Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know

OBJECTIVE

To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS).

METHODS

A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis.

RESULTS

The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure.

CONCLUSION

Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

Survey of the quality and origins of websites on penile low-intensity shockwave therapy in Canada

INTRODUCTION

The aim of this study was to establish the quality of patient-facing websites advertising low-intensity shockwave therapy (LISWT) for erectile dysfunction (ED) and Peyronie's disease (PD) patients in Canada.

METHODS

Canadian websites offering LIWST for ED or PD were identified using online web searches. The characteristics of these websites were reviewed, along with examining the presence of HONCode certification, assigning a brief DISCERN score (a tool designed to evaluate health information online) and readability scores. We also examined the LIWST technology advertised, as well as benefits of LIWST cited by the websites.

RESULTS

Twenty-five unique websites linked to 46 clinics were identified and reviewed. Twenty-four percent of websites were run by a urologist. Other specialties offering LISWT included general practitioners, anesthesiologists, naturopaths, nurse practitioners, physiotherapists, and registered massage therapists. Twenty-four percent of the websites advertised the use of a focused shockwave generator. Forty percent of the websites had peer-reviewed references. The average brief DISCERN score was 14 (standard deviation 3.4). There was no association between the physician-or non-physician-led websites and the use of peer-reviewed references, readability scores, the number of clinic locations, or higher brief discern scores.

CONCLUSIONS

LISWT is readily advertised online for ED and PD patients in Canada; however, only a minority use a focused shockwave generator. There is a wide diversity of practitioners offering LISWT. Websites offering LISWT are generally of poor quality and do not provide adequate information for patients to make educated treatment decisions.

Patients' perspectives on informational needs surrounding gender-affirming vaginoplasty

This study aimed to investigate the informational preferences of patients undergoing gender-affirming vaginoplasty during their surgical journey. An anonymous survey was sent to 30 such patients who had the procedure between September 2018 and September 2020. The survey included Likert-scale questions about the importance of various topics and inquired about their preferred sources and formats for receiving this information. The responses of 17 individuals (56.7% response rate) were analyzed using descriptive statistics and qualitative thematic analysis. Key findings indicated that all topics in the survey were rated as moderately important or higher. Specifically, for 29 out of 30 pre-operative topics (96.7%), participants preferred written information, and for 27 topics (90.0%), they favored receiving information directly from their surgeon. Thematic analysis revealed five main themes: recovery process, satisfaction, trust in healthcare providers, information delivery, and neovaginal dilation and depth. In conclusion, individuals undergoing gender-affirming vaginoplasty have significant informational needs. They prefer to receive information from their surgical team, supplemented by written resources and verbal discussions. Notably, the importance of understanding neovaginal dilation and being aware of possible complications emerged as a key concern. The study also highlighted the importance of cultural competence and trust-building with healthcare providers, underscoring the need for more inclusive care practices.

Patient reported symptoms and adverse outcomes seen in Canada's first vaginoplasty postoperative care clinic

IMPORTANCE

Vaginoplasty is a relatively common gender-affirming surgery with approximately 200 Ontarians seeking this surgery annually. Although Ontario now offers vaginoplasty in province, the capacity is not meeting demand; the majority of trans and gender-diverse patients continue to seek vaginoplasty out of province. Out-of-province surgery presents a barrier to accessing postsurgical follow-up care leaving most patients to seek support from their primary care providers or providers with little experience in gender-affirming surgery.

OBJECTIVE

To provide an account of the common postoperative care needs and neovaginal concerns of Ontarians who underwent penile inversion vaginoplasty out of province and presented for care at a gender-affirming surgery postoperative care clinic.

DESIGN, SETTINGS, AND PARTICIPANTS

A retrospective chart review of the first 80 patients presenting to a gender-affirming surgery postoperative care clinic who had undergone vaginoplasty at an outside surgical center was performed. Descriptive analyses were performed for all variables.

