Vaginoplasty in male transsexuals using penile skin and a urethral ap

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1 BJU Interntionl (2000), 86, 843±850 Vginoplsty in mle trnssexuls using penile skin nd urethrl p S.V. PEROVIC, D.S. STANOJEVIC nd M.L.J. DJORDJEVIC Belgrde Gender Dysphori Tem, University of Belgrde, Yugoslvi Ojectives To descrie nd present the results of onestge vginoplsty in mle-to-femle sex ressignment surgery. Ptients nd methods The present technique is sed on penile disssemly nd the use of ll penile components for vginoplsty (except the corpor cvernos). The neovgin consists of two prts; long vsculrized urethrl p nd pedicled islnd tue skin p creted from the penile skin. The urethrl p is emedded into the skin tue. The tue, consisting of skin nd the urethrl p, is inverted, thus forming the neovgin. The new vgin is inserted into the previously prepred perinel cvity etween the urethr, ldder nd rectum. The neovgin is then xed to the scrospinous ligment. The li minor nd mjor re formed from remining penile nd scrotl skin. The new method ws used in 89 ptients (men ge 28 yers, rnge 18±56) with men (rnge) follow-up of 4.6 (0.25±6) yers. Results Good cosmetic nd functionl results were otined in 77 of the 89 ptients (87%). Importntly, the neovgin produced in most ptients ws of stisfctory depth nd width. There ws only one mjor compliction, rectovginl stul cused y intropertive injury to the rectum. Conclusions The technique produces vgin with more norml ntomicl nd physiologicl chrcteristics thn those produced y other methods, s ll the penile components re used (except for the corpor cvernos) to form lmost norml externl femle genitli. Vginoplsty using pedicled penile skin with urethrl p is good lterntive to other methods of vginoplsty in mle-to-femle sex ressignment surgery. Keywords trnssexuls, vginoplsty, penile skin p, urethrl p Introduction Vginoplsty is the min surgicl prolem in mle-tofemle sex ressignment surgery; there re mny opertive techniques [1±3] reported, ut none is idel. Thus there is continuing serch for new nd etter solutions. We reported n erlier contriution to these opertive techniques in mle-to-femle surgery [4] nd hve continued to improve this technique; we now present the most recent vrint. Ptients nd methods Between Jnury 1994 nd Novemer 1999, 89 ptients (men ge 28 yers, rnge 18±56) underwent vginoplsty during mle-to-femle sex ressignment surgery. To crete new vgin, vsculrized inverted penile skin nd urethrl p were used in 85 ptients. Nine of the ptients hd short inverted penile skin p nd long vsculrized urethrl p. The other four vgins were Accepted for puliction 30 August 2000 creted using vsculrized urethrl p nd free penile skin grfts. Severl su-procedures re required to form the new vgin. After the usul ilterl orchidectomy, the penis is dissected into its ntomicl components, i.e. the corpor cvernos, the glns cp with the urethr nd the neurovsculr undle, nd the vsculrized penile skin. The corpor cvernos re removed up to their ttchments to the puic ones. Remnnts of the corpor cvernos (erectile tissue) re destroyed nd the tunic lugine sutured with 2/0 sorle sutures. This prevents ny postopertive erection (which cn hinder future sexul intercourse). The glns cp is divided into two prts, ventrl nd dorsl (Fig. 1,); the dorsl prt of the glns is reduced y excising the centrl ventrl tissue, leving the sides of the glns intct. Lterl excisions on the glns re not recommended, to void injuring the neurovsculr undle which enters the glns cp lteroventrlly. However, the sides re de-epithelilized nd sutured, to otin conicl shpe for the neoclitoris (Fig. 2) The ventrl hlf of the glns, which remins ttched to the # 2000 BJU Interntionl 843

