Outcomes of penile inversion vaginoplasty and robotic-assisted peritoneal flap vaginoplasty in obese and nonobese patients.

AIM: To explore the impact of body mass index (BMI) on the outcomes of gender-affirming vaginoplasty. METHODS: A cohort consisting of all gender-affirming vaginoplasties in our practice between September 27th, 2018, and September 1st, 2022 were identified, and data were retrospectively collected. Patients were classified as obese if their BMI was ≥30 kg/m2 at the time of surgery and nonobese if their BMI was <30 kg/m2 . Complications were assigned a Clavien-Dindo grade and grouped as Grade ≥2 versus Grade ≤1. Patient-reported functional outcomes of intact erogenous sensation, tactile sensation, ability to achieve penetrative vaginal intercourse, and cosmetic satisfaction were assessed. RESULTS: A total of 58 patients with a mean follow-up time of 6.9 months were included. Seventeen patients (mean BMI = 36.8 kg/m2 ) were classified as obese and 41 patients (mean BMI = 25.1 kg/m2 ) were classified as nonobese. No significant differences in outcomes were identified in the obese versus nonobese groups in terms of the incidence of complications. Patient-reported functional outcomes did not differ significantly between the two groups. CONCLUSIONS: Similar results can be achieved with gender-affirming vaginoplasty in obese patients when compared to their nonobese counterparts. Eligibility for this procedure should not be restricted based on BMI alone.

Gender-affirming vaginoplasty: Technical considerations in patients with genital skin deficiency.

INTRODUCTION: Gender dysphoria affects over 1 million American adults. Vaginoplasty is a critical step in gender affirmation, and many patients have insufficient genital skin for full-depth penile inversion vaginoplasty (PIV). We reviewed the literature for technical considerations addressing this and present our data supporting the use of peritoneal flaps (Davydov technique). MATERIALS AND METHODS: A comprehensive review of modern literature was conducted. Second, we present a retrospective case review of our experience with PIV, including data from procedures utilizing peritoneal flaps. RESULTS: We identified 20 original articles, including retrospective and prospective case and cohort studies. Approaches included the application of local soft tissue grafts and flaps, peritoneal flaps, and intestinal segments. Between June 2018 and February 2021, 47 patients at our institution, underwent PIV for the treatment of gender dysphoria. Nineteen of those patients underwent robotic-assisted peritoneal flap procedure in addition to PIV. In this cohort, the mean follow-up was 200.6 ± 124.8 days. Mean neovaginal depth was 13.1 ± 3.0 cm intra-operatively and 11.0 cm at the last follow-up. Twenty-six percent of complications were Clavien Grade 1 or 2; others included wound dehiscence (30.4%), perianal and urethral fistula (13.0%), and neovaginal stenosis (8.7%). The majority of patients reported satisfactory results in terms of sexual function with intact tactile and erogenous sensation. Almost half were able to have penetrative vaginal intercourse at the last follow-up. We did not aim to perform statistical calculations to compare the outcomes of PIV with and without robotic-assisted peritoneal flap augmentation, as the groups were not constructed in that manner. However, it is evident that anatomical and functional results as well as the distribution of postoperative complications seem similar. CONCLUSION: Vaginoplasty is indicated in a growing population of patients with a wide range of medical histories and anatomic variations. Genitourinary reconstructive surgeons must have several methods to achieve full-depth vaginoplasty in cases of inadequate genital skin. Peritoneal flaps serve as a versatile, safe, and functionally advantageous solution.

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.

International urogynecology consultation chapter 1 committee 2: Epidemiology of pelvic organ prolapse: prevalence, incidence, natural history, and service needs.

INTRODUCTION AND HYPOTHESIS: This narrative review describes the existing epidemiologic literature and identifies gaps regarding pelvic organ prolapse (POP) prevalence, incidence, natural history, and current and future service needs. MATERIALS AND METHODS: A PubMed search identified relevant citations published in 2000 or later. Pre-specified criteria were used to screen titles, abstracts, and manuscripts, including reference sections. Study findings were summarized to define what is known, identify gaps in current knowledge, and suggest priority areas for future research. RESULTS: The reported prevalence of POP varies widely (1-65%) based on whether its presence is ascertained by symptoms (1-31%), pelvic examination (10-50%), or both (20-65%). Most existing population-based surveys do not include physical examination data. White women from higher income countries are overrepresented in the existing literature. Incidence and natural history data are limited and consist mainly of cohorts that follow women after pregnancy or menopause. Given global increases in aging populations in well-resourced countries, the need for POP treatment is anticipated to increase in the coming decades. In lower and middle income countries (LMICs) where demographic trends are different, there is a dearth of information about anticipated POP service needs. CONCLUSION: Future POP incidence, prevalence, and natural history studies should include non-white women from LMICs and should combine pelvic examination data with validated patient-reported outcome measures when feasible. Anticipated future service needs differ globally, with a greater demand for POP treatment services in well-resourced settings where aging populations are prevalent.

