Gender affirmation surgery remains one of the greatest challenges in transgender medicine. In recent years, there have been continuous discussions on bioethical aspects in the treatment of persons with gender dysphoria. Gender reassignment is a difficult process, including not only hormonal treatment with possible surgery but also social discrimination and stigma. There is a great variety between countries in specified tasks involved in gender reassignment, and a complex combination of medical treatment and legal paperwork is required in most cases. The most frequent bioethical questions in transgender medicine pertain to the optimal treatment of adolescents, sterilization as a requirement for legal recognition, role of fertility and parenthood, and regret after gender reassignment. We review the recent literature with respect to any new information on bioethical aspects related to medical treatment of people with gender dysphoria.
Radiotherapy-induced urethral strictures (RIUS) decrease quality of life and present a great challenge for surgical reconstruction, especially due to proximal location, compromised vascular supply, and poor wound healing. It is unclear whether urethroplasty is an option in cases with stricture resulting from exposure to pelvic radiation. We review the pathophysiology, diagnostic workup, and disease-specific aspects of RIUS. Furthermore, we discuss several management alternatives such as excision and primary anastomosis, as well as techniques for open reconstruction with flaps. The most extensive techniques in the treatment of strictures include, for example, those using gracilis muscle flaps, as they can involve periurethral tissue to provide sufficient vascularity for excellent post-surgery urethral healing. In brief, RIUS represent a significant challenge. In carefully chosen patients, urethroplasty should be considered as a feasible and durable treatment. However, medical practitioners should always take into consideration that the results of urethroplasty in RIUS are not comparable to urethroplasties without a radiation background.
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