Double longitudinal myotomy in gender-affirming colovaginoplasty: an innovative surgical technique to prevent and treat neovaginal spasms.

BACKGROUND: Gender-affirming colovaginoplasty (GACv) presents excellent postoperative results. However, neovaginal spasms, reported as painful cramps, can affect the sexual life of patients. AIM: The study sought to describe an innovative surgical technique and evaluate its impact on the prevention and treatment of neovaginal spasms. METHODS: This was a single-center prospective observational study with 2 series of patients: (1) patients who underwent GACv with double myotomy (DM) for spasm prevention (series A), in which longitudinal myotomies were performed across the defunctionalized colon, transecting the taenias, and resecting 2 strips of the intestinal muscle layer of approximately 1- to 2-mm wide and tall, leaving intact colonic tissue between strips; and (2) patients who reported neovaginal spasms in whom intravaginal-DM was performed as treatment surgery (series B), in which the posterior wall of the neovagina was dissected from the rectum and transected by longitudinal myotomies, resecting 2 strips of endoluminal mucosa and submucosal muscle of approximately 1- to 2-mm wide and tall, and the colonic mucosa was subsequently closed. OUTCOMES: Patient-reported outcomes and neovaginal examination were performed following standardized protocols. RESULTS: In series A, 177 patients underwent GACv with the DM technique and were prospectively followed for a median time of 18 months (interquartile range, 13-60 months). No patients reported neovaginal spasms. In series B, 18 patients who reported neovaginal spasms after GACv were treated with intravaginal DM. After a median time of 35 months (interquartile range, 26-45 months), 83% (n = 15 of 18) reported remission of symptoms. CLINICAL IMPLICATIONS: Double longitudinal myotomy performed on the derived portion of the colon in colovaginoplasty is an easy-to-perform and safe technique that may prevent and treat postoperative neovaginal spasms. STRENGTHS AND LIMITATIONS: Our results presented certain limitations, mainly associated with a low prevalence of neovaginal spasms, which, being of personal perception, can be underdiagnosed. To the same extent, the fact that it is a monocentric experience limits the possibility of extrapolating it to other centers. Moreover, a more trained surgical team may be the cause of fewer postoperative complications. On the other hand, the fact of being a reference center for gender-affirming surgery, having our procedures protocolized, and the prospective nature of the study allowed us to obtain a certain homogeneity and granularity of the results. CONCLUSION: DM is a safe procedure and appears to be highly effective for the prevention and treatment of neovaginal spasms after GACv. Routine use of this technique does not increase the operating time or postoperative complications. Multicenter, prospective studies are required to validate our results.

Cosmetic Revision Surgeries after Transfeminine Vaginoplasty.

BACKGROUND: Vaginoplasty is the most frequent genital gender-affirming surgery. Although both functional and aesthetic outcomes after transfeminine vaginoplasty have improved over the years, cosmetic revision surgeries demand after transfeminine vaginoplasty appears to be increasing and requires updated knowledge. METHODS: All patients who underwent vulvar cosmetic revision surgeries at our institution following transfeminine vaginoplasty from January 2014 to April  2022 were studied. The prevalence, topography and surgical techniques of cosmetic revision surgeries after transfeminine genital gender-affirming surgery were examined using clinical charts review and statistical analysis. RESULTS: During the study period, 354 patients underwent gender-affirming vaginoplasty at our single institution (212 penile inversion vaginoplasty, 122 colovaginoplasty and 20 penile inversion vaginoplasty with scrotal skin graft patients). Forty out of these 354 patients (11.29%) required cosmetic revision surgery after transfeminine vaginoplasty; additionally, 44 patients with vaginoplasty performed at other centres also underwent vulvar cosmetic revision surgery at our clinic during the study period. From all performed cosmetic revision surgeries, most of them (31.42%) were labia corrections, followed by clitoris (23.26%) repair surgeries. Mons Venus (10.20%), urethral meatus (9.38%), spongiosus tissue remnants (8.57%) and introitus (6.53%) revisions followed in frequency. Corrections of peri-inguinal scars (5.30%), anterior commissure (2.84%) and inferior fourchette (2.42%) were less prevalent. No differences were found among the different studied vaginoplasty techniques regarding cosmetic revision surgery prevalence or topography following transfeminine vaginoplasty (p < 0.05). CONCLUSIONS: Cosmetic revision surgeries after transfeminine vaginoplasty are frequent. In our large and long-term cohort study, labiaplasty followed by clitoroplasty were found as the most required cosmetic revision surgical procedures. Further multicentre, prospective and controlled studies are necessary to improve cosmetic outcomes and scientific evidence after transfeminine vaginoplasty. LEVEL OF EVIDENCE IV: 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 .

