Sexual quality of life after total phalloplasty in men with penile deficiency: an exploratory study

Techniques for Penile Augmentation Surgery: A Systematic Review of Surgical Outcomes, Complications, and Quality of Life

The increase in practices related to enhancing penile size can be attributed to the belief that an improved genital appearance contributes to a man's virility, coupled with an altered self-perception of his body. It is crucial to tailor interventions to meet the genuine needs of patients by thoroughly assessing their history, psychological state, and potential surgical benefits, all while considering the associated risks of complications. This systematic review aims to summarize the available evidence on outcomes, complications, and quality of life after penile augmentation surgery, examining both minimally invasive and more radical techniques. A search of the PubMed and Scopus databases, focusing on English-language papers published in the last 15 years, was performed in December 2023. Papers discussing surgery in animal models and case reports were excluded from the present study unless further evaluated in a follow-up case series. The primary outcomes were changes in penile dimensions, specifically in terms of length and girth, as well as the incidence of surgical complications and the impact on quality of life. A total of 1670 articles were retrieved from the search and 46 were included for analysis. Procedures for penile length perceived enhancements include lipoplasty, skin reconstruction plasty, V-Y and Z plasty, flap reconstruction, scrotoplasty, ventral phalloplasty, and suspensory ligament release; techniques for increasing corporal penile length include penile disassembly, total phalloplasty, and sliding elongation. Finally, penile girth enhancement may be performed using soft tissue fillers, grafting procedures, biodegradable scaffolds, and Penuma®. In conclusion, while penile augmentation surgeries offer potential solutions for individuals concerned about genital size, the risks and complexities need to be accounted for.

Male esthetic genital surgery: recommendations and gaps to be filled

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Long-term active problems in patients with cloacal exstrophy: A systematic review

BACKGROUND

Cloacal exstrophy (CE) is the most severe end of the Exstrophy-Epispadias Complex malformations spectrum. Improvements in postnatal management and well-established operative techniques have resulted in survival rates approaching 100%. This systematic review aims to define the prevalence of long-term active medical problems affecting CE patients after the first decade of life.

METHODS

PubMed/Medline, Embase, Scopus, and ISI Web of Knowledge databases were used for the literature search. Original articles related to medical, surgical, and psychosocial long-term problems in CE patients >10 years of age were included in the study. Quality assessment of the articles was performed through the Newcastle-Ottawa Scale. Prevalence estimates and 95% CI were assessed for each outcome.

RESULTS

Twelve studies were included. The most common long-term active problems identified were: urinary incontinence with a prevalence ranging from 9.1% to 85%; sexual function issues related to vaginal anomalies with a prevalence ranging from 8.3% to 71.3%, and uterine anomalies, with a prevalence from 14.3% to 71%; gender identity issues in 46, XY patients raised female had a prevalence from 11.1% to 66.7%. There is no documented history of paternity. Impairment of ambulatory capacity was recorded in 13.8% of patients. Only one paper studied psychological well-being, reporting significantly higher levels of depression among gender reassigned patients.

CONCLUSIONS

Teenagers and adults born with CE have well defined long-term problems compared to the general population. Recognition and expert management are crucial to improve care and quality of life during and after the transition into adulthood.

Penile reconstruction: An up-to-date review of the literature

Objective

: To review the literature on adult penile reconstruction due to Peyronie’s disease, trauma and cosmesis, while emphasising specific surgical techniques and procedures such as phalloplasty, radial forearm free flap reconstruction, and penile transplant.

Methods

: A comprehensive review of the literature for the years 1992–2020 of the PubMed and SpringerLink databases was performed to identify articles on penile reconstruction. Search terms included ‘penile reconstruction’, ‘penile trauma’, ‘phalloplasty’, ‘penile transplant’, and ‘treatment of Peyronie’s’. Relevant articles were selected. All included studies were performed on adults and written in English.

Results

: We were able to identify 46 papers from PubMed and SpringerLink that included the research terms. From these, we included technical details of procedures and gleaned photographs of their works. Additionally, we included photographs from our institution’s own plication surgery cases.

Conclusions

: The field of adult penile reconstruction is performed for a plethora of reasons. From cosmetic to urgent and from routine to complex, it is most certainly a growing subset of Urology that plays a vital role for the men who need it. To our knowledge, this is the most up-to-date review of adult penile reconstruction.

