gender reassignment surgery icd 10 pcs

This Clinical Policy Bulletin addresses gender affirming surgery. 

: Some plans may cover gender affirming procedures in addition to the following policy. Please check the specific benefit plan documents.

Aetna considers gender affirming surgery medically necessary when criteria for each of the following procedures is met:

Gender-specific services may be medically necessary for transgender persons appropriate to their anatomy.  Examples include:

Aetna considers reversal of gender affirming surgery (performing surgical procedures to return anatomy to that of the sex assigned at birth) medically necessary for persons who regret their gender-related surgical intervention, where applicable requirements for gender affirming surgery listed above are met.

Aetna considers gonadotropin-releasing hormone medically necessary to suppress puberty in trans identified adolescents if they meet World Professional Association for Transgender Health (WPATH) criteria (see ).

Aetna considers more than one breast augmentation not medically necessary. This does not include the medically necessary replacement of breast implants (see ).

Aetna considers the following procedures that may be performed as a component of a gender transition as not medically necessary and cosmetic (not an all-inclusive list) (see also ):

The International Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) and the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) are the diagnostic classifications and criteria manuals used in the United States.  Notwithstanding, the World Professional Association of Transgender Health Standard of Care 8th edition (WPATH SOC8) states: “While Gender Dysphoria (GD) is still considered a mental health condition in the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5-TR) of the American Psychiatric Association. Gender incongruence is no longer seen as pathological or a mental disorder in the world health community. Gender Incongruence is recognized as a condition in the International Classification of Diseases and Related Health Problems, 11th Version of the World Health Organization (ICD-11). Because of historical and current stigma, TGD people can experience distress or dysphoria that may be addressed with various gender-affirming treatment options. While nomenclature is subject to change and new terminology and classifications may be adopted by various health organizations or administrative bodies, the medical necessity of treatment and care is clearly recognized for the many people who experience dissonance between their sex assigned at birth and their gender identity.”

Gender dysphoria refers to discomfort or distress that is caused by a discrepancy between an individual’s gender identity and the gender assigned at birth (and the associated gender role and/or primary and secondary sex characteristics). A diagnosis of gender dysphoria requires a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. This condition may cause clinically significant distress or impairment in social, occupational or other important areas of functioning.  

Gender affirming surgery is performed to change primary and/or secondary sex characteristics. For transfeminine (assigned male at birth) gender transition, surgical procedures may include genital reconstruction (vaginoplasty, penectomy, orchidectomy, clitoroplasty), breast augmentation (implants, lipofilling), and cosmetic surgery (facial reshaping, rhinoplasty, abdominoplasty, thyroid chondroplasty (laryngeal shaving), voice modification surgery (vocal cord shortening), hair transplants) (Day, 2002). For transmasculine (assigned female at birth) gender transition, surgical procedures may include mastectomy, genital reconstruction (phalloplasty, genitoplasty, hysterectomy, bilateral oophorectomy), mastectomy, and cosmetic procedures to enhance male features such as pectoral implants and chest wall recontouring (Day, 2002).

The criterion noted above for some types of genital surgeries is based on expert clinical consensus that this experience provides ample opportunity for patients to experience and socially adjust in their desired gender role, before undergoing irreversible surgery (Coleman, et al., 2022). 

It is recommended that transfeminine persons undergo feminizing hormone therapy (minimum 6 months) prior to breast augmentation surgery. The purpose is to maximize breast growth in order to obtain better surgical (aesthetic) results.

In addition to hormone therapy and gender affirming surgery, psychological adjustments are necessary in affirming sex. Treatment should focus on psychological adjustment, with hormone therapy and gender affirming surgery being viewed as confirmatory procedures dependent on adequate psychological adjustment. Mental health care may need to be continued after gender affirming surgery. The overall success of treatment depends partly on the technical success of the surgery, but more crucially on the psychological adjustment of the trans identified person and the support from family, friends, employers and the medical profession.

Nakatsuka (2012) noted that the third versions of the guideline for treatment of people with gender dysphoria (GD) of the Japanese Society of Psychiatry and Neurology recommends that feminizing/masculinizing hormone therapy and genital surgery should not be carried out until 18 years old and 20 years old, respectively.  On the other hand, the sixth (2001) and the seventh (2011) versions of the standards of care for the health of transsexual, transgender, and gender non-conforming people of World Professional Association for Transgender Health (WPATH) recommend that transgender adolescents (Tanner stage 2, [mainly 12 to 13 years of age]) are treated by the endocrinologists to suppress puberty with gonadotropin-releasing hormone (GnRH) agonists until age 16 years old, after which gender-affirming hormones may be given.  A questionnaire on 181 people with GID diagnosed in the Okayama University Hospital (Japan) showed that female to male (FTM) trans identified individuals hoped to begin masculinizing hormone therapy at age of 15.6 +/- 4.0 (mean +/- S.D.) whereas male to female (MTF) trans identified individuals hoped to begin feminizing hormone therapy as early as age 12.5 +/- 4.0, before presenting secondary sex characters.  After confirmation of strong and persistent trans gender identification, adolescents with GD should be treated with gender-affirming hormone or puberty-delaying hormone to prevent developing undesired sex characters.  These treatments may prevent transgender adolescents from attempting suicide, suffering from depression, and refusing to attend school. 

Spack (2013) stated that GD is poorly understood from both mechanistic and clinical standpoints.  Awareness of the condition appears to be increasing, probably because of greater societal acceptance and available hormonal treatment.  Therapeutic options include hormone and surgical treatments but may be limited by insurance coverage because costs are high.  For patients seeking MTF affirmation, hormone treatment includes estrogens, finasteride, spironolactone, and GnRH analogs.  Surgical options include feminizing genital and facial surgery, breast augmentation, and various fat transplantations.  For patients seeking a FTM gender affirmation, medical therapy includes testosterone and GnRH analogs and surgical therapy includes mammoplasty and phalloplasty.  Medical therapy for both FTM and MTF can be started in early puberty, although long-term effects are not known.  All patients considering treatment need counseling and medical monitoring.

Leinung and colleagues (2013) noted that the Endocrine Society's recently published clinical practice guidelines for the treatment of transgender persons acknowledged the need for further information on transgender health.  These investigators reported the experience of one provider with the endocrine treatment of transgender persons over the past 2 decades. Data on demographics, clinical response to treatment, and psychosocial status were collected on all transgender persons receiving gender-affirming hormone therapy since 1991 at the endocrinology clinic at Albany Medical Center, a tertiary care referral center serving upstate New York.  Through 2009, a total 192 MTF and 50 FTM transgender persons were seen.  These patients had a high prevalence of mental health and psychiatric problems (over 50 %), with low rates of employment and high levels of disability.  Mental health and psychiatric problems were inversely correlated with age at presentation.  The prevalence of gender affirming surgery was low (31 % for MTF).  The number of persons seeking treatment has increased substantially in recent years.  Gender-affirming hormone therapy achieves very good results in FTM persons and is most successful in MTF persons when initiated at younger ages.  The authors concluded that transgender persons seeking hormonal therapy are being seen with increasing frequency.  The dysphoria present in many transgender persons is associated with significant mood disorders that interfere with successful careers.  They stated that starting therapy at an earlier age may lessen the negative impact on mental health and lead to improved social outcomes.

