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Background: Penile inversion vaginoplasty is the surgical gold standard for genital gender-affirmative surgery in transgender women. However, there is an increase of attention for gender-confirming vulvoplasty (GCV), in which no neovaginal cavity is created., Aim: To describe underlying motives and surgical outcomes of GCV in transgender women., Methods: All transgender women who underwent GCV were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording underlying motives, demographics, perioperative complications, and reoperations., Outcomes: Underlying motives and perioperative complication rate., Results: In the period January 1990 to January 2020, 17 transgender women underwent GCV at our center. Most women reported that their motivation to undergo GCV was because they had no wish for postoperative neovaginal penetration (n = 10, 59%). This was due to a sexual preference toward women without the wish for neovaginal penetrative intercourse (n = 6, 35%) or due to a negative sexual experience in the past (n = 4, 24%). Some women desired vaginoplasty with neovaginal cavity creation but were ineligible for this because of their medical history (n = 4, 24%), for example, due to locoregional radiotherapy. The median clinical follow-up was 34 months (range 3-190). The postoperative course was uncomplicated in 11 (65%) women. Postoperative complications comprised the following: meatal stenosis (n = 2, for which surgical correction), remnant corpus spongiosum tissue (n = 1, for which surgical correction), minor wound dehiscence (n = 3, for which conservative management), and postoperative urinary tract infection (n = 1, successfully treated with oral antibiotics). One woman, who developed meatal stenosis, had a history of radiotherapy because of rectal carcinoma and needed 2 surgical procedures under general anesthesia to correct this. Information on self-reported satisfaction was available for 12 women. All were satisfied with the postoperative result and they graded their neovagina an 8.2 ± 0.9 out of 10., Clinical Implications: GCV may be added to the surgical repertoire of the gender surgeon. Transgender women with a desire for genital gender-affirmative surgery should be counseled on surgical options and its (dis)advantages., Strengths & Limitations: Strengths of this study comprise that it is from a high-volume center. A weakness of this study is the retrospective design. The absence of a self-reported outcome measure validated for the transgender persons is a well-known problem., Conclusion: An increase is observed in transgender women who opt for GCV; however, the absolute number undergoing this surgery remains small in our center. Postoperative complications do occur but are generally minor and treatable. van der Sluis WB, Steensma TD, Timmermans FW, et al. Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes. J Sex Med 2020;17:1566-1573., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Penile inversion vaginoplasty is a commonly performed genital gender-affirming procedure in transgender women. The creation of an adequate functional neovaginal depth in cases of too little usable penile skin is a challenge. The bilateral pedicled epilated scrotal flap (BPES-flap) can be used as an easy adjunctive technique and may serve as a tool in the surgical armamentarium of the gender surgeon., Aim: To describe the use, dissection, design subtypes, and surgical outcomes of the BPES-flap in vaginoplasty., Methods: Perioperative considerations and different flap design subtypes were described to illustrate the possible uses of the BPES-flap in vaginoplasty. A retrospective chart study was performed on the use of this flap in 3 centers (blinded for review purposes)., Outcomes: The main outcome measures are description of surgical technique, flap design possibilities, and postoperative complications., Results: A total of 42 transgender women were included (median age: 28 years (range 18-66), mean body mass index: 24.5 ± 3.5). The mean penile length and width preoperatively were 9 ± 3.1 and 2.9 ± 0.2 cm, respectively. With a mean follow up of 13 ± 10 months, total flap necrosis occurred in one case (2.4%). Partial flap necrosis occurred also in one. Neovaginal reconstruction was successful in all patients with a mean vaginal depth of 13.5 ± 1.3 cm and width of 3.3 ± 1.3 cm. Partial prolapse of the neovaginal top occurred in 3 patients (7%)., Clinical Implications: The BPES-flap is a useful addition to the arsenal of surgeons performing feminizing genital reconstructive surgery., Strengths & Limitations: Strenghts comprise (1) the description of the surgical technique with clear images, (2) completeness of data, and (3) that data are from a multicenter study. A weakness is the retrospective nature with limited follow-up time., Conclusion: The BPES-flap is a vascularized scrotal flap that can be raised on the bilateral inferior superficial perineal arteries. It may be used for neovaginal depth creation during vaginoplasty and may be quicker to perform than full-thickness skin grafting. Nijhuis THJ, Özer M, van der Sluis WB, et al. The Bilateral Pedicled Epilated Scrotal Flap: A Powerful Adjunctive for Creation of More Neovaginal Depth in Penile Inversion Vaginoplasty. J Sex Med 2020;17:1033-1040., (Copyright © 2020 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

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.

