Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients

Abstract

Background

The authors sought to compare the perioperative morbidity of Stage 1 phalloplasty with asynchronous vs concurrent hysterectomy among transmasculine patients.

Methods

This retrospective study included transmasculine patients undergoing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy at Kaiser Permanente Northern California from January 1, 2017, to September 9, 2019. The primary outcome was differences in surgical site infection rates. Secondary outcomes included perioperative and other postoperative complications. Comparisons of demographics and outcomes were made by F-tests and Fisher’s exact tests. A p value of < 0.05 was considered statistically significant.

Results

Of 66 transmasculine patients undergoing Stage 1 phalloplasty, 32 (48%) had an asynchronous hysterectomy and 34 (52%) had a concurrent hysterectomy. Overall, surgical site infection rates were low, and there were no significant differences between groups. Patients who had undergone asynchronous hysterectomy had more neourethral complications with Stage 1 phalloplasty than those undergoing concurrent procedures (28% vs 3%, p < 0.05). There were no significant differences in estimated blood loss, length of stay, urinary tract infection, overactive bladder or narcotic use between groups.

Conclusion

Overall, there were no differences between groups in most postoperative complication rates. Although more neourethral complications were found in those undergoing asynchronous hysterectomy prior to Stage I phalloplasty, this may be partially explained by increasing surgeon experience over time given this difference did not remain statistically significant after the first year of the study period. Gynecologists seeking to provide comprehensive and inclusive care to transmasculine patients should take these findings into consideration when counseling patients planning genital gender affirmation surgery.

Introduction

Providing inclusive and affirming gynecologic care for transgender and nonbinary patients is essential to reduce the inequities experienced by this community. Patients who are assigned female at birth who have a masculine or nonbinary gender identity need comprehensive gynecologic care when pelvic organs are present and may see a gynecologist at any point on their gender journey. ^1,2 Some transgender patients may seek information regarding transition options from their gynecologist, including options for gender affirmation surgery. ³

Transgender individuals encounter many obstacles to receiving care. Only a minority of gynecologists feel comfortable addressing the health care needs of transmasculine and nonbinary patients. ^4–6 The 2015 U.S. Transgender Survey by the National Center for Transgender Equality showed that 25% of transgender individuals were denied coverage for hormones and 55% were denied coverage for transition-related surgery. One-third of individuals who had seen a health care provider in the past year reported having at least one negative experience related to being transgender, such as verbal harassment, refusal of treatment, or having to teach the health care provider about transgender people to receive appropriate care. Finally, 23% of respondents did not see a practitioner when they needed to because of fear of being mistreated as a transgender person. ⁷ Gynecologists play a key role in minimizing these barriers by taking on the primary care practitioner role for transgender patients, especially during the transition process.

Hysterectomy is one of the most commonly performed genital gender affirmation surgeries in transmasculine and nonbinary patients, with 79% of the relevant population surveyed in the U.S. Transgender Survey wanting to undergo or having undergone a hysterectomy. ⁷ Gynecologists should understand the benefits and risks of a hysterectomy in the transition process and the impact of hysterectomy if done asynchronously vs concurrently with other genital gender affirming surgeries. Providers should also understand common motives for surgery, including completing the surgery as a preventive measure due to concern about future medical problems and the hope to avoid gynecologic visits, as well as the gender affirmation felt by many in removing organs that are incongruent with one’s individual identity. ^2,8 Only when planning vaginectomy is hysterectomy required because such surgery would prevent screening for cervical cancer and there would be risk of hematometra. ⁹

At Kaiser Permanente Northern California, transgender and gender-expansive patients who are seeking specialized transition-related care or evaluations for surgery have been cared for by clinicians at 2 regional referral centers with specialized multidisciplinary clinics since 2013. Services are provided in a gender-inclusive environment and include hormone management, behavioral health, surgical consultations, nursing-care coordination, and social work. In addition to these regional referral centers, routine preventive care for Kaiser Permanente Northern California’s large volume of transgender patients is provided locally in gynecology and primary care clinics.

The authors compared complication rates among transmasculine patients undergoing Stage I phalloplasty after prior (asynchronous) hysterectomy vs concurrent hysterectomy. The primary outcome was 3-month surgical site infection (SSI) rate, and secondary outcomes included all other peri- and postoperative complications. The authors also compared inpatient and 3-month postoperative pain medication requirements between cohorts.

