Diana Bowen: Hi, my name's Diana Bowen, and thank you for having me. I have no disclosures.

So my talk is really expanding on the last two talks, to try to give you some practical tips on how to make any gender diverse patient coming to your clinic have a great affirming equitable experience. And so, I kind of broke it down into just the general clinic experience, and then some specifics with urologic concerns outside of bottom surgery.

So why am I talking about this? Well, like Dr. Figler, we created at Northwestern, a program that's comprehensive about four years ago, surgeon led, but we understood very quickly, we needed to touch all aspects of care. And so, I'm drawing from some of these lived experiences with patients and our health system, to hopefully give you some knowledge about that.

I think that, just like the explosion of bottom surgery, there's an explosion of transgender legislation. But it really doesn't matter whether you're in a state that has gender expansive legislation, or gender restrictive legislation going on, there's increasing acceptance nationally, culturally. And so, you will be seeing gender patients, and they deserve to get great urologic care.

I won't belabor this because Dr. Figler went through this, but it has to be in the scope of the fact that, most of these patients have had either a negative healthcare experience. They don't want to see a doctor because they're afraid, or they have to report teaching their doctor about their own care.

When I think about the clinic experience, I kind of broke it down into three different domains. There's the overall physical environment, there's the workforce, and then there's patient information.

And so, the physical environment matters. Patients coming into your office, seeing perhaps, an all gender restroom for a single stall, that's important. Seeing a waiting space that may have magazines or posters that are not just cis heteronormative. And potentially, even going as far as to have safe space signage, which we developed at Northwestern, and offered to all the different departments, as an opt-in to put in their waiting room.

For workforce, I'll get into this in a little bit, but terminology and pronouns are really important, and not just for you, right? A patient may see three, four other people before they get to you. And so, educating your work staff about these issues is important, through cultural competency trainings. And then, how do you get this information through intake sheets, and through the EMR?

Before I get into those, things to keep in mind, I think it's important that affirming care goes just beyond your gender diverse patients. You most likely have staff that are gender diverse, they may not be out to you, and the same goes for patients not being out to you as well. So I think that putting some of this language into daily use is a really good idea.

We put together some cultural competency trainings when we started this program for the whole institution, Northwestern. It was a big undertaking, but we focused on terminology because we found that people were really hungry for terminology, and ways to use language. Right? And that was the feedback we got. They just want resources.

And so, we provide these resources, and I'm happy to provide any of these for you. Things like staff tip sheets, where you give them the language to say, "Hi, my name is so and so. I use these pronouns." Everybody's scared about what people will say back to them. Right? And so, giving them language to address those concerns, like this is a question we ask everyone because, and so on. I think those are always helpful.

You can modify your intake forms that can be additive. It doesn't need to change dramatically, but putting in things like a preferred name and optional pronouns, as well as after legal sex, gender identity, also optional.

The EMR is a bear, but it can also be a tool, like in most things. And so, there's actually good studies showing most TGD patients would like their preferred name and pronoun documentation to be part of it. You can contact your EMR provider for the latest updates in the SOGI data. And I'll touch on organ inventory.

So is, we use EPIC. This is obviously a fake patient, but you can see here in that top left, you have the patient's legal name, and then in quotations you have their preferred name, and then female with an I, showing that it doesn't match up with their legal sex.

The patient can put that in through MyChart, or you can do it in your encounter. And that lets everybody, again, PSRs, the MAs, the nurses, know how to address the patient. And right here is an example of all the different options they have to choose from, and they can also put in their pronouns.

And I think in the future, organ inventories are going to be really important, as patients start to come in and not just identify as transgender or female. They want to s=ay, "I'm female, well, but I have a prostate." And so, that's important for cancer screenings going forward.

So lastly, we'll talk about urologic care. So again, outside of bottom surgery, any urologic complaint, right? Patients will come in with stones, phimosis, hydrocele. And so, it's important to collect a detailed information history, about their bottom surgery history, or any gender affirming interventions, especially hormones. But you can't assume that they've had these things. The majority of patients have not had bottom surgery.

