Metoidioplasty in Gender Affirmation: A Review.

Metoidioplasty is a variant of the gender affirmation technique neophalloplasty, where a hormonally enlarged clitoris is reconstructed to become a small penis. The goals of metoidioplasty are male appearance of the genitalia, voiding in standing position, and completely preserved erogenous sensation of the neophallus. However, it does not enable penetrative sexual intercourse due to the small dimensions of the neophallus. Basic principles of metoidioplasty were established 50 years ago, and many refinements of the technique have been reported since. The latest improvements are based on the advances in urethroplasty, perioperative care, and new insights into female genital anatomy. The current metoidioplasty technique is a one-stage procedure that includes vaginectomy, straightening and lengthening of the clitoris, urethral reconstruction by combined flaps and grafts, and scrotoplasty with insertion of testicular implants. Good aesthetic, functional, and psychosexual outcomes are achieved with this type of neophalloplasty.

Musculocutaneous Latissimus Dorsi Phalloplasty.

The treatment of gender dysphoria consists of psychiatric evaluation, initiation of hormonal therapy, and the final step in an individual's transition, performing gender-affirming surgery. Construction of the neophallus is one of the most demanding tasks in genital affirming surgery of transgender men. The main objectives of phalloplasty are to achieve a cosmetically acceptable and functional phallus, with a neourethra that allows voiding in standing position, sufficient length and strength for possible penetrative intercourse, preserved tactile and orgasmic sensation, and acceptable donor site morbidity. The musculocutaneous latissimus dorsi flap has reliable and suitable anatomy (good size, volume, and length of neurovascular pedicle) to meet the esthetic and functional requirements of neophallus reconstruction. Despite many advantages, the main disadvantage of this flap is the lack of sensitivity. Although the radial free forearm flap technique is the most commonly performed procedure, musculus latissimus dorsi flap is an acceptable choice in gender-affirming surgery.

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.

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.

Cross-Cultural Adaptation and Quantitative Evaluation of Dysfunctional Voiding and Incontinence Scoring System in Pediatric Serbian Population.

Background and objective: Dysfunctional voiding (DV) presents relatively frequent problem in pediatric urologist practice. The necessity for implementation of DV evaluation in the pediatric population is of particular importance, since there is no clear consensus on the clinical assessment of such condition. The aims of our study were to evaluate the test/retest reliability and reproducibility of dysfunctional voiding and incontinence scoring system: Serbian version (DVISSSR) in patients with voiding and incontinence dysfunctions without structural deformities, and to estimate cut-off value for DVISSSR. Methods: The cross-sectional study included 57 children with voiding and incontinence dysfunctions and 30 healthy pediatric controls. For the evaluation of voiding and incontinence dysfunction we used DVISS. The forward-backward method was applied for translation of the DVISS questionnaire from English into Serbian language. Reproducibility was analyzed by Interclass Correlation Coefficient (ICC). Sensitivity and specificity of DVISSSR scores was done by receiver operating curve (ROC) curve. Results: There was a significant difference in DVISSSR score between patients and controls (p < 0.001). For reliability and reproducibility of the questionnaire, there was no significant difference between repeated measurements (p = 0.141), and strong reliability (ICC = 0.957; p < 0.001). Conclusion: We have demonstrated successful translation and validation of the DVISSSR score. Moreover, a reliable scoring system of children with voiding dysfunctions should include evaluations of symptom scoring systems at the multicentric level.

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.

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals.

BACKGROUND: Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations. AIM: To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery. METHODS: During a period of 9 years (2007-2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons. OUTCOMES: Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS. RESULTS: Mean follow-up was 44 months (range = 10-92). Mean surgery time was 270 minutes (range = 215-325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient. CLINICAL IMPLICATIONS: Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates. STRENGTHS AND LIMITATIONS: To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure. CONCLUSIONS: Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, et al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Reversal Surgery in Regretful Male-to-Female Transsexuals After Sex Reassignment Surgery.

