Differences in Surgical Complications for Stage 1 Phalloplasty With Concurrent Versus Asynchronous Hysterectomy in Transmasculine Patients.

Background The authors sought to compare the perioperative morbidity of Stage 1 phalloplasty with asynchronous vs concurrent hysterectomy among transmasculine patients. Methods This retrospective study included transmasculine patients undergoing Stage 1 phalloplasty with either asynchronous or concurrent hysterectomy at Kaiser Permanente Northern California from January 1, 2017, to September 9, 2019. The primary outcome was differences in surgical site infection rates. Secondary outcomes included perioperative and other postoperative complications. Comparisons of demographics and outcomes were made by F-tests and Fisher's exact tests. A p value of < 0.05 was considered statistically significant. Results Of 66 transmasculine patients undergoing Stage 1 phalloplasty, 32 (48%) had an asynchronous hysterectomy and 34 (52%) had a concurrent hysterectomy. Overall, surgical site infection rates were low, and there were no significant differences between groups. Patients who had undergone asynchronous hysterectomy had more neourethral complications with Stage 1 phalloplasty than those undergoing concurrent procedures (28% vs 3%, p < 0.05). There were no significant differences in estimated blood loss, length of stay, urinary tract infection, overactive bladder or narcotic use between groups. Conclusion Overall, there were no differences between groups in most postoperative complication rates. Although more neourethral complications were found in those undergoing asynchronous hysterectomy prior to Stage I phalloplasty, this may be partially explained by increasing surgeon experience over time given this difference did not remain statistically significant after the first year of the study period. Gynecologists seeking to provide comprehensive and inclusive care to transmasculine patients should take these findings into consideration when counseling patients planning genital gender affirmation surgery.

Urethrographic Evaluation of Anatomic Findings and Complications after Perineal Masculinization and Phalloplasty in Transgender Patients.

Transgender patients seeking gender-affirming surgery are a growing population with unique health care needs. The radiologist must understand the challenges these patients face to facilitate a positive patient-physician interaction during the series of postoperative fluoroscopic evaluations. The authors present a standard two-stage surgical approach and common postoperative fluoroscopic findings after perineal masculinization and phalloplasty procedures. Perineal masculinization including urethral lengthening is performed first, followed by skin-flap-based phalloplasty. Patients undergo voiding cystourethrography (VCUG) after intravesical administration of contrast media by way of an indwelling suprapubic catheter after each stage. Retrograde urethrography plays a complementary role to supplement the limitations of VCUG after the second stage. The article reviews the expected postoperative anatomy and explains standardized terminology developed at the authors' institution. Imaging features of common and rare complications are discussed, including contained leak, stenosis, occlusion, and fistula. The successful postoperative imaging study in a transmasculine patient relies on open communication among the interdisciplinary team of specialized surgeons, radiologists, and medical providers, as well as special modifications to existing imaging techniques. ©RSNA, 2020.

Antibiotic prophylaxis for selected gynecologic surgeries.

BACKGROUND: Antibiotic prophylaxis for surgery is commonly used and is recommended by multiple organizations. OBJECTIVE: To critically review gynecology-specific data regarding surgical antibiotic prophylaxis in selected benign gynecologic surgeries. SEARCH STRATEGY: MEDLINE and Cochrane databases were searched from inception to July 2010. SELECTION CRITERIA: Randomized controlled trials of benign vaginal, cervical, transcervical, abdominal, or laparoscopic procedures other than hysterectomy comparing prophylactic antibiotic use with placebo or with another antibiotic. Outcomes of interest were postoperative infections, additional treatments, and adverse events. DATA COLLECTION AND ANALYSIS: In total, 19 trials met the inclusion criteria. Studies were individually assessed for methodologic quality, then grouped by procedure and evaluated for evidence quality. MAIN RESULTS: There was no difference in infectious outcome for loop electrosurgical excision, hysteroscopic ablation, or laparoscopy, although evidence quality was poor. Fair evidence supports antibiotic prophylaxis for suction curettage or laparotomy. There were insufficient data regarding vaginal surgery prophylaxis. CONCLUSION: Antibiotic prophylaxis may be beneficial in first-trimester suction curettage and laparotomy. No advantage was found for loop electrosurgical excision, hysteroscopy, or laparoscopic gynecologic surgery. Newer procedures and vaginal surgery lack research and merit study.

Surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery.

OBJECTIVE: To assess surgeon practice patterns for antibiotic prophylaxis in gynecologic surgery. METHODS: A survey was distributed at the 2011 annual scientific meeting of the Society of Gynecologic Surgeons regarding antibiotic prophylaxis practices. RESULTS: The response rate was 51%. Most surgeons did not use antibiotic prophylaxis for dilation and curettage without products of conception, hysteroscopy, and loop electrocautery excision procedure/cone biopsy. For laparoscopy without graft placement, 45.9% did not use prophylaxis. Prophylaxis was common for hysterectomy. For midurethral slings, 8.2% did not use prophylaxis. When graft material was used in prolapse surgery, at least 93% of surgeons administered some form of antibiotic prophylaxis. Only 70% of respondents prescribe antibiotic prophylaxis for hysterectomy consistent with recommendations from the American College of Obstetricians and Gynecologists, whereas 78% are consistent with specifications from the Joint Commission. CONCLUSIONS: Wide variability exists in antibiotic prophylaxis in gynecologic surgery. Surgeon preference or local hospital policies affect choice of prophylaxis less than 14.9% of the time.

Systematic review highlights difficulty interpreting diverse clinical outcomes in abnormal uterine bleeding trials.