Meyer-Bahlburg (2013) summarized for the practicing endocrinologist the current literature on the psychobiology of the development of gender identity and its variants in individuals with disorders of sex development or with transgenderism.  Gender reassignment remains the treatment of choice for strong and persistent gender dysphoria in both categories, but more research is needed on the short-term and long-term effects of puberty-suppressing medications and cross-sex hormones on brain and behavior.

Note on Breast Reduction/Mastectomy and Nipple Reconstruction

The CPT codes for mastectomy (CPT codes 19303) are for breast cancer, and are not appropriate to bill for reduction mammaplasty for female to male (transmasculine) gender affirmation surgery. CPT 2020 states that “Mastectomy procedures (with the exception of gynecomastia [19300]) are performed either for treatment or prevention of breast cancer.” CPT 2020 also states that "Code 19303 describes total removal of ipsilateral breast tissue with or without removal of skin and/or nipples (eg, nipple-sparing), for treatment or prevention of breast cancer.” There are important differences between a mastectomy for breast cancer and a mastectomy for gender reassignment. The former requires careful attention to removal of all breast tissue to reduce the risk of cancer. By contrast, careful removal of all breast tissue is not essential in mastectomy for gender reassignment. In mastectomy for gender reassignment, the nipple areola complex typically can be preserved. 

Some have tried to justify routinely billing CPT code 19350 for nipple reconstruction at the time of mastectomy for gender reassignment based upon the frequent need to reduce the size of the areola to give it a male appearance. However, the nipple reconstruction as defined by CPT code 19350 describes a much more involved procedure than areola reduction. The typical patient vignette for CPT code 19350, according to the AMA, is as follows: “The patient is measured in the standing position to ensure even balanced position for a location of the nipple and areola graft on the right breast.  Under local anesthesia, a Skate flap is elevated at the site selected for the nipple reconstruction and constructed.  A full-thickness skin graft is taken from the right groin to reconstruct the areola.  The right groin donor site is closed primarily in layers.”  

The AMA vignette for CPT code 19318 (reduction mammaplasty) clarifies that this CPT code includes the work that is necessary to reposition and reshape the nipple to create an aesthetically pleasing result, as is necessary in female to male breast reduction. "The physician reduces the size of the breast, removing wedges of skin and breast tissue from a female patient. The physician makes a circular skin incision above the nipple, in the position to which the nipple will be elevated. Another skin incision is made around the circumference of the nipple. Two incisions are made from the circular cut above the nipple to the fold beneath the breast, one on either side of the nipple, creating a keyhole shaped skin and breast incision. Wedges of skin and breast tissue are removed until the desired size is achieved. Bleeding vessels may be ligated or cauterized. The physician elevates the nipple and its pedicle of subcutaneous tissue to its new position and sutures the nipple pedicle with layered closure. The remaining incision is repaired with layered closure" (EncoderPro, 2019). CPT code 19350 does not describe the work that that is being done, because that code describes the actual construction of a new nipple.  Code 19350 is a CCI “incidental to” edit to code 19318, and, accordingly, the services of code 19350 are included in code 19318. Similarly, graft codes, such as code 15200 (full thickness skin graft) and 15877 (liposuction), are CCI “incidental to” edits to code 19318, and, accordingly, the services of graft codes, such as 15200, and liposuction codes, such as 15877, are included in code 19318. 

Vulvoplasty Versus Vaginoplasty as Gender-Affirming Genital Surgery for Transgender Women

Jiang and colleagues (2018) noted that gender-affirming vaginoplasty aims to create the external female genitalia (vulva) as well as the internal vaginal canal; however, not all patients desire nor can safely undergo vaginal canal creation.  These investigators described the factors influencing patient choice or surgeon recommendation of vulvoplasty (creation of the external appearance of female genitalia without creation of a neovaginal canal) and evaluated the patient's satisfaction with this choice.  Gender-affirming genital surgery consults were reviewed from March 2015 until December 2017, and patients scheduled for or who had completed vulvoplasty were interviewed by telephone.  These investigators reported demographic data and the reasons for choosing vulvoplasty as gender-affirming surgery for patients who either completed or were scheduled for surgery, in addition to patient reports of satisfaction with choice of surgery, satisfaction with the surgery itself, and sexual activity after surgery.  A total of 486 patients were seen in consultation for trans-feminine gender-affirming genital surgery: 396 requested vaginoplasty and 39 patients requested vulvoplasty; 30 Patients either completed or are scheduled for vulvoplasty.  Vulvoplasty patients were older and had higher body mass index (BMI) than those seeking vaginoplasty.  The majority (63 %) of the patients seeking vulvoplasty chose this surgery despite no contraindications to vaginoplasty.  The remaining patients had risk factors leading the surgeon to recommend vulvoplasty.  Of those who completed surgery, 93 % were satisfied with the surgery and their decision for vulvoplasty.  The authors concluded that this was the first study of factors impacting a patient's choice of or a surgeon's recommendation for vulvoplasty over vaginoplasty as gender-affirming genital surgery; it also was the first reported series of patients undergoing vulvoplasty only. 

Drawbacks of this study included its retrospective nature, non-validated questions, short-term follow-up, and selection bias in how vulvoplasty was offered.  Vulvoplasty is a form of gender-affirming feminizing surgery that does not involve creation of a neovagina, and it is associated with high satisfaction and low decision regret.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Transfeminine Reassignment Surgery

Seyed-Forootan and colleagues (2018) stated that plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells.  These researchers compared the results of amnion grafts with amnion seeded with autograft fibroblasts.  Over 8 years, these investigators compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction; 16 patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining.  The depths, sizes, secretions, and sensations of the vaginas were evaluated.  The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding.  The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years.  Patients were followed-up from 30 months to 8 years (mean of 36 ± 4) after surgery.  The depth of the vaginas for group A was 14 to 16 and 13 to 16 cm for group B.  There was no stenosis in neither group.  The diameter of the vaginal opening was 34 to 38 mm in group A and 33 to 38 cm in group B.  These researchers only had 2 cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A.  All of the patients had good and acceptable sensation in the neo-vagina; 75 % of patients had sexual experience and of those, 93.7 % in group A and 87.5%  in group B expressed satisfaction.  The authors concluded that the creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina.  The size of neo-vagina, secretion, sensation, and orgasm was good and proper.  More than 93.7 % of patients had satisfaction with sexual intercourse.  They stated that amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation.  The constructed vagina has a 2-layer structure and is much more resistant to trauma and laceration.  No cases of stenosis or stricture were recorded.  Level of Evidence = IV.  These preliminary findings need to be validated by well-designed studies.

Pitch-Raising Surgery in Transfeminine Persons

Van Damme and colleagues (2017) reviewed the evidence of the effectiveness of pitch-raising surgery performed in male-to-female transsexuals.  These investigators carried out a search for studies in PubMed, Web of Science, Science Direct, EBSCOhost, Google Scholar, and the references in retrieved manuscripts, using as keywords "transsexual" or "transgender" combined with terms related to voice surgery.  They included 8 studies using cricothyroid approximation, 6 studies using anterior glottal web formation, and 6 studies using other surgery types or a combination of surgical techniques, leading to 20 studies in total.  Objectively, a substantial rise in post-operative fundamental frequency was identified.  Perceptually, mainly laryngeal web formation appeared risky for decreasing voice quality.  The majority of patients appeared satisfied with the outcome.  However, none of the studies used a control group and randomization process.  The authors concluded that future research needs to investigate long-term effects of pitch-raising surgery using a stronger study design. 

