Genital Gender-Affirming Surgery in Transgender Men in The Netherlands from 1989 to 2018: The Evolution of Surgical Care

Abstract

Background: 

The number of individuals with gender identity incongruence seeking treatment, including genital gender-affirming surgery, has increased over the past decade. Surgical techniques for genital gender-affirming surgery in transgender men have evolved considerably. The aim of this study was to present an overview of the evolution of genital gender-affirming surgery for transgender men in a single, high-volume center.

Methods: 

The authors performed a retrospective analysis of medical records of all transgender men who underwent genital gender-affirming surgery from January of 1989 to January of 2018 at their institution. Subject demographics, type of surgery, and surgical techniques were recorded.

Results: 

Over time, four hundred transgender men underwent genital gender-affirming surgery. Metoidioplasty was performed in 222 patients (56 percent) and phalloplasty in 178 patients (44 percent). Before 2010, the majority of patients underwent metoidioplasty, whereas since 2010, phalloplasty has been performed in most patients. Of 400 patients, 332 (83 percent) underwent urethral lengthening. The option to undergo genital surgery without urethral lengthening was offered from 2004. Since then, 68 (34 percent) patients chose to undergo genital gender-affirming surgery without urethral lengthening. The choice of surgical options for genital gender-affirming surgery in transgender men has grown from five in 1989 to 12 techniques currently. The variety and combination of flaps used for phalloplasty has increased over time. Conversely, the use of some flaps has been abandoned, whereas other flaps have reemerged.

Conclusions: 

Genital gender-affirming surgery has developed over time in line with reconstructive surgical innovations. Despite technical advancements, there is no one ideal technique, and every technique has specific advantages and disadvantages. With the increase in surgical options, shared decision-making and a shift from surgeon-centered toward more patient-centered care are required.

The number of people with gender identity incongruence that consult specialized gender identity clinics has increased significantly in the past decade.¹ Of transgender men that seek gender-affirming care, some express the wish to undergo genital gender-affirming surgery. Multiple studies have found that, in general, transgender men report an improved quality of life and satisfactory sexual function after genital gender-affirming surgery (e.g., metoidioplasty and phalloplasty).^2,3

Reconstruction of the neophallus is considered one of the most challenging surgical procedures in transgender men.⁴ The ideal phallus is reconstructed in a one-stage procedure, includes the creation of a neourethra to allow voiding while standing, has both tactile and erogenous sensibility, is bulky enough to tolerate the insertion of a penile prosthesis, and produces an aesthetically acceptable result with minimal scarring and without functional loss in the donor area.⁵

Over time, genital gender-affirming surgery at our center has developed in accordance with the reconstructive surgical innovations, improved knowledge of genital anatomy, and the trend toward patient-centered decision making. A wide variety of surgical techniques is currently offered to transgender men that wish to undergo genital gender-affirming surgery, to meet patients’ individual needs. Each technique has its own advantages and disadvantages. The choice for a specific surgical technique depends on the patient’s individual desires, expectations, and psychological well-being, and on the surgical feasibility of the procedure.⁶ This underscores the importance thorough preoperative counseling and knowledge about surgical options, risks, and benefits.

To date, few studies have addressed the evolution of genital gender-affirming surgery in transgender men. Given the increase in people seeking genital gender-affirming surgery and the parallel increase of gender clinics worldwide, having insight into this matter is essential.^1,7,8 Such information could assist gender clinics in the field to provide up-to-date information on technical options to transgender men applying for surgery. The aim of this study was to present an overview of the evolution of genital surgical care over time for transgender men in a single, high-volume center. More than 95 percent of transgender men in The Netherlands undergo genital gender-affirming surgery in our clinic—the Amsterdam University Medical Center, VU University—ideally placing it as a marker for trends.

PATIENTS AND METHODS

All transgender men who underwent genital gender-affirming surgery between January of 1989 and January of 2018 were retrospectively identified form the hospital records of our institution. A systematic retrospective chart review was conducted, recording the following data: (1) date of surgery; (2) surgical team composition (i.e., plastic surgeon, urologist and/or gynecologist); (3) type of genital gender-affirming surgery (i.e., phalloplasty or metoidioplasty); (4) phalloplasty flap type (i.e., radial free forearm flap, anterolateral thigh flap, superficial circumflex iliac artery perforator flap, abdominal flap, lateral upper arm flap and fibula flap); and (5) urethral reconstruction technique [i.e., perineostomy, buccal mucosa, full-thickness skin grafts, tube-in-tube design (only in radial free forearm flap phalloplasty pedicled labia minora flap or a second fasciocutaneous flap), radial free forearm flap, or superficial circumflex iliac artery perforator flap]. Descriptive statistics were used to assess the data.