OBJECTIVES: (1) To systematically collect and organize into clinical categories all outcomes reported in trials for abnormal uterine bleeding (AUB); (2) to rank the importance of outcomes for patient decision making; and (3) to improve future comparisons of effects in trials of AUB interventions. STUDY DESIGN AND SETTING: Systematic review of English-language randomized controlled trials of AUB treatments in MEDLINE from 1950 to June 2008. All outcomes and definitions were extracted and organized into major outcome categories by an expert group. Each outcome was ranked "critically important," "important," or "not important" for informing patients' choices. RESULTS: One hundred thirteen articles from 79 trials met the criteria. One hundred fourteen different outcomes were identified, only 15 (13%) of which were ranked as critically important and 29 (25%) as important. Outcomes were grouped into eight categories: (1) bleeding; (2) quality of life; (3) pain; (4) sexual health; (5) patient satisfaction; (6) bulk-related complaints; (7) need for subsequent surgical treatment; and (8) adverse events. CONCLUSION: To improve the quality, consistency, and utility of future AUB trials, we recommend assessing a limited number of clinical outcomes for bleeding, disease-specific quality of life, pain, sexual health, and bulk-related symptoms both before and after treatment and reporting satisfaction and adverse events. Further development of validated patient-based outcome measures and the standardization of outcome reporting are needed.

Women with diabetes: understanding urinary incontinence and help seeking behavior.

PURPOSE: We examined the association of urinary incontinence with diabetes status and race, and evaluated beliefs about help seeking for incontinence in a population based cohort of women with vs without diabetes. MATERIALS AND METHODS: We performed a cross-sectional analysis of 2,270 middle-aged and older racially/ethnically diverse women in the Diabetes Reproductive Risk factors for Incontinence Study at Kaiser. Incontinence, help seeking behavior and beliefs were assessed by self-report questionnaires and in-person interviews. We compared incontinence characteristics in women with and without diabetes using univariate analysis and multivariate models. RESULTS: Women with diabetes reported weekly incontinence significantly more than women without diabetes (weekly 35.4% vs 25.7%, p <0.001). Race prevalence patterns were similar in women with and without diabetes with the most vs the least prevalence of incontinence in white and Latina vs black and Asian women. Of women with diabetes 42.2% discussed incontinence with a physician vs 55.5% without diabetes (p <0.003). Women with diabetes were more likely than those without diabetes to report the belief that incontinence is rare (17% vs 6%, p <0.001). CONCLUSIONS: Incontinence is highly prevalent in women with diabetes. Race prevalence patterns are similar in those with and without diabetes. Understanding help seeking behavior is important to ensure appropriate patient care. Physicians should be alert for urinary incontinence since it is often unrecognized and, thus, under treated in women with diabetes.

Graft use in transvaginal pelvic organ prolapse repair: a systematic review.

OBJECTIVE: To estimate the anatomic and symptomatic efficacy of graft use in transvaginal prolapse repair and to estimate the rates and describe the spectrum of adverse events associated with graft use. DATA SOURCES: Eligible studies, published between 1950 and November 27, 2007, were retrieved through Medline and bibliography searches. METHODS OF STUDY SELECTION: To assess anatomic and symptomatic efficacy of graft use, we used transvaginal prolapse repair studies that compared graft use with either native tissue repair or repair with a different graft. To estimate rates of adverse events from graft use, all comparative studies and case series with at least 30 participants were included. For spectrum of adverse events, all study designs were included. TABULATION, INTEGRATION AND RESULTS: Eligible studies were extracted onto standardized forms by one reviewer and confirmed by a second reviewer. Comparative studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic-absorbable, synthetic nonabsorbable) and outcome (anatomic, symptomatic). We found 16 comparative studies, including six randomized trials, 37 noncomparative studies with at least 30 women, 11 case series with fewer than 30 women, and 10 case reports of adverse events. One randomized trial and one prospective comparative study evaluating synthetic, nonabsorbable graft use in the anterior compartment reported favorable anatomic and symptomatic outcomes with graft use. Data regarding graft use for posterior and apical compartments or for biologic or synthetic absorbable graft use in the anterior compartment were insufficient to determine efficacy. Rates and spectrum of adverse events associated with graft use included bleeding (0-3%), visceral injury (1-4%), urinary infection (0-19%), graft erosion (0-30%), and fistula (1%). There were insufficient data regarding dyspareunia, sexual, voiding, or defecatory dysfunction. CONCLUSION: Overall, the existing evidence is limited to guide decisions regarding whether to use graft materials in transvaginal prolapse surgery. Adequately powered randomized trials evaluating anatomic and symptomatic efficacy as well as adverse events are needed.

Effectiveness of the McCall culdeplasty in maintaining support after vaginal hysterectomy.

The aim of this study was to evaluate the effectiveness of a McCall culdeplasty in maintaining support of the post-hysterectomy vaginal cuff in women undergoing surgery for uterine prolapse. A retrospective chart review was performed on all patients who had a vaginal hysterectomy and McCall culdeplasty for uterine prolapse without prolapse of the posterior vaginal fornix. Patients were examined pre- and postoperatively using the International Continence Society (ICS) staging system. Data were analyzed using repeated measures analysis of variance (ANOVA) for correlation between preoperative point D and the two postoperative point C measurements. Of the 43 patients studied, 39 (90%) had stage 0 prolapse and 3 (7%) had stage I prolapse of the vaginal cuff 1 year postoperatively. In patients who have hysterectomies for uterine prolapse with good support of the posterior vaginal fornix, the McCall culdeplasty is a highly successful procedure in maintaining proper anatomic support of the vaginal cuff.