Targeted demethylation and activation of NLRC5 augment cancer immunogenicity through MHC class I.

Impaired expression of MHC (major histocompatibility complex) class I in cancers constitutes a major mechanism of immune evasion. It has been well documented that the low level of MHC class I is associated with poor prognosis and resistance to checkpoint blockade therapies. However, there is lmited approaches to specifically induce MHC class I to date. Here, we show an approach for robust and specific induction of MHC class I by targeting an MHC class I transactivator (CITA)/NLRC5, using a CRISPR/Cas9-based gene-specific system, designated TRED-I (Targeted reactivation and demethylation for MHC-I). The TRED-I system specifically recruits a demethylating enzyme and transcriptional activators on the NLRC5 promoter, driving increased MHC class I antigen presentation and accelerated CD8+ T cell activation. Introduction of the TRED-I system in an animal cancer model exhibited tumor-suppressive effects accompanied with increased infiltration and activation of CD8+ T cells. Moreover, this approach boosted the efficacy of checkpoint blockade therapy using anti-PD1 (programmed cell death protein) antibody. Therefore, targeting NLRC5 by this strategy provides an attractive therapeutic approach for cancer.

Perineal Squamous Cell Carcinoma Arising in an Epidermal Cyst.

A 90-year-old Japanese woman who had been aware of a subcutaneous mass on the right perineal region for 5 years was referred to our hospital for further examination and treatment because of the rapid growth of the mass and bleeding that began 3 months earlier. A biopsy of the mass revealed a diagnosis of well-differentiated squamous cell carcinoma. On preoperative examination, the tumor was 90×40 mm in size and was suspected to have partially invaded the levator ani muscle and external sphincter. Since a preoperative cardiac evaluation indicated severe aortic stenosis, we performed transcatheter aortic valve implantation. A radical resection was then performed with general anesthesia. The skin and subcutaneous tissue defects were reconstructed with a posterior gluteal-thigh propeller flap, and a sigmoid colostomy was created. The patient had a good postoperative course and was transferred to a rehabilitation facility 28 days after the surgery. Epidermal cysts are a common benign tumor, and clinicians should keep in mind that these cysts can become malignant.

CYP2C8-Mediated Formation of a Human Disproportionate Metabolite of the Selective NaV1.7 Inhibitor DS-1971a, a Mixed Cytochrome P450 and Aldehyde Oxidase Substrate.

Predicting human disproportionate metabolites is difficult, especially when drugs undergo species-specific metabolism mediated by cytochrome P450s (P450s) and/or non-P450 enzymes. This study assessed human metabolites of DS-1971a, a potent Nav1.7-selective blocker, by performing human mass balance studies and characterizing DS-1971a metabolites, in accordance with the Metabolites in Safety Testing guidance. In addition, we investigated the mechanism by which the major human disproportionate metabolite (M1) was formed. After oral administration of radiolabeled DS-1971a, the major metabolites in human plasma were P450-mediated monoxidized metabolites M1 and M2 with area under the curve ratios of 27% and 10% of total drug-related exposure, respectively; the minor metabolites were dioxidized metabolites produced by aldehyde oxidase and P450s. By comparing exposure levels of M1 and M2 between humans and safety assessment animals, M1 but not M2 was found to be a human disproportionate metabolite, requiring further characterization under the Metabolites in Safety Testing guidance. Incubation studies with human liver microsomes indicated that CYP2C8 was responsible for the formation of M1. Docking simulation indicated that, in the formation of M1 and M2, there would be hydrogen bonding and/or electrostatic interactions between the pyrimidine and sulfonamide moieties of DS-1971a and amino acid residues Ser100, Ile102, Ile106, Thr107, and Asn217 in CYP2C8, and that the cyclohexane ring of DS-1971a would be located near the heme iron of CYP2C8. These results clearly indicate that M1 is the predominant metabolite in humans and a human disproportionate metabolite due to species-specific differences in metabolism. SIGNIFICANCE STATEMENT: This report is the first to show a human disproportionate metabolite generated by CYP2C8-mediated primary metabolism. We clearly demonstrate that DS-1971a, a mixed aldehyde oxidase and cytochrome P450 substrate, was predominantly metabolized by CYP2C8 to form M1, a human disproportionate metabolite. Species differences in the formation of M1 highlight the regio- and stereoselective metabolism by CYP2C8, and the proposed interaction between DS-1971a and CYP2C8 provides new knowledge of CYP2C8-mediated metabolism of cyclohexane-containing substrates.

