Abstracts from the New England Section of the AUA 2020: A Virtual Experience

NE AUA 2020 Abstracts Evaluating a Rural Transgender andGender Diverse Population and Interest inGenital Gender Confirming Surgery Amanda R. Swanton, MD/PhD , Ella A. Damiano, MD, John F. Nigriny, MD, Benjamin Boh, DO, MS, John H. Turco, MD, William Bihrle, III, MD, Rachel A. Moses, MD, MPH Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA Introduction: In addition to the multiple psychosocial and health disparities faced by transgender and gender diverse persons (TGGD) seeking hormonal and surgical interventions, those living in rural areas face additional barriers to healthcare. The 2015 U.S. Transgender Survey revealed up to 25%of respondents had undergone genital gender confirmation surgery (GCS): 10% TGGD female and 2% of TGGDmale respondents. Little is published regarding the transition related health care utilization for TGGD persons from rural areas. We sought to evaluate such a population. Materials & Methods: This is a single center descriptive study evaluating a population of TGGD persons seeking gender related care in a rural academic hospital between September 2015 and February of 2020. The electronic medical record was reviewed to identify TGGD personscarryingICD-10andF64CPTcodesdelineating“genderidentitydisorder”or“gender dysphoria”.Patientvariablesincludingage,genderassignedatbirth,useofhormones,history of GCS, and home zip code were abstracted through administrative data and retrospective chart review. Of those patients who had not previously undergone GCS, a granular chart review was performed to capture documented interest in pursuing GCS. Patient variables weretabulatedusingR,andcomparisonsweremadeusingchi-squaredtests.Zipcodeswere used to determine if patients resided in rural versus metropolitan locations. P17 Results: During this time period, 1466 patients were identified with gender identity CPT codes; 43 patients were excluded due to the patient being deceased or suspected coding errors. Of the 1423 patients included in the final analysis, 837 (59%) of patients were assigned female sex and 586 (41%) were assigned male sex at birth. Though most patients were between the ages of 18-60, 279 (20%) were younger than 18 and 45 (3%) were 65 or older. Hormone use was documented in 1036 (73%) of patients, including 588 (70%) TGGD males and 448 (76%) TGGD females (p = 0.012). Genital reconstruction was documented in only 42 (3%) of patients, including 6 (1%) TGGD males and 36 (6%) TGGD females (p < 0.001). Of those who had not received genital reconstruction, 100 (7%) patients had a documented interest in the medical record, including 21 (3%) TGGD males and 79 (14%) TGGD females (p < 0.001). The hospital drew patients from a large, multi-state region with 817 (57%) patients coming from rural zip codes. Conclusions: Alarge number of TGGD persons from surrounding rural andmetropolitan areas sought gender health care at this rural academic medical center, predominately adolescents and young adults, with a slightly higher proportion of TGGD males. The majority of patients receive hormone therapy. While a relatively small proportion have undergone genital gender confirming surgery, nearly 10% of patients had a documented interest in GCS which due to the limitations of the study, may be an under-estimation in this population. Further research is needed to determine transition related surgical healthcare needs of this population and to further develop rural comprehensive gender health programs. Autologous Dermal Fat Graft Augmentation Glansplasty for Management of Transmasculine Neo-glans Atrophy following Penile Prosthesis Placement Rachel A. Moses, MD, MPH 1 , Amanda R. Swanton, MD/PhD 1 , Mang L. Chen, MD 2 1 Dartmouth-HitchcockMedical Center, Lebanon, NH, USA; 2 G.U. Recon, San Francisco, CA, USA Introduction : Neo-glans atrophy is a described complication following penile prosthesis insertion in the transmasculine neophallus in which the neo-glans appears hypoplastic despite proper device fitting. This aesthetic result may cause patient dissatisfaction with the neophallus. Additionally, though long-term outcome data in this population is not available, the decreased tissue support between the device and skin may predispose to cylinder erosion. The purpose of this abstract is to describe a novel technique to address neo-glans atrophy which utilizes interposition of a full thickness dermal graft to correct the hypoplastic contour. Materials &Methods : We provide a description of an autologous dermal fat graft tissue transfer to address neo-glans atrophy. Steps include harvest of the graft from a non-hair bearing area, graft preparation, development of the plane for tissue insertion without disturbance of the prosthetic device, and graft placement within the neo-glans. Results : Autologous dermal fat graft neo-glansplasty has been demonstrated to be a feasible technique that improves cosmetic appearance of a hypoplastic neo-glans following penile prosthesis insertion (see Figure) and durably address neo-glans atrophy in this unique population. Conclusions : Reconstructive urologists managing patients with neo-glans atrophy following penile prosthesis insertion may utilize this technique. Further work is needed to gather data on long term outcomes with this technique. Figure 1: Appearance of transmasculine neophallus with penile prosthesis previously inserted thatdemonstratesneo-glansatrophypre-operatively(A), intraoperativecorrection with autologous dermal fat graft insertion (B), and post-operative outcome (C) P18 Established and Experimental Techniques to Improve Phalloplasty Outcomes: Optimization of a Hypercomplex Surgery Erin Carter, MS 1 , Curtis Crane, MD 2 , Richard Santucci, MD 2 1 Boston University School of Medicine, Boston, MA, USA; 2 The Crane Center for Transgender Surgery, Austin, TX, USA Introduction: An increasing number of transgender and gender non-conforming patients are seeking genital gender-affirming surgeries across the US. Phalloplasty is the most complex of these surgeries, in that it combines many different smaller procedures into one or more stage(s). Each of these components have different risk profiles, and phalloplasty as a whole has a wide variety of possible complications. Some targets for improvement inoutcomesconcernurethralfistula/stricture,efficacyofreinnervationof the phalloplasty flap, postoperative flap monitoring, and donor site morbidity. In the setting of no established “gold standard”, we sought describe interventions—some experimental, some established—that can be applied to improve outcomes of this ultracomplex surgery. Materials & Methods: We reviewed the entirety of the English-language literature regarding established techniques for prevention of common complications after phalloplasty and complex flap surgery in general. We also identified promising reports on experimental techniques to further minimize urethral complications, enhance nerve regeneration, improve postoperative flap monitoring, control of postoperative bleeding, and manage flap donor site morbidity. Results: Our high-volume phalloplasty group has achieved industry-low urethral complication rates of 22% by technical optimization of the urethroplasty portion of phalloplasty. We use transcutaneous visual light spectroscopy (Tstat™) monitoring for intraoperativedecision-makingandpostoperativeflapsurveillance.Weusecollagenmatrix sheets [Integra® Wound Matrix (Thin)] to improve aesthetic and functional outcomes at the flap donor site. We use thrombin-gelatin hemostatic matrix (Floseal™) to eliminate the need for scrotal drains and limit scrotal hematoma. We continue to investigate the role of extracellular matrix nerve connection sheaths (Axoguard™) to improve the efficiency of nerve regeneration to the flap. Further evaluation of dehydrated human amnion/ chorionmembrane allograft (Amniofix™) to decrease urethral fistula/stricture is planned. Conclusions: One stage phalloplasty is a massive surgical endeavor (~ 200 RVUs per case) requiring several experienced surgeons working over 6-12 hours. Through a combination of surgical technique improvement and incorporation of promising new technology, we have attempted to optimize the results of this massive free-flap surgery. Ultimately, with continued innovation and sharing of improved surgical techniques, it may be possible to better standardize care and improve outcomes of this complicated and increasingly common surgery. P16 Poster Session II 37