Genital Reconstructive Surgery Research Articles

A Bibliometric and Visualisation Analysis on the Research of Female Genital Plastic Surgery Based on the Web of Science Core Collection Database.

Due to the increasing demand for improving the morphology and function of the external genitalia amongst women, it is necessary to conduct statistical analysis of research data on female genital reconstruction. The current study aimed to use bibliometric analysis to analyse the research hotspots and trend frontiers of the female genital reconstructive research. Publications on the female genital reconstructive research were extracted from the Web of Science Core Collection database. VOSviewer 1.6.18 was used to establish visualisation maps and find top authors, institutions, countries, burst keywords, co-cited authors, journals, research hotspots, and trends. A total of 2207 studies published by 364 different journals authored by 7479 researchers were contained in this study. In the co-authorship analysis, the bulk of the retrieved studies was conducted by the USA, followed by England, Italy, and Netherlands, whilst the most productive institution, journal, and author were U.S. Univ Calif San Francisco, Journal of Sexual Medicine, and Bouman Mark-Bram, respectively. In the co-cited analysis, the top most-cited author and journal were Hage JJ and Journal of Sexual Medicine, respectively. The map of keywords occurrence revealed the most active research aspects were focussed on "vaginoplasty", "feminised genitoplasty", "laser treatment of vaginal atrophy", "transsexualism", and "labiaplasty". The time overlay mapping showed that the study of female genital plastic surgery focusses on the energetic treatment of genitourinary syndromes caused by transsexualism and menopause, especially by using management and treatment of vulvovaginal atrophy for the research trends, and through the vaginoplasty, feminising genioplasty, and laser treatments in the direction of treatments related to physical and mental problems. This novel inclusive bibliometric analysis can help research workers to quickly understand the potential and active researchers, landmark studies, and topics within their interests. We are willing to provide more beneficial data to contribute valuable research of female genital plastic surgery through this study. The journal asks authors to assign a level of evidence to each article. For a complete description of Evidence-Based Medicine ratings, see the Table of Contents or the online Instructions for Authors at www.springer.com/00266 .

A Retrospective Study for Labia Minora Reduction by Serrated-shaped Resection.

The demand for genital plastic surgery has increased dramatically among female patients globally. Although various labia minora reduction procedures have been applied with different indications, advantages, and disadvantages, none has been universally accepted as the best method. So, we presented an innovative strategy for this increasingly demanded reconstructive procedure. In this retrospective study, we included 29 patients seen between November 2020 and May 2023 with hypertrophic labia minora. The patients with hypertrophic labia minora after serrated-shaped resection were included for analysis. Patient satisfaction and complications were evaluated through the follow-up after the operation. Patients with a mean age of 27.1 years (range 19-47 y) performed labia minora reduction via serrated-shaped resection. One patient experienced incision dehiscence, requiring additional surgical revision. One patient experienced postoperative cosmetic asymmetry and also performed secondary repair surgery. One patient experienced urinary retention, which was relieved after urinary catheterization. High overall patient satisfaction has been achieved after a median follow-up of 6.7 months (range 1-24 months). No flap necrosis, sexual dysfunction, or hypertrophic scarring has been reported. Results suggested that serrated-shaped resection is a novel technique for repairing hypertrophic labia minora with high efficiency and satisfaction. The procedure could effectively improve the appearance of the labia minora and reduce complications.

Unconsummated marriage: a systematic review of etiological factors and clinical management.