Effects of glucokinase activator, DS-7309, on embryo-fetal developmental toxicity in rats and rabbits.

The toxicological effects of DS-7309, a glucokinase activator, on pregnancy and embryo-fetal development in rats and rabbits and maternal blood glucose levels were examined. DS-7309 was administered at 3, 10, or 100 mg/kg to rats from Days 7-17 of pregnancy or at 10, 30, or 100 mg/kg to rabbits from Days 6-18 of pregnancy. In rats, maternal hypoglycemia (approximately 50 mg/dL) was seen at 3 and 10 mg/kg, but it recovered 7 h after dosing, leading to no toxic changes. In contrast, continuous severe maternal hypoglycemia (approximately 40 mg/dL, ≥7 h), fetal eye anomalies, and decreased fetal body weight were noted at 100 mg/kg. In rabbits, no fetal anomalies were seen at 10 and 30 mg/kg where maternal blood glucose level dropped to approximately 60-90 mg/dL, but recovered by 7 h after dosing at the latest. In contrast, at 100 mg/kg, severe hypoglycemia (around 60 mg/dL) was maintained and did not recover until 24 h after dosing; it resulted in decreased fetal viability and increased fetal skeleton anomalies. These findings indicate that DS-7309 could lead to embryo-fetal toxicity in rats and rabbits, with such toxicity considered to be related to continuous severe maternal hypoglycemia.

Genital Feminizing Surgery without Vaginoplasty as a Safe, Aesthetic, and Cost-Effective Option for Gender-Affirming Surgery for Transwomen.

Gender affirming surgery (GAS) has important impacts for people with gender incongruence (GI), both physically and socially. As the societal acceptance of gender diversity spreads, the number of individuals with GI who wish to be identified as the gender of their choice is increasing. Indeed, many elderly people who have lived a long time with GI now wish to undergo GAS, but face greater surgical risks due to greater burdens of underlying medical conditions. Generally, vaginoplasty is performed for transwomen; however, this surgery is time-consuming and involves heavy bleeding, and thus, should be avoided in elderly people. A less invasive technique is needed. In this article, we describe a new, less invasive genital feminizing surgical technique for transwomen with reports from two clinical cases. We present this novel technique as a safe, aesthetic, and cost-effective option for gender-affirming surgery for transwomen.

MHC class I transactivator NLRC5 in host immunity, cancer and beyond.

The presentation of antigenic peptides by major histocompatibility complex (MHC) class I and class II molecules is crucial for activation of the adaptive immune system. The nucleotide-binding domain and leucine-rich repeat receptor family members CIITA and NLRC5 function as the major transcriptional activators of MHC class II and class I gene expression, respectively. Since the identification of NLRC5 as the master regulator of MHC class I and class-I-related genes, there have been major advances in understanding the function of NLRC5 in infectious diseases and cancer. Here, we discuss the biological significance and mechanism of NLRC5-dependent MHC class I expression.

The COVID-19 Pandemic and Families in Japan.

This paper, which is authored by members of the Japanese Association of Family Therapy (JAFT), describes the COVID-19 pandemic in Japan from a family systems perspective. The authors are active members of JAFT and include current and past presidents and officers. We describe the course of the pandemic and the ways in which government policies to mitigate the pandemic have affected Japanese families. Challenges that affect Japanese families include the inability to participate in family and social rituals, prescribed gender roles that specifically affect women, high suicide rates, and prejudice against those who are at risk of spreading the infection. The need to shelter in place has also forced family homes to function as a workplace for parents, classrooms for children, and day care services for frail elders, which has resulted in psychological distress among individuals and conflicts among families. We discuss ways that therapists have worked with Japanese families using online therapy.

Low C4 as a risk factor for severe neuropsychiatric flare in patients with systemic lupus erythematosus.