Methods

This was a retrospective cohort study of all transmasculine patients who underwent Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy within Kaiser Permanente Northern California between January 1, 2017, and September 30, 2019. Institutional Review Board exemption was obtained for this study. Patients were identified using their listed gender, procedure(s) performed, and diagnosis description(s) in the electronic medical record (EMR).

Transmasculine genital gender affirmation surgery is commonly performed in separate stages that may include either asynchronous or concurrent hysterectomy. These stages are not standardized among institutions. Within Kaiser Permanente Northern California, Stage I phalloplasty procedures consist of a vaginectomy, urethral lengthening (UL), and suprapubic catheter placement (SPC) with possible scrotoplasty. A hysterectomy with or without salpingo-oophorectomy is performed concurrently if not done previously. Stage 2 procedures consist of flap reconstruction with or without glansplasty and connection of urinary flow from the lengthened urethra to the flap, with SPC placement. Later stages include penile and testicular implants and glansplasty if it is not done with a flap. Prior to 2017, transmasculine patients commonly underwent a hysterectomy with or without salpingo-oophorectomy within Kaiser Permanente Northern California and underwent Stage I phalloplasty elsewhere. In 2017, the authors internalized these procedures with a multidisciplinary team that includes a gynecologic surgeon, urogynecologist, reconstructive urologist, and plastic surgeon.

Inclusion criteria included transmasculine patients 18 years of age and older who had undergone an asynchronous or concurrent hysterectomy and a Stage 1 phalloplasty procedure. Patients who underwent a metoidioplasty or penile skin reconstruction without a UL/vaginectomy or who did not have 3-month postoperative outcomes available were excluded. In addition, patients who underwent a hysterectomy and/or vaginectomy for reasons other than gender incongruence (i.e., malignancy) were excluded.

Once patients were identified, they were categorized into 2 groups: The asynchronous group had a hysterectomy prior to Stage I phalloplasty; and the concurrent group had a hysterectomy at the same time as Stage I phalloplasty. The authors did not have any nonbinary individuals in the Stage I phalloplasty groups. Baseline patient characteristics including age, race, and body mass index (BMI) were abstracted from the EMR. Operative and postoperative data, including American Society of Anesthesiologists (ASA) classification and previous oophorectomy performed, operating time, blood loss, hospital length of stay, requirement for intra- and/or postoperative blood transfusion, and pre- and postoperative hemoglobin and hematocrit were abstracted from the EMR. A chart review was performed to confirm the procedure performed and to identify significant postoperative events (including 3-month complications, readmission, and reoperation data). Neourethral complications included strictures and/or fistulas. A patient was reported as having undergone an oophorectomy only if both ovaries had been removed. The oophorectomy may have been performed at the time of the combined hysterectomy and Stage I phalloplasty or at any point prior to or concurrently with previous hysterectomy. Patients who returned to the operating room for simple cystoscopy or urethroscopy were not counted as having additional procedures. All diagnoses of urinary tract infections (UTIs) were reviewed and included only if they were culture-proven or if the patient had filled a prescription for antibiotics. A patient was considered to have a diagnosis of overactive bladder (OAB) if they were prescribed oxybutynin within 3 months of their surgery.

The primary outcome was differences in SSI rates at 3 months postoperatively, defined as the presence of International Classification of Diseases (ICD)-9 and ICD-10 codes for occurrence of superficial SSI, deep incision SSI, organ space SSI, and wound disruption. Secondary outcomes, including peri- and postoperative complications, were also extracted using ICD-9 and ICD-10 codes. Inpatient pain medication requirements were extracted as morphine equivalents (MEs) administered during the patient’s inpatient evaluation. Outpatient pain medication requirements were calculated as the number of narcotic pain medication prescriptions filled which was then converted to the ME dose for comparison. Outpatient pain medication requirements included any narcotic prescriptions filled at the time of discharge, and the standard of care is to provide patients with a prescription of the narcotic they were using as an inpatient during their hospitalization.

For variables found to be statistically significant, comparisons were also performed with the variable stratified by year of surgery to explore the possible effect of surgeon experience on peri- and postoperative complications. F-tests and Fisher’s exact tests were used to compare differences between continuous and categorical variables, respectively. Statistical analysis was performed using SAS (version 9.4; SAS Institute, Inc., Cary, NC). A p value of < 0.05 was considered statistically significant.