Preoperative Evaluation

Preoperatively, patients are screened and counseled in accordance with the Standards of Care.⁹ The Standards of Care is an international guideline published by the World Professional Association for Transgender Health to promote the highest standards of health care and to assist transgender people. The World Professional Association for Transgender Health is a world leading professional organization devoted to the understanding and treatment of gender dysphoria. Assistance may include primary care, gynecologic and urologic care, mental health services, and surgical treatments (e.g., top and/or bottom surgery). In our institution, patients attend a group-based educational program that addresses relevant knowledge concerning the perioperative course, the clinical outcomes, and complications, which enhances group interactions and enables patients to learn from the experience of others. In addition, psychological and sexologic evaluation is prerequisite for genital gender-affirming surgery to identify contraindications and to better understand patients’ motivation, readiness, behavioral challenges, and emotional factors that may have an impact. Since 2018, an online decision aid has been available to assist patients in making a well-informed decision about the preferred surgical procedure.

The main contraindications for surgery are a body mass index less than 18 or above 30 kg/m², smoking (patients have to quit smoking for at least 3 months before surgery). The final decision to undergo a specific surgical technique is based on the patient preference, patient risk factors, psychological well-being, surgical feasibility, and risk of the procedure.

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 Declaration of Helsinki and its later amendments or comparable ethical standards. According to the Dutch Central Committee for Human Research, retrospective medical research is exempt from institutional review board approval.

RESULTS

General Trends

From January of 1989 to January of 2018, a total of 400 transgender men underwent genital gender-affirming surgery. The number of genital gender-affirming surgery procedures performed has doubled over time, from an average of 11 per year before 2011, to an average of 22 procedures per year since 2015 (Fig. 1). The surgical choices offered to the transgender man at our institution have increased from five options, to a choice of 12 surgical techniques (Fig. 2), consisting of metoidioplasty and phalloplasty with or without urethral lengthening. The phalloplasty techniques consist of different combinations of fasciocutaneous free or pedicled flaps. Before 2007, a plastic surgeon was mainly involved in the surgical care of transgender men. Since 2007, the gynecologist has played a more prominent role in the multidisciplinary surgical team by performing the primary colpectomy and the presurgical fertility counseling. Since 2013, the urologist performs the scrotoplasty, urethral lengthening, and erectile and testicular prosthesis implantation and is therefore responsible for preservation of urinary and sexual function.

Fig. 1.: Overview of metoidioplasty and phalloplasty procedures performed over time.

Fig. 2.: Metoidioplasty and phalloplasty options currently offered to transgender men at the Amsterdam University Medical Center, VU University. ALT, anterolateral thigh; RFFF, radial forearm free flap; SCIP, superficial circumflex iliac artery perforator; PLMF, pedicled labia minora flap.

Metoidioplasty

Metoidioplasty was performed in 222 patients (55.5 percent) and was the most frequently performed genital gender-affirming surgery procedure between 1992 and 2010. Twenty-seven patients (12 percent) were unsatisfied with the metoidioplasty and underwent a secondary phalloplasty.

Phalloplasty

A total of 178 transgender men (44.5 percent) underwent free or pedicled flap phalloplasty. When comparing metoidioplasty and phalloplasty procedures, a shift was observed from 2010 onward, when phalloplasty became the most frequently performed genital gender-affirming surgery procedure. An overview of the used flaps is presented in Table 1. A historical overview of phalloplasty procedures is presented in Figure 3. Multiple trends were observed over the past decade. In general, the radial free forearm flap phalloplasty was the most frequently performed phalloplasty procedure. The noninnervated abdominal flap was popular in the early 1990s, but has not been performed since 2002. Striving for a sensate neophallus with a less conspicuous donor site, the use of the innervated pedicled anterolateral thigh flap was introduced in 2004, and its use has increased since then. The use of combination flaps (composite phalloplasty), using two free or pedicled flaps for shaft and neourethral construction, was introduced in 2005, and the technique has been performed increasingly. The use of the noninnervated superficial circumflex iliac artery perforator flap was abandoned in 2003, but this technique reemerged in 2017 with the introduction of the innervated superficial circumflex iliac artery perforator flap.