OBJECTIVE: This study aimed to explore the risk factors for 'severe' neuropsychiatric (NP) flare in patients with systemic lupus erythematosus (SLE). METHODS: This retrospective study comprised newly diagnosed 184 adult SLE patients who visited Hokkaido University Hospital between 2006 and 2017. In this study, severe NP flare was defined as the occurrence of at least one newly developed British Isles Lupus Assessment Group A score in the neurological domain. Overall severe NP flare-free survival was estimated by Kaplan-Meier analysis. Clinical and demographic profiles at SLE diagnosis were assessed as potential risk items in the adjusted multivariate Cox regression model. RESULTS: The median follow-up period was 7.9 years (interquartile range (IQR) 4.6-12.3) years. A total of 28 (15.2%) patients had one or more severe NP flares during the observation period. The median time from patient enrolment date to severe NP flare occurrence was 3.1 years (IQR 0.9-6.3 year). The 2- and 10-year severe NP flare-free survival rates were 92.7% and 86.0%, respectively. Among the manifestations of severe NP flare, psychosis was the most frequent (19.1%). In the multivariate model, low serum levels of C4 (hazard ratio (HR) = 3.67, p = 0.013) and severe NP manifestations at SLE diagnosis (HR = 7.11, p < 0.001) emerged as independent risk factors for developing severe NP flare. CONCLUSION: The first severe NP flare presented early in the course of SLE. Low C4 level and severe NP manifestations at SLE diagnosis could predict the development of severe NP flare.

Effects of single ingestion of rice cracker and cooked rice with high resistant starch on postprandial glucose and insulin responses in healthy adults: two randomized, single-blind, cross-over trials.

Rice with double mutation of starch synthase IIIa and branching enzyme IIb (ss3a/be2b) has much higher amounts of apparent amylose and resistant starch (RS) than usual varieties. In this study, we conducted two randomized, single-blind, crossover trials to investigate the effect of single ingestion of two processed foods composed of ss3a/be2b mutant rice on postprandial blood glucose and insulin response in healthy adults, compared to those of usual cultivar. In trial 1, of ingestion of rice crackers, the incremental area under the curves of glucose (IAUCglc) and insulin (IAUCins) in RS group was significantly lower than in the control group. In trial 2, of the ingestion of cooked rice, IAUCglc in the RS group was significantly lower than in the control group. These results showed that the ss3a/be2b-mutant rice cracker and cooked rice having high RS can attenuate postprandial blood glucose and insulin response.

The Novel Eryngii Method of Nipple Reduction for Female-to-Male Transsexuals.

Mastectomy is usually the first and most important surgical procedure in female-to-male (FTM) individuals with gender identity disorder. Nipple reduction is also important in the process of reconstructing the chest wall for a more male appearance. If the nipples remain large after a mastectomy, the results may be disappointing to many FTM transsexuals. Nipple reduction enables these individuals to go to the beach or Japanese public baths, where they may go topless in public. We therefore consider that nipple reduction is indicated for all FTM transsexuals who desire it. There are a variety of methods for the reduction of enlarged nipples for women or non-FTM patients, but only a few reports have described the process used to create masculine-appearing nipples for FTM transsexuals. We developed a novel technique called the Eryngii method for creating male-like nipples using a 4-mm diameter dermal punch knife. The name of the method refers to the Eryngii king trumpet mushroom, which the nipple resembles after the surgical process. The main strength of this method is that it permits the creation of ideal nipples without difficulty. Here we introduce the technique and discuss our history of surgical methods for nipple reduction, including improvements and elaborations.

Flap Combination Phalloplasty in Female-to-Male Transsexuals.

BACKGROUND: Although phalloplasty with a free radial forearm (RF) flap is the gold standard for sex reassignment surgery in female-to-male transsexuals, it can result in unsightly scars, lymphedema, and numbness of the hand. AIM: To introduce the concept of flap combination phalloplasty and its clinical application. METHODS: This is a retrospective chart review study of patients undergoing phalloplasty using various multiple flaps. Demographic data, surgical data, and outcomes were recorded. OUTCOMES: Of the 15 cases, 5 were urethral fistulas; 4 were venous thrombosis; 2 were urethral calculus; and 1 was a partial flap loss. RESULTS: 15 patients were included (age range 25-43 years, median 34 years). An RF flap and a deep inferior epigastric artery perforator flap combination were most frequently used. The median operative time for flap combination phalloplasty was 10.5 hours (range 6.5-12.5 hours). There was no total flap necrosis, but there was 1 case of partial flap loss. There were urethral fistulas in 5, venous thrombosis in 4, and urethral calculus in 2 cases. CLINICAL IMPLICATIONS: Flap combination phalloplasty will become the third option when both the RF flap and the anterolateral thigh pedicle flap are not useful. STRENGTH & LIMITATIONS: Flap combination phalloplasty is a complex operative procedure with a prolonged operative time, but it can provide more flap selection and reduce the morbidity at each donor site. Choosing from many different options can be beneficial to patients. CONCLUSION: Flap combination phalloplasty has a similar complication rate to other procedures and has advantages in terms of flexibility and less donor site morbidity; it may thus be an option when either the RF flap or the anterolateral thigh pedicle flap cannot be used. Namba Y, Watanabe T, Kimata Y. Flap Combination Phalloplasty in Female-to-Male Transsexuals. J Sex Med 2019;16:934-941.

