The effect of colpectomy on lower urinary tract function in transgender men.

Background: In transgender men, effects of colpectomy on voiding function are unknown, except for the incidence rates of urinary tract infections and urinary retention. Aims: To provide insight into the effect of colpectomy on Lower Urinary Tract Function (LUTF) in transgender men. Methods: A retrospective chart review was conducted among transgender men who underwent colpectomy between January 2018 and October 2020. Primary outcomes were objective and subjective changes in voiding. Secondary outcomes were transurethral catheterization length and the need for clean intermittent self-catheterization (CISC). Results: Of 132 men, 89 (67%) underwent Robot-assisted Laparoscopic Colpectomy (RaLC) and 43 (33%) Vaginal Colpectomy (VC). Maximum flow rate on uroflowmetry decreased following RaLC (mean of 29.1 vs. 38.3 mL/s, p = 0.002) and VC (mean of 29.2 vs. 40.3 mL/s, p < 0.001) after a median of four months postoperatively. An increase in total International Prostate Symptom Score was seen more frequently following VC compared to RaLC. Subjective changes were indicated by 39%, more often by men who underwent VC, of which the majority improved during the first months postoperatively. Trial without catheter (TWOC) on the first postoperative day was more successful after RaLC (79/89, 89%) than VC (24/43, 56%). Secondary TWOC was successful in 22/132 (17%) patients after a median of eight days postoperatively. In 5/132 (4%) men (three VC and two RaLC), temporary CISC was necessary for a period ranging from 5 to 21 days. The last 2/132 (2%) men after RaLC were still performing CISC at end of follow-up. Eventually, 5% (two VC and four RaLC) had to refrain from genital gender-affirming surgery with urethral lengthening due to voiding dysfunction. Discussion: After colpectomy, most objective and subjective worsening in LUTF is of a temporary nature, however, 5% had to refrain from genital gender-affirming surgery with urethral lengthening due to persistent voiding dysfunction, despite the desire to void while standing.

Comparison of surgical outcomes and urinary functioning after phalloplasty with versus without urethral lengthening in transgender men.

Background: Phalloplasty in transgender men is performed with or without Urethral Lengthening (UL). To create clear expectations in the choice of UL, an overview and comparison of outcomes is useful. Aims: To provide and compare surgical outcomes and urinary functioning after phalloplasty with versus without UL in transgender men. Methods: A single-center, retrospective chart review was conducted among transgender men who underwent phalloplasty with or without UL between 01-2013 and 10-2020. Primary outcomes were differences in complication and reoperation rates. Secondary outcomes were end-stages of voiding at last follow-up and differences in voiding analyses pre- and postoperatively. Results: Of 136 men, 91 (67%) underwent phalloplasty with, and 45 (33%) without UL. Wound infection (31 vs. 16%, p = 0.06) and partial flap loss (35 vs. 13%, p = 0.008) were predominately seen after UL. In the UL group, 43% urethral fistulas and 60% urethral strictures were observed, relative to one man without UL who had a urethral fistula (both p < 0.001). Meatal or perineal orifice stenosis was seen in 29% with versus 11% without UL (p = 0.02). Reoperation was needed in 81% with versus 27% without UL (p < 0.001). At follow-up, 80/91 (88%) after UL reached end-stage of voiding, with 60/80 (75%) able to void while standing and 20/80 (25%) having a definitive urethrostomy. The remaining 11/91 (12%) men were awaiting further treatment for urological complications. The men able to void while standing had a median of one reoperation (range 0-6), and a significant decrease in maximum flow rate on postoperative uroflowmetry (21.4 vs. 29.8 mL/s, p < 0.001). After phalloplasty without UL, all men had a definitive perineostomy without changes in voiding analyses. Discussion: The choice for or against UL during phalloplasty has become more relevant over the years. This comparison of surgical outcomes and urinary functioning can be useful in the shared decision-making process to come to the most suitable choice of phalloplasty.

Is It the Load That Breaks You or the Way You Carry It: How Demanding Is Endourology?

