Operated Male-to-Female Sexual Function Index: Validity of the First Questionnaire Developed to Assess Sexual Function after Male-to-Female Gender Affirming Surgery.

PURPOSE: No questionnaire is currently available to evaluate sexual function after male-to-female gender affirming surgery. Such a limit leads to a suboptimal evaluation in postoperative sexual function in these patients. We developed and validated a new questionnaire, the oMtFSFI (operated Male-to-Female Sexual Function Index), for assessing sexual function in male-to-female patients after surgery. MATERIALS AND METHODS: A panel of experts in gender dysphoria defined the main content areas to be assessed, including genital self-image, desire, arousal, lubrication, orgasm, satisfaction and sexual pain. After a pretest on 10 patients the oMtFSFI was applied in the main study to 65 operated male-to-female patients, recruited at 7 Italian centers, and 57 women. The participants provided self-ratings on online oMtFSFI, Female Sexual Function Index, Beck Depression Inventory for Primary Care and Short Form Health Survey questionnaires. Operated male-to-female patients completed the oMtFSFI twice, 4 weeks apart. RESULTS: Principal component analysis performed on self-ratings provided by operated male-to-female patients on oMtFSFI items yielded a 3-domain structure of sexual dissatisfaction, sexual pain and genital self-image. The 3 domains were internally consistent and test-retest reliable. Convergent associations with Female Sexual Function Index scales emerged for sexual dissatisfaction and sexual pain but not for genital self-image. Male-to-female patients reported lower sexual function levels than cisgender women. CONCLUSIONS: The present preliminary results support reliability and psychometric validity of the oMtFSFI in the assessment of key sexual function domains in transgender women, further revealing that genital self-image represents an assessment area to be considered in male-to-female patients, in addition to domains that are salient for cis women as well.

Sociodemographic and clinical features of gender identity disorder: an Italian multicentric evaluation.

INTRODUCTION: Male to female (MtFs) and female to male (FtMs) subjects with gender identity disorder (GID) seem to differ with regard to some sociodemographic and clinical features. Currently, no descriptive studies focusing on MtFs and FtMs attending an Italian clinic are available. AIM: To describe the sociodemographic characteristics of a GID population seeking assistance for gender transition and to assess possible differences in those features between MtFs and FtMs. METHODS: A consecutive series of 198 patients was evaluated for gender dysphoria from July 2008 to May 2011 in four dedicated centers. A total of 140 subjects (mean age 32.6 ± 9.0 years old) meeting the criteria for GID, with their informed consent and without genital reassignment surgery having already been performed, were considered (92 MtFs and 48 FtMs). Diagnosis was based on formal psychiatric classification criteria. MAIN OUTCOME MEASURES: Medical history and sociodemographic characteristics were investigated. Subjects were asked to complete the Body Uneasiness Test (a self-rating scale exploring different areas of body-related psychopathology), Symptom Checklist-90 Revised (a self-rating scale to measure psychological state), and the Bem Sex Role Inventory (a self-rating scale to evaluate gender role). The presence of psychiatric comorbidities was evaluated using the Structured Clinical Interviews for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) (SCID I and SCID II). RESULTS: Several significant differences were found between MtFs and FtMs regarding lifestyle and sociodemographic factors and in psychometric test scores. No differences were found in terms of psychiatric comorbidity. CONCLUSIONS: This is the first large study reporting the sociodemographic characteristics of a GID sample referring to Italian clinics, and it provides different profiles for MtFs and FtMs. In particular, FtMs display significantly better social functioning.

Intra-peritoneal versus retropubic implantation of three-piece inflatable penile prosthesis: Patient-reported outcomes and complications.

INTRODUCTION: The role of reservoir position was investigated in this series of patients treated with three-pieces penile prosthesis implantation (PPI). The outcomes and the patients' reported quality of life after insertion of the balloon in the retropubic space, or the Retzius's space (SOR), were compared with the outcomes of patients who received an intraperitoneal implantation (IP). The study aimed to analyze how the anatomy of the SOR influenced the long-term results of PPI, especially in patients who have been previously exposed to pelvic surgery or radiotherapy. The SOR has usually been identified as ideal for concealing and protecting the reservoir; nevertheless, an increasing rate of patients that ask for a PPI do not conserve the typical favorable characteristic of the SOR. In these cases, the tissue alteration can cause a higher rate of undesired events and can impair the satisfaction from device use. In the recent literature, few articles focus on the topic of reservoir position and very poor information is available about the results of the IP insertion. MATERIALS: Our cohort of patients was retrospectively inspected; the two different subgroups, according to the reservoir position (SOR or IP) were evaluated considering the pre-operative condition, the post-operative complication, the development of undesired events or uncomfortable sensations during the follow-up. The quality of life after PPI was observed as well, with a questionnaire specifically developed for patients treated with PPI. The surgical technique adopted for the intraperitoneal implantation was described. RESULTS: The results of penile prosthesis functionality and patients' and partners' reported quality of life (QoL) showed similar results between the two groups but greater satisfaction in the relational domain of the questionnaires adopted was described in the IP subgroup. CONCLUSION: According to our observations, the IP reservoir insertion guarantees good functionality and lower rates of undesired events after PPI.

