Urethral Lengthening in metoidioplasty (female-to-male sex reassignment surgery) by combined buccal mucosa graft and labia minora flap.

OBJECTIVES: To develop a technique for urethral reconstruction using a combined labia minora flap and buccal mucosa graft. Urethral lengthening is the most difficult part in female transsexuals and poses many challenges. METHODS: From April 2005 to February 2008, 38 patients (aged 19-53 years) underwent single-stage metoidioplasty. The technique starts with clitoral lengthening and straightening by division of both clitoral ligaments dorsally and the short urethral plate ventrally. The buccal mucosa graft is quilted to the ventral side of the corpora cavernosa between the native orifice and the tip of the glans. The labia minora flap is dissected from its inner surface to form the ventral aspect of the neourethra. All suture lines are covered by the well-vascularized subcutaneous tissue originating from the labia minora. The labia majora are joined in the midline and 2 silicone testicular implants are inserted to create the scrotum. The neophallus is covered with the remaining clitoral and labial skin. RESULTS: The median follow-up was 22 months (range 11-42). The median neophallic length was 5.6 cm (range 4-9.2). The total length of the neourethra was 9.4-14.2 cm (median 10.8). Voiding while standing was reported by all 38 patients, and temporary dribbling and spraying were noted by 12. Two fistulas and one urethral erosion resulted from the testicular implant and required secondary revision. CONCLUSIONS: A combined buccal mucosa graft and labia minora flap present a good choice for urethral reconstruction in female-to-male transsexuals, with minimal postoperative complications.

Metoidioplasty: a variant of phalloplasty in female transsexuals.

OBJECTIVE: To describe metoidioplasty, a technique for creating a neophallus from an enlarged clitoris in female transsexuals, without needing the complex, multi-staged surgical construction of a large phallus, as this reconstruction is one of the most difficult in female transsexuals. PATIENTS AND METHODS: From September 1995 to April 2002 metoidioplasty was used in 22 patients (aged 18-33 years). The technique is based on the repair of the most severe form of hypospadias and intersex. The 'urethral plate' and urethra are completely dissected from the clitoral corporeal bodies, then divided at the level of the glanular corona, and the clitoris straightened and lengthened. A longitudinal vascularized island flap is designed and harvested from the dorsal skin of the clitoris, transposed to the ventral side, tubularized and anastomosed with the native urethra. The new urethral meatus is brought to the top of the neophallus, and the skin of the neophallus and scrotum reconstructed using labia minora and majora flaps. RESULTS: The mean (range) follow-up was 3.9 (0.5-6) years; the neophallus was 5.7 (4-10) cm, considered satisfactory in 17 patients but the remaining five required additional phalloplasty. The complications were urethral stenosis in two and fistula in three patients. CONCLUSIONS: Metoidioplasty is an alternative to phalloplasty, allowing voiding while standing. In patients who desire a larger phallus, various techniques of phalloplasty can also be used.

The penile disassembly technique in the surgical treatment of Peyronie's disease.

OBJECTIVE: To present an approach for treating Peyronie's disease, using the penile disassembly technique for reconstructive surgery. PATIENTS AND METHODS: From November 1996 to September 2000, 74 patients with Peyronie's disease were treated surgically. The penile disassembly technique was used in 46 of the patients (mean age 51 years, range 21-63). The indications were severe penile deviation under the glans cap, plaque in the distal third of the corpora cavernosa with the 'hour-glass' phenomenon, and more than one plaque at different sites. The corporal bodies are separated from the glans, neurovascular bundle and urethra. The technique enables the complete preservation of all structures of the neurovascular bundle, especially if it is incorporated into the plaque. The method provides an excellent approach to the repair of all deformities on the completely free corpora cavernosa and that are affected by the plaque. In the plaque region, incisional grafts are placed using full-thickness penile skin or saphenous vein. The technique also enables reduction corporoplasty, i.e. amputation of the tips of the corpora cavernosa that include plaque, in those with sufficient penile length. Penile re-assembly involves joining the glans, neurovascular bundle, urethra and repaired corpora cavernosa into their normal anatomical relationships. RESULTS: The mean (range) follow-up was 27 (6-53) months. The penis was completely straightened in 40 patients (87%) but the deviation recurred in six. In four patients the deformity was <10 degrees and in two was <20 degrees. Penile shortening occurred in 9% of the patients. There was no evidence of inflammation or infection after surgery. There were no injuries of either the neurovascular bundle or urethra. CONCLUSION: The penile disassembly technique could be a good alternative to other surgical techniques in treating selected patients with Peyronie's disease; it allows an excellent approach to penile deformities which can then be easily and safely corrected.

