Multimodal Prehabilitation in Patients Undergoing Complex Colorectal Surgery, Liver Resection, and Hyperthermic Intraperitoneal Chemotherapy (HIPEC): A Pilot Study on Feasibility and Potential Efficacy.

BACKGROUND: Surgery for complex primary and metastatic colorectal cancer (CRC), such as liver resection and hyperthermic intraperitoneal chemotherapy (HIPEC), in academic settings has led to improved survival but is associated with complications up to 75%. Prehabilitation has been shown to prevent complications in non-academic hospitals. This pilot study aimed to determine the feasibility and potential efficacy of a multimodal prehabilitation program in patients undergoing surgery in an academic hospital for complex primary and metastatic CRC. METHODS: All patients awaiting complex colorectal surgery, liver resection, or HIPEC from July 2019 until January 2020 were considered potentially eligible. Feasibility was measured by accrual rate, completion rate, adherence to the program, satisfaction, and safety. To determine potential efficacy, postoperative outcomes were compared with a historical control group. RESULTS: Sixteen out of twenty-five eligible patients (64%) commenced prehabilitation, and fourteen patients fully completed the intervention (88%). The adherence rate was 69%, as 11 patients completed >80% of prescribed supervised trainings. No adverse events occurred, and all patients expressed satisfaction with the program. The complication rate was significantly lower in the prehabilitation group (37.5%) than the control group (70.2%, p = 0.020). There was no difference in the type of complications. CONCLUSION: This pilot study illustrates that multimodal prehabilitation is feasible in the majority of patients undergoing complex colorectal cancer, liver resection, and HIPEC in an academic setting.

Laparoscopic Probe for Sentinel Lymph Node Harvesting Using Magnetic Nanoparticles.

OBJECTIVE: Sentinel lymph node harvesting is an essential step in the surgical treatment of a growing number of malignancies. Various techniques are available to facilitate this purpose. The present study reports a new laparoscopic technique for lymph node harvesting using magnetic nanoparticles containing a superparamagnetic iron-oxide core and dextran coating. This study assesses the clinical relevance of the prototype and provides input for further technological development on the way to clinical implementation. METHODS: A laparoscopic differential magnetometer prototype was built, utilizing a nonlinear detection principle (differential magnetometry) for magnetic identification of lymph nodes. The iron content sensitivity, depth & spatial sensitivity, and angular sensitivity were analyzed to investigate clinical options. RESULTS: The minimum detectable amount of iron was 9.8 µg at a distance of 1 mm. The detection depth was 5, 8, and 10 mm for samples containing 126, 252, and 504 µg iron, respectively. The maximum lateral detection distance was 5, 7, and 8 mm for samples containing 126, 252, and 504 µg iron, respectively. A sample containing 504 µg iron was detectable at all angulations assessed (0°, 30°, 60° and 90°). CONCLUSION: The laparoscopic differential magnetometer demonstrates promising results for further investigation and development towards laparoscopic lymph node harvesting using magnetic nanoparticles. SIGNIFICANCE: The laparoscopic differential magnetometer facilitates a novel method for sentinel lymph node harvesting, which helps to determine prognosis and treatment of cancer patients.

Real-time indocyanine green fluorescent angiography in laparoscopic sigmoid vaginoplasty to assess perfusion of the pedicled sigmoid segment.

