Gender-Affirming Vaginoplasty: A Comparison of Algorithms, Surgical Techniques and Management Practices across 17 High-volume Centers in North America and Europe.

Penile inversion vaginoplasty is the most common gender-affirming genital surgery performed around the world. Although individual centers have published their experiences, expert consensus is generally lacking. Methods: Semistructured interviews were performed with 17 experienced gender surgeons representing a diverse mix of specialties, experience, and countries regarding their patient selection, preoperative management, vaginoplasty techniques, complication management, and postoperative protocols. Results: There is significant consistency in practices across some aspects of vaginoplasty. However, key areas of clinical heterogeneity are also present and include use of extragenital tissue for vaginal canal/apex creation, creation of the clitoral hood and inner labia minora, elevation of the neoclitoral neurovascular bundle, and perioperative hormone management. Pathway length of stay is highly variable (1-9 days). Lastly, some surgeons are moving toward continuation or partial reduction of estrogen in the perioperative period instead of cessation. Conclusions: With a broad study of surgeon practices, and encompassing most of the high-volume vaginoplasty centers in Europe and North America, we found key areas of practice variation that represent areas of priority for future research to address. Further multi-institutional and prospective studies that incorporate patient-reported outcomes are necessary to further our understanding of these procedures.

A Historical Cohort in Kidney Transplantation: 55-Year Follow-Up of 72 HLA-Identical, Donor-Recipient Pairs.

The impact of HLA matching on graft survival has been well characterized in renal transplantation, with a higher degree of matching associated with superior graft survival. Additionally, living donor grafts are known to confer superior survival compared to those from deceased donors. The purpose of this study is to report our multi-decade institutional experience and outcomes for patients who received HLA-identical living donor grafts, which represent the most favorable scenario in kidney transplantation. We conducted a retrospective analysis of these graft recipients performed at a Duke University Medical Center between the years of 1965 and 2002. The recipients demonstrated excellent graft and patient survival outcomes, superior to a contemporary cohort, with median patient and graft survival of 24.2 and 30.9 years, respectively, among Duke recipients vs. 16.1 and 16.0 years in a cohort derived from national data. This study offers a broad perspective on the importance of HLA matching and graft type, and demonstrates a historical best-case-scenario in renal transplantation.

Overview of surgical techniques in gender-affirming genital surgery.

Gender related genitourinary surgeries are vitally important in the management of gender dysphoria. Vaginoplasty, metoidioplasty, phalloplasty and their associated surgeries help patients achieve their main goal of aligning their body and mind. These surgeries warrant careful adherence to reconstructive surgical principles as many patients can require corrective surgeries from complications that arise. Peri-operative assessment, the surgical techniques employed for vaginoplasty, phalloplasty, metoidioplasty, and their associated procedures are described. The general reconstructive principles for managing complications including urethroplasty to correct urethral bulging, vaginl stenosis, clitoroplasty and labiaplasty after primary vaginoplasty, and urethroplasty for strictures and fistulas, neophallus and neoscrotal reconstruction after phalloplasty are outlined as well.

Current Concepts in Feminizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital feminization. 3. Recognize key steps and anatomy during facial feminization, feminizing mammaplasty, and vaginoplasty. 4. Discuss major risks and complications of vaginoplasty. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various feminizing gender-affirming surgical procedures.

Current Concepts in Masculinizing Gender Surgery.

LEARNING OBJECTIVES: After reading this article and viewing the video, the participant should be able to: 1. Discuss appropriate treatment guidelines, including preoperative mental health and hormonal treatment before gender-affirmation surgery. 2. Name various surgical options for facial, chest, and genital masculinization. 3. Recognize key steps and anatomy during chest-wall contouring and phalloplasty reconstruction. 4. Discuss major risks and complications of chest-wall contouring and phalloplasty reconstruction. SUMMARY: Transgender and gender-nonconforming individuals may experience conflict between their gender identity and their gender assigned at birth. With recent advances in health care and societal support, appropriate treatment has become newly accessible and has generated increased demand for gender-affirming care, which is globally guided by the World Professional Association for Transgender Health. This CME article reviews key terminology and standards of care, and provides an overview of various masculinizing gender-affirming surgical procedures.

Gender-Affirming Penile Inversion Vaginoplasty.

In recent years, greater acceptance of transgender individuals in society and the inclusion of medical coverage for gender-affirmation surgeries has led to an increasing number of patients seeking gender-affirming vaginoplasty. Since the first descriptions of neovaginal reconstruction for gender affirmation were described in the early and mid-1900s, various techniques and revisions have been introduced. This article provides a brief historical perspective, defines the goals of surgical treatment within a multidisciplinary approach adhering to World Professional Association for Transgender Health standards, and focuses on issues related to what is currently the most common approach to primary neovaginal reconstruction, the penile inversion vaginoplasty.

Surgical nuances of partial sacrectomy for chordoma.

BACKGROUND: Sacral chordomas are rare, slow growing, locally aggressive tumors. Unfortunately, aggressive surgical resection is often associated with increased neurological morbidity. METHODS: This technical note focuses on the utilization of partial sacrectomy for the resection of complex spinal chordomas. RESULTS: The case presented documents the potential range of postoperative morbidity seen in patients undergoing partial sacrectomy for chordomas. Despite iatrogenic morbidity and tumor recurrence, with the cooperation of medical and surgical spine specialists, majority of patients can achieve good long-term outcomes. CONCLUSIONS: Sacral chordomas are rare lesions and pose a therapeutic challenge for spinal surgeons and oncologists. En-bloc surgical resection (e.g., partial sacrectomy) is the treatment of choice for these lesions, and the cooperation between subspecialists can lead to good neurologic outcomes, particularly if gross total resection is achieved.