Unconsummated marriage (UCM) is the inability of the heterosexual married couple to have penovaginal sexual intercourse. The study sought to systematically review current evidence regarding the etiological factors and clinical management of UCM. A comprehensive bibliographic search on the MEDLINE, Scopus, Web of Science, and Cochrane Library databases was performed in June 2023. Studies were selected if they described married couples who never had sexual intercourse in case report or case series evaluating the related causes and/or management and reporting data with qualitative, quantitative, or mixed methods. The review was reported according to PRISMA (Preferred Reporting Items for Systematic Review and Meta-analyses) statement and registered in PROSPERO with ID CRD42023433040. A total of 27 studies including 1638 males and 1587 females were selected. Eight (29.6%) articles were case reports involving a single couple and 19 (70.4%) studies were case series. Mean Murad score was 4.1 (range, 1-8) showing low-intermediate overall study quality. All articles had a level of evidence of 4. Most of studies were conducted in Egypt (n = 5 [18.4%]), Israel (n = 4 [14.9%]), and the United States (n = 4 [14.9%]). The mean age of males and females varied between 24.2 and 37.6years and from 21 to 27.4years, respectively. The reasons for the medical visit that led to the diagnosis of UCM were inability to consummate in 23 (85.2%) studies, inability to conceive in 1 (3.7%) article, and mixed in 3 (11.1%) articles. The mean duration of UCM varied from 7days to 3.5years. Eight studies involving both men and women showed that vaginismus (8.4%-81%) and erectile dysfunction (10.5%-61%) were the most common causes of UCM. Three articles reported that 16.6% to 26% of all UCM cases were due to both male and female factors. Sildenafil, tadalafil, intracavernosal injection, penile plication, female genital reconstructive surgery, vaginal dilators, lubricants, psychosexual therapy, and sex education were the various treatment modalities in 27 studies to achieve consummation rate of 66.6% to 100%. A strength is that this is the first systematic review covering the entire spectrum of UCM. Limitations comprised the low quality of most of the included articles and the large percentage of UCM cases probably not published. Erectile dysfunction and vaginismus are the most reported causes of UCM; however, a strong psychological component certainly underlies a significant number of cases. A multidisciplinary approach based on strategic integration of sex education, medical therapy, psychosexual support, and surgical treatment would seem the most suitable option to manage couples with UCM.

206 Outcome Measures Reported Following Feminising Genital Reconstructive Surgery for Gender Affirmation in Transgender Women and Gender Diverse Individuals: A Systematic Review

Abstract Background The comparison of differing methods of gender affirming feminising genital reconstructive surgery (fGRS) in transgender women and gender diverse individuals may be confounded by variable outcome reporting and the use of inconsistent outcomes and definitions. Method This systematic review examined all outcomes and outcome definitions reported in published studies after gender affirming fGRS in transgender women. Candidate studies were sourced via an electronic, multi-database literature search. Search terms were broad to maximise capture of fGRS procedures. All primary, clinical research studies were included with no date limits. Paired collaborators screened each study for inclusion and performed data extraction. Results After screening 1225 studies, 93 studies proceeded to data extraction, representing 7681 patients. 2621 separate individual outcomes were reported, 857 (32.7%) were defined, and the time of outcome assessment was given for 1856 outcomes (70.8%) but relied on wide, non-specific ranges of follow-up dates. 24 discreet outcomes were reported 10 or more times and comprised 20.7% of all outcomes reported. Profound heterogeneity existed in the definitions used for these and for all outcomes reported in general. Only 6 studies declared a primary outcome. Conclusions Outcomes and outcome definitions reported following fGRS in transgender women and gender diverse individuals were varied and heterogenous. Improved outcome definitions and the adoption of a consistent Core Outcome Set will aid the fair comparison of future studies evaluating the outcomes of fGRS. This review is the first step in the process of developing such a Core Outcome Set.

