Is size in the eye of the beholder? Visual estimation of penis size among transgender and cisgender people and implications for genital gender-affirming surgery and sexual medicine

BACKGROUND

Transgender men (TM) seeking gender-affirming phalloplasty and transgender women (TW) seeking vaginoplasty and desiring insertive intercourse must consider penis size. Evidence has shown that, at least among cisgender men (CM), penile dimensions tend to be poorly estimated. In transgender patients desiring gender-affirming surgery, inaccuracy in estimation of penis dimensions may lead to unnecessary morbidity: for TW, trauma to the neovagina; for TM with excess girth, an inability to insert. Studies on the accuracy with which transgender and cisgender patients estimate penis size are limited.

AIM

To assess the degree of accuracy with which CM and CW, as well as TM and TW, visually estimate the size of the human penis, including length, width, and girth.

METHODS

There were 142 participants included (25 TM, 47 TW, 30 CM, and 40 CW; net mean ± SD age, 36.6 ± 11.2 years). Participants were shown these models and asked to estimate length, width, and midshaft girth by visual inspection of 6 realistic models of a penis and scrotum of varying lengths and widths. We evaluated the accuracy of the visual measurements by comparing mean perceived dimensions with the actual dimensions of each model.

OUTCOMES

We used a multivariate model of all 3 bias dimensions to test for differences in average bias among gender groups (CM, CW, TM, and TW).

RESULTS

TM significantly overestimated length across the longest models. TW significantly overestimated length in the longer 3 models. All groups except for TM significantly underestimated girth in at least 1 model. No groups significantly underestimated width. CM, CW, and TM significantly overestimated width in all 6 models.

CLINICAL IMPLICATIONS

When transgender patients use numbers to express penis size (either in neophallus or vaginal depth based on perceived partner size), the result is likely to be larger than expected. Use of realistic penis models as a decision-making tool may help manage patient expectations and surgery decision making preoperatively and improve postoperative patient satisfaction and safety.

STRENGTHS AND LIMITATIONS

To our knowledge, this is the first study to assess visual estimation in penis size in TM and CM, as well as TW and CW. The penile models in our study were shown side by side and in the flaccid state despite having dimensions more consistent with an erect penis, which may have influenced estimations across all dimensions.

CONCLUSION

Men and women (cisgender and transgender) tend to significantly overestimate penis length and width.

Cancer Screening for Transgender Individuals: Guidelines, Best Practices, and a Proposed Care Model

Few transgender-specific cancer screening recommendations exist. This review aims to cover current guidelines and practice patterns of cancer screening in transgender patients and, where evidence-based data are lacking, to draw from cisgender screening guidelines to suggest best practices for transgender patients based on anatomic inventory. Sufficient evidence does not exist to determine the long-term effects of gender-affirming hormone therapy on cancer risk. In the future, cancer screening and prevention should be focused on anatomic inventory and high-risk behaviors.

Shallow-depth vaginoplasty: preoperative goals, postoperative satisfaction, and why shallow-depth vaginoplasty should be offered as a standard feminizing genital gender-affirming surgery option

BACKGROUND

Shallow-depth vaginoplasty (SDV), also referred to as vaginoplasty without creation of a vaginal canal, is an understudied alternative to full-depth vaginoplasty (FDV), or vaginoplasty with creation of a vaginal canal. SDV is associated with fewer short- and long-term risks and shorter recovery, and does not require a lifelong commitment to vaginal dilation and douching.

AIM

To describe a surgical technique for SDV that creates a dimpled introitus, together with clinical outcomes, decision-making prioritization, and satisfaction data. We hypothesize that SDV patients prioritize comparable appearance and sexual function to FDV over shorter-term risk factors, and experience high satisfaction.

METHODS

We describe (1) a surgical technique for SDV; (2) the proportion of patients who underwent SDV vs. FDV, with SDV complication rates; and (3) the results of an anonymous, electronic questionnaire administered via Qualtrics that assessed SDV patient demographics, terminology preferences, prioritization of decision-guiding factors for choosing SDV over FDV, and postoperative satisfaction across various domains.

OUTCOMES

A total of 110 patients underwent primary feminizing genital gender-affirming surgery at a single institution between April 2017 and July 2022: 35 (32%) of 110 underwent SDV and 75 (68%) underwent FDV. The 35 SDV patients were invited to answer the study questionnaire, of which 29 (83%) completed it (mean age 51.9 ± 16.7 years, mean body mass index 27.3 ± 5.3 kg/m2).

RESULTS

All but one survey respondent met one or more of the following characteristics: (1) ≥40 years of age, (2) exclusively feminine-identifying sexual partners, and/or (3) significant aversion to performing long-term vaginal dilation and douching. Ranking of 8 decision-guiding factors revealed prioritization of long-term over short-term outcomes. Postoperatively, patients reported high satisfaction across all 3 domains. When asked if they had to choose between SDV and FDV over again, 86% reported that they would choose SDV. While 14% would choose FDV, all but one reported new interest in receptive vaginal intercourse due to finding masculine-identifying partners post-SDV surgery. A total of 27% of SDV patients experienced complications that required additional surgeries; 82% of complications were related to urinary spraying.

CLINICAL IMPLICATIONS

SDV is a lower-risk alternative to FDV and is associated with reduced postoperative maintenance and high postoperative satisfaction.

STRENGTHS AND LIMITATIONS

This study describes the clinical outcomes of the largest documented cohort of patients to undergo SDV to date. Limitations include recall bias due to the retrospective survey and use of nonvalidated questions attributed to the paucity of validated gender-affirming surgery questionnaires.

CONCLUSION

SDV's appeal to a large subset of patients (32% in this study), low complication rate, high satisfaction, and low decisional regret suggests that this surgical option should be offered to all patients seeking feminizing genital gender-affirming surgery.

Simultaneous Bladder Drainage via Suprapubic and Urethral Catheters: Which Drains More Completely and Why?

Background

Reconstructive urologists often place both a urethral and suprapubic catheter intraoperatively to prevent extravasation of undrained urine across anastomosis sutures. As no consensus exists on which catheter drains the bladder more completely, many surgeons leave one catheter to gravity drainage and cap the other postoperatively. We sought to identify differences in catheter urine outflow during dual bladder drainage with suprapubic and urethral catheters in postoperative urology patients.

Methods

Urine output (UOP) from transgender men who underwent Stage II Phalloplasty with urethral lengthening was retrospectively reviewed. Both 16 French urethral and suprapubic catheters were placed to gravity drainage postoperatively. Urine output from each catheter was recorded separately, twice daily. Mixed model regression modeling tested for differences in urine output by time of day (day/night) and activity status (Bedrest: Postop Day 0-2, Ambulatory: Postop Day 3+).

Results

The aggregate number of 12-hour shift urine output observations was 250 (125 for urethral and 125 for suprapubic catheters) across 14 inpatients. Suprapubic catheters had a mean 410 ml higher output than urethral catheters per 12-hour shift (p=0.002; 95% CI: 185, 636 ml). During daytime, Suprapubic catheters demonstrated higher UOP than urethral catheters per 12-hour shift (Estimated Difference: 464 ml; p=0.002; 95% CI: 211, 718 ml). During nighttime, a similar phenomenon was observed (Estimated Difference: 356 ml; p=0.009; 95% CI: 104, 606 ml). When comparing mean UOP from each catheter during the Bedrest Phase, suprapubic catheters averaged an estimated 295 ml higher UOP compared to urethral catheters per 12-hour shift with a trend toward statistical significance (p=0.052; 95% CI -3, 594 ml). During the Ambulatory Phase, mean suprapubic catheter UOP was an estimated 472 ml higher than urethral catheters per 12-hour shift (p=0.009; 95% CI 142, 802 ml).

