One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals

Abstract

Background Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations. Aim To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery. Methods During a period of 9 years (2007–2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons. Outcomes Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS. Results Mean follow-up was 44 months (range = 10–92). Mean surgery time was 270 minutes (range = 215–325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient. Clinical Implications Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates. Strengths and Limitations To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure. Conclusions Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries.

Combining total laparoscopic hysterectomy and bilateral salpingo-oophorectomy with subcutaneous mastectomy in trans men: The effect on safety outcomes

“…Only few studies have previously examined the occurrence of hematomas in trans men after mastectomy in combined procedures. Smaller cohorts were described by Cizek et al (2017) (n ¼ 25) and Stojanovic et al (2017) (n ¼ 79), who reported fewer complications associated with the mastectomy (4% and 7.6% respectively), while similar complication rates after a combined procedure were reported by Hager et al (16.7% hematomas,3.7% reoperations, n ¼ 108) Some studies assessed whether combining plastic surgery procedures affects safety outcomes, with varying conclusions. Coon et al investigated the effects of combining body contouring procedures on complications (Coon et al, 2010).…”

“…All authors concluded that the combined procedure is safe, feasible, timeand cost-saving and valuable (Cizek et al, 2017;Hager et al, 2019;Ott et al, 2010;Sinkey et al, 2016;Stojanovic et al, 2017). Only minor adverse events were described in these studies, and, if reported, described complications were mainly hematomas (Hager et al, 2019;Stojanovic et al, 2017). Cizek et al stated that no complications could be attributed to the fact that the two procedures were combined in a single incident (Cizek et al, 2017).…”

“…Combined surgery could be of value for trans men for several reasons: patients require general anesthesia only once, consume shorter hospital stays, have a reduced recovery time and therefore experience lower levels of stress and anxiety (Hager et al, 2019;Kaiser et al, 2011;Mitchell, 2003). To date, only five studies reviewed the outcomes of this combined procedure, four in trans men (Cizek et al, 2017;Hager et al, 2019;Ott et al, 2010;Stojanovic et al, 2017) and one in cis women (Sinkey et al, 2016). All authors concluded that the combined procedure is safe, feasible, timeand cost-saving and valuable (Cizek et al, 2017;Hager et al, 2019;Ott et al, 2010;Sinkey et al, 2016;Stojanovic et al, 2017).…”

“…To date, only five studies reviewed the outcomes of this combined procedure, four in trans men (Cizek et al, 2017;Hager et al, 2019;Ott et al, 2010;Stojanovic et al, 2017) and one in cis women (Sinkey et al, 2016). All authors concluded that the combined procedure is safe, feasible, timeand cost-saving and valuable (Cizek et al, 2017;Hager et al, 2019;Ott et al, 2010;Sinkey et al, 2016;Stojanovic et al, 2017). Only minor adverse events were described in these studies, and, if reported, described complications were mainly hematomas (Hager et al, 2019;Stojanovic et al, 2017).…”

Novel surgical techniques in female to male gender confirming surgery

“…Recently, Belgrade centre reported their original technique of neophalloplasty/metoidioplasty, based on the repair of most severe forms of hypospadias with goal to improve results of urethral reconstruction and minimize complication rate in one stage repair ( 13 , 14 ). This work later resulted in many modifications of this original technique, aimed at changing the feminine appearance of the external genitalia to a more masculine morphology and at allowing voiding while standing ( 15 , 16 ). The novel technique is based on the similarity in penile and clitoral anatomy and the statement first introduced by Williams, that the clitoris is thus in many details a small version of the penis, but that it differs basically in being entirely separate from the urethra ( 17 ) ( Figure 1 ).…”