Microscopic Features of Vaginectomy Specimens from Transgender Patients

Reproducibility and Consistency of Isolation Protocols for Fibroblasts, Smooth Muscle Cells, and Epithelial Cells from the Human Vagina

(1) Background: For the reconstruction of a human vagina, various surgical procedures are available that are often associated with complications due to their failure to mimic the physiology of the human vagina. We recently developed a vascularized, organ-specific matrix from healthy human vaginal wall tissue with suitable biomechanical properties. A superior graft would require further extensive colonization with autologous vaginal cells to reduce complications upon implantation. However, reports on isolation of vaginal cells from biopsies are scarce, and published protocols rarely contain sufficient details. In this study, we aimed to examine protocols for inconsistencies and identify (where possible) the optimal protocol in terms of reproducibility and efficiency for isolation of human vaginal fibroblasts (FBs), epithelial cells (VECs), and smooth muscle cells (SMCs). Overall, this study aims to guide other researchers and aid future tissue engineering solutions that rely on autologous cells. (2) Methods: A total of 41 isolation protocols were tested: four protocols specific to FBs, 13 protocols for VECs, and 24 protocols for SMCs. Protocols were derived from published reports on cell isolation by enzymes, with exclusion criteria including the need for specialized equipment, surgical separation of tissue layers, or missing protocol details. Enzymatic digestion with collagenase-I, collagenase-IV, and dispase-II was used for isolation of VECs, collagenase-IV for isolation of SMCs, and collagenase-IA for isolation of FBs. Fluorescent immunostaining was applied to identify VECs with cytokeratin, SMCs with desmin, endothelial cells with UEA-1, and FBs with vimentin. Protocols were assessed based on (>95%) homogeneity, duplicate consistency, cell viability, and time to first passage. (3) Results: A total of 9 out of the 41 protocols resulted in isolation and expansion of vaginal FBs. This involved 1 out of 13 VEC protocols, 6 out of 24 SMC protocols, and 2 out of 2 FB protocols. Isolation of vaginal SMCs or VECs was not achieved. The best results were obtained after digestion with 0.1% collagenase-IV, where pure FB colonies formed with high cell viability. (4) Conclusions: Today, vaginoplasty is considered the gold standard for surgically creating a neovagina, despite its considerable drawbacks and limitations. Tissue-engineered solutions carry great potential as an alternative, but cell seeding is desired to prevent complications upon implantation of grafts. In this study, we examined isolation of human vaginal FBs, SMCs, and VECs, and identified the most efficient and reliable protocol for FBs. We further identified inconsistencies and irreproducible methods for isolation of VECs and SMCs. These findings aid the clinical translation of cell-based tissue engineering for the reconstruction and support of vaginas, fulfilling unmet medic needs.

Ectopic Prostatic Tissue in Female Urethral Diverticulum

BACKGROUND

Ectopic prostatic tissue in female patients is rare. It is theorized that the presence of prostatic tissue in female patients is likely a Wolffian remnant or transformation of hormonally mediated tissue of the uterus, cervix, Skene's gland, and, rarely, periurethral tissue. Due to the increase in the use of testosterone and gender-affirming therapies, it is important to understand the role of testosterone in mediating the presence of ectopic prostatic tissue.

CASE

We present a case of ectopic prostatic tissue in a urethral diverticulum in a female patient with exposure to testosterone hormone therapy and review the literature on this finding.

CONCLUSION

Although rare, ectopic prostatic tissue should be considered in the differential diagnosis of anterior vaginal cysts, especially in the setting of testosterone supplementation.

Chronic pelvic pain among transgender men and gender diverse adults assigned female at birth

BACKGROUND

There are limited data on pelvic pain among transgender men and gender diverse people, and the impact of testosterone on pelvic pain is poorly understood.

OBJECTIVE

Characterize the prevalence and correlates of chronic pelvic pain (CPP) among transgender men and gender diverse people and examine the association between testosterone use and CPP.

MATERIALS AND METHODS

We used 2020-2022 data from The Population Research in Identity and Disparities for Equality (PRIDE) Study, an online prospective cohort study of sexual and gender minority adults in the United States, to conduct complementary cross-sectional and longitudinal analyses. Our primary outcome was self-reported CPP lasting 3 months or longer measured using the Michigan Body Map.

