Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study

Sarra Cristofari; Eloi Ramelli; Yih Chyn Phan; Curtis L Cetrulo Jr; Zhi Yang Ng; Alexandre G Lellouch

doi:10.1016/j.bjps.2023.04.002

Genitourinary vascularized composite allotransplantation for gender affirmation in trans men: An anatomical feasibility study

J Plast Reconstr Aesthet Surg. 2023 Aug:83:117-125. doi: 10.1016/j.bjps.2023.04.002. Epub 2023 Apr 17.

Authors

Sarra Cristofari¹, Eloi Ramelli¹, Yih Chyn Phan², Curtis L Cetrulo Jr³, Zhi Yang Ng⁴, Alexandre G Lellouch⁵

Affiliations

¹ LVTS, INSERM U1148, X. Bichat hospital, INSERM, Paris, France.
² Department of Urology, Queen Alexandra Hospital, Portsmouth, UK.
³ Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic Surgery, Shriners Hospitals for Children, Boston, MA, USA.
⁴ Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
⁵ Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Plastic Surgery, Shriners Hospitals for Children, Boston, MA, USA; Service de Chirurgie Plastique, Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris (APHP), Université Paris Descartes, Paris, France. Electronic address: alellouch@mgh.harvard.edu.

PMID: 37276729
DOI: 10.1016/j.bjps.2023.04.002

Abstract

Purpose: Gender affirmation in trans men requires multiple staged procedures. The final masculinizing step involves phalloplasty or metoidioplasty and further incorporation of penile and testicular prostheses. However, these are functionally suboptimal and associated with high complication rates. Therefore, we sought to investigate the anatomical feasibility of one-stage genitourinary vascularized composite allotransplantation (GUVCA) for such gender-affirming surgeries.

Methods: Twenty fresh cadaveric dissections were performed to delineate the neurovascular anatomy of the proposed GUVCA. Specifically, in donors (n = 14), besides the penis and scrotum, the GUVCA included an inferior bladder patch with the urinary sphincter, prostate, seminal vesicles, as well as a strip of the pubic bone. In trans men recipients, osteotomies of the pubic bone to match that of the donor GUVCA were required. Five cadaveric GUVCA transplants were then performed to simulate one-stage gender affirmation surgery.

Results: The GUVCA required (1) vascular anastomoses between the recipient's deep inferior epigastric, external pudendal, and superficial circumflex iliac (or superficial inferior epigastric) vessels to the donor's internal pudendal, external pudendal and genitofemoral vessels respectively; (2) neurosynthesis between the recipient pudendal and dorsal clitoral nerves to the donor pudendal and genitofemoral nerves; and (3) urinary bladder anastomosis at the bladder neck, upstream of the urinary sphincter. Average donor measurements (length (cm), diameter (mm)) were: external pudendal artery (2.5, 2.0) and vein (2.0, 3.5), internal pudendal artery (15.0, 4.0), pudendal (15.0, 3.0) and genitofemoral nerves (8.0, 2.0).

Conclusions: We have described the anatomical basis for a one-stage GUVCA in trans masculine genitourinary reconstruction.

Keywords: Allotransplantation; Anatomy; Cadaver; Gender affirmation; Genitourinary.

MeSH terms

Cadaver
Feasibility Studies
Femoral Artery
Humans
Male
Penis / surgery
Vascularized Composite Allotransplantation* / methods