Functional, aesthetic, and sensory postoperative complications of female genital gender affirmation surgery: A prospective study.

BACKGROUND: Female genital gender affirmation surgeries have increased in recent years. Prospective studies with homogeneous standardized techniques and outcomes assessment are scarce in the current literature. This study aims to: 1) report the functional, aesthetic, and sensory postoperative complications (POCs) of primary genital gender confirmation surgeries performed on transgender women and 2) compare functional and aesthetic POCs amongst three vaginoplasty techniques: inverted penile skin, penoscrotal skin graft, and pedicled intestinal flap vaginoplasty. METHODS: All (n = 84) consecutive transfemale individuals who underwent primary genital gender confirmation surgery from January 2015 to December 2016 at IMCLINIC were prospectively followed. Functional, aesthetic, and sensory POCs were registered according to the Clavien-Dindo POC classification. RESULTS: Functional POC rates after vaginoplasty at our centre were 19%, 12%, 13%, and 1% at short (one month), mid-early (three months), mid-late (six months), and long-term (one year) follow-up visits, respectively. None of them were severe complications (grades IV-V), 25% were grade III, and less than 20% were low-grade complications (grades I-II). Overall, aesthetic satisfaction was high (90%). The total number of secondary surgeries needed to satisfy the cosmetic outcome was 20 (aesthetic POC grade IIIb). No differences regarding functional or aesthetic complication rates amongst vaginoplasty techniques were encountered. Twelve months after surgery, 81% of patients had initiated sexual intercourse, and 96% reported clitoral sensitivity. CONCLUSIONS: In our experience, female genital gender affirmation surgery is a feasible, low-complication surgery that offers high satisfaction in the long term. Further multicentric well-designed research is mandatory to improve outcomes.

Transgender patients: considerations for routine gynecologic care and cancer screening.

In the last several years, demand for transgender care from gynecologists has increased significantly. Transgender people comprise a diverse group who do not identify with the sex they were assigned at birth. Worldwide, it is estimated that 25 million people identify as transgender. Some undergo hormonal and/or surgical treatment aiming to feminize or masculinize their bodies. Cross-sex hormone treatment for transgender women-individuals assigned as male at birth who identify themselves as women-includes exogenous estrogen and/or progestin administration in combination with anti-androgens, whereas testosterone is used for transgender men-individuals whose natal sex is women but identify themselves as men. Although it is usually rare, hormone-sensitive malignancies may arise, and long-term effects remain unknown. In addition, reconstructive surgeries may include breast augmentation and vaginoplasty (creation of a vagina) for transgender women, and chest masculinization surgery (bilateral mastectomy) and metoidioplasty (lengthening of the clitoris to create a microphallus) or phalloplasty (creation of a phallus) for transgender men. Evidence relating to breast and reproductive tract cancers in the trans population is limited and insufficient to estimate cancer prevalence, and recommendations for screening and preventive care depend on the patients' hormonal and surgical status. Even less information exists regarding the sub-set of individuals with genetic predisposition for these malignancies. In this review, we aimed to summarize current recommendations for gynecologists and gynecologic oncologists regarding cancer screening and personalized cancer-risk assessment in transgender people.

Combined Breast Reduction Augmentation.

BACKGROUND: Numerous methods have been designed to reduce breasts size and weight. The goal today is to not only to reduce size but also to create a pleasing shape. Breast reduction techniques do not obtain the desired upper pole fullness, and commonly recurrent ptosis develops. To improve and maintain breast shape in the late postoperative period, we combine breast reduction with implants. METHODS: Three hundred and sixty-six patients who underwent combined breast reduction or mastopexy with implants from January 2014 to November 2017 at IM Clinic were retrospectively reviewed. We present the indications, surgical technique, and outcomes of these patients to determine the safety and efficacy of our technique. RESULTS: No major complications were noted in an average of 2 years of follow-up (range 2 months to 4 years). Minor complications occurred in 61 patients, of whom 46 required revision surgery (12.6%). The most common tissue-related complications were dog ears (7.6%) and poor scarring (4.9%). The most common implant-related complication was capsular contracture (0.8%). CONCLUSIONS: Breast reduction with implants is a reliable option to provide additional volume to the upper pole of the breast to improve long-term breast shape and avoid ptosis recurrence. Our study indicates that the procedure is safe and has complication and revision rates comparable to traditional breast reduction or augmentation mastopexy techniques. LEVEL OF EVIDENCE IV: 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 .

Aesthetic Refinement in the Creation of the Clitoris, Its Preputial Hood, and Labia Minora in Male-to-Female Transsexual Patients.

