Genital gender-affirming surgery for transgender women

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.</p

Genital gender-affirming surgery for transgender women

Transgender women may opt for genital gender-affirming surgery (gGAS), which comprises bilateral orchiectomy, gender-affirming vulvoplasty, or vaginoplasty. Vaginoplasty is chosen most frequently in this population, penile inversion vaginoplasty being the surgical gold standard. In selected cases, skin graft vaginoplasty, intestinal vaginoplasty, or peritoneal vaginoplasty may be indicated. In this article, we discuss the various types of gGAS for transgender women, (contra)-indications, intraoperative considerations, techniques, surgical outcomes, and postoperative patient-reported outcomes.</p

Predictors of women's sexual outcomes after implant-based breast reconstruction

Objective: Although breast reconstruction has become an important treatment modality following mastectomy, few studies assessed predictors of postoperative sexual outcomes after breast reconstruction. Therefore, we aimed to study three sexual outcomes following implant-based breast reconstruction (IBBR), and associate multiple biopsychosocial factors with these outcomes. Methods: Data collection was part of a multicenter prospective study on IBBR. A predictive model was tested including medical, background and psychological predictors, partner relationship factors and physical sexual function. Data collection included clinical and questionnaire data (preoperatively and 1 year following reconstruction) using the BREAST-Q Sexual well-being scale (BQ5), and questions regarding sexual dysfunction and sexual satisfaction questions (Female Sexual Function Index). Results: The study sample consisted of 88 women who underwent mastectomy and IBBR. Mean postoperative BQ5 scores were lower than before surgery (M = 58 [SD = 18] vs 65 [SD = 20]; P =.01, Wilks' Lamdba =.88). Sexual dysfunctions were related strongest to orgasm inability and vaginal lubrication issues. The tested models predicted 37%-46% of the sexual outcomes: sexual outcomes were mostly predicted by psychosocial well-being, physical sexual function and partner support. Preoperative sexual and psychosocial well-being were positively associated with postoperative sexual well-being (r = 0.45 and r = 0.47). Conclusions: Although moderately positive sexual outcomes were reported after IBBR, some women reported issues with vaginal lubrication, breast sensation and orgasm. Sexual dysfunctions were predicted by vaginal lubrication and medical treatments, while sexual well-being and satisfaction were more predicted by psychosocial well-being and partner support. We advocate supportive care that includes partners and psychosocial functioning to optimize sexual outcomes after IBBR

The aesthetic items scale: A tool for the evaluation of aesthetic outcome after breast reconstruction

__Background:__ Valid tools to assess aesthetic outcomes after breast reconstructive surgery are scarce. Previously a professional aesthetic assessment scale was introduced, the Aesthetic Items Scale (AIS). We aim to determine if this method is a valid and reliable tool to assess aesthetic outcome after breast reconstructive surgery. __Methods:__ The study population was consenting women who underwent prophylactic mastectomy with subsequent implant-based breast reconstruction. The aesthetic outcome with regard to breast volume, shape, symmetry, scars, and nipple areola complex was rated on a 5-point scale using standardized photographs to give a summed total score. Photographs were evaluated by the patient, 5 plastic surgeons, and 3 mammography nurses. An overall rating of aesthetic outcome on a 1-10 scale was given separately. We determined the intraclass correlation coefficient and assessed interobserver agreement. To assess validity, we calculated the correlation between total score and overall rating of aesthetic outcome. __Results:__ Interobserver reliability was highest between plastic surgeons for the subitem and overall scores and ranged between 0.56 and 0.82. The summed score of the AIS correlates strongly with the overall rating in professionals but not in patients. __Conclusions:__ The AIS is a valid and reliable method for evaluating aesthetic outcome of breast reconstruction by plastic surgeons. The results indicate that patients judge aesthetic outcome differently, taking into account factors that are not represented in the AIS. Professionals can use this method to evaluate surgical results, but other measurements are needed to map satisfaction of the patient with her breasts

Ileal vaginoplasty as vaginal reconstruction in transgender women and patients with disorders of sex development: an international, multicentre, retrospective study on surgical characteristics and outcomes

OBJECTIVE: To describe the surgical outcomes of ileal vaginoplasty in transgender women and patients with disorders of sex development (DSD). PATIENTS AND METHODS: Transgender women and patients with DSD, who underwent ileal vaginoplasty at the VU University Medical Center Amsterdam, University Hospital Trieste, University Hospital Essen, and Belgrade University Hospital, were retrospectively identified. A chart review was performed, recording surgical technique, intraoperative characteristics, complications, and re-operations. RESULTS: We identified a total of 32 patients (27 transgender and five non-transgender), with a median (range) age of 35 (6-63) years. Ileal vaginoplasty was performed as the primary procedure in three and as a revision procedure in the remaining 29. The mean (sd) operative time was 288 (103) min. The procedure was performed laparoscopically (seven patients) or open (25). An ileal 'U-pouch' was created in five patients and a single lumen in 27. Intraoperative complications occurred in two patients (one iatrogenic bladder damage and one intraoperative blood loss necessitating transfusion). The median (range) hospitalisation was 12 (6-30) days. Successful neovaginal reconstruction was achieved in all. The mean (sd) achieved neovaginal depth was 13.2 (3.1) cm. The median (range) clinical follow-up was 35 (3-159) months. In one patient a recto-neovaginal fistula occurred, which lead to temporary ileostomy. Introital stenosis occurred in four patients (12.5%). CONCLUSION: Ileal vaginoplasty can be performed with few intra- and postoperative complications. It appears to have similar complication rates when compared to sigmoid vaginoplasty. It now seems to be used predominantly for revision procedures

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570