[Genital gender affirming surgery in trans men]

OBJECTIVE

Genital surgery for masculinisation in the context of gender incongruence is characterised by the reconstruction of male genitalia using multiple surgical techniques - free flap phalloplasty, pedicled flap phalloplasty or metaoidioplasty - which this article aims to describe.

MATERIAL AND METHODS

A narrative review of the literature on these trans surgeries was carried out.

RESULTS

Each technique has specific advantages and disadvantages, and does not produce the same results in terms of surgical risks, size of the reconstructed phallus, sensitivity, sexual function and urinary function.

CONCLUSION

This surgical decision must therefore be shared with the person concerned, based on a clear understanding of their expectations and objectives. Long-term follow-up is recommended.

[Genital gender affirming surgery in trans women: Vulvo-vaginoplasty review]

INTRODUCTION

A trans woman is a woman who was assigned male at birth, and who has a female gender identity. The majority are requesting a gender affirming genital surgery by vulvo-vaginoplasty. The objective is to review this surgery based on its history, then by presenting the different surgical techniques and their success and complication rates.

MATERIAL AND METHODS

A narrative review was performed, based on a bibliography search with keywords from 2000 to 2022 on Pubmed.

RESULTS

Vulvo-vaginoplasty for trans women began in 1931, and the first case series date from 1969. The procedure includes excision of scrotal skin, orchiectomy, clitoroplasty, urethroplasty, labioplasty, recto-vesico-prostatic dissection and creation of a vaginal cavity (performed by penile skin inversion and graft, intestine, or peritoneum). Vulvo-vaginoplasty by penile skin inversion (VPPI) is today the reference surgical technique. It represents the vast majority of surgeries performed with the longest follow-up. The majority of trans women are satisfied with the procedure aesthetically (90%) and functionally (80%), with an active sexuality. Major complications are rare (< 5%), they correspond to fistulas or vaginal stenosis.

CONCLUSION

VPPI is the gold standard technique with satisfactory overall results, but long-term follow-up is requested.

Tolerance and efficacy of platelet-rich plasma injections in Peyronie's disease: Pilot study

INTRODUCTION

Platelet-rich plasma (PRP) injections are increasingly proposed for the treatment of Peyronie's disease since the discontinuation of Xiapex® despite poorly understood results.

OBJECTIVES

Evaluation of the tolerance and efficacy of intra-plate PRP injections in patients with Peyronie's disease.

METHODS

Three intra-plate injections of PRP were performed 15 days apart in 17 patients with Peyronie's disease. The Peyronie's Disease Questionnaire (PDQ) and the measurement of the angle of curvature of the erect penis were assessed before treatment and then 1, 3 and 6 months after treatment. Erectile function was assessed by different questionnaires (IIEF-EF, EHS, SEP, sexual discomfort score).

RESULTS

No side effects were noted during the study period. Three months after treatment, all three PDQ domains were significantly improved (P=0.002; P=0.015; P=0.017 respectively). The angle of curvature of the penis was significantly decreased by 11.8° with a mean angle of 40.4° before treatment and 28.6° after (P=0.007). The IIEF-EF score was significantly improved after treatment (mean preoperative value: 10.67) with a gain of 5 points at months 1 and 6 (P=0.01 and P=0.036 respectively) and 7 points at month 3 (P=0.04).

CONCLUSION

Our initial experience suggests that PRP injections for Peyronie's disease are safe. Although the limited data is suggestive of efficacy, a placebo control will be required for confirmation.

Pilot study of intra-cavernous injections of platelet-rich plasma (P-shot®) in the treatment of vascular erectile dysfunction

INTRODUCTION

Intracavernosal injections of platelet-rich plasma (PRP) or P-shot® are increasingly proposed as a curative treatment for organic sexual dysfunction despite the lack of evidence of effectiveness.

OBJECTIVES

We conducted a pilot study to evaluate the safety and efficacy of intracavernous PRP injections in patients with vascular erectile dysfunction (ED).

METHODS

Three intracavernosal injections of PRP were performed 15days apart in 15 patients with vascular ED unresponsive to medical treatment with 5-phosphodiesterase inhibitors and/or prostaglandin E instillations or injections. Questionnaires assessing erectile function (IIEF-EF, EHS, SEP, Sexual discomfort score) were completed prior to treatment and 1, 3 and 6 months after the last injection.