2 844 S.V. PEROVIC et l. Dorsl hlf of glns cp with neurovsculr undle Preputil nd penile skin Penile skin flp Bulospongiosl muscle Deepithelilized re Vsculrized pedicle of the flp Remnnts of the corpor cvernos Urethr Ventrl hlf of the glns cp Ventrl hlf of glns cp with urethr Fig. 1. After penile disssemly, the corpor cvernos re removed up to their ttchments to the puic ones. Remnnts of the corpor cvernos re destroyed (inset). The ulospongiosus muscle is removed from the ulous prt of urethr. The glns cp is divided into two prts, i.e. ventrl with urethr nd dorsl with neurovsculr undle. urethr, is used to form the neocervix t the se of the new vgin. The ulospongiosus muscle is removed from the ulous prt of the urethr; the dissection of the ulr urethr must e precise to void injury to the fscil sheth. The urethr is then sptulted, including the ulr prt, nd used to crete the mucosl prt of the neovgin. Any leeding in the ulr urethr is Fig. 2. The glns is trimmed to the size of clitoris (). The urethr is sptulted dorslly, including its ulous prt. A penile skin p with long vsculrized pedicle is creted () nd hole mde on the se of the pedicle (, inset). # 2000 BJU Interntionl 86, 843±850

3 VAGINOPLASTY IN MALE TRANSSEXUALS 845 Vsculrized flp pedicle New urethrl metus (femle type) Urethrl metus Urethrl flp Sptulted urethr (urethrl flp) Penile skin flp Sucutneous tissue Penile skin flp Neovginl se (ventrl hlf of the glns) c Fig. 3., The urethrl p nd neoclitoris re trnsposed through the hole on the pedicle se. On the dorsl side of the penile skin only skin is incised; vsculrized sucutneous tissue remins intct., the urethrl p is emedded nd sutured t the skin tue incision. The new femle urethrl metus is in continuity with the urethrl p. The ottom of the tue is closed using the ventrl prt of the glns cp. The epithelil surfces of the penile skin p, urethrl p nd glns remin outside. The skin tue with urethrl p is invginted (inset). c, the vsculrized islnd penile skin p creted on long vsculrized pedicle. The urethrl p is inserted into the islnd skin tue p. The ventrl hlf of the glns will e used to form pseudocervix t the se of the new vgin. d, the new vgin is formed fter invginting the tue; wounded surfces re outside. d # 2000 BJU Interntionl 86, 843±850

4 846 S.V. PEROVIC et l. Urethrl flp Penile skin flp Insufficient penile skin flp Urethrl flp Urethrl flp Free penile skin grfts c d Fig. 4. Types of neovgin: the neovgin is composed of;, vsculrized penile skin nd vsculrized urethrl p;, only from vsculrized urethrl p; c,d from vsculrized urethrl p nd free penile skin grfts. controlled with hemosttic sutures. The extensive use of electrocutery is not recommended s the urethrl p vsculriztion could e compromised. A femletype urethr is then formed nd the neoclitoris xed ove the new urethrl metus. In reconstructing the new vgin, the skin of the penile ody nd prepuce (if present) re fshioned into vsculrized islnd tue p. It is importnt to otin long vsculrized pedicle for the tue nd therefore, the level of the incision is < 2 cm ove the se of the moilized penile skin (Fig. 2). Only here does the existing loose sucutneous tissue permit the formtion of long vsculrized pedicle. At the se of the pedicle hole is mde to trnspose the urethrl p (Fig. 3,). On the dorsl side of the skin tue p only the skin is incised, wheres the vsculrized sucutneous tissue remins intct. The urethrl p, which is trnsposed through the pedicle hole, is emedded into the skin tue nd sutured (Fig. 3c). The ottom of the tue is closed with the distl prt of the urethr nd/or the remining # 2000 BJU Interntionl 86, 843±850

