ESGURS: Penile reconstruction for genital gender affirmation surgery

Mr. Wai Gin (Don) Lee St. Peter’s Andrology Centre University College London Hospital London (GB)

waigin.lee@nhs.net

Mr. Nim Christopher St. Peter’s Andrology Centre University College London Hospital London (GB)

nim@ andrology.co.uk

Prof. David Ralph St. Peter’s Andrology Centre University College London Hospital London (GB)

david@ andrology.co.uk

Centres in Europe and the United Kingdom have been at the forefront of genital gender affirmation surgery (GAS) for transmasculine individuals over the recent decades. Originating from China, the groundbreaking use of microvascular free-flap transfer from the radial forearm (RF) by Chang and Hwang1 for penile reconstruction led to a renaissance in this field in 1984. Subsequently, significant advances have continued predominantly in European centres. Alternative tissue flaps and reconstructive refinements have been developed and our understanding of the staging and outcomes of genital GAS have progressed considerably since that time.

This article discusses the role of genital GAS and summarises some of the centres in Europe and the UK that offer genital GAS for transmasculine individuals. The contemporary techniques offered by these centres are briefly discussed, and the functional outcomes reported.

Role of genital GAS Incongruence between the gender identity of an individual and their sex assigned at birth is distressing with significant repercussions, such as the risk of self-harm and suicide. Half of transgender and gender non-binary (transmasculine) individuals have attempted suicide2 and they are subject to stigmatisation, physical abuse and sexual assault. Most choose to transition physically to align with their gender identity more closely by use of gender affirming hormone therapy and surgery.

Genital GAS further ameliorates gender dysphoria experienced by transmasculine individuals who are on gender affirming hormone therapy. Body satisfaction scores are higher following surgery and gender affirming hormone therapy compared to hormone therapy alone3. Furthermore, individuals awaiting genital GAS were less satisfied compared to those who did not wish to have genital GAS. Hence, transmasculine individuals should not be deprived of surgery if they desire it.

Assessment for genital surgery Transmasculine individuals seeking genital GAS should meet the World Professional Association for Transgender Health Standards of Care4. Revised guidelines (version 8) are due for release in 2021. Individuals should have persistent and documented gender dysphoria and be of adult age in their country. They need to have received 12 months of continuous gender affirmation hormone therapy (unless contraindicated) and have lived in a gender role that is congruent with their gender identity for a similar period. European centres for gender affirmation surgery Most European centres were invited to contribute their data and thirteen responded in time for publication (see Table 1). Amsterdam (NL) was the first centre established for genital GAS in 1980. They remain the largest centre in Europe for phalloplasty (8 surgeons) and have contributed significant innovations to this field5. London (UK) currently has the highest volume for phalloplasty and was the first to combine two tissue flaps for penile and urethral reconstruction in 2003. The number of centres has increased by 63% in the last 3 years. Most centres offer several different flaps for phalloplasty to accommodate the requirements of each transmasculine individual.

Funding Models of funding differed significantly between centres. Centres in the United Kingdom, Germany, France, the Netherlands and Italy offer genital GAS fully funded by the government or health service for residents. Other centres like Belgium require a co-payment by the patient while some others were only available to those who self-fund or are privately insured. Some centres (e.g., London and Belgrade) also offer genital GAS to individuals from abroad on a self-funded or insured basis.

Options for penile reconstruction The ideal neophallus should be aesthetically appealing and sensate (to both tactile and erogenous stimulus) while allowing standing micturition and penetrative intercourse6. This should be achieved in a single operation with minimal donor-site morbidity. Disappointingly, there is no single technique that currently meets all the above requirements.

Transmasculine individuals can choose between micro (metoidioplasty) or full-size (phalloplasty) penile reconstruction. Both options offer advantages and disadvantages, and it is the role of the reconstructive surgeon to guide and tailor the approach to the individual. Not all individuals will want, require or qualify for all procedures.

Phalloplasty Phalloplasty offers the most complete genital transformation currently available (see Figs. 1 and 2). A full-size neophallus is necessary to engage in penetrative intercourse. Most centres in Europe prefer distant tissue flaps that require microsurgical techniques (free flaps) or transfer of the flap while preserving the original blood supply (pedicled flaps). The primary advantage of free flaps is that the urethra can be integrated in the flap design resulting in a single stage, well-vascularised “tube-within-a-tube” urethra. Several centres (see Table 1) perform urethral join-up (or lengthening) at the time of phalloplasty.

Radial forearm free flap The most common flap for phalloplasty in Europe (and the world) is the RF free flap1 (see Table 1). The RF flap is considered the gold standard because of the thin, pliable forearm skin, which is often hairless in the urethral segment. Also, the flap has a reliable vascular pattern with a long pedicle and multiple sensory cutaneous nerves to facilitate flap transfer. The primary disadvantages are the visible donor site on the forearm and the neophallus colour mismatch with the surrounding skin. The neophallus may also lack girth in individuals with less subcutaneous fat.