Results

There were 66 patients who met inclusion criteria: 32 had an asynchronous hysterectomy, and 34 had a concurrent hysterectomy with Stage 1 phalloplasty. Patient characteristics are presented in Table 1. Patients who had a concurrent hysterectomy with Stage I phalloplasty were younger (31 vs 40 years of age, p < 0.01) and less likely to have had a bilateral oophorectomy (38% vs 69%, p = 0.03). There were no differences in BMI, racial composition, or ASA class between groups.

Table 1:

Patient characteristics

Variable	Stage 1 phalloplasty with asynchronous hysterectomy	Stage 1 phalloplasty with concurrent hysterectomy	p value
Patients % (n)	15 (32)	16 (34)	—
Age, y	40 (30–49)	31 (23–36)	< 0.01
BMI, kg/m2	29 (25–33)	27 (24–32)	0.44
Race
Black	13 (4)	15 (5)	0.37
Asian/Pacific Islander	6 (2)	9 (3)	0.37
Hispanic	16 (5)	18 (6)	0.37
Other	6 (2)	3 (1)	0.37
White	59 (19)	56 (19)	0.37
ASA
1	19 (6)	38 (13)	0.46
2	72 (23)	59 (20)	0.46
3	9 (3)	3 (1)	0.46
Previous oophorectomy	69 (22)	38 (13)	0.03
Route of hysterectomy
Laparoscopic	69 (22)	32 (11)	—
Vaginal	13 (4)	68 (23)	—
Laparoscopic-assisted vaginal	6 (2)	—	—
Abdominal	3 (1)	—	—
Unknown	9 (3)	—	—

Data are expressed as mean (IQR) or % (n). p values calculated using F-tests for continuous variables and Fisher’s exact tests for categorical variables. (N = 66).

ASA, American Society of Anesthesiologists; BMI, body mass index; IQR, interquartile range.

In patients who underwent a hysterectomy concurrent with Stage I phalloplasty, 11 (32%) were performed laparoscopically and 23 (68%) were performed vaginally. In patients who had Stage I phalloplasty with asynchronous hysterectomy, 22 (69%) were performed laparoscopically, 4 (13%) vaginally, 2 (6%) laparoscopic-assisted vaginally, and 1 (3%) abdominally. SSI rates were low in both groups, and there were no statistically significant differences between the 2 groups (Table 2). In patients who had Stage I phalloplasty with asynchronous hysterectomy, 9% had a superficial SSI, 3% had a deep incision SSI, and 3% had a wound disruption SSI. Among patients who had a concurrent hysterectomy with a Stage I phalloplasty, 6% had a deep incision SSI.

Table 2:

Primary and secondary outcomes

Primary and secondary outcomes	Stage 1 phalloplasty with asynchronous hysterectomy (N = 32)	Stage 1 phalloplasty with concurrent hysterectomy (N = 34)	p value
SSI within 3 mo
Superficial SSI	9 (3)	0	0.11
Deep incision SSI	3 (1)	6 (2)	1
Organ space SSI	0	0	—
Wound disruption SSI	3 (1)	0	0.49
Intraoperative details
Incision to close (min)	297 (257–335)	321 (275–347)	0.08
Estimated blood loss (mL)	254 (150–350)	224 (150–300)	0.45
Hospital length of stay (d)	4 (4–5)	4 (4–5)	0.84
Intraoperative transfusion	0	0	—
Urinary tract related complications within 3 mo
Neourethral complications (stricture, fistula)	28 (9)	3 (1)	< 0.01
Urinary tract infection	50 (16)	56 (19)	0.81
Overactive bladder	75 (24)	74 (25)	1
Pain medication requirements
MEs during inpatient evaluation (mg)	125 (98–146)	121 (94–141)	0.7
No. of opioid prescriptions within 3 mo
0	3 (1)	3 (1)	0.42
1	47 (15)	59 (20)	0.42
2	19 (6)	24 (8)	0.42
3	9 (3)	9 (3)	0.42
≥ 4	22 (7)	6 (2)	0.42

Data are expressed as mean (IQR) or % (n). p values calculated using F-tests for continuous variables and Fisher’s exact tests for categorical variables.

ME, morphine equivalent; SSI, surgical site infection .

The mean operative time for a Stage I phalloplasty in patients who had an asynchronous hysterectomy was 297 minutes compared with 321 minutes for patients who underwent concurrent hysterectomy (p = 0.08). The estimated blood loss at the time of Stage 1 phalloplasty for patients who had asynchronous hysterectomy was 254 mL compared with 224 mL in patients undergoing concurrent procedures (p = 0.45). Length of hospitalization was similar for both groups (mean, 4 d, p = 0.84). No patients required blood transfusions intraoperatively and 1 patient in the concurrent group required a blood transfusion postoperatively. There were no statistically significant differences in rates of UTI or OAB between the 2 groups.

