Association between genital gender-affirming surgery and psychiatric comorbidities in individuals with gender incongruence.

BACKGROUND: Previous studies present mixed evidence on the relationship between psychiatric comorbidities and genital gender-affirming surgery (GGAS) in individuals with gender incongruence (GI). AIM: This research aims to investigate the psychiatric comorbidity rates post-GGAS in the GI population-namely, depressive disorders, anxiety disorders, posttraumatic stress disorders, substance abuse disorder, and suicidality. METHODS: Based on the TriNetX health care database, an international database with >250 million patients, a cross-sectional study was executed comparing psychiatric comorbidity rates among cases of GI with and without GGAS. Individuals were matched for demographic and health-related variables, which included history of cardiovascular disease, diabetes, and obesity. OUTCOMES: The main focus was to establish the rates and changes in psychiatric comorbidities following GGAS. RESULTS: Among individuals with GI, the study identified 4061 with GGAS and 100 097 without. At 1 year post-GGAS, there was a significant decrease in depression (odds ratio [OR], 0.748; 95% CI, 0.672-0.833; P < .0001), anxiety (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), substance use disorder (OR, 0.730; 95% CI, 0.658-0.810; P < .0001), and suicidality (OR, 0.530; 95% CI, 0.425-0.661; P < .0001), and these reductions were maintained or improved on at 5 years, including posttraumatic stress disorder (OR, 0.831; 95% CI, 0.704-0.981; P = .028). CLINICAL IMPLICATIONS: The findings indicate that GGAS may play a crucial role in diminishing psychiatric comorbidities among individuals with GI. STRENGTHS AND LIMITATIONS: This is the largest known study to evaluate the effect of GGAS on psychiatric comorbidities in the GI population, offering robust evidence. The reliance on the precision of CPT and ICD-10 codes for data extraction poses a limitation due to potential coding inaccuracies. CONCLUSION: The evidence suggests a significant association between GGAS and reduced psychiatric comorbidities in individuals with GI.

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021.

Introduction: In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods: We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results: We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion: In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

[Thoracic reassignment surgeries]. / Chirurgie de réassignation : techniques chirurgicales pour le thorax.

Thoracic reassignment surgeries are the most common gender reassignment surgeries. They represent the first and sometimes the only step in the reassignment process for transgender patients. Surgical techniques for thoracic reassignment derive from those used for the cisgender population and are accessible to plastic surgeons who do not usually treat transgender patients. On the other hand, there are some anatomical differences between men and women that they should understand, for instance, the positioning of the neo-NAC, the neo-inframammary fold and the scars. It is therefore important to understand these anatomical differences in order to optimize the cosmetic results of these surgeries so that they correspond to the expectations of these patients. In addition, the plastic surgeon will also have to be careful to adapt his approach to the relational level, with these patients, such as avoiding misgendering or using the "dead name". Finally, even if these operations are theoretically covered at 100% by the French health insurance, a request for prior agreement may be required in certain cases.

Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique.

BACKGROUND: Phalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. AIM: To evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. METHODS: Between 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients' demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. RESULTS: Patients' demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. CLINICAL IMPLICATION: Optimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. STRENGTHS & LIMITATION: This retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. CONCLUSION: The Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty. Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661-668.

The impact of incisional negative pressure wound therapy on scar quality and patient-reported outcomes: A within-patient-controlled, randomised trial.

Literature provides a moderate level of evidence for the beneficial effects of incisional negative pressure wound therapy (iNPWT) on scar quality. The purpose of this study was to establish if iNPWT results in improved scar outcomes in comparison to the standard of care. Therefore, a within-patient randomised controlled, open-label trial was conducted in transgender men undergoing gender-affirming mastectomies. A unilateral side was randomised to receive iNPWT (PICO™, Smith&Nephew) without suction drains and contrastingly the standard dressing (Steri-Strips™) with suction drain. Scar quality and questionnaires were bilaterally measured by means of objective assessments and patient-reported outcome measures (PROM) at 1, 3 and 12 months. Objective scar outcomes were scar pliability (Cutometer®), colouration (DSM-II) and scar width (3-D imaging). PROM outcomes were related to scars (POSAS and SCAR-Q) and body satisfaction (BODY-Q). From 85 included patients, 80 were included for analyses. No significant difference between treatments was seen in the quantitative outcomes of scar pliability, colour, and width. For qualitative scar outcomes, several significant findings for iNPWT were found for several subscales of the POSAS, SCAR-Q, and BODY-Q. These effects could not be substantiated with linear mixed-model regression, signifying no statically more favourable outcome for either treatment option. In conclusion, this study demonstrated that some PROM outcomes were more favourable for the iNPWT compared to standard treatment. In contrast, the quantitative outcomes showed no beneficial effects of iNPWT on scar outcomes. This suggests that iNPWT is of little benefit as a scar-improving therapy.

