The field of gender-affirming surgery is one of the fastest growing surgical specialties in the country. Within the last few years, the number of procedures has increased markedly – with a total of 16,353 performed in 2020 compared with 8,304 in 2017.1,2 As the number of surgeries increases, so does the need for a standardized approach to preoperative evaluation and patient preparation.
Gender-affirming genital surgery for transfeminine individuals encompasses a spectrum of procedures that includes removal of the testicles (orchiectomy), creation of a neovaginal canal (full-depth vaginoplasty), and creation of external vulvar structures without a vaginal canal (zero-depth vaginoplasty). Each of these requires different levels of preoperative preparedness and medical optimization, and has unique postoperative challenges. Often, these postoperative complications can be mitigated with adequate patient education.
Dr. K. Ashley Brandt
Many centers that offer genital gender-affirming surgery have a multidisciplinary team composed of a social worker, mental health providers, care coordinators, primary care providers, and surgeons. This team is essential to providing supportive services within their respective scope of practices.
The role of the mental health provider cannot be understated. While the updated standards of care from the World Professional Association for Transgender Health no longer require two letters from mental health providers prior to genital surgery, it is important to recognize that many insurance companies have not yet updated their policies and still require two letters. Even when insurance companies adjust their policies to reflect current standards, a mental health assessment is still necessary to determine if patients have any mental health issues that could negatively affect their surgical outcome.3 Furthermore, a continued relationship with a mental health provider is beneficial for patients as they go through a stressful and life-changing procedure.4
As with any surgery, understanding patient goals and expectations is a key element in achieving optimal patient satisfaction. Patients with high esthetic or functional expectations experience higher rates of disappointment after surgery and have more difficulty coping with complications.5
Decisions about proceeding with a particular type of genital surgery should consider a patient’s desire to have vaginal-receptive intercourse, their commitment to dilation, financial stability, a safe environment for recovery, a support network, and the ability to understand and cope with potential complications.4 Patients will present with a wide variety of educational backgrounds and medical literacy, and will have differing intellectual capabilities.4 Consultations should take into account potential challenges these factors may play in patients’ ability to understand this complex surgery.
An adequate amount of time should be allotted to addressing these challenges. In my practice, a consultation for a gender-affirming genital surgery takes approximately 60 minutes. A preoperative packet with information is mailed to the patient ahead of time that will be reviewed at the time of the visit. During the consultation, I utilize a visual presentation that details the preoperative requirements and different types of surgical procedures, shows preoperative and postoperative surgical results, and discusses potential complications. Before the consultation, I advise that patients bring a support person (ideally the person who will assist in postoperative care) and a list of questions that they may have.
Both full- and shallow-depth procedures are reviewed at the time of initial consultation. For patients who seek a full-depth vaginoplasty procedure, it is important to determine whether patients are committed to dilation and have a safe, supportive environment to do so. Patients may have physical limitations, such as obesity or mobility issues, that could make dilation difficult or even impossible. Patients may not have stable housing, may experience financial restrictions that would impede their ability to purchase necessary supplies, and lack a support person who can care for them in the immediate postoperative period. Many patients are unaware of the importance these social factors play in a successful outcome. Social workers and care coordinators are important resources when these challenges are encountered.
Medical optimization is not unlike other gynecologic procedures with a few exceptions. Obesity, diabetes, and smoking play larger roles in surgical complications than in other surgeries as vaginoplasty techniques use pedicled flaps that rely on adequate blood supply. Obesity, poorly controlled diabetes, and smoking are associated with increased rates of wound infection, poor wound healing, and graft loss. Smoking cessation for 8 weeks prior to surgery and for 4 weeks afterward is mandatory.
For patients with a history of smoking, a nicotine test is performed within 4 weeks of surgery. Many surgeons have body mass index requirements, typically ranging between 20 and 30 kg/m2, despite limited data. This paradigm is shifting to consider body fat distribution rather than BMI alone. Extensive body fat in the mons or groin area can increase the difficulty of pelvic floor dissection during surgery and impede visualization for dilation in the postoperative period. There are reports of patients dilating into their rectum or neourethra, which can have catastrophic consequences. For these patients, a zero-depth vaginoplasty or orchiectomy may initially be a safer option.
Many patients are justifiably excited to undergo the procedures as quality of life is typically improved after surgery. However, even with adequate counseling, many patients often underestimate the extensive recovery process. This surgical procedure requires extensive planning and adequate resources.4 Patients must be able to take off from work for prolonged periods of time (typically 6 weeks), which can serve as a source of financial stress. To maintain the integrity of suture lines in the genital region, prolonged or limited mobilization is recommended. This can create boredom and forces patients to rely on a caregiver for activities of daily living, such as household chores, cooking meals, and transportation.
Gender-affirming genital surgery is not only a complex surgical procedure but also requires extensive preoperative education and postoperative support. As this field continues to grow, patients, providers, and caregivers should work toward further developing a collaborative care model to optimize surgical outcomes and patient satisfaction.
Dr. Brandt is an ob.gyn. and fellowship-trained gender affirming surgeon in West Reading, Pa.
References
1. American Society of Plastic Surgeons. Plastic Surgery Statistics Report–2020.
2. American Society of Plastic Surgeons. Plastic Surgery Statistics Report–2017.
3. Coleman E et al. Standards of care for the health of transgender and gender diverse people. Version 8. Int J Transgender Health. 23(S1):S1-S258. doi :10.1080/26895269.2022.2100644.
4. Penkin A et al. In: Nikolavsky D and Blakely SA, eds. Urological care for the transgender patient: A comprehensive guide. Switzerland: Springer, 2021:37-44.
5. Waljee J et al. Surgery. 2014;155:799-808.