(053) Multidisciplinary Treatment of Transgender Woman with Severe Gender Dysphoria and Comorbid Psychiatric Disorders - Case Report

Abstract Introduction Gender dysphoria is a distress a person feels due to incongruence between their gender identity and their birth assigned sex. Transgender people have higher rates of mood disorders, suicidal ideations and suicide attempts as well as poorer general health. They often abuse psychoactive substances. There is also a correlation between perceived stigma and discrimination. Objectives The purpose of this case report is to show the treatment process of a transgender person born as a man using multidisciplinary approach based on the bio-psycho-social model, taking sex history, comorbid psychiatric disorders, social constraints and psychological needs into account. Methods A 45-year old male came to the Transgender clinic in Ljubljana, Slovenia. He wanted to transition from male to female. At that time, his appearance, sex and gender was male. He was a miner, married to a woman and lived with his wife in the countryside. His family was ashamed of him because he would go on nights out in public dressed as a woman and had a drinking problem. In the diagnostic phase we confirmed alcohol dependency and severe depression and had him join the addiction treatment programme, which proved successful as he reached stable abstinence. Having overcoming alcohol addiction he still tried very hard to repress his desire to become a woman. His wife tried to get pregnant but he avoided sexual intercourse. He had serious problems with erection and painful sex ascribed to phimosis and eventually got circumcised. He also confessed that he still dressed as a woman in secret, that he wanted to become a woman and consequently started referring to himself as ‘a she’. The wife demanded a divorce. Clinical psychological assessment showed no psychiatric contraindications to start with hormone therapy, first with antiandrogens and a year later with oestrogens, which successfully reduced her gender dysphoria. She reached emotional stability and stopped taking antidepressants. She did not need any otorhinolaryngological procedures or voice therapy. She had face laser therapy and genital epilation as well as nose operation, breast augmentation and genital reconstructive surgery. She received support from the Slovenian non- government organisations and other transgender women. She got a permanent new job in the same firm. Her family of the origin finally accepted her. Results Treatment, which lasted for ten year, resulted in a complete medical and social transition without any regrets. She now lives as a woman, uses dilatators and wants to have a biological male partner. She is on permanent therapy with oestradiol, aldactone, dutasteride, and vitamin D. She does not drink alcohol, has no comorbid psychiatric disorders neither gender dysphoria. She is emotionally stable with positive body image and self-esteem. She wears a wig because of hair loss. Conclusions Treatment, which lasted for ten year, resulted in a complete medical and social transition without any regrets. She now lives as a woman, uses dilatators and wants to have a biological male partner. She is on permanent therapy with oestradiol, aldactone, dutasteride, and vitamin D. She does not drink alcohol, has no comorbid psychiatric disorders neither gender dysphoria. She is emotionally stable with positive body image and self-esteem. She wears a wig because of hair loss. Disclosure No.

(002) Transfeminine Genital Reconstructive Surgery Complications Based on Insurance Claims Data

Abstract Introduction Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Currently, various vaginoplasty techniques are performed by different surgeons across the United States. Surgical outcomes of individual surgeons and groups have been published in the literature, however complications using an insurance claims database have yet to be reported. Objective Our objective is to present post-vaginoplasty complication rates among surgeons in the United States using a large claims database. Methods A retrospective review was conducted of all transgender women who underwent vaginoplasty using IBM MarketScan insurance claims database between 2011-2020. Baseline patient characteristics, including age, obesity, smoking status, Charlson Comorbidity Index (CCI) and the region the surgery was performed were obtained. Patients were followed after surgery to identify complications. Common surgical complications, such as bleeding/hematoma, wound dehiscence, postsurgical infection, DVT, PE, and MI, and complications specific to gender affirming surgery, such as pelvic pain, dyspareunia, rectal injury, urinary issues, urethral stricture, loss of neovaginal depth, and prolapse, were investigated using ICD-9/ICD-10 and CPT codes. Hazard ratios (HRs) were calculated to determine how baseline factors influenced complications. Results A total of 1588 privately insured patients who underwent vaginoplasty for gender affirmation with 414 different surgeons were identified. The mean age was 34 years (22-53 years), 16% were obese and 8% were smokers. The majority (70%) of patients had a CCI of 0. Overall, at a mean follow-up of 14 months (5-28 months), 66% of patients had a complication. A common surgical complication occurred in 19% of patients and a gender affirming surgery complication occurred in 61% of patients. Among those with a gender affirming surgery complication, 17% had pelvic pain, 3% had dyspareunia, <1% had a rectal injury, 21% had urinary issues, 19% had a urethral stricture, 16% had loss of neovaginal depth and 15% had prolapse. A CCI of 2 had a HR of 1.82 (p=0.004) for a common complication and age had a HR of 1.01 (p<0.001) for a gender affirming complication. Smoking was associated with a statistically significant HR for both common complications and gender affirming complications (1.48 and 1.26, respectively; P<0.05). Conclusions Post-vaginoplasty, the majority of patients have at least one complication based on insurance claims data. All patients should be counseled on smoking cessation prior to surgery to potentially decrease the risk of complications. Disclosure No