Objective: Surgical outcomes are dependent on multiple factors. Besides patient-related or procedure-related factors, several surgeon-related factors contribute to surgical outcomes. The Surgery Task Load Index (SURG-TLX) questionnaire helps to assess the impact of several stressors on the perceived demands of surgeons during surgery. In this study, we evaluate the applicability of the SURG-TLX questionnaire for endourologic procedures and set a first point of reference. Materials and Methods: Between March and August 2022, 15 urologists and urology residents at a tertiary referral center for endourology completed the SURG-TLX questionnaire after endourologic procedures. After data acquisition, all participants were asked to evaluate the applicability of the questionnaire for endourologic procedures. Results: A total of 130 procedures were included between March and August 2022. Situational stress had the lowest median score (3.0/20; interquartile range [IQR] 2.0-7.0) and task complexity the highest (5.0/20; IQR 3.0-8.0). After weighing, the dimensions showed different proportions when compared with the nonweighted scores. Distractions received the highest score (15.0/100; IQR 7.5-32.8), temporal demands (6.0/100; IQR 3.0-12.5), and situational stress the lowest (6.0/100; IQR 2.0-21.0). This was caused by the higher weight that was attributed to distractions (3.4/5), as opposed to task complexity (2.6/5). In the questionnaire regarding applicability of the SURG-TLX, the overall satisfaction (6.0/10; IQR 5.0-7.0) and clarity (6.5/10; IQR 5.0-7.5) were moderate. The user-friendliness and applicability of the questionnaire were rated high (7.0/10; IQR 5.5-8.0 and 7.0/10; IQR 6.0-8.0, respectively) and task load (3.0/10; IQR 2.0-5.0) and time load (2.0/10; IQR 2.0-3.5) low. Conclusion: The SURG-TLX questionnaire is appropriate to assess the different dimensions of workload during endourologic procedures. Furthermore, the perceived workload during endourologic procedures is relatively low.

Surgical outcomes and proposal for a treatment algorithm for urethral strictures in transgender men.

OBJECTIVES: To assess our results of surgical treatment for urethral strictures in transgender men, and to provide a surgical treatment algorithm. PATIENTS AND METHODS: A single centre, retrospective cohort study was conducted of transgender men who underwent surgical correction of their urethral stricture(s) between January 2013 and March 2020. The medical charts of 72 transgender men with 147 urethral strictures were reviewed. The primary outcomes were the success and recurrence rates after surgical treatment for urethral strictures. RESULTS: The median (interquartile range [IQR]) follow-up was 61 (25-202) months. At last follow-up, 50/72 (69%) were able to void while standing (after one [60%], two [20%], three [6%], four [8%], five [4%], or seven [2%] procedures), 10/72 (14%) await further treatment, two of the 72 (3%) sat to void despite good urodynamic function, and 10/72 (14%) had a definitive urethrostomy. Of 104 surgical treatments included in separate success rate analysis, 65 (63%) were successful (43/75 [57%] after phalloplasty, 22/29 [76%] after metoidioplasty). The highest success rates in short urethral strictures were seen after a Heineke-Mikulicz procedure (six of seven cases), and in longer or more complicated urethral strictures after two-stage with graft (four of six), two-stage without graft (10/12), pedicled flap (11/15, 73%), and single-stage graft (seven of seven) urethroplasties. Grafts used were buccal mucosa or full-thickness skin grafts. Success rates improved over time, with success rates of 38% and 36% in 2013 and 2014, to 71% and 73% in 2018 and 2019, respectively. We concluded with a surgical treatment algorithm based on previous literature, stricture characteristics, and our surgical outcomes. CONCLUSION: The highest success rates were seen after a Heineke-Mikulicz procedure in short urethral strictures; and after graft, pedicled flap, or two-stage urethroplasties in longer or more complicated urethral strictures. Finally, most of the transgender men were able to void while standing, although in some multiple surgical procedures were necessary to accomplish this.

Perineal Cyst in Transgender Men: A Rare Complication Following Gender Affirming Surgery - A Case Series and Literature Overview.

