Laparoscopy Assisted Peritoneal Pull-Through Vaginoplasty in Transgender Women.

BACKGROUND: Penile inversion vaginoplasty still remains the gold standard in genital gender affirming surgeries in transwomen. However, insufficiency of the penile skin due to either radical circumcision or puberty blockers presents great challenge in vaginal reconstruction. Peritoneal pull-through vaginoplasty is well known technique for the treatment of vaginal absence in cis-woman due to vaginal agenesis or trauma. OBJECTIVE: We describe our laparoscopy assisted technique of using peritoneal flaps for neovaginal construction in male to female gender affirming surgery METHODS: In period from March 2016 to June 2021, 52 transwomen, aged from 19 to 52 years (mean 27) underwent laparoscopy assisted peritoneal pull-through vaginoplasty. Indications were genital skin insufficiency (radical circumcision in 16, scrotal skin insufficiency in 3 and lichen sclerosis in 3 cases) and prepubertal blockers in 22 and 17 cases, respectively. In remaining 13 candidates, peritoneal pull-through vaginoplasty was preferable method of choice. Two peritoneal flaps are harvested from posterior bladder wall and anterior rectosigmoid peritoneum, using laparoscopy approach. Vaginal channel is created by combined perineal and laparoscopy approaches. Good vascularized peritoneal flaps are maximally mobilized and pulled-through to be joined with inverted penile skin. Peritoneal flaps are joined laterally to create neovagina. Gender affirming surgery is completed with reconstruction of external female genitalia, clitoris, labia minora and majora, and urethra. Vaginal packing is placed for 7 days postoperatively and followed by proper vaginal dilation for the first 12 months postoperatively. RESULTS: Follow-up ranged from 6 to 69 months (mean 29 months). Complications occurred in 7 cases: 3 had prolonged hematoma of the labia majora, one had neovaginal introitus dehiscence and one had superficial necrosis of the left labia majora. None of the complications required additional surgeries. The depth of the neovagina at the control check-up in 6 months after surgery was 14.7 ± 0.5 cm, while width was about 3.4 ± 0.4 cm. Majority of patients (≈96%) were satisfied with the new genitalia, sensitivity, lubrication and possibility of engaging in sexual intercourse according to self-reports. One patient required reduction of the size of her clitoris because of hypersensitivity and the other one requested laser treatment of the incisional scars. CONCLUSION: Although known for quite a long time in vaginal reconstruction for cis-women with vaginal agenesis and different forms of vaginal absence, peritoneal pull-through vaginoplasty offers promising outcomes in transgender women, as an option that will give self-lubricating neovagina, with insignificant scarring and complications and high degree of patient's satisfaction.

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

PURPOSE: Despite a variety of free flaps that have been described for creation of the neophallus in gender affirmation surgery, none present an ideal solution. We evaluated our patients and outcomes after gender affirmation phalloplasty using musculocutaneous latissimus dorsi free flap. METHODS: Between January 2007 and May 2017, 129 female transsexuals, aged 20-53 years (mean 24 years) underwent total phalloplasty using latissimus dorsi free flap. Urethral lengthening was performed by combining a vaginal flap, labia minora flaps and a clitoral skin flap. Suitable sized testicular implants are inserted into the new scrotum. Penile prosthesis implantation, additional urethral lengthening and glans reshaping were performed in the following stages. RESULTS: The mean follow-up period was 43 months (ranged from 13 to 137 months). There were one partial and two total flap necrosis. The average size of the neophallus was 14.6 cm in length and 12.4 cm in girth. Total length of the reconstructed urethra during the first stage ranged from 13.4 to 21.7 cm (mean 15.8 cm), reaching the proximal third or the midshaft of the neophallus in 91% of cases. Satisfactory voiding in standing position was confirmed in all patients. Six urethral fistulas and two strictures were observed and repaired by minor revision. Malleable and inflatable prostheses were implanted in 39 and 22 patients, respectively. CONCLUSION: Musculocutaneous latissimus dorsi flap is a good choice for phalloplasty in gender affirmation surgery. It provides an adequate amount of tissue with sufficient blood supply for safe urethral reconstruction and penile prosthesis implantation.