RESULTS

The sample consisted of 80 individuals with the mean age of 39 years (19-73). Most patients had surgery at another surgical center in Canada (76.3%). Many patients (22.5%) accessed care in the first 3 months after surgery, with the majority (55%) seeking care within the first perioperative year. Most patients (61.3%) were seen for more than one visit and presented with more than two symptoms or concerns. Common patient-reported symptoms during clinical visit included pain (53.8%), dilation concerns (46.3%), and surgical site/vaginal bleeding (42.5%). Sexual function concerns were also common (33.8%) with anorgasmia (11.3%) and dyspareunia (11.3%) being the most frequent complications. The most common adverse outcomes identified by health care providers included hypergranulation (38.8%), urinary dysfunction (18.8%), and wound healing issues (12.5%).

CONCLUSIONS AND RELEVANCE

Findings from chart review offer valuable insights into the postoperative needs and neovaginal concerns of Ontarians who have had vaginoplasty out of province. This study demonstrates the need for routine postoperative care in patients undergoing vaginoplasty. Patients experience numerous symptoms and concerns that often correlate with clinical findings and require multiple follow-up appointments. Health care providers may benefit from further education on the more common nonsurgical issues identified in this study.

Urinary complications after penile inversion vaginoplasty in transgender women: Systematic review and meta-analysis

Introduction: Penile inversion vaginoplasty (PIV) remains the gold standard technique for vaginoplasty, a gender-affirming feminizing surgery, but has been associated with urinary complications; however, there is little literature synthesizing urinary complications after PIV surgery, and there is a need to compile these complications to counsel patients pre- and postoperatively on managing surgical expectations. In this systematic review, we summarize the prevalence of urinary complications following PIV. Methods: We searched the MEDLINE, EMBASE, CINAHL, and Scopus databases in July 2020. The primary outcome was the prevalence of urinary and surgical complications in patients after penile inversion vaginoplasty. Pooled prevalence was determined from extrapolated data. ROBINS-I tool was used to assess study quality. The study was prospectively registered on PROSPERO (CRD42020204139). Results: Of 843 unique records, 27 articles were pooled for synthesis, with 3388 patients in total. Overall patient satisfaction ranged from 80–100%. The most common urological complications included poor/splayed stream (11.7%, 95% confidence interval [CI] 5.7–19.3), meatal stenosis (6.9%, 95% CI 2.7–12.7), and irritative symptoms (frequency, urgency, nocturia) (11.5%, 95% CI 2.6–25.1). Other urinary complications included retention requiring catheterization (5.1%, 95% CI 0.3–13.8), incontinence (8.7%, 95% CI 3.4–15.6), urethral stricture (4.6%, 95% CI 1.2–9.8), and urinary tract infection (5.6%, 95% CI 2.7–9.4). Most pooled studies had moderate risk of bias. Conclusions: The available evidence suggests that there is a low prevalence of urinary complications following PIV. Overall, there is a need for standardization of data in transgender surgical care to better understand surgical outcomes and improve postoperative management.

International Continence Society (ICS) report on the terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction

INTRODUCTION

The terminology for sexual health in men with lower urinary tract (LUT) and pelvic floor (PF) dysfunction has not been defined and organized into a clinically based consensus terminology report. The aim of this terminology report is to provide a definitional document within this context that will assist clinical practice and research.

METHODS

This report combines the input of the members of sexual health in men with LUT and PF Dysfunction working group of the International Continence Society (ICS), assisted at intervals by external referees. Appropriate core clinical categories and a sub-classification were developed to give coding to definitions. An extensive process of 18 rounds of internal and external review was involved to exhaustively examine each definition, with decision-making by collective opinion (consensus). The Committee retained evidence-based definitions, identified gaps, and updated or discarded outdated definitions. Expert opinions were used when evidence was insufficient or absent.

RESULTS

A terminology report for sexual health in men with LUT and PF dysfunction, encompassing 198 (178 NEW) separate definitions, has been developed. It is clinically based with the most common diagnoses defined. Clarity and user-friendliness have been key aims to make it interpretable by practitioners and trainees in all the different speciality groups involved. Conservative and surgical managements are major additions and appropriate figures have been included to supplement and clarify the text. Emerging concepts and measurements, in use in the literature and offering further research potential, but requiring further validation, have been included as an appendix. Interval (5-10 years) review is anticipated to keep the document updated.