Living with someone else's penis: The lived experiences of two South African penile allograft recipients: A descriptive phenomenological study

Background

In South Africa, penile loss is a recognised complication of ritual circumcision which has a profoundly negative effect on these men's psyches and their everyday lives. The purpose of this paper was to investigate the experiences of the first two South African penile allograft transplantation recipients in order to assess the psychosocial impact of this surgery.

Materials and methods

A qualitative descriptive phenomenology approach was used. A total of four in-depth interviews were conducted with the two South African penile transplant recipients. The interviews were transcribed verbatim while adding the field and observational notes. Thematic analysis was used to derive meaning from the collected data.

Results

After the penile loss, both participants reported feeling suicidal for the following reasons: their communities shunned them and regarded them as ‘dead,’ they felt severely ashamed of their disfigured bodies, they were unable to develop intimate relationships and could not have children. Transplantation gave them a fully functional penis, which resolved the majority of these issues. The participants were able to build relationships and satisfy their own and their partners' sexual and relationship needs. The transplant led to complete restoration of their self-image and manhood. They were, however, still persecuted by their traditional communities as they had not successfully completed the ritual circumcision ceremony.

Conclusion

This study emphasises the necessity of offering penile transplantation as treatment for penile loss as this is not only life enhancing but lifesaving, especially within the South African context.

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Recipients fully accepted the transplanted penis as their own.

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Penile function was fully restored including sexual function and therefore the ability to reproduce.

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Penile transplantation had positive impact on recipients' psychological state and self-image.

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Despite need for lifelong immunosuppressants, recipients were satisfied with decision to have penile tansplant.

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The emotional and social transformation which occurred in the recipients were not only life-enhancing, but lifesaving.

Transgender Scrotoplasty and Perineal Reconstruction With Labia Majora Flaps: Technique and Outcomes From 147 Consecutive Cases

PURPOSE

Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps.

METHODS

We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin.

RESULTS

The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention.

CONCLUSIONS

Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

The hypospadias-specific health-related quality of life conceptual framework: a scoping review of the literature

PURPOSE

Health-related quality of life (HRQoL) is an important yet understudied construct for individuals with hypospadias (HS). An important barrier towards understanding HRQoL and integrating it into research and clinical care for people with HS is the absence of an underlying conceptual framework to illustrate this construct. We propose a conceptual framework for HS-specific HRQoL based upon a scoping review of the HS literature.

METHODS/MATERIALS

We conducted a literature review of articles published between 1989 and 2019. Our search in Embase and Pubmed used the keyword "hypospadias" in combination with "quality of life" and "patient-reported outcomes." We used thematic analysis of the resulting publications to identify core HRQOL domains. From these results and review of HRQoL literature in other pediatric populations, we developed a conceptual framework representing HS-specific HRQoL.

RESULTS

We identified five domains of HRQOL previously studied in research with youth and adults with HS: penile appearance, voiding, social interaction, sexual health, and psychological or behavioral function. We propose a model of HS-specific HRQoL comprised of these domains and their areas of overlap, based upon the findings and conceptual mapping of our literature review.

CONCLUSION

This novel conceptual framework provides a foundation for understanding disease-specific HRQoL in individuals with HS and may serve as a guide for the conduct of future qualitative studies of the HS population. The overlapping biopsychosocial domains illustrate the possible effects of HS on day-to-day life. This framework may guide future surgical, clinical, and behavioral interventions that aim to improve medical care and quality of life outcomes for HS patients.

Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications and Outcomes

BACKGROUND

Males born with bladder exstrophy-epispadias complex generally have a shorter phallus, split corpora with dorsal curvature, and a scarred and flattened glans, so substitution phalloplasty is often required.

AIM

The aim of this study was to review the techniques, complications, and outcomes of substitution phalloplasty in bladder exstrophy-epispadias complex patients to determine the ideal surgical procedure and gauge the risks and benefits for the patient.

METHODS

A systematic review of the literature was performed using PubMed/MEDLINE and the Cochrane Library with the following terms: ("phalloplasty"); (("epispadias") OR ("bladder exstrophy") OR ("cloacal exstrophy")). We included only full-text articles reporting data about techniques and outcomes of substitution phalloplasty in patients with bladder exstrophy-epispadias complex.