A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes.

BACKGROUND: Vaginoplasty is a crucial part of genital gender-affirming surgery with the number of trans women undergoing this intervention steadily, however, up to date, there is still no standardized vaginoplasty technique. AIM: This retrospective single-center study compares single-stage vs two-stage penile skin inversion vaginoplasty techniques and their long-term outcomes. METHODS: Medical records of 63 consecutive patients who underwent single-stage vaginoplasty, as described by Dr Preecha Tiewtranon, and 62 consecutive patients who underwent 2-stage vaginoplasty were reviewed. RESULTS: The mean postoperative hospital stay was 7 days for patients who underwent single-stage vaginoplasty vs 16 days for patients who underwent 2-stage vaginoplasty. Neovaginal depth proved constant in patients who underwent single-stage vaginoplasty, whereas a loss of more than 30% was observed in patients who underwent 2-stage vaginoplasty during the first postoperative year. Early complications were more common than late-onset complications in both groups. The most common complication in the single-stage group was wound dehiscence (4.8%). There were significantly more complications in 2-stage collective, among which wound dehiscence (33.9%), unsatisfactory cosmetic outcome (25.8%), and urethral stenosis (14.5%) were the most common. In the single-stage cohort, 4 (6.4%) patients needed one revision surgery, whereas 35 (56.5%) patients in the 2-stage cohort necessitated one or more reoperations with up to 10 quaternary revisions. All patients reported to have sensitivity to neoclitoris in the single-stage group, whereas 3 (4.8%) patients in the 2-stage group were deprived of it because of neoclitoral necrosis. CLINICAL IMPLICATIONS: Optimizing a vaginoplasty surgical technique and its postoperative protocol. STRENGTHS & LIMITATIONS: The present retrospective study with a mean follow-up of more than 3.5 years offers the first ever comparison of 2 different PSI vaginoplasty surgical techniques performed in the same center. CONCLUSION: Significantly lower complication and revision rates, shorter recovery time, and superior esthetic and functional outcomes were observed in the single-stage than in the two-stage penile skin inversion vaginoplasty surgical technique. Fakin RM, Giovanoli P. A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes. J Sex Med 2021;18:391-399.

Breast cancer in a female to male transgender patient 20 years post-mastectomy: Issues to consider.

The incidence of breast cancer reduces by almost 90% after bilateral mastectomy. This applies also to female-to-male (FtM) trans-gender who undergo bilateral mastectomy as part of gender reassignment surgery (GRS). To date, there are only four reported cases in the literature on FtM transgender breast cancer. We present a case of a female-to-male transgender patient who was diagnosed with breast cancer 20 years after having bilateral mastectomy performed as part of GRS. We will describe all similar cases from literature and discuss some important issues related to transgender breast cancer.

Total vaginectomy and urethral lengthening at time of neourethral prelamination in transgender men.

INTRODUCTION AND HYPOTHESIS: For transgender men (TGM), gender-affirmation surgery (GAS) is often the final stage of their gender transition. GAS involves creating a neophallus, typically using tissue remote from the genital region, such as radial forearm free-flap phalloplasty. Essential to this process is vaginectomy. Complexity of vaginal fascial attachments, atrophy due to testosterone use, and need to preserve integrity of the vaginal epithelium for tissue rearrangement add to the intricacy of the procedure during GAS. We designed the technique presented here to minimize complications and contribute to overall success of the phalloplasty procedure. METHODS: After obtaining approval from the Institutional Review Board, our transgender (TG) database at the University of Miami Hospital was reviewed to identify cases with vaginectomy and urethral elongation performed at the time of radial forearm free-flap phalloplasty prelamination. Surgical technique for posterior vaginectomy and anterior vaginal wall-flap harvest with subsequent urethral lengthening is detailed. RESULTS: Six patients underwent total vaginectomy and urethral elongation at the time of radial forearm free-flap phalloplasty prelamination. Mean estimated blood loss (EBL) was 290 ± 199.4 ml for the vaginectomy and urethral elongation, and no one required transfusion. There were no intraoperative complications (cystotomy, ureteral obstruction, enterotomy, proctotomy, or neurological injury). One patient had a urologic complication (urethral stricture) in the neobulbar urethra. CONCLUSIONS: Total vaginectomy and urethral lengthening procedures at the time of GAS are relatively safe procedures, and using the described technique provides excellent tissue for urethral prelamination and a low complication rate in both the short and long term.