CONCLUSION

A consensus-based terminology report for sexual health in men with LUT and PF dysfunction has been produced to aid clinical practice and research. The definitions that have been adopted are those that are most strongly supported by the literature at this time or are considered clinical principles or consensus of experts' opinions.

Availability of platelet-rich plasma for treatment of erectile dysfunction and associated costs and efficacy: A review of current publications and Canadian data

INTRODUCTION

Platelet-rich plasma (PRP) is an increasingly used unconventional treatment option for erectile dysfunction (ED). The validity of PRP as a potential treatment for ED has been proposed in limited human trials. Furthermore, the costs associated with PRP for ED treatment are not readily promoted to patients. The goal of this review was to determine the efficacy and costs of PRP based on currently available literature and Canadian data.

METHODS

A comprehensive literature review of available PRP studies and current published data pertaining to cost, availability, and provider clinics globally was conducted using the PubMed database. Physicians offering genital PRP in Canada were identified using internet searches and PRP provider directories. Physician qualifications, clinic locations, and cost information were obtained from provider websites and telephone calls to identified clinics.

RESULTS

Availability of PRP injections offered for treating ED is increasing globally. There are currently no peer-reviewed publications to substantiate anecdotal evidence pertaining to the efficacy of PRP as a viable treatment option for ED patients. Our results indicate 19 providers for PRP injections in Canada, costing on average $1777 CAD per injection. No providers were affiliated with academic institutions and providers varied in their area of clinical speciality and training.

CONCLUSIONS

To our knowledge, there is currently no research underway investigating the clinical efficacy of PRP for ED treatment despite its broad availability and significant cost. Patients should be informed of the lack of substantiated efficacy and safety data, as the reliability of PRP treatments requires further evaluation.

Virtual temporal bone: creation and application of a new computer-based teaching tool

The human temporal bone is a 3-dimensionally complex anatomic region with many unique qualities that make anatomic teaching and learning difficult. Current teaching tools have proved only partially adequate for the needs of the aspiring otologic surgeon in learning this anatomy. We used a variety of computerized image processing and reconstruction techniques to reconstruct an anatomically accurate 3-dimensional computer model of the human temporal bone from serial histologic sections. The model is viewed with a specialized visualization system that allows it to be manipulated easily in a stereoscopic virtual environment. The model may then be interactively studied from any viewpoint, greatly simplifying the task of conceptualizing and learning this anatomy. The system also provides for simultaneous computer networking that can bring distant participants into a single shared virtual teaching environment. Future directions of the project are discussed.

The virtual temporal bone

The human temporal bone is a 3-dimensionally complex portion of the skull that contains delicate and vital anatomic structures imbedded within dense bone. Current teaching tools have proven to be only marginally adequate for the needs of the aspiring otologic surgeon in learning this anatomy. A variety of image processing and reconstruction techniques were used to reconstruct an anatomically accurate 3-dimensional model of the human temporal bone from serial histologic sections. Using CAVE technology, the model can be manipulated in a stereoscopic virtual environment so that it can be studied from any viewpoint, greatly simplifying the task of learning this anatomy. Applications in surgical planning and Internet based teaching are discussed.

Web-based segmentation and display of three-dimensional radiologic image data

In many clinical circumstances, viewing sequential radiological image data as three-dimensional models is proving beneficial. However, designing customized computer-generated radiological models is beyond the scope of most physicians, due to specialized hardware and software requirements. We have created a simple method for Internet users to remotely construct and locally display three-dimensional radiological models using only a standard web browser. Rapid model construction is achieved by distributing the hardware intensive steps to a remote server. Once created, the model is automatically displayed on the requesting browser and is accessible to multiple geographically distributed users. Implementation of our server software on large scale systems could be of great service to the worldwide medical community.

Echocardographic features of papillary fibroelastoma and their consequences and management

Thirty-five percent of patients (5 of 15) were diagnosed with ischemic stroke from left-sided papillary fibroelastomas by diagnosis of exclusion, whereas 40% of patients (6 of 15) did not have ischemic stroke.