OBJECTIVE: To assess the feasibility of intraoperative use of indocyanine green (ICG) fluorescent angiography in laparoscopic intestinal vaginoplasty to determine intestinal segment perfusion and viability. DESIGN: Intestinal vaginoplasty may be performed as a vaginal (re)construction procedure. During surgery, a pedicled intestinal segment is transferred caudally to line the neovaginal cavity. Most commonly, a sigmoid or ileal segment is used. In obtaining adequate mobility of the segment, arterial structures sometimes have to be sacrificed, with possible detrimental effects on segment perfusion and subsequently viability. ICG may be used as an aid to assess segment perfusion. We present a case series of six consecutive patients who underwent intestinal vaginoplasty with intraoperative use of ICG. SETTING: Tertiary university hospital. PATIENT(S): Six transgender women undergoing laparoscopic sigmoid vaginoplasty with intraoperative use of ICG from October 2017 to October 2018. INTERVENTION(S): Intraoperative use of ICG in laparoscopic sigmoid vaginoplasty to determine sigmoid segment perfusion and viability. MAIN OUTCOME MEASURE(S): Value and feasibility of ICG in this reconstructive procedure. RESULT(S): Intraoperative use of ICG demonstrated segment viability in five patients. In one patient, vascularization of the segment was deemed to be inadequate and reconstruction was aborted. CONCLUSIONS: ICG fluorescent angiography may be used intraoperatively to assess perfusion of the pedicled sigmoid segment during sigmoid vaginoplasty.

Laparoscopic Intestinal Vaginoplasty in Transgender Women: An Update on Surgical Indications, Operative Technique, Perioperative Care, and Short- and Long-Term Postoperative Issues.

"Surgical (re)construction of a vagina (vaginoplasty) is performed in biological women with congenital or postablative vaginal absence and in transgender women. Penile inversion vaginoplasty is the gold surgical standard for genital Gender Affirmation Surgery in transgender women. In absence of sufficient penoscrotal skin, due to penoscrotal hypoplasia, circumcision, penile trauma with loss of penile skin quantity and/or quality, or when primary vaginoplasty has failed, intestinal vaginoplasty can be performed. This article provides an update on surgical indications of intestinal vaginoplasty, operative technique, perioperative care, and short- and long-term postoperative issues. A review of recent literature is performed."

The effect of surgical fecal stream diversion of the healthy colon on the colonic microbiota.

OBJECTIVES: The intestinal microbiota plays an important role in intestinal health. After colonic diversion from the fecal stream, luminal nutrients for bacteria are expected to be depleted, inducing changes in microbial composition. In this study, we describe microbial changes in the healthy colon following surgical fecal stream diversion, studied in the surgically constructed sigmoid-derived neovagina. METHODS: At various postoperative times after sigmoid vaginoplasty, rectal, neovaginal, and skin microbial swabs were obtained for microbial analysis by interspacer profiling, a PCR-based bacterial profiling technique. Differences in bacterial profiles, in terms of bacterial abundance and phylum diversity, were assessed. Microbial dissimilarities between anatomical locations were analyzed with principal coordinate analysis and partial least squares discriminant analysis. RESULTS: Bacterial samples were obtained from 28 patients who underwent sigmoid vaginoplasty. By principal coordinate analysis, microbial profiles of samples from the sigmoid-derived neovagina were distinctively different from rectal samples. Partial least squares discriminant analysis showed that the most discriminative species derived from the phylum Bacteroidetes. The abundance and diversity of Bacteroidetes species were reduced following fecal stream diversion compared with rectal samples (median Shannon diversity index of 2.76 vs. 2.18, P<0.01). Similar abundance of Phyla Firmicutes, Actinobacteria, Fusobacteria, Verrucomicrobia, and Proteobacteria was observed. CONCLUSION: By analyzing the microbiome of sigmoid-derived neovaginas, we studied the effects of fecal diversion on the microbial composition of the healthy intestine. Most changes were observed in the phylum Bacteroidetes, indicating that these bacteria are likely part of the diet-dependent (butyrate-producing) colonic microbiome. Bacteria of other phyla are likely to be part of the diet-independent microbiome.

Personalised perioperative care by e-health after intermediate-grade abdominal surgery: a multicentre, single-blind, randomised, placebo-controlled trial.