Consensus Definitions and Interpretation Templates for Magnetic Resonance Imaging of Defecatory Pelvic Floor Disorders: Proceedings of the Consensus Meeting of the Pelvic Floor Disorders Consortium of the American Society of Colon and Rectal Surgeons, the Society of Abdominal Radiology, the International Continence Society, the American Urogynecologic Society, the International Urogynecological Association, and the Society of Gynecologic Surgeons.

The Pelvic Floor Disorders Consortium (PFDC) is a multidisciplinary organization of colorectal surgeons, urogynecologists, urologists, gynecologists, gastroenterologists, radiologists, physiotherapists, and other advanced care practitioners. Specialists from these fields are all dedicated to the diagnosis and management of patients with pelvic floor conditions, but they approach, evaluate, and treat such patients with their own unique perspectives given the differences in their respective training. The PFDC was formed to bridge gaps and enable collaboration between these specialties. The goal of the PFDC is to develop and evaluate educational programs, create clinical guidelines and algorithms, and promote high quality of care in this unique patient population. The recommendations included in this article represent the work of the PFDC Working Group on Magnetic Resonance Imaging of Pelvic Floor Disorders (members listed alphabetically in Table 1). The objective was to generate inclusive, rather than prescriptive, guidance for all practitioners, irrespective of discipline, involved in the evaluation and treatment of patients with pelvic floor disorders.

Complications of urethral bulking therapy for female stress urinary incontinence.

AIMS: To review, report, and discuss the complications associated with urethral bulking therapy in female stress urinary incontinence. METHODS: An extensive nonsystematic literature review on complications associated with injectable bulking agents used in the clinical practice was conducted. We reviewed articles published in English and indexed in the PubMed, Embase, and Google Scholar databases. Original articles, case reports, and case series were taken into consideration. Data regarding the safety of injectable bulking agents and the complications associated with their utility within the context of urethral bulking therapy for female stress urinary incontinence were extracted and discussed. RESULTS: Approximately, 1/3 of the patients experience some type of a complication after urethral bulking therapy. The majority of these complications are of low grade, transient, do not necessitate additional surgical intervention, and amenable to treatment with conservative measures such as clean intermittent catheterization and antibiotics. However, more serious complications such as abscess formation, delayed hypersensitivity reactions, and vaginal erosion have been reported. Some of the injectable bulking agents have been withdrawn from the market because of their unfavorable adverse effect profile. CONCLUSIONS: Urethral bulking therapy can be considered as a low-risk procedure. However, it is not without complications which can be severe in rare instances. The search for the ideal urethral bulking agent is ongoing and future comparative studies assessing the safety and efficacy of these compounds in randomized controlled settings are warranted.

Coital Incontinence in Women With Urinary Incontinence: An International Study.

