Isolated Male Epispadias Repair: Long-Term Outcomes

Isolated male epispadias is one of the most severe congenital genital anomalies that require surgical correction. The goals of the surgery are to reach good aesthetic and functional outcomes. The aim of this retrospective study was to analyze the long-term outcomes of surgical reconstruction of male epispadias. A total of 31 patients with a mean age of 17 years, who underwent surgical repair of isolated male epispadias from January 2000 to January 2015, were involved. The main outcome measures were defined as: aesthetic outcome, continence, postoperative complications, sexual function, and quality of life. The follow-up period ranged from 8 to 23 years, with an average of 14.4 years. Each patients underwent an average of 2.2 surgical procedures in this period. The most common postoperative complications were urethral fistula and residual curvature, in 22.6% and 12.9%, respectively. Satisfactory aesthetic outcome was reported in 71.4% of cases. The repair of male epispadias usually includes more than two procedures with satisfactory aesthetic outcome. Unsolved urinary incontinence remains a significant issue and has a high impact on the quality of life. Follow-up should be extended even after complete sexual maturity. Comprehensive long-term evaluation is necessary for proper treatment of isolated epispadias.

Musculocutaneous Latissimus Dorsi Phalloplasty: Technique and Tips

BACKGROUND

Musculocutaneous latissimus dorsi (MLD) phalloplasty is a gender-affirming surgical option for transmen which permits penile prosthesis, glansplasty, and urethral extension at later stages. This surgery allows for a neophallus of adequate length and girth, and minimal donor site morbidity, but is technically complex.

OBJECTIVE

This video demonstrates a step-by-step technique and tips to optimize outcomes and simplify the operation for the MLD phalloplasty.

MATERIALS AND METHODS

A 33-year-old transmale who previously underwent metoidioplasty presented for an MLD phalloplasty. With the patient in a supine position, the superficial femoral artery and saphenous vein are isolated at the recipient site. The patient is repositioned into a lateral flank position, the flap harvested and tubularized, and inferior aspects of the wound closed prior to harvesting the thoracodorsal artery (TDA) and thoracodorsal vein (TDV) to minimize cold ischemia time. The TDA and TDV are dissected to their root at the subscapular artery and vein. The artery is removed with a patch of the subscapular artery. The patient is initially in a supine position and then returned to a supine position to minimize ischemia time of the flap. The neophallus is attached to the previously created recipient site, and an end-to-side anastomosis is created between the superficial femoral artery and TDA and an end-to-end anastomosis between the saphenous vein and the TDV. If the patient has a thick latissimus dorsi muscle or subcutaneous fat, a split-thickness skin graft can be used to close the ventral phallus to minimize tension on the tubularized neophallus and provide a plate for a future urethral lengthening procedure. Positioning and close post-op monitoring of the neophallus are critical.

RESULTS

A neophallus of adequate length and girth is created with the option for future urethral extension and penile prosthesis placement.

CONCLUSION

Our video demonstrates the technique for a gender-affirming MLD phalloplasty in a transman and tips to optimize outcomes and simplify the operation.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

Adult non-urethral complications after hypospadias repair in childhood: presentation, treatment and outcomes

Purpose

This study aimed to evaluate a group of adult patients with non-urethral complications after hypospadias repair in childhood, their surgical treatment, and outcomes.

Materials and methods

We analyzed 97 patients, mean age 22.5 years, who were treated in our center between January 2009 and December 2020, for non-urethral complications after previous hypospadias repair in childhood. Non-urethral complications were defined as glans deformity, residual curvature and trapped penis due to insufficient penile skin. A radical surgical approach was used to correct all deformities, in a one-stage or a two-stage procedure. A successful outcome was defined as a straight penis with good length, anatomically regular glans, and cosmetically acceptable appearance, without need for additional surgeries. Sexual function was evaluated using International Index of Erectile Function.

Results

Mean follow-up was 75 months (ranged from 24 to 168 months). One-stage and two-stage repair were performed in 85.5% and 14.5% of cases, respectively. A higher success rate was noted after one-stage repair (94% compared to 86%). Complications included four cases of penile curvature with late onset, one case of glans dehiscence and partial skin necrosis. Erectile dysfunction was determined in 24% of patients.

Discussion

Non-urethral complications may occur many years after primary hypospadias repair, with a strong impact on the quality of life. Treatment is individualized and usually involves a radical surgical approach to correct all associated deformities and to achieve successful cosmetic and psychosexual outcomes.

Treatment of Urethral Intercourse and Impact on Female Sexual Function

Background

Urethral intercourse is a very rare entity which usually presents as urinary incontinence during and after intercourse and is most commonly seen in patients with vaginal agenesis (Mayer–Rokitansky–Hauser Syndrome) or hypoplasia, or other rear vaginal anomalies.

Aim

To evaluate management and outcomes for vaginal and urethral consequences of urethral intercourse, including urinary incontinence.