Risk Factors for Postoperative Hematoma after Chest Wall Contouring for Female-to-Male Transsexuals: A Clinical Study.

Gender dysphoria is a condition in which a discrepancy between biological sex and gender identity causes distress. Many female-to-male transsexuals (FTMTS) are uncomfortable with female breasts. Chest wall contouring surgery is effective for obtaining a male-type chest, reducing mental stress, and increasing sexual satisfaction in such cases. At the Okayama University Hospital Gender Center, we have obtained positive results using an algorithm to determine the most appropriate surgical method for chest wall contouring in FTMTS patients. However, serious complications requiring reoperation, such as hematoma, may still occur. Postoperative hematomas were found in 15 (4.18%) of 358 FTMTS patients who underwent chest contouring surgery at our hospital between 2006 and 2018. Postoperative hematoma was examined retrospectively. The median time to the onset of hematoma was 7 (6-12) h after the initial surgery. The main blood vessels causing bleeding were those in the head-side skin flap region where visual confirmation was difficult and the perforator vessels from the pectoralis major muscle. Intraoperative bleeding and the operation time had a significant impact on the onset of postoperative hematoma. This is the first retrospective study that investigated the blood vessels and other factors contributing to postoperative hematoma development after chest wall contouring.

Laparoscopic Rectosigmoid Colon Vaginoplasty in Male-to-Female Transsexuals: Experience in Japan.

Intestinal vaginoplasty has several advantageous features, such as scarless surgery, low incidence of contraction of the reconstructed vagina, maintenance of vaginal depth, spontaneous mucus production, and a low rate of complications. Therefore, this technique is becoming popular in many countries. Following the global trend, the demand for intestinal vaginoplasty for transsexuals is also increasing in Japan. However, there are few reports on intestinal vaginoplasty in Japan. In this study, we examined the safety and effectiveness of rectosigmoid colon vaginoplasty in the Japanese population. We retrospectively surveyed 18 male-to-female transsexuals who underwent laparoscopic rectosigmoid colon vaginoplasty at the Okayama University Hospital Gender Center between October 2012 and December 2017. One patient had developed an anastomotic leak and 2 patients experienced vaginal prolapse, which needed revision surgery. Both adverse outcomes were comparable with those from previous studies. The anastomotic leak was managed adequately with conservative treatment. To avoid vaginal prolapse, it is important to decide the length of the rectosigmoid segment so that a pull on it does not cause it to become lax, while excessive stress on the feeder vessels is avoided. Based on our study, we concluded that rectosigmoid vaginoplasty was a reliable technique in the Japanese population.

Reverse-supercharged, distally based latissimus dorsi flap for lumbar defect: A case report.

Well-vascularized tissue is required for successful reconstruction of a soft tissue defect in the lumbar region. There are several options for reconstruction; however, controversy exists regarding the optimal technique. Here, we present a case of a lumbar defect following tumor resection in a 75-year-old patient that was repaired using a reverse-supercharged, distally based latissimus dorsi flap. The defect of size 15 × 12 cm2 was localized to the lumbar region. An 11 × 7 cm2 -sized, distally based latissimus dorsi flap was designed cephalad to the latissimus dorsi muscle. After the flap was tunneled to the defect, vascular insufficiency of the skin flap was observed. Supercharging was subsequently performed by anastomosing the serratus anterior branch in a reverse manner to the lumbar perforator. The diameters of the vessels at the end-to-end anastomosis site were 1.0 mm (artery) and 1.2 mm (vein), respectively, and there was slight discrepancy in their calibers. After microvascular anastomosis, the vascular supply of the flap improved, and the flap survived uneventfully, without venous congestion. The patient was discharged 17 days after the surgery, and no recurrence of the tumor was observed at the 2-year follow-up. We report a case of successful salvage of a distally based latissimus dorsi flap by the reverse-supercharge technique based on a serratus anterior branch. This flap might be a suitable alternative for use in the lumbar region in the case of limited availability of reconstructive choices.

