Surgical reconstruction for male-to-female sex reassignment

Bastian Amend, Joerg Seibold, Patricia Toomey, Arnulf Stenzl, Karl-Dietrich Sievert
European Urology 2013, 64 (1): 141-9

BACKGROUND: The primary challenge of male-to-female reassignment surgery is to create natural-appearing female genitalia with neovaginal dimensions adequate for intercourse, neoclitoris sensitivity, and minimal risk of complications. Surgical positioning is an important component of the procedure that successfully minimizes the risk of morbidity.

OBJECTIVE: We modified various vaginoplasty techniques to better position the urethral neomeatus in the proper anatomic location to minimize the chance for complications and enhance aesthetic satisfaction.

DESIGN, SETTING, AND PARTICIPANTS: We retrospectively reviewed data stored in a prospective database for 24 consecutive patients who underwent male-to-female gender reassignment at a German university clinic between January 2007 and March 2011.

SURGICAL PROCEDURE: First, orchiectomy and penile disassembly are performed with the patient in the supine position. Both corpora cavernosa are resected with the patient in the lithotomy position, and neovaginal construction is accomplished with the incorporation of the penile urethra into the penile shaft skin. The glans is preserved and resized to form the neoclitoris. The assembled neovagina is inverted, inserted into the expanded rectoprostatic space, and secured to the sacrospinous ligament. Scrotal skin is tailored to create the labia.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Complications and patient satisfaction with neovaginal depth, appearance, neoclitoral sensation, and capacity for sexual intercourse were evaluated.

RESULTS AND LIMITATIONS: The mean neovaginal depth was 11cm (range: 10-14cm); median follow-up was 39.7 mo (range: 19-69 mo). All patients reported satisfactory vaginal functionality. One patient noted stenosis after 4 yr that was histologically confirmed as lichen sclerosus. Neoclitoral sensation was good or excellent in 97% of patients; 33% reported regular intercourse. No major complications were observed. Because this is a retrospective review to describe a complex reconstructive surgery and illustrate these techniques in the accompanying intraoperative surgery-in-motion video, no control group was undertaken.

CONCLUSIONS: Gender reassignment can be performed with minimal complications using penile skin with incorporated penile urethra and intraoperative repositioning of the patient to achieve adequate neovaginal dimensions for intercourse and neoclitoral sensation.

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