Outcome Measures Reported Following Feminizing Genital Reconstructive Surgery for Gender Affirmation in Transgender Women and Gender Diverse Individuals: A Systematic Review

Introduction: Feminizing genital reconstructive surgery (vaginoplasty, labiaplasty, clitoroplasty and other feminizing genital gender affirming procedures) may be sought by transgender women and gender diverse individuals as part of their gender affirmation process. The comparison of different published methods of feminizing genital surgery is expected to be confounded by variable outcome reporting and the use of inconsistent outcomes and definitions. Materials and Methods: Candidate studies were sourced via an electronic, multi-database literature search performed using a search strategy developed with the assistance of an information search specialist. All primary, clinical research studies published from the date of inception of each database, up until November 2020; were included. Paired researchers screened each study for inclusion and performed data extraction independently. Data extracted included: the outcomes reported by each study, whether these were defined and the definitions used. Results: A total of 1225 studies were screened. 93 studies were eligible for full data extraction; consisting of 68 case series, 22 cohort studies, and 3 cross-sectional studies. The majority of these studies had been published within the last decade (n=57). These studies provided data from 7681 patients who had undergone feminizing genital reconstructive surgery. There were 2621 individual outcomes reported, an average of 28 outcomes per study. Just 857 outcomes (32.7%) were sufficiently defined to be replicable in future studies. The declaration of a primary outcome took place in 6 studies only. Outcomes that featured most commonly were from domains relating to the “Reproductive system” and the “Need for further intervention.” Conclusion: Outcomes reported following feminizing genital reconstructive surgery in transgender women and gender diverse individuals were heterogenous and incompletely defined. This makes the comparison of similar studies challenging, thus confounding the fair comparison of feminizing genital reconstructive surgery success rates, complications and patient satisfaction. Primary outcomes were infrequently declared, exposing the studies to the risks of outcome reporting bias.

Progress (patient reported outcomes in genital reconstructive surgeries) a validated patient reported outcome measure questionnaire to assess post operative functional improvement following feminising genital reconstructive surgery

Progress (patient reported outcomes in genital reconstructive surgeries) a validated patient reported outcome measure questionnaire to assess post operative functional improvement following feminising genital reconstructive surgery

Quantitative analysis of the labia minora morphology in 400 Chinese women: A new method for assessing the shape of the labia minora.

To investigate the shape of labia minora in Chinese adult women. Women who visited the Genital Plastic Surgery Center from January 2021 to February 2022 were included and the vulvar regions were photographed. The shape of the labia minora was converted into quantifiable values [left side line segment 1-9 (L1-L9 values) and right side line segment 1-9 (R1-R9 values)]. The 400 enrolled patients were grouped by age, parity, and the types of vulvar surgeries they planned to undergo. After a graphic-to-digital and digital-to-graphic conversion, the simulated average image of the labia minora in Chinese adult women was constructed based on the mean values of L1-L9 and R1-R9. Comparing the values of Ln and Rn in the four age groups revealed that the mean values of Ln and Rn gradually decreased with age, but only two subgroups showed statistically significant differences (P-value <0.05). When the patients were stratified according to the number of births and whether labiaplasty was planned to perform, there were no significant differences among all groups (P-value >0.05). To measure and evaluate the labia minora, a new assessing method was used. It is an innovative attempt to transform the simple rough description of the shape of the labia minora into more precise data reflecting the shape features. It allows the comparison of labia minora shape between individuals by comparing quantifiable values. Besides, the average shape of labia minora in Chinese adult women was provided visually. Factors including age, parity, and whether the patient planned to undergo labiaplasty were not significantly associated with the shape of the labia minora.

