Erectile dysfunction and testosterone replacement therapy: When, why and how

Testosterone deficiency (TD) is of growing concern to clinicians, as the prevalence has increased over time with increasing aging of the population in the western world. In this chapter we will show that both the biochemical and clinical diagnosis is difficult because in men with previously normal virilisation, symptoms of hypogonadism are relatively mild even if serum T concentrations are low. And, what makes it more difficult, hypogonadism mimics symptoms that go along with physiological aging, such as reduced libido, sexual dysfunction, asthenia, low energy, depressed mood, and more specific symptoms such as reduced volume of the ejaculate and slower grow of facial hair. The fact however that TD often occurs in combination with certain clinical conditions such as chronic disease in general, the metabolic syndrome in particular and certain medication makes it possible to a sketch a profile of a man with TD and to identify those who may benefit from testosterone replacement therapy (TRT). TRT is safe in the short term (long-term data are lacking), but conclusive evidence of effectiveness is lacking. Furthermore, there are more and more indications that a change to a healthy lifestyle, especially more physical activity, diet, stress reduction and social support, is a valid alternative

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 after treatment of urethral complications following metoidioplasty in transgender men

Background: Several treatment options for urethral complications following metoidioplasty in transmen are described in the literature, yet little is known with regard to the surgical outcomes. Aim: The aim of this study was to analyze the surgical outcomes after treatment of urethral strictures and urethral fistulas following metoidioplasty. Methods: A multicenter retrospective cohort study was conducted with transmen treated for strictures and fistulas after metoidioplasty in 3 tertiary referral centers. Outcomes: The primary outcome was the recurrence-free rate after surgical treatment of urethral strictures and urethral fistulas over a time period of 3 years postoperatively. Results: Of 96 transmen included in this study with a urethral complication, 44 (46%) experienced a urethral fistula, 31 (32%) a urethral stricture, and 21 (22%) both complications simultaneously. The recurrence-free rate for urethral strictures following endoscopic management (ie, urethral dilation or direct visual internal urethrotomy) was 61% after 1, 50% after 2, and 43% after 3 years, compared to 82% following open treatment options after 1, 2, and 3 years (P = .002). Open treatment options were Heineke-Mikulicz procedure (7/9, 78% success), excision and primary anastomosis (3/3, 100%), 2-stage without graft (9/9, 100%), pedicled flap urethroplasty (1/1, 100%), and buccal mucosa graft urethroplasty (2/4 [50%] single-stage, 1/1 [100%] 2-stage). The recurrence-free rate for small urethral fistulas located at the pendulous urethra was 79% after 1, and 72% after 2 and 3 years, compared to 45% after 1, and 41% after 2 and 3 years for large fistulas, generally located at the urethral anastomoses of the fixed urethra. Treatment options for urethral fistulas were fistulectomy (26/48, 54%), fistulec-tomy & (redo) colpectomy (7/11, 64%), buccal mucosa graft urethroplasty (1/1, 100%), and retubularization of the urethral plate (3/4, 75%). A colpectomy before or during reoperation of a urethral fistula at the proximal urethral anastomosis showed higher success rates compared to without a colpectomy (7/11 [64%] vs 2/13 [15%] respectively, P = .03). Clinical Implications: This study provides insight in the treatment possibilities and corresponding outcomes of urethral complications following metoidioplasty in transmen. Strengths & Limitations: Strengths were the relatively large sample size and the overview of multiple treatment options available. Limitations were the heterogeneity of the cohort, underexposure of some surgical modalities, and absence of patient-reported outcomes. Conclusion: Open surgical techniques show better long-term outcomes in the management of urethral strictures compared to endoscopic options, and a colpectomy is beneficial before or during urethral fistula repair at the proximal urethral anastomosis. Copyright (C) 2021 The Authors. Published by Elsevier Inc. on behalf of the International Society for Sexual Medicine