Azul and associates (2017) evaluated the currently available discursive and empirical data relating to those aspects of trans-masculine people's vocal situations that are not primarily gender-related, and identified restrictions to voice function that have been observed in this population, and made suggestions for future voice research and clinical practice.  These researchers conducted a comprehensive review of the voice literature.  Publications were identified by searching 6 electronic databases and bibliographies of relevant articles.  A total of 22 publications met inclusion criteria.  Discourses and empirical data were analyzed for factors and practices that impact on voice function and for indications of voice function-related problems in trans-masculine people.  The quality of the evidence was appraised.  The extent and quality of studies investigating trans-masculine people's voice function was found to be limited.  There was mixed evidence to suggest that trans-masculine people might experience restrictions to a range of domains of voice function, including vocal power, vocal control/stability, glottal function, pitch range/variability, vocal endurance, and voice quality.  The authors concluded that more research into the different factors and practices affecting trans-masculine people's voice function that took account of a range of parameters of voice function and considered participants' self-evaluations is needed to establish how functional voice production can be best supported in this population.

Facial Feminization Surgery

Raffaini and colleagues (2016) stated that gender dysphoria refers to the discomfort and distress that arise from a discrepancy between a person's gender identity and sex assigned at birth.  The treatment plan for gender dysphoria varies and can include psychotherapy, hormone treatment, and gender affirmation surgery, which is, in part, an irreversible change of sexual identity.  Procedures for transformation to the female sex include facial feminization surgery, vaginoplasty, clitoroplasty, and breast augmentation.  Facial feminization surgery can include forehead re-modeling, rhinoplasty, mentoplasty, thyroid chondroplasty, and voice alteration procedures.  These investigators reported patient satisfaction following facial feminization surgery, including outcome measurements after forehead slippage and chin re-modeling.  A total of 33 patients between 19 and 40 years of age were referred for facial feminization surgery between January of 2003 and December of 2013, for a total of 180 procedures.  Surgical outcome was analyzed both subjectively through questionnaires administered to patients and objectively by serial photographs.  Most facial feminization surgery procedures could be safely completed in 6 months, barring complications.  All patients showed excellent cosmetic results and were satisfied with their procedures.  Both frontal and profile views achieved a loss of masculine features.  The authors concluded that patient satisfaction following facial feminization surgery was high; they stated that the reduction of gender dysphoria had psychological and social benefits and significantly affected patient outcome.  The level of evidence of this study was IV.

Morrison and associates (2018) noted that facial feminization surgery encompasses a broad range of cranio-maxillofacial surgical procedures designed to change masculine facial features into feminine features.  The surgical principles of facial feminization surgery could be applied to male-to-female transsexuals and anyone desiring feminization of the face.  Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately 1 in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed.  These researchers appraised the current facial feminization surgery literature.  They carried out a comprehensive literature search of the Medline, PubMed, and Embase databases was conducted for studies published through October 2014 with multiple search terms related to facial feminization.  Data on techniques, outcomes, complications, and patient satisfaction were collected.  A total of 15 articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports.  Articles covered a variety of facial feminization procedures.  A total of 1,121 patients underwent facial feminization surgery, with 7 complications reported, although many articles did not explicitly comment on complications.  Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction.  The authors concluded that facial feminization surgery appeared to be safe and satisfactory for patients.  These researchers stated that further studies are needed to better compare different techniques to more robustly establish best practices; prospective studies and patient-reported outcomes are needed to establish quality-of-life (QOL) outcomes for patients.  

In a systematic review, Gorbea et al (2021) provided a portrait of gender affirmation surgery (GAS) insurance coverage across the U.S., with attention to procedures of the head and neck.  State policies on transgender care for Medicaid insurance providers were collected for all 50 states.  Each state's policy on GAS and facial gender affirmation surgery (FGAS) was examined.  The largest medical insurance companies in the U.S. were identified using the National Association of Insurance Commissioners Market Share report.  Policies of the top 49 primary commercial medical insurance companies were examined.  Medicaid policy reviews found that 18 states offer some level of gender-affirming coverage for their patients, but only 3 include FGAS (17 %); 13 states prohibit Medicaid coverage of all transgender surgery, and 19 states have no published gender-affirming medical care coverage policy; 92 % of commercial medical insurance providers had a published policy on GAS coverage.  Genital reconstruction was described as a medically necessary aspect of transgender care in 100 % of the commercial policies reviewed; 93 % discussed coverage of FGAS, but 51 % considered these procedures cosmetic.  Thyroid chondroplasty (20 %) was the most commonly covered FGAS procedure.  Mandibular and frontal bone contouring, rhinoplasty, blepharoplasty, and facial rhytidectomy were each covered by 13 % of the medical policies reviewed.  The authors concluded that while certain surgical aspects of gender-affirming medical care are nearly ubiquitously covered by commercial insurance providers, FGAS is considered cosmetic by most Medicaid and commercial insurance providers.  Level of Evidence = V.

Hohman and Teixeira (2022) stated that with respect to gender affirmation procedures for the face, the majority of interventions will occur in patients transitioning from male to female, i.e., transgender women.  While there are slightly more transgender women than transgender men in the population (33 % transgender women, 29 % transgender men, 35 % non-binary, 3 % cross-dressers, according to the USTS), the reason that more females require surgery than males is that testosterone therapy typically produces enough changes in secondary sex characteristics of the face (growth of facial hair, thickening of the skin, increase in frontal bossing, lowering of the voice, etc.) that surgery is not necessary . In some cases, placement of implants or fat transfer can increase volume in the lower 1/3 of the face and contribute to masculinization.  Still, the primary area of focus for facial feminization is generally the upper 1/3.  Feminization of the upper 1/3 of the face often requires several techniques to be applied in combination: The advancement of the hairline, hair transplantation, brow-lifting, and reduction of frontal bossing or "frontal cranioplasty".  While the advancement of a scalp flap, hair transplant, and pretrichial brow-lifting are commonly employed cosmetic surgery interventions, frontal cranioplasty bears special consideration.  Several methods of reducing the brow's prominence are often described as type 1, 2, and 3 frontal cranioplasties.  Type 1 cranioplasty reduces the supra-orbital ridge's protrusion, usually using a drill, including decreasing the thickness of the anterior table of the frontal sinus.  This technique is the simplest, but it is only effective in patients with either a very thick anterior frontal sinus table or an absent pneumatized frontal sinus.  Type 2 cranioplasty involves augmentation of the forehead's convexity using bone cement or methyl methacrylate in addition to a reduction of the supra-orbital ridge with a drill.  Type 3 cranioplasty is advocated by many prominent facial feminization surgeons and consists of removal of the anterior table of the frontal sinus, thinning of the bone flap, and replacement of that bone onto the frontal sinus but in a more recessed position, in addition to a reduction of the remainder of the supra-orbital ridge.  An alternative to removal and recession of the frontal sinus's anterior table is to thin the bone with a drill and then fracture it in a controlled fashion to produce the desired contour, which is also performed routinely by some authors.

