Tissue Options for Construction of the Neovaginal Canal in Gender-Affirming Vaginoplasty.

Gender-affirming vaginoplasty (GAV) comprises the construction of a vulva and a neovaginal canal. Although technical nuances of vulvar construction vary between surgeons, vulvar construction is always performed using the homologous penile and scrotal tissues to construct the corresponding vulvar structures. Therefore, the main differentiating factor across gender-affirming vaginoplasty techniques is the tissue that is utilized to construct the neovaginal canal. These tissue types vary markedly in their availability, histology, and ease of harvest and have different advantages and disadvantages to their use as neovaginal lining. In this narrative review, the authors provide a comprehensive overview of the tissue types and associated operative approaches used for construction of the neovagina in GAV. Tissue choice is guided by several factors, such as histological similarity to natal vaginal mucosa, tissue availability, lubrication potential, additional donor site morbidity, and the specific goals of each patient. Skin is used to construct the neovagina in most cases with a combination of pedicled penile skin flaps and scrotal and extra-genital skin grafts. However, skin alternatives such as peritoneum and intestine are increasing in use. Peritoneum and intestine are emerging as options for primary vaginoplasty in cases of limited genital skin or revision vaginoplasty procedures. The increasing number of gender-affirming vaginoplasty procedures performed and the changing patient demographics from factors such as pubertal suppression have resulted in rapidly evolving indications for the use of these differing vaginoplasty techniques. This review sheds light on the use of less frequently utilized tissue types described for construction of the neovaginal canal, including mucosal tissues such as urethral and buccal mucosa, the tunica vaginalis, and dermal matrix allografts and xenografts. Although the body of evidence for each vaginoplasty technique is growing, there is a need for large prospective comparison studies of outcomes between these techniques and the tissue types used to line the neovaginal canal to better define indications and limitations.

The Current State of Transgender Health Curricula in Graduate Surgical Education: A Systematic Review of Survey Data.

OBJECTIVES: Transgender and gender diverse (TGD) individuals in the U.S. face significant healthcare disparities, which can be further exacerbated by providers' unfamiliarity with this population's specific needs. ACGME currently does not have requirements for gender-affirming surgery (GAS) in the residency programs of surgical specialties that are responsible for providing this care. This systematic review evaluates gender-affirming care (GAC) and GAS training in surgical residency programs in the U.S. through the analysis of survey respondent data. METHODS: Six databases (PubMed, Embase, Web of Science and Scopus, Cochrane Library and Google Scholar) were searched in December 2022 and May 2023. The search process ultimately yielded 22 survey-based studies, published between 2015 and 2023, with responses from 3020 respondents (2582 trainees and/or attending physicians, 438 program directors). RESULTS: Six different surgical specialties were the focus of included studies, and common questions revolved around GAS training availability, comfort in treating TGD patients, and the importance of GAS in graduate surgical education (GSE). Less than half of trainees indicated that they received some form of previous GAC or GAS training, and less than half of program directors indicated that their residency or fellowship program offered such training. CONCLUSIONS: While comfort levels around treating TGD patients ranged, the studies indicated an overall perceived importance of GAS training. These findings highlight the need to incorporate GAS training into graduate surgical education to improve access to and quality of care for TGD patients.

Outcomes of Orchiectomy for Gender-affirming Surgery: A National Surgical Quality Improvement Program Study.

OBJECTIVE: To identify perioperative outcomes of transgender orchiectomy (TGO) and to broadly compare outcomes of TGO to cisgender orchiectomy (CGO) for nononcologic indications. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2020, a retrospective study was performed on patients with ICD-9/10 codes for gender dysphoria, testicular torsion, and testicular pain who underwent simple orchiectomy. Demographics and surgical outcomes were summarized. Welch two-sample t test and chi-square test were used for group analysis. A trend analysis was performed for temporal trends of these surgeries. RESULTS: 246 patients underwent TGO and 997 patients underwent CGO (607 testicular torsion, 390 testicular pain). Overall complication rates between TGO and CGO did not differ for testicular torsion (3.7% vs 4.4%, P = .6) or testicular pain (3.7% vs 5.9%, P = .2). No differences in patient characteristics were seen within the TGO group when comparing those who experienced complications to those who didn't. From 2015 to 2020, TGO cases significantly increased by, on average, 9.5 cases per year (95% CI: 6.3-12.7, P = .001), while CGO had showed no significant temporal change. CONCLUSION: Standalone TGO can be performed safely in an outpatient setting with an acceptable complication profile in medically diverse patients.

