BackTable / Urology / Article
Gender Affirming Bottom Surgery Complications
Ishaan Sangwan • Jun 27, 2022 • 31 hits
Many transgender and gender diverse individuals choose to undergo gender affirming pelvic surgery, colloquially called bottom surgery, in order to better allign their anatomy with their gender identity. Female to male (FTM) individuals may want a phalloplasty or metoidioplasty, whereas male to female (MTF) individuals may opt for a vaginoplasty. Many patients travel for these procedures, since only a few specialized surgeons perform them. Because of this, the primary surgeon may not always be available if complications arise, and a community urologist may have to manage these complications.
Dr. Aditya Bagrodia and Dr. Jennifer Anger sit down to discuss the most common complications of bottom surgery procedures and their management on the BackTable Urology Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable Urology Brief
• The most common complication of all types of bottom surgery is urethral stricture formation, which can be treated with urethral catheter placement or suprapubic catheter placement.
• Vaginal stenosis can also occur after vaginoplasty, and can be treated with dilators.
• When complications arise, it is important to touch base with the original surgeon and to ensure that they agree with the plan.
• For those interested in expanding to provide bottom surgery, sabbaticals and specialized fellowships are viable options.
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Table of Contents
(1) FTM Bottom Surgery Complications: Phalloplasty and Metoidioplasty
(2) MTF Bottom Surgery Complications: Vaginoplasty
(3) Getting Started in Gender Affirming Bottom Surgery
FTM Bottom Surgery Complications: Phalloplasty and Metoidioplasty
The biggest risk after phalloplasty and metoidioplasty is that of a stricture forming in the urethra. For phalloplasty, a stricture could occur at the junction of the proximal native urethra and the graft, or along the grafted pendulous urethra. With a metoidioplasty, there is no neophallus, and therefore no risk of strictures in the pendulous urethra, but a stricture may still occur at the junction of the native urethra and the graft in the enlarged clitoris. In both these cases, if the patient presents emergently, a urologist can try to insert a small catheter to keep the urethra patent, or insert a suprapubic catheter. In non-emergent cases, it is best to contact the primary surgeon and seek guidance.
[Dr. Jennifer Anger]
So transgender men who have had metoidioplasty or phalloplasty, the worst scenario, I think for them is a stricture and, phalloplasty has, you have the native urethra proximally, a urethra made of a combination of either buccal graft or just vaginal flaps, and then they have the pendulous urethra. And at both of those junctions, there could be stricture. And so if someone's not comfortable, but the patient's in an emergency situation, one option is to put them to sleep, do a cystoscopy, try to get a little catheter in, often it could be a very small catheter and if not, they might need a suprapubic catheter.
And so that's probably what you'll see after a phalloplasty. Metoidioplasty, there's no phallus, the majority of metoidioplasty is elongation of the clitoris and then recreating a urethra from vaginal wall flaps, often combined with buccal graft, depending on the technique. And they could have stricturing as well. And so if someone's not comfortable, they could always have a suprapubic catheter, or you can try to perform cystoscopy. And that's where maybe giving the surgeon a call just to get some, a little more detail would be helpful.
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MTF Bottom Surgery Complications: Vaginoplasty
For individuals getting vaginoplasty, the two biggest post-op concerns are urethral strictures and vaginal stenosis. Urethral strictures can typically be managed similar to phalloplasty and metoidioplasty strictures, by gently dilating the urethra with a small catheter or placing a suprapubic catheter. Vaginal stenosis, on the other hand, involves a narrowing of the vaginal opening with the possible development of a mucus seal. This usually does not present emergently unless an infection develops, and can be managed with dilation.
[Dr. Jennifer Anger]
For vaginoplasty, I think there's sort of two main issues that we see, in sort of an emergency postoperative setting. One could be a stricture at the urethra, which is usually just a bulbar stricture. It looks almost like a perineal urethrostomy. And usually a gentle dilation will reveal a normal bulbar urethra proximally. Again, if you're not comfortable or if it's obliterated, you could just place a suprapubic catheter. And then they can have what's called vaginal stenosis and the vaginal opening can narrow. And if that becomes too narrow, they can develop, we've seen sort of, where you can develop almost like the vaginal canal inside can develop like a mucus seal or where you have purulent material building. So, that sort of scenario could require a small dilation to be able to just open any canal. But usually that's not as much of an emergency situation unless it's obliterated and there's actually like an infection. But, I think the bigger, the more acute issues would be that of the stricture. And I think most, most urologists can, you know, I would say all urologists are able to put in a suprapubic catheter if necessary.
Getting Started in Gender Affirming Bottom Surgery
Due to a dearth of urologists who are familiar with these procedures, there is always a demand for more urologists entering the field. Managing complications is a great way to start familiarizing oneself with these procedures. While doing so, it is important to touch base with the original surgeon and ensure that they agree with the clinical and surgical plan. Routes to getting started with performing gender affirming surgeries include sabbaticals and specialized fellowships. Dr. Anger shares that she entered the field through her strong reconstructive background, and encourages interested urologists to not get discouraged from pursuing this rewarding field.
[Dr. Jennifer Anger]
Like I personally will, if I have a patient who's had surgery elsewhere, I call the surgeon. I talked to them and if they need revision surgery, I'll make sure that the surgeon is like, they need a revision. Are you all right if I perform the revision surgery? And so I think it's important to, I like to be in touch with the original surgeon and I welcome patients who have had surgery elsewhere. They tend to be, it's not the word shunned, but many doctors are like, I don't want to deal with that. I don't know how to deal with that. We often, if we're not comfortable with something as providers, we tend to not care for it, but these patients really need us, and I encourage urologists to be willing to see that patient.
I have a strong reconstructive background, but people were like, well, what are you doing? Like, why are you doing this? you're FPMRS surgeon. You don't know how to do these surgeries. And I had to kind of have some faith in myself and, say, you know, I have a strong reconstructive background and I've done bits and pieces of all of these surgeries and then, take the extra time to train, and then once I started seeing that this is going really well and we're having good outcomes that I think it's important that I, I think, the.desire to do a good job is very important and how, whether you do a specialized fellowship in gender affirming surgery, and there's not a lot of them yet, or you do sabbaticals, like a lot of us have done and you have a strong reconstructive background. I think you can help provide care and provide good care for these patients. And so, I think, for me it was, I definitely had a passion for it. I felt like the surgeries were definitely within my reconstructive skillset. And I was seeing surgeries that were not going well. And I felt like I know I could help this population. And so it's been very rewarding being able to, you know, help someone who's had surgery, who can't pee, with the suprapubic catheter and we can reconstruct the urethra and help someone enjoy the outcome of their surgery. Right. I think that's very, very rewarding.
Dr. Jennifer Anger
Dr. Jennifer Anger is a urologist and gender affirming pelvic surgeon at UC San Diego in California.
Dr. Aditya Bagrodia
Dr. Aditya Bagrodia is an associate professor of urology and genitourinary oncology team leader at UC San Diego Health in California and adjunct professor of urology at UT Southwestern.
Cite This Podcast
BackTable, LLC (Producer). (2022, March 16). Ep. 33 – Gender-Affirming Care: A Primer [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.