RESULTS

No side effects were noted during the study period. The IIEF-EF score was significantly improved after treatment (P<0.001) with a gain of 5 points at 1month, 4 points at 3months and 3 points at 6months (respectively P=0.001, P=0.003 and P=0.022). The other questionnaires did not change significantly. In total, 20% of patients considered that the erection lasted long enough to have a sexual intercourse (SEP score) before P-shot® versus 26.7% after the treatment (P=1).

CONCLUSION

This study suggests that the effect of P-Shot® remains moderate in cases of ED with vascular origin. Larger clinical studies are needed to determine the real effectiveness of this therapeutic strategy.

LEVEL OF PROOF

2.

[Biotherapies for erectile dysfunction and Peyronie's disease: Where are we now?]

INTRODUCTION

Clinical trials of cell therapy for erectile dysfunction (ED) and Peyronie's disease (PD) were recently conducted after preclinical studies.

AIMS

The aims of this study are to give an update on biotherapy for ED and PD and to describe the regulatory framework for these therapies.

MATERIALS AND METHODS

A literature review was performed through PubMed and Clinical.trials.gov addressing cell therapy for ED and PD and using following keywords "erectile dysfunction", "Peyronie's disease", "stem cell", and "platelet-rich plasma".

RESULTS

Preclinical studies in rodent models have shown the potential benefit of cell therapy for ED after radical prostatectomy or caused by metabolic diseases, and PD. The tissues used to obtain the therapeutic product were bone marrow, adipose tissue and blood (PRP, platelet-rich plasma). Mechanism of action was shown to be temporary and mainly paracrine. Four clinical trials were published concerning ED after radical prostatectomy and in diabetic patients and one for PD. Eleven clinical trials including three randomized trials are currently going on. Preclinical and preliminary clinical results suggested the possibility to improve spontaneous erectile function and response to pharmaceutical treatment in initially non-responder patients. This effect is mediated by an improvement of penile vascularization. A reduction of penile curvature without side effect was noted after injections into the plaque of PD patients. Most of these therapeutic strategies using autologous cells were considered as "Advanced Therapy Medicinal Products" with strict regulatory frameworks imposing heavy constraints, in particular in case of "substantial" modification of the cells. The regulatory framework remains unclear and more permissive for PRP and cell therapy processes with extemporaneous preparation/injection and no "substantial" modifications.

CONCLUSIONS

First results on cell therapy for ED and PD are promising. The regulatory framework can significantly change according to cell preparations and origins leading to various constraints. This regulatory framework is crucial to consider for the choice of the procedure.

Factors affecting guideline adherence in the initial treatment of non-muscle invasive bladder cancer: Retrospective study in a French peripheral hospital

OBJECTIVES

To assess whether the initial treatment of non-muscle invasive bladder cancer (NMIBC) was performed according to the guidelines, and to determine the reasons why initial treatment was not provided in nonadherence cases.

MATERIALS AND METHODS

We retrospectively reviewed all patients with NMIBC who underwent their first transurethral resection of bladder tumor (TURBT) at a peripheral hospital, between 2007 and 2016. The treatment offered to the patient was compared to the European Association of Urology guidelines according to risk stratification. For each patient who did not receive the treatment according to the guidelines, one of the following reasons was identified: poor patient compliance, poor patient general health status, urologist's decision, lack of resources.

RESULTS

One hundred fifty-nine patients were included with a mean age of 72.2 years at the time of NMIBC diagnosis. The low-risk patients were strictly treated according to the guidelines. Among the intermediate-risk patients, 14% received mitomycin C. Among the high-risk patients, 39% received intravesical Bacillus Calmette-Guerin. In the nonadherence cases (61%), the reasons were related to the patient in 44% of cases (poor compliance, 21%; poor patient general health status, 23%), urologist's decision in 54% of cases, and lack of resources in 2% of cases. Thirty-seven percent of the high-risk patients underwent re-resection.

CONCLUSIONS

Overall, adherence to NMIBC guidelines was low in all treatment types (intravesical therapy, re-resection, or cystectomy for very high-risk patients), but this finding was similar to that in previous studies. Reasons were mainly related to the urologist's decision or to the patient condition (poor compliance or poor general health status).

LEVEL OF EVIDENCE

3.