The impact of the desire to void while standing on surgical transition in transgender men
Authors:   , de Rooij Freek Pieter Willem 
Published: August 2024

Summary
Voiding while standing is desired by the majority of transgender men undergoing genital Gender-Affirming Surgery (gGAS). In order to achieve standing micturition postoperatively, Urethral Lengthening (UL) during gGAS is necessary. After surgery, transgender men may experience voiding in an easier and more ‘natural’ way, which enhances their feelings of masculinity and alleviates gender dysphoria. However, the transitional trajectory of gGAS with UL is extensive, and it is important for transgender men to be aware of all possible risks and outcomes. Although the amount of research regarding this topic is rising, a lot of questions are still unanswered. For clinicians to be able to fully inform transgender men regarding their transitional trajectory, the aim of this thesis was to increase the knowledge on how the desire to void while standing affects several aspects of surgical transition in transgender men. In chapter 1, a general introduction was provided with a summary of what we currently know about the desire to void while standing and its impact on surgical transition. Subsequently, knowledge gaps were described together with an explanation on how this thesis aimed to address these gaps.

Part I. Colpectomy in preparation for genital gender-affirming surgery with urethral lengthening
Chapter 2 focused on the urological outcomes of colpectomy (i.e. removal of the vaginal cavity) in transgender men. Colpectomy is mandatory in our institution prior to gGAS with UL to prevent urethral complications at a later stage, and is optional in case of gGAS without UL. The insights provided by this chapter can be helpful during preoperative counseling.

Part II. Comparison of clinical outcomes after genital gender-affirming surgery with versus without urethral lengthening
Urological complications (e.g. urethral strictures or fistulas) are frequently seen after gGAS with UL. Consequently, surgical treatment is often necessary to maintain the ability to void while standing. As a surgical alternative with less complications it is possible to perform gGAS without UL, after which transgender men still need to void while sitting down postoperatively. This treatment option has been offered in our institution since 2004, and since then approximately one third of men has opted for it. To provide transgender men prior to gGAS with important information regarding the choice for or against UL, an overview and comparison of clinical outcomes is useful. Therefore, a comparison of surgical outcomes and urinary functioning after phalloplasty with versus without UL was discussed in chapter 3. Subsequently in chapter 4, patient-reported outcomes were compared between men who underwent gGAS with versus without UL. No significant differences in patient-reported outcomes were observed between both groups, yet more complications and reoperations were observed after gGAS with UL. In a linear regression analysis, satisfaction with the appearance of the neophallus and with voiding were found to be positive predictors of overall patient satisfaction at the end of urological follow-up, as opposed to the complication and reoperation rates postoperatively.

Part III. Urological complications after genital gender-affirming surgery with urethral lengthening
In the third part of this thesis we took a closer look at the incidence rates and surgical treatment of urological complications after gGAS with UL. Chapter 5 summarized the incidence rates of different urological complications per type of surgery, followed by a comparison of urinary functioning in men who were able to void from the tip of the neophallus at the end of follow-up. The aim of chapter 6 was to provide an overview of surgical outcomes in the treatment of urethral strictures and to conclude with a treatment algorithm. Furthermore, surgical outcomes after treatment of urethral strictures and urethral fistulas specifically in transgender men following metoidioplasty with UL were assessed in chapter 7.