Refinements of pre-, intra-, and postoperative care to prevent complications of vaginoplasty in male transsexuals.

In the period of 1980 to 1992, primary genital reassignment surgery was performed for 200 male-to-female transsexuals aged 18 to 71 years. For this, the penile and scrotal skin inversion technique was used. Because, apart from minor complications in 32 patients, neovaginal obliteration was encountered only twice and early in this series, we believe it is worthwhile to report in detail our pre-, intra-, and postoperative measures. Discontinuation of hormonal treatment may prevent venous thrombosis. The preoperative rectal rinse and antibiotics are believed to be of importance to avoid rectovaginal fistulae. A soft and pliable intravaginal Vaseline tampon may prevent sloughing of the inverted skin. Intermittent daily neovaginal dilatation may successfully ensure neovaginal depth and width and, in our opinion, is superior to a long-term continuous intravaginal stent.

The anatomic basis of the anterior vaginal flap used for neourethra construction in female-to-male transsexuals.

For lengthening of the urethra in female-to-male transsexuals, an anterior vaginal wall flap is used. This flap is separated from the posterior urethral wall down to the attachment at the urethral meatus following a glistening cleavage plane. In this paper we present the anatomic and histologic basis of this flap. Prior to this, the relevant vaginal anatomy will be discussed. The anterior vaginal wall and posterior urethral wall are not indissectible structures; this is true even in the caudal two-thirds of the urethra. A long and narrow flap can be raised, thanks to the abundant vascular supply of the vaginal wall and the musculomucosal quality of the flap. A previously performed anatomic and histologic survey of the anterior vaginal wall has shown that the glistening cleavage plane is not composed solely of fascia, but rather consists of longitudinal strands of muscle, fibrous tissue, and elastin.

Sculpturing the glans in phalloplasty.

One of the goals of phalloplasty is the construction of an aesthetically appealing neophallus with a urethral meatus at its tip. Aesthetic considerations imply the creation of a glanslike structured tip. A review of the scarce literature on sculpturing of a glans is given. In cases in which microsurgical free-flap techniques are applied in our hospital, the glans is usually sculptured to its final appearance during the actual phalloplasty. If, on the other hand, an abdominal or inguinal skin flap is used, final sculpturing will be done as a subsequent separate procedure. From a review of the literature on this subject and from our experience, one may conclude that the Norfolk technique of coronal ridge and sulcus construction has best results. We consider Munawar's technique to be obsolete, since it tends to lead to flattening of the coronal ridge.

Preconstruction of the pars pendulans urethrae for phalloplasty in female-to-male transsexuals.

One of the goals of phallic construction in female-to-male transsexuals should be the creation of a competent neourethra that allows patients to void while standing. Apart from constructing the perineal fixed part of the neourethra, it is therefore necessary to create a phallus with a pendulant part of the neourethra to be connected to the pars fixa urethrae. In patients in whom we apply microsurgical free-flap techniques for phalloplasty, the pars pendulans is usually created the Chinese way (n = 8). If, on the other hand, pedicled abdominal or inguinal skin flaps are used, a skin-lined urethral tube to be incorporated in the phallus should already be extant in the donor area of the flap (n = 25). In the 20-year period 1971-1991, such a preconstruction of the pars pendulans urethrae has been attempted in 25 female-to-male transsexuals employing Snyder's technique. This has been successful in all and uneventful in 17 patients. If malelike micturition while standing is the goal and the use of microsurgical free-flap techniques is not indicated, this procedure seems to be the method of choice.

Construction of the neophallus in female-to-male transsexuals: the Amsterdam experience.

Until April 1991, 31 phalloplasties were performed in 28 patients at our hospital. Operative techniques and results of the use of the superficial inferior epigastric pedicled skin flap, rectus abdominis myocutaneous pedicled flap and radial forearm free flap for phalloplasty are presented and discussed. Functionally and cosmetically, the microsurgical free flap phalloplasty techniques lead to the best results. In all cases of free flap phalloplasty in our series tactile sensitivity recurred in the neophallus. However, erogenous sensibility should not be expected. We regard use of the infraumbilical flap to be a technique with few indications and it should not be applied to obese patients. Use of the rectus abdominis myocutaneous pedicled flap is a reliable technique. Primary connection of the pars fixa and pars pendulans urethrae often leads to formation of fistulas at the level of the anastomosis. Genital reassignment surgery in female-to-male transsexuals can seldom be achieved in 1 stage and this should be made clear to the patient before any form of surgery is done.

Obtaining rigidity in the neophallus of female-to-male transsexuals: a review of the literature.

In phalloplasty, the use of transplants and implants to obtain sufficient rigidity allowing for sexual penetration is difficult and often has resulted in complications and failure. Resorption, curving, and fracture of autologous cartilage and bone transplants are reported, and rigid implants have a tendency to erode and extrude. Besides, a constantly rigid phallus may serve as a source of embarrassment to the patient. On the other hand, hydraulic prostheses frequently show mechanical failure compared with nonhydraulic implants. For these reasons, some authorities have their patients use external devices for erection. Others fully rely on edema, scar fibrosis, or congestion to give sufficient rigidity. In this review, the literature on baculum implantation--on the use of external devices as well as on the use of no stiffener at all--is discussed.

Construction of the fixed part of the neourethra in female-to-male transsexuals: experience in 53 patients.

Genital construction in female-to-male transsexuals should ideally involve the creation of a competent neourethra, allowing the patients to void while standing. A short review of the literature on this subject is given. In our hospital, construction of the fixed part of the urethra up to the level of the clitoris has been accomplished using an anterior vaginal flap as described by Thompson and by Bouman in 46 subjects. Initially, serious complications such as vesicovaginal and urethrovaginal fistulas and urinary incontinence were encountered in this series. Subsequently, in experienced hands, this seems to be a technique with few risks. Formation of a urethrocutaneous fistula at the level of the female external urethral orifice can be successfully prevented using this flap. The problem of neourethral urine residue has still to be solved.