Table 1. - Overview of Phalloplasty Flap Type

Phalloplasty Flap Type	No. (%)
Total	178 (100)
RFFF	76 (43)
Combination flaps	42 (24)
ALT and RFFF	28 (16)
SCIP and SCIP	6 (4)
SCIP and PLMF	4 (2)
ALT and SCIP	2 (1)
ALT and PLMF	1 (1)
SCIP and RFFF	1 (1)
ALT	22 (12)
AF	17 (10)
SCIP	11 (6)
LUAF	8 (4)
FF	2 (1)

AF, abdominal flap; ALT, anterolateral thigh; FF, fibula flap; LUAF, lateral upper arm flap; PLMF, pedicled labia minora flap; RFFF, radial forearm free flap; SCIP, superficial circumflex iliac artery perforator.

Fig. 3.: Distribution of phalloplasty flap type. AF, abdominal flap; ALT, anterolateral thigh; RFFF, radial forearm free flap; FF, fibula flap; LUAF, lateral upper arm flap; PLMF, pedicled labia minora flap; SCIP, superficial circumflex iliac artery perforator.

Urethral Lengthening

Of 400 patients, 332 (83 percent) underwent urethral lengthening. Anatomically, the urethra after urethral lengthening in genital gender-affirming surgery in transgender men consists of three parts: the native urethra, the pars fixa, and the pars pendulans. Depending on the genital gender-affirming surgery technique, the neourethra can be constructed using various techniques.

Pars fixa reconstruction in metoidioplasty is performed in much the same way as in phalloplasty. Currently, the infundibular tissue of the labia minora is tubularized around a Foley catheter to reconstruct the pars fixa. Additional coverage of the proximal urethral anastomosis (between the native urethra and pars fixa) with well-vascularized tissue is important to prevent urethral fistula formation. For this purpose, the anterior vaginal flap was introduced in 1993 by Hage et al.¹⁰ However, addition of the vaginal flap was associated with increased urethral complications (e.g., strictures and fistulas) and has not been used since the early 2000s. Since 2009, a colpectomy is performed in our center to obtain well-vascularized tissue for urethral anastomosis coverage and successful reduction of the urethral fistula rate.^11,12

There are multiple surgical options available for pars pendulans reconstruction in metoidioplasty and phalloplasty. In metoidioplasty, the pars pendulans of the neourethra is constructed with the cranial part of the labia minora. Buccal mucosa may be added for additional lengthening.

In phalloplasty, pars pendulans reconstruction with full-thickness skin graft prelamination, a tube-in-tube design (only in radial forearm free flap phalloplasty), or a second fasciocutaneous flap (tube-in-tube design) can be performed. An overview of the urethral lengthening techniques in phalloplasty is given in Figure 4. Between 1989 and 2002, prelamination with full-thickness skin graft was used in the abdominal flap, lateral upper arm flap, and the fibula flap to lengthen the urethra. Since 2002, these flaps, including prelamination with full-thickness skin graft, have not been performed. The use of a second fasciocutaneous flap for reconstruction of the pendulant part of the neourethra has increased since 2005 in accordance with the increase of combination flap phalloplasty. The option of genital gender-affirming surgery without urethral lengthening has been offered since 2004. From 2004 to 2018, 68 patients (33.6 percent) underwent genital gender-affirming surgery without urethral lengthening. Since 2017, a new technique for urethral lengthening in phalloplasty has been introduced: the pedicled labia minora flap.

Fig. 4.: Overview of urethral lengthening techniques in phalloplasty. FTG, full-thickness graft; PLMF, pedicled labia minora flap.

DISCUSSION

In this study, a historical overview of genital gender-affirming surgery in transgender men in a single high-volume center was presented, as a reflection of developments in patient care. Four hundred transgender men underwent genital gender-affirming surgery and were included in this retrospective analysis. Specific trends were observed over the past three decades.

