Clinical factors affecting semen improvement after microsurgical subinguinal varicocelectomy: which subfertile patients benefit from surgery?

Background: The exact mechanism of varicocele-related infertility is still elusive, therefore, the current challenges for its management lie in determining which patients stand to benefit most from surgical correction. The authors aimed to assess the clinical factors affecting semen improvement after left microsurgical subinguinal varicocelectomy (MSV) in relation to patient age, ultrasound varicocele grading (USVG), and presence of a right subclinical varicocele (RSV). Methods: From 2010 to 2017 a total of 228 infertile patients underwent left MSV for clinical varicocele. Descriptive statistics were used to describe the cohort and verify the surgical benefit in terms of semen improvement, in addition, subsets of patients were selected according to clinical covariates. Logistic regression modeling was applied to evaluate the presence of RSV, operative time, age, and USVG as explanatory variables. Results: Sperm concentration (SC), progressive sperm motility (PSM), and normal sperm morphology (NSM) increased significantly after surgery (p = 0.002; p = 0.011; p = 0.024; respectively). Mean SC improved after MSV in > 35 year-old patients and the grade 3 USVG group (p = 0.01; p = 0.02; respectively). Logistic regression modeling showed a that the probability of SC improvement was 76% lower in subjects presenting RSV (p = 0.011). In addition, patients with a grade 3 USVG presented a three-times greater probability of SC improvement compared with patients with a lower USVG (p = 0.035). In addition, older patients showed a greater probability of SC improvement after MSV (p = 0.041). Conclusions: MSV is an effective varicocele-related infertility treatment that should also be offered to older patients. In addition, patients with a higher USVG benefit from surgery. In infertile men with an RSV in association with a left clinical disease, a bilateral varicocele repair should be considered

Avaliação dos resultados cirúrgicos, estéticos e funcionais em pacientes submetidas a cirurgia afirmativa de gênero masculino para feminino

Introdução:desde 1998, é conduzido no Hospital de Clínicas de Porto Alegre (HCPA) o Programa de Transtorno de Identidade de Gênero (PROTIG), o pioneiro no Brasil e um dos principais na América Latina, completamente coberto pelo sistema de saúde público. Como tratamento cirúrgico, o flap penoescrotal invertido é considerada a técnica padrão para cirurgia afirmativa de gênero (GAS – gender-affirming surgery) e é a realizada no nosso serviço. Objetivos: o objetivo deste estudo foi descrever os resultados e complicações do GAS realizadas em mulheres transexuais para determinar a segurança e eficácia da cirurgia de afirmação de gênero. Métodos: estudo de coorte retrospectivo de base hospitalar realizado com dados de prontuários de pacientes do Hospital de Clínicas de Porto Alegre (HCPA). Nossa amostra populacional incluiu 186 mulheres transexuais que passaram por GAS de janeiro de 2000 a julho de 2017 no HCPA. Todos os indivíduos foram submetidos a uma clássica vaginoplastia de inversão peniana, sendo utilizado o retalho cutâneo invertido do pênis como revestimento da neovagina. As medidas de desfecho incluíram complicações intra-operatórias e pósoperatórias, reoperações, técnicas cirúrgicas secundárias e prováveis fatores de risco. Resultados: a média de idade dos pacientes foi de 32,2 anos (18-61) e o tempo médio de cirurgia foi de 3,3 horas (2-5); a duração média da terapia hormonal antes da cirurgia foi de 12 anos (variação de 1-39). As complicações pós-operatórias mais frequentes foram: tecido de granulação e estenose uretral (23,6%), estenose do intróito da neovagina (18%) e hematoma/sangramento excessivo (10,2%). Um total de 36 pacientes (19,3%) foi submetido a alguma forma de reoperação. Cento e quarenta e seis (80,7%) pacientes em nossa - 8 - série foram capazes de ter relações sexuais regulares, e nenhum indivíduo lamentou ter sofrido GAS. Conclusões: nosso estudo demonstra que o GAS é uma operação geralmente segura, com baixos índices de complicações graves e enfatiza o alto índice de funcionalidade da neovagina, bem como a satisfação pessoal subjetiva.Introduction: since 1998, the Gender Identity Disorder Program (PROTIG), the pioneer in Brazil and one of the main ones in Latin America, completely covered by the public health system, has been conducted at the Hospital de Clínicas de Porto Alegre (HCPA). As a surgical treatment, the inverted penoscrotal flap is considered the standard technique for vaginoplasty and is performed in our service. Aims: The objective of this study was to describe the results and complications of GAS performed on transsexual women to determine the safety and efficacy of gender-affirming surgery (GAS). Methods: This report describes a hospital-based retrospective cohort study performed using data from patients' records at Hospital de Clínicas de Porto Alegre (HCPA). Our population sample included 187 transsexual women who underwent GAS from January 2000 to July 2017 at HCPA. All individuals underwent a classic penile inversion vaginoplasty, with an inverted penis skin flap being used as the lining for the neovagina. Outcome measures included intra-operative and postoperative complications, re-operations, secondary surgical techniques, and probable risk factors. Results: The mean age of the patients was 32.24 years (18-61), and the mean surgery time was 3.34 hours. The most commonsminor postoperative complications were granulation tissue (23.6 percent) and introital stricture of the neovagina (18 percent) andthe major complications included urethral stenosis (23.6 percent) and hematoma/excessive bleeding (10.2 percent). A total of 36 patients (19.3 percent) underwent some form of reoperation. One hundred fortysix (80.7 percent) patients in our series were able to have regular sexual intercourse, and no individual regretted having undergone GAS. Conclusions: Our study demonstrates GAS to be a generally safe operation with low rates of - 10 - serious complications and emphasizes the high index of functionality of the neovagina, as well as subjective personal satisfaction

Full-thickness skin mesh graft vaginoplasty: a skin sparing technique

ABSTRACT Introduction: The ideal vaginoplasty method should promote good cosmetic and functional results with low morbidity. We describe a new technique for congenital vaginal agenesis using a full-thickness perforated skin graft. Materials and Methods: We report an 18 year old patient with vaginal agenesis (Morris syndrome) that undergone a modified version of McIndoe vaginoplasty. Patient is set in a low lithotomy position and lateral traction sutures are placed in labia and a 16Fr urethral catheter inserted. An inverted “V”-shaped incision is made in the mucosal plaque below the urethra. Blunt dissection in a cephalic posterior direction forms a space between the rectum and urethra. Special care is taken to avoid rectal tear during this maneuver. A full-thickness skin graft is removed from the lower abdomen measuring 12.0×6.0cm as an aesthetic abdominoplasty. The fat tissue is removed, remaining epidermis and dermis and the graft is perforated, allowing a great surface increase. After suturing over a mold, the graft is fixed in the created space. The donor site is closed with intradermal transversal suture. Results: From January 2009 to August 2015, seven patients diagnosed with vaginal agenesis underwent this technique. There were no major complications or need for blood transfusions. At the six-month follow-up, all patients reported satisfactory sexual intercourse. There were no significant complications at donor site or neovagina that needed surgical intervention. Conclusion: Vaginal reconstruction using the perforated graft is viable with excellent functional results. Applying this modification, we yielded the good results of a classic McIndoe technique with lower donor site morbidity