Undergoing Gender Reassignment Surgery Research Articles

Differences in sexual development-S2k guideline update

Human beings with adifference in sexual development (DSD) often underwent gender reassignment surgery during early childhood. However, the medical decision was often not congruent with the gender identity that affected persons developed later on. To represent the interests of affected persons, an interdisciplinary guideline in cooperation with support groups was written. The revision of the first version of the guideline, published in 2016, was edited by 18professional societies and working groups as well as 3support groups. Aliterature search was performed for each of the 12chapters. Recommendations and statements created by the working groups were voted on during four consensus conferences. The guideline highlights the right of self-determination of affected persons. In this context, new legal requirements are reported. Other than necessary primary diagnostics, medical procedures should be postponed. Most important is the psychological support of parents and patients. Tumor risk of the gonads and protection of fertility are analyzed and discussed in detail. The content of the guideline represents aparadigm shift in dealing with human beings with adifference of sexual development. Projects as DSD Care and Empower-DSD help to promote the practical implementation of the guideline's recommendations.

Life experiences leading to the choice of surgery-A qualitative study exploring reasons behind the choice of undergoing gender affirmative surgery.

Gender dysphoria is frequently accompanied by physical dissatisfaction and body image issues. The primary objective of this study is to explore subjective experiences and perceptions among those who has undergone gender reassignment surgery, as well as their retrospective path to that decision. Sixteen qualitative in-depth interviews were conducted with 9 participants. The participants were accepted for gender affirming surgery and interviewed before and after surgery. Cultural norms, and values in relation to time and context were highlighted as significant in reference to the opportunity one had to display a gender identity that corresponded to prevailing expectations. Participants gradually began to recognize their differences and divergence from others in social interactions and experiencing "wrong" bodily changes during puberty created even greater discrepancy. Several impression control measures, such as avoiding certain situations and using concealing techniques, were employed to prevent what was described as both felt and enacted stigma. The significance of having genital organs that accurately reflect one's gender identity was emphasized to prevent emotional distress and dysphoria caused by this discrepancy. Socio-cultural expectations, combined with enacted stigma, seem to cause, or re-enforce self-stigma as people internalize these attitudes and suffer from physical and mental consequences as a result. Thus, societal, and cultural trends seem to have a strong influence and feed the idea of being born in the wrong body. However, even though several participants underwent socially inspired alterations, they all experienced dysphoria in the extent that they continued to see reassignment surgery as a solution.

Suicide ideation and the related factors among Iranian transgender people: a cross-sectional study

ObjectiveSuicide is a significant public health concern worldwide, and efforts to prevent it are crucial. This study aims to assess suicide ideation among transgender individuals in Iran. A cross-sectional design was used, with 235 transgender participants recruited through snowball sampling across Iran. The data collection included a questionnaire containing demographic inquiries, while the Beck Scale for Suicide Ideation was employed to gather data. Descriptive and analytical statistics were performed using SPSS software.ResultsThe findings indicate that the prevalence of suicidal ideation among the transgender individuals in the study was 83%, with a mean score of 12.8 ± 8.8 on the suicide ideation scale. Individuals with lower levels of education, younger age, unemployment, and being divorced or single demonstrated significantly higher scores compared to others (p < 0.05). This study highlights the high prevalence of suicidal ideation among Iranian transgender individuals, particularly among those with lower age and education levels, as well as those who have not undergone gender reassignment surgery.

