Abstract
Background: One of the more common procedures conducted through the transition-related surgeries (TRSs) program is simple orchiectomy. Due to the relative novelty of TRS in Canada, national perioperative guidelines for simple orchiectomy in the context of TRS are yet to be developed. Furthermore, there is a void in the literature describing the indications and outcomes of simple orchiectomy among transgender individuals.
Aims: This study is the first descriptive case series in Canada highlighting our experience with simple orchiectomy in the context of TRS.
Methods: This study retrospectively assessed data from electronic patient medical records of 16 patients who had simple orchiectomy procedures at Women’s College Hospital in Toronto, Canada from August 2018 to April 2019. Data were collected using a standardized data collection form which includes patient baseline demographic data, and objective and subjective clinical outcomes.
Results: Mean age at surgery was 32.6 ± 10.4 years and mean time to surgery following the initial approval of referral was 9.9 ± 8.5 weeks. A majority of referrals (n = 13, 81.3%) were from urban areas with specialized TRS services. The average time on hormones was 3.1 ± 1.9 years. In terms of post-surgical complications at the 30-day day follow-up visit, there was a single post-operative sperm granuloma reported. There were no other complications identified post-surgery in our patient case series.
Discussion: In Ontario, the growing recognition of the benefits of TRS has led to the development of a publicly funded pathway to TRS surgery. This study is the first assessment of simple orchiectomy performed for TRS in Canada, and it has shown that the procedure is safe and reproducible. Due to its benefits, coordinating safe and efficient access of care for this procedure should be an important action item for health systems. This study is limited by its low sample size.
Keywords: Simple orchiectomy, transgender, case series, transition-related surgery, clinical outcome, complications
Introduction
Transgender individuals makeup 0.5–1.3% of the general population (Winter et al., 2016). Recently, the transgender community has been formally recognized by the World Health Organization as a population whose health needs are on the margins of past healthcare agendas (Thomas et al., 2017). In Canada, transgender specific healthcare services are becoming more widely available. Women’s College Hospital in Toronto, Ontario has established the first publicly funded transition-related surgery (TRS) program in the country. Patients from across Canada are currently being seen in the program for orchiectomy, scrotectomy, chest masculinization, breast augmentation, and vaginoplasty. One of the more common procedures conducted through the TRS program is simple orchiectomy. Unlike radical inguinal orchiectomy, simple orchiectomy is typically conducted in the context of TRSs. This is a scrotal sparing procedure that is sometimes conducted as a precursor to vaginoplasty. Transgender individuals who undergo simple orchiectomy typically do so to be able to discontinue hormone therapy used for medical transitioning (Hehemann & Walsh, 2019).
Due to the relative novelty of TRS in the country, national perioperative guidelines for simple orchiectomy in the context of TRS are yet to be developed. Current practice is highly informed by general guidelines published by the World Professional Association for Transgender Health (WPATH). However, WPATH’s guidelines and standards of care do not address the unique perioperative needs of transgender individuals (Coleman et al., 2012; Etienne Tollinche et al., 2018). Furthermore, there is a void in the literature describing the indications and outcomes of simple orchiectomy among transgender individuals. We herein present a case series highlighting our experience with simple orchiectomy in the context of TRS.
Methods
This is a case series using electronic patient medical records as the data source. Participants who were lost to follow up after their simple orchiectomy were excluded from the study. Indications for simple orchiectomy for TRS at Women’s College Hospital include the Ministry of Health and Long-Term Care Approval for OHIP funding. This is approval is preceded by an assessment and approval for access to ministry funding conducted by a qualified healthcare provider.
Patients are counseled about the option of having an orchiectomy as part of vaginoplasty. For those either not interested or still contemplating vaginoplasty, we discuss the risks and benefits of standalone orchiectomy. Patients are counseled that orchiectomy prior to vaginoplasty does not significantly impact the vaginoplasty especially in patients with adequate penile length. Furthermore, patients are informed that orchiectomy can reduce scrotal size over time. Due to the atrophic nature of testicular tissues (secondary to hormonal therapy), we see this risk as relatively low but do counsel patients that orchiectomy prior to vaginoplasty may reduce scrotal tissue and impact vaginal depth if penile tissue is also not adequate.
