Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018: The Evolution of Surgical Care

Abstract

Background: The number of individuals with gender identity incongruence seeking treatment, including genital gender-affirming surgery, has increased over the past decade. Surgical techniques for genital gender-affirming surgery in transgender men have evolved considerably. The aim of this study was to present an overview of the evolution of genital gender-affirming surgery for transgender men in a single, high-volume center. Methods: The authors performed a retrospective analysis of medical records of all transgender men who underwent genital gender-affirming surgery from January of 1989 to January of 2018 at their institution. Subject demographics, type of surgery, and surgical techniques were recorded. Results: Over time, four hundred transgender men underwent genital gender-affirming surgery. Metoidioplasty was performed in 222 patients (56 percent) and phalloplasty in 178 patients (44 percent). Before 2010, the majority of patients underwent metoidioplasty, whereas since 2010, phalloplasty has been performed in most patients. Of 400 patients, 332 (83 percent) underwent urethral lengthening. The option to undergo genital surgery without urethral lengthening was offered from 2004. Since then, 68 (34 percent) patients chose to undergo genital gender-affirming surgery without urethral lengthening. The choice of surgical options for genital gender-affirming surgery in transgender men has grown from five in 1989 to 12 techniques currently. The variety and combination of flaps used for phalloplasty has increased over time. Conversely, the use of some flaps has been abandoned, whereas other flaps have reemerged. Conclusions: Genital gender-affirming surgery has developed over time in line with reconstructive surgical innovations. Despite technical advancements, there is no one ideal technique, and every technique has specific advantages and disadvantages. With the increase in surgical options, shared decision-making and a shift from surgeon-centered toward more patient-centered care are required.

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

“…1 The number of transgender men opting for gGAS has increased significantly over the last decade in our center, from an average of 11 per year before 2011, to an average of 22 per year since 2015. 2 Depending on personal preference, expectations, and physical characteristics, a phalloplasty or metoidioplasty is performed. The importance of voiding out of the tip of the phallus makes gGAS with urethral lengthening (UL) an important treatment option.…”

Metoidioplasty using labial advancement flaps for urethroplasty

“…Admittedly, there is considerable heterogeneity in the surgical techniques used and how to classify complications. This makes it hard to compare techniques and even make comparisons with phalloplasty outcomes, for those patients who are weighing the risks of each procedure [13,14] . When patients request a metoidioplasty, we believe that they are seeking the most reliable technique for standing to void, with the least recovery and scar burden.…”

Evaluation of the Decision Aid for Genital Surgery in Transmen

“…2e9 At this moment, transmen have a higher variety of surgical options than trans women with regard to genital genderaffirming surgery. 10,11 The reproductive organs can be removed, and the external genital can be masculinized in various different ways. Each option comes with different physical requirements, expected outcomes, and risk of complications.…”

“…1,14e17 Over the past decades, major improvements in surgical approaches have been made, and follow-up studies repeatedly show positive effects on psychosocial outcomes. 10,18 At the same time, despite extensive preoperative counseling, postoperative satisfaction varies, which has partially been attributed to a mismatch between expectations and surgical outcomes in certain individuals. 14,15,19,20 Numerous studies showed that decision aids (DAs) improve the patients' ability to make an informed choice by enhancing the patients' knowledge and participation in the process, help create more realistic expectations of potential benefits and harms of treatment, and support patients to make a decision as per their informed values.…”