A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes

BackgroundVaginoplasty is a crucial part of genital gender-affirming surgery with the number of trans women undergoing this intervention steadily, however, up to date, there is still no standardized vaginoplasty technique.AimThis retrospective single-center study compares single-stage vs two-stage penile skin inversion vaginoplasty techniques and their long-term outcomes.MethodsMedical records of 63 consecutive patients who underwent single-stage vaginoplasty, as described by Dr Preecha Tiewtranon, and 62 consecutive patients who underwent 2-stage vaginoplasty were reviewed.ResultsThe mean postoperative hospital stay was 7 days for patients who underwent single-stage vaginoplasty vs 16 days for patients who underwent 2-stage vaginoplasty. Neovaginal depth proved constant in patients who underwent single-stage vaginoplasty, whereas a loss of more than 30% was observed in patients who underwent 2-stage vaginoplasty during the first postoperative year. Early complications were more common than late-onset complications in both groups. The most common complication in the single-stage group was wound dehiscence (4.8%). There were significantly more complications in 2-stage collective, among which wound dehiscence (33.9%), unsatisfactory cosmetic outcome (25.8%), and urethral stenosis (14.5%) were the most common. In the single-stage cohort, 4 (6.4%) patients needed one revision surgery, whereas 35 (56.5%) patients in the 2-stage cohort necessitated one or more reoperations with up to 10 quaternary revisions. All patients reported to have sensitivity to neoclitoris in the single-stage group, whereas 3 (4.8%) patients in the 2-stage group were deprived of it because of neoclitoral necrosis.Clinical ImplicationsOptimizing a vaginoplasty surgical technique and its postoperative protocol.Strengths & LimitationsThe present retrospective study with a mean follow-up of more than 3.5 years offers the first ever comparison of 2 different PSI vaginoplasty surgical techniques performed in the same center.ConclusionSignificantly lower complication and revision rates, shorter recovery time, and superior esthetic and functional outcomes were observed in the single-stage than in the two-stage penile skin inversion vaginoplasty surgical technique.Fakin RM, Giovanoli P. A Single-Center Study Comparison of Two Different Male-to-Female Penile Skin Inversion Vaginoplasty Techniques and Their 3.5-Year Outcomes. J Sex Med 2021;18:391–399.     

Vaginoplasty in Male-to-Female Transsexual Surgery: A Training Concept Incorporating Dissection Room Experience to Optimize Functional and Cosmetic Results

IntroductionLearning a new technique, even for an established surgeon, requires a learning curve; however, in transsexual surgery especially, there is a lack of professional and public tolerance for suboptimal aesthetic and functional results due to a learning curve.AimsIn this context, we have tried to build a learning concept for vaginoplasty that includes four steps: (i) formal identification of the surgical steps in order to provide both measure of surgical process and measures of outcomes; (ii) training on cadavers with expert assistance; (iii) performing the live surgery with assistance from expert; and (iv) performing the surgery alone. Herein, we emphasize the second step of our learning concept.Material and MethodsBetween September 2013 and December 2013, 15 cadavers were operated on by an established surgeon learning vaginoplasty under assistance from two expert practitioners. Mean global time and mean time necessary to perform each step of the operation were recorded by the experts. Intraoperative complications were systematically registered. The final depth and diameter of the neaovaginal cavity were precisely measured. For each cadaver, the aesthetic results were assessed by one of the experts.ResultsMean total operating time was 179 ± 34 minutes and decreased from 262 minutes for the first training attempt to 141 minutes for the last one. Intraoperative expert correction included modification of the scrotal triangular flap design and change of position of the urethra: This happened during the first training. No lesion of the urethra or of the anus occurred. The two experts judged the outcomes as excellent in seven cases, very good in four cases, good in two cases, and fair in two cases.ConclusionDespite the numerous reports on vaginoplasty in the literature, there is a real lack of published information on the learning curve of this operation. We make the hypothesis that introducing a learning concept with assistance from expert practitioners at the beginning of the surgeon's experience can optimize both the duration of his learning curve and reduce the risk of major complications. Leclère FM, Casoli V, and Weigert R. Vaginoplasty in male-to-female transsexual surgery: A training concept incorporating dissection room experience to optimize functional and cosmetic results.     

Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty

BackgroundMany patients have goals related to sexual health when seeking gender-affirming vaginoplasty, and previous investigations have only studied the ability to orgasm at cross-sectional timepoints.AimOur aim is to quantify the time to orgasm postoperative gender-affirming vaginoplasty and describe potential correlative factors, including preoperative orgasm, to improve preoperative counseling.MethodsA retrospective chart review was utilized to extract factors thought to influence pre and postoperative orgasm in patients undergoing robotic peritoneal flap vaginoplasty. Mean days to orgasm plus one standard deviation above that mean was used to define the time at which patients would be considered anorgasmic.OutcomesOrgasm was documented as a categorical variable on the basis of surgeon interviews during pre and postoperative appointments while time to orgasm was measured as days from surgery to first date documented as orgasmic in the medical record.ResultsA total of 199 patients underwent surgery from September 2017 to August 2020. The median time to orgasm was 180 days. 178 patients had completed 1 year or greater of follow-up, and of these patients, 153 (86%) were orgasmic and 25 patients (14%) were not. Difficulty in preoperative orgasm was correlated only with older age (median age 45.9 years vs 31.7, P = .03). Postoperative orgasm was not significantly correlated with preoperative orgasm. The only factor related to postoperative orgasm was smoking history: 12 of 55 patients (21.8%) who had a positive smoking history and sufficient follow-up reported anorgasmia (P-value .046). Interventions for anorgasmic patients include testosterone replacement, pelvic floor physical therapy, and psychotherapy.Clinical ImplicationsPreoperative difficulty with orgasm improves with gender-affirming robotic peritoneal flap vaginoplasty, while smoking had a negative impact on postoperative orgasm recovery despite negative cotinine test prior to surgery.Strengths & LimitationsThis investigation is the first effort to determine a timeline for the return of orgasmic function after gender-affirming vaginoplasty. It is limited by retrospective review methodology and lack of long-term follow-up. The association of smoking with postoperative orgasm despite universal nicotine cessation prior to surgery may indicate prolonged smoking cessation improves orgasmic outcomes or that underlying, unmeasured exposures correlated with smoking may be the factor inhibiting recovery of orgasm.ConclusionThe majority of patients were orgasmic at their 6-month follow-up appointments, however, patients continued to become newly orgasmic in appreciable numbers more than 1 year after surgery.Blasdel G, Kloer C, Parker A, et al. Coming Soon: Ability to Orgasm After Gender Affirming Vaginoplasty. J Sex Med 2022;19:781–788.     

Exploring Factors Associated with Decisions about Feminizing Genitoplasty in Differences of Sex Development

Study ObjectiveInfants with genital development considered atypical for assigned female sex may undergo feminizing genitoplasty (clitoroplasty and/or vaginoplasty) in early life. We sought to identify factors associated with parent/caregiver decisions regarding genitoplasty for their children with genital virilization.DesignLongitudinal, observational studySettingTwelve pediatric centers in the United States with multidisciplinary differences/disorders of sex development clinics, 2015-2020ParticipantsChildren under 2 years old with genital appearance atypical for female sex of rearing and their parents/caregiversInterventions/Outcome MeasuresData on the child's diagnosis and anatomic characteristics before surgery were extracted from the medical record. Parents/caregivers completed questionnaires on psychosocial distress, experience of uncertainty, cosmetic appearance of their child's genitalia, and demographic characteristics. Urologists rated cosmetic appearance. For 58 patients from the study cohort with genital virilization being raised as girls or gender-neutral, we compared these data across 3 groups based on the child's subsequent surgical intervention: (i) no surgery (n = 5), (ii) vaginoplasty without clitoroplasty (V-only) (n = 15), and (iii) vaginoplasty and clitoroplasty (V+C) (n = 38).ResultsFathers’ and urologists’ ratings of genital appearance were more favorable in the no-surgery group than in the V-only and V+C groups. Clitorophallic length was greater in the V+C group compared with the V-only group, with substantial overlap between groups. Mothers’ depressive and anxious symptoms were lower in the no-surgery group compared with the V-only and V+C groups.ConclusionsSurgical decisions were associated with fathers’ and urologists’ ratings of genital appearance, the child's anatomic characteristics, and mothers’ depressive and anxious symptoms. Further research on surgical decision-making is needed to inform counseling practices.     