OUTCOMES

To determine whether patients with bladder exstrophy-epispadias complex might benefit from substitution phalloplasty.

RESULTS

We selected 7 studies involving 47 patients. All the studies were characterized by a low level of evidence and a heterogeneous approach during treatment and outcome assessment. The free radial forearm flap was the most commonly performed technique (89%) with an overall complication rate of 15%. Urethroplasty was performed in 22 of 47 (47%) patients, and in most cases (20/22) a "tube-within-the-tube" technique was performed simultaneously with the phalloplasty (20/47). Urethroplasty complications were recorded in 12 of 22 (54%) patients with 6 fistulae and 6 stenoses. A penile prosthesis was implanted in 32 of 47 (68%) patients and complications occurred in 8 of 32 (25%) patients with 6 erosion. Aesthetic, sexual, and psychological outcomes were satisfactory, but none of the studies used validated instruments for the final assessment.

CLINICAL IMPLICATIONS

It was not possible to formulate any recommendations based on a high level of evidence regarding substitution phalloplasty in patients with bladder exstrophy-epispadias complex.

STRENGTH & LIMITATION

To our knowledge, this is the first review to address bladder exstrophy-epispadias complex patients only. The limitations are mainly represented by the small number of cases because of the rarity of this disease and by the fact that no studies used validated instruments.

CONCLUSION

Substitution phalloplasty in patients with bladder exstrophy-epispadias complex can achieve good functional, aesthetic, psychological, and sexual outcomes. It requires multiple procedures and carries a high complication rate. Multicentric studies including the assessment of patients by means of a validated questionnaire which investigates both sexual function and psychosexual satisfaction are required. Berrettini A, Sampogna G, Gnech M, et al. Substitution Phalloplasty in Patients With Bladder Exstrophy-Epispadias Complex: A Systematic Review of Techniques, Complications, and Outcomes. J Sex Med 2021;18:400-409.

Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances

INTRODUCTION

To date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied.

AIM

The aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007-2018 in the English language, were included.

METHODS

MEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies.

MAIN OUTCOME MEASURE

The panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations.

RESULTS

In the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon's ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric ("CURSED") has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie's disease. Ectopic high submuscular reservoir placement can be considered as an alternative method.

CLINICAL IMPLICATIONS

There is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw.

STRENGTH & LIMITATIONS

All studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation.

CONCLUSION

This ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance. Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210-237.

Prosthetic Placement After Phalloplasty

Significant developments have enabled the transformation of phalloplasty to a functional organ. Differences exist in the surgical placement of a prosthesis when within a phallus, such as the lack of corpora, pubic fixation requirement, distal sock placement, and the consideration of a vascular pedicle. Increased complications compared with nonphalloplasty cohorts remain one of the biggest challenges, including rates of infection, erosion, mechanical malfunction, and malposition. Nonetheless, the placement of penile prosthesis within a phalloplasty enables trans men to achieve a once near-impossible goal of penetrative sexual intercourse without an external device.

Sexuality in Adults with Differences/Disorders of Sex Development (DSD): Findings from the dsd-LIFE Study

For various reasons, sexuality of individuals with differences/disorders of sex development (DSD) may be affected. The aim of the study was to describe sexual activity, satisfaction with sex life, satisfaction with genital function, and sexual problems in people with different DSD conditions. Data were collected from 1,040 participants in Europe. Many people with a variety of DSD conditions do not appear to be satisfied with their sex life, experience a variety of sexual problems, and are less sexually active than the general population; therefore sexuality should be explicitly addressed in the care of people with DSD.

First Outcomes of the ZSI 475 FtM, a Specific Prosthesis Designed for Phalloplasty

INTRODUCTION

The ZSI 475FtM is a new prosthesis that has recently been specifically designed for phalloplasty. It has several functions that have been conceived to answer the challenges of implantation after phalloplasty: a large base for pubic bone fixation, realistically shaped hard glans, and a pump shaped like a testicle.

AIM

To assess the safety, feasibility, and patient satisfaction of the ZSI 475 FtM.