Autologous Fibroblast-Seeded Amnion for Reconstruction of Neo-vagina in Male-to-Female Reassignment Surgery.

BACKGROUND: Plastic surgeons have used several methods for the construction of neo-vaginas, including the utilization of penile skin, free skin grafts, small bowel or recto-sigmoid grafts, an amnion graft, and cultured cells. PURPOSE: The aim of this study is to compare the results of amnion grafts with amnion seeded with autograft fibroblasts. MATERIALS AND METHODS: Over 8 years, we compared the results of 24 male-to-female transsexual patients retrospectively based on their complications and levels of satisfaction. Sixteen patients in group A received amnion grafts with fibroblasts, and the patients in group B received only amnion grafts without any additional cellular lining. The depths, sizes, secretions, and sensations of the vaginas were evaluated. The patients were monitored for any complications, including over-secretion, stenosis, stricture, fistula formation, infection, and bleeding. RESULTS: The mean age of group A was 28 ± 4 years and group B was 32 ± 3 years. Patients were followed up from 30 months to 8 years, (mean 36 ± 4) after surgery. The depth of the vaginas for group A was 14-16 and 13-16 cm for group B. There was no stenosis in neither group. The diameter of the vaginal opening was 34-38 mm in group A and 33-38 cm in group B. We only had two cases of stricture in the neo-vagina in group B, but no stricture was recorded for group A. All of the patients had good and acceptable sensation in the neo-vagina. Seventy-five percent of patients had sexual experience and of those, 93.7% in group A and 87.5% in group B expressed satisfaction. CONCLUSION: The creation of a neo-vaginal canal and its lining with allograft amnion and seeded autologous fibroblasts is an effective method for imitating a normal vagina. The size of neo-vagina, secretion, sensation, and orgasm was good and proper. More than 93.7% of patients had satisfaction with sexual intercourse. Amnion seeded with fibroblasts extracted from the patient's own cells will result in a vagina with the proper size and moisture that can eliminate the need for long-term dilatation. The constructed vagina has a two-layer structure and is much more resistant to trauma and laceration. No cases of stenosis or stricture were recorded. 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 .

Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery.

INTRODUCTION: A cornerstone of treating gender dysphoria for transgender women is gender reassignment surgery (GRS) encompassing vaginoplasty and clitoroplasty. The neoclitoris is harvested as a flap with a neurovascular pedicle from the proximal dorsal part of the glans penis. Few long-term follow-ups exist on postoperative sensation and patient-reported sexual functionality of the neoclitoris. AIM: To examine the sensitivity of the neoclitoris and its relation to orgasm and sexual function at least 1 year after GRS. METHODS: Twenty-two patients were included, with a mean follow-up of 37 months (range = 12-63) after initial surgery. Tactile and vibratory sensitivities were measured with Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A questionnaire was provided to the patients, as were interview questions about body image, orgasm, pain, and general satisfaction with the surgery. MAIN OUTCOME MEASURES: Tactile and vibratory sensitivities of the neoclitoris and questionnaire on satisfaction with orgasm, sexual function, and general satisfaction. RESULTS: The average tactile threshold for the clitoris was 12.5 g/mm2 and the average vibratory threshold was 0.3 µm. Most participants (86%) experienced orgasm after surgery, had no or little pain, and were satisfied with the surgery. No statistical correlation was found between better or worse objective pressure and vibratory thresholds and patient answers to questions about the clitoris in the Body Image Scale for Transsexuals questionnaire. CONCLUSION: The neoclitoris derived from the glans penis in GRS provides long-term clitoral sensation that is erogenous. Overall, the vast majority of patients who undergo male-to female GRS experience orgasm and are satisfied with the surgery.

Urological issues following gender reassignment surgery.