5 VAGINOPLASTY IN MALE TRANSSEXUALS 847 Scrospinous ligment Scrospinous ligment Neovgin Dechmps ligture Penile skin flp Urethrl flp Fig. 5., The neovgin is xed to the scrospinous ligment with Deschmps ligture. Both ends of the suture re rought out., One of the ends is pssed through the skin prt while other is pssed through the urethrl prt of the neovgin nd tied. ventrl hlf of the glns cp fter the de-epitheliliztion of its inner side. The tue, consisting of skin nd urethrl p, is inverted, thus forming the new vgin (Fig. 3). If there is insuf cient penile skin ( smll nd/or circumcised penis) the short skin tue nd long urethrl p will not e in proportion. The vgin cn then e formed in two wys. The proximl prt t the se of the vgin is formed only from the urethrl p, which initites secondry epitheliliztion. If the tue pedicle is too short to plce the tue into the perinel cvity, the new vgin is creted using the vsculrized urethrl p nd free penile skin grfts. In this cse the vsculrized urethrl p plys the key role in creting the new vgin (Fig. 4). Spce for the new vgin is creted in the perineum; two tunnels re mde on oth sides on the tendineus centre; this nd the recto-urethrl muscle re cut, llowing ccess to the deep nd wide perinel cvity etween the urethr, ldder nd rectum. Prticulr cre should e tken to void injuring the rectum. The neovgin is xed to the scrospinous ligment, usully on the right; this ligment is plpted etween the ischil spine nd coccyx. After exposing the ligment, longhndled Deschmps ligture crrier pre-loded with 2/0 sorle suture is used to pierce the ligment medilly to the ischil spine. Cre must e tken not to plce the suture close to the ischil spine, to prevent injury of the pudendl nerve nd internl pudendl vessels. Also, the suture must not e plced ehind the ligment, to prevent injury to the pudendl rtery whose course is vrile nd my e t ny distnce from the ischil spine. Both ends of the suture re rought out; one is pssed through the skin prt while the other is pssed through the urethrl prt of the distl third of the neovgin nd tied. Vginopexy to the scrospinous ligment is crried out nd the neovgin plced deep in the perinel cvity. This provides good plcement of the neovgin nd prolpse is voided (Fig. 5) Vulvoplsty involves the cretion of the li minor nd mjor. The remining prt of the se of the penile skin is used to form the li minor, which re sutured to the de-epithelilized re of the neoclitoris; thus the neoclitoris is hooded with li minor. Excessive scrotl skin is removed nd the remining prt used to form the li mjor (Fig. 6 nd 7). A peri-vginl Jckson-Prtt drin is left for 3 dys; the urethrl ctheter nd vginl pcking ( condom lled with soft mteril) re removed on 7 dys fter surgery. Vginl stenting depends on the type of the new vgin; if the vgin is formed from suf cient penile skin, the vginl stent is pplied during the night for 6 weeks. If the vgin is formed from insuf cient penile skin or from free penile skin ps, the stent is pplied continuously dy nd night for one yer. Results The men (rnge) follow-up ws 4.6 (0.25±6) yers. The most importnt fetures of the new vgin re depth nd width; the men (rnge) depth ws 11.6 (9±18) cm ut # 2000 BJU Interntionl 86, 843±850

6 848 S.V. PEROVIC et l. Penile skin Penile skin flps Li minor Li mjor Vginl introitus c d Fig. 6. Vulvoplsty:, the remining penile skin is split ventrlly nd incised prtly on the dorsl side, forming two sliding penile skin ps for creting the li minor. c,d li minor re sutured to the de-epithelilized re of the neoclitoris. The li mjor re creted from scrotl skin. precise mesurement of the vginl width is dif cult. It ws estimted in the present ptients using the vginl stent, ccording to which eight vgins were `smll', 67 were `medium' nd 12 were lrge. Another importnt chrcteristic of the new vgin is surfce moisture; this ws stisfctory in 71 nd unstisfctory in 16 ptients. # 2000 BJU Interntionl 86, 843±850