Over the 3-year study period, more patients who had an asynchronous hysterectomy had a neourethral complication compared with those who had a concurrent hysterectomy (28% vs 3%, p < 0.01). Analysis of all neourethral complications suggests a significant difference based on year, with 7 neourethral complications in 2017, 1 in 2018, and 2 in 2019 despite similar surgical volumes (Table 3). When the rate of neourethral complications was compared between groups for the years 2018 and 2019 only (Table 4), there was no statistically significant difference in the rate of neourethral complications between patients who had an asynchronous hysterectomy and those who had these procedures performed concurrently (13% vs 4%, p = 0.28).

Table 3:

Neourethral complication rates overall, by year of surgery

Year of surgery	Neourethral complication		No neourethral complication		p value
	n (%)	95% CI	n (%)	95% CI
2017	7 (30)	0.13–0.53	16 (70)	0.47–0.87	0.03
2018	1 (4)	0.00–0.21	23 (96)	0.79–1.00	0.03
2019	2 (11)	0.01–0.33	17 (89)	0.67–0.99	0.03

Data are expressed as n (%). p value from Fisher’s exact test.

CI, confidence interval.

Table 4:

Neourethral complication rates in 2018–2019, by surgery type

Type of surgery	Neourethral complication		No neourethral complication		p value
	n (%)	95% CI	n (%)	95% CI
Stage 1 phalloplasty with asynchronous hysterectomy	2 (13)	0.02–0.40	13 (87)	0.60–0.98	0.28
Stage 1 phalloplasty with concurrent hysterectomy	1 (4)	0.00–0.18	27 (96)	0.82–1.00	0.28

Data are expressed as n (%). p value from Fisher’s exact test.

CI, confidence interval.

During hospitalization, patients who had a Stage 1 phalloplasty with asynchronous hysterectomy received 125 (IQR 98–146) mg of ME, whereas patients who had a concurrent hysterectomy received 121 (IQR 94–141) mg of ME (p = 0.70). There was no significant difference in 3-month post-discharge opioid prescriptions, with most patients requiring 1 additional opioid prescription (Table 2).

Discussion

This retrospective study presents findings from a large cohort of transmasculine patients having had an asynchronous hysterectomy with or without adnexal surgery and Stage I phalloplasty compared with those having concurrent hysterectomy with or without adnexal surgery and Stage I phalloplasty. The authors found overall complication rates were low in both groups, with no differences found in most perioperative and 3-month postoperative complication rates, length of stay, and pain medication requirements.

The authors found that transmasculine patients who underwent an asynchronous hysterectomy with Stage I phalloplasty had more neourethral complications, such as strictures and/or fistulas, during their 3-month postoperative time period. However, this difference was no longer statistically significant when using data only from the latter 2 years of the study period. In this study population, 70% of neourethral complications occurred in the first year of the study period. This concentration of complications in the first year followed by a decrease in subsequent years may be explained by increasing surgeon experience over time. A correlation between decreasing complication rates and increasing surgeon experience has been substantiated by several large studies looking specifically at hysterectomies. In one study, the overall complication rates for non-transgender women who underwent a hysterectomy with very low-volume surgeons (i.e., 1 procedure per year) was 32% compared with 10% for those treated by other surgeons. ¹⁰ Furthermore, the overall rate of neourethral complications was lower than has been previously reported. This may be due to advancing techniques and/or to the fact that the authors did not include creation of a neophallus in the Stage I phalloplasty. For instance, a retrospective study of transmasculine patients undergoing UL with either a metoidioplasty or phalloplasty (including the neophallus shaft creation at the same time) reported a stricture formation rate of 63%. Twenty-seven percent of transmasculine patients who had undergone a phalloplasty and 30% of men who had undergone a metoidioplasty developed a urethral fistula. ¹¹ Of note, upon discovering the rate of UTIs in these patients, several preventive measures were implemented starting in 2019, including the utilization of a cranberry supplement twice daily when an SPC was in place, prophylactic antibiotics before catheter removal and voiding cystourethrogram, and a preoperative urinalysis and urine culture to identify and treat asymptomatic bacteriuria.