It has been estimated that 0.2% of the UK population identifies as transgender. For those who seek gender reassignment, the pathway can involve the expertise of multiple disciplines, including primary care, psychology, endocrinology and speech and language therapy. A small but significant number of the transgender population will also elect to undergo gender-affirming genital surgery in order to achieve gender congruence. In the UK, very few specialist centres provide genital gender-affirming surgery for trans-men and women. The population accessing these services spans the entire UK, and with such geographical dispersion, trans-patients with uro-genital complications after surgery in both the short and long term are likely to present locally, with initial assessment/management often conducted in a non-specialist setting. This article aims to help familiarise nurses with genital gender reassignment/affirming surgery and the resultant altered anatomy. It explores the urological issues trans-men and women may experience as a consequence of surgery.

Postoperative imaging of phalloplasties and their complications.

OBJECTIVE: In this article, we summarize the common phalloplasty indications, surgical techniques, and relevant anatomy. We review the appropriate imaging techniques used in postoperative evaluation of the neophallus and illustrate the postoperative appearance and complications associated with phalloplasty. CONCLUSION: Phalloplasty is an infrequently encountered yet complex procedure requiring careful postoperative imaging assessment. Modern microsurgical techniques have made free flaps the reference standard in phalloplasty, and the radiologist must be aware of the expected postoperative appearance and complications to appropriately manage these patients.

Evaluation of the quality of life among transgender men before and after gender reassignment surgery: a survey from Iran.

BACKGROUND: Gender dysphoria, characterized by a misalignment between one's gender identity and assigned sex, propels individuals towards medical interventions like gender reassignment surgery (GRS) to harmonize their bodies with their gender. This process aims to enhance overall quality of life (QoL), functioning, and body image. Recognizing the importance of cultivating a positive body image for transgender individuals navigating societal norms, this narrative highlights the ongoing debate surrounding QoL post-GRS. In response, our study is outlined, aiming to scrutinize QoL and self-image among transgender men post-GRS, offering valuable insights into societal perceptions and psychological well-being in this context. METHOD: This cross-sectional survey focused on transgender men aged 15 to 35 who underwent gender reassignment surgery (GRS) in 2018-2022 in Shiraz, Iran. Participants, after passing psychiatric evaluations, completed World Health Organization Quality of Life (WHOQOL-100) questionnaires pre- and at least one-year post-surgery. The scores of the Brief-WHOQOL questionnaire were evaluated in four domains of physical health, psychological health, social relationships, and environmental health. RESULTS: A total of 60 individual who underwent GRS completed our questionnaire. The average age of the patients was 24.1 ± 3.8 years. Following GRS, the most increase was observed in the psychological factor (by 25.6%). The increase in score was statistically significant in all subgroups (P < 0.001) after operation. Urban living location had a significant association with higher increase in physical health (P < 0.010), psychological health (P = 0.005), and environmental health (P = 0.012) after GRS. In regards to physical health, the low socioeconomic group had a significantly less physical score improvement in QoL compared to the moderate group (P = 0.024) following GRS. In regards to environmental health, the high socioeconomic groups had significantly higher improvement in QoL compared to the low (P = 0.006) and moderate (P < 0.001) group after operation. CONCLUSION: The results demonstrate that GRS brings about improvements across all aspects of QoL. However, this enhancement is less pronounced among patients hailing from low socioeconomic backgrounds and rural areas.

Roux-en-Y gastric bypass in a transgender patient: a case report.

The frequency of transgender individuals seeking gender affirming care is increasing over the last decade. Transgender patients suffer from obesity and psychiatric illness at elevated levels compared with the general population. A 54-year-old male-to-female transition patient presented with morbid obesity, hyperlipidaemia, and weight gain 2 years after their gender-transition and hormonal therapy. She received a Roux-en-Y gastric bypass (RYGB). At 7 months postoperatively, the patient has experienced 49% excess body weight loss, her body dissatisfaction had resolved and has completed further plastic surgery. The RYGB is an effective method for weight loss as well as benefits from cardiovascular disease, cancer, metabolic related conditions, and psychosocial wellbeing. Holistic treatment in conjunction with dietetic and psychology services can help maintain long-term weight management. Bariatric surgery combined with a multidisciplinary care team addressing medical and psychiatric concerns is integral to achieving and maintaining weight loss and gender identity.

Gender dysphoria: Quality of online information for gender reassignment surgery.

