Patient-Reported Outcomes in Gender Confirming Surgery

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The article “Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women” reports the largest retrospective study to date on male-to-female gender-confirming surgery using the penile inversion technique.1 The authors should be commended on their presentation of the techniques, outcomes, and complications associated with penile inversion vaginoplasty. As noted in their study, penile inversion is the most common procedure for male-to-female genital gender-confirming surgery and is often the procedure of choice both for patients and for providers.2 However, a multitude of surgical techniques have demonstrated safe and reliable means of gender confirmation, each providing significant improvement in the quality of life of transgender patients.3 With increasing societal acceptance and awareness, more transgender patients may seek gender-confirming surgery. It is therefore imperative for plastic and reconstructive surgeons to establish best-practice techniques that improve transgender patient quality of life while minimizing associated risk.
Patient-reported outcomes are an emerging standard in all areas of outcomes-based research.4 Patient-reported outcomes inherently target patient goals and perceptions, which may or may not align with physician/surgeon aims and perspectives. For example, reports of complications are often of greater interest to the provider, whereas quality-of-life patient-reported outcomes are of greater interest to the patient. We would argue that studies reporting on just one instead of both of these aspects are incomplete.
In addition, validated patient-reported outcomes instruments, such as the BREAST-Q, have allowed for consistent interpretation of results between studies in plastic and reconstructive surgery.5 Without such metrics, it remains difficult to report results in a reliable and standardized fashion. In turn, interpretation of results between studies is nearly impossible. In the era of improving patient-reported outcomes and increased interest in the topic of gender-confirming surgery, we argue for the necessity of a standardized and reliable procedure-specific instrument for our transgender patients. Patient-reported outcomes measures relevant to gender-confirming surgery might include metrics specific to the patients’ own perceptions of the cosmesis and function of the reconstruction. This type of information could offer insight not only to providers, but also to our transgender patients and allow them to better understand exactly how these operations impact overall well-being and quality of life.
Previous studies explored patient-reported outcomes in intestinal vaginoplasty, yet the questionnaires used were not specific for trans women.6 As penile inversion vaginoplasty is the most commonly used technique in male-to-female genital gender-confirming surgery, we recommend creating a standardized and reliable transgender patient-reported outcomes instrument based on this specific procedure. Ultimately, through multidisciplinary collaboration, a universal patient-reported outcomes scale needs to be established that can encompass all aspects of gender-confirmation surgery. With a validated patient-reported outcomes metric, we could begin to establish best-practice techniques that translate to the highest improvement in patient quality of life while minimizing risk for our transgender patients.
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