Forehead Feminization Cranioplasty

Eggerstedt and colleagues (2020) stated that forehead feminization cranioplasty (FFC) is an important component of gender-affirming surgery and has become increasingly popular in recent years.  However, there is little objective evidence for the procedure's safety and clinical impact via patient-reported outcome measures (PROMs).  In a systematic review, these researchers determined what complications are observed following FFC, the relative frequency of complications by surgical technique, and what impact the procedure has on patient's QOL.  They carried out database searches in PubMed/Medline, Scopus, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and PsycINFO.  The search terms included variations of forehead setback/FFC.  Both controlled vocabularies (i.e., MeSH and CINAHL's Suggested Subject Terms) and keywords in the title or abstract fields were searched.  Two independent reviewers screened the titles and abstracts of all articles; and 2 independent surgeon reviewers examined the full text of all included articles, and relevant data points were extracted.  Main outcomes and measures included complications and complication rate observed following FFC.  Additional outcome measures were the approach used, concurrent procedures carried out, and the use and findings of a PROM.  A total of 10 articles describing FFC were included, entailing 673 patients.  The overall pooled complication rate was 1.3 %; PROMs were used in 50 % of studies, with no standardization among studies.  The authors concluded that complications following FFC were rare and infrequently required reoperation.  Moreover, these researchers stated that further studies into standardized and validated PROMs in facial feminization patients are needed.  Level of Evidence = III.

Hand Feminization and Masculinization

Lee and colleagues (2021) noted that anatomical characteristics that are incongruent with an individual's gender identity can cause significant gender dysphoria.  Hands exhibit prominent dimorphic sexual features, but despite their visibility, there are limited studies examining gender affirming procedures for the hands.  These researchers examined the anatomical features that define feminine and masculine hands, the surgical and non-surgical approaches for feminization and masculinization of the hand; and adapted established aesthetic hand techniques for gender affirming care.  They carried out a comprehensive database search of PubMed, Embase OVID and SCOPUS to identify articles on the characterization of feminine or masculine hands, hand treatments related to gender affirmation, and articles related to techniques for hand feminization and masculinization in the non-transgender population.  From 656 possibly relevant articles, 42 met the inclusion criteria for the current literature search.  There is currently no medical literature specifically examining the surgical or non-surgical options for hand gender affirmation.  The available techniques for gender affirming procedures discussed in this paper were appropriated from those more commonly used for hand rejuvenation.  The authors concluded that there is very little evidence addressing the options for transgender individuals seeking gender affirming procedures of the hand.  These researchers stated that although established procedures used for hand rejuvenation may be employed in gender affirming care, further study is needed to determine relative salience of various hand features to gender dysphoria in transgender patients of various identities, as well as development of novel techniques to meet these needs.  Level of Evidence = III.

Peritoneal Pull-Through Technique Vaginoplasty in Neovagina Construction in Gender-Affirming Surgery

Tay and Lo (2022) reviewed the application, effectiveness and outcomes of a novel surgical technique, peritoneal pull-through technique vaginoplasty, in gender-affirming surgery.  Specific outcome parameters included healing time, depth of cavity achieved,) alleviation of dysphoria, and morbidity of the surgery.  These researchers carried out a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and PROSPERO registration obtained before commencement.  A search was performed in OVID Medline, Embase, Willey Online Library and PubMed.  Specialty-related journals, grey literature and reference lists of relevant articles were manually searched.  From 476 potentially relevant articles, 12 articles were analyzed; and the publications were all level 4 or level 5 evidence.  Healing times were poorly reported or often not mentioned.  A total of 8 authors reported neovagina cavity depth of at least 13 cm and good patient satisfaction.  Alleviation of dysphoria was not discussed by any of the publications and only 6reported complications.  Average follow-up ranged from 6 weeks to 14.8 months.  The authors concluded that the use of peritoneal pull-through vaginoplasty in gender-affirming surgery is promising and novel; however, there is a paucity of data.  These investigators stated that further research and longer-term data are needed to examine the safety and effectiveness of this technique including stabilization of vaginal depth, later morbidity and complications.  Patients seeking this surgery overseas should be informed of the potential difficulties they may face.

Urethral Complications and Outcomes in Transgender Men

Hu et al (2022) noted that urologic problems, such as urethral fistulas and strictures, are among the most frequent complications following phalloplasty.  Although many studies have reported successful phalloplasty and urethral reconstruction with reliable outcomes in transgender men; so far, no method has become standardized.  These researchers examined the reports on urological complications and outcomes in transgender men with respect to various types of urethral reconstruction.  They carried out a comprehensive literature search of PubMed, Scopus, and Google Scholar databases for studies related to phalloplasty in transsexuals.  Data on various phallic urethral techniques, urethral complications, and outcomes were collected and analyzed using the random-effects model.  A total of 21 studies (1,566 patients) were included: 8 studies (1,061 patients) on "tube-in-tube", 9 studies (273 patients) on "prelaminated flap,  and 6 studies (221 patients) on "second flap".  Compared with the tube-in-tube technique, the pre-laminated flap was associated with a significantly higher urethral stricture/stenosis rate; however, there was no difference between the pre-laminated flap and the 2nd flap techniques.  For all phalloplasty patients, the pooled rate of urethral fistula or stenosis was 48.9 %, the rate of the ability to void while standing was 91.5 %, occurrence rate of tactile or erogenous sensation was 88 %, the prosthesis complication rate was 27.9 %, and patient-reported satisfactory outcome rate was 90.5 %.  The authors concluded that urethral reconstruction with a pre-laminated flap was associated with a significantly higher urethral stricture rate and increased need of revision surgery compared with that observed using a skin flap.  Overall, most patients were able to void while standing and were satisfied with the outcomes.

DSM 5 Criteria for Gender Dysphoria in Adults and Adolescents

A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months duration, as manifested by two or more of the following:

• A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or, in young adolescents, the anticipated secondary sex characteristics)
• A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or, in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
• A strong desire for the primary and/or secondary sex characteristics of the other gender
• A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
• A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
• A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender).

The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

There is no minimum duration of relationship required with mental health professional.  It is the professional’s judgment as to the appropriate length of time before a referral letter can appropriately be written.  A common period of time is three months, but there is significant variation in both directions.

Evaluation of candidacy for gender affirmation surgery by a mental health professional is covered under the member’s medical benefit, unless the services of a mental health professional are necessary to evaluate and treat a mental health problem, in which case the mental health professional’s services are covered under the member’s behavioral health benefit. Please check benefit plan descriptions.

Characteristics of a Qualified Health Professionals (From SOC-8)

Qualifications of Mental Health Professional for assessing transgender and gender diverse adults for physical treatments (from WPATH SOC-8):

• Are licensed by their statutory body and hold, at a minimum, a master’s degree or equivalent training in a clinical field relevant to this role and granted by a nationally accredited statutory institution.
• Are able to identify co-existing mental health or other psychosocial concerns and distinguish these from gender dysphoria, incongruence, and diversity.
• Are able to assess capacity to consent for treatment.
• Have experience or be qualified to assess clinical aspects of gender dysphoria, incongruence, and diversity.
• Undergo continuing education in health care relating to gender dysphoria, incongruence, and diversity.
• Liaise with professionals from different disciplines within the field of transgender health for consultation and referral on behalf of gender diverse adults seeking gender-affirming treatment, if required.

