Solely Penile Skin for Neovaginal Construction in Sex Reassignment Surgery

Evaluation of the Efficacy of Magnetic Resonance Imaging for Feminizing Gender Affirmation Genital Surgery: A Novel Approach

Background Gender dysphoria is treated with gender affirmation surgery (GAS) for assigned male at birth (AMAB) individuals. This study aimed to evaluate the postoperative anatomical changes in AMAB individuals who underwent GAS using magnetic resonance imaging (MRI) and to compare it with cis-females, thereby assessing the efficacy of the surgical technique in achieving pelvic anatomy similar to cis-females. Methodology This was a prospective observational study done in a tertiary care hospital. AMAB individuals who underwent gender affirmation genital surgery using single-stage solely penile skin inversion vaginoplasty were included after informed consent and approval by the Institutional Human Ethics Committee. Patients with complications such as deep space surgical site infection (SSI) and neo-vaginal prolapse were excluded. All the study participants were advised a vaginal self-dilatation regimen, reviewed three months after the surgery, and subjected to an MRI of the pelvis with a vaginal tutor. Parameters such as neo-vaginal depth, alpha (α) angle, rectovaginal thickness, and remnant of corpora cavernosa were measured and compared with cis-female parameters measured from images in the archives from the Department of Radiology. Result A total of 21 patients were included in the study, with a mean age of 27±4.7. Between the study group and cis-females, no significant difference was seen in vaginal depth, and cis-females had significantly higher values in other parameters. There was a significant difference between the subgroups, i.e., defaulters and non-defaulters in soft tissue parameters such as vaginal depth (p=0.001), α angle (p=0.002), and rectovaginal thickness (p=0.002) with the non-defaulter patients having higher values. Conclusion Single-stage penile skin inversion vaginoplasty is capable of producing anatomical parameters, importantly neo-vaginal depth, which is fairly comparable with cis-female, as evident in the non-defaulter subgroup patients. Proper compliance with the vaginal dilatation regimen plays a significant role in the maintenance of soft tissue pelvic anatomical parameters.

Vaginal Canal Reconstruction in Penile Inversion Vaginoplasty with Flaps, Peritoneum, or Skin Grafts: Where Is the Evidence?

BACKGROUND

To optimize neovaginal dimensions, several modifications of the traditional penile inversion vaginoplasty are described. Options for neovaginal lining include skin grafts, scrotal flaps, urethral flaps, and peritoneum. Implications of these techniques on outcomes remain limited.

METHODS

A systematic review of recent literature was performed to assess evidence on various vaginal lining options as adjunct techniques in penile inversion vaginoplasty. Study characteristics, neovaginal depth, donor-site morbidity, lubrication, and complications were analyzed in conjunction with expert opinion.

RESULTS

Eight case series and one cohort study representing 1622 patients used additional skin grafts when performing penile inversion vaginoplasty. Neovaginal stenosis ranged from 1.2 to 12 percent, and neovaginal necrosis ranged from 0 to 22.8 percent. Patient satisfaction with lubrication was low in select studies. Three studies used scrotal flaps to line the posterior vaginal canal. Average neovaginal depth was 12 cm in one study, and neovaginal stenosis ranged from 0 to 6.3 percent. In one study of 24 patients, urethral flaps were used to line the neovagina. Neovaginal depth was 11 cm and complication rates were comparable to other series. Two studies used robotically assisted peritoneal flaps with or without skin grafts in 49 patients. Average neovaginal depth was approximately 14 cm, and complication rates were low.

CONCLUSIONS

Skin grafts, scrotal flaps, urethral flaps, and peritoneal flaps may be used to augment neovaginal canal dimensions with minimal donor-site morbidity. Further direct comparative data on complications, neovaginal depth, and lubrication are needed to assess indications in addition to advantages and disadvantages of the various lining options.

[CLINICAL OUTCOMES OF GENDER AFFIRMING SURGERY FOR GENDER DYSPHORIA/INCONGRUENCE: A SINGLE-INSTITUTE EXPERIENCE]