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

PURPOSE: Severe hypospadias repair still presents a great challenge. We evaluated a novel approach of using a specially shaped buccal mucosa graft for simultaneous ventral tunica grafting and new urethral plate creation, in combination with longitudinal dorsal island skin flap, as a one-stage repair of severe hypospadias. METHODS: Between July 2014 and September 2017, 26 patients (aged from 12 to 22 months) underwent scrotal hypospadias repair. Short and non-elastic urethral plate is divided. Buccal mucosa graft is harvested from the inner cheek, and designed in a special "watch" shape, with the spherical part in the middle and two rectangular parts on both sides. Tunica albuginea is opened ventrally for penile straightening and grafted to the spherical part of the "watch-shaped" buccal mucosa with 6-8 "U-shape" stitches. The rectangular parts are fixed to the tip of the glans distally and native urethral meatus proximally. Longitudinal dorsal skin flap is harvested, button-holed ventrally and joined with buccal graft. Penile skin reconstruction is performed using available penile skin. RESULTS: The mean follow-up was 22 months (range from 9 to 46 months). Satisfactory results were achieved in 22 patients. Two urethral fistulas were successfully repaired by minor surgery after 3 months, while one meatal stenosis and one urethral diverticulum were successfully treated by temporary urethral dilation. There were no cases of residual curvature. CONCLUSION: Specially shaped buccal mucosa graft for simultaneous curvature correction and urethroplasty could be a good choice for single-stage repair of scrotal hypospadias with severe curvature.

Total Phalloplasty With Latissimus Dorsi Musculocutaneous Flap in Female-to-male Transgender Surgery.

OBJECTIVE: To present our technique of musculocutaneous latissimus dorsi (MLD) free-flap total phalloplasty. This technically demanding female-to-male gender reassignment surgery consists of creating a neophallus from extragenital tissue. METHODS: The presented technique included: removal of internal and/or external female genitalia, creation of neophallus using latissimus dorsi free flap, clitoral incorporation into the neophallus, urethral lengthening, and insertion of testicular implants into the newly created scrotum. The MLD flap with proper dimension is harvested from nondominant side and tubularized. Microvascular anastomosis is done between thoracodorsal vessels and femoral artery and saphenous vein. Neophallus is positioned in adequate place. Urethroplasty is performed by combining different genital flaps that are harvested from anterior vaginal wall, urethral plate, and both labia minora and clitoral skin. Scrotoplasty is done by joining both labia majora with implantation of testicular implants. RESULTS: Operative time was 427 minutes with minimal blood loss. Both donor site and graft healed well, and the patient reports voiding well while standing. Penile prosthesis implantation as well as neophallic urethroplasty are planned for the second stage. CONCLUSION: Total MLD flap phalloplasty with urethral lengthening is a challenging and complex surgical procedure. This technique presents good variant for female transgenders with acceptable cosmetic outcome and enables good volume of neophallus, sexual arousal, and voiding while standing.

An overview of neovaginal reconstruction options in male to female transsexuals.

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Fast-track surgery concepts for congenital urogenital anomalies.

AIM: To investigate the possibility of fast-track surgery concepts in pediatric urology department as a single center study model of a developing country. MATERIAL OF STUDY: The study included 1620 patients surgically treated at the pediatric urology department, from 2009 to 2011. According to the congenital anomalies, all patients were classified in one of four groups: I - testicular anomalies (197 patients); II - external genital anomalies (453); III - upper urinary tract anomalies (801) and IV - associated anomalies (169). We analyzed the total duration of stay in the hospital of all patients among all treating doctors concerning the anomaly. RESULTS: Statistically significant difference in total length of hospitalization of all patients in Group I was noted in Doctors 1 and 5 (F=10.36** for F0.05;5;12=3.11 and F0.01;5;12=5.06), as well as in the Group II (F=17.01** for F0.05;5;12=3.11 and F0.01;5;12=5.06). Statistical analysis was not possible to be performed in groups III and IV because of lack of the patients. DISCUSSION: Analyzing the length of hospitalization of the patients treated at the urology department, all doctors showed the tendency to shorten the total length of hospitalization in patients of all groups. Majority of the studies carried out on pediatric urology departments in developed countries, showed that over 50% of children were successfully treated using fast-track surgery concept. CONCLUSIONS: Modern methods of surgical management and anesthesia allow decrease of hospitalization length, financial savings to the healthcare system and better comfort for patients.