Penile lengthening.

OBJECTIVE: To describe a technique for penile lengthening and the results achieved. PATIENTS AND METHODS: The penis is completely disassembled into its anatomical parts; the glans cap remains attached dorsally to the neurovascular bundle and ventrally to the urethra and corporal bodies. A space is created between glans cap and the tip of corpora cavernosa; this space is used to insert autologous cartilage previously harvested from the rib, the space being measured beforehand when the corpora cavernosa are erect. The anatomical entities and inserted cartilage are joined together to form a longer penis. The increased length of the penis depends directly on the elasticity of the urethra and especially of the neurovascular bundle. From June 1995 to March 1999 the technique was applied in 19 patients aged 18-52 years, who were followed for a mean (range) of 3.3 (1-4.5) years. RESULTS: The increase in penile length was moderate, at 2-4 cm; there were no injuries of the neurovascular bundle or urethra, and no erectile dysfunction. Fifteen patients reported painless sexual intercourse, the remaining four patients providing no data. During the follow-up the cartilage insert remained at about the same size as that at initial implantation. CONCLUSION: The penile disassembly technique combined with the interposition of rib cartilage in the space between the glans cap and tips of the corpora cavernosa provides a genuine increase in penile length, with satisfactory results.

Vaginoplasty in male transsexuals using penile skin and a urethral flap.

OBJECTIVES: To describe and present the results of a one-stage vaginoplasty in male-to-female sex reassignment surgery. PATIENTS AND METHODS: The present technique is based on penile disassembly and the use of all penile components for vaginoplasty (except the corpora cavernosa). The neovagina consists of two parts; a long vascularized urethral flap and a pedicled island tube skin flap created from the penile skin. The urethral flap is embedded into the skin tube. The tube, consisting of skin and the urethral flap, is inverted, thus forming the neovagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder and rectum. The neovagina is then fixed to the sacrospinous ligament. The labia minora and majora are formed from remaining penile and scrotal skin. The new method was used in 89 patients (mean age 28 years, range 18-56) with a mean (range) follow-up of 4. 6 (0.25-6) years. RESULTS: Good cosmetic and functional results were obtained in 77 of the 89 patients (87%). Importantly, the neovagina produced in most patients was of satisfactory depth and width. There was only one major complication, a rectovaginal fistula caused by intraoperative injury to the rectum. CONCLUSIONS: The technique produces a vagina with more normal anatomical and physiological characteristics than those produced by other methods, as all the penile components are used (except for the corpora cavernosa) to form almost normal external female genitalia. Vaginoplasty using pedicled penile skin with a urethral flap is a good alternative to other methods of vaginoplasty in male-to-female sex reassignment surgery.

Augmentation ureterocystoplasty could be performed more frequently.