RESULTS

Among 2579 transgender men and gender diverse people assigned female at birth included in our sample, 457 (18%) reported CPP. CPP correlates included: inflammatory bowel disease, irritable bowel syndrome (IBS), kidney stones, pelvic inflammatory disease, polycystic ovary syndrome (PCOS), uterine fibroids, current hormonal intrauterine device use, prior pregnancy, vaginal delivery, hysterectomy, and oophorectomy. Individuals with CPP reported a high prevalence of IBS (37%), PCOS (20%), uterine fibroids (9%), post-traumatic stress disorder (51%), and severe depression and anxiety symptoms (42% and 25%, respectively). Current testosterone use was associated with a 21% lower prevalence of CPP (adjusted prevalence ratio (aPR) 0.79, 95% confidence interval [CI]: 0.65-0.96). In longitudinal analyses (N = 79), 15 (19%) participants reported any CPP after initiating testosterone: eight (56%) of whom reported CPP prior to testosterone initiation, and seven (47%) who reported new-onset CPP.

DISCUSSION AND CONCLUSIONS

The relationship between CPP and testosterone is complex. Although testosterone use was associated with a lower prevalence of CPP, some transgender and gender diverse individuals experienced new-onset pelvic pain after testosterone initiation. Given the significant impact that CPP can have on mental health and quality of life, future research must examine the role of testosterone in specific underlying etiologies of CPP and identify potential therapies.

Cervical cancer in a transgender man: lessons learnt to improve care

We describe a case of rapid progression of cervical dysplasia to stage IVB cervical cancer in a previously healthy transgender young adult man on testosterone therapy. The cancer diagnosis came 7 months after routine pap smear showed low-grade dysplasia with high-risk human papillomavirus in preparation for gender-affirming hysterectomy/bilateral-salpingo-oophorectomy. After diagnosis, our patient faced unique challenges as a transgender man receiving gynecologic oncology care. This case highlights the challenges of and barriers to cervical cancer screening and treatment that transgender men confront. This case also considers whether gender-affirming testosterone therapy is associated with cervical cancer risk. We offer suggestions on how to improve cervical cancer screening and treatment for the transgender population.

Creation of a decellularized vaginal matrix from healthy human vaginal tissue for potential vagina reconstruction: experimental studies

BACKGROUND

When a disorder causes the absence of a healthy, full-size vagina, various neovaginal creation methods are available. Sometimes dilation or stretching of the vaginal cavity is sufficient, but intestinal or dermal flap tissue is generally required. However, different inherent tissue properties cause complications. Therefore, a lost body part should be replaced with a similar material. The use of organ-specific acellular vaginal tissue carries great potential, as its similar architecture and matrix composition make it suitable for vaginal regeneration.

METHODS

The authors developed an optimized protocol for decellularization of healthy human vaginal tissue. Resected colpectomy tissue from 12 healthy transgender patients was used. Successful decellularization was confirmed by applying acellular criteria from in-vivo remodeling reports. Suitability as a tissue-mimicking scaffold for vaginal reconstruction was determined by visible structural features, biocompatibility during stretching, and the presence of visible collagen, elastin, laminin, and fibronectin.

RESULTS

Histological examination confirmed the preservation of structural features, and minimal cellular residue was seen during fluorescence microscopy, DNA and RNA quantification, and fragment length examination. Biomechanical testing showed decreased peak load (55%, P <0.05), strain at rupture (23%, P <0.01), and ultimate tensile stress (55%, P <0.05) after decellularization, while the elastic modulus (68%) did not decrease significantly. Fluorescence microscopy revealed preserved Fibronectin-I/II/III and Laminin-I/II, while Collagen-I and Ficolin-2B were decreased but mostly retained.

CONCLUSIONS

The absence of cellular residue, moderately altered biomechanical extracellular matrix properties, and mostly preserved structural proteins appear to make our decellularized human vaginal matrix a suitable tissue-mimicking scaffold for vagina transplantation when tissue survival through vascularization and innervation are accomplished in the future.