M. Bizic

ORIGINAL RESEARCH–INTERSEX AND GENDER IDENTITY DISORDERS: Metoidioplasty as a Single Stage Sex Reassignment Surgery in Female Transsexuals: Belgrade Experience

INTRODUCTIONnMetoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses.nnnAIMnOur aim is to describe our technique and highlight its advantages.nnnMETHODSnBetween September 2002 and April 2007, 82 female transsexuals, aged 18-54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed.nnnMAIN OUTCOME MEASURESnPatients personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data.nnnRESULTSnThe median follow-up was 32 months (range 14-69). The mean neophallic length was 5.7 cm (range 4-10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients.nnnCONCLUSIONSnMetoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

Objective Long-Term Evaluation after Bladder Autoaugmentation with Rectus Muscle Backing

PURPOSEnBladder autoaugmentation with rectus muscle backing is an efficient surgical technique for bladder augmentation. We evaluated long-term outcomes to determine the value of this procedure.nnnMATERIALS AND METHODSnBetween August 1999 and June 2004 autoaugmentation was performed in 16 girls and 7 boys 4 to 13 years old (median age 8). The indication was neurogenic bladder with small capacity and poor compliance due to myelomeningocele in 18 patients, tethered cord in 3 and sacral agenesis in 2. Detrusorectomy usually involved the whole upper half of the bladder. The prolapsed bladder urothelium was hitched to the 2 rectus muscles to prevent retraction and provide easier bladder emptying with voluntary muscle contractions.nnnRESULTSnAt the median early followup of 27 months (range 9 to 49) bladder volume had increased significantly in all 23 patients (median 338 ml, range 190 to 462). At the current median long-term followup of 134 months (range 94 to 159) bladder volume continued to be significant compared to median bladder capacity preoperatively (median 419 ml, range 296 to 552). Voluntary voiding was achieved in 14 patients without post-void residual urine. Nine patients used clean intermittent catheterization, of whom only 4 could not empty the bladder voluntarily and relied only on clean intermittent catheterization.nnnCONCLUSIONSnDetrusorectomy with a rectus muscle hitch and backing is a minimally invasive, completely extraperitoneal, simple and safe procedure. However, the technique is indicated only in select cases without anterior abdominal wall anomalies.

One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals

BACKGROUNDnFemale-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations.nnnAIMnTo present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery.nnnMETHODSnDuring a period of 9 years (2007-2016), 473 patients (mean agexa0= 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons.nnnOUTCOMESnPrimary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS.nnnRESULTSnMean follow-up was 44 months (rangexa0= 10-92). Mean surgery time was 270 minutes (rangexa0= 215-325). Postoperative hospital stay was 3 to 6 days (meanxa0= 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient.nnnCLINICAL IMPLICATIONSnFemale-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates.nnnSTRENGTHS AND LIMITATIONSnTo our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure.nnnCONCLUSIONSnThrough a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries. Stojanovic B, Bizic M, Bencic M, etxa0al. One-Stage Gender-Confirmation Surgery as a Viable Surgical Procedure for Female-to-Male Transsexuals. J Sex Med 2017;14:741-746.

Gender Dysphoria: Bioethical Aspects of Medical Treatment

Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.

Hysterectomy with Bilateral Salpingo-Oophorectomy in Female-to-Male Gender Affirmation Surgery: Comparison of Two Methods

Introduction The optimal route for hysterectomy with bilateral salpingo-oophorectomy in female-to-male gender affirmation surgery is still under debate, due to the quite limited and inconsistent published data. The aim of this study is to present and compare the results of vaginal and laparoscopic hysterectomy as part of gender affirmation surgery in female-to-male transsexuals. Materials and Methods Between 2012 and 2017, 124 female-to-male transsexuals, aged 18–43 years (mean age: 28.5), underwent hysterectomy with bilateral salpingo-oophorectomy, followed by colpocleisis and gender affirmation surgery. Transvaginal and laparoscopic hysterectomy were performed in 92 and 32 patients, respectively. Standard outcome measures (types and rates of complications, operative time, blood loss, and postoperative hospital stay) were used to compare the two groups of patients. Results The mean follow-up was 41 months (ranged from 6 to 65 months). The duration of transvaginal approach was significantly shorter (51 minutes compared to 76 minutes, p < 0.001). The total complication rates (less than 3%), reoperation rates (0%), blood loss, and postoperative hospital stays (4.3 days compared to 4.5 days) showed no statistical difference. Conclusions Both approaches are safe, with minimal complications. However, we prefer transvaginal hysterectomy due to its shorter operative time, cost-effectiveness, and simpler continuation with one-stage female-to-male gender affirmation surgery.