PURPOSE: Megaureter represents the ideal tissue for bladder augmentation but to date ureterocystoplasty has been used only in select cases. We demonstrate that ureterocystoplasty can be used more frequently by dividing the megaureter and using its distal part for bladder augmentation and proximal part for reimplantation into the bladder. This technique can be performed as a 1 or 2-stage procedure. MATERIALS AND METHODS: From November 1995 to October 1998 ureterocystoplasty was performed in 16 patients 3 to 12 years old (mean age 6.6). In 9 cases with impaired renal function loop cutaneous ureterostomy had been previously done to preserve and improve renal function. In the remaining 7 cases bladder augmentation and simultaneous ureteroneocystostomy were performed without cutaneous ureterostomy. Ureterocystoplasty was done extraperitoneally. This distal part of megaureter was used for bladder augmentation and the proximal part was implanted into the bladder using extravesical detrusor tunneling ureteroneocystostomy in a majority of cases. RESULTS: Followup ranged from 12 months to 4 years (mean 2.8). The new increased bladder capacity ranged 296 to 442 ml. (mean 371) in both groups. Compliance was improved in all cases with a decrease in the number of clean intermittent catheterizations daily, and there was no further worsening of renal function. Vesicoureteral reflux was noted in 3 patients without clinical symptoms. CONCLUSIONS: Megaureter presents the ideal tissue for bladder augmentation. Division of the ureter and use of its distal part for augmentation is always possible. Augmentation ureterocystoplasty performed this way can be done more frequently.

Penile disassembly technique for epispadias repair: variants of technique.

PURPOSE: We present 2 variants of the penile disassembly technique for epispadias repair that refine some details of the Mitchell technique. In some cases the urethral plate retracts and shortens, and there may be poor vascularization at the most distal portion. In addition, when the neurovascular bundles of the separated hemicorporeal glanular bodies are intact, it is difficult to achieve excellent correction of dorsal chordee. MATERIALS AND METHODS: Between 1995 and 1998 we performed the modified Mitchell technique in 11 boys 2 to 14 years old using 1 of 2 variants. For variant 1 the hemiglans and urethral plate remain connected by a small tissue bridge to avoid shortening the urethral plate and ensure a better blood supply. For variant 2 each corporeal body is dissected from the glans cap and neurovascular bundle to achieve complete mobility. This procedure enables ideal mobility of the corporeal bodies as well as curvature repair. When corporeal rotation was unsuccessful, we corrected persistent dorsal chordee using the Ransley corporotomy with corporostomy in 2 patients and with dermal grafting in 1. RESULTS: Mean followup was 17 months (range 6 to 30). Dorsal curvature was corrected in all cases. Cosmetic appearance was good. Complications included meatal stenosis and urethral fistula in 1 case each. CONCLUSIONS: Our variants of epispadias repair may be good alternatives to the Ransley and Mitchell complete penile disassembly techniques.

[Penile disassembly technique: a new approach in the surgical reconstruction of hypospadias]. / Technique de désassemblage du pénis: une nouvelle approche de la chirurgie reconstructrice de l'hypospade.

We report our experiences with penile disassembly technique in the treatment of severe hypospadias. During a period from November 1995 to December 1997 the technique was applied to 102 patients, aged from 9 months to 32 years. The principle of the technique involves separation of the penis into its component parts: glans cap with neurovascular bundle (dorsally) together with undivided or divided urethra and urethral plate (ventrally), and corpora cavernosa. After correction of the curvature and different techniques of urethroplasty the penile entities are joined into normal anatomical relationships. Our goal was also to achieve some degree of penile enlargement in small hypospadiac penises. The patients were followed from 4 to 29 months (mean 19.2 months). Straightening of the penis was achieved in all cases without recurrence of curvature. Complications were related to urethroplasty: 3 urethral stenoses, 2 fistulas and 2 diverticulum. Penile disassembly technique is very effective for most severe hypospadias. Possibility of penile augmentation is real with this technique.

A new approach to the treatment of penile curvature.

