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Pubic phalloplasty in female-to-male
transsexuals
C Bettochi, DJ Ralph, JP Pryor
Institute of Urology, The Middlesex Hospital, U.C.H. London, UK
[Abstract] Full Text [PDF]
A considerable variety of phalloplasty
techniques has been described using either pedicled or free flaps. We report
our experience at The Middlesex Hospital-London during the period 1989-96 in
phallic construction for female-to-male transsexuals using a pubic pedicled
flap.
Patients and method
Sixty five patients were referred to our
department after a psychiatric assessment. All of them had a male hormonal
replacement therapy. Usually they have undergone a mastectomy previously and
they had a hysterectomy and oophorectomy at the same time as the
phalloplasty. The patients were fully informed about the operation,
objectives to achieve and risk of complications. Operative technique: with
the patient in a supine position, the phallus was formed by anterior
abdominal wall skin, and the flap fashioned 10cm wide and 10cm length from
the clitoris, mobilized and tubed after insertion of the neourethra. The
skin cover was performed by a complete mobilization of the anterior
abdominal wall skin and umbilicus up to the costal margin. The neourethra
was fashioned in one stage at the same time as the phalloplasty up to 1993
and subsequently in 2 stages. The first stage occurred at the time of the
phallus formation and this was fashioned using a major labial flap, tubed
over a 18 Fr silicone catheter, and turned through a skin tunnel into the
neophallus. The second stage involved the isolation of the opposite major
labia and this was tubed in a similar fashion and anastomosed to the native
urethra.
Results
Thirty seven patients had a one-stage
phalloplasty (Group A) and 28 had a two-stage operation (Group B). Group A:
one patient experienced the total loss of the phallus due to gangrene. Five
patients did not want the neourethra because of the high risk of
complications. Neourethral problems were frequent, being present in all but
one patient; strictures (94%) and fistula (97%) required numerous
re-operations (average three per patient) such as dilation, meatotomy/plasty
and urethrotomy/plasty. The stenoses were usually in the distal part of the
phallus and in the meatus (75%), while the fistula were always in the
perineal area. Three patients reported to be able to penetrate just with the
neophallus stiffness itself, while five others required a penile prosthesis:
unfortunately in 3 of them it was removed due to perforation. Five patients
have an implant of testicular prostheses bilaterally. The cosmetic outcome
was considered good in 59% of patients. Group B: two patients had to have
the amputation of the neophallus due to infection and necrosis. The
incidence of neourethra complications was lower (86%), being present as
either strictures (71%) and/or fistulas (36%). At the present time, 15 (60%)
patients have completed the second stage of the urethroplasty and the flow
was found to be satisfactory in 80% of them. Two patients were able to
penetrate without prosthesis implant and four are on the waiting list for
this procedure. The cosmetic outcome was considered good in 73% of patients.
Discussion
The ideal technique for phalloplasty still has
to come and this explains the presence of such a variety of techniques. We
think that pubic phalloplasty is a simple and relatively quick procedure,
with minimal scarring or disfigurements in the donor area, esthetically
acceptable to the patient and his partner, as for all the other techniques,
and the use of new forms of urethroplasty may help to sort this problem out.
Citation: XV Harry
Benjamin International Gender Dysphoria Association Symposium , an article
published on the Internet by The International Journal of Transgenderism,
1997 <http://www.symposion.com/ijt/>
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