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Keywords:

  • male-to-female transsexuality;
  • gender transforming surgery;
  • results;
  • long-term follow-up

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

Objective To report experience of a new surgical technique in male-to-female transsexual patients, the complications, and the functional and psychosocial long-term results.

Patients and methods From April 1995 to July 2000, 66 male patients underwent gender-transforming surgery at our institution and were registered prospectively. The operation should result in a normal appearing introitus, a vaginoplasty allowing for sexual intercourse and a sensitive clitoris. This was achieved by preserving the neurovascular bundle. The glans was transformed into a clitoris, the phallic cylinder used as a vagina and labia were formed from the scrotal folds.

Results Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients. Ten patients with insufficient penile skin had the phallic cylinder augmented with a free-skin mesh graft, but in three of these patients an ileal augmentation was finally constructed because scarring occurred at the suture line between the penile skin and the augmented graft. A long-term follow-up questionnaire about the functional and psychosocial aspects was completed by 31 patients. More than 90% of the patients were satisfied with the cosmetic result and capacity for orgasm; 58% reported having sexual intercourse.

Conclusion Male-to-female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender-transforming surgery.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

Male-to-female transsexual surgical techniques are well defined, and give good cosmetic and functional results. Techniques include the creation of a normal appearing female introitus, a vaginoplasty allowing for sexual intercourse and the capability of clitoral orgasm. Although the surgical steps are mostly standard, some specific ‘tricks of the trade’ are of interest. From our experience, in a clinic undertaking many male-to-female transsexual operations, we describe our technique, report the possible complications and provide the long-term follow-up of patients for the cosmetic, functional and psychosocial results.

Patients and methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

From April 1995 to July 2000, 66 male transsexual patients underwent gender-transforming surgery at our institution; they were registered prospectively for further analysis of the functional outcome and psychosocial aspects. The median (range) age of the patients was 36.9 (20–57) years; 16 were 20–29, 22 were 30–39 and 27 were 40–50 years old, with the oldest patient 57. All patients underwent a two-stage procedure; the first stage comprised the main steps of the transformation and at the second (≈8 weeks later) only minor functional and cosmetic corrections were made.

The surgical technique was as follows: beginning 2 days before surgery, the bowel was prepared and antibiotics, e.g. mezlocillin and metronidazole, administered at the start of surgery. While penicillin was given for 3 days, metronidazole was only continued if there was a rectal lesion. The patient was placed in the straddle position and pneumatic cuffs used for the legs. A beta-isodona/iodoform pad was placed into the rectum. Through a vertical perineal incision the testicles and spermatic cords were removed at the level of the external inguinal ring, followed by a blunt preparation of the subcutaneous tissue up to the umbilicus and positioning of four sutures (Fig. 1), which were tied later lateral to the introitus. The phallus was then degloved, and the glans and neurovascular bundle separated. The corpora cavernosa were completely resected. The corpus spongiosum was partially resected on the ventral side of the urethra (Fig. 2). The centrum tendineum was incised for blunt preparation of a cavity, the neovagina, between the urethra and bladder on one side and rectum on the other. The phallic cylinder was inverted and closed at its end (in all patients, the phallic skin was used to create the neovagina; 10 patients who had been circumcised received additional augmentation of the phallic cylinder with a free skin mesh graft to achieve a minimal length of 12 cm for the neovagina). Stabilized by an obturator (stent) the phallic cylinder was placed inside the cavity (Fig. 3), and the position of the clitoris and the urethra determined. Only a quarter of the glans was left uncovered to form the clitoris, while three-quarters were de-epithelialized and placed subcutaneously. The urethra was shortened. The final insertion of the phallic cylinder with the obturator inside was undertaken using fibrin glue. Labia majora were formed from the scrotal folds (Fig. 4). A suprapubic catheter was inserted and a compressive dressing applied. After surgery the dressing was changed every 2 days. During the second change the obturator was removed for the first time and the vaginal cavity inspected. If everything was satisfactory the patient was instructed in the use of the obturator. Afterwards, the suprapubic catheter was closed to allow spontaneous voiding. If this was possible with no problems, the catheter was removed. If the postoperative course was uneventful the patient left the hospital 8 days after surgery.