METHODS

Surgical outcomes were analyzed after implantation of the prosthesis between June 2016 and September 2017 (single institution, single surgeon). Patients were then asked to answer a satisfaction questionnaire that included the International Index of Erectile Function-5, Erectile Dysfunction Inventory of Treatment Satisfaction, and Self-Esteem and Relationship, as well as other non-validated questions.

MAIN OUTCOME MEASURE

Complication rates and the scores of the different questionnaires were reviewed.

RESULTS

20 patients who had gender dysphoria and underwent operation for a female-to-male procedure were included. The mean age was 37.9 years. Complications after 21 implantations included 2 (9.5%) infections that were medically treated (Clavien II), 1 (4.7%) infection treated by explantation (Clavien IIIb), 2 (9.5%) mechanical failures (Clavien IIIb), and 1 (4.7%) malpositioning (Clavien IIIb). The mean follow-up was 8.9 months (SD 4.0), with 50% of the implanted patients having >12 months of follow-up. 14 patients (70%) answered the satisfaction questionnaire. 12 patients (85.7%) had regular penetrative sexual intercourse. The mean International Index of Erectile Function-5 score was 20.2 of 25 (standard deviation [SD] 7.9), the mean Self-Esteem and Relationship score was 84.5 of 100 (SD 9.9), and the mean Erectile Dysfunction Inventory of Treatment Satisfaction score was 82 of 100 (SD 17.5). 13 patients (92.8%) were satisfied or very satisfied with the prosthesis.

CLINICAL IMPLICATIONS

This new innovative prosthesis could better answer the challenges faced by the implantation of an erectile device by phalloplasty.

STRENGTH & LIMITATIONS

Our study is the first to report data on this new prosthesis. The main limitation is the small number of patients and the short follow-up.

CONCLUSION

Preliminary results for the ZSI 475 FtM are encouraging. Safety seems to be satisfactory, and patient satisfaction is high. Long-term studies are needed for further analysis. Neuville P, Morel-Journel N, Cabelguenne D, et al. First Outcomes of the ZSI 475 FtM, a Specific Prosthesis Designed for Phalloplasty. J Sex Med 2019;16:316-322.

Systematic Review of Quality of Patient Information on Phalloplasty in the Internet

BACKGROUND

An increasing number of patients, considering aesthetic surgery, use Internet health information as their first source of information. However, the quality of information available in the Internet on phalloplasty is currently unknown. This study aimed to assess the quality of patient information on phalloplasty available in the Internet.

METHODS

The assessment of the Web sites was based on the modified Ensuring Quality Information for Patients (EQIP) instrument (36 items). Three hundred Web sites were identified by the most popular Web search engines.

RESULTS

Ninety Web sites were assessed after, duplicates, irrelevant sources and Web sites in other languages rather than English were excluded. Only 16 (18%) Web sites addressed >21 items, and scores tended to be higher for Web sites developed by academic centers and the industry than for Web sites developed by private practicing surgeons. The EQIP score achieved by Web sites ranged between 4 and 29 of the total 36 points, with a median value of 17.5 points (interquartile range, 13-21). The top 5 Web sites with the highest scores were identified.

CONCLUSIONS

The quality of patient information on phalloplasty in the Internet is substandard, and the existing Web sites present inadequate information. There is a dire need to improve the quality of Internet phalloplasty resources for potential patients who might consider this procedure.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mystery and realities of phalloplasty: a systematic review

The neophallus creation is still a mystery and it remains challenging even today. In this article, we performed a comprehensive review of the literature regarding phalloplasty and penile reconstructive surgery between January 2008 and May 2016. In this review, we have included 15 research articles and the results of 276 patients were examined. Studies revealed several indications and when indications were reviewed, 191 patients were female-to-male transgender, 9 patients had disorder of sex development/micropenis, 16 had penile amputation/trauma, 9 had ambiguus genitalia, 40 had exstrophy and/or epispadias, 11 had other problems. As a result of this review, phalloplasty is a reliable and useful operation with good functional and aesthetical results.

Novel Technique for Proximal Bone Anchoring of Penile Prosthesis After Radial Forearm Free Flap Neophallus

OBJECTIVE

To describe outcomes of bone anchoring of penile implant in a neophallus with an accompanying video focusing on operative technique and salient tips for surgeons performing these procedures. Penile prosthesis insertion allows individuals with a neophallus to achieve erectile function. Lack of corporal bodies to accommodate cylinders makes anchoring of any prosthesis challenging. Anchoring the device to the pubic bone is one strategy to achieve proximal stabilization.