Sub-regional skin grafting for perineal resurfacing after excision of superficial vulvar tumors: An excellent method to achieve an aesthetically pleasing appearance.

To investigate the effect of sub-regional split-thickness skin grafting in perineal resurfacing. A single-center retrospective study was conducted in the Genital Plastic Surgery Center. Detailed clinical data of 14 consecutive patients who underwent split-thickness skin grafting after vulvar tumor resection from February 2013 to June 2022 were analyzed. Clinical data, postoperative photographs, scoring of vulvar appearance, and questionnaire results of the Female Sexual Function Index before and after surgery were analyzed. The patients had sub-regional split-thickness skin grafting ranging from 7 × 8cm to 11 × 12 cm (88.86 ± 24.99 cm2 ). After a follow-up of 8.21 ± 2.22 months (mean ± SD), all patients had a three-dimensional and aesthetically pleasing vulva and high scoring of vulvar appearance (mean ± SD, 4.43 ± 0.65). All patients had good healing of both the recipient and donor sites without major complications. Only one patient had minor dehiscence in the perineal region and recovered soon after proper treatment. The scores of the Female Sexual Function Index were significantly improved after surgery. Among the included domains, scores of "desire," "arousal," "orgasm" and "satisfaction" increased significantly after surgery (p value <0.05). Sub-regional split-thickness skin grafting could achieve excellent cosmetic outcomes with few complications in perineal reconstruction after the excision of superficial vulvar tumors. It can provide an aesthetically pleasing appearance in the vulvar region and improve female sexual function to some extent. In general, sub-regional split-thickness skin grafting could be a recommended reconstructive option to repair vulvar defects.

Evaluation and management of urologic complications following transmasculine genital reconstructive surgery.

Transmasculine genital reconstructive surgery involves the creation of a neourethra by way of metoidioplasty or phalloplasty. We aim to describe approaches in identifying complications associated with these procedures as well as the various reparative techniques that can be utilized to reestablish the neourethral tract. We prepared a guide to diagnostic and procedural interventions for urologic complications following transmasculine genital reconstructive surgery based on our clinical experience as well as those of our colleagues. We reviewed all current peer-reviewed publications based on this topic. These procedures have a considerable revision rate for urologic complications, which include urethrocutaneous fistulae, persistent vaginal remnant, and urethral strictures. These complications often present simultaneously and require appropriate workup and treatment. Several reconstructive techniques can be employed to restore the neourethral tract, as we describe in detail.

Outcome measures reported following feminising genital reconstructive surgery for gender affirmation in transgender women and gender diverse individuals: a systematic review

Outcome measures reported following feminising genital reconstructive surgery for gender affirmation in transgender women and gender diverse individuals: a systematic review

An Overview of Gender-affirming Surgical Fellowships in the United States

PURPOSE: In recent years, there has been a significant increase in the awareness and demand of gender transition surgery. Surgical transition often occurs in specialized centers due to the involvement of a multidisciplinary team. Thus, residents may have limited clinical experience in gender transition and seek out fellowships. This study aims to assess the formation and characteristics of gender-affirming surgical fellowships in the United States. METHOD: A cross-sectional study was performed on all institutions with an accredited plastic surgery residency program in the United States. The official website for each program was reviewed for the presence of a gender transition fellowship. The authors then contacted program coordinators through email or telephone interview to collect data on the characteristics of the fellowship. RESULTS: The authors included 102 academic institutions in this study, less than half (n=48, 47%) were known as ‘Leader in LGBT Healthcare’ centers. Seven transgender fellowships were identified; however, data was only available for 6 fellowships. All fellowships (n=6) had a 12 month duration and the average stipend was $81,225. All offered training in masculinizing and feminizing chest reconstruction. Five provided training in both masculinizing and feminizing genital reconstruction (83%), whereas one fellowship provided training in neither. Strikingly, significantly more fellowships offered facial feminization training than facial masculinization (83% vs 33%, p<0.001). CONCLUSION: The creation of transgender surgery fellowships in plastic surgery reflects the growing demand for gender-affirming surgical training and provision. Although there is universal fellowship training in chest reconstruction, there are fewer learning opportunities for genital reconstruction and facial masculinization surgery.