(Purpose) To investigate clinical outcomes of gender affirming surgery performed for gender dysphoria/incongruence. (Material and methods) This retrospective observational study included 59 transgender persons (41 transgender men and 18 transgender women) who received gender affirming surgery at Sapporo Medical University Hospital from June 2006 through December 2018. Their medical charts were reviewed and peri- and postoperative complications within one year after surgery were checked and graded according to the Clavien-Dindo classification. In addition, the voiding condition in transgender men, and the length of the constructed vagina in transgender women were investigated over time as functional outcomes. (Results) The median age at surgery was 32 years and the median duration of gender affirming hormone treatment was 40 months. In transgender men, the median operation time and blood loss were 393 minutes and 970 ml, respectively. Two subjects needed red blood cell transfusion. For transgender women, the operation time was 347 minutes, and the blood loss was 590 ml, and none needed transfusion. Some postoperative complications were observed in the 18 transgender men, and 6 patients required surgical repair associated with the neo-urethra. Among the transgender women, 17 had postoperative complications but none of them was classified as grade 3 or more. Gait disorder occurred in 7, and remained in three even in the final observational period. This event occurred more often in those with a body mass index of 25 kg/m² or more, higher values of postoperative serum creatine kinase, and was more likely to occur with the use of a boot-type leg holder. As functional outcomes, urinary retention was observed in one transgender man after the cystostomy was removed, and temporary re-catheterization was needed. Others had no complaint about their urination. In the transgender women, the constructed vaginal length after skin inversion was gradually shortened (from 10 to 8 cm) for three months after surgery. (Conclusion) Gender affirming surgery was performed safely in our institution. It is necessary to investigate the long-term functional outcomes and/or the changes in quality of life between the pre- and postoperative periods in the future.

Sexual and functional long-term outcomes following advanced pelvic cancer and reconstruction using vertical rectus abdominis myocutaneous and gluteal myocutaneous flap

INTRODUCTION

After extensive pelvic surgery for cancer two flap types are used at Skåne University Hospital (SUS), Sweden for perineal reconstruction: vertical rectus abdominis myocutaneous flap and gluteal flap with or without vaginal reconstruction. The objective was to study the long-term outcomes in patients treated for advanced pelvic cancer receiving a flap.

METHOD

Patients with pelvic cancer subjected to surgery including perineal reconstruction between January 2010 and August 2016 at SUS were included retrospectively. Participating patients were scheduled for an out-patient visit. Questionnaires addressing quality of life, (QLQ-C30 and EQ-5D) and sexual function (FSFI and IIEF) were filled in. Sensitivity test, using monofilaments on the gluteal/posterior thigh area, neovaginal measurements using silicon gauges and muscular functionality tests (timed stands test and stairs test) were performed.

RESULTS

Thirty-six (24 women, 12 males) out of 71 invited patients conceded participation. Patients scored a median of 85/100 regarding global health using EQ-5D. All women reported sexual dysfunction and 75% (9/12) of men reported severe erectile dysfunction. Neovaginal measurements showed adequate reconstructions. Sensitivity test implied decreased sensitivity on the operated side compared to the unoperated side in patients with gluteal flap. Both physical tests demonstrated adequate muscular functionality in everyday life activities after reconstructions using gluteal flap.

CONCLUSION

This long-term follow up after extensive surgery treating pelvic cancer with perineal flap reconstruction implies high quality of life, good muscular functionality and adequate neovaginal measurements. However sexual function is impaired among both sexes and sensitivity in the surgical area of the gluteal flap is decreased.

Male-to-Female Sex Reassignment Surgery using the Combined Vaginoplasty Technique: Satisfaction of Transgender Patients with Aesthetic, Functional, and Sexual Outcomes

BACKGROUND

Currently available patient-reported outcome measures are limited in the field of sex reassignment surgery (SRS). Standardized questionnaires deliver high evidence data on satisfaction of male-to-female (MTF) transgender patients but do not allow any modification in their clinical application. We therefore designed a prospective study using self-developed indication-specific questionnaires to evaluate the aesthetic, functional, and sexual outcomes of MTF patients undergoing SRS.

METHODS

Forty-nine adult MTF transgender patients who underwent two-stage SRS were eligible for study inclusion between September 2012 and January 2014. Forty patients (= N) ultimately filled out both parts of the questionnaire sets: 1 day before the first stage (T0) and 6 months after the second stage of SRS (T1). These questionnaires focused on demographic characteristics, the satisfaction with aesthetic and functional results, and sexuality.

RESULTS

Patients rated their surgical satisfaction of most items with mean scores above 7 on a 0-10-point scale. Many items evaluating everyday life activities improved significantly after SRS compared to T0 (p < 0.01). All but one patient (97.5%) reported no regrets about having undergone surgery, and the majority recommended it to other patients with gender dysphoria. Femininity and sexual activity increased significantly postoperatively (p < 0.01). Satisfaction with intercourse and orgasm was high: 6.70 and 8.21, respectively, on a 0-10 scale.

CONCLUSION

Satisfaction with the cosmetic outcome, as well as the functional and sexual outcomes, reveal positive effects of SRS using the combined technique on transgender patient lives. Nevertheless, standardized and validated SRS-specific questionnaires are lacking.

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 .