Introduction: Some transgender men express the wish to undergo genital gender-affirming surgery. Metoidioplasty and phalloplasty are procedures that are performed to construct a neophallus. Genital gender-affirming surgery contributes to physical well-being, but dissatisfaction with the surgical results may occur. Disadvantages of metoidioplasty are the relatively small neophallus, the inability to have penetrative sex, and often difficulty with voiding while standing. Therefore, some transgender men opt to undergo a secondary phalloplasty after metoidioplasty. Literature on secondary phalloplasty is scarce., Aim: Explore the reasons for secondary phalloplasty, describe the surgical techniques, and report on the clinical outcomes., Methods: Transgender men who underwent secondary phalloplasty after metoidioplasty were retrospectively identified in 8 gender surgery clinics (Amsterdam, Belgrade, Bordeaux, Austin, Ghent, Helsinki, Miami, and Montreal). Preoperative consultation, patient motivation for secondary phalloplasty, surgical technique, perioperative characteristics, complications, and clinical outcomes were recorded., Main Outcome Measure: The main outcome measures were surgical techniques, patient motivation, and outcomes of secondary phalloplasty after metoidioplasty in transgender men., Results: Eighty-three patients were identified. The median follow-up was 7.5 years (range 0.8-39). Indicated reasons to undergo secondary phalloplasty were to have a larger phallus (n = 32; 38.6%), to be able to have penetrative sexual intercourse (n = 25; 30.1%), have had metoidioplasty performed as a first step toward phalloplasty (n = 17; 20.5%), and to void while standing (n = 15; 18.1%). Each center had preferential techniques for phalloplasty. A wide variety of surgical techniques were used to perform secondary phalloplasty. Intraoperative complications (revision of microvascular anastomosis) occurred in 3 patients (5.5%) undergoing free flap phalloplasty. Total flap failure occurred in 1 patient (1.2%). Urethral fistulas occurred in 23 patients (30.3%) and strictures in 27 patients (35.6%)., Clinical Implications: A secondary phalloplasty is a suitable option for patients who previously underwent metoidioplasty., Strengths & Limitations: This is the first study to report on secondary phalloplasty in collaboration with 8 specialized gender clinics. The main limitation was the retrospective design., Conclusion: In high-volume centers specialized in gender affirming surgery, a secondary phalloplasty in transgender men can be performed after metoidioplasty with complication rates similar to primary phalloplasty. Al-Tamimi M, Pigot GL, van der Sluis WB, et al. The Surgical Techniques and Outcomes of Secondary Phalloplasty After Metoidioplasty in Transgender Men: An International, Multi-Center Case Series. J Sex Med 2019;16:1849-1859., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To assess surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty., Patients and Methods: Transgender men who underwent penile prosthesis implantation after phalloplasty between January 1989 and September 2018 were retrospectively identified. A chart study was performed recording patient demographics, perioperative complications, and reoperations., Results: A total of 32 patients were identified: 22 underwent free radial forearm flap, 5 anterolateral thigh, 4 anterolateral thigh/free radial forearm flap, and 1 fibular flap phalloplasty. The median age at prosthesis implantation was 36 (range 21-59) years, the mean BMI 25.9 ± 4.0 kg/m 2 . At first implantation, 16 inflatable (AMS Dynaflex (n = 13), AMS Ambicor (n = 3)) and 16 malleable (Coloplast genesis (n = 14), AMS Spectra (n = 2)) prostheses were placed. Of these, 5 (16%) were removed/replaced because of infection, 2 (6%) because of leakage, 2 because of extrusion, 2 because of dislocation, 2 because of dysfunction, and 1 (3%) because of pain. The postoperative course was completely uneventful in 10 (31.3%) patients. Of all implanted prostheses, including revision procedures (n = 45), 21 (44%) were surgically replaced or removed., Conclusion: Prosthesis explantation, replacement, or revision surgery occurs frequently after penile prosthesis implantation. Patients need to be well-informed preoperatively on these complication rates., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Testicular prosthesis implantation may be used for neoscrotal augmentation in transgender men., Aim: Assess the clinical outcomes and risk factors for postoperative complications of this procedure in transgender men., Methods: All transgender men who underwent neoscrotal augmentation with testicular implants between January 1992 and December 2018 were retrospectively identified. A retrospective chart study was performed that recorded surgical characteristics and postoperative complications. Risk factors on complications were identified using uni- and multivariate analyses., Main Outcome Measure: Surgical outcomes included explantation due to infection, extrusion, discomfort, or leakage., Results: We identified 206 patients, and the following prostheses were placed: Dow Corning (n = 22), Eurosilicone (n = 2), Nagor (n = 205), Polytech (n = 10), Promedon (n = 105) , Prometel (n = 22), Sebbin (n = 44), and unknown (n = 2). The mean clinical follow-up time was 11.5 ± 8.3 years. In 43 patients (20.8%), one or both prostheses were explanted due to infection, extrusion, discomfort, prosthesis leakage, or urethral problems. Currently, scrotoplasty according to Hoebeke is the most frequently performed technique. Our review found that for this technique explantation occurred in 6 of 52 patients (11.5%). A history of smoking was a risk factor for postoperative infections and prosthesis explantation. In earlier years, larger prostheses were immediately placed at scrotal reconstruction; however, a trend can be seen toward smaller and lighter testicular prostheses and delayed implantation., Clinical Implications: Patients wanting to undergo this procedure can be adequately informed on postoperative outcomes., Strengths & Limitations: Strengths of this study include the number of patients, long clinical follow-up time, and completeness of data. Weaknesses of this study include its retrospective nature and the high variability of prostheses and surgical techniques used., Conclusion: Over the years, scrotoplasty techniques and testicular prostheses preferences have changed. Explantation rates have dropped over the last decade. Pigot GLS, Al-Tamimi M, Ronkes B, et al. Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men. J Sex Med 2019;16:1664-1671., (Copyright © 2019 International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD)., Patients and Methods: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations., Results: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%)., Conclusion: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures., (© 2018 The Authors BJU International © 2018 BJU International Published by John Wiley & Sons Ltd.)