P-431 Effect of biphasic CAPA-IVM on ovarian tissue oocytes of transgender men

Abstract Study question Can CAPA-IVM (Biphasic in-vitro maturation) with C-type natriuretic peptide (CNP), followed by in vitro maturation (IVM) improve ovarian tissue oocyte (OTO) maturation in transgender patients? Summary answer Biphasic CAPA-IVM did not show any significant difference in maturation competence and genetic variations when compared with in-house IVM. What is known already OTO-IVM is a method of fertility preservation in patients where prior ovarian stimulation is undesired. It has resulted in live births in cancer and polycystic ovarian syndrome (PCOS) patients. CAPA-IVM has further improved the OTO competency in these patients. Similarly, OTO could be collected from transgender men without ovarian stimulation during gender reassignment surgery. Even having adequate survival and maturation, OTO-IVM in transgender men has exhibited decreased fertilization rate and severely compromised developmental competency probably due to long testosterone treatment before surgery. For this reason, we sought to investigate whether this compromised potential can be rescued through biphasic CAPA-IVM. Study design, size, duration Patients were recruited from July 2022 to December 2022. Ovaries were collected from 4 transgender patients (age= 18-26 years, mean age=21 years) who underwent gender reassignment surgery after testosterone treatment (mean length= 32 months). All ovaries were collected in cold medium (4oC) and manipulation was performed within 30 minutes of the collection for the retrieval of cumulus oocyte complexes (COCs). Participants/materials, setting, methods COCs collected during ovarian manipulation were cultured either in in-house IVM medium for 48 hours or in biphasic CAPA-IVM for 54 hours. Following maturation, these oocytes were analyzed for Calcium (Ca2+)-releasing potential and developmental competency after ICSI. In vitro matured GV (germinal vesicle), MI (metaphase I) and in vivo matured oocytes with clusters of smooth endoplasmic reticulum (SERa) served as controls. Genetic analysis was performed on subsequent embryos to detect chromosomal abnormalities in all groups. Main results and the role of chance A Total of 133 COCs were collected (44 in CAPA-IVM and 53 in in-house IVM) and both showed a similar maturation rate i.e. 55%. After culture period, the survival rate tended to be higher in the in-house IVM compared to CAPA-IVM (78% vs. 68%, p = 0.184). Following ICSI, 8/11 CAPA-IVM and 8/13 in-house IVM oocytes were normally fertilized, comparable to controls (5/5) (p = 0.195 and p = 0.103 respectively). Blastocyst rates were lower in both CAPA-IVM (1/8) and in house IVM (2/8) compared to controls (3/5), however not significant (p = 0.071 and p = 0.207 respectively). Ca2+-releasing potential of oocytes was determined as a product of amplitude and frequency, in arbitrary units (AU). The average values for CAPA-IVM (1.61) and in-house IVM (1.58) were similar (p = 0.97). Shallow whole genome sequencing (Shallow WGS) of developed embryos showed that 3/5 in PMC group, 3/7 in in-house IVM group were chromosomally abnormal. Limitations, reasons for caution The number of included patients is low, so obtained results should be interpreted with caution. Wider implications of the findings To the best of our knowledge, this is the first study on the use of biphasic CAPA-IVM for transgender OTO-IVM oocytes. Further investigation on the added value of CAPA-IVM together with the effect of testosterone treatment length might help shape more accurate guidelines for the fertility preservation of transgender men. Trial registration number not applicable

Health status and health seeking behaviour in transgenders in Kakinada: a community based cross-sectional study

Background: Transgender (TG) is a term used to define individuals with a gender identity that is incongruent with the gender identity accorded to them at birth. Over the last two decades, health research on TGs has focused mainly on their sexual practices, leading to lack of information on their health problems and healthcare-seeking behaviour beyond STDs /HIV. The current study aimed to gain insight into the health status of TGs. Methods: A community based cross-sectional descriptive study was carried out in transgenders living in an urban area from December 2022 to January 2023 with a sample size of 160. Snowball sampling technique was used till the sample size was achieved. Data was collected using a pretested semi-structured questionnaire. Data was entered and analysed in MS Excel with descriptive statistics. Results: Majority of the study subjects belonged to 20-30 years of age. 43% were illiterates, 87% were living in rented houses. 89% screened for HIV in last 6 months, 57% underwent gender reassignment surgery. All study subjects gave history of suffering from STIs at least once, 11.9% were experienced STDs in past 1 year. 6.9% were tested positive for HIV and were on regular ART. 23.1% were diagnosed with anyone of NCD. First point care is contacting outreach worker in 58.8% of TGs. Conclusions: A more receptive attitude from the entire healthcare system is essential for improving the health status of this community. The inclusiveness promoted by universal health coverage will help each of these people's health statuses improve.