Ethnic Disparities in Thrombotic and Bleeding Diatheses Revisited: A Systematic Review of Microsurgical Breast Reconstruction across the East and West.

BACKGROUND: Ethnicity has been shown to play a role in disparate coagulative responses between East Asian and Caucasian patients undergoing nonmicrovascular surgery. In this study, we sought to further investigate this hematologic phenomenon between the two ethnic groups within the field of microsurgical breast reconstruction. METHODS: A systematic review examining the reported incidence of microvascular thrombosis and all-site bleeding among breast free flaps in East Asians and Westerners was performed. Statistical analysis was performed using the chi-square test. RESULTS: Ten East Asian studies with 581 flaps and 99 Western studies with 30,767 flaps were included. A statistically significant higher rate of thrombotic complications was found in Westerners compared with East Asians (4.2 vs. 2.2%, p = 0.02). Conversely, bleeding events were more common in East Asians compared with Westerners (2.6 vs. 1.2%, p = 0.002). CONCLUSION: There appears to be an ethnicity-based propensity for thrombosis in Westerners and, conversely, for bleeding in East Asians, as evident by the current systematic review of microvascular breast reconstruction data. It is therefore advisable to consider ethnicity in the comprehensive evaluation of patients undergoing microsurgical procedures.

Increased antibiotic duration improves survival of irrigation and debridement after revision total joint arthroplasty.

BACKGROUND: We sought to evaluate reoperation-free survival following I&D with modular component exchange of revision total joint arthroplasty (TJA). METHODS: Of revision TJAs from 2004 to 2012 (n = 4,166), 30 were I&D with modular component exchange after index revision for aseptic indications. Patients with (n = 12) and without (n = 18) reoperation for infection recurrence were analyzed. RESULTS: Reoperation-free survival (60% at mean 4.8 year follow-up) improved with increased duration of antibiotic therapy (p = 0.0185), with maximum benefit at 2 years. CONCLUSIONS: At least 2 years of antibiotic therapy should be administered after I&D with modular component exchange for acutely infected revision TJA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Factors affecting failure of irrigation and debridement with liner exchange in total knee arthroplasty infection.

BACKGROUND: We sought to determine if reoperation-free survival following irrigation and debridement with polyethylene liner exchange of acutely infected primary TKA is affected by: 1) postoperative antibiotic duration; 2) patient characteristics or surgical factors; 3) infecting organism; or 4) whether infection was acute postoperative versus hematogenous. METHODS: Of revision TKAs from 2004 to 2012 (n = 1735), 76 underwent irrigation and debridement (I&D) with liner exchange after primary TKA with mean 3.5-year follow-up. We analyzed those requiring reoperation for infection (n = 21) versus those who did not (n = 55). RESULTS: Increased duration of postoperative antibiotic therapy (p = 0.0163) decreased reoperation for infection. Atrial fibrillation (p = 0.0053), chronic obstructive pulmonary disease (COPD) (p = 0.0122), more than 15 cells per high powered field (HPF) (p = 0.0124), or higher preoperative C-reactive protein (p = 0.0025) increased reoperation for infection. Incidence of infection recurrence was highest with Methicillin resistant S. aureus (MRSA) and lowest with Gram negative organisms. There was no difference in reoperation-free survival between acute postoperative and hematogenous infections. CONCLUSION: Reoperation-free survival following I&D with polyethylene liner exchange of acutely infected primary TKA: 1) improves with increased postoperative antibiotic therapy duration so chronic antibiotic suppression should be considered following TKA I&D with liner exchange; 2) is worse with atrial fibrillation, COPD, >15 cells/HPF, preoperative C-reactive protein >500 mg/L, or MRSA so two-stage revision may be favored in these patients; and 3) is equivalent in acute postoperative and hematogenous infections.

Increased antibiotic duration improves reoperation free survival after total hip arthroplasty irrigation and debridement.

