|
Surgical conversion of genitalia in
transsexual patients
L. Jarolim
Department of Urology of the 1st Medical Faculty,
Charles University of Prague, Czech Republic.
Abstract [Full Text] [PDF]
Abstract
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.
Conclusions 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’.
Introduction
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
[3]. 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
[4].
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 [5], 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 [6]. 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 [7]. In 1990, in the Czech Republic the
prevalence of transsexualism was 1:10 000 inhabitants [8].
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 [9] 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 [10]. 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 [11].
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 [14]. 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.
Results
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.
Discussion
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 [17]. 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 [18]. 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 [19].
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 [20] 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.[21] 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 [22]; Gilbert et al.[23] 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.
References
- Benjamin H. Transvestitism and
transsexualism. Int J Sexuol 1953; 7: 12
- Benjamin H. Transvestitism and
transsexualism as psycho–somatic and somato–psychic syndromes. Am J
Psychotherapy 1954; 8: 219–30
- Brzek A, Šípová L. Dnešní moznost zmìny
pohlaví u transsexualismu. Prakt Lék 1979; 59: 752–6
- Block NI, Tessler AN. Transsexualism and
surgical procedures. Surg Gynecol Obstr 1971; 132: 517–25
- Laub DR, Laub Dr II, Biber S. Vaginoplasty
for gender confirmation. Clin Plast Surg 1988; 15: 463–70
- Gooren L. The endocrinology of
transsexualism: a review and commentary. Psychoneuroendocrinology 1990; 15:
3–14
- Landén M, Lundström B. Incidence and sex
ratio in transsexualism. XIV Harry Benjamin International Gender Dysphoria
Symposium. Abstract book. Ulm: HBIGDA, 1995: 52
- Fifková H. O Sexu, Praha: Grada Publishing,
1998: 67
- Pandya NJ, Stuteville OH. A one–stage
technique for constructing female external genitalia in male transsexuals. Br
J Plast Surg 1973; 26: 277–82
- Fang RH, Chen CF, Ma S. A new method for
clitoridoplasty in male–to–female sex reassignment surgery. Plast
Reconstr Surg 1992; 89: 679–82
- Meyer R, Kesselring UK. One stage
reconstruction of the vagina with penile skin as an island flap in male
transsexuals. Plast Reconstr Surg 1980; 66: 401–5
- Abraham FZ. Genitalumwandlung an zwei männlichen
Transvestiten. Zeitschr Sexualwissensch Sexualpolitik 1931; 28:
223–5
- Edgerton MT, Knorr NJ, Callison JR. The
surgical treatment of transsexual patients. Plast Reconstr Surg 1970;
45: 38–46
- Puckett CL, Montie JE. Construction of male
genitalia in the transsexual, using a tubed groin flap for the penis and a
hydraulic inflation device. Plast Reconstr Surg 1978; 61: 523–30
- Durfee R, Rowland W. Penile substitution
with clitoridal enlargement and urethral transfer. In Laub DR, Gandy P, eds,
Proceedings of the Second Interdisciplinary Symposium on Gender Dysphoria
Syndrome. Palo Alto: Stanford University Press, 1973: 181–3
- Jarolím L. Kirurška terapija zenskog
transseksualizma. In Kröpfl D, Novak R, Tucak A, eds, Rekonstrukcijska
urološka kirurgia. Zagreb: Medicinska naklada, 1999: 451–4
- Jayaram BN. Complications and undesirable
results of sex–reassignment surgery in male–to–female transsexuals. Arch
Sex Behav 1978; 7: 337–45
- van Kesteren P, Asscheman H, Megens J et al.
Side effects of cross–sex hormonal treatment: An update of mortality and
morbidity in 1109 transsexuals. XIV Harry Benjamin International Gender
Dysphoria Symposium. Abstract book, Ulm: HBIGDA, 1995: 36
- Thurston AV. Carcinoma of the prostate in a
transsexual. Br J Urol 1994; 73: 217
- Chang TS, Hwang WY. Forearm flap in
one–stage reconstruction of the penis. Plast Reconstr Surg 1986;
74: 251–8
- Koshima I, Tai T, Yamasaki M. One–stage
reconstruction of the penis using an innervated radial forearm
osteocutaneous flap. J Reconstr Microsurg 1986; 3: 19–23
- Meyer R, Daverio PJ. One–stage palloplasty
without sensory deprivation in female transsexuals. World J Urol 1987;
5: 9–13
- Gilbert DA, Horton CE, Terzis JK et al. New
concept in phallic reconstruction. Ann Plast Surg 1987; 18: 128–31
Citation:
BJU International 2000 http://www.bjui.org/85/7/article/bju624.asp
|
