Non-grafted Vaginal Depth Augmentation for Transgender Atresia, Our Experience and Survey of Related Procedures.

INTRODUCTION: Neovaginal atresia especially following male-to-female transgender vaginoplasty is a distressing concern. A pelvic space must be re-created. Traditionally, an epithelial or mucosal lining is employed to cover the space. However, in our series of 18 patients, a non-grafted approach has been equally efficacious, as previously described by others. AIM: To follow the outcome of male-to-female transsexuals undergoing secondary depth enhancement without use of graft or flap. METHODS: Patient selection included two operated on elsewhere, one of whom had a lower abdominal skin graft, and the remainder done here using an inverted penile skin flap supplemented by a scrotal graft extension as needed. The time lag from primary to revision surgery varied from 5 months to 23 years, average 3.7 years. The fascial plane of Denonvilliers was reopened and packed for 7 days to facilitate maintenance of a pelvic space. Patients are requested to perform serial self-dilations with a stent set indefinitely to maintain patency and procure additional depth. Immuno-histochemistry staining was performed to demonstrate estrogen receptor (ER) presence in male genital skin. Estrogen cream may be utilized to facilitate wound healing. Main outcome measures were post-operative depth results and Female Sexual Function Index (FSFI) scores. Several attempts were made to contact all patients for completion of a FSFI. Ten out of 18 responded. RESULTS: Following revision of the pelvic space, static depths increased two-fold on average, from 2.4 in. (6.2 cm) to 5.0 in. (12.7 cm). The FSFI domain scores (of desire, arousal, lubrication, orgasm, satisfaction, and pain) were all mid-range or above. Full scale FSFI scores (compilation score) averaged 23.4 (range limits 2-36). Histologic staining showed the presence of ER in genital skin of all genetic males tested regardless of estrogen usage and perceived gender. CONCLUSIONS: Given adequate development of the rectal-vesical space and preservation of that space with self-dilation, epithelialization will ensue providing sexual gratification for patient and partner (as per patient). LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Neutrophil extracellular traps and NETosis: a report of two autopsies and review of literature.

: Recent studies reveal that neutrophil extracellular traps (NETs) play a significant role in platelet entrapment and consequent activation of the coagulation cascade. Herein we present two autopsy cases of NETosis. The first case is a 76-year-old man, with metastatic squamous cell carcinoma of the lung who expired 5 days post admission. Autopsy revealed extensively necrotic poorly differentiated squamous cell carcinoma of the right lung. A 30-cm cylindrical thrombus was identified, extending from the left ventricle to the thoracic aorta, composed of numerous neutrophils enmeshed in abundant fibrin representing a NET. The second case is a 73-year-old man who suffered a cardiopulmonary arrest of unknown cause and expired 2 days post admission. Autopsy revealed a 5-cm mural thrombus with numerous neutrophils in the descending aorta consistent with NET, bilateral bronchopneumonia and infarcted bowel. These two autopsies highlight the pathogenic role of NET in causing thrombosis.

Acute gastric volvulus: a deadly but commonly forgotten complication of hiatal hernia.

Gastric volvulus is a rare condition resulting from rotation of the stomach beyond 180 degrees. It is a difficult condition to diagnose, mostly because it is rarely considered. Furthermore, the imaging findings are often subtle resulting in many cases being diagnosed at the time of surgery or, as in our case, at autopsy. We present the case of a 76-year-old man with an extensive medical history, including coronary artery disease with multiple bypass grafts, who became diaphoretic and nauseated while eating. His presumptive diagnosis at arrival to the hospital was an acute coronary event; however, his initial cardiac work-up was negative. A computed tomography scan revealed a type III hiatal hernia. The following day, after consistent complaints of nausea and episodes of nonbloody emesis, he suddenly became hypotensive, tachycardic and had an episode of coffee-ground emesis. Subsequently, the patient's condition suddenly deteriorated and resuscitation attempts were unsuccessful. The autopsy revealed a partially sliding hiatal hernia, which was consistent with the radiologic impression. Additionally, a gastric volvulus was present with extensive, focally transmural necrosis involving the body/fundus. Gastric volvulus is a rare entity with variable, nonspecific clinical presentations, which requires a high level of suspicion for radiologic diagnosis. Acute cases have a high mortality rate and require emergency surgery. This case highlights the value of autopsy in the diagnosis of unsuspected cases of gastric volvulus when death occurs prior to surgical intervention.