METHODS

A single-institution, retrospective chart review of 10 neophallus patients undergoing penile prosthesis placement from 2006 to 2015 was done. The pubic symphysis is exposed and corticotomy created for placement of the rear tip extender of the implant using a Stryker TPS bone drill. Anchoring sutures through the corticotomy defect, rear tip, and proximal cylinder seat the implant. The remainder of the implantation procedure mirrors that used in native tissue.

RESULTS

The overall perioperative complication rate was 20%, with a mean follow-up of 49 months. Seventy percent of the patients required reoperation, with a mean of 1.4 prosthesis revision surgeries per patient. Primary causes of revision included infection, poor fixation of the rear tip, and prosthesis failure. Despite high revision rates, 80% of the patients have fully functioning prosthesis as of last follow-up. Limitations include retrospective study design and the small patient cohort.

CONCLUSION

Penile prosthesis placement in the neophallus is feasible and effective. A bone-anchored rear tip is an option to provide proximal stabilization. Continued efforts to minimize the need for revisions are ongoing and necessary.

World's First Baby Born Through Natural Insemination by Father With Total Phalloplasty Reconstruction

Techniques for neophallus reconstruction have become increasingly refined, fulfilling more criteria for what is considered to be the ideal penis reconstruction. For both trauma and transgender populations, the radial forearm free flap remains the gold standard, although the pedicled or free anterolateral thigh flap is becoming a favored alternative. Despite the remarkably high rates of sexual activity reported by patients having benefited from these techniques, sexual function remains a significant challenge due to frequent complications including autologous and prosthetic stiffener failure, fistula formation, and inadequate erogenous sensation. Perhaps the ultimate criterion for neophallus reconstruction is one which not only avoids these complications by meeting the immediate goals of a competent neourethra, sensitivity, bulk, and aesthetic form but also successfully combines them into their true overarching function: procreation. In this article, we report the case of a pedicled anterolateral thigh flap neophallus reconstruction which allowed a patient to naturally conceive a child through penetrative intercourse without use of a stiffener, and led to pregnancy and subsequent birth of a baby son. We review the surgical techniques and factors that led to this patient's successful progeny.

Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma

INTRODUCTION

Disorders of Sex Development (DSD) are a wide range of congenital conditions characterized by an incongruence of components involved in sexual differentiation, including gender psychosexual development. The management of such disorders is complex, and one of the most crucial decision is represented by gender assignment. In fact, the primary goal in DSD is to have a gender assignment consistent with the underlying gender identity in order to prevent the distress related to a forthcoming Gender Dysphoria. Historically, gender assignment was based essentially on surgical outcomes, assuming the neutrality of gender identity at birth. This policy has been challenged in the past decade refocusing on the importance of prenatal and postnatal hormonal and genetic influences on psychosexual development.

AIMS

(1) to update the main psychological and medical issues that surround DSD, in particular regarding gender identity and gender assignment; (2) to report specific clinical recommendations according to the different diagnosis.

METHODS

A systematic search of published evidence was performed using Medline (from 1972 to March 2016). Review of the relevant literature and recommendations was based on authors' expertise.

RESULTS

A review of gender identity and assignment in DSD is provided as well as clinical recommendations for the management of individuals with DSD.

CONCLUSIONS

Given the complexity of this management, DSD individuals and their families need to be supported by a specialized multidisciplinary team, which has been universally recognized as the best practice for intersexual conditions. In case of juvenile GD in DSD, the prescription of gonadotropin-releasing hormone analogues, following the World Professional Association for Transgender Health and the Endocrine Society guidelines, should be considered. It should always be taken into account that every DSD person is unique and has to be treated with individualized care. In this perspective, international registries are crucial to improve the understanding of these challenging conditions and clinical practice, in providing a better prediction of gender identity.