Conclusions

Simultaneous bladder drainage with urethral and suprapubic catheters shows greater drainage from the suprapubic catheter (35% vs 65%). When using two catheters, both can be placed to gravity to maximize bladder drainage as the suprapubic catheter can drain residual urine not adequately drained by the urethral catheter.

Phase Ib study of talimogene laherparepvec in combination with atezolizumab in patients with triple negative breast cancer and colorectal cancer with liver metastases

BACKGROUND

Talimogene laherparepvec (T-VEC), a first-in-class oncolytic viral immunotherapy, enhances tumor-specific immune activation. T-VEC combined with atezolizumab, which blocks inhibitor T-cell checkpoints, could provide greater benefit than either agent alone. Safety/efficacy of the combination was explored in patients with triple negative breast cancer (TNBC) or colorectal cancer (CRC) with liver metastases.

METHODS

In this phase Ib, multicenter, open-label, parallel cohort study of adults with TNBC or CRC with liver metastases, T-VEC (10⁶ then 10⁸ PFU/ml; ≤4 ml) was administered into hepatic lesions via image-guided injection every 21 (±3) days. Atezolizumab 1200 mg was given on day 1 and every 21 (±3) days thereafter. Treatment continued until patients experienced dose-limiting toxicity (DLT), had complete response, progressive disease, needed alternative anticancer treatment, or withdrew due to an adverse event (AE). The primary endpoint was DLT incidence, and secondary endpoints included efficacy and AEs.

RESULTS

Between 19 March 2018 and 6 November 2020, 11 patients with TNBC were enrolled (safety analysis set: n = 10); between 19 March 2018 and 16 October 2019, 25 patients with CRC were enrolled (safety analysis set: n = 24). For the 5 patients in the TNBC DLT analysis set, no patient had DLT; for the 18 patients in the CRC DLT analysis set, 3 (17%) had DLT, all serious AEs. AEs were reported by 9 (90%) TNBC and 23 (96%) CRC patients, the majority with grade ≥3 [TNBC, 7 (70%); CRC, 13 (54%)], and 1 was fatal [CRC, 1 (4%)]. Evidence of efficacy was limited. Overall response rate was 10% (95% confidence interval 0.3-44.5) for TNBC; one (10%) patient had a partial response. For CRC, no patients had a response; 14 (58%) were unassessable.

CONCLUSIONS

The safety profile reflected known risks with T-VEC including risks of intrahepatic injection; no unexpected safety findings from addition of atezolizumab to T-VEC were observed. Limited evidence of antitumor activity was observed.

Anatomic maps of erogenous sensation and pleasure in the penis: are there difference between circumcised and uncircumcised men?

BACKGROUND

The effects of male circumcision on sexual function remain controversial. Heterogeneity across previous studies and low-quality scientific evidence have resulted in poor understanding of the effects of circumcision on erogenous sensation of the penis and orgasm function.

AIM

In this study we sought to describe and assess differences in erogenous genital sensation and reported orgasm function in circumcised compared with uncircumcised men.

METHODS

Adult male subjects who were recruited on a paid anonymous online survey platform were shown illustrations of 12 anatomic regions of the penis. Subjects were prompted to designate regions as pleasurable when touched during partnered sex and to rate each on a 1-10 scale, with higher erogeneity scores correlating with greater pleasure. Subjects were also asked to characterize their orgasms across 6 experiential domains.

OUTCOMES

Outcomes were differences between circumcised and uncircumcised men in the probabilities that regions would be designated as pleasurable, average pleasure scores, and self-reported orgasm parameters.

RESULTS

In total, 227 circumcised (mean [SD] age 46.6 [17.7] years) and 175 uncircumcised men (47.8 [18.1] years) completed the survey. There were no significant differences in average ratings across all regions between circumcised and uncircumcised men. However, significantly more circumcised men reported preferences for the tip of the penis (38% vs 17%, P = .02) and the middle third of the ventral penile shaft (63% vs 48%, P = .04). Additionally, there were no significant differences in orgasm quality and function across all queried domains between circumcised and uncircumcised cohorts.

CLINICAL IMPLICATIONS

Our findings suggest that circumcision does not change how men describe erogenous genital sensation or how they experience orgasm.

STRENGTHS AND LIMITATIONS

In this study we expanded upon existing literature regarding comparison of sexual function in circumcised and uncircumcised men in its scale and investigation of diverse domains. Limitations include the survey format of data collection.

CONCLUSION

We found no differences in reported erogenous ratings or orgasm function between circumcised and uncircumcised men. These findings suggest that male circumcision does not negatively impact penile erogeneity or orgasm function.

Seeing the unseen: how can we best identify transgender women within the Veterans Affairs healthcare system's electronic medical record?

BACKGROUND

One challenge in transgender research is reliably identifying patients through electronic medical records data, as there is no universal transgender International Classification of Diseases (ICD) code, but rather multiple ICD codes that can be used.

AIM

To explore the sensitivity and specificity of 5 commonly used ICD codes to identify transgender patients overall and transgender women specifically (assigned male sex at birth) by using data from the Veterans Affairs (VA), the largest integrated health system in the United States.

METHODS

Patients aged ≥18 years were identified via ICD-9 codes 302.5 and 302.6 (Ninth Revision) and ICD-10 codes F64.0, F64.8, and F64.9 (Tenth Revision) using VA health records from 2000 to 2021 and stratified by bilateral orchiectomy status.

OUTCOMES

Detailed chart review was performed on 32 randomly selected patients for each code (half with and half without orchiectomy) to confirm transgender status and to perform descriptive analyses.

RESULTS

For each ICD code, rates of confirmed transgender status ranged from 88% to 100% for those with and without an orchiectomy, with the majority being transgender women (consistent with most veterans being assigned male sex at birth). Most transgender women (66%-100%) were undergoing estrogen gender-affirming therapy. The majority of provider-driven entries of transgender status took place from 2011 to 2020, with 75% of entries made from 2011 to 2020, consistent with increased recognition and societal acceptance of this population. False negatives were detected at a rate of 15%. Based upon these 5 ICD codes alone, we estimate that the VA has records for 9,449 to 10,738 transgender individuals.

CLINICAL IMPLICATIONS

All 5 codes are very sensitive in identifying transgender patients, and the combination of these codes with orchiectomy is extremely sensitive in identifying transgender women, specifically.

STRENGTHS AND LIMITATIONS

Major strengths of the study are the use of universal ICD codes and a large patient sample size that spans health records nationally and across multiple decades, potentially making our data more generalizable. The main limitation of this study is that subanalyses were performed on a limited number of patients, which prevented us from capturing all false positives and thus from calculating specificity for each code. Similarly, our true negatives were derived from a small, random subset of the population; as such, our calculation for specificity is an estimate.

CONCLUSION

This study highlights a novel method to identify transgender women and paves the way for further research.

An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap

INTRODUCTION

Gender-affirming peritoneal vaginoplasty has been described, and previous descriptions are modifications of the Davydov technique.

AIM

To describe our alternative technique for gender-affirming peritoneal vaginoplasty (PV) using a single-pedicled, urachus-peritoneal hinge flap, discussing proposed advantages.