BACKGROUND: We aimed to determine if reoperation-free survival following irrigation and debridement (I&D) with head and liner exchange of infected primary THA is affected by: 1) postoperative antibiotic duration; 2) patient characteristics; 3) infecting organism; or 4) postoperative versus hematogenous infection. METHODS: Revision THAs from 2006 to 2012 (n = 1184) were observed; 26 underwent I&D with head and liner exchange with mean 4.1-year follow-up. Patients with reoperation for infection (n = 2) versus those without reoperation (n = 24) were analyzed. RESULTS: Increased postoperative antibiotic therapy duration (p = 0.0333) decreased risk of reoperation for infection. CONCLUSION: Chronic antibiotic suppression should be considered following THA I&D with head and liner exchange.

Restoring femoral offset is the most important technical factor in preventing total hip arthroplasty dislocation.

PURPOSE: Our aim was to determine if acetabular component position, femoral offset restoration, or leg-length equality is most important for total hip arthroplasty (THA) stability. METHODS: A matched case (n = 67)-control (n = 247) design and conditional logistic regression model were used to examine risk factors for dislocation in primary THA. RESULTS: When femoral offset was at least 3 mm greater than that of the contralateral hip, risk of dislocation was lower (p = 0.0192). Neither leg-length difference nor acetabular component abduction or version angle was associated with dislocation. CONCLUSIONS: Our data suggest restoring femoral offset is the most important technical factor in preventing THA dislocation.

Mineralocorticoid receptors in immune cells: emerging role in cardiovascular disease.

Mineralocorticoid receptors (MRs) contribute to the pathophysiology of hypertension and cardiovascular disease in humans. As such, MR antagonists improve cardiovascular outcomes but the molecular mechanisms remain unclear. The actions of the MR in the kidney to increase blood pressure are well known, but the recent identification of MRs in immune cells has led to novel discoveries in the pathogenesis of cardiovascular disease that are reviewed here. MR regulates macrophage activation to the pro-inflammatory M1 phenotype and this process contributes to the pathogenesis of cardiovascular fibrosis in response to hypertension and to outcomes in mouse models of stroke. T lymphocytes have recently been implicated in the development of hypertension and cardiovascular fibrosis in mouse models. MR activation in vivo promotes T lymphocyte differentiation to the pro-inflammatory Th1 and Th17 subsets while decreasing the number of anti-inflammatory T regulatory lymphocytes. The mechanism likely involves activation of MR in antigen presenting dendritic cells that subsequently regulate Th1/Th17 polarization by production of cytokines. Alteration of the balance between T helper and T regulatory lymphocytes contributes to the pathogenesis of hypertension and atherosclerosis and the associated complications. B lymphocytes also express the MR and specific B lymphocyte-derived antibodies modulate the progression of atherosclerosis. However, the role of MR in B lymphocyte function remains to be explored. Overall, recent studies of MR in immune cells have identified new mechanisms by which MR activation may contribute to the pathogenesis of organ damage in patients with cardiovascular risk factors. Conversely, inhibition of leukocyte MR may contribute to the protective effects of MR antagonist drugs in cardiovascular patients. Further understanding of the role of MR in leukocyte function could yield novel drug targets for cardiovascular disease.

Electrochemical characterization of Escherichia coli adaptive response protein AidB.

When exposed to known DNA-damaging alkylating agents, Escherichia coli cells increase production of four DNA repair enzymes: Ada, AlkA, AlkB, and AidB. The role of three enzymes (Ada, AlkA, and AlkB) in repairing DNA lesions has been well characterized, while the function of AidB is poorly understood. AidB has a distinct cofactor that is potentially related to the elusive role of AidB in adaptive response: a redox active flavin adenine dinucleotide (FAD). In this study, we report the thermodynamic redox properties of the AidB flavin for the first time, both for free protein and in the presence of potential substrates. We find that the midpoint reduction potential of the AidB flavin is within a biologically relevant window for redox chemistry at -181 mV, that AidB significantly stabilizes the flavin semiquinone, and that small molecule binding perturbs the observed reduction potential. Our electrochemical results combined with structural analysis allow for fresh comparisons between AidB and the homologous acyl-coenzyme A dehydrogenase (ACAD) family of enzymes. AidB exhibits several discrepancies from ACADs that suggest a novel catalytic mechanism distinct from that of the ACAD family enzymes.