Background: For many transgender women, vaginoplasty is the final stage in the gender-confirming process. Penile inversion vaginoplasty is considered the gold standard for vaginal construction in transgender women. In this study, the authors assessed intraoperative and postoperative complications after penile inversion vaginoplasty., Methods: All patients who underwent penile inversion vaginoplasty between January of 2000 and January of 2014 were identified retrospectively from the authors' hospital registry. A retrospective chart review was conducted. Outcome measures were intraoperative and postoperative complications, reoperations, secondary surgical procedures, and possible risk factors., Results: Between January of 2000 and January of 2014, 475 patients underwent penile inversion vaginoplasty, 405 of whom did not have and 70 of whom did have additional full-thickness skin grafts. The median patient age at surgery was 38.6 years (range, 18.1 to 70.8 years). Median follow-up was 7.8 years (range, 1.0 to 15.9 years). The most frequently observed intraoperative complication was rectal injury [n = 11 (2.3 percent)]. Short-term postoperative bleeding that required transfusion [n = 23 (4.8 percent)], reoperation [n = 7 (1.5 percent)] or both [n = 2 (0.4 percent)] occurred in some cases. Major complications comprised three (0.6 percent) rectoneovaginal fistulas, which were successfully treated. Revision vaginoplasty was performed in 14 patients (2.9 percent). Comorbid diabetes was associated with a higher risk of local infection (OR, 9.8; p = 0.003; 95 percent CI, 2.8 to 34.4), and use of psychotropic medication predisposed to postoperative urinary retention (OR, 2.1; p = 0.006; 95 percent CI, 1.2 to 3.5)., Conclusions: Successful vaginal construction without the need for secondary functional reoperations was achieved in the majority of patients. Intraoperative complications are scarce. Postoperative complications occur frequently but are generally minor and easily treated., Clinical Question/level of Evidence: Therapeutic, IV.

Background: In young transgender women previously treated with puberty-suppressing hormones, penoscrotal hypoplasia can make penoscrotal inversion vaginoplasty unfeasible. The aim of this study was to prospectively assess surgical outcomes and follow-up of total laparoscopic sigmoid vaginoplasty as primary reconstruction in a cohort of transgender women with penoscrotal hypoplasia., Methods: Baseline demographics, surgical characteristics, and intraoperative and postoperative complications of all performed total laparoscopic sigmoid vaginoplasty procedures were prospectively recorded., Results: From November of 2007 to July of 2015, 42 transgender women underwent total laparoscopic sigmoid vaginoplasty as primary vaginal reconstruction. The mean age at the time of surgery was 21.1 ± 4.7 years. Mean follow-up time was 3.2 ± 2.1 years. The mean operative duration was 210 ± 44 minutes. There were no conversions to laparotomy. One rectal perforation was recognized during surgery and immediately oversewn without long-term consequences. The mean length of hospitalization was 5.7 ± 1.1 days. One patient died as a result of an extended-spectrum beta-lactamase-positive necrotizing fasciitis leading to septic shock, with multiorgan failure. Direct postoperative complications that needed laparoscopic reoperation occurred in three cases (7.1 percent). In seven cases (17.1 percent), long-term complications needed a secondary correction. After 1 year, all patients had a functional neovagina with a mean depth of 16.3 ± 1.5 cm., Conclusions: Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery. Primary total laparoscopic sigmoid vaginoplasty is a feasible gender-confirming surgical technique with good functional outcomes for transgender women with penoscrotal hypoplasia., Clinical Questio/level of Evidence: Therapeutic, IV.

