Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience

Abstract

Background and purpose: What factors influence transgender men's decisions to undergo (and to not undergo) specific genital gender confirming surgeries (GCS) has not been described in the literature. Sexual function outcomes related to clitoral transposition and penile prosthesis placement is also not well described. Durability of neophallus dimensions after phalloplasty has not been described. A better understanding of these factors is necessary for pre-op counseling. We sought to assess patient genital-GCS related satisfaction, regret, pre/post-op sexual function, genital preferences, and genital measurements post-op.

Materials and methods: We evaluated ten female to male transgender patients who had previously undergone suprapubic pedicle-flap phalloplasty [suprapubic phalloplasty (SP); N=10] and 15 who had undergone radial artery forearm-flap phalloplasty [(RAP); N=15; 5/15 without and 10/15 with cutaneous nerve to clitoral nerve anastomosis] at our center (UK). We queried patients' surgery related preferences and concerns, satisfaction, and sexual function pre/post-surgery, and accounted for whether patients had undergone clitoral transposition and/or cutaneous-to-clitoral nerve anastomosis. We measured flaccid and (where applicable) erect length and girth using a smart-phone app we designed.

Results: Mean age at surgery and follow-up for those that underwent SP was 35.1 and 2.23 years, and 34 and 6.8 for those that underwent RAP. Mean satisfaction scores were 9.1/10 and 9/10 for those that underwent SP and RAP, respectively. No patient (0%) regretted starting genital-GCS surgery. All (100%) patients that could achieve orgasm before GCS with clitoral transposition could achieve orgasm after surgery, and the vast majority reported preserved quality of erogenous sensation by our transposition technique. All (100%) RAP and 9/10 SP patients reported masturbation with their phallus. Inflatable penile prosthesis placement was not associated with decreased erogenous sensation/orgasm. Penile dimensions were relatively stable through follow-up for both groups. Our App length measurements correlated with a ruler within ±<4.5%.

Conclusions: Female-to-male genital-GCS offered in 3-stages was associated with high overall satisfaction and no regret among our sample. Sexual function appears to be preserved after both clitoral transposition and inflatable prosthesis placement, and consolidation of erogenous sensation to the phallus was described as important to all subjects. Discussion of patient's pre-op sexual function, as well as specific concerns and preferences related to specific genital-GCS surgeries is important.

Keywords: Transgender; clitoral nerve anastomosis; genital gender confirming surgery (GCS); penis size; phalloplasty; sexual function.

Figure 1

The MedMeasure Apple smartphone app (selected country: UK) was used to measure neophallus length. (A) “1£ coin” was selected from the App’s drop-down menu of Reference Objects. A U.K. 1£ coin was placed by the patient on the surface of the neophallus at time of image capture; (B) To calibrate MedMeasure’s scalable digital caliper, the caliper jaws are positioned (by finger pinch using the orange “finger pads” on the jaws, as shown) to encompass the diameter of the coin. When complete, the “calibrate” (top-right of screen; circled) button is pressed; (C) The actual length of the reference object (1£ coin) is immediately displayed (2.45 cm); (D) The caliper is then moved into position and the caliper jaws are opened to encompass the length of the neophallus. The actual length is displayed in the results window in the top-center of the screen (e.g., 9.80 cm). Note: each measurement is date and time stamped (bottom of screen).