Double flap phalloplasty in transgender men: Surgical technique and outcome of pedicled anterolateral thigh flap phalloplasty combined with radial forearm free flap urethral reconstruction

Introduction: Radial forearm free flap (RFFF) tube-in-tube phalloplasty is the most performed phalloplasty technique worldwide. The conspicuous donor-site scar is a drawback for some transgender men. In search for techniques with less conspicuous donor-sites, we performed a series of one-stage pedicled anterolateral thigh flap (ALT) phalloplasties combined with RFFF urethral reconstruction. In this study, we aim to describe this technique and assess its surgical outcome in a series of transgender men. Patients and Methods: Between January 2008 and December 2015, nineteen transgender men (median age 37, range 21-57) underwent pedicled ALT phalloplasty combined with RFFF urethral reconstruction in one stage. The surgical procedure was described. Patient demographics, surgical characteristics, intra- and postoperative complications, hospitalization length, and reoperations were recorded. Results: The size of the ALT flaps ranged from 12 × 12 to 15 × 13 cm, the size of the RFFFs from 14 × 3 to 17 × 3 cm. Median clinical follow-up was 35 months (range 3-95). Total RFFF failure occurred in two patients, total ALT flap failure in one patient, and partial necrosis of the ALT flap in one patient. Long-term urinary complications occurred in 10 (53%) patients, of which 9 concerned urethral strictures. Conclusions: In experienced hands, one-stage pedicled ALT phalloplasty combined with RFFF urethral reconstruction is a feasible alternative surgical option in eligible transgender men, who desire a less conspicuous forearm scar. Possible drawbacks comprise flap-related complications, difficult inner flap monitoring and urethral complications

Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men—A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction

Background: Genital gender-affirming surgery (gGAS) with urethral lengthening (UL) in transgender men is associated with high urological complication and reoperation rates. Since 2009, we offer gGAS without UL to avoid these complications. Aim: The aim of this study was to assess what portion of the transgender men opted for gGAS without UL and to assess functional, surgical outcomes, and patient satisfaction after gGAS without UL. Material and methods: Retrospective data were collected from patients’ charts. The International Prostate Symptom Score, uroflowmetry, and 24-hour frequency voiding chart were used to assess voiding, and a self-constructed semistructured questionnaire was used to assess patient-reported outcomes. Transgender men who underwent gGAS without UL between January 2009 and January 2018 were included, and 56 transgender men were approached to complete the patient-reported outcome measurement. The simple statistical analysis combined with the Mann-Whitney U test and the Wilcoxon signed-rank test was used. Outcomes: 68 transgender men were included. Median follow-up time was 24 (6–129) months. Uroflowmetry and the International Prostate Symptom Score were completed by 44 transgender men, whereas 13 completed the frequency voiding chart preoperatively and postoperatively, respectively. The patient-reported outcome measurement was completed by 40 of 56 (71%) transgender men. Result: Postoperative surgical and urological complications occurred in 9 of 68 (13%) and 8 of 68 (12%) patients, respectively. Storage and voiding function remained unchanged. The median quality of life because of urinary symptoms was scored as “pleased.” Sexual functioning and voiding were scored satisfactory and very satisfactory in 18 of 40 (45%) and 21 of 40 (53%) patients, respectively. The number of patients satisfied with the penis and neoscrotum was 25 of 40 (63%) and 26 of 40 (65%), respectively. Increased self-esteem was reported by 32 of 40 (80%), 32 of 40 (80%) would undergo the surgery again, and 28 of 40 (70%) would recommend it to others. Clinical Implications: gGAS without UL should be part of the surgical armamentarium in centers performing gender-affirming surgery. Strengths and limitations: Strengths of this study comprise the number of patients, the completeness of data, incorporation of patient-reported outcomes, and description of a relatively new surgical approach that may be well-suitable for a subgroup of transgender men. Limitations are the retrospective study design and the lack of validated questionnaires. Conclusion: gGAS without UL shows good surgical and urological outcomes. After extensive counseling, the majority of this selective group of patients shows favorable patient-reported outcomes. Pigot GLS, Al-Tamimi M, Nieuwenhuijzen JA, et al. Genital Gender-Affirming Surgery Without Urethral Lengthening in Transgender Men—A Clinical Follow-Up Study on the Surgical and Urological Outcomes and Patient Satisfaction. J Sex Med 2020;17:2478–2487

Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen

Background: As genital gender-affirming surgery (GAS) is a demanding and life-changing intervention, transmen should be able to make choices about the surgical treatment based on outcomes that are most important to them, while taking into consideration the concomitant risks involved. Aim: Develop a decision aid (DA) for genital surgery in transmen (DA-GST) that can assist both transmen and health care professionals (HCPs) in making a well-informed decision about the surgical treatment. Methods: A qualitative focus group study was performed. 5 Focus groups were organized with both HCPs and transmen. These were led by an independent professional moderator. Data collected during these focus groups were analyzed to provide content for the DA. Outcomes: To develop content for a DA-GST. Results: Data collected during the focus groups related to the treatment options, information deemed relevant by transmen, and the arguments for or against each treatment option. Collected items were divided into the following themes: outcome, quality of life, environment, sexuality, and beliefs. Clinical Implications: The tool will be useful in assisting both transmen and HCPs in the shared decision-making process regarding genital GAS by exploring which domains are most relevant for each specific individual. Strengths & Limitations: This DA was developed according to an iterative participatory design approach to fit the needs of both transmen and HCPs. Issues that transmen find important and relevant pertaining to genital GAS were translated into arguments that were incorporated in the DA-GST. The study is limited by the group that had participated. Not all arguments for or against specific surgical options may be covered by the DA-GST. Conclusion: An online DA was developed to support transmen with their decision-making process concerning all surgical options for removal of reproductive organs and genital GAS. Özer M, Pigot GL, Bouman M‐B, et al. Development of a Decision Aid for Genital Gender-Affirming Surgery in Transmen. J Sex Med 2018;XX:XXX–XXX

Surgical and Functional Outcomes of Bladder Neck Incision for Primary Vesico-Urethral Anastomosis Stricture after Robot-assisted Radical Prostatectomy are Influenced by the Presence of Pre- or Postoperative Radiotherapy

Objective: To report the intermediate- to long-term outcomes of bladder neck incision (BNI) for vesico-urethral anastomosis stricture (VUAS) after robot-assisted radical prostatectomy (RARP) and the influence of pre- or post-RARP radiotherapy on these outcomes. Methods: A retrospective cohort study was performed with patients who underwent BNI for VUAS after RARP in a high-volume prostatectomy centre between 2006 and July 2021. Data was collected from patient charts. The cohort was divided into 4 groups: VUAS after (1) RARP-only, (2) RARP, but before salvage radiotherapy (SRT) (VUAS pre-SRT), (3) RARP and after SRT (VUAS post-SRT), and (4) primary radiotherapy and salvage RARP (SRARP). The VUAS recurrence rates, the ability to perform functional transurethral micturition and the post-BNI urinary continence rates were reported. Results: BNI was performed in 90 patients. The median time between first BNI and last follow-up was 32 months (interquartile range 10-58, range 0-171). The majority of VUAS occurred within 6 months after (S)RARP. In those who underwent BNI, recurrent VUAS was reported in 12%, 57%, 29%, and 50% of patients after RARP-only, VUAS pre-SRT, VUAS post-SRT, and SRARP, respectively. Ultimately, transurethral micturition was possible in 94%, 93%, 71%, and 80%, respectively. Severe urinary-incontinence rates (>1 pads/d) were 6%, 16%, 10%, and 29% for RARP-only, VUAS pre-SRT, VUAS post-SRT, and SRARP patients, respectively. Conclusion: Primary radiotherapy before RARP and SRT after RARP significantly influenced the success rates of BNI. Those who underwent BNI after SRARP had worse outcomes than patients who underwent RARP only