INTRODUCTION: Coital urinary incontinence (CUI) is not much explored during clinical history, and this could lead to an underestimation of the problem. AIM: To evaluate the prevalence and clinical risk factors of CUI in women with urinary incontinence (UI), and to measure the impact of CUI on women's sexuality and quality of life. METHODS: This was a multicenter international study, conducted in Italy, Greece, the United States, and Egypt. Inclusion criteria were: sexually active women with UI and in a stable relationship for at least 6 months. Exclusion criteria were: age <18 years and unstable relationship. The UI was classified as stress UI (SUI), urgency UI (UUI), and mixed UI (MUI). Women completed a questionnaire on demographics and medical history, in particular on UI and possible CUI and the timing of its occurrence, and the impact of CUI on quality and frequency of their sexual life. MAIN OUTCOME MEASURES: To evaluate the CUI and its impact on sexual life we used the open questions on CUI as well as the International Consultation on Incontinence questionnaire and Patient Perception of Bladder Condition questionnaire. RESULTS: In this study 1,041 women (age 52.4 ± 10.7 years) were included. In all, 53.8% of women had CUI: 8% at penetration, 35% during intercourse, 9% at orgasm, and 48% during a combination of these. Women with CUI at penetration had a higher prevalence of SUI, women with CUI during intercourse had higher prevalence of MUI with predominant SUI, and women with CUI at orgasm had higher prevalence of UUI and MUI with predominant UUI component. Previous hysterectomy was a risk factor for CUI during any phase, while cesarean delivery was a protective factor. Previous failed anti-UI surgery was a risk factor for CUI during penetration and intercourse, and body mass index >25 kg/m2 was a risk factor for CUI at intercourse. According to International Consultation on Incontinence questionnaire scores, increased severity of UI positively correlated with CUI, and had a negative impact on the quality and frequency of sexual activity. CLINICAL IMPLICATIONS: This study should encourage physicians to evaluate the CUI; in fact, it is an underestimated clinical problem, but with a negative impact on quality of life. STRENGTHS & LIMITATIONS: The strength of this study is the large number of women enrolled, while the limitation is its observational design. CONCLUSION: CUI is a symptom that can affect sexual life and should be investigated during counseling in all patients who are referred to urogynecological centers. Illiano E, Mahfouz W, Giannitsas K, et al. Coital Incontinence in Women With Urinary Incontinence: An International Study. J Sex Med 2018;15:1456-1462.

Gender Confirmation Surgery: Guiding Principles.

BACKGROUND: At this time, no formal training or educational programs exist for surgeons or surgery residents interested in performing gender confirmation surgeries. AIM: To propose guiding principles designed to aid with the development of formal surgical training programs focused on gender confirmation surgery. METHODS: We use expert opinion to provide a "first of its kind" framework for training surgeons to care for transgender and gender nonconforming individuals. OUTCOMES: We describe a multidisciplinary treatment model that describes an educational philosophy and the institution of quality parameters. RESULTS: This article represents the first step in the development of a structured educational program for surgical training in gender confirmation procedures. CLINICAL IMPLICATIONS: The World Professional Association for Transgender Health Board of Directors unanimously approved this article as the framework for surgical training. STRENGTHS AND LIMITATIONS: This article builds a framework for surgical training. It is designed to provide concepts that will likely be modified over time and based on additional data and evidence gathered through outcome measurements. CONCLUSION: We present an initial step in the formation of educational and technical guidelines for training surgeons in gender confirmation procedures. Schechter LS, D'Arpa S, Cohen MN, et al. Gender Confirmation Surgery: Guiding Principles. J Sex Med 2017;14:852-856.

Two-year outcomes for the Altis® adjustable single incision sling system for treatment of stress urinary incontinence.

AIMS: Evaluate the Altis single-incision sling for treatment of female stress urinary incontinence through 24 months. METHODS: This was a prospective, multi-center, industry-sponsored (Coloplast Corp.), single-arm trial with primary efficacy defined as ≥50% reduction in 24 h pad weight from baseline at 6-months. Device- and procedure-related complications were collected for safety. Secondary measures included cough stress test, Urogenital Distress Inventory-Short Form, Incontinence Impact Questionnaire-Short Form, and Patient Global Impression of Improvement. RESULTS: Of the 113 women implanted, 94 remained at 24-months. The average procedure time was 12.8 ± 8.4 min across all settings. Of those with paired baseline and follow-up data at 24-months, 90.0% (81/90) achieved ≥50% reduction in pad weight, 81.1% (73/90) were dry (pad weight ≤4.0 g), and 87.9% (80/91) had a negative cough stress test. Significant median reductions of 44.4 in Urogenital Distress Inventory (P-value <0.0001) and 52.0 in Incontinence Impact Questionnaire scores (P-value <0.0001) were observed. Additionally, 90.4% (85/94) of subjects reported "very much better" or "much better" on the Patient Global Impression of Improvement. No new device- or procedure-related adverse events occurred between the 12 and 24 month visits. CONCLUSIONS: The Altis single-incision sling is a durable and effective treatment with a favorable safety profile for surgical treatment of women with stress or stress-predominant mixed urinary incontinence.

ICS teaching module: Ambulatory urodynamic monitoring.