INTRODUCTION: Genital gender affirming surgery (gGAS) is usually the final stage in the medical transition for transgender men and consists of creating a neophallus and neo-scrotum, with or without urethral lengthening(UL). To reduce the complication risks of UL, a mandatory colpectomy is performed prior to UL. Colpectomy is considered a complex surgery, which may lead to various perioperative complications. There are few long-term complications reported. AIM: To describe the clinical presentation and management of 3 consecutive transgender men presenting with a perineal cyst following gGAS. METHODS: After obtaining informed consent all clinical data was collected, including medical history, current symptoms, imaging, as well as surgery and histological outcomes. Furthermore, a literature search was performed. MAIN OUTCOME MEASURE: To hypothesize the aetiology of the perineal cyst based on current published literature. RESULTS: Three otherwise healthy transgender men, ages 26-46 with a similar medical history, presented with a perineal cyst several months or years following colpectomy and gGAS with UL. All patients underwent surgery to remove the cyst. Several theories regarding aetiology of this perineal cyst are discussed in this report. CONCLUSION: There remain several gaps in our knowledge regarding the aetiology and management of this perineal cyst. Therefore, further research is necessary. Asseler JD, Ronkes BL, Groenman FA, et al. Perineal Cyst in Transgender Men: A Rare Complication Following Gender Affirming Surgery - A Case Series and Literature Overview. J Sex Med 2021;9:100415.

Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men.

BACKGROUND: In our institution, genital Gender-Affirming Surgery (gGAS;phalloplasty or metoidioplasty) in transgender men is offered with or without Urethral Lengthening (UL). AIM: The aim of this cross-sectional and retrospective study was to assess the effect of gGAS with or without UL on several Patient-Reported Outcomes (PROs), and to identify predictors of overall patient satisfaction at follow-up. METHODS: A self-constructed Patient-Reported Outcome Measure (PROM) was sent to transgender men who were ≥1 year after gGAS. The survey comprises 25 questions divided into 5 domains: type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. OUTCOMES: Answers to the survey were compared between groups, and a linear regression analysis was conducted to identify predictors of overall patient satisfaction. RESULTS: Of 154 eligible transgender men, the PROM was sent to 118 (77%) willing to participate, and 102 (66%) completed the survey. The majority previously underwent phalloplasty (n = 74;73%) compared to metoidioplasty (n = 28;27%). Urethral Lengthening was performed in 56/102 (55%) participants, 51/74 (69%) in phalloplasty, 5/28 (18%) in metoidioplasty. The mean number of complications and reoperations was significantly higher in the UL group (2.7vs1 and 1.6vs0.4 respectively, both P < .001). Most participants were satisfied to very satisfied with life (75%), the appearance (66%), voiding (59%), the effect of surgery on masculinity (82%), and confirmed that the end surgical result matched their expectations (61%), independently of UL. Lowest scores in satisfaction were observed for the sexual functioning of the neophallus, with 34% satisfied to very satisfied participants. Both satisfaction with the appearance of the neophallus (P < .001) and with voiding (P = .02) were positive predictors of overall patient satisfaction at follow-up, in contrast to the complication and reoperation rate postoperatively (P = .48 and P = .95 respectively). CLINICAL IMPLICATIONS: Transgender men choosing for gGAS with or without UL can be adequately informed on PROs regarding type of surgery, satisfaction with the appearance and functionality, quality of life, feelings of masculinity, and sexuality. STRENGTHS & LIMITATIONS: Study strengths comprise the relatively large cohort, long duration of follow-up, completeness of the data, and innovativeness of the studied outcomes. Limitations are the cross-sectional and retrospective design, possible participation bias and non-validated survey. CONCLUSION: No significant differences in several PROs were observed between participants who chose gGAS with or without UL in this retrospective study. Additionally, according to this study, satisfaction with the appearance of the neophallus and with voiding were positive predictors of overall patient satisfaction at follow-up. de Rooij FPW, van de Grift TC, Veerman H, et al. Patient-Reported Outcomes After Genital Gender-Affirming Surgery With Versus Without Urethral Lengthening in Transgender Men. J Sex Med 2020;18:974-981.