Oocyte Retrieval during Laparoscopic Vaginoplasty to Reduce Invasiveness in the Treatment of Mayer-Rokitansky-Küster-Hauser Syndrome

Study ObjectiveTo evaluate the treatment of patients with Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome with a combination of oocyte retrieval and surgical vaginoplasty in a single laparoscopic procedure.DesignA case series.SettingThe study was conducted at 2 tertiary referral facilities for MRKH syndrome in Milan, Italy, between July 2017 and September 2018.PatientsEleven patients presented with MRKH and required surgical vaginoplasty while expressing a desire for future fertility.InterventionsTwo experienced surgeons and an expert in assisted reproductive technology performed concomitant vaginoplasty according to the modified technique of Davydov and laparoscopic oocyte retrieval for gamete cryopreservation.Measurements and Main ResultsBefore the procedure, patients underwent extensive counseling and gave written consent. At the start of surgery, 10.4 ± 4.4 (mean ± standard deviation [SD]) oocytes were retrieved laparoscopically, and 8.8 ± 3.1 (SD) mean mature oocytes were cryopreserved. After oocyte retrieval, the steps of the modified Davydov technique were followed. The total operative time was 116 ± 16 minutes (mean ± SD), and no intraoperative/postoperative complications were observed.ConclusionThis is the first report of combined oocyte retrieval and vaginoplasty for patients with MRKH syndrome. The approach was found to be feasible in patients with a desire for future fertility. It is our belief that physicians treating patients with MRKH should refer patients to centers with expertise in both vaginoplasty and assisted reproductive technology.     

Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence,Motivation Analysis,and Surgical Outcomes

BackgroundPenile inversion vaginoplasty is the surgical gold standard for genital gender-affirmative surgery in transgender women. However, there is an increase of attention for gender-confirming vulvoplasty (GCV), in which no neovaginal cavity is created.AimTo describe underlying motives and surgical outcomes of GCV in transgender women.MethodsAll transgender women who underwent GCV were retrospectively identified from a departmental database. A retrospective chart study was conducted, recording underlying motives, demographics, perioperative complications, and reoperations.OutcomesUnderlying motives and perioperative complication rate.ResultsIn the period January 1990 to January 2020, 17 transgender women underwent GCV at our center. Most women reported that their motivation to undergo GCV was because they had no wish for postoperative neovaginal penetration (n = 10, 59%). This was due to a sexual preference toward women without the wish for neovaginal penetrative intercourse (n = 6, 35%) or due to a negative sexual experience in the past (n = 4, 24%). Some women desired vaginoplasty with neovaginal cavity creation but were ineligible for this because of their medical history (n = 4, 24%), for example, due to locoregional radiotherapy. The median clinical follow-up was 34 months (range 3-190). The postoperative course was uncomplicated in 11 (65%) women. Postoperative complications comprised the following: meatal stenosis (n = 2, for which surgical correction), remnant corpus spongiosum tissue (n = 1, for which surgical correction), minor wound dehiscence (n = 3, for which conservative management), and postoperative urinary tract infection (n = 1, successfully treated with oral antibiotics). One woman, who developed meatal stenosis, had a history of radiotherapy because of rectal carcinoma and needed 2 surgical procedures under general anesthesia to correct this. Information on self-reported satisfaction was available for 12 women. All were satisfied with the postoperative result and they graded their neovagina an 8.2 ± 0.9 out of 10.Clinical ImplicationsGCV may be added to the surgical repertoire of the gender surgeon. Transgender women with a desire for genital gender-affirmative surgery should be counseled on surgical options and its (dis)advantages.Strengths & LimitationsStrengths of this study comprise that it is from a high-volume center. A weakness of this study is the retrospective design. The absence of a self-reported outcome measure validated for the transgender persons is a well-known problem.ConclusionAn increase is observed in transgender women who opt for GCV; however, the absolute number undergoing this surgery remains small in our center. Postoperative complications do occur but are generally minor and treatable.van der Sluis WB, Steensma TD, Timmermans FW, et al. Gender-Confirming Vulvoplasty in Transgender Women in the Netherlands: Incidence, Motivation Analysis, and Surgical Outcomes. J Sex Med 2020;17:1566–1573.     