Epispadias repair after failed surgery in childhood.

INTRODUCTION: Redo surgery in failed epispadias presents a great challenge. Our aim was to present a radical approach for correction of penile deformities as well as urethral reconstruction in patients after failed epispadias repair. MATERIALS AND METHODS: Between January 2006 and January 2011, 13 patients, aged 13 to 22 years, underwent redo surgery due to failed epispadias repair in childhood. All patients presented with severe dorsal curvature and short urethra. First stage included penile disassembly technique with complete separation of corporal bodies, urethral dissection, and transposition and subtotal glans mobilization. Residual dorsal curvature was corrected by tunical incision and grafting of the defect. Short urethra was dissected and transposed ventrally with opening at the base of the penis. Penile entities were reassembled in normal anatomical relationship. Penile body was covered using available vascularized skin flaps. After 6 months, second stage was performed and included reconstruction of the penile urethra using buccal mucosa graft and scrotal hairless skin flap. RESULTS: Follow-up ranged from 12 to 60 months (mean 33 months). Acceptable outcome is achieved in all the patients. Complete penile lengthening and straightening is obtained in 10 out of 13 patients. Mild curvature is noted in three patients without consequences. Satisfactory sexual activity was reported from nine patients. One patient developed fistula that was closed after 4 months, whereas all other patients reported normal voiding with no difficulties. CONCLUSIONS: Redo surgery of failed epispadias is very demanding procedure. Radical approach in these cases is necessary for complete repair of all penile deformities with satisfactory postoperative outcome.

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

PURPOSE: Urethral stricture is the second most common complication of hypospadias repair after urethrocutaneous fistula. Usually more than 1 procedure is needed for correction due to a lack of available tissue after previous repairs. We evaluated 1-stage urethral stricture management after hypospadias repair using a ventral buccal mucosal graft. We describe the importance of graft hanging and coverage. MATERIALS AND METHODS: From August 2004 to April 2009, 15 patients 9 to 17 years old underwent urethral stricture repair after failed hypospadias surgery. Mean time after primary surgery was 7.2 years (range 4 to 13). Vascularized periurethral tissue around the stenotic part of the neourethra was dissected. The urethra was opened ventrally and a buccal mucosal graft of appropriate size was inserted to allow urethral augmentation. Using several U stitches the graft was anchored to the surrounding periurethral tissue to prevent its folding and retraction. Recurrent chordee in 12 patients and secondary vesicoureteral reflux in 3 were also corrected at this time. RESULTS: Mean followup was 37 months (range 17 to 73). Successful results were confirmed in all patients by urethrography and uroflowmetry. One urethral fistula was corrected 3 months later by minor surgery. Recurvature did not develop in this group. There was no recurrent reflux in endoscopically treated patients. CONCLUSIONS: Ventral buccal mucosal grafting is a simple, safe option for urethral stricture repair. Hanging the graft to periurethral tissue is important for its survival and to prevent postoperative folding and retraction.

Metoidioplasty as a single stage sex reassignment surgery in female transsexuals: Belgrade experience.

INTRODUCTION: Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. AIM: Our aim is to describe our technique and highlight its advantages. METHODS: Between September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. MAIN OUTCOME MEASURES: Patients' personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. RESULTS: The median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. CONCLUSIONS: Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

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

OBJECTIVES: Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. METHODS: Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. RESULTS: The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. CONCLUSIONS: Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

[Conservative treatment of hypertrophic pyloric stenosis in children]. / Konservativno lecenje hipertroficne stenoze pilorusa kod dece.