Scrotal Reconstruction in Transgender Men Undergoing Genital Gender Affirming Surgery Without Urethral Lenghtening: A Stepwise Approach.

BACKGROUND: Scrotal (re)construction, scrotoplasty, is performed as part of gender affirming surgery in transgender men. OBJECTIVE: To describe, step-by-step, our scrotal reconstruction technique in transgender men undergoing genital gender affirming surgery without urethral lengthening. MATERIAL AND METHODS: A 29-year-old transgender men underwent scrotal reconstruction and phalloplasty without urethral lengthening. For this purpose, the traditional scrotal reconstruction technique in patients that undergo urethral lengthening was modified. The patient is placed in lithotomy position. A pedicled horseshoe-shaped pubic flap, clitoral hood, and U-shaped labia majora flaps are used for scrotal reconstruction. The inner part of the labia minora (this is used to reconstruct the fixed part of the neourethra) is resected. The cranially pedicled U-shaped labia majora flaps are rotated 90 degrees medially to bring the neo-scrotum in front of the legs. Pedicled labia majora fat pads are released bilaterally and relocated in the neo-scrotum to achieve bulkiness. The meatus and vaginal orifice are diverted underneath the scrotum and a perineostomy is performed. RESULTS: We present our scrotoplasty technique as a step-by-step video guide. The technique results in the reconstruction of a perineostomy at the perineal scrotal transition, an augmented neo-scrotum, minimal visible scars, and proper neo-perineal length. CONCLUSION: Scrotal reconstruction using a horseshoe-shaped pedicled pubic flap, labia majora fat pads, and 2 cranially pedicled U-shaped labia majora flaps results in a neo-scrotum that resembles the biological scrotum closely in terms of bulkiness, size, shape, tactile sensation, and anatomical position.

The First Experience of Using the Pedicled Labia Minora Flap for Urethral Lengthening in Transgender Men Undergoing Anterolateral Thigh and Superficial Circumflex Iliac Artery Perforator Flap Phalloplasty: A Multicenter Study on Clinical Outcomes.

OBJECTIVE: To describe the novel surgical technique of urethral lengthening in anterolateral thigh and superficial circumflex iliac artery perforator flap phalloplasty with a pedicled labia minora flap (PLMF) and report on the clinical outcomes. METHODS: Between March 2014 and August 2018, 16 transgender men underwent phalloplasty with a PLMF for urethral lengthening at the Amsterdam UMC (VU university), the Netherlands and the Belgrade University Hospital, Serbia. Patient demographics, surgical characteristics, neourethra characteristics, intra- and postoperative complications, pre-and postoperative voiding evaluation, and the length of hospital stay were retrospectively identified from chart reviews. RESULTS: The mean neourethral length was 16.8 ± 2.3 cm, and the pars pendulans 11.7 ± 2.2 cm. The neomeatus was localized on top of the neophallus in 12 (75%) patients. No intraoperative complications occurred. Urethral fistula formation occurred in 4 (25%) patients and strictures in 6 (37.5%) patients. In 3 (18.7%) patients a (temporary) perineostomy had to be performed. Voiding from a standing position was possible in 9 (56.3%) patients. CONCLUSION: The PLMF for urethral reconstruction, both pars fixa and pars pendulans, in phalloplasty is a feasible surgical technique in transgender men undergoing anterolateral thigh or superficial circumflex iliac artery perforator flap phalloplasty with sufficient labia minora tissue.

Effectiveness of Preoperative Depilation of the Urethral Donor Site for Phalloplasty: Neourethral Hair Growth and its Effects on Voiding.