BACKGROUND: Instructing and guiding patients after surgery is essential for successful recovery. However, the time that health-care professionals can spend with their patients postoperatively has been reduced because of efficiency-driven, shortened hospital stays. We evaluated the effect of a personalised e-health-care programme on return to normal activities after surgery. METHODS: A multicentre, single-blind, randomised controlled trial was done at seven teaching hospitals in the Netherlands. Patients aged 18-75 years who were scheduled for laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication were recruited. An independent researcher randomly allocated participants to either the intervention or control group using computer-based randomisation lists, with stratification by sex, type of surgery, and hospital. Participants in the intervention group had access to a perioperative, personalised, e-health-care programme, which managed recovery expectations and provided postoperative guidance tailored to the patient. The control group received usual care and access to a placebo website containing standard general recovery advice. Participants were unaware of the study hypothesis and were asked to complete questionnaires at five timepoints during the 6-month period after surgery. The primary outcome was time between surgery and return to normal activities, measured using personalised patient-reported outcome measures. Intention-to-treat and per-protocol analyses were done. This trial is registered in the Netherlands National Trial Register, number NTR4699. FINDINGS: Between Aug 24, 2015, and Aug 12, 2016, 344 participants were enrolled and randomly allocated to either the intervention (n=173) or control (n=171) group. 14 participants (4%) were lost to follow-up, with 330 participants included in the primary outcome analysis. Median time until return to normal activities was 21 days (95% CI 17-25) in the intervention group and 26 days (20-32) in the control group (hazard ratio 1·38, 95% CI 1·09-1·73; p=0·007). Complications did not differ between groups. INTERPRETATION: A personalised e-health intervention after abdominal surgery speeds up the return to normal activities compared with usual care. Implementation of this e-health programme is recommended in patients undergoing intermediate-grade abdominal, gynaecological, or general surgical procedures. FUNDING: ZonMw.

Ileal vaginoplasty as vaginal reconstruction in transgender women and patients with disorders of sex development: an international, multicentre, retrospective study on surgical characteristics and outcomes.

OBJECTIVE: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD). PATIENTS AND METHODS: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations. RESULTS: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%). CONCLUSION: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures.

Survival of patients with colorectal peritoneal metastases is affected by treatment disparities among hospitals of diagnosis: A nationwide population-based study.

BACKGROUND: In the Netherlands, surgery for peritoneal metastases of colorectal cancer (PMCRC) is centralised, whereas PMCRC is diagnosed in all hospitals. This study assessed whether hospital of diagnosis affects treatment selection and overall survival (OS). METHODS: Between 2005 and 2015, all patients with synchronous PMCRC without systemic metastases were selected from the Netherlands Cancer Registry. Treatment was classified as cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC), systemic therapy or other/no treatment. Hospitals of diagnosis were classified as: (1) non-teaching or academic/teaching hospital and (2) HIPEC centre or referring hospital. Referring hospitals were further classified based on the frequency of CRS/HIPEC as high-, medium- or low-frequency hospital. Multivariable regression analyses were used to assess the independent influence of hospital categories on the likelihood of CRS/HIPEC and OS. RESULTS: A total of 2661 patients, diagnosed in 89 hospitals, were included. At individual hospital level, CRS/HIPEC and systemic therapy ranged from 0% to 50% and 6% to 67%, respectively. Hospital of diagnosis influenced the likelihood of CRS/HIPEC: 33% versus 13% for HIPEC centres versus referring hospitals (odds ratio (OR) 3.66 [2.40-5.58]) and 11% versus 17% for non-teaching hospitals versus academic/teaching hospitals (OR 0.60 [0.47-0.77]). Hospital of diagnosis affected median OS: 14.1 versus 9.6 months for HIPEC centres versus referring hospitals (hazard ratio (HR) 0.82 [0.67-0.99]) and 8.7 versus 11.5 months for non-teaching hospitals versus academic/teaching hospitals (HR 1.15 [1.06-1.26]). Compared with diagnosis in medium-frequency referring hospitals, median OS was increased in high-frequency referring hospitals (12.6 months, HR 0.82 [0.73-0.91]) and reduced in low-frequency referring hospitals (8.1 months, HR 1.12 [1.01-1.24]). CONCLUSION: Treatment disparities among hospitals of diagnosis and their impact on survival indicate suboptimal treatment selection for PMCRC.