Natural language processing with machine learning to predict outcomes after ovarian cancer surgery

ObjectiveTo determine if natural language processing (NLP) with machine learning of unstructured full text documents (a preoperative CT scan) improves the ability to predict postoperative complication and hospital readmission among women with ovarian cancer undergoing surgery when compared with discrete data predictors alone.MethodsMedical records from two institutions were queried to identify women with ovarian cancer and available preoperative CT scan reports who underwent debulking surgery. Machine learning methods using both discrete data predictors (age, comorbidities, preoperative laboratory values) and natural language processing of full text reports (preoperative CT scans) were used to predict postoperative complication and hospital readmission within 30 days of surgery. Discrimination was measured using the area under the receiver operating characteristic curve (AUC).ResultsWe identified 291 women who underwent debulking surgery for ovarian cancer. Mean age was 59, mean preoperative CA125 value was 610 U/ml and albumin was 3.9 g/dl. There were 25 patients (8.6%) who were readmitted and 45 patients (15.5%) who developed postoperative complications within 30 days. Using discrete features alone, we were able to predict postoperative readmission with an AUC of 0.56 (0.54–0.58, 95% CI); this improved to 0.70 (0.68–0.73, 95% CI) (p < 0.001) with the addition of NLP of preoperative CT scans.Conclusions: Natural language processing with machine learning improved the ability to predict postoperative complication and hospital readmission among women with ovarian cancer undergoing surgery.     

Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center,International Survey of 129 Transmasculine Patients

BackgroundCurrent literature on surgical outcomes after gender affirming genital surgery is limited by small sample sizes from single-center studies.AimTo use a community-based participatory research model to survey a large, heterogeneous cohort of transmasculine patients on phalloplasty and metoidioplasty outcomes.MethodsA peer-informed survey of transmasculine peoples’ experience was constructed and administered between January and April 2020. Data collected included demographics, genital surgery history, pre- and postoperative genital sensation and function, and genital self-image.OutcomesOf the 1,212 patients completing the survey, 129 patients underwent genital reconstruction surgery. Seventy-nine patients (61 percent) underwent phalloplasty only, 32 patients (25 percent) underwent metoidioplasty only, and 18 patients (14 percent) underwent metoidioplasty followed by phalloplasty.ResultsPatients reported 281 complications requiring 142 revisions. The most common complications were urethrocutaneous fistula (n = 51, 40 percent), urethral stricture (n = 41, 32 percent), and worsened mental health (n = 25, 19 percent). The average erect neophallus after phalloplasty was 14.1 cm long vs 5.5 cm after metoidioplasty (P < .00001). Metoidioplasty patients report 4.8 out of 5 erogenous sensation, compared to 3.4 out of 5 for phalloplasty patients (P < .00001). Patients who underwent clitoris burial in addition to primary phalloplasty did not report change in erogenous sensation relative to primary phalloplasty patients without clitoris burial (P = .105). The average postoperative patient genital self-image score was 20.29 compared with 13.04 for preoperative patients (P < .00001) and 21.97 for a historical control of cisgender men (P = .0004).Clinical ImplicationsThese results support anecdotal reports that complication rates following gender affirming genital reconstruction are higher than are commonly reported in the surgical literature. Patients undergoing clitoris burial in addition to primary phalloplasty did not report a change in erogenous sensation relative to those patients not undergoing clitoris burial. Postoperative patients report improved genital self-image relative to their preoperative counterparts, although self-image scores remain lower than cisgender males.Strengths & LimitationsThese results are unique in that they are sourced from a large, heterogeneous group of transgender patients spanning 3 continents and dozens of surgical centers. The design of this study, following a community-based participatory research model, emphasizes patient-reported outcomes with focus on results most important to patients. Limitations include the recall and selection bias inherent to online surveys, and the inability to verify clinical data reported through the web-based questionnaire.ConclusionComplication rates, including urethral compromise and worsened mental health, remain high for gender affirming penile reconstruction.Robinson IS, Blasdel G, Cohen O, et al. Surgical Outcomes Following Gender Affirming Penile Reconstruction: Patient-Reported Outcomes From a Multi-Center, International Survey of 129 Transmasculine Patients. J Sex Med 2021;18:800–811.     