BACKGROUND: For transgender men choosing to undergo phalloplasty with urethral lengthening, there is a potential for hair growth in the neourethra. Depilation of the urethral donor site may reduce subsequent intraurethral hair growth. OBJECTIVES: To evaluate the effectiveness of preoperative laser depilation and assess the correlation between urethral hair density and voiding among transgender men undergoing phalloplasty with urethral lengthening. DESIGN, SETTING, AND PARTICIPANTS: This was a retrospective study of 25 transgender men undergoing phalloplasty with urethral lengthening between July 2010 and April 2015 at the VU University Medical Center in Amsterdam. INTERVENTION: Phalloplasty with urethral lengthening using skin with or without preoperative depilation. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Data on preoperative laser depilation treatments were obtained from the local laser center. Intraurethral images were captured via urethroscopy and used to rate hair density. Images of the contralateral forearm were used as a reference. Hair density was rated in terms of the number of hairs per view as zero, low (1-9), moderate (10-19), or high (≥20). Voiding was assessed using the International Prostate Symptom Score (IPSS) questionnaire, a 24-h voiding diary, and uroflowmetry. RESULTS AND LIMITATIONS: Twenty-five patients underwent urethroscopy. In the depilation group (n = 14) the hair reduction was significant and hair density was downgraded on average by 1.0 points (95% confidence interval [CI] 0.5-1.5). The mean number of laser treatment sessions was 6 (range 2-10). In the no-depilation group (n = 11), hair density did not significantly differ between the urethra and the contralateral arm (mean difference 0.18, 95% CI 0.5-0.9). The majority of the patients reported mild voiding complaints (median IPSS score 7, range 2-28) and had a normal functional bladder capacity and a nonobstructed urinary flow with low postvoid volumes. CONCLUSIONS: Laser epilation treatment reduces hair growth but does not eliminate hair. Voiding complaints do not seem to be related to hair density in the urethra. PATIENT SUMMARY: For skin donor sites used in penis construction for transgender men, the amount of hair growth is reduced by preoperative laser depilation, but hair is still present in the new urethra. Hair in the urethra does not cause urinary voiding complaints.

Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty.

INTRODUCTION: After free or pedicled flap phalloplasty, many transgender men need penile prosthesis implantation to successfully engage in penetrative sexual intercourse. Postoperative complications occur frequently. There is a choice between inflatable and malleable penile prostheses. Until recently, no prostheses were designed specifically for this population. AIM: The aim of this study was to describe our preliminary experience with, and surgical outcomes of, implantation of the ZSI 100 FtM Malleable Penile Implant after phalloplasty in transgender men. METHODS: A retrospective chart study was conducted on surgical characteristics and postoperative complications after implantation of the ZSI Malleable Penile Implant in transgender men in 3 European centers for genital transgender surgery in Amsterdam, Stockholm, and Reykjavik. MAIN OUTCOME MEASURE: The main outcomes measures were surgical outcome, complications, and reason of implant failure. RESULTS: 25 patients were retrospectively identified, with a mean age of 36 ± 9 years at implantation. The mean time between prosthesis implantation and phalloplasty was 3.6 ± 2.5 years. 10 patients previously underwent free radial forearm flap phalloplasty, 6 patients had anterolateral thigh flap phalloplasty, 2 patients had superficial circumflex iliac artery perforator phalloplasty, 1 patient had groin flap phalloplasty, and 6 patients underwent combination flap phalloplasty. With a mean follow-up of 6.3 months, prosthesis explantation because of complications was performed in 8 patients (32%), because of infection (n = 3), protrusion (n = 4), or pubic pain (n = 1). In an additional 3 patients, the prosthesis was explanted due to difficulty living with the malleable prosthesis. Of those with the prosthesis in place, 13 of 14 patients (93%) were able to engage in penetrative sexual intercourse. CLINICAL IMPLICATIONS: The current article provides advantages and disadvantages of this medical device. STRENGTH & LIMITATIONS: This is the first study on the ZSI Malleable Penile Implant prostheses in this patient group. It also provides information on the use of malleable prostheses; whereas current literature predominantly focusses on inflatable devices. Limitations comprise the small patient population, short follow-up time, and retrospective nature of the study. CONCLUSION: Complication rates of the ZSI Malleable Penile Implant prosthesis seem high at the start of the learning curve. Although designed specifically for the transgender community, not all transgender patients will be eligible for this type of prosthesis. Patients need to be well counseled on specific (dis)advantages of the prosthesis. Pigot GLS, Sigurjónsson H, Ronkes B, et al. Surgical Experience and Outcomes of Implantation of the ZSI 100 FtM Malleable Penile Implant in Transgender Men After Phalloplasty. J Sex Med 2020;17:152-158.

Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men.

INTRODUCTION: Testicular prosthesis implantation may be used for neoscrotal augmentation in transgender men. AIM: Assess the clinical outcomes and risk factors for postoperative complications of this procedure in transgender men. METHODS: All transgender men who underwent neoscrotal augmentation with testicular implants between January 1992 and December 2018 were retrospectively identified. A retrospective chart study was performed that recorded surgical characteristics and postoperative complications. Risk factors on complications were identified using uni- and multivariate analyses. MAIN OUTCOME MEASURE: Surgical outcomes included explantation due to infection, extrusion, discomfort, or leakage. RESULTS: We identified 206 patients, and the following prostheses were placed: Dow Corning (n = 22), Eurosilicone (n = 2), Nagor (n = 205), Polytech (n = 10), Promedon (n = 105) , Prometel (n = 22), Sebbin (n = 44), and unknown (n = 2). The mean clinical follow-up time was 11.5 ± 8.3 years. In 43 patients (20.8%), one or both prostheses were explanted due to infection, extrusion, discomfort, prosthesis leakage, or urethral problems. Currently, scrotoplasty according to Hoebeke is the most frequently performed technique. Our review found that for this technique explantation occurred in 6 of 52 patients (11.5%). A history of smoking was a risk factor for postoperative infections and prosthesis explantation. In earlier years, larger prostheses were immediately placed at scrotal reconstruction; however, a trend can be seen toward smaller and lighter testicular prostheses and delayed implantation. CLINICAL IMPLICATIONS: Patients wanting to undergo this procedure can be adequately informed on postoperative outcomes. STRENGTHS & LIMITATIONS: Strengths of this study include the number of patients, long clinical follow-up time, and completeness of data. Weaknesses of this study include its retrospective nature and the high variability of prostheses and surgical techniques used. CONCLUSION: Over the years, scrotoplasty techniques and testicular prostheses preferences have changed. Explantation rates have dropped over the last decade. Pigot GLS, Al-Tamimi M, Ronkes B, et al. Surgical Outcomes of Neoscrotal Augmentation with Testicular Prostheses in Transgender Men. J Sex Med 2019;16:1664-1671.

A Retrospective Cohort Study on Surgical Outcomes of Penile Prosthesis Implantation Surgery in Transgender Men After Phalloplasty.

OBJECTIVES: To assess surgical outcomes of penile prosthesis implantation in transgender men who underwent phalloplasty. PATIENTS AND METHODS: Transgender men who underwent penile prosthesis implantation after phalloplasty between January 1989 and September 2018 were retrospectively identified. A chart study was performed recording patient demographics, perioperative complications, and reoperations. RESULTS: A total of 32 patients were identified: 22 underwent free radial forearm flap, 5 anterolateral thigh, 4 anterolateral thigh/free radial forearm flap, and 1 fibular flap phalloplasty. The median age at prosthesis implantation was 36 (range 21-59) years, the mean BMI 25.9 ± 4.0 kg/m2. At first implantation, 16 inflatable (AMS Dynaflex (n = 13), AMS Ambicor (n = 3)) and 16 malleable (Coloplast genesis (n = 14), AMS Spectra (n = 2)) prostheses were placed. Of these, 5 (16%) were removed/replaced because of infection, 2 (6%) because of leakage, 2 because of extrusion, 2 because of dislocation, 2 because of dysfunction, and 1 (3%) because of pain. The postoperative course was completely uneventful in 10 (31.3%) patients. Of all implanted prostheses, including revision procedures (n = 45), 21 (44%) were surgically replaced or removed. CONCLUSION: Prosthesis explantation, replacement, or revision surgery occurs frequently after penile prosthesis implantation. Patients need to be well-informed preoperatively on these complication rates.

Vaginal Colpectomy in Transgender Men: A Retrospective Cohort Study on Surgical Procedure and Outcomes.