Credentials of surgeons who perform gender-affirming surgical procedures (fromWPATH SOC-8):

• Training and documented supervision in gender-affirming procedures;
• Maintenance of an active practice in gender-affirming surgical procedures;
• Knowledge about gender diverse identities and expressions;
• Continuing education in the field of gender-affirmation surgery;
• Tracking of surgical outcomes.

Characteristics of health care professionals working with gender diverse adolescents:

• Are licensed by their statutory body and hold a postgraduate degree or its equivalent in a clinical field relevant to this role granted by a nationally accredited statutory institution.
• Receive theoretical and evidenced-based training and develop expertise in general child, adolescent, and family mental health across the developmental spectrum.
• Receive training and have expertise in gender identity development, gender diversity in children and adolescents, have the ability to assess capacity to assent/consent, and possess general knowledge of gender diversity across the life span.
• Receive training and develop expertise in autism spectrum disorders and other neurodevelopmental presentations or collaborate with a developmental disability expert when working with autistic/neurodivergent gender diverse adolescents.
• Continue engaging in professional development in all areas relevant to gender diverse children, adolescents, and families.

The above policy is based on the following references:

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• Boczar D, Huayllani MT, Saleem HY, et al. Surgical techniques of phalloplasty in transgender patients: A systematic review. Ann Transl Med. 2021;9(7):607.
• Bowman C, Goldberg J. Care of the Patient Undergoing Sex Reassignment Surgery. Vancouver, BC: Vancouver Coastal Health, Transcend Transgender Support & Education Society, and the Canadian Rainbow Health Coalition; January 2006. 
• Buncamper ME, Honselaar JS, Bouman MB, et al. Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals. J Sex Med. 2015;12(7):1626-1634.
• Byne W, Bradley SJ, Coleman E, et al.; American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Arch Sex Behav. 2012;41(4):759-796.
• Claes KEY, D'Arpa S, Monstrey SJ. Chest surgery for transgender and gender nonconforming individuals. Clin Plast Surg. 2018;45(3):369-380. 
• Colebunders B, Brondeel S, D'Arpa S, et al. An update on the surgical treatment for transgender patients. Sex Med Rev. 2017;5(1):103-109.
• Coleman E, Radix AE, Bouman WP, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.  Int J Transgend. 2022; 23 sup1:S1-S259.
• Coleman E, Adler R, Bockting W, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. Version 7. Minneapolis, MN: World Professional Association for Transgender Health (WPATH); 2011.
• Coleman E, Bockting W, Botzer M, et al. Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. Int J Transgend. 2011;13:165-232.
• Day P. Trans-gender reassignment surgery. NZHTA Tech Brief Series. Christchurch, New Zealand: New Zealand Health Technology Assessment (NZHTA); 2002;1(1). 
• Djordjevic ML, Bizic MR, Duisin D, et al. Reversal surgery in regretful male-to-female transsexuals after sex reassignment surgery. J Sex Med. 2016;13(6):1000-1007.
• Eggerstedt M, Hong YS, Wakefield CJ, et al. Setbacks in forehead feminization cranioplasty: A systematic review of complications and patient-reported outcomes. Aesthetic Plast Surg. 2020;44(3):743-749.
• Falcone M, Preto M, Timpano M, et al. The surgical outcomes of radial artery forearm free-flap phalloplasty in transgender men: Single-centre experience and systematic review of the current literature. Int J Impot Res. 2021;33(7):737-745.
• Gooren LJG, Tangpricha V. Treatment of transsexualism. UpToDate [serial online]. Waltham, MA: UpToDate; reviewed April 2014.
• Gorbea E, Gidumal S, Kozato A, et al. Insurance coverage of facial gender affirmation surgery: A review of Medicaid and commercial insurance. Otolaryngol Head Neck Surg. 2021;165(6):791-797.
• Guan X, Bardawil E, Liu J, Kho R. Transvaginal natural orifice transluminal endoscopic surgery as a rescue for total vaginal hysterectomy. J Minim Invasive Gynecol. 2018;25(7):1135-1136.
• Hembree et al. Endocrine Treatment of Transsexual Persons:  An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2009; 94(9):3132-3154.
• Hohman MH, Teixeira J. Transgender surgery of the head and neck. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing; February 27, 2022.
• Horbach SE, Bouman MB, Smit JM, et al. Outcome of vaginoplasty in male-to-female transgenders: A systematic review of surgical techniques. J Sex Med. 2015;12(6):1499-1512.
• Hu C-H, Chang C-J, Wang S-W, Chang K-V. A systematic review and meta-analysis of urethral complications and outcomes in transgender men. J Plast Reconstr Aesthet Surg. 2022;75(1):10-24.
• Jiang D, Witten J, Berli J, Dugi D 3rd. Does depth matter? Factors affecting choice of vulvoplasty over vaginoplasty as gender-affirming genital surgery for transgender women. J Sex Med. 2018;15(6):902-906.
• Jolly D, Wu CA, Boskey ER, et al. Is clitoral release another term for metoidioplasty? A systematic review and meta-analysis of metoidioplasty surgical technique and outcomes. Sex Med. 2021;9(1):100294.
• Kaariainen M, Salonen K, Helminen M, Karhunen-Enckell U. Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scand J Surg. 2016;106 (1):74-79.
• Lawrence AA, Latty EM, Chivers ML, Bailey JM. Measurement of sexual arousal in postoperative male-to-female transsexuals using vaginal photoplethysmography. Arch Sex Behav. 2005;34(2):135-145.
• Lawrence AA. Factors associated with satisfaction or regret following male-to-female sex reassignment surgery. Arch Sex Behav. 2003;32(4):299-315.
• Lee J, Nolan IT, Swanson M, et al. A review of hand feminization and masculinization techniques in gender affirming therapy. Aesthetic Plast Surg. 2021;45(2):589-601.
• Lee YL, Hsu TF, Jiang LY, et al. Transvaginal natural orifice transluminal endoscopic surgery for female-to-male transgender men. J Minim Invasive Gynecol. 2019;26(1):135-142.
• Leinung MC, Urizar MF, Patel N, Sood SC. Endocrine treatment of transsexual persons: Extensive personal experience. Endocr Pract. 2013;19(4):644-650.
• Meriggiola MC, Jannini EA, Lenzi A, et al. Endocrine treatment of transsexual persons: An Endocrine Society Clinical Practice Guideline: Commentary from a European perspective. Eur J Endocrinol. 2010;162(5):831-833.
• Meyer-Bahlburg HF. Sex steroids and variants of gender identity. Endocrinol Metab Clin North Am. 2013;42(3):435-452.
• Miller TJ, Wilson SC, Massie JP, et al. Breast augmentation in male-to-female transgender patients: Technical considerations and outcomes. JPRAS Open. 2019;21:63-74. 
• Morrison SD, Vyas KS, Motakef S, et al. Facial feminization: Systematic review of the literature. Plast Reconstr Surg. 2016;137(6):1759-1770. 
• Nakatsuka M. [Adolescents with gender identity disorder: Reconsideration of the age limits for endocrine treatment and surgery]. Seishin Shinkeigaku Zasshi. 2012;114(6):647-653.
• Ngaage LM, Knighton BJ, McGlone KL, et al. Health insurance coverage of gender-affirming top surgery in the United States. Plast Reconstr Surg. 2019;144(4):824-833. 
• Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 1: Breast/chest, face, and voice). Ann Surg. 2022;275(1):e52-e66.
• Oles N, Darrach H, Landford W, et al. Gender affirming surgery: A comprehensive, systematic review of all peer-reviewed literature and methods of assessing patient-centered outcomes (Part 2: Genital reconstruction). Ann Surg. 2022;275(1):e67-e74.
• Olson-Kennedy J, Warus J, Okonta V, et al. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatr. 2018;172(5):431-436.
• Patel H, Arruarana V, Yao L, et al. Effects of hormones and hormone therapy on breast tissue in transgender patients: A concise review. Endocrine. 2020;68(1):6-15.
• Raffaini M, Magri AS, Agostini T. Full facial feminization surgery: Patient satisfaction assessment based on 180 procedures involving 33 consecutive patients. Plast Reconstr Surg. 2016;137(2):438-448..
• Rafferty J; Committee on Psychosocial Aspects of Child and Family Health; Committee on Adolescence; Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics. 2018;142(4).
• Salgado CJ, Fein LA. Breast augmentation in transgender women and the lack of adherence amongst plastic surgeons to professional standards of care. J Plast Reconstr Aesthet Surg. 2015;68(10):1471-1472.
• Sarıkaya S, Ralph DJ. Mystery and realities of phalloplasty: A systematic review. Turk J Urol. 2017;43(3):229-236.
• Schechter LS. Gender confirmation surgery: An update for the primary care provider. Transgender Health. 2016;1.1:32-40.
• Seyed-Forootan K, Karimi H, Seyed-Forootan NS. Autologous fibroblast-seeded amnion for reconstruction of neo-vagina in male-to-female reassignment surgery. Aesthetic Plast Surg. 2018;42(2):491-497.
• Smith YL, Cohen L, Cohen-Kettenis PT. Postoperative psychological functioning of adolescent transsexuals: A Rorschach study. Arch Sex Behav. 2002;31(3):255-261.
• Spack NP. Management of transgenderism. JAMA. 2013;309(5):478-484.
• Sutcliffe PA, Dixon S, Akehurst RL, et al. Evaluation of surgical procedures for sex reassignment: A systematic review. J Plast Reconstr Aesthet Surg. 2009;62(3):294-306; discussion 306-308.
• Tay YT, Lo CH. Use of peritoneum in neovagina construction in gender-affirming surgery: A systematic review. ANZ J Surg. 2022;92(3):373-378.
• Tonseth KA, Bjark T, Kratz G, et al. Sex reassignment surgery in transsexuals. Tidsskr Nor Laegeforen. 2010;130(4):376-379.
• Tugnet N, Goddard JC, Vickery RM, et al.  Current management of male-to-female gender identity disorder in the UK. Postgrad Med J. 2007;83(984):638-642.
• UK National Health Service (NHS), Oxfordshire Primary Care Trust, South Central Priorities Committee. Treatments for gender dysphoria. Policy Statement 18c. Ref TV63. Oxford, UK: NHS; updated September 2009.
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Next Review: 07/11/2024

