In this episode of BackTable Urology, Dr. Esther Han (USMD Hospital) and Dr. Richard Santucci (Crane Center) discuss genital gender affirming surgery techniques and postoperative management.

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SHOW NOTES

First, Dr. Santucci discusses his career pivot from academic trauma reconstruction to private practice gender affirming reconstruction. After 17 years at Detroit Medical Center as director of trauma reconstruction fellowship, he left his position to learn gender-affirming surgery at the Crane Center in Austin, Texas. He was drawn to gender affirming surgery because of the dynamic techniques and novel research in the field. Next, the doctors review of vocabulary for transgender patients. Dr. Crane notes that vocabulary is always changing and advises doctors to not assume a patient’s gender or surgical preferences based on appearance. Additionally, Dr. Han explains why using the word “normal” over medically correct terms can confuse and cause discomfort in patients.

Next, Dr. Santucci summarizes the gender affirming surgeries he performs. He explains trans women surgeries, such as full vaginoplasty and vulvoplasty. In trans men, he performs metoidioplasty and phalloplasty. However, Dr. Santucci emphasizes that patients are given the freedom to customize their own surgeries by picking which anatomical parts they would like to keep, change, or remove. Complications, such as urethral strictures and infections may occur in all these surgeries. Additionally, he emphasizes the need for addressing fertility with trans men, as some of them would like to keep their ovaries for egg harvesting.

Then, the doctors discuss the recent change in World Professional Association for Transgender Health (WPATH guidelines), which now only require one letter from a therapist instead of two in order to receive genital surgery; however, insurance companies may require more letters. The doctors also contemplate the presence of post-operative regret, since gender affirming surgery is difficult to reverse. Dr. Santucci explains that regret is often tied to postoperative complications.

Then, he delves deeper into the management of phalloplasty complications, such as postoperative incontinence, postoperative infections, and erosions. He also emphasizes the importance of prostate cancer screening for trans women. Although it is rare, the prostate cancer they develop is testosterone independent, making it more difficult to treat and more aggressive.

Finally, Dr. Santucci shares what a typical week in his life looks like and reflects on how multidisciplinary collaboration in the OR has made his operations more efficient and effective.