7 VAGINOPLASTY IN MALE TRANSSEXUALS 849 Fig. 7. The results t the end of the surgery; the li minor cover the neoclitoris (hooded clitoris). Informtion on sensitivity nd orgsm ws otined y interviewing the ptients; the sensitivity ws reportedly good in 83, while 73 ptients hd experienced orgsm. The genitli were estheticlly norml in ppernce in 78 ptients, ut in nine some dditionl esthetic correction ws necessry. Six months fter surgery, 69 ptients (79%) were cple of norml sexul intercourse, ut despite hving n dequte vgin some ptients refrined from intercourse. There ws only one mjor compliction, rectovginl stul cused y intropertive injury to the rectum. Other complictions were vginl shrinkge in two ptients ecuse the vginl pedicle ws too short (vginopexy under high tension), which ws resolved y rectosigmoid vginoplsty. There ws stenosis of the vginl introitus in six ptients, lte stenosis of the urethrl metus in one cused y injury during sexul intercourse, urethrl prolpse in two ptients, esily resolved y simple excision, nd posterior vginl wll rupture during intercourse in one ptient, ut with no injury to the rectum. Discussion Surgery for mle trnssexuls still presents mjor chllenge in creting new vgin; our previous opertive technique [4] ws improved using severl re nements [5]. The importnt dvnce in the present technique is complete penile disssemly, which idelly enles the use of ll penile components (except the corpor cvernos) in the construction of the new vulv, clitoris nd vgin. This lso provides idel exposure of the corpor cvernos for their removl t the level of ttchment to the puic rmi. Remnnts of the corpor cvernos (erectile tissue) re lso destroyed to prevent ny postopertive erection which could hinder sexul intercourse. The glns, with neurovsculr undle dorslly nd urethr ventrlly, is lifted from the tips of the corpor cvernos together with Buck's fsci, thus completely preserving these components. As the glns cp is divided into two, the dorsl prt is used to crete the neoclitoris; this is smll nd hs excellent vsculriztion nd sensitivity. Brown [6] nd Ruin [7] rst used the glns penis to crete neoclitoris in trnssexuls; the technique ws lter improved [8,9]. In the present technique, the new vgin is creted from n inverted pedicled islnd penile skin p nd vsculrized urethrl p. In the erly 1980s, Krzeski nd Borkowski [10] descried the use of pedunculted ldder wll for vginl reconstruction. Success in vginoplsty depends on the mount of skin ville. The essentil fctor in the use of penile skin is to otin long pedicle, llowing the penile skin p to e rought into the new vginl spce with no tension. If there is insuf cient skin there re two possiilities. One is to use the penile skin to crete only the distl prt of the vgin, voiding tension. In this cse the proximl prt nd the se of the vgin re formed from the urethrl p nd y secondry epitheliliztion, which egins on the edges of the well-vsculrized urethrl p. If the tue pedicle is too short to plce it into the perinel cvity, the new vgin is creted using vsculrized urethrl p nd free penile skin grfts. Thus, the technique my lso e used in ptients with smll nd/or circumcised penis. In the present vginoplsty the vsculrized urethrl p is essentil; it is of dequte length nd is never the limiting fctor in vginoplsty. Using penile disssemly the corpus spongiosum is completely preserved nd ensures n excellent lood supply. Also, the urethrl p llows wider neovgin, especilly the introitus. If the penile skin is insuf cient, the cretion of the vgin depends on the urethrl p, which lso provides moisture nd sensitivity to the neovgin. The results of the interviews showed tht orgsm ws minly dependent on the urethrl p. The pseudocervix, mde from the ventrl prt of the divided glns cp, # 2000 BJU Interntionl 86, 843±850

