Robot-assisted laparoscopic colpectomy in female-to-male transgender patients; technique and outcomes of a prospective cohort study

Abstract

BackgroundGender-affirming surgeries in female-to-male (FtM) transgender patients include mostly hysterectomy, bilateral salpingo-oophorectomy and mastectomy. Sometimes further surgery is performed, such as phalloplasty. Colpectomy may be performed to overcome gender dysphoria and disturbing vaginal discharge; furthermore, it may be important in reducing the risk of fistulas due to the phalloplasty procedure with urethral elongation. Colpectomy prior to the reconstruction of the neourethra seems to reduce fistula rates on the very first anastomosis. Therefore, at our center, colpectomy has become a standard procedure prior to phalloplasty and metoidioplasty with urethral elongation. Colpectomy is known as a procedure with potentially serious complications, e.g., extensive bloodloss, vesicovaginal fistula or rectovaginal fistula. Colpectomy performed via the vaginal route can be a challenging procedure due to lack of exposure of the surgical field, as many patients are virginal. Therefore, we investigated whether robot-assisted laparoscopic hysterectomy with bilateral salpingo-oophorectomy (TLH–BSO) followed by robot-assisted laparoscopic colpectomy (RaLC) is an alternative for the vaginal approach.MethodsRobot TLH/BSO and RaLC as a single-step procedure was performed in 36 FtM patients in a prospective cohort study.ResultsMedian length of the procedure was 230 min (197–278), which reduced in the second half of the patients, median blood loss was 75 mL (30–200), and median discharge was 3 days (2–3) postoperatively. One patient with a major complication (postoperative bleeding with readmission and transfusion) was reported.ConclusionTo our knowledge, this is the first report of RaLC. Our results show that RaLC combined with robot TLH–BSO is feasible as a single-step surgical procedure in FtM transgender surgery. Future studies are needed to compare this technique to the two-step surgical approach and on its outcome and complication rates of subsequent phalloplasty.Electronic supplementary materialThe online version of this article (doi:10.1007/s00464-016-5333-8) contains supplementary material, which is available to authorized users.

Use of the IDEAL framework in the urological literature: where are we in 2018?

“…Four studies (4.8%) related to preclinical research (IDEAL phase 0). The 43 remaining original research studies that applied IDEAL were mapped to the corresponding IDEAL stage: IDEAL with nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three (7.0%) publications, respectively .…”

Histerectomía por laparoscopia en un transexual masculino: reporte de caso y revisión de la literatura

“…Of these, 11 studies were selected based on their relevance for this case in terms of the performance of hysterectomy in male transsexual individuals using different techniques, emphasizing the laparoscopic technique (Figure 1). The studies included 1 controlled clinical trial (16), 4 retrospective cohorts (8,9,17,18), 2 prospective cohorts (19,20), 1 case report (14), and 3 case series (20)(21)(22). The studies were conducted in the United States (8,9) Czech Republic (15)(16)(17), Italy (14,19), France (18), The Netherlands (23), Germany (20), and Belgium (21).…”

“…It is considered to be safe and to be associated with good prognosis in terms of quality of life. Groenman et al, in a prospective cohort study that included 36 female-to-male transsexual subjects report on laparoscopic robot-assisted hysterectomy plus bilateral salpingo-oopherectomy and robot-assisted laparoscopic colpectomy, and present it as a viable alternative to the vaginal approach (20). However, current evidence on this approach is limited.…”

Phalloplasty: understanding the chaos

“…For vaginectomy, there is variation in the specific technique used to ablate the vaginal mucosa. Although direct surgical excision may entail more blood loss, and although fulgarization may result in a higher chance of retained vaginal mucosa, at present, there appear to be limited data [14] indicating the superiority of any one of the three commonly employed methods: fulgarization [15] , direct surgical excision [16] , or dual-approach, robotically assisted excision [17] . The selected method depends on surgeon expertise and preference and on the staging and specific method of pars fixa construction.…”

“…For patients desiring urethral lengthening, pars fixa construction with concomitant vaginectomy provides additional layers of vascularized tissue that may prevent urologic complications [15] . However, due to anecdotal reports of urinary leakage and chronic accumulation in the vaginectomy cavity, which can require complex, secondary correction, some centers opt to perform vaginectomy at the time of hysterectomy and salpingo-oophorectomy [17,18] . Still, many high-volume centers prefer to perform vaginectomy at the time of pars fixa construction to allow the use of vascularized anterior vaginal myomucosal flaps to create a portion of the pars fixa urethra, hypothesizing that this may reduce the incidence of urinary strictures and fistulas [15,[19][20][21] .…”