Urethrographic Evaluation of Anatomic Findings and Complications after Perineal Masculinization and Phalloplasty in Transgender Patients

Abstract

Transgender patients seeking gender-affirming surgery are a growing population with unique health care needs. The radiologist must understand the challenges these patients face to facilitate a positive patient-physician interaction during the series of postoperative fluoroscopic evaluations. The authors present a standard two-stage surgical approach and common postoperative fluoroscopic findings after perineal masculinization and phalloplasty procedures. Perineal masculinization including urethral lengthening is performed first, followed by skin-flap-based phalloplasty. Patients undergo voiding cystourethrography (VCUG) after intravesical administration of contrast media by way of an indwelling suprapubic catheter after each stage. Retrograde urethrography plays a complementary role to supplement the limitations of VCUG after the second stage. The article reviews the expected postoperative anatomy and explains standardized terminology developed at the authors' institution. Imaging features of common and rare complications are discussed, including contained leak, stenosis, occlusion, and fistula. The successful postoperative imaging study in a transmasculine patient relies on open communication among the interdisciplinary team of specialized surgeons, radiologists, and medical providers, as well as special modifications to existing imaging techniques. © RSNA, 2020 • radiographics.rsna.org

“Urinary Reconstruction in Genital Gender-Affirming Surgery: Checking Our Surgical Complication Blind Spots”

“…Our review revealed a lack of description of colpectomy complications, but there was high incidence (7.8% to 43.7%) of this finding in alternative cohorts of patients presenting for revision surgery. 14 Inconsistent language for similar findings may be the reason for this discrepancy, as the literature reported revisions for “perineal cyst,” 39 “persistent vaginal cavity,” 40 “fistula to native vagina,” 41 “diverticulum,” 42,43 and “mucocele.” 44 Vaginal remnant may have been used to refer to a space upon which full colpectomy was never performed, 45–47 whereas today, colpectomy is frequently advised in patients who wish to ultimately stand to void without device assistance. 48 Avoidance of this complication begins with complete, sharp excision of the vaginal mucosa using a transperineal, laparoscopic, or robotically assisted approach, and closure of the vaginal space with suture, 49 whereas some advocate for the use of an additional gracilis flap to further obliterate this space and buttress the urethral anastomosis.…”

Multidisciplinary approach to imaging for gender-affirming surgery: engaging surgeons, radiologists, and patients to ensure a positive imaging experience

“…Voiding cystourethography and retrograde urethography are frequently used for the evaluation of neourethral patency and integrity after perineal masculinization (phalloplasty, metoidioplasty) (19). Imaging facilities should schedule extra time for the urethrographic studies in transmasculine persons as patients may have heightened anxiety given that these procedures may require exposure of sensitive anatomic areas.…”

Imaging evaluation for the diagnosis and management of complications of gender-affirming surgeries

“…VCUG is generally the test of choice for immediate post-operative evaluation as suprapubic catheters are generally placed at the time of surgery allowing for access to the urinary bladder with minimal manipulation of the neourethra (Figure 3). Patients who no longer have suprapubic catheters in place undergo RUG (9). Urethrography readily identifies most of the complications, of which urethrocutaneous fistulas occur with the highest frequency and an incidence ranging from 15% to 70% (10).…”