Urological Care for the Transgender Patient: A Comprehensive Guide

Description

This book is designed to familiarize general urologists with the care of transgender and gender non-conforming individuals. Written by experts in reconstructive urology, it characterizes the process of gender affirmation and explains the surgical anatomy of both feminizing and masculinizing gender-affirming procedures including vaginoplasty, orchiectomy, hysterectomy, vaginectomy, phalloplasty, metoidioplasty, and prosthetics. Guiding the clinician in identification of immediate and long-term risks of gender-affirming surgery, it instructs clinicians in endocrinological care, options for fertility preservation, evaluation of malignancies after hormonal therapy, appropriate postsurgical follow-up, and the management of common complications involving urethral stricture, fistula, neo-vaginal stenosis, and incontinence. Urological Care for the Transgender Patient: A Comprehensive Guide is a necessary tool to prepare urological clinics and clinicians in serving the growing population of transgender patients presenting at various stages of their transformation. Preface Contents Contributors Part I: Overview, Decision Making, Endocrinological Care, and Pre-operative Considerations 1: The Current State of Transgender Care A Changing Landscape for Patients and Physicians Disparities and the Road to Healthcare Equality Medical Education References 2: Decision-Making in Masculinizing Surgery and Feminizing Surgery Masculinizing Genital Gender Affirming Surgery Choice for Phalloplasty Donor Site Phallus Length Desired Length and Appearance Desired Length and Surgical Outcomes Desired Length and Future Penile Prosthesis Placement Decision-Making Aids Erogenous Sensation Genitourinary Prosthetics Testicle Prosthesis Size Inflatable Penile Prosthesis Type and Size Number of Cylinders Feminizing Genital Gender Affirming Surgery Vaginoplasty Weighing the Relative Advantages and Disadvantages Associated with a Vaginal Canal General Concerns Related to Feminizing gGAS that Many Patients Share Development of a Feminizing gGAS Discussion Aid Decision-Making and Vaginal Depth Conclusions References 3: Endocrinological Care for Patients Undergoing Gender Affirmation (Including Risk of Thromboembolic Events) Introduction to the Role of Hormonal Therapy Hormone Therapy for Transgender Women Estrogens Anti-androgens Progesterone and Progestins Expected Effects of Feminizing Hormone Therapy Risks of Feminizing Hormone Therapy Venous Thromboembolism Cardiovascular Disease Liver and Gallstones Prolactin Prostate Cancer Breast Cancer Monitoring Feminizing Hormone Therapy Hormone Therapy for Transgender Men Testosterone Regimens Adjuvant Therapies Expected Effects of Virilizing Hormone Therapy Risks of Virilizing Hormone Therapy Polycythemia Venous Thromboembolism Cardiovascular Risk Skin and Hair Perioperative Hormone Management Discontinuation of Estrogen Before Surgery Discontinuation of Testosterone Before Surgery Role of DHT Cream Prior to Metoidioplasty References 4: Preoperative Preparation and Perioperative Considerations for Gender-Affirming Genital Surgery Introduction Understanding Patient Desires and Expectations Patient Education Patient Preparation for Surgery Clinic and Hospital System Preparedness Trauma-Informed Care Conclusion References Part II: Surgical Anatomy: Transgender Female Patients 5: Surgical Anatomy: Orchiectomy and Fertility Preservation Options Introduction Surgical Anatomy Inguinal Region Gross Anatomy Arterial Supply and Venous Drainage Scrotum Gross Anatomy Arterial Supply Venous Drainage Lymphatic Drainage Nerve Supply Spermatic Cord Gross Anatomy Arterial Supply and Venous Drainage Lymphatic Supply Orchiectomy Techniques and Approaches Staged (Early) Orchiectomy Inguinal Approach [6] Scrotal Approach [7] Single-Stage Orchiectomy and Vaginoplasty Prevention and Management of Complications Fertility Preservation Options Sperm Cryopreservation Testicular Sperm Extraction Testicular Tissue Cryopreservation Financial Considerations Conclusion References 6: Surgical Anatomy: Vaginoplasty Introduction History of the Procedure Demographics Preoperative Planning and Assessment WPATH Guidelines Our Practice Preferences Considerations for Minors Preoperative Patient-Related Factors Surgical Anatomy Review of the Female Genital Anatomy Aesthetic Parameters of Transgender Female Genitalia Anatomy of Colon Anatomy of Perineum and Rectum Vaginoplasty Techniques Standard Inversion Technique Visceral Interposition (Fig. 6.14) Peritoneal Vaginoplasty After Discharge Care Pathway Outcomes Patient Satisfaction Sexual Function Revision Rates Patient Regrets Complications Immediate Perioperative Complications Vaginal Stenosis Rectovaginal Fistula Conclusions References 7: Complications of Vaginoplasty Introduction Brief Overview of Complications and Outcomes Intraoperative Complications Rectal Injury Bladder or Urethral Injury Pelvic Floor Muscle Dissection Associated Complications Early Postoperative Complications Periurethral Bleeding and Hematoma Formation Urinary Retention Urinary Tract Infections Neovaginal Prolapse Graft Loss Granulation Tissue Wound Dehiscence Delayed Complications Vaginal Stenosis Rectoneovaginal Fistula Urethroneovaginal Fistula Urethral Stricture and Urethral Malposition Urethral Bulb Bulge Lower Urinary Tract Function Hair in the Neovaginal Canal Clitoral Exposure/Cosmesis Conclusion References Part III: Surgical Anatomy: Transgender Male Patients 8: Surgical Anatomy - Hysterectomy for Transgender Men Introduction Pelvic Anatomy of