Administration of cross-sex hormones to male-to-female transsexual subjects, usually oestrogens + often anti-androgens, such as cyproterone acetate, carries a risk of venous thromboembolism (VTE). VTE usually occurs in the first year of oestrogen administration. Ethinyl oestradiol, due to its chemical structure, was in 2003 identified as a major factor in the occurrence of VTE. Most clinics do not prescribe ethinyl oestradiol any longer, but people who take hormones without medical supervision use often oral contraceptives containing ethinyl oestradiol, many times in overdose. Cessation of use of ethinyl oestradiol and peri-operative thrombosis prophylaxis for surgery have reduced prevalence rate of VTE. Other oral oestrogens should not be overdosed, and transdermal oestrogen is to be preferred. Thrombosis prophylaxis for surgery is mandatory. It seems advisable to stop hormone use at least 2 weeks before major surgery, to be resumed only after 3 weeks following full mobilisation.

OBJECTIVE To assess the long‐term outcome of forearm free‐flap phalloplasty in transsexuals, as obtaining a satisfying neophallus in female‐to‐male transsexuals is a surgical challenge. PATIENTS AND METHODS We analysed retrospectively 56 transsexuals who had a phalloplasty using a radial forearm free‐flap in our department from 1986 to 2002. The complication rate was assessed by regular examination. Patient satisfaction was evaluated by a questionnaire about cosmetic aspects, sexual life and overall satisfaction. RESULTS The mean follow up was 110 months; 53 of the 56 patients (95%) currently have a neophallus, after a mean of six surgical procedures. Satisfaction was assessed in 53 patients using a specific questionnaire: 51 (93%) of the patients reported that the phalloplasty allowed them to accord their physical appearance with their feeling of masculinity. There were flap complications in 14 patients (25%); three (5%) flaps were lost, with one each due to early haematoma, cellulitis and late arterial thrombosis. The other 11 flap complications were all transitory, e.g. infection, haematomas and vascular thrombosis. There were prosthesis complications in 11 of 38 patients (29%). Moreover, seven of 19 patients (37%) who had a urethroplasty presented with complex strictures and fistulae that led to perineal urethrostomy. CONCLUSION Our study shows that phalloplasty with a forearm free‐flap leads to good results in term of flap survival and patient satisfaction. However, there was a high rate of complications. Patients must be clearly informed that the procedure can seldom be achieved in one stage.

Until now, complete ex vivo spermatogenesis has been reported only in the mouse. In this species, the duration of spermatogenesis is 35 days, whereas it is 54 days in the rat and 74 days in humans. We performed long-term (until 60 days) cultures of fresh or frozen rat or human seminiferous tubule segments in a bioreactor made of a hollow cylinder of chitosan hydrogel. Testicular tissues were obtained from 8- or 20-day-old male rats or from adult human subjects who had undergone hormone treatments leading to a nearly complete regression of their spermatogenesis before bilateral orchiectomy for gender reassignment. The progression of spermatogenesis was assessed by cytological analyses of the cultures; it was related to a dramatic increase in the levels of the mRNAs specifically expressed by round spermatids, Transition protein 1, Transition protein 2, and Protamine 3 in rat cultures. From 2% to 3.8% of cells were found to be haploid cells by fluorescence in situ hybridization analysis of human cultures. In this bioreactor, long-term cultures of seminiferous tubule segments from prepubertal rats or from adult men allowed completion of the spermatogenic process leading to morphologically mature spermatozoa. Further studies will need to address the way of optimizing the yield of every step of spermatogenesis by adjusting the composition of the culture medium, the geometry, and the material properties of the chitosan hydrogel bioreactors. Another essential requirement is to assess the quality of the gametes produced ex vivo by showing their ability to produce normal offspring (rat) or their biochemical normality (human).