Uneventful Pregnancy and Delivery after Thrombolysis Plus Thrombectomy for Acute Ischemic Stroke: Case Study and Literature Review.

BACKGROUND: Intravenous thrombolysis with recombinant tissue plasminogen activator and endovascular mechanical thrombectomy are known to be the most effective treatments in the acute phase of ischemic stroke. However, the safety of intravenous systemic thrombolysis with recombinant tissue plasminogen and endovascular mechanical thrombectomy during pregnancy is not well-confirmed. We describe a case of an uneventful pregnancy and delivery after thrombolysis plus endovascular mechanical thrombectomy for acute ischemic stroke. MATERIALS AND METHODS: The patient's medical records were reviewed retrospectively. A comprehensive systemic literature search of the PubMed database was conducted. CASE PRESENTATION: A 36-year-old woman at 21 weeks gestation presented with a sudden headache, dysarthria, and right hemiparesis. Magnetic resonance angiography revealed occlusion of the left internal carotid artery. Recombinant tissue plasminogen activator was administered intravenously 193 minutes after symptom onset, and endovascular mechanical thrombectomy was started immediately. Recanalization of her left internal carotid artery was achieved. The patient continued to experience mild hemiparesis after the initial treatment and started rehabilitation. The fetus remained in satisfactory condition during the pregnancy and was delivered at 38 weeks without obvious maternal or neonatal complications. No apparent abnormality has been observed in the newborn in the first year of life. CONCLUSIONS: Intravenous recombinant tissue plasminogen and endovascular mechanical thrombectomy could be considered as treatment for acute ischemic stroke during pregnancy unless high risks of hemorrhage or preterm labor are expected.

Raoultella planticola bacteremia-induced fatal septic shock following burn injury.

BACKGROUND: Raoultella planticola, a Gram-negative, aerobic bacillus commonly isolated from soil and water, rarely causes invasive infections in humans. Septic shock from R. planticola after burn injury has not been previously reported. CASE PRESENTATION: A 79-year-old male was admitted to the emergency intensive care unit after extensive flame burn injury. He accidently caught fire while burning trash and plunged into a nearby tank filled with contaminated rainwater to extinguish the fire. The patient developed septic shock on day 10. The blood culture detected R. planticola, which was identified using the VITEK-2 biochemical identification system. Although appropriate antibiotic treatment was continued, the patient died on day 12. CONCLUSIONS: Clinicians should be aware of fatal infections in patients with burn injury complicated by exposure to contaminated water.

Pedicled Flaps Versus Free Flaps for Back Reconstruction.

BACKGROUND: Back reconstructions using a flap are relatively rare, and clinical reports on such reconstructions are few. We analyzed whether a pedicled flap or free flap was best for treating back defects and established a simplified algorithm for flap selection. METHODS: We retrospectively analyzed the cases of 22 patients who underwent flap reconstructions for the back between July 2000 and August 2016. We extracted data on the operative time, defect size, patients' height and body weight, and reoperation, and each defect size was calculated as a percentage in relation to the body surface area (BSA). We compared these values between both flap types using univariate analysis. In addition, reconstructions using pedicled flaps were classified as single pedicled flap and combination pedicled flap reconstructions. The reasons for reoperation were also reviewed. RESULT: Seventeen patients underwent reconstructions using pedicled flaps, and 5 patients underwent reconstructions using free flaps. The operative time and the percentage of defect size in relation to the BSA were significantly lower when using pedicled flaps than when using free flaps (P = 0.002, P = 0.046, respectively). There was no significant difference in terms of the rate of reoperation (P = 0.16) between the 2 types of reconstructions. The operative time was also significantly shorter when using combination pedicled flaps than when using free flaps. However, there was no significant difference in terms of the percentage of defect size in relation to the BSA between combination pedicled flaps and free flaps. Reoperation was necessary because of flap necrosis in pedicled flaps and skin graft necrosis in free flaps. CONCLUSIONS: Our results demonstrated that pedicled flaps should be the first choice for back reconstruction, independent of the defect size, reoperation rate, and reason for reoperation. This is because the operation time required is significantly lower, which benefits patients and surgeons. Free flaps can be used when pedicled flaps cannot be used efficiently.

