Gender Reassignment Surgery at Charing Cross Hospital
Mr. James Bellringer
[Abstract] Full Text [PDF]
Reprinted with the kind permission of Mr James Bellringer
James Bellringer was born in 1958, and educated at King’s College School Wimbledon, Pembroke College Cambridge, and St Thomas’ Hospital Medical School in London. After qualifying in 1982, he embarked on Surgical and Urological training. Following time at the Institute of Urology, he was appointed a Consultant Urological Surgeon in 1995. In 1999, he was invited to train in Gender Reassignment Surgery, and received training from Mr. Michael Royle. He currently performs in the region of 65 reassignment operations each year.
Away from work, he is married with 3 children. He is active sportsman, who continues to play rugby, and cycles to work each day.
James Bellringer was trained in Gender Reassignment Surgery by Mike Royle from Brighton UK. He now works at Charing Cross Hospital in London, and is happy to offer both NHS and private operations. In addition to using the peno-scrotal flap technique employed by Mr. Royle, he has developed a penile inversion technique. Whilst this technique is not possible in all patients it gives a larger capacity vagina than penoscrotal flap in most cases, and avoids the problem of hair growth in the neo vagina. Both techniques are discussed fully with all patients prior to surgery. In addition, for patients who do not wish to have a functional vagina, a “cosmetic” procedure can be performed. All patients are offered a sensitive clitoris, which most patients want!
The operation takes approximately two and a half hours, and patients are normally able to be discharged a week later.
The Post Operative Protocol.
“When I first took over at Charing Cross, patients followed the protocol used by my predecessors James Dalrymple and Mike Royle. This essentially involved lying flat in bed for 5 days on clear fluids only, with the theatre dressing remaining in position. Both the nursing staff and I had significant concerns about this.”
“Firstly, there seemed to be a high risk of DVT and other thrombotic complications.”
Secondly, any problems with the wound only became apparent after 5 days.
“Thirdly, being starved for 7 days (including the 2 days before the operation) seemed to us to be unnecessary; some of the patients were almost too weak to stand at the end of it.”
“The protocol was therefore gradually changed to that shown below. This was carefully audited at all stages, and we were pleased to find that early mobilisation resulted in a halving of the prolapse rate. Changing the type of pack has reduced prolapse rates yet further. There has not been any rise in infection rates or of haematoma formation. Reducing the dressing early, allowing early mobilisation, and allowing normal diet has made the whole process much more pleasant for the patients, and has significantly reduced the risk of thromboembolic complications.”
The current post operative protocol is;
Day 0 Operation
Day 1 Take down theatre dressing, and inspect wound. Remove drains. Redress with light dressing. Commence light diet. Sit out in chair if comfortable.
Day 2 Build up to normal diet. Continue to mobilise as comfort permits. Remove drip and (usually) PCA analgesia.
Day 3-4 Continue mobilisation with short walks around the ward.
Day 5 Remove pack and urinary catheter. Teach dilation. Commence mild laxative if bowels not yet open.
Day 6-7 Home! If passing urine, bowels open and confident regarding dilation technique.
Both techniques give a good cosmetic result in most patients. Examples can be seen in the links below. (These are photographs of patients’ genitalia; please do not follow this link if you do not wish to see such material.)
Cost of Gender Reassignment Surgery by Mr. Bellringer.
Mr Bellringer has negotiated a package price with Charing Cross Hospital private patients wing, and Parkside Hospital in Wimbledon. This package includes all hospital and medical fees, and the cost of dilators and drugs/pessaries to take home from hospital, and one follow up consultation with Mr. Bellringer. Initial consultation is not included, nor any psychiatric opinions.
For full GRS (with vaginoplasty and clitoroplasty) the cost is approximately £10,000, at Charing Cross Hospital, and slightly less at Parkside. For Òcosmetic operations (without vaginoplasty) the cost is £8,000. This fee is payable in full on admission to the Hospital.
Hair removal prior to surgery
Hair removal before GRS
Hair removal is not essential prior to surgery, but, if a scrotal flap is used, this will continue to grow hair, and subsequent removal of hairs from the vagina is not practical.
In addition, the small area at the base of the penis in the pubic area is inverted to make a clitoral hood. If hair removal is being carried out, this area should also be treated. A semicircle about 2cm in diameter from the penis would normally be sufficient.
Patients who wish to be referred to Mr. Bellringer for Gender reassignment
Referral for Gender Reassignment Surgery
Mr Bellringer is happy to receive patient referrals from psychiatrists with an interest in gender dysphoria and transsexualism. Before proceeding to surgery, he will require two psychiatric opinions to the effect that a patient has fulfilled the Harry Benjamin criteria for surgery. These include the completion of a Real Life Test.