Data were collected using a standardized data collection form which includes patient baseline demographic data, and a plethora of objective and subjective clinical outcomes. The demographic data included the patient’s age at the time of surgery, place of residence, the time it took to have surgery from the date of health ministry approval for TRS funding, the location of their referring healthcare provider, any comorbidities they had at the time of the surgery, and the length of time they were on hormone therapy prior to the surgery. The subjective clinical outcomes include patient reported feelings regarding the surgery and post-operative recovery, and the patient’s post-operative analgesic use. The objective clinical outcomes include the testicular specimen size, if sperm production was present in the testicles, any surgical complications, and if the patient opted in for a scrotectomy as well as fertility preservation.
The study took place at the Women’s College Hospital Transition Related Surgeries Program. The catchment area for the center includes adult (>18 years of age) patients from across Ontario. Data were collected from medical records from patients who had simple orchiectomy procedures conducted by one surgeon at the Women’s College Hospital from August 2018 to April 2019. As Women’s College Hospital Transition Related Surgeries Program is the only publicly funded center in Canada that provides TRSs, its medical records are the only sources of data in the country regarding TRS services. This study has received ethics approval from the Women’s College Hospital Research Ethics Board. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.
Descriptive statistics will be presented by frequency, simple proportions, mean ± SD, as appropriate. All statistical analyses were conducted using the IBM SPSS statistical software.
Surgical approach
The surgical approach to a simple orchiectomy involves sharply and bluntly dissecting the cremasteric fibers off the cord. This allows the maximal cord length. We strive to ligate the cord as close to the external ring as possible. A high ligation reduces the chances of palpable cord stumps and does not seem to impact future vaginoplasty. There is a careful attention to remove only the testicle and cord leaving behind maximal tissue in case vaginoplasty is performed at a future time.
Results
Between August 2018 and April 2019 sixteen patients (Table 1) underwent simple orchiectomy for TRS at our institution, with two patients opting for a complete scrotectomy at the time of the procedure. Mean age at surgery was 32.6 ± 10.4 years and mean time to surgery following the initial approval of referral was 9.9 ± 8.5 weeks. Two patients opted for fertility preservation. With respect to post-surgical complications at the 30-day day follow-up visit, one patient reported a post-operative sperm granuloma. There were no other complications identified post-surgery in our series of patients. Nine patients did not have any co-morbidities at the time of surgery. Of the remaining seven patients, reported comorbidities included cardiovascular risk factors (diabetes, hyperlipidemia, obstructive sleep apnea, previous myocardial infarction) (3/16, 18%), psychiatric conditions (Bipolar II, Autism, ADD) (2/16, 12.5%), respiratory conditions (COPD, Asthma) (3/16, 18%), infectious diseases (HIV)(1/16, 6.25%), and hypothyroidism (1/16, 6.25%)
Table 1.
Characteristics of patients in case series.
| Patient ID | Age (yrs.) | Referring provider location | Time from initial approval to surgery (weeks) | Time on hormones (years) | Fertility opt-in | Medical comorbidities |
|---|---|---|---|---|---|---|
| 1 | 34 | Toronto | 7 | 5 | No | N/A |
| 2 | 51 | Toronto | 21 | 3 | No | N/A |
| 3 | 23 | London | 13 | 1.5 | No | N/A |
| 4 | 33 | Toronto | 11 | 7 | No | HIV |
| 5 | 37 | Toronto | 11 | 3 | No | Bipolar II |
| 6 | 24 | Toronto | 1 | 1 | Yes | N/A |
| 7 | 24 | Toronto | 3 | 1 | No | N/A |
| 8 | 27 | Toronto | 5 | 4 | No | Asthma, Autism, ADD |
| 9 | 33 | Toronto | 1 | No | N/A | |
| 10 | 36 | Toronto | 13 | 1.5 | No | OSA |
| 11 | 61 | Toronto | 31 | 3.5 | No | COPD, Hyperlipidemia, OSA, history of MI |
| 12 | 25 | Toronto | Approval arrived 4 weeks after surgery | 6 | No | N/A |
| 13 | 34 | Toronto | 14 | 2 | No | DM, Asthma |
| 14 | 28 | Toronto | 10 | 3 | No | Hypothyroidism |
| 15 | 24 | Sudbury | 10 | 5 | Yes | |
| 16 | 27 | Hamilton | 2 | 2.5 | No |
Referral patterns
The permanent place of residence for most patients was outside of the Greater Toronto Area (GTA) (n = 9, 56.3%). A majority of the referrals were from providers located in the immediate Toronto-based area (n = 13, 81.3%). The Centre for Addictions and Mental Health, a major Toronto-based, tertiary care mental health center accounted for up to 37.5% (n = 6) of all referrals. Results from Spearman correlation demonstrate a significant positive association between the age of the patient on approval of surgery and the length of time until surgery completion, with older patients waiting longer for completion of their TRS surgery (r = 0.635, p < 0.05).