Natural Orifice Transluminal Endoscopic Surgery-assisted Versus Single-port Laparoscopic-assisted Vaginal Hysterectomy: A Case-matched Study

ObjectiveNatural orifice transluminal endoscopic surgery (NOTES) is currently a very important procedure for surgeons. This study aimed to describe the initial clinical experience of NOTES-assisted vaginal hysterectomy (NAVH) and to investigate its feasibility and surgical outcomes compared with single-port laparoscopic-assisted vaginal hysterectomy (SP-LAVH).DesignRetrospective chart analysis (Canadian Task Force classification II-1).SettingOne university-affiliated hospital.PatientsWomen undergoing NAVH or SP-LAVH for benign uterine diseases.InterventionNAVH using a novel homemade NOTES system comprised a glove-wound retractor NOTES port or SP-LAVH using conventional laparoscopic instruments and an umbilical glove port.Measurements and Main ResultsSince July 2012, 16 patients with benign uterine disease have undergone NAVH. Another 32 paired, SP-LAVH patients from the registered database were used to compare these 2 modalities of laparoscopic-assisted techniques for vaginal hysterectomy. All NAVHs were completed successfully without the need of an additional port or conversion to the standard laparoscopic approach. Intraoperative and postoperative surgical outcomes were assessed in both groups of patients. There was also no significant difference between both groups in perioperative outcomes such as estimated blood loss, decrease in hemoglobin on postoperative day 1, amount of analgesic drugs used, postoperative visual analog scale pain score, and febrile complications, except for operative time and length of postoperative hospital stay. The mean operative time was 70.6 ± 12.8 minutes for NAVH and 93.2 ± 21.4 minutes for SP-LAVH (p < .001). The median postoperative hospital stay was 3.5 days (range, 3–5) for NAVH and 4 days (range, 3–6) for SP-LAVH (p < .001).ConclusionThe findings show that NAVH is a feasible and safe surgical technique and has a short operative time and postoperative hospital stay compared with SP-LAVH. This new technique at least offers similar surgical outcomes and superior cosmesis in our opinion compared with SP-LAVH. However, prospective studies are needed to determine its full clinical application.     

Plastie vaginale par technique de Vecchietti cœlioscopique : résultats anatomiques et fonctionnels

ObjectivesTo evaluate vaginoplasty by Vecchietti technique adapted to laparoscopy and the anatomical and functional long term outcomes.Patients and methodsWe retrospectively studied the patients with vaginal agenesis (a Mayer-Rokitansky-Küster-Hauser syndrome for seven of young adults) operated from 1997 to 2011. The data of eight patients with a median age of 18 years old was collected. Surgical complications were analysed. The functional outcomes were compared to a control group with the Female Sexual Function Index (FSFI).ResultsNo major complication occurred during surgery. The postoperative mean vaginal measurement was 7.2 cm (4.4–10). The total FSFI scores did not differ from that of the control group (19.2 versus 18 p = 0.82). Desire, arousal, lubrication, orgasm, satisfaction, and pain of the patients were similar to controls.Discussion and conclusionLaparoscopic Vecchietti technique is a fast, simple and safe procedure to create a neovagina, and guarantees good anatomic and functional results.     

Concomitant ventral phalloplasty during penile implant surgery: a novel procedure that optimizes patient satisfaction and their perception of phallic length after penile implant surgery