Estrogenicity of glabridin in Ishikawa cells.

Glabridin is an isoflavan from licorice root, which is a common component of herbal remedies used for treatment of menopausal symptoms. Past studies have shown that glabridin resulted in favorable outcome similar to 17ß-estradiol (17ß-E2), suggesting a possible role as an estrogen replacement therapy (ERT). This study aims to evaluate the estrogenic effect of glabridin in an in-vitro endometrial cell line -Ishikawa cells via alkaline phosphatase (ALP) assay and ER-α-SRC-1-co-activator assay. Its effect on cell proliferation was also evaluated using Thiazoyl blue tetrazolium bromide (MTT) assay. The results showed that glabridin activated the ER-α-SRC-1-co-activator complex and displayed a dose-dependent increase in estrogenic activity supporting its use as an ERT. However, glabridin also induced an increase in cell proliferation. When glabridin was treated together with 17ß-E2, synergistic estrogenic effect was observed with a slight decrease in cell proliferation as compared to treatment by 17ß-E2 alone. This suggest that the combination might be better suited for providing high estrogenic effects with lower incidences of endometrial cancer that is associated with 17ß-E2.

Comparison of flow rates in the antegrade and retrograde internal mammary vein for free flap breast reconstruction.

BACKGROUND: The internal mammary vein (IMV) is commonly used as a recipient vessel in the direction of antegrade flow for free flap breast reconstruction. Recent reports show that the distal IMV is valveless and can accommodate retrograde flow. We sought to quantify blood velocity and flow through the distal IMV following free tissue transfer. METHODS: Ten free flap breast reconstructions were performed. The larger vena comitans of the DIEA was anastomosed to the antegrade internal mammary vein (AIMV). The smaller vena comitans was anastomosed to the retrograde internal mammary vein (RIMV) in five free flaps, and the superficial inferior epigastric vein (SIEV) was anastomosed to the RIMV in five other free flaps. RESULTS: The mean diameter of the larger vena comitans (3.4 ± 0.5 mm) was significantly greater than that of the smaller vena comitans (2.4 ± 0.4 mm; P = 0.003). Mean velocity in the AIMV after anastomosis was 10.13 ± 5.21 mm/s compared with 7.01 ± 2.93 mm/s in the RIMV (P = 0.12). Mean blood flow in the AIMV and the RIMV was 81.33 ± 52.81 mm(3) /s and 57.84 ± 45.11 mm(3) /s, respectively (P = 0.30). Mean blood flow in the RIMV was not significantly affected by whether the donor vein was the smaller vena comitans (70.78 ± 61.43 mm(3) /s) or the SIEV (44.90 ± 19.70 mm(3) /s; P = 0.40). CONCLUSIONS: Blood flow in the RIMV was less but not significantly different from flow in the AIMV. The difference is likely due to the smaller-sized donor vein anastomosed to the RIMV. The RIMV is a reliable, useful option when the antegrade vein is not available, or when a second recipient vein is needed.

Technical challenges of total esophageal reconstruction using a supercharged jejunal flap.

OBJECTIVE: To review our experience and technique of the supercharged jejunal flap for total esophageal reconstruction. BACKGROUND: A gastric pull-up is the first choice for total esophageal reconstruction. When this fails or when the stomach is unavailable, a supercharged jejunal flap may reestablish alimentary tract continuity. METHODS: We performed a retrospective review of 51 patients who underwent a supercharged jejunal flap for total esophageal reconstruction between March 2000 and September 2009 at a single institution. Patient characteristics, technical details, and outcomes were analyzed. RESULTS: Thirty-six men and 15 women patients were included with a mean age of 55 (28-74) years. An immediate reconstruction was performed in 34 (67%) patients and delayed in 17 patients. The jejunal conduit was passed through a substernal route in 31 (60%) patients and a retrocardiac route in 20 patients. Most common recipient arteries were the internal mammary and transverse cervical. Most common recipient veins were the internal mammary and internal jugular. The overall success rate was 94% with 3 flap failures. A total of 33 patients experienced 1 or more complications with abdominal wound infection and pulmonary complications being the 2 most frequent. Mean length of hospital stay was 21.5 ± 14.0 days. Forty-four (90%) patients were able to achieve a regular diet and 39 (80%) patients discontinued their tube feeds. CONCLUSION: This technically challenging operation requires a multidisciplinary approach and careful planning, yet can be successfully performed with good long-term function and acceptable morbidity. An algorithm delineating the operative strategy is presented.

Beckwith-Wiedemann syndrome and juvenile fibroadenoma: a case report.

Beckwith-Wiedemann syndrome (BWS) is a complex overgrowth disorder usually recognized at birth. Children diagnosed with BWS, particularly those with hemihypertrophy, experience an increased risk of developing benign and malignant tumors. This case report presents a 12-year-old girl with BWS and hemihypertrophy who rapidly developed enlarging, asymmetric tumors of bilateral breasts. Few cases of patients with BWS and benign breast tumors exist in the literature. The differential diagnosis of breast tumors in the adolescent female is described. The treatment plan and reconstruction options particular to the developing young female are also discussed.

Blood vessels engineered from human cells.

Tissue engineering has made considerable progress in the past decade, but advances have stopped short of clinical application for most tissues. We postulated that an obstacle in engineering human tissues is the limited replicative capacity of adult somatic cells. To test this hypothesis, the effectiveness of telomerase expression to extend cellular lifespan was assessed in a model of human vascular tissue engineering. Telomerase expression in vascular cells isolated from elderly patients enabled the successful culture of engineered autologous blood vessels. Engineered vessels may one day provide a source of bypass conduit for patients with atherosclerotic disease.