Surgical conversion of genitalia in transsexual patients
Department of Urology of the 1st Medical Faculty,
Charles University of Prague, Czech Republic.
Abstract [Full Text] [PDF]
Objectives To describe the techniques and outcome of genital and urethral reconstructive surgery during gender conversion as part of the treatment of transsexuals.
Patients and methods From 1992 to 1999, 82 patients were surgically converted after previous sexual and hormonal therapy. Using the male genital tissue to create new female genitalia, and vice versa, 30 female and 52 male transsexuals were converted. For male–to–female transsexuals, the technique of penile skin inversion was used 29 times and sigmoidocolpoplasty five times (in one patient primarily and in four patients to correct inadequate neovaginal size after penile skin inversion). In female–to–male transsexuals, 28 meta–idoioplasties and seven neophalloplasties were performed using the groin skin–flap technique, with 42 breast reductions also included as a part of the therapy.
Results Surgical gender reassignment of the female transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis, with the potential to void while standing.
The morphological proportions of each patient vary, and the different shapes and sizes of the tissues can be used for plastic operations. Thus the modelling of each individual genital in transsexuals can be considered ‘original’.
Transsexualism is defined as a disorder of sexual identification; a person with this dysfunction has the genetic, somatic and hormonal apparatus of one sex but identifies sexually with the opposite gender. The syndrome of transsexualism was first described by Benjamin in 1953 [1, 2]. Transsexualism and transvestitism are similar in that the patient desires the role of the opposite sex; however, transvestites identify somatically with their sex and dress as the opposite sex to attain arousal . Conversely, transsexuals permanently feel they are members of the opposite sex ‘trapped’ in the wrong body.
Transsexualism has been recorded since ancient times; Herodotos wrote about the mystical Skythenian disease from north of the Black sea. Externally, normal men wore women’s clothing, did women’s work and were notable in that they had a feminine personality as well as female behaviour. The picture of Hercules wearing a dress, serving Omphala, is as a prime example of transsexualism in ancient Greece. In the middle ages the most famous transvestites were three Frenchmen, the brother of King Henry III, the Abbé of Choisy and the diplomat Chevalier d’Eon. The term ‘eonism’, a synonym for transvestitisms, was named after the diplomat .
The international organization which was founded by Harry Benjamin [The Harry Benjamin International Gender Dysphoria Association] plays a major role in the research and treatment of transsexualism. The organization, founded in 1978 , devised a protocol (regularly revised) used as a guideline for the therapy of transsexuals. It provides time limits for individual steps in the diagnosis and therapy of this illness. Its aim is to exclude other pathological states in the differential diagnosis and to confirm the dysfunction. An error in diagnosis and incorrect indication of surgical conversion could permanently damage the patient. Considered in the differential diagnosis are homosexuality, psychosis, personality disorders, organic brain lesion and transvestitism.
In 1990, the incidence of transsexualism was estimated at 1:20 000 in men and 1:50 000 in women . In Sweden the incidence is the same in both sexes and reaches values of 0.14 per 100 000 inhabitants over the age of 15 years . In 1990, in the Czech Republic the prevalence of transsexualism was 1:10 000 inhabitants .
After the diagnosis of transsexualism is confirmed therapy commences with psychotherapeutic preparation for the conversion, and after conversion, long–term patient rehabilitation. The indication for surgery is chronic discomfort caused by discord with the patient’s natural gender, intense dislike of developing secondary sex characteristics and the onset of puberty.
The surgical conversion of transsexuals is the main step in the complex care of these problematic patients. The sexologist decides when and if the patient can undergo conversion, based on a detailed and long–term psychological follow–up. The long observation period aims to verify adaptation to the new social role, associated with the hormonal therapy, and continues even after legalization of the sex change. The present report details the procedures and outcome of patients undergoing this process.
