catheter is in native urethra, now tunneled through the bulbar urethra or pars fixa. And there is a neophallus in place. Final product before catheter removal and this is a donor site after several months with the split thickness skin graft already healed. So this is probably one of the most important slides here. I have maybe three important slides here. This is, again, a diagram of how this flap works. You can see that radial artery, cephalic vein are traveling to supply the big piece of this flap. And you have to realize that the urethra is supplied in a retrograde fashion. So the worst part of the blood supply, the watershed area, is actually at the anastomosis or the proximal part of this urethra. This is the part that will suffer with potentially ischemia more than anything else on this flap. And this is what you connect to the pars fixa. So this is why we see complications and I will show you many complications and hopefully you will remember this picture here, why. So this is, again, rotation of both flaps around the catheter. Both parts of the flap around the catheter. And this is the final product. So you could see that this is the second most important slide. This is a retrograde and antigrade urethragram. The bladder is on top. Native urethra is marked. Then there is a pars fixa or neobulbar urethra. And then there is this weakened anastomosis that we always pay attention to. Polycurethra is distal. And the largest series here from Belgium, close to 300 patients show almost half of them had urologic complications, sometimes fistula, stricture, or both. So at this point, it was four years ago, I have an unexpected patient come into my clinic, 18-year-old transgender male, phalloplasty three months earlier, had radiophoreal neophallus, complicated with early perineal abscess that had incision and drainage. Fixed with catheters. Then catheter came out. Failed trial avoid. Comes to me with a suprapubic tube. And you can see the desperation. I'm doing antigrade, retrograde urethragrams and simultaneous suprapubic flexible cystoscopy. Still can't understand what I'm seeing. There's definitely a stricture, and then there's something else. Physical exam shows potential fistula, but not really extravasation of contrast to the fistula. And that's when I had to call the original surgeon and figure out what was connected to what. What was the original operation? What is the expected new anatomy? And what went wrong with the expected new anatomy? That's when I come in to figure it out and to fix it. So once I did the surgery, actually I found something unexpected. You could see on top there is a native meatus, and then under the meatus there is this cavity that I didn't expect to see because radiography didn't show it. Once I opened the incision, I found this large cavity that basically ended up being kind of a remnant vagina or recurrent vagina that I had to remove during the surgery. After that was obliterated, I found the aberrant stenosis anastomosis, refreshed it, created new anastomosis, closed everything, was very happy with this procedure. And then as soon as the catheter was removed, the stricture recurred in exactly the same place. This was kind of unusual because in a cisgender male, this is the best possible procedure. You cut the stricture, connect the dots, and everything heals well in over 90% of the time. But here it immediately recurred. So the lesson is this doesn't behave like a well-vascularized native male's spongiosum. This is a totally different construction here. So this particular patient came back, and I did a two-stage urethroplasty. You could see a second stage here when Baclomycosa was placed to replace that stenose segment. And once it healed six months later, it was tubularized around the foley catheter and closed in as many layers as I could. This time, fortunately, it healed well. And now I see this patient for close to four years, and we still have the same good flow. But lesson learned. The following patients came after that, and number one observed complication was an asthmatic stricture. There was also proximal urethrocutaneous fistula. Half of the patients had pelvic cavity remnant, vaginal remnant. There was a meatal stenosis, distal urethrocutaneous fistula, or even worse, the worst complication was obliteration of phallic urethra. What I learned from this experience after numerous patients is that we need to expect numerous simultaneous complications and create a surgery that would address as many complications as possible in as little number of steps as possible, especially because patients are coming from long distances and wouldn't be able to travel for multistage procedures. So the techniques that we are using, these are just the names, and I'll give you examples. Metaplasty, excision and primary anastomosis, or EPA, which I'm not a big fan of in transgender population. Heineken-Mikowitz procedure, not a big fan of this. And oral mucosa graft with one or two stage or three stage of necessary procedures and pedicle flap. So with my co-author, Lee Zhao from NYU, we kind of put our heads together and we decided that we actually like the same exact protocol independently. This is the protocol that depends on location of the stricture, length of the stricture, and patient's preference to go on with multiple numerous surgeries forward or just give up with the idea of void and upright and just create a perineal urethrostomy. So based on this simple protocol, these are the examples. So meatal stenosis is seen here, very common. And metaplasty is very easy when you just advance the urethra more distally and put a couple of observable stitches here. This is the worst kind of complication, two-stage repair for entire pendulous obliteration. So some patients opt for just a simple perineal