INTRODUCTION: Sex reassignment surgery (SRS) has proved an effective intervention for patients with gender identity disorder. However, misdiagnosed patients sometimes regret their decision and request reversal surgery. This review is based on our experience with seven patients who regretted their decision to undergo male-to-female SRS. AIMS: To analyze retrospectively seven patients who underwent reversal surgery after regretting their decision to undergo male-to-female SRS elsewhere. METHODS: From November 2010 through November 2014, seven men 33 to 53 years old with previous male-to-female SRS underwent reversal phalloplasty. Preoperatively, they were examined by three independent psychiatrists. Surgery included three steps: removal of female genitalia with scrotoplasty and urethral lengthening, total phalloplasty with microvascular transfer of a musculocutaneous latissimus dorsi flap, and neophallus urethroplasty with penile prosthesis implantation. MAIN OUTCOME MEASURES: Self-reported esthetic and psychosexual status after reversion surgery and International Index of Erectile Function scores for sexual health after phalloplasty and penile prosthesis implantation. RESULTS: Follow-up was 13 to 61 months (mean = 31 months). Good postoperative results were achieved in all patients. In four patients, all surgical steps were completed; two patients are currently waiting for penile implants; and one patient decided against the penile prosthesis. Complications were related to urethral lengthening: two fistulas and one stricture were observed. All complications were repaired by minor revision. According to patients' self-reports, all patients were pleased with the esthetic appearance of their genitalia and with their significantly improved psychological status. CONCLUSION: Reversal surgery in regretful male-to-female transsexuals after SRS represents a complex, multistage procedure with satisfactory outcomes. Further insight into the characteristics of persons who regret their decision postoperatively would facilitate better future selection of applicants eligible for SRS.

Objective long-term evaluation after bladder autoaugmentation with rectus muscle backing.

PURPOSE: Bladder autoaugmentation with rectus muscle backing is an efficient surgical technique for bladder augmentation. We evaluated long-term outcomes to determine the value of this procedure. MATERIALS AND METHODS: Between August 1999 and June 2004 autoaugmentation was performed in 16 girls and 7 boys 4 to 13 years old (median age 8). The indication was neurogenic bladder with small capacity and poor compliance due to myelomeningocele in 18 patients, tethered cord in 3 and sacral agenesis in 2. Detrusorectomy usually involved the whole upper half of the bladder. The prolapsed bladder urothelium was hitched to the 2 rectus muscles to prevent retraction and provide easier bladder emptying with voluntary muscle contractions. RESULTS: At the median early followup of 27 months (range 9 to 49) bladder volume had increased significantly in all 23 patients (median 338 ml, range 190 to 462). At the current median long-term followup of 134 months (range 94 to 159) bladder volume continued to be significant compared to median bladder capacity preoperatively (median 419 ml, range 296 to 552). Voluntary voiding was achieved in 14 patients without post-void residual urine. Nine patients used clean intermittent catheterization, of whom only 4 could not empty the bladder voluntarily and relied only on clean intermittent catheterization. CONCLUSIONS: Detrusorectomy with a rectus muscle hitch and backing is a minimally invasive, completely extraperitoneal, simple and safe procedure. However, the technique is indicated only in select cases without anterior abdominal wall anomalies.

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.

Personality disorders in persons with gender identity disorder.

BACKGROUND: Investigations in the field of gender identity disorder (GID) have been mostly related to psychiatric comorbidity and severe psychiatric disorders, but have focused less on personality and personality disorders (PDs). AIMS: The aim of the study was to assess the presence of PDs in persons with GID as compared to cisgendered (a cisgender person is a person who is content to remain the gender they were assigned at birth) heterosexuals, as well as to biological sex. METHODS: The study sample consisted of 30 persons with GID and 30 cisgendered heterosexuals from the general population. The assessment of PDs was conducted by application of the self-administered Structured Clinical Interview for DSM-IV Axis II PDs (SCID-II). RESULTS: Persons with GID compared to cisgender heterosexuals have higher presence of PDs, particularly Paranoid PD, avoidant PDs, and comorbid PDs. In addition, MtF (transwomen are people assigned male at birth who identify as women) persons are characterized by a more severe psychopathological profile. CONCLUSIONS: Assessment of PDs in persons with GID is of great importance as it comprises a key part of personalized treatment plan tailoring, as well as a prognostic factor for sex-reassignment surgery (SRS) outcome.

Isolated Male Epispadias Repair: Long-Term Outcomes.