Patients and methods
From 1992 to 1999, 82 patients (mean age 29 years, range 17–51) underwent surgery in the author’s department; 30 were males (mean age 29 years) and 52 females (mean age 28 years). For the female transsexual conversion, 29 patients had female genitalia constructed from inverted penile skin, and in five from a part of the sigmoid colon; 28 of the male transsexuals underwent metaidoioplasties, seven the formation of a neophallus from a groin flap and 42 underwent breast reduction.
The first step in the surgical technique in female transsexuals was demasculinization, comprising orchidectomy and penectomy; orchidectomy is the basis for a legal sex change. Vaginal  and vulval formation followed. Patients received an intestinal preparation to maintain the safety of the operation. After disinfecting the operating field an adhesive preservative drape was inserted into the rectum to keep dissection of the vaginal canal sterile. The right index finger was used to create the neovagina via blunt dissection. The procedure commenced with a longitudinal incision in the midline of the perineum dorsal from the scrotal base and 3 cm from the anus so that the smallest possible perineum resulted. A small perineum was the basis for natural anatomical proportions, which allowed the formation of a vagina which was properly orientated to allow intromission. The dorsal pole of the incision could be terminated in the shape of an inverted ‘Y’. In this way, tension from the anastomosis between the perineum and penile skin could be reduced.
Dissection continued up the scrotum and the testes, and the spermatic cords were freed from the surrounding tissue. The spermatic cords were cut and ligated with absorbable suture at the level of the external inguinal rings. Cord stumps spontaneously pulled up into the inguinal canals and painful palpable granulomas did not develop. Penile skin was gradually dissected with scissors, along with subcutaneous tissue and vessels, up to the coronary sulcus where it was disrupted circularly. The incision was deepened in the centre of the perineum into a tunnel–like shape between the rectum and bladder, so that the space could accommodate a neovagina. The ischiocavernosal muscles were divided and later fixed in the introitus. The bulbar urethra was divided from the cavernosal bodies up to the crural junction and was shortened to the normal female length. The end of the urethra was sutured through an opening in the skin in the usual position. The bulbus was massive, so it was better to resect it and to suture it through several times.
A clitoridoplasty of the penis glans followed to ensure sexual sensitivity . After releasing penile skin, the dorsal neurovascular bundle housing the dorsal penile nerve and deep dorsal penile vein and artery was divided by two longitudinal incisions from the penile suspensory ligament to the corona, penetrating the tunica albuginea. The incision continued on the glans penis, where it separated a small area of the glans (6 × 5 mm) from which the glans clitoris would be formed. The neurovascular bundle ensured its innervation and blood supply, and was inserted freely in the subcutaneous tissue. The glans clitoris was sutured into an opening in the skin 2–3 cm along the urethral meatus.
The abdominal skin was liberated superiorly just under and up to the umbilicus, during which the anastomoses of the superficial inferior pudendal artery, superficial inferior epigastric artery and superficial circumflex iliac artery anastomoses were protected. By stretching the liberated skin and subcutaneous tissue, 5–7 cm could be gained so that the skin from the covering of the penis could be moved caudally and dorsally. The abdominal skin was then fixed to the symphysis by two sutures and then knotted on the skin over a sponge.
The incision in the perineal centre was made deeper, to form a tunnel between the rectum and bladder, which would house the neovagina. This cavity was monitored by the left index finger inserted into the drape. The second index finger penetrated the centre of the perineum and superficial transverse perineal muscle; the tendon centre was then opened.
The rectourethral muscle was dissected just under the external leaf of Denonvillier’s fascia. The medial fibres of the levator ani were severed and a tubular penile skin flap sealed at the distal end, and inserted into the prepared pelvic cavity. Its stability was ensured by a modelling rod 15–20 cm long and 4 cm in diameter. Any unnecessary scrotal skin was resected.
A capillary or suction drain was inserted and the neovagina tamponaded for 2–3 days. On removing the tamponade, lubricating gel was instilled to prevent eversion of the vaginal walls. The patient self–dilated the neovagina regularly. The catheter was left in the bladder for 7–10 days. The labia majora could be converged in the second phase using a double Z–plasty, which transfered the skin with a layer of subcutaneous tissue .