Recurrent branch of anterior interosseous artery perforator-based propeller flap for distal forearm injuries: Report of 2 cases.

Despite various options for the reconstruction of soft tissue defects in the distal forearm, perforator-based propeller flap is rarely used. Here, we presented 2 cases of distal forearm injuries that were repaired using the recurrent branch of anterior interosseous artery perforator-based propeller flap. Patients in these cases were 57 and 67 years of age. Wounds resulting from farming machine injury and pyogenic extensor tenosynovitis following cat bite wounds were localized to the distal forearm and dorsum of the hand. Defect dimensions were 5 cm × 10 cm and 5 cm × 8 cm. The 12 cm × 7 cm and 21 cm × 4 cm sized recurrent branch of anterior interosseous artery perforator-based propeller flap was designed adjacent to the wounds. In the latter case, the absence of the posterior interosseous artery in the distal forearm was observed. One perforator from the recurrent branch of the anterior interosseous artery emerged through the septum between the extensor digiti minimi and extensor carpi ulnaris 7.5 cm and 6.0 cm proximal to the ulnar head in cases 1 and 2, respectively. Perforators were identified using multidetector computed tomographic angiography and handheld Doppler. Extending to two-thirds or almost the full length of the forearm, the flaps were raised and rotated by 90° and 120° to cover the defect. The donor sites were closed using free skin graft. Both flaps survived. Except for minor wound dehiscence and hemarthrosis, no other postoperative complications occurred. Patients returned to work or daily activities at 3- and 4-month follow-up after surgery.

Clinical significance of plasma presepsin levels in patients with systemic lupus erythematosus.

OBJECTIVES: Presepsin (PSEP: soluble CD14 subtype) is produced from bacteria-stimulated monocytes or neutrophils, thus recognized as a biomarker of sepsis. Aberrant functions in monocyte or neutrophils are increasingly recognized in systemic lupus erythematosus (SLE). We investigated whether plasma PSEP reflects disease activity in patients with SLE. METHODS: This retrospective study comprised 35 patients with SLE and 72 with non-SLE autoimmune diseases who visited our facility during the period from August 2012 to September 2015. Plasma PSEP levels and laboratory data were compared between SLE and non-SLE. Clinical markers of SLE disease activity, including SLE disease activity index 2000 (SLEDAI-2K), serum complement concentrations and serum anti-ds-DNA antibodies were assessed in correlation with plasma PSEP levels. RESULTS: Plasma PSEP levels in SLE were higher than those in non-SLE. This phenomenon holds true when comparing SLE and non-SLE patients in the absence of infection (p = .0008). Plasma PSEP levels in SLE patients negatively correlated with C3 (r = -0.4454, p = .0430), CH50 (r = -0.4502, p = .0406) and positively with SLEDAI-2K (r = 0.4801, p = .0237). CONCLUSION: Elevated plasma PSEP levels were correlated with disease activity of SLE, suggesting inappropriate monocyte or neutrophil activation in the pathophysiology of SLE exacerbation.

Vaginoplasty with a Pudendal-groin Flap in Male-to-female Transsexuals.

Many vaginoplasty techniques have been introduced to improve the outcomes of sex reassignment surgery for male-to-female transsexuals. Some vaginoplasty patients still require additional skin grafts, making dilation mandatory to overcome shrinkage. We developed a new vaginoplasty method (called the "pudendal-groin flap") that uses pudendal-groin flaps. One of this procedure's advantages is that skin grafts are unnecessary, even for patients with small penises and scrotums. We introduce the procedure here and describe our evaluation of its utility. We retrospectively analyzed the cases of the 15 patients who underwent vaginoplasty using pudendal-groin flaps from May 2010 to January 2016 at our institution. We compared the complications as well as the functional and aesthetic outcomes with those of previous studies. The most common complication was bleeding, which occurred at the corpus spongiosum or while creating a new vaginal cavity. Bleeding can be reduced with more careful hemostasis and dissection. Aside from inadequate vaginal depth in one patient, the incidence of other complications, sexual intercourse, and aesthetic outcomes were acceptable. The pudendal- groin flap is thin and pliable and can create sufficient vaginal depth without skin grafts. The resulting scar is inconspicuous. Our findings suggest that vaginoplasty using the pudendal-groin flap method is feasible.