Expression of Phosphodiesterase (PDE) Isoenzymes in the Human Male and Female Urethra.

PurposeAlthough it has been supposed that the NO/cyclic GMP system produces inhibitory signals to reduce the resistance of the bladder outlet and urethra during the micturition phase, little is known on the mechanisms controlling the function of urethral smooth muscle. The aim of the present study was to examine in the male and female urethra the expression of phosphodiesterase (PDE) isoenzymes, known as key proteins of the cyclic GMP/AMP signaling.MethodsUrethral tissue was obtained from 4 female cadavers and 7 male patients (who had undergone gender reassignment surgery). The expression of mRNA encoding for PDE1A, 1B, 1C, 2A, 4B, 4D, 5A, 10A and 11A was investigated by means of real-time polymerase chain reaction. Western blot (WB) analysis was conducted to detect PDE isoenzymes.ResultsRT-PCR revealed relevant amounts of mRNA encoding for PDE1A, 2A, 4B, 5A, 10A and 11A in male and female urethral tissue. The expression of PDE1A, 2A, 4B and 10A was 2-fold higher in the female than in the male urethra, whereas the expression of PDE11A mRNA was 7-fold higher in the male tissue. In the WB experiments, immunosignals specific for PDE1A, PDE4A and 4B and PDE11A were of higher degree in the female than the male tissue specimens, while an almost equivocal expression of PDE2A, PDE5A and PDE10A was registered.ConclusionOn the level of mRNA and function proteins, different patterns of expression of PDE isoenzymes were registered in human male and female urethra. Future studies may clarify whether inhibition of PDE isoenzymes is likely to facilitate the relaxation of the outflow region in both sexes.

Assessment of the medical radiation and non-radiation risks for the patients undergoing the surgical gender reassignment from female to male

The aim of the current study was to perform a comparative assessment of the radiation and non-radiation health risks for the sample of transgenders as well as the assessment of their perception of these risks. The study was performed on the sample of patients, undergoing the gender reassignment surgery from female to male. The structure of surgical procedures and the corresponding X-ray examinations was analyzed with the subsequent assessment of the radiation and non-radiation health risks. The level of patient knowledge on the risks and benefits of the medical procedures and perception of the ratio of radiation and non-radiation risks were evaluated based on the results of the sociological study. The study included the patients that underwent gender reassignment surgery in August 2012 – February 2018 on the base of I.M. Sechenov First Moscow State Medical University. Data collection and questioning were performed in August 2019 – March 2020. Data on the structure of the surgical procedures and X-ray examinations was collected for 99 patients; 86 patients agreed to participate in the questioning. The results indicate that the selected sample of patients, undergoing the gender reassignment surgery from female to male, is a high risk group both for radiation and non-radiation factors. For the whole multi-stage gender reassignment surgery, a patient could receive a total effective dose up to 250 mSv due to repeated computed tomography scans of chest, abdomen and head with contrast, corresponding to the lifetime attributive radiation risk of up to 1×10-2. Comparison of radiation and non-radiation risks for that patient sample indicates the dominance of the risk of successful suicide attempts (5×10-2). Radiation risks are equal to or even exceed (for the final stages of the gender reassignment surgery) the other risks of mortality from the non-radiation factors (anesthesia – 5,4×10-5, thrombosis – 2×10-5, post-surgical complications – 6×10-2). The reduction of suicide risks, as a result of the treatment, outweighs all other risk factors and justifies the gender reassignment surgery. The results of a sociological study show a decrease from 77% to 23% of suicidal thoughts among the patients. The study indicates that risk-communication was performed on the unsatisfactory level: less than 40% of the patients were informed about the possible health risks during the treatment; less than 50% of respondents knew about the benefits of X-ray examinations. About 70% of the patients rate their current problems with health higher compared to the risks from diagnostics and surgery. It explains the lack of interest to the radiation risk.