Hormone therapy at time of surgery
The average time on hormones was 3.1 ± 1.9 years. At the time of surgery, all patients were on a combination of hormones including one estrogen-containing compound and one anti-androgen (Table 2). A majority of those undergoing surgery (n = 15, 93.8%) were on 17B-Estradiol therapy, with two patients using transdermal patches as a means of drug delivery. One patient was using conjugated estrogen at the time of surgery. In addition to an estrogen-containing compound, 62.5% (n = 10) of patients were on spironolactone and the remainder were on cyproterone acetate at the time of surgery. One patient was using progesterone (Depo-Provera) in combination with conjugated estrogen and spironolactone. Following orchiectomy, all patients discontinued their testosterone blocker medication
Table 2.
Hormone therapy at time of surgery.
| Hormone | Frequency of use | Dose range | Comments | |
|---|---|---|---|---|
| Estrogens | ||||
| 17B-Estradiol | 15 | 3–6 mg/daily | Two patients used the transdermal patch 75 mcg/h ×3/week and 200 mcg/h ×2/week | |
| Conjugated Estrogen | 1 | 0.625 mg/daily | ||
| Anti-androgens | ||||
| Spironolactone | 10 | 100–400 mg/daily | ||
| Cyproterone Acetate | 6 | 25–100 mg/daily | ||
| Progesterone | ||||
| Depo-Provera | 1 | 50 mg/2 weeks | Included in a three drug combo of spironolactone and conjugated estrogen | |
Testicular volume and sperm production
Following surgery, testicular samples were preserved for assessment. Average testicular mass was 25.43 g. There was no correlation between average testicular mass and time spent on hormones (−0.013, p = 0.962). Sperm pathology reports were available for 10 patients – 8 patients (8/10, 80%) had absent spermatogenesis and 2 patients (2/10, 20%) had significantly reduced spermatogenesis.
Discussion
The present study has demonstrated that simple orchiectomy as a form of TRS can be safely performed at our institution with minimal follow-up complications. This study is the first assessment of simple orchiectomy performed for TRS in Canada, and it has shown that the procedure is safe and reproducible. The 30-day complication rate of this procedure is 6.2% (n = 1), with the development of a single semen granuloma as the sole reported complication.
Transgender individuals currently face higher rates of physical and mental health conditions and reduced access to medical and social services relative to the general population. The Lancet Commission on Transgender Health identified a variety of barriers to ensuring that transgender individuals attain the highest standards of physical and mental wellbeing (Reisner et al., 2016). This limited access to care stems from a plethora of factors, including stigma, discrimination, as well as a lack of transgender inclusive healthcare providers and transgender-specific healthcare programs (Winter et al., 2016). Transgender specific programs include transgender-specific mental health services, hormone therapies, and TRSs. Due to the sparsity and novelty of transgender-specific health services, there is a gap in research and guidelines specific to transgender individuals (Wylie et al., 2016).
TRS is any surgical procedure that brings a closer alignment between one’s body and gender identify (Pan & Honig, 2018). Orchiectomy remains one of the most desired and commonly performed interventions in the male to female transition cycle. Motivations to undergo orchiectomy are unique to an individual’s journey in transitioning. Common reasons to pursue orchiectomy include it being used as a stepping stone to complete vaginoplasty, a patient not being eligible for vaginoplasty, or as a means to discontinue anti-testosterone hormones (van der Sluis et al., 2020). The 2015 US Transgender Survey surveyed over 27,715 transgender individuals across 50 states. Regarding surgical procedures for transgender women, the survey found that 4% of respondents has undergone a tracheal shave, 6% had undergone facial feminization surgery, 8% had augmentation mammoplasty (top surgery), 9% had undergoing orchiectomy, and 10% of respondents having undergone vaginoplasty and/or labiaplasty. Of respondents, 47% reported a desire to have the orchiectomy procedure at some point in the future. Moreover, results from the TransPULSE survey – a community-based research project surveying transgender Ontarians (n = 205) – found that orchiectomy is the most common surgical procedure performed (excluding hair removal) with up to 21% of transgender women in Ontario having received an orchiectomy (Scheim & Bauer, 2015).