Isolated male epispadias is one of the most severe congenital genital anomalies that require surgical correction. The goals of the surgery are to reach good aesthetic and functional outcomes. The aim of this retrospective study was to analyze the long-term outcomes of surgical reconstruction of male epispadias. A total of 31 patients with a mean age of 17 years, who underwent surgical repair of isolated male epispadias from January 2000 to January 2015, were involved. The main outcome measures were defined as: aesthetic outcome, continence, postoperative complications, sexual function, and quality of life. The follow-up period ranged from 8 to 23 years, with an average of 14.4 years. Each patients underwent an average of 2.2 surgical procedures in this period. The most common postoperative complications were urethral fistula and residual curvature, in 22.6% and 12.9%, respectively. Satisfactory aesthetic outcome was reported in 71.4% of cases. The repair of male epispadias usually includes more than two procedures with satisfactory aesthetic outcome. Unsolved urinary incontinence remains a significant issue and has a high impact on the quality of life. Follow-up should be extended even after complete sexual maturity. Comprehensive long-term evaluation is necessary for proper treatment of isolated epispadias.

Treatment for failed epispadias repair presenting in adults.

PURPOSE: We evaluated the results of 1-stage and multistage penile reconstruction in adults with complications after multiple failed epispadias repairs. MATERIALS AND METHODS: A total of 23 adults underwent penile disassembly for repeat epispadias repair from February 2006 to June 2011. Median age at surgery was 27 years (range 17 to 41). Surgical treatment included penile disassembly with complete straightening and lengthening of the penis, followed by urethral reconstruction. The corpora cavernosa were completely separated from the glans cap with the neurovascular bundles and from the urethra. The urethra, which was short in all cases, was divided at the glans level. Penile straightening and lengthening were achieved by tunica albuginea incision and grafting. The urethra was reconstructed 3 to 6 months later using combined buccal mucosa graft and genital skin flaps. Success was defined as a functional penis without urethral fistula or stricture, or residual chordee as well as a cosmetically acceptable penile appearance. RESULTS: Mean followup was 33 months (range 14 to 78). Of the patients 19 had a completely straightened and lengthened penis. Improved length of the erect penis was 2.7 to 6.6 cm. In 4 patients mild curvature developed without the need for additional correction. Urethral fistula in 3 cases was repaired 6 months after urethroplasty in 2, while it closed spontaneously in 1. All 21 sexually active patients reported good erectile function. CONCLUSIONS: Adults with complications after childhood epispadias repair are still a difficult population to treat. A radical surgical approach must be used to achieve a successful outcome.

Comparison of two different methods for urethral lengthening in female to male (metoidioplasty) surgery.

INTRODUCTION: Metoidioplasty presents one of the variants of phalloplasty in female transsexuals. Urethral lengthening is the most difficult part in this surgery and poses many challenges. AIM: We evaluated 207 patients who underwent metoidioplasty, aiming to compare two different surgical techniques of urethral lengthening, postoperative results, and complications. METHODS: The study encompassed a total of 207 patients, aged from 18 to 62 years, who underwent single stage metoidioplasty between September 2002 and July 2011. The procedure included lengthening and straightening of the clitoris, urethral reconstruction, and scrotoplasty with implantation of testicular prostheses. Buccal mucosa graft was used in all cases for dorsal urethral plate formation and joined with one of the two different flaps: I-longitudinal dorsal clitoral skin flap (49 patients) and II-labia minora flap (158 patients). MAIN OUTCOME MEASUREMENT: Results were analyzed using Z-test to evaluate the statistical difference between the two approaches. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating subjects as well as overall satisfaction. RESULTS: The median follow-up was 39 months (ranged 12-116 months). The total length of reconstructed urethra was measured during surgery in both groups. It ranged from 9.1 to 12.3 cm (median 9.5) in group I and from 9.4 to 14.2 cm (median 10.8) in group II. Voiding while standing was significantly better in group II (93%) than in group I (87.82%) (P < 0.05). Urethral fistula occurred in 16 patients in both groups (7.72%). There was statistically significant difference between the groups, with lower incidence in group II (5.69%) vs. group I (14.30%) (P < 0.05). Overall satisfaction was noted in 193 patients. CONCLUSION: Comparison of the two methods for urethral lengthening confirmed combined buccal mucosa graft and labia minora flap as a method of choice for urethroplasty in metoidioplasty, minimizing postoperative complications.

Adult non-urethral complications after hypospadias repair in childhood: presentation, treatment and outcomes.