Methods

Between February 2006 and March 2021, 8 women aged from 17 to 22 years underwent genital and urethral reconstruction due to consequences of urethral sexual intercourse. Vaginal reconstruction included sigmoid vaginoplasty and introitoplasty with division of the vaginal septum in cases of vaginal agenesis (5 cases) and vaginal duplication (3 cases), respectively. Incontinence was treated by sling procedures in 5 women with longer history of urethral coitus and evident bladder neck prolapse.

Outcomes

Sexual and psychosexual outcomes assessment was based on the Female Sexual Function Index and standardized questionnaires.

Results

Follow-up ranged from 9 to 188 months (mean 78 months). Good esthetical and functional results were achieved in all 8 women. All patients reported satisfactory sexual intercourse. All 5 incontinent women who had underwent sling procedure were continent. In one of 3 nontreated cases, additional sling treatment was indicated 6 months after vaginal reconstruction with satisfactory outcome. One patient with vaginal duplication reported a successful pregnancy with a Caesarean section delivery.

Clinical Implications

Urinary incontinence with megalourethra in young women, along with the presence of Mullerian anomalies should raise suspicion of urethral coitus. Surgical treatment includes correction of vaginal anomalies and management of consequences.

Strengths and Limitations

This study represents one of the largest series for urethral intercourse, with assessment of psychosexual outcome. The limitation is the lack of statistical analysis due to small sample size.

Conclusion

Urethral intercourse is very rare, but it can cause severe consequences. It is important to recognize this occurrence and treat it by well-known vaginal or urethral reconstructive procedures.

Djordjevic ML, Bizic M, Stojanovic B, et al. Treatment of Urethral Intercourse and Impact on Female Sexual Function. Sex Med 2022;10:100534.

Penile Prosthesis in Transgender Men after Phalloplasty

A penile prosthesis can be successfully implanted after phalloplasty in transgender men to permit sexual intercourse. A prosthesis can be categorized as malleable or inflatable. The most common penile prosthesis implanted after masculinizing genital surgery is the inflatable prosthesis but this can be a challenging operation with high complication rates. Penile prosthesis in transgender patients differs from cis-patients in many respects but one critical difference is the absence of the tough, protective tunica of the corporal body to contain the prosthesis. This causes greater mobility of the prosthesis under the skin and increases the risk of migration and erosion of the device through the skin. In addition, to overcome the absence of a corpora cavernosa, the proximal portion of the prosthesis must be anchored to bone. Complications include injury to the urethra, vascular injury, skin breakdown, infection, device migration, device failure, extrusion, and erosion. There is no robust data on the use of penile prosthesis in transgender men with only multiple reports of small numbers of patients. While successful implantation can improve patients' quality of life, surgeons should counsel patients about the relatively high risk of the need for revision surgery.

Musculocutaneous Latissimus Dorsi Phalloplasty

The treatment of gender dysphoria consists of psychiatric evaluation, initiation of hormonal therapy, and the final step in an individual's transition, performing gender-affirming surgery. Construction of the neophallus is one of the most demanding tasks in genital affirming surgery of transgender men. The main objectives of phalloplasty are to achieve a cosmetically acceptable and functional phallus, with a neourethra that allows voiding in standing position, sufficient length and strength for possible penetrative intercourse, preserved tactile and orgasmic sensation, and acceptable donor site morbidity. The musculocutaneous latissimus dorsi flap has reliable and suitable anatomy (good size, volume, and length of neurovascular pedicle) to meet the esthetic and functional requirements of neophallus reconstruction. Despite many advantages, the main disadvantage of this flap is the lack of sensitivity. Although the radial free forearm flap technique is the most commonly performed procedure, musculus latissimus dorsi flap is an acceptable choice in gender-affirming surgery.

Metoidioplasty in Gender Affirmation: A Review

Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.

Metoidioplasty: Surgical Options and Outcomes in 813 Cases

INTRODUCTION

Metoidioplasty is a variant of phalloplasty for transmen that includes the creation of the neophallus from a hormonally enlarged clitoris, urethral lengthening and scrotoplasty. The procedure results in male appearance of genitalia, voiding in standing position and preserved sexual arousal, but without possibility for penetrative intercourse. We evaluated outcomes of metoidioplasty at our center, based on latest surgical refinements.

METHODS

During the period of 14 years (from February 2006 to April 2020), 813 transmen with mean age of 24.4 years and mean body mass index of 24.6, underwent one stage metoidioplasty. Hysterectomy was simultaneously performed in 156, and mastectomy in 58 cases. Hysterectomy, mastectomy and metoidioplasty were done as a one-stage procedure in 46 transmen. Patients are divided in 5 groups, depending on the type of urethroplasty. Postoperative questionnaires were used to evaluate cosmetic and functional outcomes, as well as patients' satisfaction.