Fluorescent Imaging With Indocyanine Green During Laparoscopic Cholecystectomy in Patients at Increased Risk of Bile Duct Injury.

BACKGROUND: Although rare, injury to the common bile duct (CBD) during laparoscopic cholecystectomy (LC) can be reduced by better intraoperative visualization of the cystic duct (CD) and CBD. The aim of this study was to establish the efficacy of early visualization of the CD and the added value of CBD identification, using near-infrared (NIR) light and the fluorescent agent indocyanine green (ICG), in patients at increased risk of bile duct injury. MATERIALS AND METHODS: Patients diagnosed with complicated cholecystitis and scheduled for LC were included. The CBD and CD were visualized with NIR light before and during dissection of the liver hilus and at critical view of safety (CVS). RESULTS: Of the 20 patients originally included, 2 were later excluded due to conversion. In 6 of 18 patients, the CD was visualized early during dissection and prior to imaging with conventional white light. The CBD was additionally visualized with ICG-NIR in 7 of 18 patients. In 1 patient, conversion was prevented due to detection of the CD and CBD with ICG-NIR. CONCLUSIONS: Early visualization of the CD or additional identification of the CBD using ICG-NIR in patients with complicated cholecystolithiasis can be helpful in preventing CBD injury. Future studies should attempt to establish the optimal dosage and time frame for ICG administration and bile duct visualization with respect to different gallbladder pathologies.

Lethal Necrotizing Cellulitis Caused by ESBL-Producing E. Coli after Laparoscopic Intestinal Vaginoplasty.

BACKGROUND: The absence of a functional vagina has a negative effect on the quality of life of women. Multiple surgical procedures have been described for vaginal reconstruction in these patients. CASE: We present a case of an 18-year-old transgender woman, who underwent laparoscopic intestinal vaginoplasty as vaginal reconstruction, and subsequently developed septic shock and multiple organ failure on the basis of an extended-spectrum ß-lactamase-producing Escherichia coli. A severe progression of the necrotizing fasciitis was lethal, despite repeated surgical debridement, intravenous antibiotic use, and supportive care at the intensive care unit. SUMMARY AND CONCLUSION: Although vaginal reconstruction has a positive influence on the quality of life in transgender women, physicians and patients need to be aware of serious complications that might arise.

Total laparoscopic sigmoid vaginoplasty.

OBJECTIVE: To demonstrate step by step our technique for total laparoscopic sigmoid vaginoplasty. DESIGN: Surgical video tutorial. SETTING: Academic medical center. PATIENT(S): Transgender women with penile hypoplasia or with a failed primary vaginoplasty and biological women with either acquired or congenital absence of a functional vagina. INTERVENTION(S): An original technique for total laparoscopic sigmoid vaginoplasty is shown on video. Surgery is performed via a simultaneous abdomino-perineal approach. The genital surgeon dissects the neovaginal cavity and performs a bilateral orchiectomy and shortening of the urethra. Out of penile and scrotal skin, a clitoro-vulvaplasty is created. Meanwhile, the laparoscopic surgeon mobilizes the sigmoid segment and transects it down to the base of the sigmoid arteries. The segment is guided in an iso-peristaltic way through the neovaginal tunnel on to the perineum. The distal staple line is opened and sutured in an exaggerated interdigitating fashion to the perineum and inverted penile skin. Length of the segment is measured with a transilluminated perspex dildo, after which the segment is stapled at the proper level. A neovaginopexy is performed on the promontory. Bowel continuity is restored with an intra-abdominal side-to-side oversewn stapled anastomosis. The patient provided written informed consent for the use of this video in this article. MAIN OUTCOME MEASURE(S): None. RESULT(S): Given current literature, intestinal vaginoplasty is associated with low complication rates. Since 2008 our group performed 42 primary and 21 secondary procedures, mainly in transgender women, with at least 1 year of clinical follow-up. Complications comprised three rectal perforations and two anastomotic leakages. These were addressed laparoscopically without long-term fistula formation. There were no conversions to laparotomy. CONCLUSION(S): Total laparoscopic sigmoid vaginoplasty is a feasible and safe procedure in the hands of an experienced team with the right infrastructure. It provides good surgical and functional results. In selected cases it is indicated for primary vaginoplasty, as well as for revision vaginoplasty.