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Male-to-Female Gender-Affirming Surgery: 20-Year Review of Technique and Surgical Results

Gabriel veber moisés da silva.

1 Serviço de Urologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

Maria Inês Rodrigues Lobato

2 Serviço de Psiquiatria, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil

Dhiordan Cardoso Silva

Karine schwarz, anna martha vaitses fontanari, angelo brandelli costa.

3 Serviço de Psiquiatria, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil

Patric Machado Tavares

Antonio rebello horta gorgen, renan desimon cabral, tiago elias rosito, associated data.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Purpose: Gender dysphoria (GD) is an incompatibility between biological sex and personal gender identity; individuals harbor an unalterable conviction that they were born in the wrong body, which causes personal suffering. In this context, surgery is imperative to achieve a successful gender transition and plays a key role in alleviating the associated psychological discomfort. In the current study, a retrospective cohort, we report the 20-years outcomes of the gender-affirming surgery performed at a single Brazilian university center, examining demographic data, intra and postoperative complications. During this period, 214 patients underwent penile inversion vaginoplasty.

Results: Results demonstrate that the average age at the time of surgery was 32.2 years (range, 18–61 years); the average of operative time was 3.3 h (range 2–5 h); the average duration of hormone therapy before surgery was 12 years (range 1–39). The most commons minor postoperative complications were granulation tissue (20.5 percent) and introital stricture of the neovagina (15.4 percent) and the major complications included urethral meatus stenosis (20.5 percent) and hematoma/excessive bleeding (8.9 percent). A total of 36 patients (16.8 percent) underwent some form of reoperation. One hundred eighty-one (85 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS.

Conclusions: Findings confirm that it is a safety procedure, with a low incidence of serious complications. Otherwise, in our series, there were a high level of functionality of the neovagina, as well as subjective personal satisfaction.

Introduction

Transsexualism (ICD-10) or Gender Dysphoria (GD) (DSM-5) is characterized by intense and persistent cross-gender identification which influences several aspects of behavior ( 1 ). The terms describe a situation where an individual's gender identity differs from external sexual anatomy at birth ( 1 ). Gender identity-affirming care, for those who desire, can include hormone therapy and affirming surgeries, as well as other procedures such as hair removal or speech therapy ( 1 ).

Since 1998, the Gender Identity Program (PROTIG) of the Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul, Brazil has provided public assistance to transsexual people, is the first one in Brazil and one of the pioneers in South America. Our program offers psychosocial support, health care, and guidance to families, and refers individuals for gender-affirming surgery (GAS) when indicated. To be eligible for this surgery, transsexual individuals must have been adherent to multidisciplinary follow-up for at least 2 years, have a minimum age of 21 years (required for surgical procedures of this nature), have a positive psychiatric or psychological report, and have a diagnosis of GD.

Gender-affirming surgery (GAS) is increasingly recognized as a therapeutic intervention and a medical necessity, with growing societal acceptance ( 2 ). At our institution, we perform the classic penile inversion vaginoplasty (PIV), with an inverted penis skin flap used as the lining for the neovagina. Studies have demonstrated that GAS for the management of GD can promote improvements in mental health and social relationships for these patients ( 2 – 5 ). It is therefore imperative to understand and establish best practice techniques for this patient population ( 2 ). Although there are several studies reporting the safety and efficacy of gender-affirming surgery by penile inversion vaginoplasty, we present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

Patients and Methods

Subjects and study setup.

This is a retrospective cohort study of Brazilian transgender women who underwent penile inversion vaginoplasty between January of 2000 and March of 2020 at the Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil. The study was approved by our institutional medical and research ethics committee.