RESULTS

Follow-up ranged from 16 to 180 months (mean 94 months). Mean surgery time was 170 minutes and mean hospital stay was 3 days. Length of the neophallus ranged from 4.8 cm to 10.2 cm (mean 5.6 cm). Urethroplasty was complication-free in 89.5% of cases, and ranged between 81% to 90.3% in different groups. Urethral fistula and stricture occured in 8.85% and 1.70% of cases, respectively. Other complications included testicular implant rejection in 2%, testicular displacement in 3.20% and vaginal remnant in 9.60% of cases. From 655 patients who answered the questionnaire, 79% were totally satisfied and 20% mainly satisfied with the result of surgery. All patients reported voiding in standing position and good sexual arousal of the neophallus, without possibility for penetrative intercourse due to small size of the neophallus.

CONCLUSION

Metoidioplasty has good cosmetic and functional outcomes, with low complication rate and high level of patients' satisfaction. In transmen who request total phalloplasty after metoidioplasty, all available phalloplasty techniques are feasable.

Metoidioplasty With Urethral Lengthening: A Stepwise Approach

BACKGROUND

Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate.

OBJECTIVE

To demonstrate an adaptation of the Belgrade technique of gender-affirming metoidioplasty and describe outcomes.

METHODS

We identified 33 patients of which 12 underwent simple metoidioplasty and 21 underwent metoidioplasty with urethral lengthening between 2016 and 2020. Prior to surgery, all patients underwent at least 1 year of testosterone therapy to maximize clitoral growth. The clitoris is degloved and the superficial suspensory ligament divided to maximize phallic length. Labia minora flaps are developed and the urethral plate is divided to allow for maximal ventral extension. The resultant urethral defect is bridged with a buccal mucosa graft. To construct the ventral aspect of the urethra, an anterior vaginal wall flap and labia minora flap are sutured to the urethral plate and tubularized over a 16 Fr catheter. The medial aspect of the contralateral labia minora is de-epithelialized and overlaps the urethra, serving as ventral skin coverage for the phallic shaft. Bilateral labia majora flaps are then rotated anteriorly and superiorly to create a neoscrotum using the Ghent technique.

RESULTS

For metoidioplasty with urethral lengthening, the median operative time was 408 minutes, estimated blood loss 400 mL, and length of stay 3 days. Of the 21 patients, 10 (47%) elected to undergo second stage scrotoplasty, 7 (33%) underwent testicular implant placement, and 2 (9%) required revision urethroplasty. Of the 10 patients (48%) who experienced postoperative complications, 7 were Clavien-Dindo grade I-II. There were no fistulae at a median follow-up time of 5.5 months (range 1-27.2).

CONCLUSION

We provide a stepwise approach to metoidioplasty with urethral lengthening using a modified Belgrade technique, which was associated with a low rate of urethral complications.

Outcomes and special techniques for treatment of penile amputation injury

INTRODUCTION

Management of severe penile trauma presents great challenges for reconstructive urologists since these injuries vary from abrasions to total emasculation. A review of our case experience with penile amputation is presented, emphasizing techniques used to salvage or reconstruct the most difficult of penile injury cases.

MATERIALS AND METHODS

A total of 13 patients with penile amputation injury referred to us between 2007 and 2016 were analyzed. Mean age at surgery was 16 years (ranged from 4 to 29 years). Etiology of penile amputation (partial or total) combined with management and outcomes were evaluated. Management included different surgical procedures with the aim to achieve good functional and esthetical outcomes. Postoperative questionnaire was used for assessment of patient's overall satisfaction.

RESULTS

Follow-up ranged from 13 to 182 months (mean 53). Causes of penile injury were iatrogenic trauma (8), self-amputation (2), electrocution (1), intentional sexual assault (1) and mother's hair strangulation (1). Outcome criteria including aesthetic appearance, urinary function and ability to engage in satisfactory coitus, were noted in 11 cases (85%). Two cases with ensuing complications relating to the total phalloplasty required additional treatment due to urethral fistula.

CONCLUSIONS

Severe penile injuries should be treated on a case by case basis utilizing the most propitious techniques. We respectfully propose that the needs of such patients are best served by referral centers with extensive experience.