Genital exams are very, very anxiety producing, provoking for patients. And so, I find that letting the patient know at the beginning of the encounter, "Hey, we're going to do an exam later on. This is why we're going to do an exam. Are you okay with that?" Let’s them process it a little bit, and tell you about any bad experience they've had. And I think that spending the extra time to do that is really important for these patients. Because many have had negative experiences in healthcare.

I see a lot of patients with lower urinary tract dysfunction. When you start a program, people start coming to you. And so, I think that it's multifactorial. A lot of patients avoid public restrooms, so they hold their urine. There's common coexisting mental health disorders. Hormones can trigger or compound existing problems. And so, I think being aware of all of those different factors, in addition to what you would normally do with any patient who came in with this problem, it's important.

Also important to know that a lot of trans women will do something called tucking, where they push the testicles up into the inguinal canal. And so, you could see maybe, things like testicular pain, orchitis UTIs, and you just have to kind of think about it a little bit differently and know that that exists. There's no real literature though, to go off of.

Cancer screening. So there's no WPATH. WPATH, Dr. Figler referenced. There's no guidelines specific to prostate cancer screening. You would think that it would be much lower with the hormones that patients are on, orchiectomy, but it's not zero. And so, we treat patients just by the AUA guidelines, as you would any patient. But there has been some kind of buzz about lowering the PSA cutoff, because of the issues with hormones.

Sexual function is a talk in and of itself, and I would encourage you to go to, you can Google it, the WPATH guidelines, there's a great section on it. They talk about gender affirming hormone treatments, and when you start to see sexual side effects, and things like that, as well as patients pre and post bottom surgery. It's a great resource if you see a patient like this.

And finally, fertility, any in the urologic sphere, right? Patients who are assigned male at birth, AMAB, should really be offered fertility preservation before starting hormone therapy. But they can still bank if they've started hormones by coming off of those. Cryopreservation is an option, and they should know that.

So my major takeaways are that, have an awareness that TGD patients are going to seek care for basic urologic issues, and they don't all follow the same path. So ask them, and if you make a mistake, apologize, it's not a big deal. Move on. They'll appreciate that.

Utilize all the resources that are out there. WPATH, the AUA has great resources, the Core Curriculum, Updates.

Find champions to refer to in sexual health, pelvic floor physical therapy, people you know that are affirming. And if you don't think you can manage it, maybe it is best handled with a multidisciplinary approach. And there are programs that are sprouting up everywhere. So that's the good news.

These are some resources for you that are available in the PowerPoint.

And then, you can always email me, or our program director at the Gender Pathways are happy to help you out with resources. Thank you.

Brad Figler: I'm going to be talking about urethral reconstruction for urethral strictures as an outpatient and in an ASC. I have no disclosures.

This is anatomy that I'm sure is familiar to everyone here. The fossa navicularis is in the distal penis, just proximal to the meatus. Bulbar urethra is in the scrotum and perineum. And the membranous urethra is just distal to the prostate.

In terms of things that we can do for urethra reconstruction and ASC before surgery, I think patient selection is key. Comorbidities like coronary artery disease, obesity, and sleep apnea, make outpatient ASC surgery a little more difficult. Anticoagulants may increase the risk of inter-op or post-op bleeding, so these patients may benefit from closer monitoring post-operatively.

For patients on chronic opioids, it may be difficult to control pain post-operatively, and therefore, these patients may need longer period of observation.

In terms of procedure selection, you'll want to consider duration of surgery, blood loss, physiologic burden of surgery, as well as post-operative pain control, and any other specialized post-operative care that the patient may need.

Communication with the patient and caregiver is really important. So we have detailed handouts for each surgery that we give to patients at the clinic visit when they book the surgery, so they know what to expect after surgery and can plan around that.

Finally, a thorough diagnostic workup will allow you to predict what's going to happen in the OR, and avoid a situation where the patient has a more invasive or more painful surgery than you anticipated.

Things to do to optimize the surgery itself include local and regional blocks to minimize pain postoperatively. Good communication with nursing and anesthesia is essential, and can allow for a quicker and less painful recovery, better discharge planning, and shorter PACU stay. Longer surgeries require more recovery, so it's important to have a plan and to communicate with everyone in the OR ahead of time, so they can anticipate needs. And finally, small things like minimizing blood loss often result in a quicker and more predictable recovery.