In The Netherlands, the number of people applying for transgender health care has increased drastically recently.¹ As our data show, this increase is accompanied by an increase in the number of transgender men undergoing genital gender-affirming surgery (Fig. 1). The exact reason for the increase in patient numbers remains unknown, but it is in part thought to be the result of growing social acceptance and recognition of gender-nonconformity in society.⁷

Reconstruction of the neophallus in transgender men involves unique technical challenges with regard to the aesthetic result, tactile and erogenous sensibility, urologic functioning, erectile function, donor-site morbidity, and complication risk. Surgical approaches have evolved considerably over time. Despite the significant progress made and the development of many surgical techniques, the creation of the ideal neophallus has yet to be achieved.^4,13 Each of these techniques has its own advantages and disadvantages. For example, performing a radial free forearm flap phalloplasty will give an aesthetically pleasing result, but will also give obvious donor-site scars that can be bothersome and stigmatizing for patients.

Metoidioplasty consists of releasing the hypertrophied clitoris and reconstructing the neophallus using local tissue.^4,14,15 Advantages are erectile capabilities, limited donor-site scar formation, and preserved tactile sensation. Also, the procedure is considered less complex, with shorter operative time, shorter hospitalization time, lower complication rates, and lower costs compared to phalloplasty.^16,17 Metoidioplasty is therefore a suitable option for transgender men that wish to have an external male genitalia including neophallus, urethra, and scrotum. Disadvantages are a relatively small neophallus and the inability to have penetrative sex and in most cases to void standing out of the zipper. Therefore, some transgender men prefer to undergo a phalloplasty or a secondary phalloplasty at a later stage. Until 2009, metoidioplasty was the most performed surgical procedure at our institution. Since then, phalloplasty has been performed more frequently. The exact reason for this shift is unclear. Possible explanation could be the improved phalloplasty surgical techniques, improved preoperative counseling, and/or a change in patients’ expectations and desires. Currently, patients are free to choose between a metoidioplasty and a phalloplasty.

Phalloplasty consists of creating a large neophallus. Pedicled flaps (e.g., superficial circumflex iliac artery perforator flap, anterolateral thigh flap, or abdominal flap) or free flaps (e.g., radial free forearm flap, latissimus dorsi flap, or fibular flap) may be used for phalloplasty.^18,19

Phalloplasty techniques have evolved considerably as plastic reconstructive surgery has evolved over the years.⁴ The multistage pedicled tube phalloplasty (e.g., abdominal flap and superficial circumflex iliac artery perforator flap) was considered the standard procedure to reconstruct the neophallus for multiple decades (until the 1980s).²⁰ The procedure was associated with high complication rates and poor neophallus sensation.²¹

However, this changed when microsurgery enabled the reconstruction of the neophallus using a tube-in-tube radial forearm free flap phalloplasty in the 1980s.²² Since then, the radial forearm free flap phalloplasty has been considered the gold standard for phalloplasty because of the reliability of the long vascular pedicle, pliability, flap thinness (which gives an aesthetically pleasing result), and being a one-stage procedure.²³ Subsequent introduction of the osteocutaneous version of the radial free forearm flap and the osteocutaneous fibula flap were expected to be the ideal phalloplasty technique that would enable voiding from a standing position while also including a neophallus stiffener to enable penetrative sexual intercourse.^24–26 However, because of an increased flap failure rate, increase in urologic complications (fistula and stricture rate up to 50 percent), and significant donor-site morbidity in osteocutaneous radial forearm free flap phalloplasty, osteocutaneous flaps have not been performed at our clinic since 2004. Major disadvantages of the radial forearm free flap phalloplasty are the donor-site morbidity, penile color mismatch, and the extensive donor-site scars, which are considered stigmatizing by most patients.^27–29 Therefore, pedicled phalloplasty remained quite popular until 2004.

With the introduction of sensate perforator flaps, the sensate anterolateral thigh flap started to increasingly replace the radial free forearm flap as the first-choice flap since 2004 because of the hidden donor site, better penile color match, and no need for microvascular anastomosis.^30–33 Disadvantages are that this flap is prone to be thicker than the radial free forearm flap, which makes it difficult to create a tube-in-tube flap for urethral reconstruction and only suitable for patients with a low body mass index. Also, there is still a considerable donor-site that has to be covered with split-thickness skin grafts.