Introduction The ZSI 475FtM is a new prosthesis that has recently been specifically designed for phalloplasty. It has several functions that have been conceived to answer the challenges of implantation after phalloplasty: a large base for pubic bone fixation, realistically shaped hard glans, and a pump shaped like a testicle. Aim To assess the safety, feasibility, and patient satisfaction of the ZSI 475 FtM. Methods Surgical outcomes were analyzed after implantation of the prosthesis between June 2016 and September 2017 (single institution, single surgeon). Patients were then asked to answer a satisfaction questionnaire that included the International Index of Erectile Function–5, Erectile Dysfunction Inventory of Treatment Satisfaction, and Self-Esteem and Relationship, as well as other non-validated questions. Main Outcome Measure Complication rates and the scores of the different questionnaires were reviewed. Results 20 patients who had gender dysphoria and underwent operation for a female-to-male procedure were included. The mean age was 37.9 years. Complications after 21 implantations included 2 (9.5%) infections that were medically treated (Clavien II), 1 (4.7%) infection treated by explantation (Clavien IIIb), 2 (9.5%) mechanical failures (Clavien IIIb), and 1 (4.7%) malpositioning (Clavien IIIb). The mean follow-up was 8.9 months (SD 4.0), with 50% of the implanted patients having >12 months of follow-up. 14 patients (70%) answered the satisfaction questionnaire. 12 patients (85.7%) had regular penetrative sexual intercourse. The mean International Index of Erectile Function–5 score was 20.2 of 25 (standard deviation [SD] 7.9), the mean Self-Esteem and Relationship score was 84.5 of 100 (SD 9.9), and the mean Erectile Dysfunction Inventory of Treatment Satisfaction score was 82 of 100 (SD 17.5). 13 patients (92.8%) were satisfied or very satisfied with the prosthesis. Clinical Implications This new innovative prosthesis could better answer the challenges faced by the implantation of an erectile device by phalloplasty. Strength & Limitations Our study is the first to report data on this new prosthesis. The main limitation is the small number of patients and the short follow-up. Conclusion Preliminary results for the ZSI 475 FtM are encouraging. Safety seems to be satisfactory, and patient satisfaction is high. Long-term studies are needed for further analysis.

Introduction The creation of a neophallus is a complex surgery that must meet functional and esthetic requirements. It is a long and demanding surgical process whose final stage consists of the implantation of a rigid or inflatable material that can be used to reproduce an erection. Data in the literature are scarce, with only the pioneering series present, which includes the use of the first devices and techniques. Aim To report the outcome of patients with phalloplasty after implantation of erectile implants using standardized surgical techniques and the use of recent prosthesis types with or without a vascular graft. Methods This is a retrospective hospital-based analysis of all patients with phalloplasty who underwent implantation of an erectile prosthesis from March 2007 to May 2015. Factors associated with complications were investigated by multivariate logistic regression analysis. Main Outcome Measures Early-onset (during the first month after surgery) and late-onset complications, including erosion, infections, malpositioning, and dysfunction. Results Sixty-nine patients were included in the study and 95 procedures were analyzed. After a median follow-up of 4 years (minimum = 169 days, maximum = 6.1 years), the original prosthesis was still in place in 43 patients (62.3%). Patients underwent phalloplasty after female-to-male transsexualism (n = 62, 89.9%), malformation (n = 4, 5.8%), or trauma (n = 3, 4.3%). The proportions for the different types of phalloplasty were 58% for forearm free flap phalloplasty (n = 40), 33.3% for suprapubic phalloplasty (n = 23), and 7% for other (n = 6). The erectile prostheses used were the two-piece AMS Ambicor (n = 71, 74.7%), the Ambicor with a vascular graft (n = 19, 20.0%), and the AMS 700CXR, AMS 700CX, or AMS600-650 (n = 5, 5.2%). There were no early-onset complications in 89 procedures (93.7%) and, when present, they were always related to infection (n = 4, 4.2%). Late-onset complications were erosion (n = 4, 4.2%), infection (n = 4, 4.2%), dysfunction (n = 10, 10.5%), and malpositioning (n = 12, 12.6%). No significant difference was observed for malpositioning (12.7% vs 10.5%, P = .87) and dysfunction (7.0% vs 10.5%, P = .78) between the AMS Ambicor prosthesis and the Ambicor prosthesis with a vascular graft. Conclusion This study provides updated data on complications after the implantation of erectile implants. Multicenter studies, including the evaluation of patient satisfaction, are needed to increase our understanding of factors associated with the outcomes.

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Although our series of 32 patients had several abnormal endocrine screenings, these results indicate no significant endocrine defects.

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