At our institution, gender-affirming surgery is indicated for transgender women who are under assistance by our program for transsexual individuals. All transsexual women included in this study had at least 2 years of experience as a woman and met WPATH standards for GAS ( 1 ). Patients were submitted to biweekly group meetings and monthly individual therapy.

Between January of 2000 and March of 2020, a total of 214 patients underwent penile inversion vaginoplasty. The surgical procedures were performed by two separate staff members, mostly assisted by residents. A retrospective chart review was conducted recording patient demographics, intraoperative and postoperative complications, reoperations, and secondary surgical procedures. Informed consent was obtained from all individual participants included in the study.

Hormonal Therapy

The goal of feminizing hormone therapy is the development of female secondary sex characteristics, and suppression/minimization of male secondary sex characteristics.

Our general therapy approach is to combine an estrogen with an androgen blocker. The usual estrogen is the oral preparation of estradiol (17-beta estradiol), starting at a dose of 2 mg/day until the maximum dosage of 8 mg/day. The preferred androgen blocker is spironolactone at a dose of 200 mg twice a day.

Operative Technique

At our institution, we perform the classic penile inversion vaginoplasty, with an inverted penis skin flap used as the lining for the neovagina. For more details, we have previously published our technique with a step-by-step procedure video ( 6 ). All individuals underwent intestinal cleansing the evening before the surgery. A first-generation cephalosporin was used as preoperative prophylaxis. The procedure was performed with the patient in a dorsal lithotomy position. A Foley catheter was placed for bladder catheterization. A inverted-V incision was made 4 cm above the anus and a flap was created. A neovaginal cavity was created between the prostate and the rectum with blunt dissection, in the Denonvilliers space, until the peritoneal fold, usually measuring 12 cm in extension and 6 cm in width. The incision was then extended vertically to expose the testicles and the spermatic cords, which were removed at the level of the external inguinal rings. A circumferential subcoronal incision was made ( Figure 1 ), the penis was de-gloved and a skin flap was created, with the de-gloved penis being passed through the scrotal opening ( Figure 2 ). The dorsal part of the glans and its neurovascular bundle were bluntly dissected away from the penile shaft ( Figure 3 ) as well as the urethra, which included a portion of the bulbospongious muscle ( Figure 4 ). The corpora cavernosa was excised up to their attachments at the symphysis pubis and ligated. The neoclitoris was shaped and positioned in the midline at the level of the symphysis pubis and sutured using interrupted 5-0 absorbable suture. The corpus spongiosum was reduced and the urethra was shortened, spatulated, and placed 1 cm below the neoclitoris in the midline and sutured using interrupted 4-0 absorbable suture. The penile skin flap was inverted and pulled into the neovaginal cavity to become its walls ( Figure 5 ). The excess of skin was then removed, and the subcutaneous tissue and the skin were closed using continuous 3-0 non-absorbable suture ( Figure 6 ). A neo mons pubis was created using a 0 absorbable suture between the skin and the pubic bone. The skin flap was fixed to the pubic bone using a 0 absorbable suture. A gauze impregnated with Vaseline and antibiotic ointment was left inside the neovagina, and a customized compressive bandage was applied ( Figure 7 —shows the final appearance after the completion of the procedures).

The initial circumferential subcoronal incision.

The de-gloved penis being passed through the scrotal opening.

The dorsal part of the glans and its neurovascular bundle dissected away from the penile shaft.

The urethra dissected including a portion of the bulbospongious muscle. The grey arrow shows the penile shaft and the white arrow shows the dissected urethra.

The inverted penile skin flap.

The neoclitoris and the urethra sutured in the midline and the neovaginal cavity.

The final appearance after the completion of the procedures.

Postoperative Care and Follow-Up

The patients were usually discharged within 2 days after surgery with the Foley catheter and vaginal gauze packing in place, which were removed after 7 days in an ambulatorial attendance.

Our vaginal dilation protocol starts seven days after surgery: a kit of 6 silicone dilators with progressive diameter (1.1–4 cm) and length (6.5–14.5 cm) is used; dilation is done progressively from the smallest dilator; each size should be kept in place for 5 min until the largest possible size, which is kept for 3 h during the day and during the night (sleep), if possible. The process is performed daily for the first 3 months and continued until the patient has regular sexual intercourse.

The follow-up visits were performed 7 days, 1, 2, 3, 6, and 12 months after surgery ( Figure 8 ), and included physical examination and a quality-of-life questionnaire.

Appearance after 1 month of the procedure.

Statistical Analysis

The statistical analysis was conducted using Statistical Product and Service Solutions Version 18.0 (SPSS). Outcome measures were intra-operative and postoperative complications, re-operations. Descriptive statistics were used to evaluate the study outcomes. Mean values and standard deviations or median values and ranges are presented as continuous variables. Frequencies and percentages are reported for dichotomous and ordinal variables.

Patient Demographics

During the period of the study, 214 patients underwent penile inversion vaginoplasty, performed by two staff surgeons, mostly assisted by residents ( Table 1 ). The average age at the time of surgery was 32.2 years (range 18–61 years). There was no significant increase or decrease in the ages of patients who underwent SRS over the study period (Fisher's exact test: P = 0.065; chi-square test: X 2 = 5.15; GL = 6; P = 0.525). The average of operative time was 3.3 h (range 2–5 h). The average duration of hormone therapy before surgery was 12 years (range 1–39). The majority of patients were white (88.3 percent). The most prevalent patient comorbidities were history of tobacco use (15 percent), human immunodeficiency virus infection (13 percent) and hypertension (10.7 percent). Other comorbidities are listed in Table 1 .

Patient demographics.

HIV, human immunodeficiency virus .

Multidisciplinary follow-up was comprised of 93.45% of patients following up with a urologist and 59.06% of patients continuing psychiatric follow-up, median follow-up time of 16 and 9.3 months after surgery, respectively.

Postoperative Results

The complications were classified according to the Clavien-Dindo score ( Table 2 ). The most common minor postoperative complications (Grade I) were granulation tissue (20.5 percent), introital stricture of the neovagina (15.4 percent) and wound dehiscence (12.6 percent). The major complications (Grade III-IV) included urethral stenosis (20.5 percent), urethral fistula (1.9 percent), intraoperative rectal injury (1.9 percent), necrosis (primarily along the wound edges) (1.4 percent), and rectovaginal fistula (0.9 percent). A total of 17 patients required blood transfusion (7.9 percent).

Complications after penile inversion vaginoplasty.

A total of 36 patients (16.8 percent) underwent some form of reoperation.

One hundred eighty-one (85 percent) patients in our series were able to have regular sexual vaginal intercourse, and no individual regretted having undergone GAS.

Penile inversion vaginoplasty is the gold-standard in gender-affirming surgery. It has good functional outcomes, and studies have demonstrated adequate vaginal depths ( 3 ). It is recognized not only as a cosmetic procedure, but as a therapeutic intervention and a medical necessity ( 2 ). We present the largest South-American cohort to date, examining demographic data, intra and postoperative complications.

The mean age of transsexual women who underwent GAS in our study was 32.2 years (range 18–61 years), which is lower than the mean age of patients in studies found in the literature. Two studies indicated that the mean ages of patients at time of GAS were 36.7 years and 41 years, respectively ( 4 , 5 ). Another study reported a mean age at time of GAS of 36 years and found there was a significant decrease in age at the time of GAS from 41 years in 1994 to 35 years in 2015 ( 7 ). According to the authors, this decrease in age is associated with greater tolerance and societal approval regarding individuals with GD ( 7 ).

