Imaging in Gender Affirmation Surgery

Abstract

Purpose of review: This review summarizes recent developments in gender affirmation surgery, imaging findings in patients undergoing these surgeries, focusing on common postoperative radiologic appearances, complications, and pitfalls in interpretation.

Recent findings: The imaging workup of masculinizing and feminizing genitourinary surgeries uses multiple modalities in presurgical planning and within the immediate and long-term postoperative period. CT and MRI can help identify immediate and remote postoperative complications. Fluoroscopic examinations can diagnose postoperative urethral complications after gender affirmation surgeries. Lastly, the patients can undergo imaging for unrelated acute and chronic pathology, and knowledge of these imaging findings can be very helpful. Imaging plays a significant role in the care of transgender patients and, particularly, in those pursuing gender affirmation surgery. As insurance coverage expands for these surgical procedures, radiologists should be prepared to encounter, understand, and interpret pre and postoperative findings.

Keywords: Bottom surgery; Gender affirmation surgery; Metoidioplasty; Penoscrotal inversion vaginoplasty; Phalloplasty complications; Transgender imaging.

Fig. 1

a Scout view from a CT in a 49-year-old transmasculine patient demonstrates the neophallus (arrow) created by anterolateral thigh pedicled flap. Surgical clips in the left groin (circle) demonstrate the site of mobilization of the vascularized pedicle. The left side is the preferred side for harvesting the muscular flap due to higher takeoff of left common femoral artery and a larger number of perforating branches. b Axial contrast-enhanced CT in the same patient demonstrates the neophallus. Inside the neophallus, the neourethra (dotted arrow) is visualized created using the “tube within the tube” technique. Alongside the urethra, a single barrel inflatable penile prosthesis (white arrow) is seen. Testicular prostheses (*) are present as well. c Fluoroscopic retrograde urethrogram in a 38-year-old transmasculine patient status post phalloplasty demonstrates an abrupt change in urethral caliber at the junction of the native urethra and neourethral pars fixa (dotted arrow), suggestive of a stricture (solid black arrow). The neourethra (dotted arrow) which was created using labia minora can normally have a diffusely irregular contour, and should not be misinterpreted as stricturing if there is no change in caliber. Urodynamic studies can be obtained to further confirm radiographic findings. d Sagittal contrast CT obtained in the immediate postoperative period in a 29-year-old transfeminine patient status post penoscrotal inversion vaginoplasty demonstrates the neovagina (dotted arrow) filled with packing material. A Foley catheter (black arrow) is present in the urethra status post urethral shortening. e Voiding cystourethrogram performed in a 32-year-old transfeminine patient status post penoscrotal inversion vaginoplasty and now complaining of urine dribbling from the neovagina demonstrates the urethra (dotted arrow) opacified with contrast. In addition, a parallel track of contrast is seen consistent with a fistulous connection between the urethra and the neovagina. f 48-year-old transfeminine patient with mature enteric vaginoplasty. The decompressed neovagina (dotted arrow) is seen behind the bladder (B). Inferior to the bladder and anterior to the neovagina, the atrophied prostate (arrowhead) is present and contains a few coarse calcifications. Prostate remains in situ in transfeminine genital surgeries and should not be misinterpreted as a soft tissue mass