Male-to-Female (MtoF) gender affirming surgery: Modified surgical approach for the glans reconfiguration in the neoclitoris (M-shape neoclitorolabioplasty).

PURPOSE: The aim of this article is to describe our modified surgical technique for the reconfiguration of the glans in the clitoris and the labia minora, known as the "M-shape neoclitorolabioplasty". METHODS: The glans with all its neurovascular bundle is isolated from the corpora cavernosa, incised in Y-shape mode and spread in order to obtain an M-shape glandular flap. The "belly" of the M-shape glans will constitute the triangular neoclitoris meanwhile the lateral flaps will constitute the labia minora. The inferior apex of the neoclitoris is fixed to the superior apex of the previously spatulated urethra. The two glans flaps are incised transversally to increase their length and sutured to the sides of the spatulated urethra forming the labia minora. Our technique permits to create an aesthetically pleasing neovagina preserving all the glandular erogenous sensitivity. RESULTS: 94 patients have been treated with our modified technique of male-to-female (MtoF) gender affirming surgery. At median follow-up of 27.57 months, 81 (86.1%) patients reported vaginal intercourse and 78 (82.9%) patients referred presence of erogenous sensitivity during dilatations, intercourse or masturbations. All the glandular tissue is preserved and reconfigured forming the neoclitoris and the labia minora. The M-shape reconfiguration permit to create an aesthetically pleasant neoclitoris. CONCLUSIONS: This technique could be applied safely and easily to patients undergoing gender affirming surgery, allowing the creation of a neovagina with the best possible erogenous sensitivity without losing aesthetical results.

Systematic review of studies reporting perioperative and functional outcomes following male-to-female gender assignment surgery (MtoF GAS): a call for standardization in data reporting.

INTRODUCTION: The aim of this study is to accomplish a systematic review on the surgical techniques available for male-to-female gender assignment surgery (MtoF GAS) published in the last 15 years, from January 2002 to May 2017, assessing advantages and disadvantages. EVIDENCE ACQUISITION: A specific search on MEDLINE, Scopus and Web of Science databases included vaginoplasty for gender exchange. Preoperative (age, gender, body mass index, prior surgery), intraoperative (mean operating time, intraoperative complications, transfusion rate, conversion rate), postoperative (hospital stays, readmission rate, early and late complication rate), postoperative sexual activity, subjective satisfaction, vaginal depth, and long-term outcomes (vaginal stenosis, prolapse, dyspareunia and labial abscess) data of vaginoplasty for sexual exchange were collected. 29 articles were included (2.402 patients). EVIDENCE SYNTHESIS: Out of the 29 papers, 19 studies assessed penile skin inversion and 10 evaluated intestinal vaginoplasty. No comparative studies were found. Penile skin inversion vaginoplasty reported slightly shorter operative time compared to intestinal vaginoplasty (109-420 vs 145-420 minutes). Intraoperative complications for penile skin inversion vaginoplasty not exceeded an incidence of 10%. No significant differences in terms of postoperative complications or hospitalization time were reported. Intestinal vaginoplasty provides a deeper neovagina. Female Sexual Function Index score was significantly higher in patients undergoing intestinal vaginoplasty. CONCLUSIONS: A standardized data collection may allow a better understanding of effectiveness and outcomes of different techniques.

Conservative Treatment of Serous Borderline Paratesticular Tumor in a Pediatric Patient.

Serous borderline tumors are rare neoplasms. Herein we report our conservative approach, whose rationale is neoplasm low-malignant potential. Tumor was removed under general anesthesia, and frozen section ruled out a germinal malignancy or a stromal tumor such as rhabdomyosarcoma. Ultrasound evaluation was initially performed every 3 months during the first 2 years, every 6 months during the next 3 years, and annually thereafter. After 8 years, the patient has not experienced any relapse, either clinical or ultrasonographical. In our opinion, conservative approach, whose final decision relies on intraoperative frozen section, represents the best option and does not jeopardize long-term oncological outcome.

Necrotizing palisading granuloma of the bladder in an otherwise healthy young man.

We describe a case of a vesical mass in a young patient, histologically characterized by an intramural lesion composed of spindle and epithelioid histiocytes arranged in a palisaded pattern, with central necrosis similar to a rheumatoid nodule. There was no clinical history of autoimmunity or previous bladder procedures, infections, or trauma. However, the smooth muscle actin and desmin positivities seen in residual ghost cells within necrotic areas argued against a granulomatous process. Reactive processes, such as myofibroblastic proliferations, can overlap neoplastic disorders, including true smooth muscle tumors. We did not observe atypia in the viable cells and mitotic figures. These features did not support a diagnosis of malignancy. The fascicular pattern, spindle cell morphology, lack of marked cytologic atypia, and smooth muscle actin and desmin reactivities, with a lack of other lineage marker expression, all supported a diagnosis of an infarcted leiomyoma. The intramural location in the bladder also favored the diagnosis.

A rare case of leiomyosarcoma of the penis with a reappraisal of the literature.

Primary leiomyosarcomas arising in the penis are rare, with only 29 reported cases to date. We review the published records on this entity and describe an additional case of penile leiomyosarcoma occurring in a 53-year-old patient who underwent postectomy for a firm nodule in the prepuce. Four years later he experienced local recurrence which was successfully treated with partial penectomy.