Revision Vaginoplasty: A Comparison of Surgical Outcomes of Laparoscopic Intestinal versus Perineal Full-Thickness Skin Graft Vaginoplasty.

BACKGROUND: Vaginal (re)construction can greatly improve the quality of life of indicated patients. If primary vaginoplasty fails, multiple surgical approaches exist for revision. The authors compared surgical results of laparoscopic intestinal versus full-thickness skin graft revision vaginoplasty. METHODS: A retrospective chart review of patients who underwent revision vaginoplasty at the authors' institution was conducted. Patient demographics, surgical characteristics, complications, hospitalization, reoperations, and neovaginal depth for both surgical techniques were recorded and compared. RESULTS: The authors studied a consecutive series of 50 transgender and three biological women who underwent revision vaginoplasty, of which 21 were laparoscopic intestinal and 32 were perineal full-thickness skin graft vaginoplasties, with a median clinical follow-up of 3.2 years (range, 0.5 to 19.7 years). Patient demographics did not differ significantly. There was no mortality. Two intraoperative rectal perforations (10 percent) occurred in the intestinal group versus six (19 percent) in the full-thickness skin graft group. Operative time was shorter for the full-thickness skin graft vaginoplasty group (131 ± 35 minutes versus 191 ± 45 minutes; p < 0.01). Hospitalization length did not differ significantly. Successful vaginal (re)construction was achieved in 19 intestinal (91 percent) and 26 full-thickness skin graft (81 percent) vaginoplasty procedures. A deeper neovagina was achieved with intestinal vaginoplasty (15.9 ± 1.4 cm versus 12.5 ± 2.8 cm; p < 0.01). CONCLUSIONS: Both laparoscopic intestinal and full-thickness skin graft vaginoplasty can be used as secondary vaginal reconstruction. Intraoperative and postoperative complications do not differ significantly, but rectal perforation was more prevalent in the full-thickness skin graft vaginoplasty group. Although the operative time of laparoscopic intestinal vaginoplasty is longer, adequate neovaginal depth was more frequently achieved than in secondary perineal full-thickness skin graft vaginoplasty. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia: A Prospective Cohort Study of Surgical Outcomes and Follow-Up of 42 Patients.

BACKGROUND: In young transgender women previously treated with puberty-suppressing hormones, penoscrotal hypoplasia can make penoscrotal inversion vaginoplasty unfeasible. The aim of this study was to prospectively assess surgical outcomes and follow-up of total laparoscopic sigmoid vaginoplasty as primary reconstruction in a cohort of transgender women with penoscrotal hypoplasia. METHODS: Baseline demographics, surgical characteristics, and intraoperative and postoperative complications of all performed total laparoscopic sigmoid vaginoplasty procedures were prospectively recorded. RESULTS: From November of 2007 to July of 2015, 42 transgender women underwent total laparoscopic sigmoid vaginoplasty as primary vaginal reconstruction. The mean age at the time of surgery was 21.1 ± 4.7 years. Mean follow-up time was 3.2 ± 2.1 years. The mean operative duration was 210 ± 44 minutes. There were no conversions to laparotomy. One rectal perforation was recognized during surgery and immediately oversewn without long-term consequences. The mean length of hospitalization was 5.7 ± 1.1 days. One patient died as a result of an extended-spectrum beta-lactamase-positive necrotizing fasciitis leading to septic shock, with multiorgan failure. Direct postoperative complications that needed laparoscopic reoperation occurred in three cases (7.1 percent). In seven cases (17.1 percent), long-term complications needed a secondary correction. After 1 year, all patients had a functional neovagina with a mean depth of 16.3 ± 1.5 cm. CONCLUSIONS: Total laparoscopic sigmoid vaginoplasty seems to have a similar complication rate as other types of elective laparoscopic colorectal surgery. Primary total laparoscopic sigmoid vaginoplasty is a feasible gender-confirming surgical technique with good functional outcomes for transgender women with penoscrotal hypoplasia. CLINICAL QUESTIO/LEVEL OF EVIDENCE: Therapeutic, IV.

Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy versus conventional laparoscopic cholecystectomy (FALCON trial): study protocol for a multicentre randomised controlled trial.

INTRODUCTION: Misidentification of the extrahepatic bile duct anatomy during laparoscopic cholecystectomy (LC) is the main cause of bile duct injury. Easier intraoperative recognition of the biliary anatomy may be accomplished by using near-infrared fluorescence (NIRF) imaging after an intravenous injection of indocyanine green (ICG). Promising results were reported for successful intraoperative identification of the extrahepatic bile ducts compared to conventional laparoscopic imaging. However, routine use of ICG fluorescence laparoscopy has not gained wide clinical acceptance yet due to a lack of high-quality clinical data. Therefore, this multicentre randomised clinical study was designed to assess the potential added value of the NIRF imaging technique during LC. METHODS AND ANALYSIS: A multicentre, randomised controlled clinical trial will be carried out to assess the use of NIRF imaging in LC. In total, 308 patients scheduled for an elective LC will be included. These patients will be randomised into a NIRF imaging laparoscopic cholecystectomy (NIRF-LC) group and a conventional laparoscopic cholecystectomy (CLC) group. The primary end point is time to 'critical view of safety' (CVS). Secondary end points are 'time to identification of the cystic duct (CD), of the common bile duct, the transition of CD in the gallbladder and the transition of the cystic artery in the gallbladder, these all during dissection of CVS'; 'total surgical time'; 'intraoperative bile leakage from the gallbladder or cystic duct'; 'bile duct injury'; 'postoperative length of stay', 'complications due to the injected ICG'; 'conversion to open cholecystectomy'; 'postoperative complications (until 90 days postoperatively)' and 'cost-minimisation'. ETHICS AND DISSEMINATION: The protocol has been approved by the Medical Ethical Committee of Maastricht University Medical Center/Maastricht University; the trial has been registered at ClinicalTrials.gov. The findings of this study will be disseminated widely through peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER: NCT02558556.

Patient-Reported Esthetic and Functional Outcomes of Primary Total Laparoscopic Intestinal Vaginoplasty in Transgender Women With Penoscrotal Hypoplasia.

INTRODUCTION: Puberty-suppressing hormonal treatment may result in penoscrotal hypoplasia in transgender women, making standard penile inversion vaginoplasty not feasible. For these patients, intestinal vaginoplasty is a surgical alternative, but knowledge on patient-reported postoperative outcomes and quality of life is lacking. AIMS: To assess patient-reported functional and esthetic outcomes, quality of life, satisfaction, and sexual well-being after primary total laparoscopic intestinal vaginoplasty in transgender women. METHODS: A survey study was performed on transgender women who underwent primary total laparoscopic intestinal vaginoplasty with at least 1 year of clinical follow-up. Thirty-one transgender women completed the questionnaires (median age at time of surgery = 19.1 years, range = 18.3-45.0) after a median clinical follow-up of 2.2 years (range = 0.8-7.5). Consenting women were asked to complete a combined questionnaire of the Subjective Happiness Scale, the Satisfaction With Life Scale, Cantril's Ladder of Life Scale, the Female Sexual Function Index, the Female Genital Self-Imaging Scale, the Amsterdam Hyperactive Pelvic Floor Scale-Women, and a questionnaire addressing postoperative satisfaction. MAIN OUTCOME MEASURES: Patient-reported functional and esthetic outcomes and postoperative quality of life. RESULTS: Patients graded their life satisfaction a median of 8.0 (range = 4.0-10.0) on Cantril's Ladder of Life Scale. Patients scored a mean total score of 27.7 ± 5.8 on the Satisfaction With Life Scale, which indicated high satisfaction with life, and a mean total score of 5.6 ± 1.4 on the Subjective Happiness Scale. Functionality was graded a median score of 8.0 of 10 (range = 1.0-10.0) and esthetics a score of 8.0 out of 10 (range = 3.0-10.0). The mean Female Sexual Function Index total score of sexually active transgender women was 26.0 ± 6.8. CONCLUSION: This group of relatively young transgender women reported satisfactory functional and esthetic results of the neovagina and a good quality of life, despite low Female Sexual Function Index scores.