METHODS

Retrospective review of all consecutive transfeminine patients with neovaginal shortening after prior penile inversion vaginoplasty (PIV) who underwent our PV technique from May 2019 to July 2022.  PV was performed via combined transperineal and laparoscopic (robot-assisted) approaches. After spatulation of the neovaginal remnant, a midline, inferiorly based urachus-peritoneal hinge flap was elevated craniocaudally from the umbilicus to the mid-posterior bladder. The free end of the flap was flipped posteriorly and sutured to posterior edge of the open canal remnant, forming a peritoneal pouch. The lateral edges of the pouch were sutured together for water-tight closure. Patients resumed dilation on POD 6 and douching on POD 10.

MAIN OUTCOME MEASURES

Ten transfeminine patients underwent PV, with good outcomes. We measured: Pre-op penile and scrotal skin lengths, intra-op tubularized scrotal skin length, pre and post-op vaginal depth and width (immediate and at last follow-up).

RESULTS

Pre-op: mean neovaginal depth was 9.2cm (SD 1.5); width was 12cm. Immediate post-op: mean depth was 15.1 cm (SD 2.2 cm, mean net increase: 5.9 cm). At mean follow-up of 18.3 months, mean depth was 12.5 cm (SD 2.1 cm, mean net increase: 3.3 cm) and width was 12 cm. There were no immediate post-op complications. Eight (80%) of the 10 patients report satisfactory vaginal receptive intercourse. The other 2 have not yet attempted vaginal receptive intercourse.

CLINICAL IMPLICATIONS

Advantages of the proposed technique over existing techniques include no tension on peritoneal suture lines and total exclusion of the rectum.

STRENGTHS AND LIMITATIONS

Strengths include a short learning curve for urologic surgeons with robotic experience.  The study is limited by small sample size.

CONCLUSIONS

Our PV technique is a safe and effective option for salvage peritoneal vaginoplasty after primary PIV. Smith SM, Yuan N, Stelmar J, et al. An Alternative Option for Gender-Affirming Revision Vaginoplasty: The Tubularized Urachus-Peritoneal Hinge Flap. Sex Med 2022;10:100572.

Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty

INTRODUCTION

No nomogram exists to predict maximum achievable neovaginal depth before penile inversion vaginoplasty (PIV) based on available penile & scrotal skin (SS). Maximal depth is important to patients and is determined by available skin and available anatomic space within the pelvis and varies with surgical technique.

AIM

We endeavored to create a nomogram to predict expected postoperative vaginal depth.

METHODS

Retrospective review of all patients undergoing primary PIV at a single institution from June 2017 to February 2020 (n = 60). Pre-op: Dorsal penile and midline scrotal skin length were measured. Intra-op: Tubularized scrotal skin length measured on a dilator. Immediate post-op: Final vaginal depth measured with a dilator.

OUTCOMES

The amount of available penile and scrotal skin was not associated with vaginal depth. The only variable that did significantly increase depth was the use of penile + scrotal skin, as compared to penile skin alone. (P < .001) RESULTS: In patients who underwent PIV-SS, the final vaginal depth (13.3 ± 1.9 cm) was 87% of pre-op measured penile skin length (15.3 ±- 3.0 cm). In patients who underwent PIV+SS, pre-op penile skin length was 11.1 ± 4.7±cm and pre-op midline scrotal length was 22.8 ± 2.6 cm. with a final post-op vaginal canal depth of 15.2 ± 1.3 cm. In 45/46 (98%) surgeries utilizing SS grafts, SS tube length exceeded the length necessary to achieve maximal vaginal depth, and required trimming and discard. Given that in most cases there was an excess of SS, final post-op depth equaled the maximal vaginal depth that could be surgically dissected, and was not limited by the amount of available skin.

CLINICAL IMPLICATIONS

Our findings suggest that for most patients it should not be necessary to include additional tissue sources (eg, peritoneum) to create a vaginal canal during primary vaginoplasty.

STRENGTHS AND LIMITATIONS

Any penile skin that was discarded due to poor quality (eg, tight phimosis, poor viability) was not measured and accounted for. This likely resulted in a slight overestimation of the contribution of the penile skin to the final vaginal depth, but did not change the overall finding that final depth was not limited by available skin.

CONCLUSION

SS grafts, when harvested and tubularized using optimized technique, supplied an excess of skin necessary to line a vaginal canal space of maximal achievable depth. We found that additional tissue sources can, instead, be reserved for future salvage surgery if it becomes necessary to augment depth. Smith SM, Yuan N, Stelmar J, et al. Penile and Scrotal Skin Measurements to Predict Final Vaginal Depth With Penile Inversion Vaginoplasty. Sex Med 2022;10:100569.

Standards of Care for the Health of Transgender and Gender Diverse People, Version 8

Background: Transgender healthcare is a rapidly evolving interdisciplinary field. In the last decade, there has been an unprecedented increase in the number and visibility of transgender and gender diverse (TGD) people seeking support and gender-affirming medical treatment in parallel with a significant rise in the scientific literature in this area. The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, public policy, and respect in transgender health. One of the main functions of WPATH is to promote the highest standards of health care for TGD people through the Standards of Care (SOC). The SOC was initially developed in 1979 and the last version (SOC-7) was published in 2012. In view of the increasing scientific evidence, WPATH commissioned a new version of the Standards of Care, the SOC-8. Aim: The overall goal of SOC-8 is to provide health care professionals (HCPs) with clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort with their gendered selves with the aim of optimizing their overall physical health, psychological well-being, and self-fulfillment. Methods: The SOC-8 is based on the best available science and expert professional consensus in transgender health. International professionals and stakeholders were selected to serve on the SOC-8 committee. Recommendation statements were developed based on data derived from independent systematic literature reviews, where available, background reviews and expert opinions. Grading of recommendations was based on the available evidence supporting interventions, a discussion of risks and harms, as well as the feasibility and acceptability within different contexts and country settings. Results: A total of 18 chapters were developed as part of the SOC-8. They contain recommendations for health care professionals who provide care and treatment for TGD people. Each of the recommendations is followed by explanatory text with relevant references. General areas related to transgender health are covered in the chapters Terminology, Global Applicability, Population Estimates, and Education. The chapters developed for the diverse population of TGD people include Assessment of Adults, Adolescents, Children, Nonbinary, Eunuchs, and Intersex Individuals, and people living in Institutional Environments. Finally, the chapters related to gender-affirming treatment are Hormone Therapy, Surgery and Postoperative Care, Voice and Communication, Primary Care, Reproductive Health, Sexual Health, and Mental Health. Conclusions: The SOC-8 guidelines are intended to be flexible to meet the diverse health care needs of TGD people globally. While adaptable, they offer standards for promoting optimal health care and guidance for the treatment of people experiencing gender incongruence. As in all previous versions of the SOC, the criteria set forth in this document for gender-affirming medical interventions are clinical guidelines; individual health care professionals and programs may modify these in consultation with the TGD person.

Comparison of Permanent Hair Removal Procedures before Gender-Affirming Vaginoplasty: Why We Should Consider Laser Hair Removal as a First-Line Treatment for Patients Who Meet Criteria

Introduction

Permanent genital hair removal is required before gender-affirming vaginoplasty to prevent hair-related complications. No previous studies have directly compared the relative efficacy, costs, and patient experiences with laser hair removal (LHR) vs electrolysis treatments. Food and Drug Administration (FDA) oversight of medical devices is poorly understood and commonly misrepresented, adversely affecting patient care.

Aim

This study compares treatment outcomes of electrolysis and LHR for genital hair removal and investigates FDA regulation of electrolysis and LHR devices.

Methods

Penile-inversion vaginoplasty and shallow-depth vaginoplasty patients completed surveys about their preoperative hair removal, including procedure type, number/frequency of sessions, cost, and discomfort. Publicly available FDA-review documents and databases were reviewed.

