Dusan Stanojevic

Vaginoplasty in male transsexuals using penile skin and a urethral flap

Objectives To describe and present the results of a one‐stage vaginoplasty in male‐to‐female sex reassignment surgery.

Rectosigmoid Vaginoplasty: Clinical Experience and Outcomes in 86 Cases

INTRODUCTION There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue. AIM To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence. METHODS Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures.  Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires. RESULTS Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%). CONCLUSIONS Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.

Combined buccal mucosa graft and dorsal penile skin flap for repair of severe hypospadias.

OBJECTIVES Urethral reconstruction in severe hypospadias presents a great challenge. We have designed a method of combining a longitudinal dorsal island skin flap and buccal mucosa graft to create a neourethra in most severe hypospadias. METHODS Between January 2003 and March 2007, 17 patients (aged from 9 to 23 months) underwent severe hypospadias repair (13 penoscrotal and 4 scrotal hypospadias). Short urethral plate was divided in all cases and remaining curvature repaired by dorsal plication. We harvested and fixed a buccal mucosa graft to the ventral side of corpora cavernosa to be the first half of a neourethra. A longitudinal dorsal island skin flap was created and buttonholed ventrally. We sutured it together with the buccal mucosa graft to form the neourethra. We fixed the abundant flap pedicle laterally to cover all suture lines of the neourethra. We performed penile skin reconstruction using available penile skin. RESULTS The mean (range) follow-up was 25 (7 to 58) months. We achieved satisfactory, functional, and aesthetic results in 14 patients. In 3 cases urethral fistula (2) and distal stricture (1) required secondary treatment. CONCLUSIONS Combined longitudinal island skin flap and buccal mucosa graft could be a good choice for urethral reconstruction in most severe hypospadias repairs.

Urethral Lengthening in Metoidioplasty (Female-to-male Sex Reassignment Surgery) by Combined Buccal Mucosa Graft and Labia Minora Flap

OBJECTIVES To develop a technique for urethral reconstruction using a combined labia minora flap and buccal mucosa graft. Urethral lengthening is the most difficult part in female transsexuals and poses many challenges. METHODS From April 2005 to February 2008, 38 patients (aged 19-53 years) underwent single-stage metoidioplasty. The technique starts with clitoral lengthening and straightening by division of both clitoral ligaments dorsally and the short urethral plate ventrally. The buccal mucosa graft is quilted to the ventral side of the corpora cavernosa between the native orifice and the tip of the glans. The labia minora flap is dissected from its inner surface to form the ventral aspect of the neourethra. All suture lines are covered by the well-vascularized subcutaneous tissue originating from the labia minora. The labia majora are joined in the midline and 2 silicone testicular implants are inserted to create the scrotum. The neophallus is covered with the remaining clitoral and labial skin. RESULTS The median follow-up was 22 months (range 11-42). The median neophallic length was 5.6 cm (range 4-9.2). The total length of the neourethra was 9.4-14.2 cm (median 10.8). Voiding while standing was reported by all 38 patients, and temporary dribbling and spraying were noted by 12. Two fistulas and one urethral erosion resulted from the testicular implant and required secondary revision. CONCLUSIONS A combined buccal mucosa graft and labia minora flap present a good choice for urethral reconstruction in female-to-male transsexuals, with minimal postoperative complications.

Rectosigmoid vaginoplasty in patients with vaginal agenesis: sexual and psychosocial outcomes

BACKGROUND The main goal in women with Mayer-Rokitansky-Küster-Hauser syndrome (vaginal agenesis) is creation of a neovagina that will satisfy the patients desire. We evaluated sexual and psychosocial adjustment in patients who underwent rectosigmoid vaginoplasty because of vaginal agenesis. METHODS A total of 36 women, aged 21 to 38 years (mean=26) who underwent rectosigmoid vaginoplasty from 1997 to 2006 were evaluated. Sexual and psychosocial appraisal included the Female Sexual Function Index (FSFI), Becks Depression Inventory (BDI), and standardised questionnaires about postoperative satisfaction, social and sexual adjustment. RESULTS Mean FSFI score was 28.9 (range=11.5-35.7) with a cut-off score of 26.55 for sexual dysfunction. Out of the 36 women, 10 (27, 8%) had sexual dysfunction. Mean BDI score was 7.55 (cut-off score=0-9 for non-depression). Twenty-eight women (77.8%) were without symptoms of depression, six women (BDI range=10-29) had moderate and two women had severe depression (BDI=42). There were a significant number of patients (P<0.01) with a high satisfaction score in FSFI and low BDI results. Thirty-two (88.9%) of the patients believed that surgery was done at the right time and the main postoperative support came from their family. Thirty-four (94.4%) of the patients reported satisfactory femininity, with a heterosexual orientation. Thirty patients (83. 3%) were very satisfied with the surgery, while 34 considered surgery as the best treatment. CONCLUSIONS The sexual function and psychosocial status of these patients should be followed long-term to estimate their quality of life.

An overview of neovaginal reconstruction options in male to female transsexuals.