After surgery, communication with PACU staff is helpful, as our comprehensive and accurate discharge instructions. These patients have a lot of questions after surgery, so you'll want to plan for an uptick in phone calls and EMR, and probably reserve some capacity in your clinic for seeing post-op patients with questions or concerns.

I'm going to move on now to surgical technique. I'll try to get through everything without going over. Penile urethral strictures are caused by lichen sclerosis, BPH surgery, and STDs. Workup includes retrograde voiding and/or pull back urethrograms. The penile urethra is fixed to the corpus cavernosum and not very robust, so excisional procedures are typically not used on the penis. Instead, we utilize a lot of tissue transfer with either a graft or a flap. The patient shown here had a long eight French stricture in his penile urethra. So we performed a ventral onlay with a fasciocutaneous flap.

This patient had a very narrow fossa navicularis stricture that was about a centimeter in length. We perform these urethroplasties through the meatus, so the scar's excised and a buccal mucosal graft is parachuted in through the meatus.

For patients with really severe penile urethral strictures, typically due to lichen sclerosis or failed hypospadias repair, we perform a staged urethroplasty. In the first stage, we apply buccal mucosal graft to the disease segment, and create a urethrostomy proximal to the repair. In the second stage, we tubularize the reconstructed urethra. In the two photos on the right, you can see how the graft and adjacent tissue soften up over time. This makes the second surgery a lot more reliable.

All of these penile reconstructions are amenable to an outpatient or an ASC setting. They can be somewhat technical, but pain is minimal with appropriate penile blocks. The surgeries are not physically demanding, and the postoperative course is predictable.

So moving on now to bulbar urethra strictures caused by trauma, instrumentation/surgery, radiation. Workup includes retrograde and sometimes avoiding urethrogram. The bulbar urethra is robust and redundant, so short strictures can be excised in the remaining urethral and sutured to each other.

When possible, we try to preserve blood supply to the corpus spongiosum. In the picture on the left, you can see that we preserve the bulbar artery. At the bottom right, there's enough mobility on the adjacent urethra to do an excision and primary anastomosis, without dividing this artery. For longer strictures, some form of tissue transfer is necessary. In the photo on the right, we're performing a dorsal onlay by suturing the buccal mucosal graft to the corpus cavernosum and then to the spatulated urethra. So bulbar urethra reconstruction's also very minimal to outpatient in a ASC setting. Pain is minimal with appropriate blocks, and post-operative course is also predictable.

Posterior urethral strictures caused by treatments for prostate cancer, or BPH, or trauma. Workup includes retrograde and voiding urethrograms. The status of the continence mechanism in the bladder neck and membranous urethra are really important parts of the treatment algorithm. So we often do cystograms to assess bladder neck function, and integrate urethroscopy to determine whether these structures are involved in the disease process. Reconstructive options depend, in large part, on etiology, status of the continence mechanisms in location. So I'll run through a few common types of posterior urethroplasties that we perform as an outpatient.

For patients with a focal membranous urethral stricture and an intact bladder neck, an excisional urethroplasty is a great option. For patients with a non-functional bladder neck, a sphincter-sparing approach is really useful.

This is a video of a sphincter-sparing membranous urethroplasty. The video is made by Reynaldo Gomez in Chile, a reconstructive urologist who allowed me to share it here. But you can see that he's dissecting the sphincter off of the membranous urethra. So for patients who don't have a good internal sphincter, and rely on the external sphincter for continence, this allows for excision of the diseased membranous urethra with maintenance of continence.

Brachytherapy strictures tend to be limited to the prostatic apex and membranous urethra, as you can see in the voiding urethrogram images at the bottom. In this case, it's pretty straightforward to perform an excision in primary anastomosis.

So recently, we've been able to offer more reconstructive options to patients with post-prostatectomy and anastomotic strictures. Jonathan Warner from Mayo Clinic developed a sheath that fits a five millimeter suturing device in a digital ureteroscope. So we can now offer these patients trans urethral incision and re-approximation, or what he calls TUIMR.

For patients who aren't candidates for, or who are failed TUIMR, we're also able to offer more formal reconstruction, either robotically, or via a perineal pre-rectal approach.

Like many of the surgeries that I discussed, these are technically involved, but not physiologically demanding or very painful, so amenable to outpatient or ASC surgery.

Thanks.