Main Outcomes Measure

Compared to electrolysis, LHR was associated with greater efficiency, decreased cost, decreased pain, and improved patient satisfaction.

Results

Of 52 total (44 full-depth and 8 shallow-depth) vaginoplasty patients, 22 of 52 underwent electrolysis only, 15 of 52 underwent laser only, and 15 of 52 used both techniques. Compared to patients that underwent LHR only, patients that underwent only electrolysis required a significantly greater number of treatment sessions (mean 24.3 electrolysis vs 8.1 LHR sessions, P < .01) and more frequent sessions (every 2.4 weeks for electrolysis vs 5.3 weeks for LHR, P < .01) to complete treatment (defined as absence of re-growth over 2 months). Electrolysis sessions were significantly longer than LHR sessions (152 minutes vs 26 minutes, P < .01). Total treatment costs for electrolysis ($5,161) were significantly greater than for laser ($981, P < .01). Electrolysis was associated with greater pain and significantly increased need for pretreatment analgesia, which further contributed to higher net costs for treatment with electrolysis vs laser. Many LHR and electrolysis devices have been FDA-cleared for safety, but the FDA does not assess or compare clinical efficacy or efficiency.

Clinical Implications

For patients with dark-pigmented hair, providers should consider LHR as the first-line treatment option for preoperative hair removal before gender-affirming vaginoplasty.

Strength and Limitations

This is the first study to compare electrolysis and LHR for genital hair removal. The discussion addresses FDA review/oversight of devices, which is commonly misrepresented. Limitations include the survey format for data collection.

Conclusion

When compared with electrolysis, LHR showed greater treatment efficiency (shorter and fewer treatment sessions to complete treatment), less pain, greater tolerability, and lower total cost. Our data suggests that, for patients with dark genital hair, providers should consider recommending laser as the first-line treatment for permanent genital hair removal before vaginoplasty.

Yuan N, Feldman A, Chin P, et al. Comparison of Permanent Hair Removal Procedures before Gender-Affirming Vaginoplasty: Why We Should Consider Laser Hair Removal as a First-Line Treatment for Patients Who Meet Criteria. Sex Med 2022;10:100545.

Procedures Never Explained in Textbooks: How to Correctly Convert a Closed-Suction Drain to a Closed-Gravity Drain, and How to Correctly Remove a Closed-Suction Drain Off Suction

OBJECTIVE

To describe a novel method to convert a closed-system suction drain to a highly efficient closed-system gravity-dependent drain and demonstrate its efficacy in an ex-vivo model.

METHODS

We reviewed the 5 top-selling urology and surgery text/reference books for information on drainage systems. An ex-vivo model was designed with a reservoir of fluid connected to a Jackson-Pratt bulb drain. We measured the volume of fluid drained from the reservoir into the bulb while on-suction and off-suction. This was repeated using a novel modified bulb, where the bulb's outflow stopper was replaced with a one-way valve oriented to allow release of pressure from the bulb.

RESULTS

With the bulb on-suction, drainage was maintained regardless of the height of the drain relative to the reservoir. With the bulb off-suction, closed passive gravity-dependent drainage occurred only when the drain was below the fluid reservoir; drainage ceased at minimal volumes. With addition of a one-way valve and maintenance of the bulb below the level of the reservoir, drainage proceeded to completion.

CONCLUSION

How surgical drains work is not described in the leading urology and general surgery textbooks/reference books. Closed-system suction drains cannot be used to achieve passive gravity-dependent drainage without allowing release of displaced air from the bulb-lumen. The novel modified drain we describe affords reversible closed-system suction and passive drainage.

Case series - COVID-19 is unlikely to affect male fertility: Results of histopathological and reverse transcriptase polymerase chain reaction analysis

INTRODUCTION

We aimed to analyze the testicular histopathology of men who died with active COVID-19 infection.

METHODS

We performed autopsy of eight consecutive men who died of COVID-19 pneumonia. Lung and testis tissue of all men were stained for SARS-CoV-2 nucleocapsid, ACE2 receptor immunohistochemistry (IHC). H&E was performed to assess for spermatogenesis and evidence of testicle tissue damage. Reverse transcriptase polymerase chain reaction (RTPCR) analysis for SARS-CoV-2 was performed on matched lung and bilateral testicular tissue samples from all men.

RESULTS

Patient age ranged from 50-79 years. SARS-CoV-2 viral RNA was detected by RTPCR in testis tissue in one man. All eight testicle specimens that underwent IHC for ACE2 receptor showed uniformly strong immunoreactivity against all testicle cell populations. By H&E, all testis specimens showed no inflammation, vascular thrombosis, vasculitis, or morphological evidence of viral changes. One case showed diminished but not absent spermatogenesis, consistent with patient age.

CONCLUSIONS

Our results suggest that SARS-CoV-2 is unlikely to affect male fertility. Contrary to all prior histological studies, our results showed no evidence of damage to reproductive tissues that might impair fertility.

‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes

Background

Most complications after masculinizing genital gender-affirming surgery (gGAS) are associated with urethral lengthening (+UL). While many transmasculine patients desire +UL for standing urination, not all patients prioritize this benefit over the significantly increased risk of complications. Currently, phalloplasty without UL (−UL) appears to be seldom offered, and previous −UL techniques create genital anatomy that is visibly different from the anatomy created by phallourethroplasty+UL (P+UL).

Aim

To describe a novel surgical technique to create a normal-appearing phallus tip, scrotum, and perineal urethral opening that avoids urethral complications associated with +UL.

Methods

We describe our surgical technique and approach to patient counseling. We report patient satisfaction outcomes from the first cohort of patients to undergo this ‘modified phallourethroplasty’ (−UL) approach to date.

Outcomes

Among patients who elected phalloplasty over metoidioplasty, 13/40 (32.5%) patients elected P−UL. Prior to 1/2020, before we standardized how we presented this option to patients, 17.4% elected this option. Of the patients that elected P−UL, 8 have completed first-stage and 7 have completed second-stage surgeries.

Results

All patients that have undergone P−UL have expressed satisfaction with body image and urinary function. Among patients asked to rank which of 14 preoperative factors were most important (1 = most important, 14 = least important), having a normal-appearing phallus (mean rank 4.14) and minimizing complications (mean rank 8.14) were ranked more highly than ability to urinate in a standing position (mean rank 9.14). When asked what factors most influenced their choice to have −UL (ranked from 1 to 9), elimination of risks was rated the most important (mean rank 2.71) and expected decrease in risk of needing revision surgery was rated the second most important (mean rank 3.57).

Clinical Implications

The significant reduction in +UL-related complications decrease morbidity, urgent revision surgeries, and cost to our healthcare system.

Strengths and Limitations

Strengths include a novel technique that provides a surgical alternative to P+UL that eliminates the majority of phalloplasty related postoperative complications. Limitations include the small number of patients who have completed first and second stage surgery, and short follow up time.

Conclusion

It is important to understand what factors drive individual patients’ choices. Patients considering masculinizing gGAS should be offered both +UL and −UL options. The costs and benefits of each option should be presented objectively and in the context of each patient's unique priorities and needs.

Smith SM, Yuan N, Lee G, et al. ‘Modified Phallourethroplasty’ as a Surgical Alternative to Phalloplasty With Urethral Lengthening: Technique, How We Present This Option to Patients, and Clinical Outcomes. Sex Med 2022;10:100495.

Use of Voice Recordings in the Consultation of Patients Seeking Genital Gender-Affirming Surgery: An Opportunity for Broader Application Throughout Surgery?