urethrostomy. Others go for two-stage repair when we have to reconstruct the entire pendulous urethra. So this is the example again. This is the second stage of the procedure when the graft was already there for six months and we want to create about a 3-centimeter urethral plate. In this case, at the tip, there was not enough buccal mucosa from the first procedure, so we added a couple of centimeters of extra buccal mucosa just before tubularization. This is the last picture of tubularization around the catheter, closing as many layers as possible to prevent fistula. And this is kind of a selfie that was sent to me six weeks later that still the repair holds. Eight months follow-up, the retrograde urethrogram was patented and patients urinated well. Another telling picture, you can see ambytoid dioplasty with a fistula on the bottom there. And the retrograde urethrogram, this is not the bladder you're seeing. This is the remnant cavity because you shouldn't see the bladder in a retrograde in a female-to-male patient. You should not see the bladder in a retrograde. This is the gigantic cavity. So fistula struct was there. We have to follow it to the cavity over the wire. Obliteration of the cavity and then closure of the urethral fistula. And then closure in layers before and after retrograde urethrograms. This was probably one of the most difficult procedures. You could see an asthmatic stricture where there's arrow points and then there's a cavity. But original surgeon placed gracilis during the original surgery to prevent the fistula. So now perineum is covered with skin and then gracilis preventing me from getting towards the repair. So instead of removing gracilis, I decided to recycle it. And this is just the steps of the procedures where buccal mucosal graft was used in two layers with the use of gracilis. So these are the steps. Vaginal cavity had to be obliterated. Gracilis was dissected carefully and retracted in a moist vase. You could see the stricture there above, very narrow, impossible to tubularize. And you also see gracilis that I decided to split into two where one was used to obliterate the cavity and the second one was held for the future steps. Then dorsal buccal mucosal graft was placed to widen the strictured area in the urethra. And then gracilis was flopped and outfitted with the second buccal mucosal graft to create a ventral plate. So basically we kind of closed the door using the gracilis over the catheter. And this is right before the closure. So this saved patients a two-stage procedure and instead we could use independently vascularized tissue to carry the grafts ventrally and dorsally, and it was fixed in one stage. And this is before, and this is at some point in follow-up after. And the patient was gracious enough to come for four-month follow-up to prove that everything works. Very infrequently we have just isolated fistula, and that was easy to close. You know the steps close in many layers. And another difficult example where the stricture was in the metoidioplasty, completely obliterated area with the fistula and the stricture. And you can see the blue indicates the inside of the urethra that was completely lifeless, and we had to remove this entire part of lifeless urethra and put bacomycosal graft for one stage. Then patient came for the second stage. The graft survived and was tubularized around the catheter with a good bleeding tissue and closed in many layers. This was before and after retrograde urethrograms. It turns out that not too much is written about the redo-redos of the fistula and stricture. There's only three papers since 1995 with just a few patients in each, except for the last one, 79 patients from Belgium. And surprising result, 41% failure rate, which again is unheard of in cisgender males' reconstructive world. Especially this anastomotic urethroplasty had such a huge failure rate. You can see that most of the strictures here occurred at the anastomosis and multiple patients required repeat urethroplasty. And this is by type of repair, excision primary anastomosis, at 43% failure rate, which is very dramatic. So to wrap up, in conclusion, expectations come in with neophallus and GU complications. These complications are very common, about 50% of the time, even in the most experienced hands. We expect numerous simultaneous problems. Anatomy is different from a native male and have a high reported failure rate. We need more data. And regardless whether patients have complications or not, after transgender surgery they will need GU follow-up. They may have stones, they may have hematuria, they may have issues with the prostate or future voiding problems and continence. So they will need to be followed up for the rest of their life. And the new GU procedures need to be tailored with respect to this new anatomy. And I think that's it. Thank you so much for your attention. I'm going to take over for a second and provide you with some take-home points. And I hope you got something out of the expertise of Cecilia Dimitri talking about the transgender surgery care. And the main point was that it is complex. As a gynecologist, you might be involved in the care of transgender patients at many different levels. For example, prescribing gender-affirming hormones is considered to be well within the scope of a range of medical providers, including primary care physicians and OBGYNs. And most medications used in gender-affirming hormone therapy are very commonly used substances which most prescribers are already familiar with. Because they're used in the management of menopause, contraception, male pattern baldness, and abnormal uterine bleeding. You can be approached, again, as a gynecologist, to perform some procedures which you're very familiar with and well-versed into