Complications following artificial urinary sphincter placement after radical prostatectomy and radiotherapy: a meta-analysis.

OBJECTIVE: To conduct a systematic review and meta-analysis of artificial urinary sphincter (AUS) placement after radical prostatectomy (RP) and external beam radiotherapy (EBRT). PATIENTS AND METHODS: There were 1 886 patients available for analysis of surgical revision outcomes and 949 for persistent urinary incontinence (UI) outcomes from 15 and 11 studies, respectively. The mean age (sd) was 66.9 (1.4) years and the number of patients per study was 126.6 (41.7). The mean (sd, range) follow-up was 36.7 (3.9, 18-68) months. A systematic database search was conducted using keywords, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Published series of AUS implantations were retrieved, according to the inclusion criteria. The Newcastle-Ottawa Score was used to ascertain the quality of evidence for each study. Surgical results from each case series were extracted. Data were analysed using CMA statistical software. RESULTS: AUS revision was higher in RP + EBRT vs RP alone, with a random effects risk ratio of 1.56 (95% confidence interval [CI] 1.02-2.72; P < 0.050; I(2) = 82.0%) and a risk difference of 16.0% (95% CI 2.05-36.01; P < 0.080). Infection/erosion contributed to the majority of surgical revision risk compared with urethral atrophy (P = 0.020). Persistent UI after implantation was greater in patients treated with EBRT (P < 0.001). CONCLUSIONS: Men receiving RP + EBRT appear at increased risk of infection/erosion and urethral atrophy, resulting in a greater risk of surgical revision compared with RP alone. Persistent UI is more common with RP + EBRT.

Current management of male-to-female gender identity disorder in the UK.

Gender identity disorder (GID), or transsexualism as it is more commonly known, is a highly complex clinical entity. Although the exact aetiology of GID is unknown, several environmental, genetic and anatomical theories have been described. The diagnosis of GID can be a difficult process but is established currently using standards of care as defined by the Harry Benjamin International Gender Dysphoria Association. Patients go through extensive psychiatric assessment, including the Real Life Experience, which entails living in the desired gender role 24 h a day for a minimum period of 12 months. The majority of GID patients will eventually go on to have gender realignment surgery, which includes feminising genitoplasty. The clinical features, diagnostic approach and management of male-to-female GID in the UK are reviewed, including the behavioural, psychological and surgical aspects.

Feminizing genitoplasty in adult transsexuals: early and long-term surgical results.

OBJECTIVE: To examine the early and late surgical outcomes of feminizing genitoplasty (FG) in adult transsexuals in a UK single surgeon practice over a 10-year period. PATIENTS AND METHODS: Computerized and manual databases were searched over the period 1994-2004 to identify patients who had undergone male to female FG. Case-notes were retrieved and analysed to identify epidemiological data, the number and type of perioperative problems, early results at outpatient review, late occurring problems and patient satisfaction. A telephone questionnaire was then conducted targeting all FG patients in our series. The questions were directed at identifying surgical complications, outcome and patient satisfaction. RESULTS: In all, 233 case-notes were identified and 222 (95%) were retrieved. All patients had penectomy, urethroplasty and labiaplasty, 207 (93%) had formation of a neoclitoris, and 202 (91%) had a skin-lined neovagina. The median (range) age was 41 (19-76) years. The median hospital stay was 10 (6-21) days. A record of the first outpatient visit was available in 197 (84.5%) cases. The median time to follow up was 56 (8-351) days. Over all, 82.2% had an adequate vaginal depth, with a median depth of 13 (5-15) cm and 6.1% had developed vaginal stenosis. Three (1.7%) patients had had a vaginal prolapse, two (1.1%) had a degree of vaginal skin flap necrosis and one (0.6%) was troubled with vaginal hair growth. In 86.3% of the patients the neoclitorizes were sensitive. There was urethral stenosis in 18.3% of the patients and 5.6% complained of spraying of urine. Minor corrective urethral surgery was undertaken in 36 patients including 42 urethral dilatations, and eight meatotomies were performed. At the first clinic visit 174 (88.3%) patients were 'happy', 13 (6.6%) were 'unhappy' and 10 (5.1%) made no comment. Of the 233 patients, we successfully contacted 70 (30%). All had had penectomy and labioplasty, 64 (91%) had a clitoroplasty and 62 (89%) a neovagina. The median age was 43 (19-76) years and the median follow up was 36 (9-96) months. Overall, 63 (98%) had a sensate neoclitoris, with 31 (48%) able to achieve orgasm; nine (14%) were hypersensitive. Vaginal depth was considered adequate by 38 (61%) and 14 (23%) had or were having regular intercourse. Vaginal hair growth troubled 18 (29%), four (6%) had a vaginal prolapse and two (3%) had vaginal necrosis. Urinary problems were reported by 19 (27%) patients, of these 18 (26%) required revision surgery, 14 (20%) complained of urinary spraying, 18 (26%) had an upward directed stream and 16 (23%) had urethral stenosis. The patients deemed the cosmetic result acceptable in 53 (76%) cases and 56 (80%) said the surgery met with their expectations. CONCLUSION: This is largest series of early results after male to female FG. Complications are common after this complex surgery and long-term follow-up is difficult, as patients tend to re-locate at the start of their 'new life' after FG. There were good overall cosmetic and functional results, with a sustained high patient satisfaction.

Development of feminizing genitoplasty for gender dysphoria.

INTRODUCTION: Determining the history and development of feminizing genitoplasty is fascinating and instructive but fraught with difficulty. Earliest examples relate to practices carried out in ancient cultures. Gender reassignment surgery (GRS) developed from reconstructive procedures for congenital abnormalities. Some surgery was disguised, techniques were not recorded, and operations were carried out in secret. AIM: The aim of this article is to review the historical development of male-to-female GRS. METHODS: Information was gleaned from Medline and general Internet searches. Further evidence was found by reviewing the references of early articles. A fascinating insight was also found in the autobiographies of GRS patients. RESULTS: The first recorded case was by Abrahams in 1931. Techniques evolved from the early vaginal absence work of Beck and Graves. Pioneers of GRS were Sir Harold Gillies in England and Georges Burou of Casablanca. In the 1950s, they both used invagination of the penile skin sheath to form a vagina. Howard Jones, of Johns Hopkins, published the second classic technique using penile and scrotal skin flaps. These two methods form the basis of male-to-female GRS today. The history of GRS reveals a struggle to improve functionality as well as cosmesis. In particular, the neovagina but also a functioning neoclitoris, which has developed from a cosmetic swelling into an innovated organ, derived from the glans penis and harvested penile neurovascular bundle. CONCLUSIONS: Improved function and cosmesis continue to be the aim of the gender dysphoria surgeon. However, this review suggests the future management of transwomen should address not only refinements of surgical techniques but also prospective collection of posttreatment quality-of-life issues.