8 850 S.V. PEROVIC et l. contriutes to the sensitivity of the neovginl se. Prolpse of the urethrl prt of the vgin, which we oserved when using the Stmey xtion procedure, is completely voided with vginl xtion to the scrospinous ligment; thus prolpse nd n exggerted posterior vginl fourchette re voided. Engorgement of the ulr urethr during sexul rousl is moderte nd does not present rrier to intercourse. Contrry to trnsvginl scrospinous ligment xtion for treting vginl prolpse in true femles [11], there re signi cnt dif culties in using this procedure in mle trnssexuls. Good exposure nd direct visuliztion of the scrospinous ligment is crucil to prevent injury to the rectum, pudendl nerve, internl pudendl rtery nd vein; extensive experience of mle pelvic surgery is required. Trnsposing the vgin to the xed side hs no clinicl consequences in mle trnssexuls, s the distnce etween the scrospinous ligments is shorter thn in femles. The present vulvoplsty llows greter sensitivity of the li minor nd neoclitoris, which helps to improve the qulity of intercourse. We recommend using vginl stent in ll ptients, to llow the ptient to hve sexul intercourse s soon s possile. As noted, the durtion of stenting depends on the type of vginoplsty; regulr sexul intercourse lso prevents neovginl contrcture. Sexul intercourse should e strted s soon s possile, even though there my e leeding from the mucosl prt of the new vgin; this is trnsitory nd ptients should persevere. Thus the present technique provides neovgin with more norml ntomy nd physiology thn those creted y other methods, s ll penile components (except the corpor cvernos) re used to form lmost norml externl femle genitli. It is n dvnce in mle-to-femle surgery, ut cnnot e regrded s nl solution. References 1 Meyer R, Kesselring UK. One-stge reconstruction of the vgin with penile skin s n islnd p in mle trnssexuls. Plst Reconstr Surg 1980; 66: 401±6 2 Belgrno E, Lissini A. L femminilizzzione dei genitli esterni e l crezione dell neovgin. In Belgrno E, Fris B, Tromett C eds. Il Trnsessulismo. Milno: Editrice Kurtis, 1999: 87±97 3 Hge JJ. Vginoplsty in mle to femle trnssexuls y inversion of penile nd scrotl skin. In Ehrlich RM, Alter GJ eds, Reconstructive nd Plstic Surgery of the Externl Genitli. Phildelphi: WB Sunders Co., 1999: 294±300 4 Perovic S. Mle to femle surgery. A new contriution to opertive technique. Plst Reconstr Surg 1993; 91: 703±12 5 Perovic SV. Vginoplsty in mle trnssexuls using penile skin nd the urethrl p. J Urol 1998; 159 (Suppl 5): Brown J. Cretion of functionl clitoris nd estheticlly plesing introitus in sex conversion. In Mrchc D, Hueston JT eds, Trnsctions of the Sixth Interntionl Congress of Plstic nd Reconstructive Surgery. Pris: Msson, 1976: 654±5 7 Ruin SO. A method of preserving the glns penis s clitoris in sex conversion opertions in mle trnssexuls. Scnd J Urol Nephrol 1980; 14: 215±21 8 Eldh J. Construction of neovgin with preservtion of the glns penis s clitoris in mle trnssexuls. Plst Reconstr Surg 1993; 91: 895±900 9 Perovic S. Construction of neoclitoris in mle trnssexuls. Plst Reconstr Surg 1994; 93: 646±8 10 Krzeski T, Borkowski A. Bldder p for reconstruction of congenitl sence of the vgin. Eur Urol 1983; 9: 125±8 11 Suer HA, Klutke CG. Trnsvginl scrospinous ligment xtion for tretment of vginl prolpse. J Urol 1995; 154: 1008±12 Authors S.V. Perovic, MD, PhD, Professor of Urology nd Surgery. D.S. Stnojevic, MD, PhD, Associte Professor of Gynecology. M.L.J. Djordjevic, MD, Assistnt Professor of Surgery nd Urology. Correspondence: S.V. Perovic, Deprtment of Urology, TirsÏov 10, Belgrde, Yugoslvi. e-mil: uromiros@eunet.yu # 2000 BJU Interntionl 86, 843±850