IntroductionDespite previous reports showing consistently elevated patient satisfaction with penile implantation, it is our impression that patients who have had a prosthesis placed often complain of penile shortening postoperatively.AimWe sought to evaluate if the release of the penoscrotal web would optimize patient perception and satisfaction regarding penile length after such procedure.Main Outcome MeasureUtilizing a questionnaire, we evaluated patient satisfaction, focusing on phallic size.MethodsNinety patients (mean age 62) underwent penile prosthesis placement during a 17-month period. Forty-three were carried out with takedown of penoscrotal web during a 17-month period (group 1). Of group 1, 39 patients had an inflatable implant placed (inflatable penile prosthesis) and 4 had a semirigid implant. The patients were directly inquired with a seven-item questionnaire 3 months after the procedure. These results were then compared to a group of 37 patients that had penile implants placed without release of the penoscrotal web (group 2). All the patients involved in the study had a high insertion of the scrotum ventrally (penoscrotal web).ResultsOf the patients, 42/43 (98%) (group 1) reported good overall satisfaction of the surgical procedure; 36/43 (84%) reported some degree of increase in penile length; 5/43 (12%) reported no significant change in their perception of penile length postoperatively. The remaining two patients reported a decreased penile length. The clinical records from group 2 demonstrated 31/37 (84%) of the patients complained of penile shortening, and only one patient reported an increase in penile length. Postoperative complications in group 1 consisted of wound hematoma (2/43) and focal superficial wound dehiscence (3/43). The operative time for group 1 patients was approximately 12 minutes (mean 11.7) longer.ConclusionsRelease of penoscrotal web is a simple, safe, and reproducible procedure that can enhance patient perception of penile length and further improve satisfaction. Miranda-Sousa A, Keating M, Moreira S, Baker M, and Carrion R. Concomitant ventral phalloplasty during penile implant surgery: A novel procedure that optimizes patient satisfaction and their perception of phallic length after penile implant surgery.     

Long-Term Surgical,Functional, and Patient Reported Outcomes of a Modified Corporoplasty: A Tertiary Referral Center Experience

BackgroundNesbit corporoplasty was proposed to address penile curvature (PC), both congenital (CPC) and acquired (APC).AimTo evaluate surgical, functional, and patient reported outcomes (PROs) of a modified corporoplasty.MethodsFrom May 2005 to January 2017, a consecutive series of patients underwent a modified corporoplasty. Data were retrospectively extrapolated. Intra and postoperative complications and hospital stay were recorded as surgical outcomes. 2 validated international questionnaires were administered preoperatively and at 12 months after surgery: International Index of Erectile Function and Sexual Encounter Profile (items 2–3). An “ad hoc” questionnaire was utilized to assess PROs.OutcomesPostoperative surgical and functional outcomes and PROs were the primary outcomes assessed in this study.Results87 out of 145 patients had complete data available and were included in the study. CPC was noted in 61 patients whilst APC, secondary to Peyronie's disease, was present in 26 patients. Median preoperative PC was 60° (interquartile range [IQR] 45–70). Functional and PROs were evaluated 12 months after surgery for all enrolled patients. Considering surgical outcomes, the median follow-up time was 110 months (IQR 27–132.5). Median operative time was 130 minutes for CPC (IQR 115–150) and 120 minutes for APC (IQR 95–140). Median hospital stay was 2 days for both groups (IQR 1–2). After the median follow-up time of 110 months (IQR 27–132.5), a recurrent curvature was observed in 9.2% of cases. Minor residual curvature (<20°) was detected in 13.8%. International Index of Erectile Function and Sexual Encounter Profile 2–3 scores improved in both groups. Long-term de novo postoperative erectile dysfunction was observed in 3.2% of CPC cases and in 38.5% in APC (P = .001). A multivariate analysis revealed that etiology (APC), patient age (>35 years), and postoperative complications represented independent risk factors for the development of postoperative erectile dysfunction. Postoperative complications, in terms of bleeding, infection, or poor esthetic wound healing, occurred in 12.6% of patients. No Clavien-Dindo grade III–IV intraoperative complications were reported. Postoperative hematoma was more frequent in CPC when compared to APC (P = .003). In relation to PROs, 26.4% of patients responded as being dissatisfied with postoperative penile length, with a higher incidence in the APC group (P = .001). Overall, a significant improvement in everyday and sexual life quality was observed in both categories.Clinical ImplicationsThe modified corporoplasty described showed better residual curvature rates, whilst maintaining similar PROs even if APC patients reported less favorable outcomes when compared to CPC.Strengths & LimitationsThe primary limitations of this study are its retrospective nature, no objective evaluation of postoperative curvature, and no penile length assessment.ConclusionThe aforementioned corporoplasty may represent an excellent option for PC correction, with low complication rate and high patient satisfaction.Falcone M, Ceruti C, Preto M, et al. Long-Term Surgical, Functional, and Patient Reported Outcomes of a Modified Corporoplasty: A Tertiary Referral Center Experience. J Sex Med 2020;17:1779–1786.     