Vascular and inflammatory effects of estrogen and anti-androgen therapy in the testis and epididymis of male to female transgender adults

The volume of ubiquitous chemicals with estrogenic properties is on the rise and some reports relate the increase in hormonal diseases to these compounds. A morphological and immunohistochemical analysis has been performed on 42 bilateral orchiectomy specimens from adult individuals who underwent gender reassignment surgery after receiving crossed-sex hormone therapy to give insight into vascular, inflammatory and epididymal changes following long-term treatment with estrogens and antiandrogens and raise awareness of the consequences of hormone therapy. The present study confirms previously reported findings in testicular parenchyma and epididymis, such as identification of three histological patterns according to lesion severity and cell dedifferentiation, and reports for the first time vascular and inflammatory lesions (atherosclerosis and vasculitis), both on testicle and epididymis. Cross-sex hormone therapy should be provided in specialized units in order to systematize treatments and ensure adequate follow-up.

The radial forearm flap with a prelaminated urethra: analysis of complications based on the Clavien-Dindo classification

All patients undergoing gender reassignment surgery in our department between 1 January 2011 and 30 June 2017 using a radial forearm phalloplasty with a prelaminated urethra for gcS were included in this study. The total number of patients was 39. The complications after colpectomy, urethral prelamination, phalloplasty, implantation of testicular implants and glans-plasty were assessed. The follow-up after phalloplasty ranged between 6 and 80 months and was 32 months on average. Complications were classified according to Clavien Dindo. Phalloplasty was uneventful in 5 out of 39 patients (12.8 %). In 22 patients (56.4 %) a grade I complication occurred. Four patients (10.3 %) sustained a grade II complication, 16 (41 %) had a grade IIIb complication and one patient had a grade IV complication (2.6 %). Twenty-eight out of 39 patients (71.8 %) developed urethral fistulas in the direct postoperative course. However, only 8 of these patients (20.5 % of the total population) required surgical revision due to fistulas. Five patients developed a urethral stenosis (12.8 %) requiring surgical revision; in two of them this happened several times (8 stenoses in total). Flap losses occurred in two patients (5.1 %). Radial forearm phalloplasty with a prelaminated urethra has become a well-established procedure in female-to-male gender reassignment surgery. In our study, the rate of urological complications was significantly reduced to a level lower than those reported in previous studies. The number of fistulas was significantly reduced during our learning curve and by surgical modifications such as a visor flap at the site of the urethral anastomosis. This large series provides a database of complications classified according to Clavien Dindo for comparison with future techniques and innovations.

Perineal soft tissue infections

Fournier's gangrene (FG) is an aggressive necrotizing soft tissue infection of the perineum. FG takes hold as a mixture of pathogenic organisms enter the host via injured gastrointestinal or genitourinary mucosa. After soft tissue insult, a synergistic, polymicrobial infection destroys tissue through an obliterative endarteritis. FG particularly affects older, obese men with type 2 diabetes mellitus, but can affect everyone. Special populations at risk include patients who have undergone gender reassignment surgery. Early, aggressive debridement and fluid resuscitation are mandatory. Careful decisions must be made regarding the fecal stream, antibiosis, topical coverings and the use of adjunctive therapy. While untreated FG is certainly fatal, with effective diagnosis and treatment survival rates approach 95%.