If it had not been possible to use penile skin for a vaginoplasty, an intestinal segment could be used to create the neovagina instead; an excluded segment of the rectosigmoid colon was used. A Pfannenstiel incision was used to create safe access to the abdominal cavity. A 15–cm segment, supplied by the arterial system of the inferior mesenteric artery and superior haemorrhoidal artery, was removed from the rectosigmoideum. Some pleasure sensation and vibration was possible in this segment because of the autonomic innervation which travels along the vessels. To renew intestinal continuity, an entero–entero–anastomosis was established using a continuous absorbable suture.
The perineal incision had the shape of an inverted Y; it started in the penile and scrotal raphe, and at the scrotal base it diverged and ran up to the ischiadic tuberosity. Penile and perineal skin was inverted into the future introitus and was joined with the transplant, which was orientated in a peristaltic configuration. To prevent stenosis caused by scarring, the intestinal anastomosis was prolonged by longitudinal incision, to increase the circumference of the intestinal ends. Scrotal skin was used to create the labia majora and penile skin the labia minora.
The legal gender change in male transsexuals was based on hysterectomy. Both hysterectomy and adnexectomy could be achieved by laparotomy through a Pfannenstiel incision. In patients where external plasty followed, colpectomy with obliteration of the vaginal cavity was performed.
Reduction mammoplasty included breast reduction with extirpation of the mammary gland and excess skin, with reduction and repositioning of the areola and mammillary complex, with minimal scar tissue formation [12,13]. Smaller breasts could be removed via sharp dissection using a semicircular incision at the border of areola and skin. Large breasts were harder to reduce, because of the excess skin. Their resection was often accompanied by the formation of complicated scars. If it was necessary to make the incision medial to the breast, then more noticeable scars would be inevitable.
The surgical correction of male external genitalia in male transsexuals included the creation of an aesthetically acceptable neophallus of the correct shape and size, with adjustment of the urethra so that the patient could void while standing, along with maintenance of erotic sensitivity. In the construction of the neophallus, the groin skin flap technique and metaidoioplasty were used.
The groin skin flap technique required 11 × 24 cm skin flaps supplied by the superficial circumflex iliac artery. The skin was released in its full thickness, with the subcutaneous tissue, and care had to be taken to preserve the inguinal lymphatic system. The flaps were rotated and sutured together in the midline . The procedure did not damage the clitoris. Meta–idoioplasty [15,16] used the medial surfaces of the labia minora in urethroplasty. The urethral meatus was positioned at the tip of the glans and the urine should flow in a direct stream without spraying. The labia minora were divided to form an inner and outer sheet. The incision led from the glans clitoridis on the edge of the labia minora dorsally to the posterior periphery of the vaginal introitus. The incision continued in the midline of the introital posterior commissure towards the vagina for 1 cm, and then turned superiorly along the introitus, anterior to the external urethral meatus. Wing–shaped flaps of the inner sheets of the labia minora resulted. These flaps were dissected from the external sheets and from the ventral clitoridal chord. The chord was ventrally severed and freed so that the clitoris straightened out. The inner sheets of the wings of the labia minora were sutured in the dorsal midline. The urethral meatus, which was anteriorly and laterally dissected from the internal sheet of labia minora, was completely released by its division from the vaginal wall via a semicircular incision. If the vagina was not removed during hysterectomy, a colpectomy was performed and the vaginal canal was obliterated by several circular sutures. The cuff of the vaginal wall beneath the meatus was liberated so that it would be easier to attach it to the neourethra. The flap formed from the inner sheet of the labia minora was sutured to the urethral meatus and tubularized in the direction of the glans along the introduced catheter. The external sheets, via a Z–plasty, cover the ventral side of the resultant micropenis. The sufficiently large sheets could be used to create the scrotum.
Colpoplasty from inverted penile skin was used in 29 patients; in 26 an imitation clitoris was created. To correct the convergence of the labia majora anteriorly, a Z–plasty was used in 18 patients. In 12 patients it was necessary to shorten the perineum and free the vaginal introitus for an easier penetration at a later date. In the second phase, nine patients underwent a surgical reduction of the labia majora.