Ontario data have shown that completing a gender transition was associated with a 62% relative risk reduction (RR = 0.38; 95% CI: 0.22, 0.66) in suicidal ideation (Rotondi et al., 2011). Bilateral orchiectomy is sometimes performed concurrently with vaginoplasty, but some patients elect for removal of testicular tissue at an earlier stage of their transition. There are several benefits of performing simple orchiectomy prior to vaginoplasty. The reduced endogenous androgen production following orchiectomy allows the patient to discontinue any anti-androgen medications. Moreover, the supplemental estrogen dose may be decreased by as much as 20–50% (Pan & Honig, 2018). Reducing the dose and pill burden of those on hormone therapy may lead to increased compliance and reduced unintended side-effects of these medications. Despite its benefits, a recent study by Canner et al. in 2018 found that although the incidence of TRS surgery increased significantly from 2000 to 2014, 56.3% of patients undergoing TRS in the US were not covered by any health insurance plan (Canner et al., 2018).
In Ontario, the growing recognition of the benefits of TRS has led to the development of a publicly funded pathway to TRS. To receive approval for TRS two independent assessments from qualified health care practitioners must confirm that an individual has a diagnosis of persistent gender dysphoria, has completed 12 continuous months of hormone therapy, and lived for 12 continuous months in the gender identity they identify with (Government of Ontario, 2016).
Medical transition is an individualized process based on each trans-person’s goals of care and comfort level. Hormone therapy is the first-line medical approach for transgender women, with the goal of reducing endogenous androgen levels and introducing exogenous estrogen to promote feminization of phenotypic features. All patients included in this case series were on a combination of an anti-androgen and estrogen therapy prior to their orchiectomy. To date, there have been no prospective RCTs on the effectiveness of different regimens. Several society guidelines exist – including the Endocrine Society Guidelines in 2017 and the Sherbourne Trans Guidelines in 2015 (Bourns, 2015; Hembree et al., 2017). The combination of 17-B Estradiol and spironolactone was the most common combination of hormone therapy in our sample.
Following orchiectomy, all patients discontinued their testosterone blocker medication. Benefits to discontinuing testosterone blocker medications include a reduced pill burden, as well as potential financial savings. This is especially pertinent for patients without drug coverage through private or public insurance. Depending on their medication use and dose requirements, patients in our study who were taking spironolactone without drug coverage benefits would save approximately $70–279 annually, while patients on cyproterone would save $255–1022 annually (Government of Ontario, 2019).
None of the patients who underwent simple orchiectomy in our sample suffered a complication that required medical or surgical intervention. Based on our initial findings, the group of patients undergoing surgery tended to be young, with relatively few medical co-existing morbidity. However, it important to note that as TRS surgery in Ontario expands and becomes more accessible, older patients and patients with multiple co-morbidities seeking TRS may begin seeking simple orchiectomy for TRS. As such, there may be more thought needed to pre-operative optimization of medical comorbidities prior to TRS. Older patients waiting for anesthesia assessments or engaging in efforts for better pre-operative optimization may in part explain our finding of older patients waiting longer until surgery is completed.
Regarding access to care given this public access, despite a majority of our patients residing outside of the Greater Toronto Area, most of the referring providers originate from within Toronto. Patients may be traveling from long distances to access transition-related care, which may act as a barrier toward receiving timely care. Although the minimum time on hormones is 12 months, the average time on hormones among patients undergoing TRS at our institution is 3.1 years. This finding may indicate that individuals are taking a longer time to explore living in their preferred gender prior to engaging in definitive surgical treatment. It may also indicate that despite being on hormones for the minimum recommended time, transgender persons have to wait an undue amount of time before publicly funded surgery is provided. If this is the case, it highlights the need for more qualified surgeons to offer the procedures as well as more streamlined referral and approval processes.
Our study has several limitations. To start, long-term outcome measures were not performed among our patient case series. This may have provided insight into patient satisfaction having done a simple orchiectomy, as well as any long-term complications of the procedure. Most complications of vaginoplasty present before 4 months (Gaither et al., 2018), therefore, conducting additional follow up appointments with our cohort may have provide a more accurate representation of the potential complications related to the procedure. Furthermore, future studies would benefit from more qualitative data points including patient reported outcome measures. Moreover, as Women’s College Hospital is the only publicly funded center in Canada to provide TRS services, our study was limited to one site with a relatively small sample size.