Introduction

It has been demonstrated that patient memory for medical information is often poor and inaccurate. The use of audio recordings for patient consultation has been described; however, to our knowledge this is the first reported use of audio recordings in consultation for gender-affirming surgery. Our aim was to determine whether, and specifically how, audio recording the consultation of patients presenting for genital gender-affirming surgery would be of benefit to patients.

Materials and Methods

We began to offer all new patients the opportunity to have their consultations recorded. At the end of the consultation the recording was uploaded to a USB, which was given to the patient to keep. We then surveyed all patients who had received a copy of their recorded consultation to query the utility of having access to an audio recording of their consultation.

Results

71/72 (98.6%) patients who were given the option to have their consultation recorded chose to do so. 50/71 (70%) of patients who had their consultation recorded responded to our survey. Patients reported that having access to a voice recording of their consultation was beneficial and was viewed overwhelmingly positively.

Conclusions

Routine audio recording of patient consultations is highly beneficial to patients, with little cost to providers, and should be considered as a valuable addition to the new patient consultation. This approach may have applications in broader clinical contexts where patients face numerous, complex, and nuanced management options. The study would benefit from continued application and a larger (multi-center, international) sample.

Feminising hormone therapy reduces testicular ACE-2 receptor expression: Implications for treatment or prevention of COVID-19 infection in men

It has been proposed that men hospitalised with COVID-19 be treated with oestrogen or progesterone to improve COVID-19 outcomes. Transgender women (male-to-female) are routinely treated with oestrogen or oestrogen +progesterone for feminisation which provides a model for the effect of feminising hormones on testicular tissue. Our goal was to analyse differences in ACE-2 expression in testicles of trans-women taking oestrogen or oestrogen +progesterone. Orchiectomy specimens were collected from trans-women undergoing gender-affirming surgery, who were taking oestrogen or oestrogen+progesterone preoperatively. For controls, we used benign orchiectomy specimens from cis-gender men. All specimens were stained with H&E, Trichrome (fibrosis), insulin-like 3 antibody (Leydig cell) and ACE-2 IHC. Cells per high-powered field were counted by cell type (Leydig, Sertoli and Germ). Stain intensity was rated on a 0-2 scale. On immunohistochemistry staining for Leydig cells and ACE-2 staining, the oestrogen+progesterone cohort had fewer Leydig cells compared with controls. The oestrogen+progesterone cohort also had greater degree of tissue fibrosis compared with controls and the oestrogen cohort. This work supports the hopeful possibility that a short course of progesterone (or oestrogen+progesterone) could downregulate ACE-2 to protect men from COVID-19 infection.

How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System

Introduction

The age at which transgender women (TW) and men (TM) first experience gender dysphoria (GD) has not been reported in a U.S. population of adults seeking genital gender-affirming surgery (gGAS). Because gender is an innate part of identity, we hypothesized that untreated GD would be a part of individuals’ earliest memories. Understanding GD onset can help guide providers with when and how to focus care to patients not yet identified as “transgender

Aim

(i) Determine the age at which transgender adults seeking gGAS first experience GD

(ii) Determine the number of life-years that transgender adults spend living with untreated GD

Methods

During initial consultation for gGAS, we asked patients the earliest age at which they experienced GD and the age at which they had their earliest episodic memory. We also queried history of anxiety, depression, and suicide attempt.

Main Outcome Measures

Patients self-reported their earliest recollections of experiencing GD, earliest memories in general, and history of anxiety, depression, and suicide attempt.

Results

Data from 155 TW (mean age 41.3; SD 16.3) and 55 TM (mean age 35.4; SD 10.8) were collected. Most patients (TM: 78%; TW: 73%) reported experiencing GD for the first time between ages 3 and 7 years.  For TM the mean age of onset was 6.17 years; for TW it was 6.71 years. A total of 81% of TW and 80% of TM described their first recollection of GD as one of their earliest memories. Mean years of persistent GD before the start of gender transition were 22.9 (TM) and 27.1 (TW). Rates of depression, anxiety, and suicide ideation decreased following gender transition.

Conclusion

Our findings suggest that GD typically manifests in early childhood and persists untreated for many years before individuals commence gender transition. Diagnosis and early management during childhood and adolescence can improve quality of life and survival.

Zaliznyak M, Yuan N, Bresee C, et al. How Early in Life do Transgender Adults Begin to Experience Gender Dysphoria? Why This Matters for Patients, Providers, and for Our Healthcare System. Sex Med 2021;9:100448.

Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions

INTRODUCTION

Masculinizing genital gender affirmation surgery (MgGAS) has witnessed significant change in recent years. With the increasing number of patients seeking out GAS, optimization of techniques is mandated.

OBJECTIVES

To critically review the evolution of MgGAS, in a manner that encompasses the history and scope of the procedures, including phalloplasty with and without urethral lengthening, metoidioplasty with and without urethral lengthening, penile prosthesis placement, scrotoplasty, testicular prosthesis placement, vaginectomy, and hysterectomy.

METHODS

A comprehensive literature review was conducted in accordance with PRISMA guidelines, using PubMed. For our search, we generated a comprehensive list of MgGAS, combined with synonyms for GAS to ensure that articles included transgender cohorts. We identified a total of 547 articles from the search terms. Of these articles, 144 abstracts were relevant. Among these abstracts, 108 manuscripts were reviewed in full of which 98 were acceptable for inclusion. We excluded non-English-language studies without translation and studies that did not describe primary gGAS (eg, revision surgeries).

RESULTS

The evolution of MgGAS encompasses mostly refinements of pre-existing procedures, rather than new techniques or "watershed" procedures. The literature is somewhat lacking in outcomes-reporting that identifies the specific anatomy and surgical technique(s) used during gGAS. Without clarity regarding anatomy and technique, it is not feasible to compare surgical outcomes.

CONCLUSION

There is no ideal MgGAS; thus, it is critical that the physician assist the patient in understanding the outcomes and potential morbidity of the procedures to make the most informed decision. We envision that the future of MgGAS will advance with refinement of surgical techniques that minimize complications, improvement of tissue therapeutic technologies, new surgical tools and prosthetics designed for gGAS, advances in aftercare, and an immense selection of surgical options. Walton A, Hellstrom WJG, Garcia M. Options for Masculinizing Genital Gender Affirming Surgery: A Critical Review of the Literature and Perspectives for Future Directions. Sex Med Rev 2021;9:605-618.

Requirement of Mental-Health Referral Letters for Staged and Revision Genital Gender-Affirming Surgeries: An Unsanctioned Barrier to Care

BACKGROUND

The World Professional Association for Transgender Health (WPATH) recommends referral letters from two mental-health providers within one year of gender-affirming genital surgery (gGAS) to ensure patient readiness before primary surgeries. Many U.S. health-insurance plans will not authorize second- and third-stage surgeries or revision surgeries without two referral letters. Such requirements are not supported by WPATH guidelines.

OBJECTIVES

This study investigates insurance requirements for referral letters and their negative impact on care.

MATERIALS AND METHODS

We retrospectively reviewed all gGAS cases over a 4-year period at our tertiary care medical center. Referral-letter requirements for insurance authorization were documented. The nation's largest insurance companies, including commercial, state-, and federally funded plans, were contacted to confirm requirements. We prospectively recorded time needed to complete insurance authorization for a patient subset. WPATH publications were reviewed.

RESULTS

Nearly all reviewed U.S. health-insurance plans required annually updated referral letters for each gGAS procedure, including staged and revision surgeries. No updated letters changed clinical management. Referral-letter requirements delayed care. WPATH states that letters should not be needed for staged surgeries. Some plans required letters even for initial surgical consultation, a practice not supported by WPATH.