The neovagina has smooth walls and the patient had to regularly self–dilate it with a vibrator. Sexual stimulation leads to the production of urethral secretions which served as natural lubrication. Converted patients can urinate while seated with no difficulty.
In five patients a functional sigmoidal neovagina was created; this was indicated in four because the neovaginal size was insufficient, and in the fifth the procedure was used to correct a rectoperineal fistula which resulted from neovaginal construction from inverted penile skin at another urology department.
Hysterectomies in 42 patients and adnexectomies in 39 patients were performed with no complications; 10 patients had hysterectomies at other departments. Colpectomies were performed in 24 patients, along with sealing of the vaginal canal. Forty–two patients underwent breast reduction; in those with smaller breasts, good cosmetic results were achieved but scarring was more noticeable in those patients with initially larger breasts.
In two of seven patients who underwent phalloplasty using groin skin, the neopenis size was corrected in the second stage, providing a longer penis by decreasing the diameter. The neophallus serves only as an imitation of the penis and erection is not possible. Twenty–eight patients underwent metaidoioplasty; seven were capable of voiding while standing and all had preserved erotogenic clitoridal activity.
Surgical gender conversion is a complex of difficult operations which serve to imitate the appearance and function of organs of the opposite sex. They dramatically alter the function and state of the original organs. Some of the functions need to be preserved while others must be disrupted. The original organs fulfilled, or were able to fulfil, their normal function before conversion; surgery can compromise the integrity of a desirable function. The risks must thus be weighed and explained to the patient. Among the usual postoperative complications are infection, herniation, and early thrombo–embolic complications. Specific complications include urinary and intestinal fistulae, incontinence of urine and stool, and necrosis of the skin graft . After conversion, patients must be permanently followed. The long–term use of androgens may elevate liver enzymes, and cause weight gain and acne. Long–term oestrogen therapy is associated with life–threatening complications such as thrombo–embolic disease, hyperprolactinaemia, depression, weight gain and transient liver enzyme elevation . Adnexectomy in male transsexuals is controversial; some sexologists consider functional ovaries useful, and hence advocate their preservation. Those transsexuals with surgically formed female genitalia may be endangered by less usual complications such as prostate cancer .
Conversely, the benefits of surgical conversion must be considered in those patients in whom surgery brings about the desired physical changes. Successful surgery can rid the patient of physical traits which the patient considers to be a handicap and which represent an insurmountable problem.
In female–to–male transsexual gender reassignment, the risks arise when flaps from distant body areas are used. The method of penile reconstruction presently used with increasing frequency, although it is a complicated technique, is that of the free forearm flap. This technique using microsurgery has been described  and termed the ‘Chinese flap method’. These authors anastomosed the free flap with neurovascular tissue from the radial part of the forearm of the subordinate arm with the iliac artery and the pudendal nerve in a one–stage procedure. Koshima et al. described an anastomosis of the cutaneous antebrachii medialis nerve of the forearm with the saphenous nerve. The initial attempts to join the nerve of the donor flap to the ilio–inguinal and iliohypogastric nerve were described by Meyer and Devario ; Gilbert et al. described a successful anastomosis with the pudendal nerve.
In conclusion, surgical gender reassignment of female transsexuals resulted in replicas of female genitalia which enabled coitus with orgasm. Depending on the technique used in the reverse conversion, the patient maintained the ability to attain orgasm, and in many cases had a satisfactory appearance of the neopenis with the potential to void while standing. The morphological proportions of each patient vary, and these different shapes and sizes of the tissue can be used for plastic operations. For this reason, the modelling of each individual genital in transsexuals can be considered ‘original’.
Editor’s Note – terms in this article have been changed. ‘Female transsexuals’ (biological female patients) have been changed to the more accurate ‘Male transsexuals’; while ‘male transsexuals’ (biologically male patients) reflect the more accurate ‘Female transsexual’ term.
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Citation: BJU International 2000 http://www.bjui.org/85/7/article/bju624.asp