BACKGROUND: In male-to-female genital sex reassignment surgery, the clitoris, its prepuce, and the labia minora remain among the most difficult structures to construct. We describe the authors' clitoroplasty and vulvoplasty technique. METHODS: All patients who underwent male-to-female sex reassignment surgery at a single center, between June 2012 and June 2016, were prospectively included. The standard pedicled island neurovascular flap of the glans penis was harvested in a letter M fashion with attached preputial skin. The central triangle of the M was used for the neoclitoris formation. Labia minora and the clitoral prepuce were created with both legs of the M and the preputial skin attached to it. Tactile and erogenous sensitivity was evaluated. RESULTS: Ninety-seven patients were included (mean age, 32 years; range, 17-54 years). All clitoroplasties and vulvoplasties were completed in the same surgical stage as the vaginoplasty. There were no cases of deep or total flap necrosis. Eight patients developed partial and superficial skin necrosis of the flap; one presented an abscess in labia majora, and another patient had urethral hematoma; both required drainage. None of the complications left any sequelae. At 6 months' follow-up all patients maintained tactile and erogenous sensitivity. CONCLUSIONS: The proposed technique represents an aesthetic refinement of the previously described pedicled glans penis flap by allowing the creation of a sensate neoclitoris, its preputial hood, and labia minora with excellent outcomes in the same surgical stage as the sex reassignment.

Clitoral Reconstruction Using a Vaginal Graft After Female Genital Mutilation.

BACKGROUND: Clitoral reconstruction after genital mutilation is a feasible and effective strategy to reduce clitoral pain, improve sexual pleasure, and restore vulvar appearance. TECHNIQUE: We describe a novel surgical technique for clitorolabial reconstruction using a vaginal graft. EXPERIENCE: We present a series of 32 consecutive women who underwent this procedure at Iván Mañero Clinic, Barcelona, Spain, and were prospectively followed. The total Female Sexual Function Index changed favorably from 16 before surgery to 29 after surgery (P<.05). Likewise, the Female Self-Image Genital Scale changed favorably from 11 to 23 (P<.05). CONCLUSION: Clitoral reconstruction after genital mutilation was associated with improved sexual function and genital aesthetic perception.

Vulvar condylomatosis after sex reassignment surgery in a male-to-female transsexual: Complete response to imiquimod cream.

BACKGROUND: The number of patients seeking sex reassignment surgery is increasing. Approximately 1:30,000 adult males and 1: 100,000 adult females seek this procedure. Neovaginal-related disorders after sex reassignment surgery are increasingly more common. Vulvar condylomatosis is the clinical manifestation of HPV 6- and 11 infection in biological women. The same HPV-subtypes are associated with anogenital warts and penile intraepithelial neoplasia in biological men. We aim to present a case of vulvar condylomatosis after sex reassignment surgery in a male-to-female transsexual and its complete response to 5% imiquimod cream. CASE: We describe a case of a 19-year-old female transexual who presented one year after male to female sex reassignment surgery by inverted penile skin vaginoplasty with condyloma accuminata of the vulva. The patient had a complete response to imiquimod 5% cream 12 weeks after initiation of treatment. CONCLUSION: Gynecologists should be prepared to treat neovaginal-related disorders in male-to-female transsexuals.

Aesthetic Refinements after Radial Free Flap Phalloplasty: Optimizing the Donor Site and the Phallus.

BACKGROUND: Phalloplasty with radial forearm flap is the gold standard for female-to-male sex reassignment surgery. However, it leaves a stigmatizing forearm scar, and as the new phallus is created with the forearm's skin and fat, it does not look like that of a biological man. The aesthetic appearance of the donor site and the neophallus can be optimized after phalloplasty. In this study, we review refinement techniques (RTs) performed after radial forearm flap phalloplasty. METHODS: We present a historical cohort of patients who underwent the following RTs: forearm fat grafting and localized laser in the forearm's scars, and micropigmentation of the neophallus. Patient's aesthetic satisfaction was evaluated using the Patient and Observer Scar Assessment Scale for the forearm's refinements and the Male Genital Self-Image Scale for the neophallus. RESULTS: Between January 2014 and January 2016, 8 patients underwent forearm fat grafting with localized laser, and 7 patients micropigmentation of the neophallus after radial flap phalloplasties. All Patient and Observer Scar Assessment Scale parameters showed a statistically significant reduction between preoperative and postoperative values. Male Genital Self-Image Scale survey showed that all patients felt positively about their genitals after micropigmentation. Patients who underwent refinement procedures were highly satisfied with the aesthetic outcome and felt more confident. They also claim that they would choose to have the refinement procedure done again. CONCLUSIONS: The proposed RTs are minimally invasive interventions to complement and enhance female-to-male sex reassignment surgery with very few complications and excellent aesthetic results of both the forearm scars and the constructed phallus.