Circumferential full-thickness skin grafting: An excellent method for the treatment of short penile skin in adult men.

Short penile skin due to excessive circumcision is a complex condition requiring surgical care. The study aims to investigate the effect of full-thickness skin grafting (FTSG) in treating short penile skin. A retrospective analysis was performed on 24 patients with insufficient penile skin. The included patients underwent full-thickness skin grafting from the scrotum and the groin region in the Genital Plastic Surgery Center between February 2014 and September 2021. Morphology of the penis, length of the penis, complication, and donor area healing status was observed by the authors. Additionally, the International Index of Erectile Function Questionnaire (IIEF-5) and the patient's evaluation of penile appearance were investigated. An aesthetically pleasing appearance of the penis was obtained by FTSG in 24 patients. The length of penis was improved after surgery (5.70 cm ± 1.24 cm vs. 6.05 cm ± 1.33 cm, P value < 0.05). All patients had good healing of the penile area without serious complications. Only 2 cases showed minor partial necrosis and recovered soon after proper treatment. A high patient's evaluation of penile appearance was received (4.08 ± 0.71, mean ± SD) and the scores of IIEF-5 increased significantly after surgery (18.38 ± 2.24 vs. 21.08 ± 1.79, P-value < 0.05). FTSG from the scrotum and inguinal skin provides good aesthetic and functional results for treating short penile skin. FTSG, particularly the scrotum-derived skin graft, offers a great supplement to penile skin. It could be suggested as a promising method of treating insufficient penile skin, which meets both functional and aesthetic needs.

Process Switching and Its Meaning towards Transgender Identity: An SFL Perspective

&lt;div class="WordSection1"&gt;&lt;p&gt;This SFL study attempts to scrutinise the process-type switching and its underlying meanings in the cyber-based interactive responses towards an issue of transgender. The issue is confined to the suspected genital reconstruction surgery of an Indonesian celebrity that becomes viral and triggers public debate on social media. 254 Indonesian clauses of interactive comments addressing the issue of transgender identity on a YouTube video of more than 2 million views were analysed. Prompting and replying responses were investigated for their categorization of process types by employing the tables of analysis adapted from the experiential meaning framework of Halliday and Matthiessen (2004). The analysis reveals some occurrences of process type switching in the interactive responses among responders in addressing the Indonesian sensitive and viral issue of transgender identity. In responding to the prompting comments, responders tended to employ relational and material clauses to establish values, evidences, and impacts in objective ways while they also used mental and verbal processes to affect one another in subjective ways. This Hallidayan study hints that the process switching among responders in addressing the issue of transgender is associated with the strategies for maintaining and spreading their ideology by confirming, strengthening, adding, and even arguing.&lt;/p&gt;&lt;/div&gt;

Evaluation of the surgical and functional outcomes of secondary vaginoplasties with free skin mesh graft in patients following transfeminine genital reconstructive surgery.