Constructing a scrotum in female-to-male transsexuals.

Genital construction in female-to-male transsexuals also should involve giving the labial region a scrotum-like appearance. A review of the literature on this subject is given. In our hospital, the construction of a scrotum in which testicular prostheses are implanted has been performed usually in combination with lengthening of the pars fixa of the urethra. A bifid scrotum is constructed using a V-Y advancement of the labial skin. Although implant expulsion (in 7 percent) and dislocation of implants (in 11 percent) were encountered in this series of 50 patients, the technique itself is easy to perform and seems to have few major drawbacks. The scars are small and hidden in the scrotal folds and hair. Tissue expansion prior to implantation of the testicular prostheses in the labial skin has proven to be unnecessary with this technique.

Silicone genital prosthesis for female-to-male transsexuals.

In the case of a female-to-male transsexual who has not yet undergone phalloplasty, one of the greatest concerns is how to give the appearance of having male external genitals. Many methods have been attempted by patients. We helped develop a silicone prosthesis after obtaining information on the demands of female-to-male transsexuals through a questionnaire sent to 120 of them. Three different models of the prosthesis were designed to enable three different methods of fixation. One of the methods of fixation involves the creation of a bipedicled skin flap in the pubic area. Thus this is the first of such prostheses that can be worn directly fixed to the body. It seems that the prosthesis developed in close cooperation with our department fulfills most of the needs of our patients.

Surgical depilation for the treatment of pseudofolliculitis or local hirsutism of the face: experience in the first 40 patients.

Forty patients underwent surgical depilation for pseudofolliculitis barbae or local hirsutism of the face during a 15-year period. The operative method and its results and pitfalls are discussed. Although it is not the treatment of choice, this operation is very useful when other therapy has not been successful. This seems especially true in male-to-female transsexuals.

[A serious complication of ritual circumcision of a 'buried' penis]. / Een ernstige complicatie ten gevolge van rituele circumcisie van een 'begraven' penis.

The buried penis is a rare congenital anomaly in which a circumcision can result in deformity and functional disorder of the penis. We describe the case history of a one-year-old boy with this anomaly who underwent ritual circumcision by a layman.

The importance of near total resection of the corpus spongiosum and total resection of the corpora cavernosa in the surgery of male to female transsexuals.

From 1980 to 1989, 13 male to female transsexuals underwent surgery for resection of the corpus spongiosum, performed at the Department of Plastic and Reconstructive Surgery of the Free University Academic Hospital, Amsterdam, The Netherlands. Except for 1, all patients underwent the primary sex-reassignment procedures in institutions other than this hospital. All had difficulties during sexual activities. After repeat surgery with near complete excision of the corpus spongiosum and also in three instances of the corpus cavernosum, improvement was noticed in all patients. The importance of the total elimination of the erectile tissue is emphasized.

Sex reassignment surgery in male to female transsexuals.

The operative technique used is first described by Stuteville, Pandya, and Arieff in 1971. The main principle of this technique is that the vagina is lined with inverted penile skin like a flap on an abdominal pedicle. All the erectile tissue is removed. In the follow-up, special attention was paid to the patients' reactions to the surgery and to the anatomical and functional results. There was only 1 patient who regretted having had the operation. All the others were well pleased and content that their external sexual organs at last fitted their body image. There were few complaints about the appearance, and only 4 patients needed further surgery to increase the size of the vagina. Some patients had a vagina that would be judged too small. They did not complain because the vagina was unimportant in their sexual activities.

Merits and considerations in the use of anti-androgen.

Anandron administration (300 mg/daily) to 16 human normal genetic male volunteers (who opted for male to female gender transformation) induced clinical signs of feminisation during 8 weeks of treatment. More than 2-fold increase in blood luteinising hormone and testosterone was measured while follicle stimulating hormone remained without any change in the levels. Prolactin showed a slight but significant increase at 8 weeks of treatment. The prostate size measured in 6 subjects using transrectal ultrasonography before and at 8 weeks of anandron treatment showed no change. The prostate size measured in 6 subjects who received androcur (100 mg/daily) in combination with ethinyl estradiol (100 micrograms/daily) for longer than 18 months did not differ compared to pre-treatment size. However, the prostate histology showed a clear predominance of stromal components with a significant reduction in the number of acini. The epithelial cells appeared atrophic. Histology of the testes showed a readily observable reduction in tubular and interstitial cells. The monodispersed cells prepared from the testes consisted of Leydig and non-Leydig cells. These cells responded to stimuli (hCG and Pregnenolone) in terms of an increase in testosterone synthesis in vitro. Anandron treatment of intact mature male rats increased the blood testosterone level. Estrogen administration dramatically reduced the anandron induced increase in testosterone to castration level. The benefits of a combination of low doses of anandron and estrogen for achieving an effective anti-androgenic action are presented.

Androgen action blockade does not result in reduction in size but changes histology of the normal human prostate.

The effect of androgen blockade on the normal human prostate was studied in 16 healthy volunteers opting for male-to-female gender reassignment. Their ages ranged from 19 to 27 years. After 8 weeks of treatment with Anandron, serum hormone levels indicated anti-androgenic action and physical signs of feminization appeared. Prostate volumes (measured by ultrasound) before and following Anandron treatment remained the same. After 18 months of treatment with cyproterone-acetate and ethinyl estradiol, prostate volumes again were not changed. However, histology revealed glandular atrophy and an increase in stromal tissue. The significance of these findings is discussed.