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Figure 1. The position of the two sutures within the subcutaneous tissue of the left lower abdomen, ≈ 5 cm above the pubic bone, tied lateral to the introitus later.

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Figure 2. The phallic cutaneous cylinder, neurovascular bundle and urethra with catheter inside after resection of the corpora cavernosa and corpus spongiosum.

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Figure 3. The neovaginal cavity and inverted phallic cutaneous cylinder with the obturator inside.

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Figure 4. The result at the end of the first operation.

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During the second procedure the posterior vaginal vault was incised to allow for a functional vaginal orifice; a mons pubis was created by a suprapubic skin plasty (Fig. 5). Finally, if necessary, cosmetic refinements can be made, e.g. reduction of excessive skin of the labia majora and creation of labia minora (Fig. 6). Additionally a mammoplasty can be undertaken during the second operation (as in 17 of the present patients).

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Figure 5. The situation before the second operation, with the incision line for the suprapubic skin plasty marked.

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Figure 6. The final result.

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After completing the whole procedure, most of the present patients consulted a gynaecologist for regular examinations, comparable with those biologically female. Nevertheless, if any problems occurred with the surgery patients were referred to our department. Therefore, it was possible to record any immediate postoperative and delayed complications. To ensure that all complications were recorded patients were asked to note all problems with the surgery using a long-term follow-up questionnaire (Appendix). The main aim of the questionnaire was to record the patient's opinions on the functional results and psychosocial aspects. If patients did not complete the questionnaire their GPs were contacted to obtain information about any further complications from the surgery.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

The mean (range) operative duration for the first procedure was 6.3 (4–9) h; Table 1 shows the complications recorded during and after surgery. The most frequent complication was meatal stenosis, which was corrected during the second procedure. Two of the three patients with rectal lesions also developed severe wound infections. All six major wound infections resulted in a retraction of the vagina; in three the neovagina was rebuilt with a free skin mesh graft. Two patients still require correction but one was satisfied despite the retraction. One patient had a minimal rectal lesion after preparation of the cavity for the neovagina. The lesion was closed primarily with no temporary colostomy. The lesion recurred after the onset of bowel movements. One patient developed a rectovaginal fistula 4 months after surgery. During the primary operation the patient had the vagina augmented with a free skin mesh graft. A thin area at the posterior vaginal wall after preparation probably resulted in a fistula when using the dilator. The lesion was repaired and the patient received a temporary colostomy. The third patient with a rectal lesion was treated with a temporary colostomy.

Table 1.  Complications after male-to-female gender transformation in 66 patients
Complicationn (%)
Meatal stenosis7 (5)
Severe wound infection6 (4)
Rectal lesion3 (2)
Necrosis of the glans3 (2)
Vaginal prolapse2 (1)
Necrosis of the distal urethra1 (0.6)
Lesion of the external urethral sphincter1 (0.6)
Urethral fistula1 (0.6)

Necrosis of the glans occurred in three patients and in one of them the distal urethra was also lost through necrosis. One of these patients developed an abscess of the glans, which finally resulted in necrosis. The other two patients had a transverse lesion of the spinal cord. There was no obvious trauma to the neurovascular bundle during surgery; apparently the blood supply was impaired before dissection. Nevertheless, all three patients developed a sensitive clitoral region during the long-term follow-up. The patient with additional necrosis of the distal urethra underwent a continent vesicostomy.

In one patient a urethral fistula was caused by a haemostatic suture after resecting the corpus spongiosum. The suture was removed during cysto-urethroscopy and urine drained by a suprapubic catheter for 14 days. Surgical repair was unnecessary. The lesion of the external urethral sphincter was repaired during surgery and healed well, with urgency being the only symptom for ≈ 4 weeks.