BackgroundGender-affirming surgery is classically done using the penile inversion vaginoplasty technique, however in some patients it may not promote adequate depth. In patients whose vaginal conduits became short or stenotic, we propose to perform a secondary vaginoplasty using an abdominal free skin mesh graft. In this study, we present ours results of a series of cases using this technique.MethodsA retrospective review of patients undergoing secondary vaginoplasty with free skin mesh graft from 2000 to 2017 at our hospital was performed. Demographic data, surgical characteristics, complications, personal satisfaction and neovagina functionality (defined as the ability to have satisfactory sexual intercourse) were evaluated.ResultsOf 186 patients who were submitted to primary vaginoplasty, 36 patients (19.3%) were then submitted to secondary vaginoplasty. This study sample included 35 patients. The average age of patients was 41.0 years (37.0 to 50.5) and the average time between gender affirmation surgery and secondary vaginoplasty was 6 months (4–24). Ten patients (28.6%) developed postoperative complication, the most frequent being: neovagina introitus stenosis (22.9%), rectal fistula (8.6%), tissue dehiscence (2.9%), and urethral fistula (2.9%). Subjective personal satisfaction and neovagina functionality of patients was reported by 77.1% of the sample.ConclusionsOur study demonstrates that secondary vaginoplasty surgery using a free skin mesh graft has good results and is a functional option with low complexity and low rate of serious complications.

Defibulation can recall the trauma of female genital mutilation/cutting: a case report

BackgroundWomen with female genital mutilation/cutting are known to have psychological sequelae from the cutting and other traumatic experiences. However, very few studies report immediate psychological sequelae of genital reconstructive surgery in this population. The present case is the first to our knowledge to report post-traumatic stress disorder symptoms immediately following defibulation, a procedure common in women with female genital mutilation/cutting type III.Case presentationWe present the case of a 31-year-old Sudanese nulliparous woman in the second trimester of pregnancy with female genital mutilation/cutting type IIIa who was referred for antepartum defibulation to facilitate a vaginal birth. Immediately after an uncomplicated surgery under local anesthesia and just before the first micturition, she developed post-traumatic stress disorder symptoms and suddenly recalled the traumatic experience of her first micturition after female genital mutilation/cutting when she was a child in Sudan. The woman was offered psychiatric follow-up with psychotherapy for 4 months and a short course of benzodiazepines. She had fully recovered by the time of delivery, 4 months after surgery.ConclusionsWe discuss the possibility of recall of a past traumatic experience of female genital mutilation/cutting during defibulation or other genital surgeries. We review the benefits and risks of defibulation, the impact of this procedure, and the setting and timing in which it is performed, focusing on women’s mental health and psychological support.

Correcting gender dysphoria –the anatomical changes with male to female gender reassignment surgery

ABSTRACT Introduction &amp; Objectives Increased Global acceptance of transgender communities, gender-affirming genital reconstructive surgery is becoming more prominent. Formalised education and training however has not quite entered the curriculum of many surgical training programs yet it remains imperative we have an understanding of modified anatomy in out patients. We demonstrate anatomical reconstruction during the transition between male to female anatomy. Methods Patient consent was obtained to take a series of photographs during gender affirming surgery from male to female. Results Contemporary patients receive both spinal and general anaesthesia prior to positioning in standard lithotomy. A perineal incision of approximately 10cm in the midline raphae exposes the corpora and spongiosum. A simple bilateral orchidectomy was performed at the level of the external inguinal ring. A neovaginal cavity was created by firstly dividing the bulbospongiosus attachments to the perineal body and the space is both blunt and sharply dissected. Further dissection is carried out in the avascular perirectal fat plant anterior to the Denonvilliers fascia. During this dissection a 18-22Fr urethral sound is used to apply downward traction on the rectum. A sterile ultrasound sleeve is placed in the rectum to allow bimanual palpation to confirm intact rectal mucosa. A circumferential incision proximal to the glans is performed to aide degloving of the penis. Bucks fasica is left intact and distal penile skin will later be used to form the clitoral hood. The dorsal neurvascular bundle is raised off the corporal bodies but an attachment to the glans remains. A triangular section of dorsal glans is preserved and dissected off the tips of corpora. The penile tissue is then disassembled separating the corpus spongiosum from the corporal bodies. The corpora are amputated at the level of the pubis, remaining erectile tissue destroyed and oversewn for haemostasis. The Urethra is shortened to an appropriate length to allow the dorsal aspect to align between the neoclitoris and neomeatus. The ventral aspect is spatulated to expose the neomeatus. The penile skin flap is invaginated within the neovaginal space and the skin incised to expose the neoclitoris and neomeatus. The penile skin is then anastomosed to the neoclitoris and neomeatus The distal end of the penile skin flaps is oversewn to create a blind ending tube and thus creating the neovagina. Labia Majora are formed by excising excess scrotal skin to create an appropriate contour. This form of neovagina is compared to methods that involve intestinal and peritoneal lining transfer. Conclusions We have outline the stepwise transition of male to female anatomy with a conventional contemporary technique. Creation of a neovagina with penile inversion has become common practice in gender affirming surgery. However there are other means of creating genitalia with alternative tissues, which subspecialised practitioners should be aware. Disclosure Work supported by industry: no.