just by the nature of your training. Not necessarily reconstructive procedures, but the hysterectomy or colpectomy part on a transgender patient can be performed without any additional training, but you need to be cognizant of the patient and anatomy and outcomes because those procedures can be a little bit different in the setting of the hormone therapy. Thirdly, you might be dealing with complications of the transgender surgery. And as Dmitry hopefully gave you a brief overview of how that part can go, you as a reconstructive surgeon can be exposed because you're an expert in this field. Along with the urologist and plastic surgery, these patients with potential complications of the surgeries can be coming to you. The other point I wanted to touch on is that long-term outcome data is lacking. All these procedures have been developed over the past several years, and, of course, improvement is always the goal of every surgery operating. But overall, we don't have a very solid long-term outcome data. And if you have a chance, if you're taking care of a transgender patient, if you have a chance to contribute to long-term data and see a way to do that, please do, because that's important. Everybody needs to know, as this patient's going to age, what the outcomes of the surgeries we were doing to improve on the techniques we currently have, because, as you can see, they're not perfect. Training standards for generally reaffirming surgery is not very widely established. So, in, like, still doing the primary procedures, we, in TPRS, we have a well-established training standards for cervical pervexis and other procedures. For the general affirmation surgery, it's not very well-defined. You just need to be aware of that and seek good training if you ever decide to move towards doing any of the primary surgeries yourself. Credentialing in the procedures is not well-defined either. You might find yourself in a situation when you feel like you can do surgery, but you will be dealing with some governing bodies of your hospital, like a credential committee, so you need to work closely with them and see what you're credentialed to do and how your hospital would want to handle that. And, in conclusion, a multidisciplinary approach works the best. So, if you're ever in a situation that there's a lack of proper care for transgender patients in your area and you are trying to deliver the best care, the best advice is to find people who can help you. And it should be an endocrinologist who works closely with the network healthcare provider in that area who has special expertise, a male reconstructive urologist, and a plastic surgeon. So I think, at bare minimum, those are the four people you need on a team to provide the best care. So, I hope you got some take-home points from that and enjoyed the time. Thank you, again, to the Education Committee to allow us to present, and I will pass it to Christina who will be taking questions. So, thank you, Dimitri, Cecile, and Ludmilla. That was an amazing talk. In the interest of time, it looks like we don't have any questions from the audience, so I'll just kind of end this on a question for whoever would like to field this. Ludmilla, you brought up this training standards aren't widely established and credentialing, so I'm wondering if one of you could speak to whether or not, on a national level or an organizational level, if there's some sort of movement to kind of standardize who should be performing these procedures and kind of standardization of training. I can speak to this. So, the surgeons who perform a lot of these primary surgeries meet regularly through WPATH, the World Professional Association of Transgender Health, as Ludmilla had pointed out earlier in her talk. And there are currently criteria that are being developed to ensure that surgeons are, in a way, credentialed to be doing this. So it's going to be run through WPATH through the core group of surgeons who have been performing these surgeries for a long time. WPATH does offer, two to three times a year, a hands-on cadaver course to learn the anatomy and also the basics of the surgery. There's a didactic portion and usually a one- to two-day cadaver course. The next one is being held in April in New York City at Mount Sinai Hospital. There's also a plan to put fellowships into place that are going to essentially have their own credentialing to do this. So, Weiss Memorial Hospital in Chicago has already started a one-year fellowship for plastic surgeons. Mount Sinai in New York has also started a fellowship and I believe currently has a plastic surgeon but is expecting to also accept reconstructive urologists. And then here at Cleveland Clinic, our goal is projected for 2020 to have a fellowship program open to urogynecologists. And I think as we start training more and more people, we're going to end up with these one- to two-year fellowships at academic centers. But a lot of this is being regulated through WPATH and it's on the agenda and a priority for the surgeons who are currently performing the surgeries. Well, thank you guys so much. And again, on behalf of the Education Committee of Augs, it's been a pleasure moderating this and I am so proud to call you guys my colleagues. So, thank you again. Thank you. Thank you. Have a good night. Thanks, everyone. On behalf of Augs, I'd like to thank you all for your participation in today's event. A post-event survey will appear requesting your feedback, so please take a moment to complete this survey as it will help Augs plan future web events. This concludes today's webinar. Thank you and have a great day.

Gender Affirmation Surgery

Urogynecologist

Webcast

Transgender care

Transgender healthcare

Metoidioplasty

Phalloplasty

Vaginoplasty

Multidisciplinary approach

WPATH