DISCUSSION AND CONCLUSION

Insurance companies' requirements for referral letters impede care and contradict WPATH guidelines. We advocate that, at minimum, referral letters should not be required for surgical consultations or for staged or revision surgeries after a patient has already had first-stage primary gGAS. Universal referral-letter requirements provide minimal clinical value, delay care, increase costs, and exacerbate gender dysphoria by invalidating gender transition. As with all procedures, surgeons themselves should be responsible for assessing patients' surgical readiness. Significant changes in mental-health status or social situation should prompt surgeons to seek reassessment. WPATH recommendations regarding referral letters should be clarified and consolidated into a single document.

Cancer screening in the transgender population: a review of current guidelines, best practices, and a proposed care model

Over the last 50 years cancer mortality has decreased, the biggest contributor to this decrease has been the widespread adoption of cancer screening protocols. These guidelines are based on large population studies, which often do not capture the non-gender conforming portion of the population. The aim of this review is to cover current guidelines and practice patterns of cancer screening in transgender patients, and, where evidence-based data is lacking, to draw from cis-gender screening guidelines to suggest best-practice screening approaches for transgender patients. We performed a systematic search of PubMed, Google Scholar and Medline, using all iterations of the follow search terms: transgender, gender non-conforming, gender non-binary, cancer screening, breast cancer, ovarian cancer, uterine cancer, cervical cancer, prostate cancer, colorectal cancer, anal cancer, and all acceptable abbreviations. Given the limited amount of existing literature inclusion was broad. After eliminating duplicates and abstract, all queries yielded 85 unique publications. There are currently very few transgender specific cancer screening recommendations. All the guidelines discussed in this manuscript were designed for cis-gender patients and applied to the transgender community based on small case series. Currently, there is not sufficient to evidence to determine the long-term effects of gender-affirming hormone therapy on an individual’s cancer risk. Established guidelines for cisgender individuals and can reasonably followed for transgender patients based on what organs remain in situ. In the future comprehensive cancer screening and prevention initiatives centered on relevant anatomy and high-risk behaviors specific for transgender men and women are needed.

Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Gender-Affirming Genital Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Services

BACKGROUND

To date, a comprehensive state-by-state assessment of transgender transition-related health care coverage for gender-affirming hormone therapy (GAHT) and genital gender-affirming surgery (GAS) has not been reported.

AIMS

The aims of this study were 1) to verify which U.S. states' Medicaid systems do/do not cover GAHT and GAS; 2) to assess the ease/difficulty for patients to determine whether GAHT and GAS are Medicaid-covered benefits; and 3) to understand possible state-related predictors of Medicaid coverage for gender-affirming care.

METHODS

We reviewed the official Medicaid Handbook and website for all 51 states (+D.C.) and 5 territories to confirm whether GAHT and GAS are covered benefits. When indeterminate, we called the Medicaid office in each state, and for many, Medicaid managed care organizations (MCOs), and individual in-state providers, to confirm coverage. We recorded our experiences, number of, and duration of phone calls to confirm coverage.

OUTCOMES

The main outcome was a definitive answer from the state/territory's Medicaid program or MCOs regarding whether GAHT and GAS are/are not covered benefits. Secondary outcome measures included responses we received and the total number/duration of phone calls necessary to confirm coverage.

RESULTS

Only 12 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAHT in their Medicaid Handbook/webpages. We confirmed that 34 of 51 state Medicaid programs do cover GAHT, whereas 9 of 51 states' and 2 of 5 territories' do not. We could not confirm coverage of GAHT in 8 of 51 states and 3 of 5 territories. Only 26 of 51 states and 0 of 5 territories featured their policy regarding coverage for GAS in their Medicaid Handbook/webpages. We confirmed that 25 of 51 state Medicaid programs do cover GAS, whereas 22 of 51 states' and 3 of 5 territories' do not. We could not confirm coverage of GAS in 4 of 51 states and 2 of 5 territories. Up to 12 calls, lasting up to 125 minutes, were required to confirm coverage for GAHT/GAS.

CLINICAL IMPLICATIONS

Our findings indicate that important health care access barriers/disparities exist today and warrant improvement.

STRENGTHS & LIMITATIONS

To our knowledge, this is the most comprehensive assessment of transgender transition-related health care coverage. Limitations include possible bias, as it could be that we were more persistent than actual patients would be to determine service coverage, and a lack of specificity regarding which specific hormone formulations or procedures are/are not covered.

CONCLUSION

Our findings show that only 34 of 51 (67%) states' Medicaid programs include GAHT and 25 of 51 (49%) include GAS as covered benefits. Our experience suggests that the process to confirm coverage can be especially time-consuming and frustrating for patients. Zaliznyak M, Jung EE, Bresee C, et al. Which U.S. States' Medicaid Programs Provide Coverage for Gender-Affirming Hormone Therapy and Genital Gender-Affirming Surgery for Transgender Patients?: A State-by-State Review, and a Study Detailing the Patient Experience to Confirm Coverage of Service. J Sex Med 2021;18:410-422.

Age at First Experience of Gender Dysphoria Among Transgender Adults Seeking Gender-Affirming Surgery

This cross-sectional study examines the age at which US transgender adults first experienced gender dysphoria and the number of life-years that transgender adults lived with untreated gender dysphoria and its comorbidities before seeking gender-affirming surgery.

Fertility preservation options for transgender individuals

Gender affirming medical and surgical treatments affect the reproductive potential of transgender individuals. Prior to the development of assisted reproductive technologies (ART), genital gender-affirming surgery frequently eliminated a patient’s reproductive potential. Today, all patients should be counseled on their fertility preservation (FP) options before medical and surgical transition, yet this appears to seldom occur in practice. The following review is the result of a systematic literature search of PubMed, Medline and Google Scholar to identify current and future FP options, barriers to treatment patients face, practice patterns of transgender health care providers, and if there were any standardized counseling protocols. Options for transwomen at any point in their transition range from simply providing a semen sample to be used with assistive reproductive techniques to experimental techniques involving testicular cryopreservation followed by in vitro initiation of spermatogenesis. Transmen before and after starting hormone therapy can pursue any assistive reproductive techniques available for ciswomen. Future options currently under investigation include ovarian tissue cryopreservation (OTC) with in vitro oocyte maturation. In addition to counseling about their FP options, patients should be advised prospectively about the requirements, process details, the total costs associated with achieving pregnancy, and the inherent risks associated with using preserved genetic material including risk of failure, and maternal and fetal health risks. Transgender patients report using assistive reproductive services difficult, due to a lack of dialogue about fertility and the lack of information offered to them- presumably because their circumstances do not fit into a traditional narrative familiar to providers. Physicians and health care providers would benefit from better educational tools to help transgender patients make informed decisions and better training about transgender patients in general, and FP options available to them.

Sexual Function After Shallow and Full-Depth Vaginoplasty: Challenges, Clinical Findings, and Treatment Strategies- Urologic Perspectives

This article presents an ordered review of the role of sexual function in discussion and planning before genital gender-affirming surgery and through recovery to initiation of sexual activity after surgery. Strategies are proposed to optimize sexual function postoperatively. Clinical observations are reviewed and genital and surgical anatomy is reviewed to explain the rationale for the treatment strategies proposed. The importance of offering shallow-depth vaginoplasty to all patients is discussed. Lastly, specific strategies to maximize and enhance recovery of erogenous sensation after surgery are focused on.

