Future directions in transfeminine genital gender-affirming surgery: tissue substitutes and transplant.

Objective: The present study reviews contemporary literature focused on uterine transplantation and tissue substitutes for the purposes of transfeminine genital gender affirming surgery (GAS). Additional background is provided for both topics to provide a more comprehensive understanding of the modern applications.

Results: Uterine transplant remains an experimental procedure in cisgender patients who wish to avoid surrogacy. A natural extension might be to apply these techniques to GAS. Technical barriers include anatomic differences and alterations to gender-affirming hormone administration protocols. Ethically, resource allocation, elective immunosuppression, societal response to organ donation, legal ramifications of parenthood as well as the potential, under-studied effects that such an elective procedure may have on the patient's offspring must be further investigated.Tissue substitutes have long been used in urologic reconstruction but more recently applied to gender affirmation surgery which has traditionally relied on autografting to line the neovaginal canal both in the context of primary and revision vaginoplasty. However, the advent of off-the-shelf xenografts have recently been posited to be safe and efficacious alternatives to autografts. Longer term studies are needed to validate whether these proposed methods are indeed noninferior to traditional approaches.

Conclusions: The field of feminizing gender affirmation surgery remains an exciting frontier for surgeons and patients alike. Given the relative nascency of the specialty and its propensity to draw techniques from various surgical disciplines there exists a unique opportunity for rapid innovation to overcome challenging problems posed by these complex procedures as evidenced by discussions around applying uterine transplantation and the use of novel tissue grafting techniques.