Repeated penile girth enhancement with biodegradable scaffolds: Microscopic ultrastructural analysis and surgical benefits

Autologous tissue engineering using biodegradable scaffolds as a carrier is a well-known procedure for penile girth enhancement. We evaluated a group of previously treated patients with the aim to analyze histomorphometric changes after tissue remodeling and to estimate the benefits of repeated procedure. Between February 2012 and December 2016, a group of 21 patients, aged 22–37 (mean 28.0) years, underwent a repeated penile girth enhancement procedure with biodegradable scaffolds. Procedure included insertion of two poly-lactic-co-glycolic acid scaffolds seeded with laboratory-prepared fibroblasts from scrotal tissue specimens. During this procedure, biopsy specimens of tissue formed after the first surgery were taken for microscopic analysis. The mean follow-up was 38 months. Connective tissue with an abundance of connective tissue fibers, small blood vessels, and inflammatory cells were observed in all analyzed surgically removed tissue. Ultrastructural analysis of these tissue samples discovered the presence of large quantities of collagen fibrils running parallel to each other, forming bundles, with a few widely spread fibroblasts. In total, the mean values of flaccid and erect gain in girth after the second surgery were 1.1 ± 0.4 (range: 0.6–1.7) cm and 1.0 ± 0.3 (range: 0.6–1.5) cm, respectively. Microscopic evaluation of newly formed tissue, induced by autologous tissue engineering using biodegradable scaffolds, showed the presence of vascularized loose connective tissue with an abundance of collagen fibers, fibroblasts, and inflammatory cells, indicating active neovascularization and fibrinogenesis. The benefit of the repeated enhancement procedure was statistically significant.

Metoidioplasty

Gender affirmation surgery for transmale patients is still challenging, as creation of the neophallus is one of the most demanding steps in surgical treatment. Metoidioplasty, as a one-stage procedure, can be considered in patients who desire gender affirmation surgery without undergoing a complex, multistage procedure with creation of an adult-sized neophallus. Metoidioplasty presents one of the variants of phalloplasty for patients in whom the clitoris is large enough under testosterone treatment. Advanced urethral reconstruction provides low complication rates with satisfying results of standing micturition.

Metoidioplasty: techniques and outcomes

Phalloplasty represents the latest step in female-to-male transitioning and still remains a great challenge for transgender surgeons. Since we have two options in this transitioning-metoidioplasty and total phalloplasty-the transgender surgeon has to fully inform the individual about all aspects such as surgical steps, outcomes, advantages and disadvantages, possible complications, and expectations. Total phalloplasty with the creation of a neophallus of a similar volume to that in genetic males, is a complex and multi-staged procedure. Many different tissues (i.e., flaps) can be used, and the ideal procedure is still not established. In contrast to the above complexities involved in total phalloplasty, metoidioplasty presents a simple and one-stage procedure for the creation of a neophallus from a hormonally enlarged clitoris. This technique is very promising for individuals who desire gender-affirmation surgery without having to undergo the difficult and multistage creation of a male-sized neophallus. Also, this technique prevents scarring to the extragenital region, making the final results more acceptable for transgender individuals. Our goal is to objectively present the techniques for metoidioplasty and to define their value based on postoperative results.

Musculocutaneous latissimus dorsi flap for phalloplasty in female to male gender affirmation surgery

PURPOSE

Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap.

METHODS

Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages.

RESULTS

The mean follow-up period was 43 months (ranged from 13 to 137 months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6 cm in length and 12.4 cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7 cm (mean 15.8 cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively.

CONCLUSION

Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.

Buccal mucosa graft for simultaneous correction of severe chordee and urethroplasty as a one-stage repair of scrotal hypospadias (watch technique)

PURPOSE

Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias.

METHODS

Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin.

RESULTS

The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature.

CONCLUSION

Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Single-stage repair of obliterated anterior urethral strictures using buccal mucosa graft and dorsal penile skin flap

OBJECTIVE

To present a single-stage repair of obliterative urethral strictures by simultaneous use of a buccal mucosa graft and longitudinal dorsal penile skin flap.

METHODS

Between February 2007 and October 2016, 51 patients with obliterative anterior urethral stricture underwent single-stage substitution urethroplasty. A buccal mucosa graft was harvested and fixed to the corpora cavernosa as the dorsal part of the neourethra, and a vascularized dorsal penile skin flap was created, transposed ventrally and sutured to the buccal mucosa graft to form ventral part of the neourethra.

RESULTS

The follow-up period was 12-129 months (mean 49 months). The mean age of the patients was 48 years (range 15-71 years). The mean length of the obliterated urethral segment, measured during the operative procedure, was 5.2 cm. The etiology of strictures was: unknown, hypospadias and trauma in 19, 27 and five patients, respectively. Five patients were lost to follow up, and 46 patients were analyzed for the outcome. At the end of the follow-up period, recurrence of the stricture occurred in seven (15.2%) patients, whereas 39 (84.8%) patients did not develop stricture. An additional three (6.5%) patients developed fistula, resulting in overall successful voiding in 36 (78.3%) patients.

CONCLUSIONS

A combined buccal mucosa graft and longitudinal dorsal penile skin flap could be a good choice for one-stage substitution urethroplasty in complex obliterative urethral strictures, with an acceptable complication rate.

