Gender-affirming care in urology: emergency care of the gender-affirming surgical patient-what the primary urologist needs to know.

OBJECTIVE: To present a narrative review of fundamental information needed to manage postoperative complications in patients who have undergone genital gender-affirming surgery (GAS). METHODS: A narrative review was performed using the following keywords: 'gender-affirming surgery', 'complications', 'emergency', 'postoperative'. Articles were included after being reviewed by two primary authors for relevance. Four clinicians with significant experience providing both primary and ongoing urological care to patients after GAS were involved in article selection and analysis. RESULTS: The most common feminising genital GAS performed is a vaginoplasty. The main post-surgical complications seen by urologists include wound healing complications, voiding dysfunction, postoperative bleeding, vaginal stenosis, acute vaginal prolapse and graft loss, rectovaginal fistula, and urethrovaginal fistula. The most common masculinising genital GAS options include metoidioplasty and phalloplasty. Complications for these surgeries include urethral strictures, urethral fistulae, and urethral diverticula. Penile implants may also accompany phalloplasties and their complications include infection, erosion, migration, and mechanical failure. CONCLUSION: Genital GAS is increasing, yet there are still many barriers that individuals face not only in accessing the surgeries, but in receiving follow-up care critical for optimal outcomes. Improved education and training programmes would be helpful to identify and manage postoperative complications. Broader cultural level changes are also important to ensure a safe, gender-inclusive environment for all patients.

The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids.

BACKGROUND: Following metoidioplasty, transmen (TM) experience sexual function challenges including erectile dysfunction, which is typically treated in cisgender men with phosphodiesterase-5 inhibitors (PDE5i) and intracavernosal injections (ICI). AIM: We aim to evaluate sexual function post-metoidioplasty and explore attitudes toward using PDE5i and ICI as potential erectile aids METHODS: All patients who had metoidioplasty completed at the Gender Surgery Program in Vancouver, British Columbia were contacted. Participants completed an electronically accessible self-constructed questionnaire consisting of 39 items on erectile function, orgasm, and penetrative intercourse which also captured Erection Hardness Scores (EHS). Data were analyzed via t-test and 1-way ANOVA. OUTCOMES: Our outcomes were the importance of erectile function, ability to orgasm, penetrative intercourse, and attitudes towards using PDE5i and ICI post-metoidioplasty. RESULTS: Fifteen out of 22 patients completed the survey (median age 32 years). Most had metoidioplasty within the past 2 years. The participants ranked the ability to orgasm and to achieve or maintain erections significantly higher than penetrative intercourse (P <.001, P =.005 respectively). Most participants reported facing challenges with penetrative intercourse (87%) and erectile function (80%). In contrast, a smaller proportion reported challenges with orgasm (33%). With regards to EHS, 83% of participants described their erections as either "larger but not hard," or "hard but not hard enough for penetration." A total of 47% of the participants had previously tried PDE5i, but none had used ICI. Although 87% were willing to use PDE5i, only 40% were willing to try ICI to improve their erections. Patients reported lack of knowledge and understanding among primary care physicians as barriers to accessing treatment for sexual dysfunction. CLINICAL TRANSLATION: The results of this study can facilitate decision making for TM undergoing genital gender-affirmation surgery and provide potential options for improving erectile function post surgery. STRENGTHS & LIMITATIONS: This study represents the first assessment of sexual function and use of erectile aids in post-metoidioplasty patients. The results of this study are limited by the small sample size and enrolment from a single surgical center. CONCLUSION: Metoidioplasty patients surveyed fail to achieve a fully rigid erection without treatment, typically retain the ability to orgasm, and are generally willing to try PDE5i. Khorrami A, Kumar S, Bertin E, et al. The Sexual Goals of Metoidioplasty Patients and Their Attitudes Toward Using PDE5 Inhibitors and Intracavernosal Injections as Erectile Aids. Sex Med 2022;10:100505.

Comparison of Adjuvant Radiation Therapy Before or After Artificial Urinary Sphincter Placement: A Multi-Institutional, Retrospective Analysis.

OBJECTIVE: To determine if the timing of radiation therapy on artificial urinary sphincter (AUS) impacts complication rates, revision rates, and number of pads per day after placement. METHODS: A retrospective review was conducted of men with prostate cancer who underwent AUS placement and radiation therapy between 1987 and 2016. RESULTS: Of 306 men, 292 (95.4%) received radiation before AUS placement (group 1) and 14 (4.6%) received radiation after AUS placement (group 2). Median follow-up was 30 months after AUS placement. Group 1 had 32 of 292 (11.0%) patients suffer from erosion, compared with 0 of 14 (0.0%) patients in group 2 (P = .191). None of the patients in group 2 had infection or mechanical failure. The number of patients who received revision in group 1 was 91 of 292 (31.2%) and in group 2 was 2 of 14 (14.3%) (P = .180). The number of pads used per day in group 1 before and after AUS placement was 5.24 ± 3.12 and 1.13 ± 1.31, respectively (P <.001). In group 2, the number of pads used per day before and after AUS placement was 6.09 ± 1.97 and 1.53 ± 0.99, respectively (P <.001). There was no significant difference in the average number of postoperative pads used per day between group 1 and group 2 (P = .907). CONCLUSION: The timing of radiation therapy does not appear to significantly affect complication rates or urinary continence, as measured in pads used after AUS placement. This multi-institutional retrospective analysis showed similar erosion and revision rates when radiation occurred after AUS placement and demonstrates preliminary safety and feasibility of the administration of radiation after AUS placement.

Time to treatment of prostate cancer through the Calgary Prostate Institute rapid access clinic.

PURPOSE: To determine the wait time between initial referral, biopsy, diagnosis and individual treatment modalities of prostate cancer treatment through the Calgary Prostate Institute rapid access clinic (RAC) and compare to historical data estimates in Alberta and to suggested standards. Biopsy rate, rate of confirmed prostate cancer and the distribution of treatment modality for patients seen through the RAC is included. MATERIALS AND METHODS: A non-consented, retrospective chart review of 1103 patients from the Calgary Health Region referred to the RAC between September 2005 and August 2006 was completed. RESULTS: Patients experienced a median wait time of 21 days between referral from their family doctor and prostate biopsy. A total of 31.4% of patients referred to the clinic were requested to have a prostate biopsy performed and 50.8% of biopsies resulted in confirmed prostate cancer requiring treatment. Median wait time between diagnosis and treatment for all treatment types was 52.0 days with a 90th percentile of 146.2 days. Median wait time between referral and treatment for all treatment modalities was 101 days with a 90th percentile of 187.2 days. CONCLUSION: Calgary rapid access clinic reduces wait time between referral and biopsy by 78%. Stratifying across treatment type indicates that watchful waiting is the shortest time duration and radiation with hormone therapy is the longest.