Leesburg, VA, August 16, 2019—An ahead-of-print article published in the December issue of the American Journal of Roentgenology (AJR) provides a much needed overview of gender affirmation surgical therapies encountered in diagnostic imaging, defining normal postsurgical anatomy and describing select complications using a multidisciplinary, multimodality approach.

With gender incongruence now categorized as a sexual health condition—no longer a mental illness—in the most recent revision to the International Classification of Diseases, lead author Florence X. Doo and colleagues at Mount Sinai West in New York City contend that all subspecialties must be prepared to identify radiologic correlates and distinguish key postoperative variations in the three major categories of gender affirmation surgery.

Genital Reconstruction
For trans-females, pelvic MRI remains the most reliable modality to evaluate the two most common complications arising from vaginoplasty: hematomas and fluid collection. Cellulitis, abscess, neovaginal prolapse, and focal skin necrosis can occur, as well. As Doo cautions, “at the end of the procedure, radiopaque vaginal packing is inserted, which should not be mistaken for other foreign bodies on postoperative imaging." Neovaginal fistulas present less frequently, and for most trans-female patients, these complications may be diagnosed on the basis of clinical symptoms and physical examinations. Although vaginoplasty typically preserves the prostate, it may have atrophied from adjuvant hormonal therapy with estrogen and progesterone, so regular prostate cancer screening guidelines should still be followed.

When evaluating urethral complications from phalloplasty in trans-males, because the neo-to-native urethra anastomosis site will evidence diameter differences, retrograde urethrograms can result in stricture overdiagnosis. Apropos, preliminary assessments should be for functional stricture, alongside the performance of urodynamic studies. “However,” notes Doo, “for confirmation of stricture with abnormal function tests and also for evaluation for fistula, a retrograde urethrogram or voiding cystourethrogram can be obtained.” Should a patient desire erectile potential with the fully-healed neophallus, an implant may be placed, which is prone to infection, attrition, malposition, and constituent separation.

For trans-males instead pursuing metoidioplasty (i.e., hormone-induced clitoral hypertrophy, followed by clitoral degloving and ligament detachment for neophallus lengthening), no penile implant presently exists that can sustain erectile rigidity for sexual function.

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