Step by step male to female transsexual surgery.

INTRODUCTION: After the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long-term patient rehabilitation is maintained for at least two years. The indication for surgery is chronic discomfort caused by discord with the patient's natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty. The surgical conversion of transsexuals is the main step in the complex care of these problematic patients (1). This surgery was first described by Benjamin H, using a flap of inverted penile skin (2) and is considered the gold standard since then. Male-to-female transsexual surgical techniques are well defined and give good cosmetic and functional results. Sex reassignment surgery promotes the improvement of psychological aspects and social relationships as shown in the World Health Organization Quality of Life Assessment applied in the patients submitted to this procedure (3). Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing sexual intercourse and the capability of clitoral orgasm (4). Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts (5). In our Hospital, we use penile and scrotal skin flaps. Until now, 174 procedures have been performed by our team using this technique with high rates of satisfaction (3). PATIENTS AND METHODS: We present a step-by-step male to female transsexual surgery. CONCLUSION: Surgical gender reassignment of male transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm (1). With this video we show step by step that a surgery using penile skin flaps is able to be performed with good cosmetic results.

Prospective evaluation of vesicourethral anastomosis outcomes in robotic radical prostatectomy during early experience in a university hospital.

PURPOSE: Robotic assisted radical prostatectomy (RARP) presents challenges for the surgeon, especially during the initial learning curve. We aimed to evaluate early and mid-term functional outcomes and complications related to vesicourethral anastomosis (VUA), in patients who underwent RARP, during the initial experience in an academic hospital. We also assessed possible predictors of postoperative incontinence and compared these results with the literature. MATERIALS AND METHODS: We prospectively collected data from consecutive patients that underwent RARP. Patients with at least 6 months of follow-up were included in the analysis for the following outcomes: time to complete VUA, continence and complications related to anastomosis. Nerve-sparing status, age, BMI, EBL, pathological tumor staging, and prostate size were evaluated as possible factors predicting early and midterm continence. Results were compared with current literature. RESULTS: Data from 60 patients was assessed. Mean time to complete VUA was 34 minutes, and console time was 247 minutes. Continence in 6 months was 90%. Incidence of urinary leakage was 3.3%, no patients developed bladder neck contracture or postoperative urinary retention. On multivariate analysis, age and pathological staging was associated to 3-month continence status. CONCLUSION: Our data show that, during early experience with RARP in a public university hospital, it is possible to achieve good results regarding continence and other outcomes related to VUA. We also found that age and pathological staging was associated to early continence status.

Impacto do câncer de mama e da mastectomia na sexualidade feminina / Impact of breast cancer and mastectomy in female sexuality

Objetivo: estimar o impacto do câncer de mama e da mastectomia na sexualidade feminina. Método: estudo descritivo, exploratório, de abordagem qualitativa, realizado com 12 mulheres mastectomizadas. Para o processamento dos dados, utilizou-se o software IRAMUTEQ (Interface de R pour lês Analyses Multidimensionnelles de Textes et de Questionnaires). Para a análise dos dados, utilizou-se a Classificação Hierárquica Descendente (CHD). Resultados: identificaram-se cinco principais classes: Alterações na feminilidade frente ao impacto de retirada da mama; Vivência feminina no enfrentamento do câncer e da mastectomia; Sentimentos vivenciados com a descoberta do câncer; A mastectomia e a sexualidade feminina e Significados do câncer de mama e da mastectomia. Após a mastectomia, a mulher apresentou limitações e dificuldades em situações como a exposição do corpo e ajuste social para realização de suas atividades diárias. Conclusão: percebeu-se inúmeras situações e alterações provocados pelo câncer e pela mastectomiana vida da mulher, principalmente em relação a sua sexualidade, feminilidade e imagem corporal.

Robotic assisted laparoscopic excision of a retroperitoneal Ganglioneuroma.