Recalled and current gender role behavior, gender identity and sexual orientation in adults with Disorders/Differences of Sex Development

The magnitude of sex differences in human brain and behavior and the respective contributions of biology versus socialization remain a topic of ongoing study in science. The preponderance of evidence attests to the notion that sexual differentiation processes are at least partially hormonally mediated, with high levels of prenatal androgens facilitating male-typed and inhibiting female-typed behaviors. In individuals with Disorders/Differences of Sex Development (DSD), hormonal profiles or sensitivities have been altered due to genetic influences, presumably affecting gender(ed) activity interests as well as gender identity development in a minority of the affected population. While continued postnatal androgen exposure in a number of DSD syndromes has been associated with higher rates of gender dysphoria and gender change, the role of a number of mediating and moderating factors, such as initial gender assignment, syndrome severity and clinical management remains largely unclear. Limited investigations of the associations between these identified influences and gendered development outcomes impede optimization of clinical care. Participants with DSD (n=123), recruited in the context of a Dutch multi-center follow-up audit, were divided in subgroups reflecting prenatal androgen exposure, genital appearance at birth and gender of rearing. Recalled childhood play and playmate preferences, gender identity and sexual orientation were measured with questionnaires and semi-structured interviews. Data were compared to those of control male (n=46) and female participants (n=79). The findings support that (a) prenatal androgen exposure has large effects on (gendered) activity interests, but to a much lesser extent on sexual orientation and that (b) initial gender of rearing remains a better predictor of gender identity contentedness than prenatal androgen exposure, beyond syndrome severity and medical treatment influences. Nonetheless, 3.3% of individuals with DSD in our sample self-reported gender dysphoria from an early age and changed gender, which further underlines the need for thorough long- term follow-up and specific clinical support.

Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?

Ten years after the consensus meeting on disorders of sex development (DSD), genital surgery continues to raise questions and criticisms concerning its indications, its technical aspects, timing and evaluation. This standpoint details each distinct situation and its possible management in 5 main groups of DSD patients with atypical genitalia: the 46,XX DSD group (congenital adrenal hyperplasia); the heterogeneous 46,XY DSD group (gonadal dysgenesis, disorders of steroidogenesis, target tissues impairments …); gonosomic mosaicisms (45,X/46,XY patients); ovo-testicular DSD; and "non-hormonal/non chromosomal" DSD. Questions are summarized for each DSD group with the support of literature and the feed-back of several world experts. Given the complexity and heterogeneity of presentation there is no consensus regarding the indications, the timing, the procedure nor the evaluation of outcome of DSD surgery. There are, however, some issues on which most experts would agree: 1) The need for identifying centres of expertise with a multidisciplinary approach; 2) A conservative management of the gonads in complete androgen insensitivity syndrome at least until puberty although some studies expressed concerns about the heightened tumour risk in this group; 3) To avoid vaginal dilatation in children after surgical reconstruction; 4) To keep asymptomatic mullerian remnants during childhood; 5) To remove confirmed streak gonads when Y material is present; 6) It is likely that 46,XY cloacal exstrophy, aphallia and severe micropenis would do best raised as male although this is based on limited outcome data. There is general acknowledgement among experts that timing, the choice of the individual and irreversibility of surgical procedures are sources of concerns. There is, however, little evidence provided regarding the impact of non-treated DSD during childhood for the individual development, the parents, society and the risk of stigmatization. The low level of evidence should lead to design collaborative prospective studies involving all parties and using consensual protocols of evaluation.

Lower genitourinary tract trauma

Lower genitourinary tract trauma comprises a substantial portion of the trauma burden in the USA. Some key trends and findings are described. Mortality is relatively high in patients with bladder trauma due to associated injuries. Urethral injuries should be suspected in patients presenting with the triad of blood at the urethral meatus, suprapubic fullness indicative of a full bladder, and urinary retention. Urethral injury is common in penetrating penile trauma, and stab wounds to the penis are more likely to involve the urethra than gunshot wounds. Penile fracture is largely a clinical diagnosis and suspicion of fracture requires urgent surgical exploration. Zipper injuries are the most common cause of presentation to the emergency department for penile trauma in adults. Toilet seat injuries are the leading cause of penile pediatric trauma presenting to the emergency department. In the setting of testicular trauma, rates of testicular salvage are excellent when exploration is prompt. Trauma in the form of animal or human bites requires treatment with broad-spectrum antibiotics in addition to repair of the injury. Military trauma has seen an increase in explosive injuries to the lower urinary tracts due to evolution of warfare tactics. Increasing awareness of presentation and context of lower genitourinary tract trauma can reduce delay of diagnosis and morbidity associated with such injuries.