Up and Away: Five Decades of Urologic Investigation in Microgravity

A renewed global interest in manned space exploration has emerged, propelled by the challenge of reaching a new frontier: travel to the Red Planet, Mars. As the physiological changes induced by microgravity bear direct relevance to the safety and viability of these goals, we provide a historical narrative of the urologic investigations in space. We review the significant contributions to the understanding of the urologic consequences associated with exposure to microgravity, considerations for prolonged missions, and forward-looking efforts to manage emergent conditions remotely. Historical insights gleaned are poised to inform interplanetary travel, where urologic pathology will remain an important practical consideration.

Mucosal stromal fibroblasts markedly enhance HIV infection of CD4+ T cells

Understanding early events of HIV transmission within mucosal tissues is vital for developing effective prevention strategies. Here, we report that primary stromal fibroblasts isolated from endometrium, cervix, foreskin, male urethra, and intestines significantly increase HIV infection of CD4+ T cells-by up to 37-fold for R5-tropic HIV and 100-fold for X4-tropic HIV-without themselves becoming infected. Fibroblasts were more efficient than dendritic cells at trans-infection and mediate this response in the absence of the DC-SIGN and Siglec-1 receptors. In comparison, mucosal epithelial cells secrete antivirals and inhibit HIV infection. These data suggest that breaches in the epithelium allow external or luminal HIV to escape an antiviral environment to access the infection-favorable environment of the stromal fibroblasts, and suggest that resident fibroblasts have a central, but previously unrecognized, role in HIV acquisition at mucosal sites. Inhibiting fibroblast-mediated enhancement of HIV infection should be considered as a novel prevention strategy.

Sex, Gender, and Transgender: Metabolic Impact of Cross Hormone Therapy

Most preclinical and clinical, animal, and human research has been biased with respect to sex and even more so with respect to gender. In fact, little is known about the impact of sex and even less about the influence of gender on overall metabolic processes. The National Institutes of Health has recognized this gap in scientific knowledge and now mandates that studies be conducted in both sexes and to include gender as variables influencing physiological processes such as metabolism. It is therefore critical to understand and appreciate how to incorporate sex and gender in preclinical and clinical research in order to enhance our understanding of the mechanisms by which metabolic processes differ by sex and gender. In this chapter, we define sex and gender and discuss when sex and gender are not aligned, such as that which occurs in transgender individuals, and how this impacts metabolic processes. We discuss the importance of understanding the influence and interactions between sex hormones and sex chromosomes rather than focusing on their relative contributions to metabolism in isolation. This knowledge will optimize therapies specific for individuals which need to encompass sex and gender.

Correction: Endoscopic Gold Fiducial Marker Placement into the Bladder Wall to Optimize Radiotherapy Targeting for Bladder-Preserving Management of Muscle-Invasive Bladder Cancer: Feasibility and Initial Outcomes

[This corrects the article DOI: 10.1371/journal.pone.0089754.].

Laser hair removal for genital gender affirming surgery

Genital gender affirming surgery (GAS) involves reconstruction of the genitals to match a patient’s identified sex. The use of hair-bearing flaps in this procedure may result in postoperative intra-vaginal and intra-urethral hair growth and associated complications, including lower satisfaction with genital GAS. Despite the significant increase in genital GAS within the past 50 years, there is limited data regarding hair removal practices in preparation for genital GAS and notable variation in hair removal techniques among dermatologists and other practitioners. We present a literature review, recommendations from our experience, and a practical laser hair removal (LHR) approach to hair removal prior to genital GAS.

Overall satisfaction, sexual function, and the durability of neophallus dimensions following staged female to male genital gender confirming surgery: the Institute of Urology, London U.K. experience

Background and purpose

What factors influence transgender men’s decisions to undergo (and to not undergo) specific genital gender confirming surgeries (GCS) has not been described in the literature. Sexual function outcomes related to clitoral transposition and penile prosthesis placement is also not well described. Durability of neophallus dimensions after phalloplasty has not been described. A better understanding of these factors is necessary for pre-op counseling. We sought to assess patient genital-GCS related satisfaction, regret, pre/post-op sexual function, genital preferences, and genital measurements post-op.

Materials and methods

We evaluated ten female to male transgender patients who had previously undergone suprapubic pedicle-flap phalloplasty [suprapubic phalloplasty (SP); N=10] and 15 who had undergone radial artery forearm-flap phalloplasty [(RAP); N=15; 5/15 without and 10/15 with cutaneous nerve to clitoral nerve anastomosis] at our center (UK). We queried patients’ surgery related preferences and concerns, satisfaction, and sexual function pre/post-surgery, and accounted for whether patients had undergone clitoral transposition and/or cutaneous-to-clitoral nerve anastomosis. We measured flaccid and (where applicable) erect length and girth using a smart-phone app we designed.

Results

Mean age at surgery and follow-up for those that underwent SP was 35.1 and 2.23 years, and 34 and 6.8 for those that underwent RAP. Mean satisfaction scores were 9.1/10 and 9/10 for those that underwent SP and RAP, respectively. No patient (0%) regretted starting genital-GCS surgery. All (100%) patients that could achieve orgasm before GCS with clitoral transposition could achieve orgasm after surgery, and the vast majority reported preserved quality of erogenous sensation by our transposition technique. All (100%) RAP and 9/10 SP patients reported masturbation with their phallus. Inflatable penile prosthesis placement was not associated with decreased erogenous sensation/orgasm. Penile dimensions were relatively stable through follow-up for both groups. Our App length measurements correlated with a ruler within ±<4.5%.

Conclusions

Female-to-male genital-GCS offered in 3-stages was associated with high overall satisfaction and no regret among our sample. Sexual function appears to be preserved after both clitoral transposition and inflatable prosthesis placement, and consolidation of erogenous sensation to the phallus was described as important to all subjects. Discussion of patient’s pre-op sexual function, as well as specific concerns and preferences related to specific genital-GCS surgeries is important.

Endoscopic gold fiducial marker placement into the bladder wall to optimize radiotherapy targeting for bladder-preserving management of muscle-invasive bladder cancer: feasibility and initial outcomes

Background and Purpose

Bladder radiotherapy is a management option for carefully selected patients with muscle-invasive bladder cancer. However, the inability to visualize the tumor site during treatment and normal bladder movement limits targeting accuracy and increases collateral radiation. A means to accurately and reliably target the bladder during radiotherapy is needed.

Materials and Methods

Eighteen consecutive patients with muscle-invasive bladder cancer (T1–T4) elected bladder-preserving treatment with maximal transurethral resection (TUR), radiation and concurrent chemotherapy. All underwent endoscopic placement of 24-K gold fiducial markers modified with micro-tines (70 [2.9×0.9 mm.]; 19 [2.1×0.7 mm.) into healthy submucosa 5-10 mm. from the resection margin, using custom-made coaxial needles. Marker migration was assessed for with intra-op bladder-filling cystogram and measurement of distance between markers. Set-up error and marker retention through completion of radiotherapy was confirmed by on-table portal imaging.

Results

Between 1/2007 and 7/2012, a total of 89 markers (3–5 per tumor site) were placed into 18 patients of mean age 73.6 years. Two patients elected cystectomy before starting treatment; 16/18 completed chemo-radiotherapy. All (100%) markers were visible with all on-table (portal, cone-beam CT), fluoroscopy, plain-film, and CT-scan imaging. In two patients, 1 of 4 markers placed at the tumor site fell-out (voided) during the second half of radiotherapy. All other markers (80/82, 98%) were present through the end of radio-therapy. No intraoperative (e.g. uncontrolled bleeding, collateral injury) or post-operative complications (e.g. stone formation, urinary tract infection, post-TUR hematuria >48 hours) occurred. Use of micro-tined fiducial tumor-site markers afforded a 2 to 6-fold reduction in bladder-area targeted with high-dose radiation.