PO-01-082 Gender Reassignment Surgery: Preliminary outcomes of the Trakya University Health Center for Medical Research and Practice

To report the first outcomes on transsexual patients in Turkey, undergoing gender reassignment surgery (GRS), by the collaboration of plastic and urologic surgeons, of a single center. The data of patients diagnosed with gender identitiy disorders, between January 2015 (start of surgery) and November 2018, who underwent female to male (FtM) and/or male to female (MtF) GRS were retrospectively analyzed. Patients were excluded if they were pseudohermaphrodites, reluctant for GRS and if their gender was not reported. A total of 58 patients referred for GRS were included. One patient was diagnosed with pseudohermaphroditism, two patients gender was not reported and eight patients were unwilled for GRS. Apart from those, 27 cases (57%) were MtF and 20 cases (43%) were FtM. For MtF cases, 27 underwent vaginoplasty, 26 of whom received breast augmentation. Top surgery (mastectomy) and phalloplasty was performed in all FtM patients, in which 10 patients received an urethral lengthening to the tip of the phallus. However, penile prothesis implantation, in none of these patients has been performed, currently. Minor complications occured in seven MtF patients like labial and/or pubic insicional scars (6 patients) and meatal stenosis (one patient), which were succesfully treated afterwhiles. Despite that, in FtM patients with urethral lengthening, complications like urethral fistula (two patients) and urethral/meatal stenosis (five patients) with more severe outcomes consisted.

Employment Law SOS

This month, our employment lawyer looks at cases surrounding an employee potentially leaving a company with sensitive information, working during the hot summer and discrimination of an employee undergoing gender reassignment surgery

A Challenging Case of Fibromuscular Dysplasia in a Transgender Patient: Is There a Hormonal Link?

IntroductionFibromuscular dysplasia (FMD) and superior mesenteric artery (SMA) aneurysms are rare vascular conditions. An unusual combination of both diseases is reported.Case reportA 54 year old woman presented with symptomatic SMA aneurysm. A diagnosis of FMD was made on the basis of computed tomography angiography (CTA). The patient had undergone gender reassignment surgery 10 years previously and continued to use both topical and oral hormonal therapy. The patient received open anatomical bypass through a retroperitoneal approach using great saphenous vein.ConclusionSuperior mesenteric artery aneurysms are rare and a diagnosis of FMD should be considered as part of the diagnosis process. Anatomical bypass should be considered carefully in relation to a patient's fitness as well as anatomical suitability.

FRI-17 “WALK LIKE A MAN”: SEX TESTING AND FEMALE GENDER IDENTITY IN INTERNATIONAL ATHLETIC COMPETITION

You have accessJournal of UrologyHistory of Urology: History Forum1 Apr 2017FRI-17 “WALK LIKE A MAN”: SEX TESTING AND FEMALE GENDER IDENTITY IN INTERNATIONAL ATHLETIC COMPETITION Unwanaobong Nseyo Unwanaobong NseyoUnwanaobong Nseyo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.2482AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES During the 2016 Rio Summer Olympic Games, Caster Semenya participated in the 800m finals and won gold. Her win, while a personal accomplishment, also had historical implications. Seven years prior, questions began to be raised about her gender ultimately leading to her temporary ban from athletic competition while she underwent “sex verification testing.” The sex-testing to which she was subjected had a historical precedent. This paper seeks to explore the historical narrative surrounding intersex disorders as the presented in the form of female athletic competition. METHODS A literature review was conducted in PubMed which identified primary and secondary sources regarding “sex testing” and “femininity certificates.” These sources were reviewed in order to evaluate the sociocultural context of sex testing among female athletes in international competition. RESULTS Sex testing began in earnest in the 1950s with the mandatory sex testing of female athletes during the European Championships, although rumblings of questioning the ender of female athletes pre-dated the creation of this mandatory law. In the 1930s, as women became increasingly involved in athletic competition, women's bodies were scrutinized if they appeared too “male-like” or exhibited athletic exceptionalism. Early sprinters such as Dora Ratjen of Germany and Stella Walsh of Poland were driven away from the sport due to claims that they were in fact men. Once testing became official, it consisted of invasive physical examinations, heavily focused on the genitalia as women were asked to “parade nude before a panel of doctors.” Often as a direct response to these athletic community's inquiries into their sexual identity, these female athletes, who were branded as male and termed “hermaphrodite” subsequently underwent surgical reassignment. While testing transitioned to include genetic and hormone testing, the results remained relatively inconclusive and significantly altered the lives of the women on whom they were conducted. CONCLUSIONS Historically, dominant performances by women on the international athletic stage called into question their gender identity. Invasive sex testing was performed and many of the individuals who were investigated would be identified as intersex today. Contemporary discussions of transgender identity add a new layer of complexity to examinations of the intersection of gender and athletic competition as transgender athletes made history in the 2016 Rio Olympic Games by competing without having undergone gender reassignment surgery. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e1066 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Unwanaobong Nseyo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Quality of life improves early after gender reassignment surgery in transgender women