Novel surgical techniques in female to male gender confirming surgery

The current management of female to male (FTM) gender confirmation surgery is based on the advances in neo phalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Reconstruction of the neophallus is one of the most difficult elements in surgical treatment of female transsexuals. While there is a variety of available surgical techniques, their results are not equally acceptable to all patients. The preference for a particular surgical technique mostly depends on the patient's desires and expectations. Nevertheless, the surgeon's duty is to fully inform the patient about all the advantages and disadvantages, as well as all complications that might occur after surgical procedure-and even to talk them out of a desired surgical technique if there are contraindications. Metoidioplasty is a technically demanding surgical procedure used in FTM transsexuals who desire a gender reassignment surgery (GRS) without undergoing a complex, multi-staged surgical creation of an adult-sized phallus. Metoidioplasty is viable in cases where the clitoris seems large enough after androgen hormonal treatment. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome of FTM transgender surgery is predictable. Various free flaps have been reported for total phalloplasty, such as radial forearm flap, latissimus dorsi flap, anterolateral tight flap, different abdominal wall flaps, free deltoid flap, scapular free flap, sensate osteocutaneous free fibula flap, tensor fasciae latae, deep epigastric artery perforator flap and dorsalis pedis flap. The fact that there are so many techniques for penile reconstruction in cases of penis absence, proves that none of the above mentioned techniques succeeded in achieving the ideal goals of penis reconstruction. We will emphasize the most commonly used surgical techniques in genital confirmation in FTM transsexuals with reference to respective eligibility criteria for each procedure.

Gender Dysphoria: Bioethical Aspects of Medical Treatment

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals

BACKGROUND

Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations.

AIM

To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery.

METHODS

During a period of 9 years (2007-2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons.

OUTCOMES

Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS.

RESULTS

Mean follow-up was 44 months (range = 10-92). Mean surgery time was 270 minutes (range = 215-325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient.

CLINICAL IMPLICATIONS

Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure.

CONCLUSIONS

Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Genital reconstruction for the transgendered individual

INTRODUCTION

Gender dysphoria is defined as one's belief that his/her body does not reflect his/her true "inner" identification of physical sex and requires medical and/or surgical treatment that will alter his/her body to better reflect what he/she believes is his/her true gender.

OBJECTIVE

The aim was to describe current surgical techniques available in genital reconstruction for female-to-male (FTM) and male-to-female (MTF) transgender patients.

STUDY DESIGN

We reviewed recently published papers concerning the most common procedures in genital reconstruction in FTM transgenders and in MTF transgenders.

RESULTS

There is a wealth of available surgical procedures for FTM transgenders that will adjust their body and genitals toward the male gender. Chest masculinization combined with either metoidioplasty or phalloplasty are the most common procedures resulting in high patient satisfaction. Standardization of the procedures for vaginoplasty in MTF transgenders led to the penile inversion skin technique becoming a "gold standard" for vaginal lining in MTF patients, providing satisfying functional and esthetical outcome of the surgery. In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from hairless skin grafts, or a section of intestine may be used (bowel vaginoplasty).

CONCLUSION

A multidisciplinary approach including psychiatrists, psychologists, plastic surgeons, urologists, and gynecologists is the only effective treatment in transgenders. The surgeons' familiarity with the surgical procedure and the patients' desired body images should meet at the same level to guarantee a successful outcome.

Buccal mucosa graft urethroplasty in a case of urethral amyloidosis presenting with long anterior urethral stricture

Urethral amyloidosis is a rare condition, but clinically relevant because it can mimic urothelial carcinoma. We report a case of localized urethral amyloidosis presenting with a long anterior urethral stricture. We used extensive grafts of buccal mucosa for standard augmentation urethroplasty, with a successful outcome at the 2-year follow-up.

Anatomy of the clitoris and its impact on neophalloplasty (metoidioplasty) in female transgenders

The current management of female to male transgender surgery is based on the advances in neophalloplasty, perioperative care and the knowledge of the female genital anatomy, as well as the changes that occur to this anatomy with preoperative hormonal changes in transgender population. Since the clitoris plays the main role in female sexual satisfaction, its impact on the outcome in female to male transgender surgery is predictable. Although female genital anatomy was poorly described in majority of anatomical textbooks, recent studies have provided a better insight in important details such as neurovascular supply, ligaments, body configuration, and relationship with urethral/vaginal complex. This article aims to review current state of knowledge of the clitoral anatomy as well its impact on clitoral reconstruction in female to male sex reassignment surgery.

Graft surgery in extensive urethral stricture disease

Surgical treatment of long urethral stricture disease remains one of the most challenging problems in urology. In recent years there has been continuous discussion with regard to the etiology, location, length, and management of extensive urethral stricture disease. Various tissues such as genital and extragenital skin, buccal mucosa, lingual mucosa, small intestinal submucosa, and bladder mucosa have been proposed for urethral reconstruction. The most frequent questions pertain to the optimal technique for urethroplasty and the optimal graft for substitution urethroplasty, as judged by both patient satisfaction and outcome success. We review the recent literature with respect to any new information on graft urethroplasty for extensive urethral stricture.