Unfortunately, he is not able to see patients who self refer other than to discuss aspects of possible future surgery, unless they can bring with them two recommendations for surgery from recognised specialists. If any such patients wish to proceed at a later date to surgery, they will need the two psychiatric opinions before any operation can be offered. Mr Bellringer knows several psychiatrists in this field, and is happy to arrange for patients to undergo the necessary psychiatric evaluation.
In the case of post-operative patients who may need revision surgery, no psychiatric opinion is needed prior to consultation, and Mr. Bellringer is happy to see patients referred from their own General Practitioner, or those who self refer.
Mr. Bellringer works closely with the Gender Identity Clinic at Charing Cross Hospital (the largest of its kind in the world). Contact information for that clinic may be found in the Transgender Zone Practitioner Guide.
Post operative instructions.
Going Home after Gender Reassignment Surgery
Now that you’ve had your operation, and are going home, I hope and expect that there will not be any problems. I do however recognise that some patients will need to make contact regarding queries and or problems which concern them before the date of their follow up clinic. If you are worried about anything, I would suggest you try the following;
1) Go to see your GP. Although the surgery is highly specialised, my experience is that most GP’s manage superficial infections and similar problems very well. Your GP will also be able to contact me for advice if he/she is concerned.
2) Call the ward in the Hospital where you had your operation. Many problems are easily sorted out over the phone by an experienced member of the nursing staff. They will also be able to ask me for advice.
3) Call me! The phone line to my Office is open 24 hours a day (020 8241 1637). If the office is unmanned, you will be given instructions by the answering machine to enable you to make contact with me. Less urgent queries may be dealt with by email. Between 9.00 and 4.30, my NHS Secretary (020 8383 0160) will usually be able to track me down.
Clearly, there may be occasions at weekends or during the night, when you feel that more urgent care is needed. Even then, it is often best to try to see your GP first, or contact the ward for advice. If neither of these is possible, you may need to go to your local hospital Casualty Department. If you do this, please take this sheet with you, so that contact numbers and names are available to the staff who see you. On the (very rare) occasions when I am not personally available, I will have left contact details for another extremely experienced surgeon who should be able to help.
Care for your new anatomy
1) Dilation. Before you left hospital, I will have shown you how to use the dilators. Initially, these should be inserted 3 times a day. Use the small dilator first, leave it in for 5 minutes after pushing it as far as it will go comfortably, then insert the large dilator and leave it in place for a minimum of 10 minutes. The process is often uncomfortable at first, and may be accompanied by a small amount of bleeding. Many patients find it easier to dilate in the bath, and this is quite acceptable. Usually by 2 months it is possible to reduce the frequency to twice daily, and you will know that this is the case if dilation is becoming very easy. Initially drop the lunchtime dilation. If the evening dilation is still relatively easy, you can safely go down to twice a day. Similar reductions in frequency at around 4 and 6 months are usually possible, so that most patients are only dilating 2 or 3 times a week by 9 months. These are general rules only, however, and there is great variation between individual patients, so you should try out each reduction in dilation frequency for yourself, and be prepared to stay on a higher frequency for longer if necessary. Remember that you need to keep dilating for the rest of your life!
2) Hygiene. If possible, you should bathe twice daily for the first month to 6 weeks. There is often a little infected looking matter on the surface, which may easily be removed by gentle washing with water and simple soap. Strong detergents are best avoided, as are strong antiseptics, although there is no harm in very dilute Dettol or similar in the bathwater if you wish. You should aim to douche daily for the first month. In my view the best solution to use is mains tap water (i.e. from the kitchen tap), as this is nearly bug free. You should have been given a suitable syringe before you went home. After the first month douche as often as you feel hygiene requires; many patients find they can stop entirely. In addition, you will have been provided with Betadine pessaries to use weekly for the first 10 weeks. One should be inserted in the evening after the last dilation.
3) Sex. It is unusual for patients to feel up to sexual contact within 2 months of the operation, and, while healing is still in progress, sex should be avoided. If the inclination and opportunity arise after 2 months you should be able to start gently and with care.
4) Hormones. Hormones may safely be restarted on discharge from the hospital. You will typically need only one third to one half of your preoperative dose. You will no longer need to take anti-androgens such as Cyproterone, Casodex and Finasteride, and these can be discontinued. Your final dose of oestrogen may be tailored to your needs by the person who supervised your pre-operative hormone therapy (typically your GP or Psychiatrist).