A modified Delphi method toward multidisciplinary consensus on functional convalescence recommendations after abdominal surgery.

BACKGROUND: Evidence-based information on the resumption of daily activities following uncomplicated abdominal surgery is scarce and not yet standardized in medical guidelines. As a consequence, convalescence recommendations are generally not provided after surgery, leading to patients' insecurity, needlessly delayed recovery and prolonged sick leave. The aim of this study was to generate consensus-based multidisciplinary convalescence recommendations, including advice on return to work, applicable for both patients and physicians. METHOD: Using a modified Delphi method among a multidisciplinary panel of 13 experts consisting of surgeons, occupational physicians and general practitioners, detailed recommendations were developed for graded resumption of 34 activities after uncomplicated laparoscopic cholecystectomy, laparoscopic and open appendectomy, laparoscopic and open colectomy and laparoscopic and open inguinal hernia repair. A sample of occupational physicians, general practitioners and surgeons assessed the recommendations on feasibility in daily practice. The response of this group of care providers was discussed with the experts in the final Delphi questionnaire round. RESULTS: Out of initially 56 activities, the expert panel selected 34 relevant activities for which convalescence recommendations were developed. After four Delphi rounds, consensus was reached for all of the 34 activities for all the surgical procedures. A sample of occupational physicians, general practitioners and surgeons regarded the recommendations as feasible in daily practice. CONCLUSION: Multidisciplinary convalescence recommendations regarding uncomplicated laparoscopic cholecystectomy, appendectomy (laparoscopic, open), colectomy (laparoscopic, open) and inguinal hernia repair (laparoscopic, open) were developed by a modified Delphi procedure. Further research is required to evaluate whether these recommendations are realistic and effective in daily practice.

Clinical Characteristics and Management of Neovaginal Fistulas After Vaginoplasty in Transgender Women.

OBJECTIVE: To describe our experience and results obtained in the management of neovaginal fistulas after vaginoplasty as gender reassignment surgery in transgender women. METHODS: A retrospective study was performed of 1,082 transgender women who underwent 1,037 primary and 80 revision vaginoplasty procedures between 1990 and 2015. Thirty-five women underwent both primary and later revision vaginoplasty at our institution. Patient, clinical, surgical, and outcome characteristics were reviewed. RESULTS: We treated 25 (2.3%) patients for 13 rectoneovaginal, 11 urethroneovaginal, and one pouch-neovaginal fistulas. Patients undergoing revision vaginoplasty were at higher risk of rectoneovaginal fistula development (0.8% compared with 6.3%, P<.01, odds ratio 8.6, 95% confidence interval 2.7-26.9). Of 23 intraoperatively identified and oversewn rectal perforations, four (17.4%) patients developed a rectoneovaginal fistula. In four patients, fecal diversion was achieved through temporary colostomy or ileostomy with direct (n=1) or delayed (n=3) fistula closure. In six patients, urethroneovaginal fistula arose after a complication such as meatal stenosis. Two patients underwent temporary suprapubic cystostomy for urinary diversion. In most patients, fistulectomy and primary closure or a local advancement flap was sufficient to treat the fistula. CONCLUSION: Neovaginal fistulas are uncommon after vaginoplasty. Symptoms of neovaginal fistulas are comparable with those of vaginal fistulas. In most patients, the diagnosis can be made based on symptoms and physical examination alone. It seems that a complicated course (eg, intraoperative rectal perforation or meatal stenosis) predisposes for fistula formation. Surgical repair of neovaginal fistulas is associated with few intraoperative and postoperative complications and does not seem to impair neovaginal function.