Simple orchiectomy remains a commonly performed, heavily desired, and effective medical intervention for transgender persons. Hence, coordinating safe and efficient access of care for this procedure should be an important action item for health systems. We report the first case series of patients in Ontario who have successfully received publicly funded simple orchiectomy in the context of TRS.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
- Bourns, A. (2015). Guidelines and protocols for hormone therapy and primary health care for trans clients. Rainbow Health Ontario, 67, 13–21. http://sherbourne.on.ca/lgbt-health/guidelines-protocols-for-trans-care/ [Google Scholar]
- Canner, J. K., Harfouch, O., Kodadek, L. M., Pelaez, D., Coon, D., Offodile, A. C., Haider, A. H., & Lau, B. D. (2018). Temporal trends in gender-affirming surgery among transgender patients in the United States. JAMA Surgery, 153(7), 609–616. 10.1001/jamasurg.2017.6231 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., … Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13(4), 165–232. 10.1080/15532739.2011.700873 [DOI] [Google Scholar]
- Etienne Tollinche, L., Burrows Walters, C., Radix, A., Long, M., Galante, L., Garner Goldstein, Z., Kapinos, Y., & Yeoh, C. (2018). The perioperative care of the transgender patient. Anesthesia and Analgesia, 127(2), 359–366. 10.1213/ANE.0000000000003371 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Gaither, T. W., Awad, M. A., Osterberg, E. C., Murphy, G. P., Romero, A., Bowers, M. L., & Breyer, B. N. (2018). Postoperative complications following primary penile inversion vaginoplasty among 330 male-to-female transgender patients. The Journal of Urology, 199(3), 760–765. 10.1016/j.juro.2017.10.013 [DOI] [PubMed] [Google Scholar]
- Government of Ontario. (2016). Gender confirming surgery. https://www.ontario.ca/page/gender-confirming-surgery
- Government of Ontario. (2019). Ontario drug benefit formulary. https://www.formulary.health.gov.on.ca/formulary/
- Hehemann, M. C., & Walsh, T. J. (2019). Orchiectomy as bridge or alternative to vaginoplasty. The Urologic Clinics of North America, 46(4), 505–510. 10.1016/j.ucl.2019.07.005 [DOI] [PubMed] [Google Scholar]
- Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T'Sjoen, G. G. (2017). Endocrine treatment of gender-dysphoric/gender-incongruent persons: An endocrine Society Clinical Practice Guideline . The Journal of Clinical Endocrinology and Metabolism, 102(11), 3869–3903. 10.1210/jc.2017-01658 [DOI] [PubMed] [Google Scholar]
- Pan, S., & Honig, S. C. (2018). Gender-affirming surgery: Current concepts. Current Urology Reports, 19(8), 10–17. 10.1007/s11934-018-0809-9 [DOI] [PubMed] [Google Scholar]
- Reisner, S. L., Poteat, T., Keatley, J. A., Cabral, M., Mothopeng, T., Dunham, E., Holland, C. E., Max, R., & Baral, S. D. (2016). Global health burden and needs of transgender populations: a review. The Lancet, 388(10042), 412–436. 10.1016/S0140-6736(16)00684-X [DOI] [PMC free article] [PubMed] [Google Scholar]
- Rotondi, N., Bauer, G., Scanlon, K., Kaay, M., Travers, R., & Travers, A. (2011). Prevalence of and risk and protective factors for depression in female-to-male transgender ontarians: Trans PULSE project. Canadian Journal of Community Mental Health, 30(2), 135–155. 10.7870/cjcmh-2011-0021 [DOI] [Google Scholar]
- Scheim, A. I., & Bauer, G. R. (2015). Sex and gender diversity among transgender persons in Ontario, Canada: Results from a respondent-driven sampling survey. Journal of Sex Research, 52(1), 1–14. 10.1080/00224499.2014.893553 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Thomas, R., Pega, F., Khosla, R., Verster, A., Hana, T., & Say, L. (2017). Ensuring an inclusive global health agenda for transgender people. Bulletin of the World Health Organization, 95(2), 154–156. 10.2471/BLT.16.183913 [DOI] [PMC free article] [PubMed] [Google Scholar]
- van der Sluis, W. B., Steensma, T. D., & Bouman, M. (2020). Orchiectomy in transgender individuals: A motivation analysis and report of surgical outcomes. International Journal of Transgender Health, 21(2), 176–176. 10.1080/26895269.2020.1749921 [DOI] [PMC free article] [PubMed] [Google Scholar]
- Winter, S., Diamond, M., Green, J., Karasic, D., Reed, T., Whittle, S., & Wylie, K. (2016). Transgender people: Health at the margins of society. The Lancet, 388(10042), 390–400. 10.1016/S0140-6736(16)00683-8 [DOI] [PubMed] [Google Scholar]
- Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S., & Baral, S. (2016). Serving transgender people: clinical care considerations and service delivery models in transgender health. The Lancet, 388(10042), 401–411. 10.1016/S0140-6736(16)00682-6 [DOI] [PubMed] [Google Scholar]