BackgroundFew studies have examined the long-term quality of life (QoL) of individuals with gender dysphoria, or how it is affected by treatment. Our aim was to examine the QoL of transgender women undergoing gender reassignment surgery (GRS).MethodsWe performed a prospective cohort study on 190 patients undergoing male-to-female GRS at Karolinska University Hospital between 2003 and 2015. We used the Swedish version of the Short Form-36 Health Survey (SF-36), which measures QoL across eight domains. The questionnaire was distributed to patients pre-operatively, as well as 1, 3, and 5 years post-operatively. The results were compared between the different measure points, as well as between the study group and the general population.ResultsOn most dimensions of the SF-36 questionnaire, transgender women reported a lower QoL than the general population. The scores of SF-36 showed a non-significant trend to be lower 5 years post-GRS compared to pre-operatively, a decline consistent with that of the general population. Self-perceived health compared to 1 year previously rose in the first post-operative year, after which it declined.ConclusionsTo our knowledge, this is the largest prospective study to follow a group of transgender patients with regards to QoL over continuous temporal measure points. Our results show that transgender women generally have a lower QoL compared to the general population. GRS leads to an improvement in general well-being as a trend but over the long-term, QoL decreases slightly in line with that of the comparison group.Level of evidence: Level III, therapeutic study.

Exploring the validity of the Transsexual Voice Questionnaire (male-to-female): Do TVQMtF scores differentiate between MtF women who have had gender reassignment surgery and those who have not?

ABSTRACTThe recently developed Transsexual Voice Questionnaire (TVQMtF) is a self-report tool that assesses the perceptions of male-to-female transsexual women (MtF women) regarding their voices and the impact of voice on their everyday lives. Initial psychometric evaluation has demonstrated strong reliability of the TVQMtF, however, there has been relatively little investigation of its validity. There is evidence in the literature to support the notion that MtF women who have undergone gender reassignment surgery (GRS) have different perceptions of their voice than MtF women who have not undergone GRS. This information was used to examine the validity of the TVQMtF using a known-groups analysis. Method: The TVQMtF scores of 26 MtF women who had undergone GRS were compared with the scores of 27 MtF women who had not undergone GRS. A one-way analysis of variance (ANOVA) was used to compare the total TVQMtF scores. Mann Whitney U tests were used for comparison across individual items. Results: Individuals who had undergone GRS perceived that they experienced fewer voice-related difficulties and impacts on their lives than individuals who had not undergone GRS. This difference was significant (F(1, 51) = 8.87, p = .004). MtF women who had undergone GRS reported less impact of voice on their gender identity, however, perceived impact of vocal-functioning and voice-related activity and participation limitations did not differ between groups. The study findings support the construct validity of the TVQMtF.