Transesophageal echocardiography-guided transvenous endomyocardial biopsy used to diagnose primary cardiac angiosarcoma

Primary cardiac tumors are rare clinical entities with the histologic diagnosis usually made from surgically obtained tissue or at postmortem examination. Transvenous endomyocardial biopsy has been used less frequently, under fluoroscopic or transthoracic echocardiographic guidance. In this case report, we utilized the transesophageal echocardiography to guide the endomyocardial biopsy from a right atrial tumor in a 35-year-old man.

ABC of medical computing. Keeping your computer healthy and legal

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ABC of medical computing. Hospital based computer systems

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ABC of medical computing. Computers in general practice--III

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ABC of medical computing. Computers in general practice--II

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ABC of medical computing. Computers in general practice--I

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ABC of medical computing. Using computers in clinical audit

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ABC of medical computing. Online searching

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ABC of medical computing. Linking your computer to the outside world

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ABC of medical computing. Getting your thoughts on paper

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ABC of medical computing. Choosing and installing software

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ABC of medical computing. Getting your computer up and running

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ABC of medical computing. Choosing a computer system

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ABC of medical computing. An introduction to computing in medical practice

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Wound healing and the aged patient

The aged patient is more susceptible to wound healing problems because of the interactions of body systems, environmental stresses, and disease with an aging process that takes place over many years. The multifactorial nature of wound healing in the elderly makes it difficult to determine whether observed healing problems are attributable to results of aging or other factors. Healing is affected by multiple factors in addition to patient age, which itself is not a dependable indicator of physiologic health. Some of these factors are disease, nutrition, perfusion, skin quality, environment, and individual responses to life events. It is particularly difficult for the aged patient to sustain the motivation to participate in care required during the healing process when cascading problems are allowed to build on the decreasing functions and reserve capacities of aging body systems and deplete available energy levels. Assessment of each individual is required because of the wide variety of aging changes and healing responses seen in aged patients. Compared with a younger adult, the aged patient generally heals well, following the same healing process but at a slower rate. Wound healing for the aged can be optimized through techniques of energy conservation, correction of existing problems, and management of risks related to aging and the individual patient. Healing problems are usually the result of decreases in systemic and local perfusion, decreases in the ability to ward off infection, and fragility of aging skin. The aged patient requires the same care as younger patients. It is more critical that this care be meticulously delivered with particular attention to care of intact skin, effects of chronic disease and medications, motivation, social habits, and discharge planning. Nurses can promote improved healing through the care they provide and by studying the progression of healing in aged patients.

Unusual ocular findings in identical twins

We report an unusual case of dissimilar strabismus in monozygotic twins and describe the anatomical features which caused it.

Herpes zoster ophthalmicus in patients at risk for the acquired immune deficiency syndrome (AIDS)

In a prospective investigation of 54 consecutive cases of herpes zoster ophthalmicus, conducted over a two-year period, immunologic evaluations included enumeration of T lymphocyte subsets and serum immunoglobulin levels. Herpes zoster ophthalmicus occurred with frequent ocular complications in a subgroup of adults distinguishable by their young age, the presence of AIDS-risk factors, alterations in T-cell subpopulations, and polyclonal increases of serum gammaglobulin. Over the study duration, 21% (three of 14) of the AIDS-risk subgroup patients have developed AIDS with a 14% (two of 14) mortality. Herpes zoster ophthalmicus in AIDS-risk group members appeared to be an early clinical marker for the immune deficiency induced by AIDS retroviral infection.

Pericardial tumor of fibrosis mimicking pericardial effusion by echocardiography

Echocardiograms of three patients with metastatic carcinoma or lymphoma showed a sonolucent space posterior to the left ventricular epicardium, as seen in pericardial effusion. However, at surgery or autopsy no pericardial fluid was found. Instead, the pericardium was infiltrated by neoplastic tissue or fibrosis. In view of this finding, we suggest caution in the interpretation of "positive" echocardiograms for pericardial effusion in patients with neoplastic disease, especially if pericardiocentesis is being considered.