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Are local clinical guidelines useful in promoting rational use of antibiotic prophylaxis in caesarean delivery

Objectives To identify changes in prescribing patterns of antibiotic prophylaxis in Caesarean delivery after introduction of local clinical guidelines. To identify changes in outcomes of prescribing antibiotics following the implementation of local clinical guidelines on antibiotic prophylaxis. Setting University of Belgrade, Medical School, Clinic of Gynaecology and Obstetrics “Narodni front” Belgrade, Serbia. Method A quantitative retrospective analysis of antibiotic use before (January–June 2005), and following (January–June 2006) implementation of guidelines on antibiotic prophylaxis in two wards. Patients who underwent Caesarean section prior to (261) and following (281) introduction of local guidelines, participated in this study. Main outcome measures Drug utilization cost presented as the number of DDD/100 bed days/eur, the average duration of hospital stay, number of wound infections. Results There was a significant change in prescribing patterns of antibiotic prophylaxis in Caesarean section following introduction of local guidelines. The use of ceftriaxone, amikacin and metronidazole decreased (57.47% vs. 11.74%; 9.19% vs. 4.27%; 61.69% vs. 46.26%, respectively). On the other hand, the use of “older” antibiotics such as gentamicin, cefuroxime, cefazolin and ampicillin increased (14.56% vs. 29.18%; 9.2% vs. 17.44%; 9.58% vs. 45.2% and 0% vs. 3.9%, respectively). DDD/100 bed days/eur analysis revealed a 47% decrease of total cost for prophylactic antibiotic treatment in Caesarean section following local guideline implementation. In contrast, rate of wound infections and duration of hospital stay were not significantly different in both groups. Conclusion In an attempt to ensure cost-effective prophylactic use of antibiotics in Caesarean delivery, local clinical guidelines were introduced. They resulted in changes in prescribing patterns of antibiotics. There was a significant decrease in use of ‘third’ generation of cephalosporin’s whereas the use of “older” antibiotics with proven efficacy and safety increased. In contrast, there was no significant change in treatment outcomes such as wound infection and average hospital stay.

Vaginoplasty in Male to Female Transsexuals Using Penile Skin and Urethral Flap

ABSTRACT. Objectives: Vaginoplasty presents the main problem in male to female surgery. There are many operative techniques that can be used, but none is ideal. We present our one stage vaginoplasty in male to female sex reassignment surgery. Patients and Methods: The principle of our technique is based on penile disassembly and usage of all penile entities for vaginoplasty except corpora cavernosa. We developed our disassembly technique on a very large number of severe hypospadias reconstruction and adrenogenital “conversions.” Penile skin flaps and urethral work are used in each of these. Our new vagina consists of two parts: a long vascularized urethral flap and a pedicled island tube skin flap created from the penile skin. The urethral flap is embedded into the skin tube. The tube, consisting of skin and urethral flap, is inverted, thus forming the new vagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder, and rectum. The new vagina is fixed to the sacrospinous ligament. The labia minora and majora are formed from the remaining penile and scrotal skin. Results: The follow-up ranged from 3 months to 6 years (mean 4.6 years). Good cosmetic and functional results were obtained in 77 out of 89 patients (87%). Conclusions: The technique provides results that have the most normal anatomical and physiological characteristics, in comparison to other methods, since all penile entities are used (except corpora cavernosa) to form almost normal external female genitalia. Vaginoplasty using pedicled penile skin with a urethral flap could be a very good alternative to other methods of vaginoplasty.

Bilateral Bartholin’s gland hematic cysts after cesarean delivery: an uncommon entity

The Bartholin’s glands (also called Bartholin glands or greater vestibular glands) were first described in the 17th century by the Danish anatomist Caspar Bartholin the Younger (1655–1738). The two glands are located slightly below and to the left and right of the opening of the vagina, in the superficial perineal pouch and secrete mucus to provide vaginal lubrication. The fluid may slightly moisten the labial opening of the vagina, serving to make contact with this sensitive area more comfortable for women [1, 2]. A Bartholin’s cyst is formed when a Bartholin’s gland is blocked, causing a fluid-filled cyst to develop. A Bartholin’s cyst is not an infection, although it can be caused by an infection, inflammation, or physical blockage (mucus or other impediment) to the Bartholin’s ducts (tubes which lead from the glands to the vulva). If infection sets in, a Bartholin’s abscess develops. Bartholin’s cysts are most likely to occur in women in reproductive age. They are extremely rare immediately after spontaneous or cesarean delivery. We report here the first case of bilateral Bartholin’s gland hematic cysts after cesarean delivery. Case history

Repair of vesicovaginal fistula caused by radiation therapy with labia maiora skin flap

INTRODUCTION Vesicovaginal fistula can occur after delivery, gynaecologic or urologic surgery, irradiation therapy or as destruction caused by a tumour or trauma. The main problem after irradiation is decreased elasticity of the tissue around the fistula. We present our experience in the treatment of three patients with vesicovaginal fistula using a labia maiora skin flap. CASE OUTLINE From May 2007 to January 2008 three patients with vesicovaginal fistula were treated using labia maiora skin flap. The fistulae occurred after mean 19 months (11, 20 and 26 months) following irradiation therapy applied to treat malignant disease. The mean age of the patients was 54 years (47, 53 and 62 years). The mean diameter of the fistulae was 3.5 cm (2, 4 and 4.5 cm). Using transvaginal approch, all devitalized and fibrous tissue was removed with the closure of the bladder wall. The labia maiora skin flap with good vascularization was transposed to close the defect and anastomozed to the vagina. The mean follow-up was 16 months (13, 17 and 18 months). Labia maiora skin flap size was mean 3.7 cm (2.6, 3.7 and 4.8 cm). We achieved satisfactory outcome in all patients. There were neither postoperative complications nor fistula recurrence. CONCLUSION Labia maiora skin flap presents a good alternative for surgical treatment of vesicovaginal fistula. The flap is more adequate for larger defects and for the repair of fibrously changed vaginal wall which is present after irradiation therapy.