An ever-increasing number of patients are using the Internet to learn about medical conditions. This study aimed to evaluate the quality of Internet-based patient information on gender reassignment surgery for people who suffer from gender dysphoria. Twenty websites identified using Google and Yahoo search engines were selected and evaluated based on the modified Ensuring Quality Information for Patients (EQIP) instrument (36 items). The EQIP tool comprises 36 questions to which the answer can be "yes" or "no". The final score for each website can be between 0 and 36. An overall score of 26 or above was considered high, because it co-related to the 72nd percentile. The average of the scores turned out to be 22.5 points, lower than our target; 7 (35%) sites were rated higher than the average and 13 (65%) were rated lower. The assessment of the websites included in the study showed a lack of information about the sequence of the medical procedures, perioperative criticalities and qualitative risks and side-effects descriptions. The overall quality of published information on gender reassignment surgery is very low. We believe that the Internet should not be used as the main source of medical information, and physicians should maintain the leadership in guiding patients affected by gender dysphoria. Level of Evidence: Level IV, case study.

HIV Prevalence and High-Risk Subgroup Identification in Transgender Women Who Undergo Primary Vaginoplasty in the Netherlands.

Purpose: Worldwide, transgender women (TGW) bear a high HIV burden. Limited data are available on HIV prevalence and risk factors among TGW in western European countries. Our aim is to assess the prevalence of TGW living with HIV who underwent primary vaginoplasty in an academic reference hospital and to identify high-risk subgroups. Methods: All TGW who underwent primary vaginoplasty between January 2000 and September 2019 at our institution were identified. A retrospective chart study was conducted, recording the medical history, age at vaginoplasty, region of birth, use of medication, injecting drug use, history of pubertal suppression, HIV status, and sexual preference at time of surgical intake. High-risk subgroups were identified using logistic regression analysis. Results: Between January 2000 and September 2019, a total of 950 TGW underwent primary vaginoplasty, of whom 31 (3.3%) individuals were known to live with HIV. Prevalence of HIV was higher in TGW born outside of Europe (20/145, 13.8%) than among those born in Europe (11/805, 1.4%), p<0.001. In addition, having a sexual preference toward men was significantly associated with HIV. None of the TGW living with HIV had a history of puberty suppression. Conclusion: The HIV prevalence in our study population is higher than the reported HIV prevalence in cisgender population in the Netherlands but lower than reported in previous studies in TGW. Further studies should investigate the need and feasibility of routine HIV testing of TGW in Western countries.

Beyond Binary: Gender Reassignment in a Case of 11ß-Hydroxylase Deficiency.

Congenital adrenal hyperplasia (CAH) encompasses a spectrum of disorders characterized by enzyme deficiencies in the hormone biosynthesis pathways of the adrenal glands, resulting in impaired cortisol synthesis. These disorders are typically inherited in an autosomal recessive pattern. Numerous enzymes participate in the hormonal synthesis within the adrenal glands, and the clinical presentation of affected individuals exhibits significant variability, contingent upon the specific enzyme deficiency and its severity. In this case, we present a compelling instance of 11ß-hydroxylase deficiency (11ßOHD). The patient initially presented as a male, with complaints of early-onset hypertension and intermittent hematuria. He had a history of precocious puberty and had experienced a progressive increase in breast size. Subsequently, the patient was found to have an XX karyotype, and a pelvic ultrasound revealed the presence of a uterus, two ovaries, and a rudimentary vagina. Gender reassignment surgery was done to this patient. This intricate case underscores the critical importance of promptly recognizing and effectively managing CAH. Timely and appropriate treatment is pivotal in ensuring the well-being of affected individuals.

The use of Integra Dermal Regeneration Template in the surgical management of revision penile inversion vaginoplasty: A case series.