Minilaparotomy vs Laparoscopic Hysterectomy: Comparison of Length of Hospital Stay

Study ObjectiveTo compare length of hospital stay for minilaparotomy vs laparoscopic hysterectomy.DesignRetrospective cohort study (Canadian Task Force classification II-2).SettingKaiser Permanente Northern California, a large integrated health care delivery system.PatientsWomen >18 years of age undergoing laparoscopic or minilaparotomy hysterectomy because of benign indications from June 2009 through January 2010.InterventionHysterectomy via minilaparotomy or laparoscopy.Measurements and Main ResultsMedical records were reviewed for outcomes of interest including length of stay and surgical and demographic data. Parametric and non-parametric analyses were used to compare the 2 groups. The study was powered to detect a difference of 8 hours in length of stay. Two hundred sixty-three cases were identified as hysterectomy via minilaparotomy (n = 100) or laparoscopy (n = 163). The laparoscopy group demonstrated a significantly shorter mean (SD) length of stay (19 [14] hours vs 42 [20] hours; p < .001) and less blood loss (126 [140] mL vs 241 [238] mL; p < .001). The minilaparotomy group experienced a shorter procedure time (113 [47] minutes vs 197 [124] minutes; p < .001). There was no difference between the groups insofar as patient morbidity including intraoperative and postoperative complications, emergency visits, readmissions, or repeat operations.ConclusionCompared with minilaparotomy, laparoscopic hysterectomy is associated with shorter length of hospital stay, longer operating time, and no increased patient morbidity.     

Clinical Characteristics and Postoperative Symptoms of 85 Adolescents with Endometriosis

Study ObjectiveEndometriosis is the most common cause of secondary dysmenorrhea among adolescents. Data on postoperative symptoms of the disease in adolescents are limited. In this study we aimed to describe the clinical characteristics and postoperative symptoms of adolescent endometriosis in our center.DesignRetrospective cohort study.SettingTertiary care institution.ParticipantsEighty-five adolescents with surgically confirmed endometriosis, age younger than 19 years, were included.InterventionsNone.Main Outcome MeasuresClinical characteristics including demographic factors, pelvic symptoms, and changes of pelvic pain after surgery.ResultsOf 11,236 patients with endometriosis who received surgical treatment between January 2008 and January 2018 in our department, 85 adolescents (85/11,236; 0.76%) were included. The mean age at the time of surgery was 16.3 (±2.4) years and pelvic pain was the main symptoms which occurred in 73/85 (85.9%). Forty-four of the 85 patients (51.8%) had associated genital malformations. The patients with genital malformations tended to present with a younger age at the time of surgery (15.1 ± 2.4 vs 17.6 ± 1.7 years; P < .001) and a shorter duration of symptoms to time of surgery (1.5 ± 1.3 vs 2.3 ± 2.1 years; P = .033). The median follow-up time was 56 months (range, 24-140 months) after surgery, and the pelvic pain had disappeared in 41.7% of patients, improved in 38.3% of patients, and had no change or worsened in 20.0% patients.ConclusionPelvic pain was the main symptom in adolescents with endometriosis and was greatly improved after surgery. It should also be noted that genital malformation might be an important factor in younger adolescents with endometriosis.     