Purpose: This study aimed to evaluate a group of adult patients with non-urethral complications after hypospadias repair in childhood, their surgical treatment, and outcomes. Materials and methods: We analyzed 97 patients, mean age 22.5 years, who were treated in our center between January 2009 and December 2020, for non-urethral complications after previous hypospadias repair in childhood. Non-urethral complications were defined as glans deformity, residual curvature and trapped penis due to insufficient penile skin. A radical surgical approach was used to correct all deformities, in a one-stage or a two-stage procedure. A successful outcome was defined as a straight penis with good length, anatomically regular glans, and cosmetically acceptable appearance, without need for additional surgeries. Sexual function was evaluated using International Index of Erectile Function. Results: Mean follow-up was 75 months (ranged from 24 to 168 months). One-stage and two-stage repair were performed in 85.5% and 14.5% of cases, respectively. A higher success rate was noted after one-stage repair (94% compared to 86%). Complications included four cases of penile curvature with late onset, one case of glans dehiscence and partial skin necrosis. Erectile dysfunction was determined in 24% of patients. Discussion: Non-urethral complications may occur many years after primary hypospadias repair, with a strong impact on the quality of life. Treatment is individualized and usually involves a radical surgical approach to correct all associated deformities and to achieve successful cosmetic and psychosexual outcomes.

Penile Microdissection: A Live Donor Feasibility Study in Feminizing Gender-Affirming Surgery.

Femininizing gender affirmation surgery includes the creation of external female genitalia such as a new clitoris, labia, and vagina with removal of the glans and urethral remnants and full corpora cavernosa. We evaluated the possibility of using preserved cavernosal bodies with glans and urethral remnants for potential live-donor penile transplantation. Between March 2021 and February 2023, penile microvascular dissection followed by gender-affirming vaginoplasty was performed in 41 patients aged 18 to 57 years (mean 30.5 years). The mean follow-up was 15 months (ranging from 6 to 26 months). The removed penile entities were properly measured. The corpora cavernosa were completely preserved in all cases; the length of remaining anterior urethra ranged from 12.70 cm to 16.40 cm, while the mean glans remnant volume was 85.37% of the total volume. All patients reported satisfactory results after gender-affirming vaginoplasty. Microvascular penile dissection in gender-affirming vaginoplasty is simple and safe, suggesting a good possibility of using the full corpora cavernosa, glans, and anterior urethra remnants for live-donor penile transplantation.

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.

ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery".

INTRODUCTION: Much has been published on the surgical and functional results following Gender Affirming Surgery ('GAS') in trans individuals. Comprehensive results regarding sexual wellbeing following GAS, however, are generally lacking. AIM: To review the impact of various GAS on sexual wellbeing in treatment seeking trans individuals, and provide a comprehensive list of clinical recommendations regarding the various surgical options of GAS on behalf of the European Society for Sexual Medicine. METHODS: The Medline, Cochrane Library and Embase databases were reviewed on the results of sexual wellbeing after GAS. MAIN OUTCOMES MEASURE: The task force established consensus statements regarding the somatic and general requirements before GAS and of GAS: orchiectomy-only, vaginoplasty, breast augmentation, vocal feminization surgery, facial feminization surgery, mastectomy, removal of the female sexual organs, metaidoioplasty, and phalloplasty. Outcomes pertaining to sexual wellbeing- sexual satisfaction, sexual relationship, sexual response, sexual activity, enacted sexual script, sexuality, sexual function, genital function, quality of sex life and sexual pleasure- are provided for each statement separately. RESULTS: The present position paper provides clinicians with statements and recommendations for clinical practice, regarding GAS and their effects on sexual wellbeing in trans individuals. These data, are limited and may not be sufficient to make evidence-based recommendations for every surgical option. Findings regarding sexual wellbeing following GAS were mainly positive. There was no data on sexual wellbeing following orchiectomy-only, vocal feminization surgery, facial feminization surgery or the removal of the female sexual organs. The choice for GAS is dependent on patient preference, anatomy and health status, and the surgeon's skills. Trans individuals may benefit from studies focusing exclusively on the effects of GAS on sexual wellbeing. CONCLUSION: The available evidence suggests positive results regarding sexual wellbeing following GAS. We advise more studies that underline the evidence regarding sexual wellbeing following GAS. This position statement may aid both clinicians and patients in decision-making process regarding the choice for GAS. Özer M, Toulabi SP, Fisher AD, et al. ESSM Position Statement "Sexual Wellbeing After Gender Affirming Surgery". Sex Med 2022;10:100471.

"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.

Rectosigmoid vaginoplasty: clinical experience and outcomes in 86 cases.

INTRODUCTION: There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue. AIM: To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence. METHODS: Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures. Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires. RESULTS: Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%). CONCLUSIONS: Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.