Discussion

Placement of the micro-tined fiducial markers into the bladder was feasible and associated with excellent retention-rate and no complications. All markers were well-visualized during radiotherapy with all imaging modalities. Bladder fiducial markers improve targeting accuracy, and may increase treatment efficacy and reduce morbidity from collateral radiation.

A pathophysiology-based approach to the management of early priapism

Priapism is a rare condition that involves persistent penile erection for greater than 4 h. Distinct variants exist, each with unique characteristics. Ischemic priapism is a painful medical emergency that may occur as a result of veno-occlusion leading to hypoxia and tissue death. Recurrent bouts of ischemic priapism, or stuttering priapism, require treatment for individual attacks as well as long-term prevention. Non-ischemic priapism is associated with trauma and may be managed conservatively. Recent advances into the pathophysiology of priapism have allowed the development of treatment algorithms that specifically target the mechanisms involved. In this review, we outline the basics of smooth muscle contraction and describe how derangement of these pathways results in priapism. A pathophysiological approach to the treatment of priapism is proposed with duration-based algorithms presented to assist in management.

Prognostic factors in Chinese patients with penile invasive squamous cell carcinoma

The incidence of penile cancer varies by ethnicity and is not well described among Chinese patients. We performed a retrospective study to assess the prognostic factors in Chinese patients with penile invasive squamous cell carcinoma (SCC). We reviewed the medical records of 83 consecutive patients treated at the National Urological Cancer Center (Beijing, China). The Kaplan-Meier method, log-rank test, and multivariate Cox proportional hazard model were used to identify the prognostic factors predicting for cancer-specific survival (CSS). Univariate and multivariate logistic regression analysis were used to analyze the predictive factors for lymph node metastasis (LNM). A total of 55 patients were followed. Twelve patients (20%) died from the disease during follow-up. By univariate analysis, older age (≥ 49 years; P = .048), radical resection (compared with local/partial resection; P = .040), high histological grade (P = .037), and LNM (P < .001) were each associated with poor prognosis. By multivariate analysis, chronological age (P = .011) and LNM (P = .002) were independent prognostic factors. High histological grade (P = .003) was an independent predictive factor for LNM. In our series, chronological age and LNM were independent prognostic factors for CSS. The histological grade, not the tumor stage, was still an influential predictive factor of LNM in Chinese patients with penile SCC.

Preimplantation mouse embryo selection guided by light-induced dielectrophoresis

Selection of optimal quality embryos for in vitro fertilization (IVF) transfer is critical to successful live birth outcomes. Currently, embryos are chosen based on subjective assessment of morphologic developmental maturity. A non-invasive means to quantitatively measure an embryo's developmental maturity would reduce the variability introduced by the current standard. We present a method that exploits the scaling electrical properties of pre-transfer embryos to quantitatively discern embryo developmental maturity using light-induced dielectrophoresis (DEP). We show that an embryo's DEP response is highly correlated with its developmental stage. Uniquely, this technique allows one to select, in sequence and under blinded conditions, the most developmentally mature embryos among a mixed cohort of morphologically indistinguishable embryos cultured in optimized and sub-optimal culture media. Following assay, embryos continue to develop normally in vitro. Light-induced dielectrophoresis provides a non-invasive, quantitative, and reproducible means to select embryos for applications including IVF transfer and embryonic stem cell harvest.

Treatment of erectile dysfunction in the obese type 2 diabetic ZDF rat with adipose tissue-derived stem cells

INTRODUCTION

Erectile dysfunction (ED) is a major complication of type 2 diabetes, and many diabetic men with ED are refractory to common ED therapies.

AIM

To determine whether autologous adipose tissue-derived stem cells (ADSCs) injected into the penis of impotent type 2 diabetic rats improve erectile function.

MAIN OUTCOME MEASURES

Blood glucose levels, intracavernous pressure (ICP) increase upon cavernous nerve (CN) electrostimulation, and immunohistochemistry.

METHODS

Twenty-two male Zucker diabetic fatty (ZDF) rats were used. At 22 weeks of age, all the animals underwent unilateral CN electrostimulation and ICP measurement to confirm impotence. Paragonadal adipose tissue was harvested to procure ADSCs. The impotent animals were randomized to ADSC treatment and sham control groups. At 23 weeks of age, the treatment group animals underwent a penile injection of 1 million ADSCs; the control group animals received vehicle only. Erectile function studies were repeated at 26 weeks of age, followed by tissue harvest.

RESULTS

The rats developed diabetes within the first 10 weeks of age. At 22 weeks of age, 20 out of the 22 rats presented with ED. The post-treatment ICP increase during CN stimulation and ICP increase/mean arterial pressure were significantly higher in the treatment group compared with controls. Three weeks after injection into the corpus cavernosum, only a small number of BrdU-labeled ADSCs was detectable within corporal tissue of the treatment group. There was a significant increase in neuronal nitric oxide synthase (nNOS) in the penile dorsal nerve and in the number of endothelial cells in the corpora cavernosa of the rats in the treatment group.

CONCLUSION

Autologous ADSCs injected into the penis were effective to improve erectile function and to alter the microarchitecture of the corpus cavernosum. Since the number of ADSCs retained in the corpus cavernosum is very small, we postulate that their paracrine function, not trans-differentiation to smooth muscle or endothelial cells, is responsible for the improvement in penile function.

Erectogenic and neurotrophic effects of icariin, a purified extract of horny goat weed (Epimedium spp.) in vitro and in vivo

INTRODUCTION

Epimedium species (aka horny goat weed) have been utilized for the treatment of erectile dysfunction in Traditional Chinese Medicine for many years. Icariin (ICA) is the active moiety of Epimedium species.

AIM

To evaluate the penile hemodynamic and tissue effects of ICA in cavernous nerve injured rats. We also studied the in vitro effects of ICA on cultured pelvic ganglia.

METHODS

Rats were subjected to cavernous nerve injury and subsequently treated for 4 weeks with daily gavage feedings of a placebo solution of normal saline and Dimethyl sulfoxide (DMSO) vs. ICA dissolved in DMSO at doses of 1, 5, and 10 mg/kg. A separate group underwent a single dose of ICA 10 mg/kg 2 hours prior to functional testing. Functional testing with cavernous nerve stimulation and real-time assessment of intracavernous pressure (ICP) was performed at 4 weeks. After functional testing, penile tissue was procured for immunohistochemistry and molecular studies. In separate experiments, pelvic ganglia were excised from healthy rats and cultured in the presence of ICA, sildenafil, or placebo culture media.

MAIN OUTCOME MEASURE

Ratio of ICP and area under the curve (AUC) to mean arterial pressure (MAP) during cavernous nerve stimulation of subject rodents. We also assayed tissue expression of neuronal nitric oxide synthase (nNOS), eNOS: endothelial nitric oxide synthase (eNOS), calponin, and apoptosis via immunohistochemistry and Western blot. Serum testosterone and luteinizing hormone (LH) were assayed using enzyme-linked immunosorbant assay (ELISA). Differential length of neurite outgrowth was assessed in cultured pelvic ganglia.

RESULTS

Rats treated with low-dose ICA demonstrated significantly higher ICP/MAP and AUC/MAP ratios compared with control and single-dose ICA animals. Immunohistochemistry and Western blot were revealing of significantly greater positivity for nNOS and calponin in penile tissues of all rats treated with ICA. ICA led to significantly greater neurite length in cultured specimens of pelvic ganglia.

CONCLUSION

ICA may have neurotrophic effects in addition to known phosphodiesterase type 5 inhibiting effects.