Fast-track surgery concepts for congenital urogenital anomalies

AIM

To investigate the possibility of fast-track surgery concepts in pediatric urology department as a single center study model of a developing country.

MATERIAL OF STUDY

The study included 1620 patients surgically treated at the pediatric urology department, from 2009 to 2011. According to the congenital anomalies, all patients were classified in one of four groups: I - testicular anomalies (197 patients); II - external genital anomalies (453); III - upper urinary tract anomalies (801) and IV - associated anomalies (169). We analyzed the total duration of stay in the hospital of all patients among all treating doctors concerning the anomaly.

RESULTS

Statistically significant difference in total length of hospitalization of all patients in Group I was noted in Doctors 1 and 5 (F=10.36** for F0.05;5;12=3.11 and F0.01;5;12=5.06), as well as in the Group II (F=17.01** for F0.05;5;12=3.11 and F0.01;5;12=5.06). Statistical analysis was not possible to be performed in groups III and IV because of lack of the patients.

DISCUSSION

Analyzing the length of hospitalization of the patients treated at the urology department, all doctors showed the tendency to shorten the total length of hospitalization in patients of all groups. Majority of the studies carried out on pediatric urology departments in developed countries, showed that over 50% of children were successfully treated using fast-track surgery concept.

CONCLUSIONS

Modern methods of surgical management and anesthesia allow decrease of hospitalization length, financial savings to the healthcare system and better comfort for patients.

Importance of revealing a rare case of breast cancer in a female to male transsexual after bilateral mastectomy

The incidence of breast carcinoma following prophylactic mastectomy is probably less than 2%. We present a 43-year-old female to male transsexual who developed breast cancer 1 year after bilateral nipple- sparing subcutaneous mastectomy as part of female to male gender reassignment surgery. In addition to gender reassignment surgery, total abdominal hysterectomy with bilateral salpingo-oophorectomy (to avoid the patient from entering menopause and to eliminate any subsequent risk of iatrogenic endometrial carcinoma), colpocleisys, metoidioplasty, phalloplasty, urethroplasty together with scrotoplasty/placement of testicular prosthesis and perineoplasty were also performed. Before the sex change surgery, the following diagnostic procedures were performed: breast ultrasound and mammography (which were normal), lung radiography (also normal) together with abdominal ultrasound examination, biochemical analysis of the blood and hormonal status.

According to medical literature, in the last 50 years only three papers have been published with four cases of breast cancer in transsexual female to male patients. All hormonal pathways included in this complex hormonal and surgical procedure of transgender surgery have important implications for women undergoing prophylactic mastectomy because of a high risk of possible breast cancer.

"Hanging" of the buccal mucosal graft for urethral stricture repair after failed hypospadias

PURPOSE

Urethral stricture is the second most common complication of hypospadias repair after urethrocutaneous fistula. Usually more than 1 procedure is needed for correction due to a lack of available tissue after previous repairs. We evaluated 1-stage urethral stricture management after hypospadias repair using a ventral buccal mucosal graft. We describe the importance of graft hanging and coverage.

MATERIALS AND METHODS

From August 2004 to April 2009, 15 patients 9 to 17 years old underwent urethral stricture repair after failed hypospadias surgery. Mean time after primary surgery was 7.2 years (range 4 to 13). Vascularized periurethral tissue around the stenotic part of the neourethra was dissected. The urethra was opened ventrally and a buccal mucosal graft of appropriate size was inserted to allow urethral augmentation. Using several U stitches the graft was anchored to the surrounding periurethral tissue to prevent its folding and retraction. Recurrent chordee in 12 patients and secondary vesicoureteral reflux in 3 were also corrected at this time.

RESULTS

Mean followup was 37 months (range 17 to 73). Successful results were confirmed in all patients by urethrography and uroflowmetry. One urethral fistula was corrected 3 months later by minor surgery. Recurvature did not develop in this group. There was no recurrent reflux in endoscopically treated patients.

CONCLUSIONS

Ventral buccal mucosal grafting is a simple, safe option for urethral stricture repair. Hanging the graft to periurethral tissue is important for its survival and to prevent postoperative folding and retraction.