Previously, it has been shown that overall postoperative complication rates after hysterectomy in transmasculine patients were low, with no difference compared with non-transgender women. ^11–13 Furthermore, all routes of hysterectomy have been supported in this population, and the study findings support this as well. ^14,15 A sizable proportion of patients in this study underwent a vaginal compared with a laparoscopic hysterectomy when the surgery was combined with Stage I phalloplasty, demonstrating that a vaginal hysterectomy is often feasible in this population. Although there are cases when a laparoscopic approach may be needed and known ahead of time, the majority of patients undergo an examination under anesthesia, and the authors evaluate for feasibility of a vaginal approach at that time. The authors do obtain priori ultrasound imaging of the pelvis in most cases, given that the size of the uterus may not be able to be accurately determined in many patients on examination alone. Although there are no studies of this to date, the experience of the authors has been that the combination of nulliparity and a de-estrogenized vagina may increase the risk at time of surgery if there is a need to morcellate a uterus to complete the surgery. In addition, the authors have identified patients with incidental large fibroids in whom the surgery may take longer and thus have recommended they have their hysterectomy completed first.

The authors found that transmasculine patients who had hysterectomy concurrently with Stage I phalloplasty were younger and less likely to have undergone a bilateral oophorectomy compared with transmasculine patients who had asynchronous hysterectomy. Previous studies have found that transgender patients undergoing hysterectomies are younger than the general population and more likely to receive concurrent adnexal surgery. ^13,15 It may be that there is now a shift in preoperative counseling in younger transmasculine patients who are seeking genital gender affirmation surgery to maintain ovarian function for other health benefits.

Patients may seek to undergo combined surgeries to limit surgical and hospital stay events. Evidence shows that combined surgeries, such as performing combined mastectomy and hysterectomy procedures, are safe, with complication rates similar to those published in the literature and may help reduce barriers to care for this patient population. ¹⁶ In this study, undergoing a concurrent hysterectomy and Stage I phalloplasty decreased the number of surgical episodes without prolonging the patient’s hospital stay. Therefore, hysterectomy counseling should include a discussion of possible interest in other gender affirming surgeries, with shared decision making as to whether it might be important for a patient to have their hysterectomy sooner given their dysphoria and medical needs or if they may want to plan to have it concurrently with other genital surgery if that is their ultimate goal. Surgical counseling should also include the possible routes of hysterectomy, overall surgical planning, and expected recovery.

The main limitations of this study include its retrospective nature and associated biases inherent to this study type. A limited sample size also precluded equivalence or non-inferiority testing on outcomes between study groups. In addition, this study population included only patients undergoing UL as the first stage of their phalloplasty. Creation of the neophallus itself can have additional neourethral complications. ¹⁷

The main strength of this study is that it captures a large sample of transmasculine patients undergoing genital gender affirmation surgery at a single institution performed by the same core surgical team. In addition, the integrated health care system allows for close follow-up both by radiologic evaluation of the neourethra by experienced radiologists and surgeons and clinical assessment in a multidisciplinary transgender clinic.

Future research is needed to understand if there is a mechanism that may explain the difference seen in neourethral complication rates in this study, such as tissue scarring, that may become more apparent with a larger sample size. Validated presurgical decision-making tools to help patients communicate their goals with their care team are also needed. For instance, previous research has focused on the ability to urinate while standing as a major reason for seeking gender affirmation surgery, whereas other studies have reported more patient emphasis on general appearance and sexual function after surgery as well. ¹⁸

Conclusion

In summary, this study showed that performing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy for genital gender affirmation surgery is safe, with very low overall perioperative and postoperative complication rates. The authors did find a higher rate of neourethral complications among patients undergoing Stage I phalloplasty who had had an asynchronous hysterectomy, possibly explained by low surgeon experience in the first year of the study period. Gynecologists play an essential role in counseling transgender patients regarding their options for genital gender affirmation surgery, and the quality of care and counseling provided before, during, and after surgery will significantly impact patient outcomes. As gynecologists interface more with transgender patients and as genital gender affirming surgery becomes more readily accessible, these practitioners will undoubtedly play an increasingly crucial role in counseling patients who may be seeking more information regarding these surgeries. These findings should be taken into consideration when counseling transmasculine and nonbinary patients regarding their options for genital gender affirmation surgery, especially in understanding how various procedures may be combined safely to minimize surgical episodes.

Disclosure Statement

This work was presented as an oral presentation at the American Urogynecologic Society, Pelvic Floor Disorders Week 2020—The Virtual Experience on October 10, 2020, and as an oral presentation at the World Professional Association for Transgender Health Virtual Scientific Symposium on November 8, 2020.