Genital reconstruction for the transgendered individual

INTRODUCTIONnGender dysphoria is defined as ones belief that his/her body does not reflect his/her true inner identification of physical sex and requires medical and/or surgical treatment that will alter his/her body to better reflect what he/she believes is his/her true gender.nnnOBJECTIVEnThe aim was to describe current surgical techniques available in genital reconstruction for female-to-male (FTM) and male-to-female (MTF) transgender patients.nnnSTUDY DESIGNnWe reviewed recently published papers concerning the most common procedures in genital reconstruction in FTM transgenders and in MTF transgenders.nnnRESULTSnThere is a wealth of available surgical procedures for FTM transgenders that will adjust their body and genitals toward the male gender. Chest masculinization combined with either metoidioplasty or phalloplasty are the most common procedures resulting in high patient satisfaction. Standardization of the procedures for vaginoplasty in MTF transgenders led to the penile inversion skin technique becoming a gold standard for vaginal lining in MTF patients, providing satisfying functional and esthetical outcome of the surgery. In extreme cases of shortage of skin, or when a vaginoplasty has failed, a vaginal lining can be created from hairless skin grafts, or a section of intestine may be used (bowel vaginoplasty).nnnCONCLUSIONnA multidisciplinary approach including psychiatrists, psychologists, plastic surgeons, urologists, and gynecologists is the only effective treatment in transgenders. The surgeons familiarity with the surgical procedure and the patients desired body images should meet at the same level to guarantee a successful outcome.

259 RECTOSIGMOID VAGINOPLASTYAND ITS IMPACT ON PSYCHOSOCIAL AND SEXUAL LIFE IN PATIENTS WITH VAGINAL AGENESIS

INTRODUCTION AND OBJECTIVES: The main goal in treatment of patients with Mayer-Rokitansky-K€ uster-Hauser syndrome (vaginal agenesis) is creation of a neovagina that will satisfy patient’s desire. We evaluated sexual and psychosocial outcome after sigmoid vaginoplasty due to vaginal agenesis. METHODS: A total of 60 women were evaluated, aged 19 to 38 years (mean 25), who underwent bowel vaginal replacement from 1997 to 2015. Sexual and psychosocial assessment included the Female Sexual Function Index (FSFI), Beck’s Depression Inventory (BDI) and standardized questionnaires about postoperative satisfaction, social and sexual adjustment. RESULTS: The mean follow-up was 8.5 years (range 9 months to 18 years). Mean FSF Index was 28.3 (range 10.5 35.7) with cut-off score 26.55 for sexual dysfunction. Out of the 60 women, 13 (21.5%) had sexual dysfunction. Mean Beck Depression Inventory (BDI) was 7.5 (cut-off score 0-9 for non-depression). A 45 women (75%) were without symptoms of depression, 12 (BDI ranged from 10-18) had moderate and 3 had severe depression (BDI 42). There was significant level (p<0.01) within high satisfaction score in FSFI and low BDI results, that indicates important predictive variable between one FSFI domain and psychological status. Fifty-one of sixty patients (85%) believed that the surgery was done at the right time, while 93% (56/60) of the patients reported satisfactory femininity with heterosexual orientation. Fifty-three patients (88%) were satisfied with the surgery, while 91% considered that this surgery is the best treatment option. CONCLUSIONS: Sexual function and psychosocial status of patients with vaginal agenesis who underwent sigmoid vaginoplasty is not affected in general and attained complete recovery. Predictive factor for sexual dysfunction is associated with lower orgasm score, while higher desire directly influences positive sexual function on the FSFI. Absence of depression and presence of sexual function precisely correlate with higher satisfaction. Multidisciplinary approach is necessary for successful postoperative outcomes and better quality of life.