Rectosigmoid vaginoplasty in patients with vaginal agenesis: sexual and psychosocial outcomes

Background The main goal in women with Mayer–Rokitansky–Küster–Hauser syndrome (vaginal agenesis) is creation of a neovagina that will satisfy the patient’s desire. We evaluated sexual and psychosocial adjustment in patients who underwent rectosigmoid vaginoplasty because of vaginal agenesis. Methods: A total of 36 women, aged 21 to 38 years (mean = 26) who underwent rectosigmoid vaginoplasty from 1997 to 2006 were evaluated. Sexual and psychosocial appraisal included the Female Sexual Function Index (FSFI), Beck’s Depression Inventory (BDI), and standardised questionnaires about postoperative satisfaction, social and sexual adjustment. Results: Mean FSFI score was 28.9 (range = 11.5–35.7) with a cut-off score of 26.55 for sexual dysfunction. Out of the 36 women, 10 (27, 8%) had sexual dysfunction. Mean BDI score was 7.55 (cut-off score = 0–9 for non-depression). Twenty-eight women (77.8%) were without symptoms of depression, six women (BDI range = 10–29) had moderate and two women had severe depression (BDI = 42). There were a significant number of patients (P < 0.01) with a high satisfaction score in FSFI and low BDI results. Thirty-two (88.9%) of the patients believed that surgery was done at the right time and the main postoperative support came from their family. Thirty-four (94.4%) of the patients reported satisfactory femininity, with a heterosexual orientation. Thirty patients (83. 3%) were very satisfied with the surgery, while 34 considered surgery as the best treatment. Conclusions: The sexual function and psychosocial status of these patients should be followed long-term to estimate their quality of life.

Severe penile injuries: a problem of severity and reconstruction

OBJECTIVES

To report our experience of treating severe penile injuries with different causes and treatments, as penile trauma presents a difficult physical and psychological problem, and the type and extent of injury varies from mild to severe, sometimes even with total amputation.

PATIENTS AND METHODS

We analysed retrospectively 43 patients (mean age 28 years, range 5-52 years) with severe penile injuries referred to us from March 1999 to August 2007. The causes of penile injuries differed, including iatrogenic trauma (20), traffic accidents (11), burns (three), self-amputation (two), ritual circumcision (two), penile fracture (two), gunshot trauma (two) and electrocution (one). The management required a wide variety of surgical techniques tailored to each patient depending on the type and extent of injury.

RESULTS

The mean (range) follow-up was 47 (10-108) months. The aesthetic and functional results, including satisfactory sexual intercourse were good in 35 patients. There were complications in seven patients; infection after implanting an inflatable penile prosthesis in one, protrusion of a semirigid prosthesis in one, urethral complications (one stenosis and two fistulae) in three and partial skin flap necrosis in two.

CONCLUSIONS

Severe penile injuries should be treated on an individual basis, applying different techniques. However, treatment can be effective and safe only in specialized centres.

One-stage repair of severe hypospadias using combined buccal mucosa graft and longitudinal dorsal skin flap

AIM OF THE STUDY

Urethral reconstruction in severe hypospadias presents a great challenge. We evaluated a method of combining longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in the most severe hypospadias. Our aim was to repair the most difficult cases in a one-stage procedure.

METHODS

Between January 2003 and July 2007, 23 patients (aged from 9 to 26 months) underwent repair of severe hypospadias (18 penoscrotal and 5 scrotal forms). The short urethral plate is divided in all cases and the remaining curvature was repaired by dorsal plication. The buccal mucosa graft is harvested and fixed to the ventral side of corpora cavernosa to form the first half of the neourethra. A longitudinal dorsal island skin flap is created and buttonholed ventrally. It is sutured to the buccal mucosa graft to form the neourethra. An abundant flap pedicle is fixed laterally to cover all the suture lines of the neourethra. Penile skin reconstruction is done using available penile skin.

RESULTS

The mean follow-up was 27 (range 11-66) months. Satisfactory results were achieved in 20 patients. There were two urethral fistula and one temporary distal urethral stricture.

CONCLUSION

A combined longitudinal island skin flap and buccal mucosa graft could be a good choice for single-stage urethral reconstruction in the repair of the most severe hypospadias.

Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias

OBJECTIVES

Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias.

METHODS

Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin.

RESULTS

The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment.

CONCLUSIONS

Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

Musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children

OBJECTIVE

Total phalloplasty is rarely performed in children due to the mutilation involved and the dilemma concerning neophallic size in children. We present a musculocutaneous latissimus dorsi free transfer flap for total phalloplasty in children with difficult psychological problems.

MATERIALS AND METHODS

Total phalloplasty was performed in eight boys aged between 10 and 15 years. Indications were small penis after failed epispadias repair (4), micropenis (3) and intersexuality (1). A musculocutaneous latissimus dorsi free flap was harvested with thoracodorsal artery, vein and nerve. The flap was transferred to the pubic region and anastomosed to the femoral artery, saphenous vein and ilioinguinal nerve. Two-staged urethroplasty was performed in five patients using buccal mucosa, while in the remaining three a Mitrofanoff channel had been created previously. An inflatable penile prosthesis was implanted in two cases after puberty.

RESULTS

Follow-up was from 6 to 53 months (mean: 29 months). Penile size varied from 13 to 16 cm in length and from 10 to 12 cm in circumference. No flap necrosis, either partial or total, was noted. The donor site healed acceptably in four cases while in the remaining four moderate scarring occurred. Function of the penile prostheses is satisfactory. Psychological status is significantly improved in all children.