Résultats fonctionnels et qualité de vie après double promontofixation cœlioscopique pour la cure du prolapsus génital

ObjectiveTo evaluate the feasibility and morbidity of laparoscopic promontofixation in the cure of genital prolapse.Patients and methodFrom March 2001 to January 2009, 101 patients with genital prolapse of grade greater than or equal to 2 (POPQ classification) were operated by laparoscopy. Complications per and postoperative as well as patient satisfaction were assessed. Quality of life was evaluated using the questionnaires Pelvic Floor Distress Inventory (PFDI 20), Pelvic Floor Impact Questionnaire (PISQ 7) and Pelvic Organ Prolaps/Urinary Incontinence Sexual Questionnaire (PISQ 12).ResultsThe mean operative time was 196 min including the time for hysterectomy done in 83% of cases. The peroperative complication rate was 7% including two bladder and one rectal injuries and 4% of laparoconversion. The postoperative complication rate was 16% corresponding to 3/4 of retention of urine. Two pelvic hematomas were observed. The distance complication rate was 3% corresponding to a vaginal erosion, a spondylodiscitis and a case of persistent pelvic pain requiring removal of material. With a mean follow-up of 30.7 months, 81% patients declared themselves satisfied with the intervention. In intention to treat, the satisfaction rate was only 67.3%. A significant improvement in quality of life was observed using the questionnaire PFDI 20 (p < 0.0001), PFIQ 7 (p < 0.0001) et PISQ 12 (p < 0.001).Discussion and conclusionOur results confirm the feasibility of the laparoscopic promontofixation with a quality of life improvement but also highlights the existence of significant morbidity requiring further trials for the choice of surgical approach for the treatment of genital prolapse.     

Long-Term Sensitivity and Patient-Reported Functionality of the Neoclitoris After Gender Reassignment Surgery

IntroductionA cornerstone of treating gender dysphoria for transgender women is gender reassignment surgery (GRS) encompassing vaginoplasty and clitoroplasty. The neoclitoris is harvested as a flap with a neurovascular pedicle from the proximal dorsal part of the glans penis. Few long-term follow-ups exist on postoperative sensation and patient-reported sexual functionality of the neoclitoris.AimTo examine the sensitivity of the neoclitoris and its relation to orgasm and sexual function at least 1 year after GRS.MethodsTwenty-two patients were included, with a mean follow-up of 37 months (range = 12–63) after initial surgery. Tactile and vibratory sensitivities were measured with Semmes-Weinstein monofilaments and the Bio-Thesiometer vibratory measurement device, respectively. A questionnaire was provided to the patients, as were interview questions about body image, orgasm, pain, and general satisfaction with the surgery.Main Outcome MeasuresTactile and vibratory sensitivities of the neoclitoris and questionnaire on satisfaction with orgasm, sexual function, and general satisfaction.ResultsThe average tactile threshold for the clitoris was 12.5 g/mm² and the average vibratory threshold was 0.3 μm. Most participants (86%) experienced orgasm after surgery, had no or little pain, and were satisfied with the surgery. No statistical correlation was found between better or worse objective pressure and vibratory thresholds and patient answers to questions about the clitoris in the Body Image Scale for Transsexuals questionnaire.ConclusionThe neoclitoris derived from the glans penis in GRS provides long-term clitoral sensation that is erogenous. Overall, the vast majority of patients who undergo male-to female GRS experience orgasm and are satisfied with the surgery.     

Single-port compared with conventional laparoscopic cystectomy for ovarian dermoid cysts

ObjectiveWe compared the immediate surgical outcomes of single-port laparoscopic cystectomy (SLC) and conventional laparoscopic cystectomy (CLC) for managing ovarian dermoid cysts.Materials and methodsA retrospective case-control study was conducted to enroll 71 patients with dermoid cysts, including 34 patients in the SLC group and 37 patients in the CLC group. The outcome measures included operative time, blood loss, postoperative pain, analgesic use, and serum levels of hormones, including estrogen (E2), follicle-stimulating hormone, luteinizing hormone, and anti-Mullerian hormone.ResultsSLC was associated with less time required for specimen retrieval (1.3 ± 0.8 vs. 12.0 ± 3.4 minutes, p < 0.001), fewer ruptured bags (0% vs. 10.8%, p = 0.049), and less need of additional wound elongation (0% vs. 27.0%, p = 0.001) when respectively compared with CLC. Additionally, patients who underwent SLC reported lower postoperative lower abdominal pain and less accumulated postoperative analgesics when respectively compared with patients who underwent CLC. There was no significant difference of hormones between two groups.ConclusionOur study demonstrated the feasibility of using the single-port method in place of CLC in the management of ovarian dermoid without increased difficulty of techniques or risk of ovarian damage.