A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen

Background Genital dissatisfaction is an important reason for transmen to undergo genital gender-confirming surgery (GCS; phalloplasty or metoidioplasty). However, little is known about motives for choosing specific techniques, how transmen benefit postoperatively, and whether psychosexual outcomes improve. Aim To evaluate motivations for and psychosexual outcomes after GCS. Methods A longitudinal study of 21 transmen at least 1 year after GCS was conducted. Participants were recruited through their surgeon. Data were collected when they applied for surgery and at least 1 year after surgery. Outcomes Data collection included semistructured questionnaires on motivations for surgery, postoperative experiences, and standardized measures of psychological symptoms, body image, self-esteem, sexuality, and quality of life (pre- and postoperative). Information on surgical complications and corrections was retrieved from medical records. Results Most participants underwent phalloplasty with urethral lengthening using a radial forearm flap. Although problematic voiding symptoms were prevalent, many participants were satisfied with their penile function. The strongest motivations to pursue penile surgery were confirmation of one's identity (100%), enabling sexual intercourse (78%), and voiding while standing (74%). No significant differences between postoperative and reference values were observed for standardized measures. After surgery, transmen were more sexually active (masturbation and with a partner) and used their genitals more frequently during sex compared with before surgery (31–78%). Clinical Implications The present study provides input for preoperative decision making: (i) main motives for surgery include identity confirmation, voiding, and sexuality, (ii) surgery can result in more sexual activity and genital involvement during sex, although some distress can remain, but (iii) complications and voiding symptoms are prevalent. Strength and Limitations Study strengths include its longitudinal design and the novelty of the studied outcomes. The main limitations include the sample size and the nature of the assessment. Conclusion Counseling and decision making for GCS in transmen should be a highly personalized and interdisciplinary practice. van de Grift TC, Pigot GLS, Boudhan S, et al. A Longitudinal Study of Motivations Before and Psychosexual Outcomes After Genital Gender-Confirming Surgery in Transmen. J Sex Med 2017;14:1621–1628

Prostate Cancer Incidence under Androgen Deprivation: Nationwide Cohort Study in Trans Women Receiving Hormone Treatment

CONTEXT: Trans women (male sex assigned at birth, female gender identity) mostly use antiandrogens combined with estrogens and can subsequently undergo vaginoplasty including orchiectomy. Because the prostate remains in situ after this procedure, trans women are still at risk for prostate cancer. OBJECTIVE: To assess the incidence of prostate cancer in trans women using hormone treatment. The incidence of prostate cancer in trans women using hormone treatment. DESIGN: In this nationwide retrospective cohort study, data of participants were linked to the Dutch national pathology database and to Statistics Netherlands to obtain data on prostate cancer diagnosis and mortality. SETTING: Gender identity clinic. PARTICIPANTS: Trans women who visited our clinic between 1972 and 2016 and received hormone treatment were included. MAIN OUTCOME MEASURES: Standardized incidence ratios (SIRs) were calculated using the number of observed prostate cancer cases in our cohort and the number of expected cases based on age-specific incidence numbers from the Netherlands Comprehensive Cancer Organization. RESULTS: The study population consisted of 2281 trans women with a median follow-up time of 14 years (interquartile range 7-24), and a total follow-up time of 37 117 years. Six prostate cancer cases were identified after a median 17 years of hormone treatment. This resulted in a lower prostate cancer risk in trans women than in Dutch reference males (SIR 0.20, 95% confidence interval 0.08-0.42). CONCLUSIONS: Trans women receiving androgen deprivation therapy and estrogens have a substantially lower risk for prostate cancer than the general male population. Our results support the hypothesis that androgen deprivation has a preventive effect on the initiation and development of prostate cancer