CONCLUSION

Phalloplasty in childhood is indicated to prevent profound psychological problems related to body dysmorphia. The musculocutaneous latissimus dorsi flap is a possible choice for phalloplasty in children that enables good neophallic size as in adults. We recommend this surgery to be performed before puberty to ensure optimal psychosexual pubertal development.

Longitudinal dorsal dartos flap for prevention of fistula after a Snodgrass hypospadias procedure

OBJECTIVES

The Snodgrass technique presents the procedure of choice for distal hypospadias. Fistula formation is the most common complication with various rates. We evaluated the importance of a urethral covering using vascularized dorsal subcutaneous tissue for fistula prevention.

METHODS

Our study included 126 patients, aged 10 months to 16 years, who underwent hypospadias repair from April 1998 through June 2005. Of the patients, 89 had distal, 30 had midshaft and 7 had penoscrotal hypospadias. All patients underwent standard tubularized incised plate urethroplasty, which was followed by reconstruction of new surrounding urethral tissue. A longitudinal dorsal dartos flap was harvested and transposed to the ventral side by the buttonhole manoeuvre. The flap was sutured to the glans and the corpora cavernosa to completely cover the neourethra with well-vascularized subcutaneous tissue.

RESULTS

Mean follow-up was 32 (6-87) months. A successful result without fistula was achieved in all 126 patients. In six patients, temporary stenosis of the glandular urethra occurred and was solved by dilation.

CONCLUSIONS

A urethral covering should be performed as part of the Snodgrass procedure. A dorsal well-vascularized dartos flap that is buttonholed ventrally represents a good choice for fistula prevention. Redundancy of the flap and its excellent vascularization depend on the harvesting technique.

New Perspectives of Penile Enhancement Surgery: Tissue Engineering with Biodegradable Scaffolds

OBJECTIVE

To evaluate in a multicenter, prospective study preliminary aesthetic and functional results of autologous ex-vivo tissue engineering for penile girth enhancement.

METHODS

From July 1999 to January 2004, 204 men of mean age 26.77 (range 19-54 years) underwent this procedure. Indications for penile girth enhancement were penile dysmorphic disorder and previous failed surgery for penile girth enhancement. Fibroblast cells harvested from 1 cc of biopsied scrotal dermal tissue were expanded in culture until the total cell number of at least 2x10(7) was reached. Suspended cells in culture medium were then seeded on pretreated tube-shaped PLGA scaffolds and incubated for 24 hours. After penile degloving, scaffolds were shape adjusted and transplanted between dartos and Buck's fascia when the skin was compliant or under the neurovascular bundle when the skin was not compliant.

RESULTS

A total of 84 randomly selected patients were followed 1 to 5 years postoperatively (median 24 months). The gain in girth ranged from 1.9 to 4.1cm (mean 3.15 cm). Postoperative complications occurred as infection in three, penile skin pressure necrosis in two and seroma formation in five patients and were all treated conservatively. Surgical intervention was appraised by patients on a scale from 1 to 5 as follows: the best mark (5) was given by 44.05%, very good (4) by 36.90%, good (3) by 19.05% and only one patient gave the mark 2 judging general penile appearance as dissatisfactory; mean score was 4.25.

CONCLUSION

Autologous tissue engineering by using biodegradable scaffolds as a carrier is a new and safe therapeutic approach for penile girth enhancement. The outcome of this study points out the necessity for its expanded clinical applicability in the future.

Metoidioplasty: a variant of phalloplasty in female transsexuals

OBJECTIVE

To describe metoidioplasty, a technique for creating a neophallus from an enlarged clitoris in female transsexuals, without needing the complex, multi-staged surgical construction of a large phallus, as this reconstruction is one of the most difficult in female transsexuals.

PATIENTS AND METHODS

From September 1995 to April 2002 metoidioplasty was used in 22 patients (aged 18-33 years). The technique is based on the repair of the most severe form of hypospadias and intersex. The 'urethral plate' and urethra are completely dissected from the clitoral corporeal bodies, then divided at the level of the glanular corona, and the clitoris straightened and lengthened. A longitudinal vascularized island flap is designed and harvested from the dorsal skin of the clitoris, transposed to the ventral side, tubularized and anastomosed with the native urethra. The new urethral meatus is brought to the top of the neophallus, and the skin of the neophallus and scrotum reconstructed using labia minora and majora flaps.

RESULTS

The mean (range) follow-up was 3.9 (0.5-6) years; the neophallus was 5.7 (4-10) cm, considered satisfactory in 17 patients but the remaining five required additional phalloplasty. The complications were urethral stenosis in two and fistula in three patients.

CONCLUSIONS

Metoidioplasty is an alternative to phalloplasty, allowing voiding while standing. In patients who desire a larger phallus, various techniques of phalloplasty can also be used.