Current status of transition medicine for 21-hydroxylase deficiency in Japan: from the perspective of pediatric endocrinologists.

To manage of 21-hydroxylase deficiency (21-OHD), transition medicine from pediatric to adult health care is an important process and requires individually optimized approaches. We sent cross-sectional questionnaire surveys on the current status of transition from pediatric to adult health care in 21-OHD patients to all councillors of the Japanese Society for Pediatric Endocrinology. Many pediatric departments (42.2%) experienced adult 21-OHD patients, and 115 patients (53 males, mean age of 26) in 46 institutions were identified. Whereas almost two-thirds of pediatric endocrinologists regarded the problems of counterparts and cooperation as hindrance of transition medicine, the major reason for continuing to be treated in pediatrics was the patient's own request. The prevalence of long-term complications including obesity, osteoporosis, infertility, menstrual disorder, gender dysphoria, and testicular adrenal rest tumor were 27.5%, 8.8%, 11.1%, 26.3%, 7.1%, 12.5%, respectively, which is comparable to those of other cohorts previously reported. However, several items, especially infertility and osteoporosis were not checked well enough in adult 21-OHD patients treated in pediatrics. Though 44 of 62 female patients had genital reconstructive surgery, more than half of them were not followed up by gynecologists or pediatric urologists. Quite a few adult 21-OHD patients had been followed up in pediatrics even after coming of age; however, surveillance by pediatric endocrinologists of gynecological, reproductive, and mental problems may be insufficient. Therefore, multidisciplinary approaches should be required in transition medicine for 21-OHD and prerequisite for graduation of pediatrics. Pediatric endocrinologists will need to play a leading role in the development of transition systems.

Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction.

Transfeminine genital reconstructive surgery is an important part of gender affirmation for many transgender women. Sexual health post-vaginoplasty is an important aspect of quality of life that can have a significant impact on overall well-being. The objective of this review is to provide a summary of the literature on the sexual outcomes of transgender females post-vaginoplasty and identify treatment strategies for those experiencing sexual dysfunction. A literature review was conducted with a focus on sexual health outcomes in transgender females post-vaginoplasty as well as treatment options for sexual dysfunction. Penile inversion vaginoplasty with or without free skin grafts or local tissue flaps and intestinal vaginoplasty are the options available to patients interested in transfeminine genital reconstructive surgery with a neovagina. Sexual satisfaction post-vaginoplasty is high regardless of the vaginoplasty technique, however up to 29% of patients may be diagnosed with a sexual dysfunction due to associated distress with a sexual function disturbance. Hormone treatment, pelvic floor physical therapy, sex therapy, and sex surrogacy are treatment options for patients with sexual dysfunctions. Patient reported outcome measures appropriately validated for this patient population are necessary to better understand sexual function outcomes, sexual dysfunction and treatment options for post-vaginoplasty patients. Schardein JN, Nikolavsky D. Sexual Functioning of Transgender Females Post-Vaginoplasty: Evaluation, Outcomes and Treatment Strategies for Sexual Dysfunction. Sex Med Rev 2022;10:77-90.