(033) Analyzing Patient-Specific Predictors of Surgical Risk and Outcomes Following Gender-Affirming Surgery
Authors: Simhal R , Shah Y , Wang K , Chung P 
Published: May 2023

Abstract

Introduction
Gender affirming surgery (GAS) has seen dramatic advances in phalloplasty and vaginoplasty for gender dysphoria. However, there is still need for better characterization of patient demographics and surgical outcomes. Recent interest has emerged in predictors of post-surgical complications, such as patient frailty and comorbidities for preoperative risk assessment. Better understanding factors predicting outcomes can help with patient selection, patient counseling, and quality improvement.

Objective
To evaluate phalloplasty and vaginoplasty outcomes and predictors of complications utilizing the National Surgical Quality Improvement Program (NSQIP) database.

Methods
CPT codes were utilized to identify phalloplasty (59980) and vaginoplasty (59970, 57335) cases recorded in NSQIP from 2006-2020. Descriptive statistics were calculated for baseline patient characteristics, operative parameters, and 30-day complications. Frailty was calculated using the modified frailty index (NSQIP-mFI-5), a previously validated 5-item score including points for diabetes, impaired functional status, COPD, CHF, and hypertension. Pre-operative morbidity probabilities were derived from the “MORBPROB” variable, which is the NSQIP morbidity probability, which uses hierarchical regression analysis on patient-specific factors. Univariate logistic regression, ANOVA, and t-test analyses were performed as appropriate to identify predictors of surgical complications, operative time, and hospital length of stay (LOS).

Results
Out of 9,637,305 patients in the NSQIP database, 58 underwent phalloplasty and 485 underwent vaginoplasty. For phalloplasty and vaginoplasty, the mean patient age was 38.4±11.8 and 36.6±12.6 years, respectively. The average operative time for phalloplasty and vaginoplasty was 331 minutes and 263 minutes respectively, and the average LOS was 5.1 days and 4.3 days, respectively. The overall 30-day complication rate for phalloplasty was 26%, with 17% of all patients experiencing minor complications, including urinary tract infections, superficial wound infections, pneumonia, and peri-operative bleeding requiring transfusion, and 16% of all patients experiencing major complications including occurrences of sepsis, DVT, stroke, reintubation, renal failure, myocardial infarction, pulmonary embolism, septic shock, would dehiscence, deep wound infections, and cardiac arrest. The overall, minor, and major complications rates for vaginoplasties were 14%, 7%, and 9%. Unplanned readmissions and reoperations each occurred in 7% phalloplasty and 5% vaginoplasty patients. In either cohort, no deaths occurred within 30 days post-operation. Upon logistic regression, NSQIP-mFI-5 scores ≥0.2 versus a score of 0 were not predictive of 30-day complications, operative time, or LOS for either procedure. Notably, for vaginoplasties, higher NSQIP-mFI-5 scores were numerically associated with higher complication rates (OR 2.02, 95% CI 0.94-4.09, p=0.072). When comparing NSQIP preoperative morbidity probabilities of ≥10% versus &lt;10%, this score was predictive of 30-day complications for both phalloplasty (OR 4.0, 95% CI 1.1-19.6, p=0.038) and vaginoplasty (OR 2.46, 95% CI 1.4-4.3, p&lt;0.001). NSQIP morbidity probability ≥10% was also predictive of extended LOS for phalloplasty patients (6.3±1.3 vs. 2.9±0.8, p=0.03).

Conclusions
This study described the complication rates of phalloplasty and vaginoplasty using the NSQIP database which are largely aligned with previously published studies. The NSQIP preoperative morbidity probability is an effective predictor of surgical complications and is a better predictor than the modified NSQIP frailty index.

Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: Paul Chung - Consultant for Boston Scientific and Coloplast.