Alternative tissue flaps The anterolateral thigh (ALT) flap (pedicled or free), musculocutaneous latissimus dorsi flap (free) and superficial circumflex iliac artery perforator (SCIP) flap (pedicled) are alternatives to the RF flap. In particular, the ALT flap is gaining in popularity because it is a pedicled flap (around 90% of the time) that does not require microsurgical anastomosis and results in a generous neophallus (see Table 2). The neophallus colour match is better than for the RF free flap but hair removal of the urethral segment is invariably required prior to phalloplasty. The thicker subcutaneous fat in the thigh may also complicate tubularisation of the neophallus and urethra in some individuals. The donor site wound in the upper thigh remains significant although it is better hidden. The abdominal (pedicled) flap (AF) continues to play a role in phalloplasty and is offered in most centres. The flap is ideal for those who wish to minimise donor site morbidity or would prefer a shorter operative and recovery time. The AF should also be considered in individuals with multiple co-morbidities that may complicate free flap phalloplasty.

Osteocutaneous flaps such as the fibular flap have fallen out of favour due to significant donor site morbidity and insufficient penile rigidity due to problematic proximal bone fixation. A permanent erection is also less desirable.

Combination flaps Some centres combine two different flaps to reduce the donor-site morbidity and defects resulting from the transfer of a single large flap with integrated urethra. A free flap urethroplasty is also useful to construct a well-vascularised urethra in a neophallus that would otherwise not have an integrated urethra.

Table 1: Centres in Europe that offer phalloplasty gender affirmation surgery

Unit (Country) Year Specialty (n) Volume (n/year) Type of flaps for phalloplasty

Amsterdam (Netherlands) 1980 Urology (6) Plastics (2) 80 RF, ALT, SCIP, AF, combination flaps

Frankfurt (Germany)

1989 Urology (2) Plastics (4) Lyon (France) 1990 Urologist (3) Plastics (1)

Belgrade 1 (Serbia) 1992 Urology (2) Plastics (1) 20

25

72 RF, ALT

RF, MLD, ALT, AF (preexpanded) MLD, ALT, AF

Ghent (Belgium) 1993 Urology (4) Plastics (2) 40 RF, ALT Staged join-up

No (mostly)

No (mostly)

Yes

Yes

No

London (UK) 2001 Urology (3) Plastics (1) 110

Belgrade 2 (Serbia) 2003 Urology (2) Plastics (1) General Surg (1) 40

Munich (Germany) 2016 Urologist (1) Plastics (1) 100

Turin (Italy) 2018 Urology (2) 20 Lille (France) 2018 Urology (1) Plastics (2) 5

Warsaw (Poland) 2018 Urology (1) 15 RF, ALT, AF, combination flaps MLD Yes

Yes

RF, ALT, SCIP/groin Yes

RF, ALT, AF RF, ALT, AF, DIEP Yes

RF, ALT, AF Yes

Belgrade 3 (Serbia) 2019 Urology (2) Plastics (1) 12 RF, MLD, AF Both

Freiburg (Germany) 2020 Urology (2) Plastics (2) RF Yes

Abbreviations: RF, radial forearm free flap; ALT, anterolateral thigh flap; SCIP, superficial circumflex iliac artery perforator flap; AF, abdominal flap; MLD, musculocutaneous latissimus dorsi flap; DIEP, deep inferior epigastric artery flap * has not started phalloplasty service

Index of gender affirmation surgery units (alphabetical order) Amsterdam: Amsterdam University Medical Centre Belgrade 1: Belgrade Centre for Urogenital Reconstructive Surgery, Belgrade University Belgrade 2: Sava Perovic Foundation Belgrade 3: Andromedic Academy Belgrade, Belgrade University Frankfurt: Agaplesion Markus Krankenhaus Freiburg: University Medical Centre Freiburg, Department for Urology, Unit for Gender Surgery Ghent: Ghent University Hospital Lille: Service d’ Urologie, Andrologie et Transplantation Rénale, Hôpital Claude Huriez London: St Peter’s Andrology Centre Lyon: Urology department, Hôpital Lyon Sud. Plastic surgery department, Hôpital de la Croix Rousse Munich: Centre for Reconstructive Urogenital Surgery, Urologische Klinik München Planegg Turin: Urology clinic, Citta della salute e della scienza, University of Turin Warsaw: Warsaw/Bydgoszcz

Table 2: Comparison of functional and aesthetic outcomes of commonly used flaps for phalloplasty

Flap Sensation Donor site morbidity Colour match Single stage urethra* Bulky RF Best Visible No Yes No ALT Yes Hidden Yes Some Yes MLD Poor Hidden No No Yes OF Yes Long term weakness No No No and instability AF Variable Hidden Yes No Yes Scapular No Hidden No Yes No

Abbreviations: RF, radial forearm free flap; ALT, anteriolateral thigh flap; MLD, musculocutaneous latissimus dorsi flap; OF, osteocutaneous fibula free flap; AF, abdominal flap *single stage/without further flap surgery