AIM: To present the ICS Teaching Module on ambulatory urodynamics monitoring (AUM). METHODS: This teaching module has been developed by the ICS Urodynamics Committee to assist ICS members in their routine clinical practice. A detailed literature search on studies published on the clinical role of AUM as well as expert opinions have been considered. A slide set on AUM has been developed, approved by all members of the ICS Urodynamics Committee and is available to the ICS membership on the ICS website. The final approved teaching module has been presented at the ICS Annual Scientific Meeting in Brazil 2014. RESULTS: The scientific evidence on the clinical role of AUM in patients with lower urinary tract symptoms is summarized. The catheters and recording systems used, the patient preparation for the test, the technique, the instructions to the patient, the analysis, interpretation, and quality control assessment of AUM trace as well as the contraindications for AUM are described. CONCLUSIONS: The clinical role of AUM is still controversial. The scientific evidence on the usefulness of AUM is still limited but the ICS Urodynamics Committee recommends its use as a second line diagnostic tool when office laboratory urodynamics have failed to achieve a diagnosis. AUM has been showed to be more sensitive than laboratory urodynamics in diagnosing detrusor overactivity but the level of evidence for this measurement is not high. This manuscript summarizes the evidence and provides practice recommendations on AUM for teaching purposes in the framework of an ICS teaching module. Neurourol. Urodynam. 36:364-367, 2017. © 2015 Wiley Periodicals, Inc.

Long-term efficacy of the trans-obturator and retropubic mid-urethral slings for stress urinary incontinence: update from a randomized clinical trial.

PURPOSE: To report the extended long-term results of the use of tension-free vaginal tape(TVT) and trans-obturator tape (TOT) for the treatment of female stress urinary incontinence (SUI). METHODS: A prospective, multicentre randomized clinical trial comparing the use of TVT and TOT was used to evaluate 87 patients. The inclusion criteria were stress or mixed UI associated with urethral hyper mobility (the stress component was clinically predominant), while the exclusion criteria were previous anti-incontinence surgery and/or pelvic organ prolapse. The objective cure criteria were a negative provocative stress test and a negative 1-h pad test, with no further treatment for SUI. The subjective cure criteria were a 3-day voiding diary, quality-of-life questionnaires (UDI6-IIQ7), and patient satisfaction on a scale from 0 to 10. RESULTS: Eighty-seven patients were evaluated (47 TOT and 40 TVT) at a median follow-up of 100 months. Subjective and objective cure rates were 59.6 and 70.2 % in the TOT group and 75 and 87.5 % in the TVT group. The mid-to-long-term trend was a decreasing continence rate in patients who underwent TOT, compared with a stable rate for TVT. The Kaplan-Meier survival curve showed that continence rate decreased for up to 25 months after surgery, with stabilization thereafter for the TVT group while continuing to drop in the TOT group, with no inter-group difference. CONCLUSION: The patients in both groups were highly satisfied at long-term follow-up. The overall continence rate worsened for both groups within 25 months. While the results tend to stabilize in the TVT group, a further decline in the TOT was observed.

Measurement of post-void residual urine.

AIMS: To present the teaching module "Measurement of Post-void residual urine." METHODS: This module has been prepared by a Working Group of the ICS Urodynamics Committee. The methodology used included comprehensive literature review, consensus formation by the members of the Working Group, and review by members of the ICS Urodynamics Committee core panel. RESULTS: In this ICS teaching module the evidence for and relevance of PVR measurement in patients with lower urinary tract dysfunction (LUTD) is summarized; in short: The interval between voiding and post-void residual (PVR) measurement should be of short duration and ultrasound bladder volume measurement is preferred to urethral catheterization. There is no universally accepted definition of a significant residual urine volume. Large PVR (>200-300 ml) may indicate marked bladder dysfunction and may predispose to unsatisfactory treatment results if for example, invasive treatment for bladder outlet obstruction (BOO) is undertaken. PVR does not seem to be a strong predictor of acute urinary retention and does not indicate presence of BOO specifically. Although the evidence base is limited, guidelines on assessment of LUTS generally include PVR measurement. CONCLUSION: Measurement of PVR is recommended in guidelines and recommendations on the management of LUTS and urinary incontinence, but the level of evidence for this measurement is not high. This manuscript summarizes the evidence and provides practice recommendations for teaching purposes in the framework of an ICS teaching module.