INTRODUCTION: Hypertrophy of the pylorus causing obstruction of the gastric outlet, or infantile hypertrophic pyloric stenosis (IHPS), is the most common indication for abdominal surgery in infancy. The incidence of the condition is 3-4 per 1000 live births, and male infants are affected more often than females, in 4:1 ratio. Vomiting, as the first symptom, most often occurs between the third and fourth week after birth, rarely after second month, but there have been few reports of vomiting as late as 5 months. Etiology of IHPS is still controversial. Two theories have been quoted most: absence of non-adrenergic and non-cholinergic nerve fibers which are mediators of smooth muscle contraction, and absence of nitric oxide inhibitory innervation of pyloric smooth-muscle resulting in unopposed contraction of the sphincter in response to muscarinic stimulation. Atropine sulfate is known to inhibit acetylcholine competitively in neuroreceptors, acting peripherally as a competitive inhibitor of the muscarinic effects of acetylcholine, leading to decreased gastrointestinal peristalsis. This action is believed to be important in IHPS cases. AIM: The aim of this paper is to provide further information on potential role of atropine in the management of patients with IHPS. METHODS: From April 2000 to October 2002, 22 patients (16 boys and 6 girls), aged 21 days to 3 months, with IHPS were treated by oral administration of atropine sulfate in our institution. Diagnosis of IHPS was based on US examination in all cases. A nasogastric tube was inserted and left in situ. Medical treatment involved initial correction of fluid and electrolyte imbalance combined with oral administration of atropine sulfate. Atropin was given in the form of aqueous solution in initial dose of 0.05 mg/kg/d. The total daily dose was divided into 8 equal doses. Each dose was formulated to be given in a volume of 1 ml. Before the administration of each dose of atropine, stomach was decompressed by suction via nasogastric tube. The infant was placed on the right side with the head on the cot elevated 20 degrees to 30 degrees for 15 to 30 minutes after each atropine dose. Oral feeding with 10 ml of 10% glucose was then attempted. If feeding was tolerated, the same dose of atropine was administered 3 hours later, followed by a trial of 20 ml of 10% glucose. If tolerated, 10 ml of conventional formula was then tried after atropine administration 3 hours later. The volume of formula was then increased 10 ml per feed until full feeding (120 ml/kg/d) was tolerated. Dribbling (2-3 times per day) was ignored. If vomiting occurred, the same dose of atropine, volume and type of feed, were tried again 3 hours later, and if still not tolerated, atropine was increased by 1 microg/kg/dose without increasing the volume of feed. This approach was repeated until oral feeding was tolerated at least twice, and only then the volume of oral feed was increased. During night shift (between 11 p.m. and 5 a.m.), atropine concentration and amount of oral feed were not increased. If vomiting recurred, the volume of oral feed was decreased to the last tolerated volume and maintained until the following day. Oral atropine was increased until predetermined maximum oral dose (0.1 mg/kg/d) was reached. If oral administration of atropine was ineffective, a decision to perform pyloromyotomy was made no later than 7 days after commencement of oral atropine. RESULTS: Atropine had effect (vomiting frequency less than twice per day) on average 3.29 days (range 1-7 days) from commencement. Oral atropine was tolerated very well, and was effective in 18 cases. Four cases were referred to pyloromyotomy, on day 4 (2 patients), day 5 (1 patient) and on day 6 (1 patient) of atropine treatment. Therapy was continued until US showed normalization of pyloric muscle thickness, passage of food through wide pyloric channel and until patients started gaining weight. Average duration of therapy was 24.05 days (11-39 days). Neither of patients from our group was treated with intravenous atropine sulfate. DISCUSSION: Although intravenous atropine is more effective (as shown by Nagita et al), there is an increased incidence of side effects such as flushing and tachycardia. Oral atropine has been used successfully by other teams without side effects, and there were no side effects or complications related to the use of atropine in this study. Prospective, randomized study comparing outcomes of medical versus surgical management of IHPS in our hospital has been currently in progress and will provide further information on potential role of atropine in the management of patients with IHPS. CONCLUSION: We believe it is unlikely that oral or intravenous atropine will ever replace surgery for IHPS, but it may be a good alternative to pyloromyotomy, particularly in children with major concurrent primary disease, or when parents are not enthusiastic about surgery in so young children.