New guidelines on Non-neurogenic Female LUTS

Early April saw the online publication of the updated 2021 EAU Guidelines, including new Guidelines on Non-neurogenic Female LUTS.

This Guideline presents a considerable expansion of the scope of the previous Incontinence Guideline to also address the significant population of women with functional urological conditions not necessarily associated with urinary incontinence that were hitherto not accounted for.

The new Panel aimed to align their text more cohesively with the existing Non-neurogenic Male LUTS Guideline and, consequently, several additional sections were added to this Guideline (including non-obstetric fistulae, female bladder outlet obstruction, underactive bladder and nocturia). Over the course of the next couple of years the scope is likely to widen further.

The authors just managed to physically meet ahead of the lockdowns, but this multidisciplinary Panel -led by Mr. Chris Harding and Prof. Mela Lapitan (chair and co-chair)- did most of their work virtually. Publication of the findings of a number of systematic reviews addressing overactive bladder syndrome and the diagnosis and treatment of female bladder outlet obstruction is pending, although the outcomes of these reviews informed the 2021 Guidelines publication.

Going forward, the Panel aim to ensure that patient-important outcomes will be driving subsequent updates. The assistance of their patient advocates was invaluable in this respect.

Our congratulations to all the Panel members with this achievement!

Meet the members of the Non-neurogenic Female LUTS panel:

Guidelines Office

Mr. Chris Harding (GB), Chair

Prof. Elisabetta Costantini (IT)

Mrs. Mary Lynne Van Poelgeest-Pomfret (NL)

Ms. Aisling Nic An Riogh (IE) Prof. Mela Lapitan (PH), Vice-Chair

Mrs. Monica De Heide (NL)

Prof. Huub Van Der Vaart (NL)

Ms. Eabhann O'Connor (IE) Prof. Salvador Arlandis (ES)

Dr. Jan Groen (NL)

Dr. Fawzy Farag (GB)

Dr. Benoit Peyronnet (FR) Prof. Kari Bø (NO)

Mr. Arjun K. Nambiar (GB)

Dr. Markos Karavitakis (GR)

Dr. Vasileios Sakalis (GR) Mw. Tine Van Den Bos (NL)

Dr. M. Imran Omar (GB) Dr. Hanny CobussenBoekhorst (NL)

Prof. Véronique Phé (FR)

Dr. Margarida Manso (PT)

Ms. Néha Sihra (GB) Dr. Serenella Monagas Arteaga (ES)

Dr. Lazaros Tzelves (GR)

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In essence, one flap is used to reconstruct the neophallus (e.g., AF or ALT flap) while another is used for urethral reconstruction (e.g., RF or SCIP flap).

Combination flaps have disadvantages. The combined flaps can be performed in a single stage, but the operative time is longer and multiple surgical teams are required. The rate of urethral complications may be higher when combined and monitoring the inner flap is challenging. Staging the construction of the neophallus and urethra may address some of these concerns but would significantly prolong the patient’s journey.

Outcomes depending on choice of flap The best functional and aesthetic outcome following phalloplasty is seen with the radial forearm flap (see Table 2). This phallus has the best chance of achieving tactile and erogenous sensation (up to 90% of patients)7. The primary criticism of the radial forearm flap is the visible donor site, and some patients choose to cover the scarring with a tattoo or undergo further aesthetic refinement procedures. Other sensate flaps include the ALT flap and the SCIP flap. The size of the phallus can be bulky following ALT, latissimus dorsi or AF phalloplasty, which may be an advantage depending on the individual’s preference.

Adjunctive procedures Further procedures can be performed in addition to phalloplasty to improve functional and aesthetic outcome. Glans sculpting or glansplasty can be performed using either a variation of the Norfolk technique or the mushroom flap technique, in which the glans is incorporated into the flap design. The clitoris can be buried and scrotoplasty, hysterectomy, salpingo-oophorectomy and vaginectomy can be offered, if requested. Insertion of an erectile device (usually inflatable) and contralateral testicular prosthesis is usually deferred by at least 6 months following scrotoplasty (see Fig. 2).

Surgical and functional outcomes Patient satisfaction Transmasculine individuals are generally satisfied following genital GAS (94-100% satisfaction). They report a good quality of life and improvement in gender dysphoria following surgery, despite the fact that the rate of urethral complications approaches 45%8. Outcomes from the UK confirmed that no regret was experienced following genital GAS9. All individuals that could experience orgasm prior to GAS continued to experience orgasm after clitoral transposition. Almost all (> 90%) reported that they could masturbate with their neophallus.

Penile prosthesis insertion and sexual activity Satisfaction remained high following penile prosthesis insertion. The majority of transmasculine individuals are satisfied with the aesthetic appearance and are able to engage in penetrative intercourse (> 80%)10 .

The most common reason for not engaging in penetrative intercourse was the lack of a partner. However, rates of mechanical failure, device infection and erosion are significantly higher when compared to devices implanted in men with corpora cavernosa. The 5-year device survival was 78% in the UK10 .

Metoidioplasty The alternative to phalloplasty is metoidioplasty. Metoidioplasty is performed by lengthening the hypertrophied clitoris following testosterone stimulation to form a micropenis. The metoidioplasty normally measures between 4 cm and 10 cm (median 5.7 cm) making it best suited for those of smaller build (body mass index < 25kg/m2)11. Most will be able to void while standing (87-100%) but most individuals will continue to void in a cubicle (rather than at a urinal). Penetrative intercourse is rarely possible (see Fig. 3). Technique for metoidioplasty Metoidioplasty is performed in one or more stages depending on the centre. If staged, the clitoral ligaments and urethral plate are first divided to lengthen the clitoris and the extended portion augmented by buccal mucosa onlay graft (similar to first-stage urethroplasty). The metoidioplasty is completed in the second stage by urethral tubularisation and lengthening, micropenis construction, scrotoplasty and removal of the “female” reproductive organs (if desired). Testicular prostheses are inserted in the third stage and mons resection can be offered to improve the relative size of the metoidioplasty.

Why metoidioplasty? Metoidioplasty is preferred by some transmasculine individuals because recovery is significantly quicker (3 weeks off work compared to 6-12 weeks for free flap phalloplasty) while the micropenis retains full erogenous and tactile sensation with natural erections.

The procedure also causes less local scarring and avoids a large donor site scar that some individuals find stigmatising. Finally, urethral complications are less common because the tissues are better vascularised.

Summary Genital GAS is offered in specialised centres in Europe and the UK. The volume of surgery in each centre is generally small due to the complexity and duration of surgery. Free flap phalloplasty is the penile reconstruction of choice and despite significant morbidity and rate of complications, patient satisfaction remains high.

Acknowledgement The authors would like to thank all the European centres that contributed to this article:

Prof. Rados Djinovic, Belgrade (RS) Prof. Miroslav Djordevic, Belgrade (RS) Dr. Marco Falcone, Turin (IT) Prof. Piet Hoebeke, Ghent (BE) Dr. Vladimir Kojovic, Belgrade (RS) Dr. Francois Marcelli, Lille (FR) Dr. Saskia Morgenstern, Frankfurt (DE) Dr. Paul Neuville, Lyon (FR) Dr. Daniel Schlager, Freiburg (DE) Dr. Piotr Swiniarski, Warsaw (PL) Dr. Wouter Van Der Sluis, Amsterdam (NL) Dr. Jens Willmichrath, Munich (DE)

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