Abdominal and Pelvic Imaging of Transgender Patients SA–CME REVIEW risk of significant blood loss. Two main surgical options for creating a neophallus include metoidioplasty and phalloplasty, with phalloplasty being the most complex gender-af- firming surgery; it oſten requires a multidisciplinary team approach. The goals of creating a neophallus might include the ability to urinate while standing, maintain sensation, and potentially participate in pene- trative sexual intercourse. Numer- ous surgical techniques exist; the most common and currently pre- ferred technique is the radial fore- arm free flap. Anterolateral thigh flap, abdominal flap, and latissimus dorsi free flap are additional but less frequently utilized techniques. Metoidioplasty is a separate surgical technique in which the neophallus is created from a hormonally hyper- trophied clitoris; however, this can limit neophallus length and prevent the ability to engage in sexual inter- course in some patients. 6 Owing to the number of surgi- cal techniques, data varies in the literature regarding postoperative complications for masculinization surgery. Overall, metoidioplasty is a less-invasive and lower-risk procedure than phalloplasty. 12 In patients undergoing phalloplasty, wound dehiscence occurs in 9.8%. This is adequately evaluated with CT to assess for the presence of underlying abscess. 11 It is essential to monitor early perfusion of the flap in the immediate postoperative setting using ultrasound with color doppler as well. 4 Minor urethral is- sues (including stenoses, strictures, or fistulas which resolved with treat- ment) occurred in 24% of patients, with major urethral complications seen in an additional 24.4% of patients. 11 These urinary complica- tions are well-evaluated fluoroscop- ically with retrograde urethrograms (Figures 5 and 6). Reported rates of urethral issues in metoidioplas- ty are lower, with minor issues in 3.9% of patients, and major urethral issues in 11.4%. However, it was also reported that 15% of patients who underwent metoidioplasty elected to undergo a secondary phalloplasty. 11 In phalloplasty patients, donor site complications are also a consider- ation, and include graſt necrosis, excessive scarring, paresthesias, and limitation of wrist motion. How- ever, these are generally beyond the scope of practice for abdominal radiologists. 11 Erectile devices can also be considered in patients who intend to engage in penetrative intercourse; they are usually placed months aſter the neophallus has healed. These devices demonstrate higher rates of complications in postoperative transgender patients compared to cis-gender individuals requir- ing prosthesis. 12 This difference is hypothesized to be secondary to earlier age of implantation and lack of supportive cavernosal fascial layers. These potential complications include mechanical device failure, malposition, and infection, and are well evaluated with CT. 4 Testicular prostheses, which are usually either silicone or saline filled, may also be placed. Complications of these pros- theses include malposition, rupture, and infection, all of which are well evaluated with CT or MRI 4 . Creating an Inclusive Environment As accessibility to gender-affirm- ing care increases, it is essential for radiologists not only to increase their knowledge of the imaging find- ings but also to ensure that imaging centers improve their inclusivity to ensure positive patient experiences. The 2015 U.S. Transgender Survey found that 33% of responders had at least one negative experience in a healthcare setting related to their gender identity. 3 Grimstad, et al, surveyed over 500 transgender and nonbinary patients, and more than 70% reported having one or more negative experience during an imaging encounter. 13 These included not being asked their correct pro- nouns, incorrect use of pronouns, personnel discomfort, and failure to protect privacy. Additionally, almost 25% were misgendered in the ra- diology report. 13 Initiating staff training cover- ing respectful communication, including correct use of pronouns, and cultural sensitivity and gen- der-affirming care standards, as well as training in proper imaging techniques for these patients, are essential for medical imaging cen- ters. Radiology residency programs should incorporate LGBTQ culture competency, as well. Gender-neu- tral restrooms/ changing facilities, as well as LGBTQ-affirming read- ing materials and signage are also essential to creating a positive and welcoming patient experience. Integrating these issues into orga- nizational accreditation guidelines, such as those provided by the Amer- ican College of Radiology, would be impactful. 13 Conclusion The rapid evolution of transgen- der healthcare across the world is allowing for greater access to care and overall improved quality of life for many with gender dysphoria. 4 As more transgender patients seek gender-affirming surgery, it is es- sential for abdominal radiologists to remain current on the latest surgical techniques, their potential complica- tions, and the appropriate imaging modalities to best evaluate them. Additionally, as they seek to provide adequate imaging interpretations, abdominal radiologists should strive for excellence in the transgender patient experience. This will help to maintain their role as integral members of the multidisciplinary transgender care team and to perpet- uate a culture of inclusivity within the medical field. Applied Radiology 12 July / August 2022