There was no grade IV or grade V complications. Excessive bleeding noticed postoperatively occurred in 19 patients (8.9 percent) and blood transfusion was required in 17 cases (7.9 percent); all patients who required blood transfusions were operated until July 2011, and the reason for this rate of blood transfusion was not identified.

The most common intraoperative complication was rectal injury, occurring in 4 patients (1.9 percent); in all patients the lesion was promptly identified and corrected in 2 layers absorbable sutures. In 2 of these patients, a rectovaginal fistula became evident, requiring fistulectomy and colonic transit deviation. This is consistent with current literature, in which rectal injury is reported in 0.4–4.5 percent of patients ( 4 , 5 , 8 – 13 ). Goddard et al. suggested carefully checking for enterotomy after prostate and bladder mobilization by digital rectal examination ( 4 ). Gaither et al. ( 14 ) commented that careful dissection that closely follows the urethra along its track from the central tendon of the perineum up through the lower pole of the prostate is critical and only blunt dissection is encouraged after Denonvilliers' fascia is reached. Alternatively, a robotic-assisted approach to penile inversion vaginoplasty may aid in minimizing these complications. The proposed advantages of a robotic-assisted vaginoplasty include safer dissection to minimize the risk of rectal injury and better proximal vaginal fixation. Dy et al. ( 15 ) has had no rectal injuries or fistulae to date in his series of 15 patients, with a mean follow-up of 12 months.

In our series, we observed 44 cases (20.5 percent) of urethral meatus strictures. We credit this complication to the technique used in the initial 5 years of our experience, in which the urethra was shortened and sutured in a circular fashion without spatulation. All cases were treated with meatal dilatation and 11 patients required surgical correction, being performed a Y-V plastic reconstruction of the urethral meatus. In the literature, meatal strictures are relatively rare in male-to-female (MtF) GAS due to the spatulation of the urethra and a simple anastomosis to the external genitalia. Recent systematic reviews show an incidence of five percent in this complication ( 16 , 17 ). Other studies report a wide incidence of meatal stenosis ranging from 1.1 to 39.8 percent ( 4 , 8 , 11 ).

Neovagina introital stricture was observed in 33 patients (15.4 percent) in our study and impedes the possibility of neovaginal penetration and/or adversely affects sexual life quality. In the literature, the reported incidence of introital stenosis range from 6.7 to 14.5 percent ( 4 , 5 , 8 , 9 , 11 – 13 ). According to Hadj-Moussa et al. ( 18 ) a regimen of postoperative prophylactic dilation is crucial to minimize the development of this outcome. At our institution, our protocol for vaginal dilation started seven days after surgery and was performed three to four times a day during the first 3 months and was continued until the individual had regular sexual intercourse. We treated stenosis initially with dilation. In case of no response, we propose a surgical revision with diamond-shaped introitoplasty with relaxing incisions. In recalcitrant cases, we proposed to the patient a secondary vaginoplasty using a full-thickness skin graft of the lower abdomen.

One hundred eighty-one (85 percent) patients were classified as having a “functional vagina,” characterized as the capacity to maintain satisfactory sexual vaginal intercourse, since the mean neovaginal depth was not measured. In a review article, the mean neovaginal depth ranged from 10 to 13.5 cm, with the shallowest neovagina depth at 2.5 cm and the deepest at 18 cm ( 17 ). According to Salim et al. ( 19 ), in terms of postoperative functional outcomes after penile inversion vaginoplasty, a mean percentage of 75 percent (range from 33 to 87 percent) patients were having vaginal intercourse. Hess et al. found that 91.4% of patients who responded to a questionnaire were very satisfied (34.4%), satisfied (37.6%), or mostly satisfied (19.4%) with their sexual function after penile inversion vaginoplasty ( 20 ).

Poor cosmetic appearance of the vulva is common. Amend et al. reported that the most common reason for reoperation was cosmetic correction in the form of mons pubis and mucosa reduction in 50% of patients ( 16 ). We had no patient regrets about performing GAS, although 36 patients (16.8 percent) were reoperated due to cosmetic issues. Gaither et al. propose in order to minimize scarring to use a one-stage surgical approach and the lateralization of surgical scars to the groin ( 14 ). Frequently, cosmetic issues outcomes are often patient driven and preoperative patient education is necessary ( 14 ).

Analyzing the quality of life, in 2016, our health care group (PROTIG) published a study assessing quality of life before and after gender-affirming surgery in 47 patients using the diagnostic tool 100-item WHO Quality of Life Assessment (WHOQOL-100) ( 21 ). The authors found that GAS promotes the improvement of psychological aspects and social relations. However, even 1 year after GAS, MtF persons continue to report problems in physical and difficulty in recovering their independence. In a systematic review and meta-analysis of QOL and psychosocial outcomes in transsexual people, researchers verified that sex reassignment with hormonal interventions more likely corrects gender dysphoria, psychological functioning and comorbidities, sexual function, and overall QOL compared with sex reassignment without hormonal interventions, although there is a low level of evidence for this ( 22 ). Recently, Castellano et al. assessed QOL in 60 Italian transsexuals (46 transwomen and 14 transmen) at least 2 years after SRS using the WHOQOL-100 (general QOL score and quality of sexual life and quality of body image scores) to focus on the effects of hormonal therapy. Overall satisfaction improved after SRS, and QOL was similar to the controls ( 23 ). Bartolucci et al. evaluated the perception of quality of sexual life using four questions evaluating the sexual facet in individuals with gender dysphoria before SRS and the possible factors associated with this perception. The study showed that approximately half the subjects with gender dysphoria perceived their sexual life as “poor/dissatisfied” or “very poor/very dissatisfied” before SRS ( 24 ).

Our study has some limitations. The total number of operated patients is restricted within the long follow-up period. This is due to a limitation in our health system, which allows only 1 sexual reassignment surgery to be performed per month at our institution. Neovagin depth measurement was not performed routinely in the follow-up of operated patients.

Conclusions

The definitive treatment for patients with gender dysphoria is gender-affirming surgery. Our series demonstrates that GAS is a feasible surgery with low rates of serious complications. We emphasize the high level of functionality of the vagina after the procedure, as well as subjective personal satisfaction. Complications, especially minor ones, are probably underestimated due to the nature of the study, and since this is a surgical population, the results may not be generalizable for all transgender MTF individuals.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Hospital de Clínicas de Porto Alegre. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GM: conception and design, data acquisition, data analysis, interpretation, drafting the manuscript, review of the literature, critical revision of the manuscript and factual content, and statistical analysis. ML and TR: conception and design, data interpretation, drafting the manuscript, critical revision of the manuscript and factual content, and statistical analysis. DS, KS, AF, AC, PT, AG, and RC: conception and design, data acquisition and data analysis, interpretation, drafting the manuscript, and review of the literature. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding. This study was supported by the Fundo de Incentivo à Pesquisa e Eventos (FIPE - Fundo de Incentivo à Pesquisa e Eventos) of Hospital de Clínicas de Porto Alegre.