Since its initial design and use for the temporary coverage of severe full-thickness burn defects, Integra® (Integra LifeSciences) Dermal Regeneration Template has been increasingly used all over the body, yielding successful results in coverage of wound beds with insufficient vascularity and suboptimal conditions for proper healing. In this study, we report an institutional case series and outcomes of gender-affirming vaginoplasty revision for vaginal lengthening or reopening of the canal via placement of Integra® to assist in optimizing the wound bed for subsequent skin grafting when wound conditions were deemed to be suboptimal. A retrospective chart review was conducted in patients who underwent this technique by a single surgeon (JM) at the authors' institution. Demographics, vaginal depth, and complications were recorded and compared. Our patient population thus far includes 178 primary vaginoplasties, of which 9 of those needing revision were treated with this approach. The age at revision mean was 47 ± 13.5 years, and the body mass index mean was 31 ± 4.1. All patients had comorbidities and five were former smokers. Eight patients had prior revision conducted without Integra®, with a mean of 1.89 ± 1.76 and the time to first revision mean was 15.89 ± 14.2 months. No long-term complications after Integra® reported and most of the patients did not require further revision. The follow-up mean was 8.48 ± 8.66 months. A mean of 6.77 ± 5.35 cm was gained after the Integra® revision (4.92 ± 4.1 cm before versus 12.54 ± 3.07 cm after). The final depth after Integra® + full-thickness skin graft mean was 13.34 ± 4.65 cm. Overall, the depth gain mean was 7.48 ± 5.77 cm; in total, seven patients gained depth after revision with an average of 78% skin graft take. Overall, Integra® presents an alternative option for revision vaginoplasty with complicated wound beds potentially aiding in the healing process before grafting.

Ethical considerations regarding penis transplantation surgery in transgender men-an empirical ethics study.

Background: The ongoing quest to surgically create the (nearly) ideal neophallus in transgender men has led to the continuous development of transgender medicine and the proposed introduction of penis transplantation. However, both technical and ethical issues arise when developing this treatment. Aim: We sought to extract ethical considerations among different stakeholder groups regarding penile transplantation surgery in transgender men and to define preliminary clinical recommendations. Methods: Three semistructured focus groups, consisting of different stakeholders, were organized to participate in discussions of ethical considerations retrieved from the ethics literature of transplantation and transgender medicine. Analysis of the results was performed according to empirical ethics. Outcomes: Study outcomes were the identification of qualitative themes describing ethical considerations pertaining to penile transplantation in transgender men. Results: Nineteen people participated in this qualitative study. The main domains that emerged included arguments in favor of and arguments against penile transplantation. Although the participants expressed positive attitudes toward developing this care, with acknowledgement of the current limitations stakeholders of all groups were reluctant to endorse the introduction of penile transplantation for transgender men at this point. Clinical Implications: Under the present circumstances, all groups expressed both a wide variety of ethical considerations as well as a tendency to prefer developing alternative treatment options or improving the results of currently available treatments in relation to penile transplantation for transgender men. Strengths and Limitations: This study was the first (empirical) study to focus on this topic and included a diversity of stakeholder perspectives. Limitations included the hypothetical nature of the discussion as well as the clinical setting in which the topic has been studied. Conclusion: Introducing penile transplantation for transgender men, under the current circumstances, comes with a wide range of ethical considerations, which deal with personal identity, autonomy, medical risks, risk for transgender support and donor willingness, and issues regarding equality. Despite the present hesitancy to use penile transplantation, should the technical side of this treatment option develop, further research in the ethical field of penile transplantation for transgender men is recommended.

Gender reassignment surgery - a narrative overview of anaesthetic considerations and implications.

The twenty-first century, with its transforming ideology and rising acceptance, is witnessing an increased number of transgender people applying for gender reassignment surgery (GRS). The procedure of GRS is a lengthy and complex one involving the active collaboration of multiple disciplines including psychology, psychiatry, family medicine, plastic surgery, endocrinology, otolaryngology, urology, gynaecology, maxillofacial surgery, and anaesthesiology. The considerable paucity of literature regarding the management of patients presenting for GRS places health care providers at a disadvantage. It is imperative to cautiously regard the specific medical, emotional, social, and economic concerns regarding these patients. Health care providers need to be trained well to deal empathetically with such patients. The present literature about GRS deals mainly with the surgeon's perspective, while the anaesthetist's approach remains hazy. This is because GRS imposes the need for anaesthesiologists to search for better and more efficient modes of anaesthesia so as to improve prognosis and minimize the associated morbidity. Anaesthetists should understand the associated psychological aspects and effects of hormone therapy while performing an extensive and informative pre-operative evaluation to formulate an effective strategy. Providing the optimal modes for anaesthesia and keeping a cautious watch for complications along with timely intervention in the advent of the same comprise the approach for high-quality anaesthetic care. This review aims to provide a detailed overview of significant considerations and competent peri-operative outcomes in patients presenting for GRS.