PURPOSE: Techniques for penile straightening generate the serious dilemma of which is most appropriate. We created and describe our penile disassembly technique to avoid penile shortening in curvature repair. MATERIALS AND METHODS: From November 1995 to March 1997 we performed our penile disassembly technique in 87 patients 12 months to 47 years old (mean age 4.5 years). Indications for surgery were isolated penile curvature and chordee with or without hypospadias, curvature of the distal third of the corpora cavernosa and a small penis with curvature. Our method consists of separation of the penis into its entities, a glans cap with its neurovascular bundle dorsally, a nondivided or divided urethra, or urethral plate ventrally and corpora cavernosa that may be partially separated in the septal region. This maneuver achieves excellent correction of penile curvature. In addition, during this procedure a space is created between the glans cap and the tips of the corpora cavernosa into which various tissues may be inserted to avoid penile shortening due to corporoplasty or even to lengthen the penis. RESULTS: Mean followup was 16 months (range 6 months to 2 years). There were no injuries to the neurovascular bundle or urethra. Complications developed only in relation to onlay or tubularized urethroplasty in 4 patients. CONCLUSIONS: Our penile disassembly technique seems to be the most effective procedure in select cases of severe curvature of the distal penile shaft, marked glans tilt and a small penis with curvature. In addition, the procedure provides the possibility of penile lengthening.

A new approach in hypospadias repair.

The field of hypospadiology remains full of challenges in the search for new and better solutions. In recent years, our concept has involved being very radical in penile reconstructive surgery, using an aggressive approach. The penile disassembly technique, either complete or incomplete, is used successfully in epispadias repair. We began using penile disassembly in hypospadias repair in November 1995. The technique was applied on 112 patients aged from 9 months to 32 years. Indications were: hypospadias with severe penile curvature (especially when the curvature was located in the distal third of the corpora cavernosa), chordee without hypospadias, and small penises with hypospadias. The principle of the technique involves separation of the penis into its component parts: the glans cap with neurovascular bundle (dorsally) together with the nondivided or divided urethra and urethral plate (ventrally) and the corpora cavernosa. This maneuver enables an excellent correction of curvature, especially if it is located in the distal third of the corporal bodies and glans tilt. With this technique, substitution urethroplasty can be avoided or its extent, decreased. It enables penile enlargement, above all its lengthening, which is a significant gain in small penises with hypospadias. The patients were followed for 3-23 months (mean 16 months). Straightening of the penis was achieved in all cases without recurrence of curvature. In 37 patients penile disassembly combined with extensive urethral mobilization solved the problem of hypospadiac meatus without the need to form a neourethra. Complications related to urethroplasty included four urethral stenoses, two fistulas, and three diverticula. There was no injury to the neurovascular bundle and urethra. Sensitivity and erection were preserved in all patients. Penile disassembly is an optimal technique for repair of hypospadias with severe curvature and small hypospadiac penises. Real penile augmentation is possible with this technique.

The penile disassembly technique in hypospadias repair.

OBJECTIVE: To report experience and results with penile disassembly in hypospadias repair. PATIENTS AND METHODS: From November 1995 to May 1997 penile disassembly was used in 92 patients aged from 9 months to 32 years. The indications for operation were hypospadias with severe penile curvature (especially with curvature in the distal third of the corpora cavernosa), chordee without hypospadias, and small penis with hypospadias. The technique involves separating the penis into its component parts, i.e. the glans cap with neurovascular bundle dorsally, together with the undivided or divided urethra and urethral plate ventrally, and the corpora cavernosa. The manoeuvre allows any curvature to be corrected, especially when in the distal third of the corporal bodies, glans tilt to be rectified, and the penis to be enlarged, particularly elongated, which is a significant gain in small penises with hypospadias. RESULTS: The patients were followed for 3-20 months (mean 14); the penis was straightened in all cases, with no recurrence of curvature. In 37 patients (40%) penile disassembly combined with extensive urethral mobilization resolved the hypospadiac meatus with no need to form a neourethra; the penis was larger after surgery. Complications were related to urethroplasty and included four urethral stenoses, two fistulae and three diverticula. There was no injury to the neurovascular bundle and urethra; sensitivity and erection were preserved in all patients. CONCLUSION: The penile disassembly technique is most effective for hypospadias with severe curvature, especially for glans tilt and curvature located distally. Penile augmentation is possible using this technique.