INTRODUCTION: Ganglioneuromas are rare benign neoplasms of the sympathetic nervous system. We describe the case of an incidentally found ganglioneuroma in a woman. To our knowledge this is the first described case of robotic excision of a retroperitoneal ganglioneuroma. CASE: A 41-year-old female had an incidental retroperitoneal mass found during a routine US. CT scan and MRI showed an 8.3cm homogeneous mass, adjacent to left kidney upper pole, with peripheral contrast enhancement. Metabolic tests were normal. Patient was positioned in a left flank position and five ports were introduced transperitoneally. A 4-arm Da Vinci SI was docked at a 45º angle to the table. Lesion was dissected along with left adrenal gland, beginning at the left renal hilum and proceeding cephalad. RESULTS: Operating time was 325min and blood loss was 50ml. Patient was discharged after 72hours. There were no post-operative complications. Pathology showed ganglionic cells with neural tissue, and normal adrenal. DISCUSSION: Ganglioneuromas rare benign tumors originating from neural crest and typically affect young adults. Most frequent locations are posterior mediastinum, retroperitoneum and adrenal gland. As in this case, ganglioneuromas are usually silent, slow growing tumors discovered incidentally or by mass effect. US and CT imaging may suggest the diagnosis while MRI findings can be specific for ganglioneuroma. Percutaneous biopsy is an option. Although benign, usually requires surgical excision for treatment. CONCLUSIONS: Our case shows that a robotic approach is feasible and allows for meticulous and safe dissection of vascular structures, facilitating adequate hemostasis while maintaining oncological principles.

Azospirillum spp. from native forage grasses in Brazilian Pantanal floodplain: biodiversity and plant growth promotion potential.

A sustainable alternative to improve yield and the nutritive value of forage is the use of plant growth-promoting bacteria (PGPB) that release nutrients, synthesize plant hormones and protect against phytopathogens (among other mechanisms). Azospirillum genus is considered an important PGPB, due to the beneficial effects observed when inoculated in several plants. The aim of this study was to evaluate the diversity of new Azospirillum isolates and select bacteria according to the plant growth promotion ability in three forage species from the Brazilian Pantanal floodplain: Axonopus purpusii, Hymenachne amplexicaulis and Mesosetum chaseae. The identification of bacterial isolates was performed using specific primers for Azospirillum in PCR reactions and partial sequencing of the 16S rRNA and nifH genes. The isolates were evaluated in vitro considering biological nitrogen fixation (BNF) and indole-3-acetic acid (IAA) production. Based on the results of BNF and IAA, selected isolates and two reference strains were tested by inoculation. At 31 days after planting the plant height, shoot dry matter, shoot protein content and root volume were evaluated. All isolates were able to fix nitrogen and produce IAA, with values ranging from 25.86 to 51.26 mg N mL-1 and 107-1038 µmol L-1, respectively. The inoculation of H. amplexicaulis and A. purpusii increased root volume and shoot dry matter. There were positive effects of Azospirillum inoculation on Mesosetum chaseae regarding plant height, shoot dry matter and root volume. Isolates MAY1, MAY3 and MAY12 were considered promising for subsequent inoculation studies in field conditions.

Full-thickness skin mesh graft vaginoplasty: a skin sparing technique.

INTRODUCTION: The ideal vaginoplasty method should promote good cosmetic and functional results with low morbidity. We describe a new technique for congenital vaginal agenesis using a full-thickness perforated skin graft. MATERIALS AND METHODS: We report an 18 year old patient with vaginal agenesis (Morris syndrome) that undergone a modified version of McIndoe vaginoplasty. Patient is set in a low lithotomy position and lateral traction sutures are placed in labia and a 16Fr urethral catheter inserted. An inverted "V"-shaped incision is made in the mucosal plaque below the urethra. Blunt dissection in a cephalic posterior direction forms a space between the rectum and urethra. Special care is taken to avoid rectal tear during this maneuver. A full-thickness skin graft is removed from the lower abdomen measuring 12.0x6.0cm as an aesthetic abdominoplasty. The fat tissue is removed, remaining epidermis and dermis and the graft is perforated, allowing a great surface increase. After suturing over a mold, the graft is fixed in the created space. The donor site is closed with intradermal transversal suture. RESULTS: From January 2009 to August 2015, seven patients diagnosed with vaginal agenesis underwent this technique. There were no major complications or need for blood transfusions. At the six-month follow-up, all patients reported satisfactory sexual intercourse. There were no significant complications at donor site or neovagina that needed surgical intervention. CONCLUSION: Vaginal reconstruction using the perforated graft is viable with excellent functional results. Applying this modification, we yielded the good results of a classic McIndoe technique with lower donor site morbidity.