BACKGROUND: Colpectomy, removal of the vaginal epithelium, may be performed in transgender men because of a disturbed male self-image, to reduce vaginal discharge, or to reduce the risk of fistula formation at the urethral-neourethral junction in future phalloplasty or metaidoioplasty. AIM: To demonstrate that vaginal colpectomy in transgender men, either alone or in combination with, for example, laparoscopic hysterectomy, metaidoioplasty, scrotoplasty, or urethroplasty, is a feasible procedure. METHODS: This single-center retrospective cohort study included 143 transgender men who underwent vaginal colpectomy between January 2006 and April 2018. Surgical details and clinical outcomes were collected from all patients. OUTCOMES: The primary outcome was the number of perioperative and postoperative complications, including intraoperative blood loss. Secondary outcomes were operating time, change in hemoglobin level, and duration of hospital stay. RESULTS: In 109 patients (76%), the procedure consisted of colpectomy only, whereas in 34 patients (23%), colpectomy was combined with other procedures. In the whole group (combined procedures included), the median blood loss was 300 mL (interquartile range [IQR] = 250 mL), the mean operating time was 132 ± 62 minutes, and the mean duration of hospital admission was 3.6 ± 1.9 days. In the colpectomy-only group, the median blood loss was 300 mL (IQR = 250 mL), mean operating time was 112 ± 40 minutes, and mean duration of hospital admission was 3.2 ± 1.5 days. For the total group, 15 patients (10%) experienced a major perioperative complication (ie, bowel injury, ureter injury, urethra injury, bladder injury, hemorrhage requiring transfusion and/or intervention and conversion to laparoscopy), and 1 patient (0.7%) had a minor perioperative complication (hemorrhage). Major postoperative complications (hemorrhage, hematoma, fistula, wound infection and prolonged pain complaints) were reported in 17 patients (12%), and minor postoperative complications (urinary tract infection, urinary retention, hemorrhage, and hematoma) occurred in 50 patients (35%). CLINICAL IMPLICATIONS: This study provides a detailed description of our technique and comprehensive reporting on perioperative and postoperative complications and reintervention rate. STRENGTHS & LIMITATIONS: Study strengths include the large number of patients included and the detailed reporting on the complications of vaginal colpectomy. The main limitation is the retrospective design, which can cause data to go missing during extraction and is prone to bias. CONCLUSION: Vaginal colpectomy is a procedure with a high complication rate, but its advantages seem to outweigh its disadvantages. In all but 1 case, no long-term sequelae were reported. However, the high complication rate and reintervention rate should be discussed with patients who are considering undergoing this procedure. Nikkels C, van Trotsenburg M, Huirne J, et al. Vaginal Colpectomy in Transgender Men: A Retrospective Cohort Study on Surgical Procedure and Outcomes. J Sex Med 2019;16:924-933.

Influenza infection and risk of acute pulmonary embolism.

BACKGROUND: Influenza infections have been associated with procoagulant changes. Whether influenza infections lead to an increased risk of pulmonary embolism remains to be established. METHODS: We conducted a nested case control study in a large cohort of patients with a clinical suspicion of having pulmonary embolism. Blood samples were collected to investigate the presence of influenza A and B by complement fixation assay (CFA). We compared case patients, in whom pulmonary embolism was proven (n = 102), to controls, in whom pulmonary embolism was excluded (n = 395). Furthermore, we compared symptoms of influenza-like illness in both patient groups 2 weeks prior to inclusion in the study, using the influenza-like illness (ILI) score, which is based on a questionnaire. We calculated the risk of pulmonary embolism associated with influenza infection. RESULTS: The percentage of patients with influenza A was higher in the control group compared to the case group (4.3% versus 1.0%, respectively, odds ratio 0.22; 95% CI: 0.03-1.72). Influenza B was not detectable in any of the cases and was found in 3 of the 395 controls (0.8%). The ILI score was positive in 24% of the cases and 25% in the control persons (odds ratio 1.16, 95% CI: 0.67-2.01). We did not observe an association between the ILI score and proven influenza infection. CONCLUSION: In this clinical study, influenza infection was not associated with an increased risk of acute pulmonary embolism. The ILI score is non-specific in this clinical setting.