048 Fertility Preservation in the Male to Female Transgender Patient: Role of Testis Sperm Extraction (TESE) and Testis Histology in Patients undergoing Gender Reassignment Surgery

048 Fertility Preservation in the Male to Female Transgender Patient: Role of Testis Sperm Extraction (TESE) and Testis Histology in Patients undergoing Gender Reassignment Surgery

Removal of an entrapped large metallic dilator from the sigmoid neovagina in a male-to-female transsexual using a laparoscopic approach

IntroductionTo describe the role of laparoscopy for removal of entrapped vaginal metallic dilator (20cm in length and 3.5cm in diameter) in a case of male-to-female transsexual. Presentation of the caseThe patient was a 24-year old male-to-female transsexual, presented with entrapment and upward migration of the vaginal metallic dilator 1 week before admission. She underwent gender reassignment surgery with sigmoid vaginoplasty 8 month before admission. After 3-port transperitoneal laparoscopic abdominopelvic exploration, through an incision over the sigmoid vagina the dilator was extracted. The sigmoid vagina was repaired with free-hand intracorporeal laparoscopic suturing and knot-tying techniques in two layers and the dilator was removed by extending the site of umbilical port. The operative time was 70min. DiscussionUp to 60% of rectosigmoidal or vaginal foreign bodies can be extracted transanally or transvaginally with adequate sedation. When surgical exploration is indicated, a longitudinal laparatomy is performed to extract the foreign body. To reduce the associated morbidity of an open procedure in our patient, we performed a laparoscopic approach for complete abdominal exploration for possible presence of intestinal or sigmoidal injuries together with removal of this large metalic dilator. ConclusionLaparoscopic approaches in cases of neovaginal foreign body are useful when the endovaginal approaches have failed, especially in transsexual patients, to prevent another major open surgery.

Effect of Angiotensin II and its Receptor Antagonists on Human Corpus Cavernous Contractility and Oxidative Stress: Modulation of Nitric Oxide Mediated Relaxation

To our knowledge the interaction between angiotensin II and nitric oxide in the control of human corpus cavernous function has not been assessed previously. We determined the presence and role of angiotensin II and its receptors in human penile function. Corpus cavernous tissue was obtained from 35 patients undergoing gender reassignment surgery. Immunohistochemical analysis was done to determine angiotensin II peptide tissue distribution. Organ bath studies were done to determine the angiotensin II/nitric oxide interaction on corpus cavernous smooth muscle function. The role of oxidative stress in the angiotensin II response was also examined using the nicotinamide adenine dinucleotide phosphate oxidase inhibitor apocynin. Angiotensin II was distributed in arteriolar endothelium, endothelium lining sinusoids and smooth muscle cells, and caused dose dependent contraction of human corpus cavernous smooth muscle strips that was inhibited by the angiotensin type 1 receptor antagonist losartan. Relaxation of corpus cavernous smooth muscle induced by the nitric oxide donor sodium nitroprusside or electrical field stimulation was potentiated by losartan. Apocynin decreased angiotensin II induced corpus cavernous contraction. Angiotensin II and nitric oxide interact to modulate human cavernous function since losartan potentiated sodium nitroprusside and electrical field stimulation mediated corpus cavernous smooth muscle relaxation. The angiotensin II response involves the production of superoxide and the development of oxidative stress. These findings support the role of angiotensin II in the regulation of human penile smooth muscle tone and suggest that angiotensin type 1 receptor inhibition may be a therapeutic approach to erectile dysfunction.

Modifications of the Radial Forearm Flap Phalloplasty for Female-to-Male Gender Reassignment

The radial forearm flap remains the preferred technique for phalloplasty. From 1999 to 2009, 19 patients with primary female transsexualism underwent gender reassignment surgery at our center. The radial forearm flap phalloplasty is modified as a two-stage procedure, with prelamination of the neourethra on the donor forearm before microsurgical transfer 3 months later. At 5-year follow-up, patients were asked to complete a survey on the functional, aesthetic, and psychological results postsurgery. The radial forearm flap reliably provided sufficient bulk with stiffness for the neophallus with acceptable aesthetic appearance. We further describe technical modifications to reduce the rate of urethral strictures and fistulas. None of the patients regretted undergoing gender transformation. Patients are satisfied with the surgical result and generally prepared to accept its potential costs, in view of the significant psychological and legal benefits.