A 46-year-old, HIV-positive transgender woman of South American ethnicity consulted our outpatient clinic to discuss the possibilities of a surgical, secondary neovaginal reconstruction because of complete stenosis of her inverted penile skin-lined neovagina. She was taking abacavir/lamivudine and nevirapine as antiretroviral therapy. We successfully performed a total laparoscopic sigmoid vaginoplasty without any complications. There was no short-term morbidity and no complications were reported after 15 months of follow-up. To our knowledge, this is the first report of laparoscopic sigmoid vaginoplasty as vaginal reconstruction in a HIV-positive transgender woman. Worldwide, transgender women have a high burden of HIV infection. This report shows that intestinal vaginoplasty is a feasible surgical option for HIV-positive transgender women in need of vaginal reconstruction. Because patients are again able to engage in penetrative sexual intercourse, we emphasise the importance of practicing safe sex and early initiation of adequate antiretroviral therapy in this patient population., (© The Author(s) 2015.)

Introduction: In the treatment of transgender women, the surgical construction of a neo-vagina, or vaginoplasty, is the final stage in the transition to the desired gender. Surgeons aim to create a neovagina that is in function and appearance as close to a biological vagina as possible. However, to date, it is insufficiently clear whether transgender women are satisfied with the functional and cosmetic outcomes of vaginoplasty., Aims: Our aim was to assess if penile skin inversion neovaginoplasty performed in transgender women meet the objectives strived for, by determining functional and aesthetic outcomes, as well as the physical and sexual well-being and satisfaction., Methods: We performed a retrospective survey study on 49 transgender women who underwent vaginoplasty using the penile skin inversion technique. Participants were asked to fill out the Female Sexual Function Index (FSFI), a combination of the Amsterdam Hyperactive Pelvic Floor Scale--Women (AHPFS-W) and the Female Genital Self-Imaging Scale, and a short questionnaire for self-evaluation of vaginoplasty. Photographs of the genitalia were taken for objective assessment by an independent panel., Main Outcome Measures: Primary outcomes were the functional and aesthetic evaluation as perceived by the trangender women themselves. Secondary outcomes were the aesthetic evaluation of the vaginoplasty by an independent panel., Results: Functionality and appearance were both given an average score of 8 out of 10. Despite this high score, 56% is sexually dysfunctional according to the FSFI, mainly because of not being sexually active, or due to problems with lubrication and discomfort. In 75%, the result met the expectation and 70% thinks their genital is feminine enough., Conclusion: This study demonstrates that, despite relatively low FSFI scores, this group of transgender women is very satisfied with both the functional and aesthetic results of neovaginoplasty using penile skin inversion., (© 2015 International Society for Sexual Medicine.)

Introduction: Gender reassignment surgery is the keystone of the treatment of transgender patients. For male-to-female transgenders, this involves the creation of a neovagina. Many surgical methods for vaginoplasty have been opted. The penile skin inversion technique is the method of choice for most gender surgeons. However, the optimal surgical technique for vaginoplasty in transgender women has not yet been identified, as outcomes of the different techniques have never been compared., Aim: With this systematic review, we aim to give a detailed overview of the published outcomes of all currently available techniques for vaginoplasty in male-to-female transgenders., Methods: A PubMed and EMBASE search for relevant publications (1995-present), which provided data on the outcome of techniques for vaginoplasty in male-to-female transgender patients., Main Outcome Measures: Main outcome measures are complications, neovaginal depth and width, sexual function, patient satisfaction, and improvement in quality of life (QoL)., Results: Twenty-six studies satisfied the inclusion criteria. The majority of these studies were retrospective case series of low to intermediate quality. Outcome of the penile skin inversion technique was reported in 1,461 patients, bowel vaginoplasty in 102 patients. Neovaginal stenosis was the most frequent complication in both techniques. Sexual function and patient satisfaction were overall acceptable, but many different outcome measures were used. QoL was only reported in one study. Comparison between techniques was difficult due to the lack of standardization., Conclusions: The penile skin inversion technique is the most researched surgical procedure. Outcome of bowel vaginoplasty has been reported less frequently but does not seem to be inferior. The available literature is heterogeneous in patient groups, surgical procedure, outcome measurement tools, and follow-up. Standardized protocols and prospective study designs are mandatory for correct interpretation and comparability of data., (© 2015 International Society for Sexual Medicine.)