To overcome these disadvantages, combination flap phalloplasty was introduced in 2005. Combination of flaps may be used to reconstruct the neophallus (e.g., anterolateral thigh or superficial circumflex iliac artery perforator flap to reconstruct the shaft combined with radial free forearm flap, superficial circumflex iliac artery perforator, or pedicled labia minora flap for urethral reconstruction) and to limit extensive (conspicuous) scarring at one donor-site.²⁸ Also, combination flaps can be performed in patients who are not eligible for a tube-in-tube phalloplasty technique because of the thick subcutaneous layer. Surgical disadvantages include prolonged surgical time, use of multiple surgical teams, and flap-related complications. Inner flap monitoring is difficult and increased urethral complications are reported, possibly because of flap swelling.¹⁹

To further improve the techniques, we recently (2017) developed a technique to perform an innervated pedicled superficial circumflex iliac artery perforator flap phalloplasty. Originally, the flap is described as an insensate flap for phalloplasty. Erogenous sensation plays an important role in sexual arousal, and protective sensibility is important to limit penile prosthesis protrusion. This was the main reason that, in our clinic, we stopped performing this phalloplasty technique in 2003. Advantages of this technique include that microvascular anastomosis is not needed, and the donor-site can be closed primarily and gives a less conspicuous donor-site.^34–36 The surgical and urologic outcomes of this technique are set to be published in the near future.

Many transgender men who opt for gender-affirming surgery express the wish to be able to void while standing. To enable this, urethral lengthening and translocation of the urethral meatus more distally is required. Urethral lengthening is considered a significant challenge in gender-affirming surgery, reflected by the high rates of urethral strictures and fistulas, especially after phalloplasty.^37,38 Reports on neourethral complications after phalloplasty are as high as 80 percent.³⁹ These urologic complications can cause great discomfort for the individual patient, and management of these complications is challenging.

Therefore, since 2004, the option to undergo genital gender-affirming surgery without urethral lengthening has been offered to patients, and 68 patients (33 percent) have opted for this procedure. This is deemed a good option for transgender men that want to minimize the risk of urologic complications. The surgical technique and outcomes of this technique have not yet been published.

Over time, the patient has become increasingly involved in health care decision-making. Currently, 12 surgical techniques are provided to choose from (Fig. 2). Recently, we developed a decision aid for genital gender-affirming surgery in transgender men, so patients can carefully consider the pros and cons of surgery before making a decision.⁴⁰ The decision aid for genital gender-affirming surgery in transgender men does not render a “best choice,” but helps transgender men to consider what is important for them as an individual. The great variety in surgical options also emphasizes the importance of having gender surgeons that are highly skilled in more than one particular genital gender-affirming surgical procedure working in a multidisciplinary fashion. Highly skilled gender surgeons can counsel patients to manage their expectations and identify contraindications for surgical procedures. Unfortunately, there is a lack of patient-reported outcome measures validated for transgender men to objectively evaluate and compare the influence of these surgical procedures.⁴¹

The practice of genital gender-affirming surgery in The Netherlands has undergone significant evolution over the past 30 years, in line with the advances made in plastic reconstructive surgery. With the ongoing advancements and innovations made in the field of plastic reconstructive surgery (e.g., biomaterials, tissue engineering, and nanotechnology), we expect that the surgical options for transgender men will continue to expand in the future. This increase in options will require a more bespoke treatment to achieve the best possible result. In addition, with the increasing complexity and amount of procedures, a shift toward subspecialization in genital gender-affirming surgery in transgender men may be inevitable.

There are some limitations to this study. The retrospective design is prone to confounding factors. Also, no reports have been made concerning the clinical outcomes and patient-reported outcome measures. In addition, the data represent our unique experience at the Amsterdam University Medical Center, VU University. However, this study is the first to give a comprehensive overview of genital gender-affirming surgery in transgender men over a period of 29 years in a single high-volume center. The trends observed in this study can be used by other (upcoming) clinics to gain insight into the development of genital surgical care in transgender men.

CONCLUSIONS

Genital gender-affirming surgery at our institution has evolved over time in accordance with reconstructive surgical innovations. Despite the technical advancements, there is no ideal technique to reconstruct the neophallus. Therefore, a wide variety of surgical techniques is offered, each of which has specific advantages and disadvantages. Having to choose between these multiple surgical options underlines the need for (1) shared decision-making, (2) a shift from surgeon-centered toward more patient-centered care, and (3) a multidisciplinary team that consists of highly qualified gender surgeons to offer these surgical options.

ACKNOWLEDGMENTS

The authors thank Jan Maerten Smit, M.D., Marlon E. Buncamper, M.D., Ph.D., and R. Jeroen A. van Moorselaar, M.D., Ph.D.