Long-Term Follow-Up of Transgender Women After Secondary Intestinal Vaginoplasty.

INTRODUCTION: Intestinal vaginoplasty with a sigmoid colon or ileal segment is an established surgical technique for vaginal reconstruction. Little has been reported on long-term (functional) outcome and postoperative quality of life. AIMS: To assess the surgical and long-term psychological outcomes of secondary intestinal vaginoplasty performed from 1970 through 2000 in transgender women. METHODS: Transgender women who underwent intestinal vaginoplasty from 1970 through 2000 were identified from our hospital registry. Demographics, surgical characteristics, complications, and reoperations were recorded. Traceable women were invited to fill out a set of questionnaires (quality-of-life questionnaire, Female Sexual Function Index, Amsterdam Hyperactive Pelvic Floor Scale for Women, Female Genital Self-Imaging Scale, and self-evaluation of vaginoplasty questionnaire) and attend the outpatient clinic for physical, endoscopic, and histologic examination of the neovagina. MAIN OUTCOME MEASURES: Primary outcomes were complications, reoperations, self-perceived quality of life, and functional and esthetic self-evaluation. RESULTS: Twenty-four transgender women were identified who underwent intestinal vaginoplasty as a secondary procedure from 1970 through 2000. There were no intraoperative complications. Three intestinal neovaginas were surgically removed because of postoperative complications. Nineteen women (79%) underwent at least one genital reoperation, most commonly introitus plasty (n = 13, 54%). Five women were deceased at time of analysis. Nine women consented to partake in the study (median age = 58 years, range = 50-73; median postoperative time = 29.6 years, range = 17.2-34.3). They were generally satisfied with life and scored 5.9 of 7 on a subjective happiness scale. Neovaginal functionality was rated as 7.3 and appearance as 7.4 of 10. CONCLUSION: In our institution, intestinal vaginoplasty before 2000 was always performed as a revision procedure after a previous vaginoplasty had failed. Although surgical corrections were frequently necessary, women reported satisfaction with the surgical outcome and with life in general.

Diversion neovaginitis after sigmoid vaginoplasty: endoscopic and clinical characteristics.

OBJECTIVE: To assess the endoscopic characteristics of the sigmoid-derived neovagina, which have been scarcely described. DESIGN: Prospective observational study. SETTING: University tertiary medical center. PATIENT(S): Patients that underwent sigmoid vaginoplasty. INTERVENTION(S): Patients were invited yearly to undergo neovaginoscopy and sigmoidoscopy, preceded by taking a medical history and physical examination, as routine follow-up. MAIN OUTCOME MEASURE(S): Endoscopic signs of neovaginal inflammation. RESULT(S): Thirty-four patients with a sigmoid neovagina underwent a total of 43 combined neovaginoscopies and sigmoidoscopies. After a mean postoperative time of 23 months, the most notable endoscopic features of the sigmoid-derived neovagina comprised a diminished vascular pattern, edema, granularity, friability, decreased resilience, and erythema. In the control rectosigmoidoscopy images, no concurrent abnormalities were observed. When applying the MAYO score to the neovaginal images, 12 (35%) patients scored MAYO 0, 19 (56%) MAYO I, 3 (9%) MAYO II, and none MAYO III. The presence of neovaginal discharge and malodor correlated with inflammatory endoscopic alterations. CONCLUSION(S): The endoscopic appearance of a sigmoid segment after use in neovaginoplasty differs significantly from that of the remaining rectosigmoid. Inflammatory changes of the sigmoid-derived neovagina were observed in most patients. Clinically, the inflammatory changes appear similar to those encountered in diversion colitis.