the Transgender Man Uterus Fallopian Tubes Ovaries Cervix Vagina External Genitalia Ureters Important Considerations Hysterectomy for a Transgender Man World Professional Association for Transgender Health Criteria Perioperative Considerations Operating Room Environment Pregnancy Testing Management of Testosterone Fertility Counseling Choosing the Route of Surgery Vaginal Approach Minimally Invasive Abdominal Approach Open Abdominal Approach Vaginal Exam and Vaginal Cuff Closure Complications Associated with Hysterectomy Concurrent Procedures at the Time of Hysterectomy Concurrent Vaginal Vault Suspension Concurrent Salpingectomy and Oophorectomy Concurrent Vaginectomy +/− Phalloplasty at the Time of Hysterectomy Concurrent Chest Surgery at the Time of Hysterectomy Postoperative Considerations Summary References 9: Surgical Anatomy: Metoidioplasty Introduction Anatomical Considerations The Clitoris Labia Minora and Majora The Urethra Metoidioplasty Techniques Simple Metoidioplasty Ring Metoidioplasty Belgrade Metoidioplasty Creation of the Neophallus Urethral Reconstruction Scrotoplasty Perioperative Care Outcomes and Complications Outcomes Complications Conclusions References 10: Surgical Anatomy: Phalloplasty Introduction Goals of Reconstruction Preoperative Considerations/Indications Reconstructive Options Surgical Anatomy Operative Technique Hospital Course Outpatient Care Outcomes/Conclusion References 11: Management of Urologic Complications Following Metoidioplasty and Phalloplasty Introduction Anatomy of Transmasculine Genital Surgery Vaginectomy Metoidioplasty Phalloplasty Urologic Complications Urethrocutaneous Fistulas Persistent Vaginal Cavity Urethral Strictures Patient Presentation Evaluation Preoperative Planning Fistula Repair Techniques Techniques for Obliteration of a Persistent Vaginal Cavity Endoscopic Stricture Management Urethroplasty Techniques Meatal Reconstruction Single-Stage Anastomotic Techniques for Anastomotic Strictures Single-Stage Substitution Techniques for Anastomotic Strictures Staged Techniques Perineal Urethrostomy Challenges of Reconstructive Surgery References 12: Prosthetics: Erectile Implant, Testicular Implants Introduction Indications for Phalloplasty Considerations in Neophallus Creation Overview of Phalloplasty Technique (Table 12.1) Alternatives to Prostheses Penile Prosthesis Prosthesis Types Surgical Technique Surgical Preparation and Approach Single vs Dual Cylinders Vascular Grafts for Neotunical Reconstruction and Proximal Anchoring Postoperative Care Complications (Table 12.2) Infection Extrusion and Erosion Migration Device Leak and Failure Vascular Compromise Device-Specific Adaptations Patient-Reported Outcomes Testicular Prostheses Criteria for Placement Types of Testicular Prostheses Postoperative Care for Testicular Implants Complications of Testicular Implants Conclusions References Part IV: Perioperative Care and Follow Up 13: General Urological and Endourological Considerations in the Care for Transgender Patients: Catheters, Scopes and Haematuria, UTI, Stones and Surgical Positioning Introduction Anatomy of Transgender Female Urethras Catheters Cystourethroscopy Haematuria Urinary Tract Infections Stones Surgical Positioning Transgender Male Urethras Catheters Cystourethroscopy Haematuria Urinary Tract Infections Stones Surgical Positioning References 14: Care of Transgender Patients: Oncological Concerns Introduction Standard Screening Prostate Cancer Screening Testicular Cancer Penile Cancer Endometrial Cancer Patient History Transgender Surgery: Surgical Extirpation Specifics Genital Surgery for a Transgender Female Removal Reconstruction Genital Surgery for the Transgender Male Removal Reconstruction Organ-Specific Cancer Concerns Transgender Females Prostate Cancer Testicular Cancer Breast Cancer Neovagina Transgender Males Cervical Cancer Breast Cancer Ovarian Cancer Vaginal Cancer Surgical Considerations Conclusion References 15: Care of Transgender Patients: Incontinence Incontinence Background and Epidemiology Risk Factors Evaluation of Urinary Incontinence Physical Examination Testing Treatment of Bladder Overactivity and Urge Incontinence Treatment of Stress Urinary Incontinence Types of Incontinence Specific to the Transgender Patient Conclusions References 16: The Role of Physical Therapy in the Care of Transgender Patients Introduction What Is Physical Therapy? What Is Pelvic Floor Physical Therapy? Elements of Patient Management (Table 16.1) [6] Examination History Systems Review (Table 16.2) Tests and Measures Evaluation Diagnosis Prognosis Intervention Outcome Measures Summary References Part V: Special Topics—Regrets, Robotics, and History 17: Regrets in Transgender Female: Reversal Phalloplasty Introduction Regret Phenomenon Reversal Surgery Conclusions References 18: Robotic Applications in Gender Affirming Genital Surgery Introduction Operative Equipment Robotic Applications in Feminizing Surgery Robotic Peritoneal Flap Vaginoplasty Technique Postoperative Care Outcomes Robotic Revision Peritoneal Flap Vaginoplasty Robotic Enteric Vaginoplasty Robotic Applications in Masculinizing Surgery Robotic Vaginectomy Technique Robotic Vaginal Remnant Excision Potential Complications of Robotic GAS Approaches Risks of Robotic Canal Dissection General Risks of Transabdominal Robotic Approaches Future Directions References 19: Brief History of Gender Affirmation Medicine and Surgery Introduction Ancient History and Mythology Modern History – Europe Modern History (Twentieth Century Onwards) – United States Transgender Individuals Today References Index