In two patients a vaginal prolapse occurred during the first change of the dressing. The vagina was re-inserted, again using fibrin glue, with no further complications. Of 10 patients treated with augmentation of the phallic cylinder by a free skin mesh graft, in five it was harvested from the lower abdomen, but they developed scars at the suture line between the penile skin and the free skin graft, causing problems during intercourse. The scarred region was incised during the second procedure. Nevertheless, three patients finally received an ileal augmentation because the stenosis recurred. In four other patients further resection of erectile tissue of the corpus spongiosum was necessary during the second procedure, because swelling of this tissue during sexual stimulation impaired penetration.

The questionnaire on functional results and psychosocial aspects was sent to 46 patients who underwent surgery between April 1995 and June 1999, with a follow-up of geqslant R: gt-or-equal, slanted 6 months. Data are available for 31 of these 46 patients; the other 15 changed address and could not be contacted by mail. Their gynaecologists were contacted by telephone to obtain further information about any surgical complications.

Patients who answered the questionnaire noted their degree of satisfaction with the cosmetic result and the depth of the vagina, and their capability for sexual intercourse and achieving orgasm. Of the 31 patients, 29 (94%) were satisfied with their external genitalia; two patients disapproved of the appearance of their labia minora. The depth of the vagina could be evaluated in 29 of 31 patients; two patients had a severe retraction of the vagina after a wound-healing problem but 22 (76%) were satisfied with the depth of the vagina. Seven patients would have preferred to have a deeper vagina. Eighteen of the 31 patients had sexual intercourse; eight of these admitted to having problems. In two patients there was too much erectile tissue from the corpus spongiosum, causing problems by swelling during intercourse. One patient reported problems of their partner passing the suture line between the penile skin and a free skin graft during intercourse. Two patients had pain during sexual intercourse and one had recurrent bleeding after intercourse. Of the 31 patients 27 (87%) reported achieving a clitoral orgasm. All patients confirmed their original decision to undergo gender-transforming surgery.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

More patients are requesting gender-transforming surgery, possibly because reports about transsexualism have been widely publicised during recent years. Being a transsexual is no longer unacceptable or censored, which encourages patients to cease being covert. Legislation enacted in Germany in the 1980s enables transsexual people to campaign publicily for their rights, with the judicial requirements detailed. Therefore, the interval from the patients publicly proclaiming their situation until gender-transforming surgery has decreased, and is currently 1.5–2 years.

Various methods for neovaginoplasty have been described and can be classified into five categories, i.e. pedicled intestinal transplants, penile skin grafts, penile skin flaps, non-genital skin flaps and non-genital skin grafts [1]. The most favoured method currently is the use of a penile skin flap [2,3]; this prevents scars at the introitus and because it has its own blood circulation there is less tendency to shrink. Moreover, inverted penile skin has no hair. However, the depth of the vagina is restricted by the penile skin available. In patients with insufficient penile skin we augment it with a non-genital skin graft. Neovaginoplasty by non-genital skin grafts was first described by Abraham [4]. Laub and Fisk reported a series of 50 transsexuals, in whom a split-skin graft was applied to achieve vaginoplasty [5]. We harvest a skin graft from the lower abdomen or both upper arms and suture it to the inverted penile skin with the dilator inside; we prefer a meshed skin graft.

The creation of a clitoris is possible by preserving the neurovascular bundle and glans. This is comparable with techniques of genitoplasty in female pseudohermaphrodites [6,7]. To guarantee full sensation we preserve the entire glans; because it is too large when used as a clitoris, three-quarters of the glans is de-epithelialized and placed subcutaneously.

Special attention is required for particular steps of the present surgical technique. Sutures between the subcutaneous tissue of the lower abdomen and the tissue lateral to the introitus relieve tension when the phallic cylinder is inserted into the prepared cavity [3,8]. Fibrin glue supports adhesion of the neovagina within the cavity. While it is obvious that the corpora cavernosa should be resected in the region of their crura near the bone, it is also necessary to resect as much of the corpus spongiosum on the ventral side of the urethra as possible, to prevent further swelling during sexual stimulation, because swelling of the introitus interferes with intercourse. This is underlined by Karim et al.[9] in 13 transsexuals undergoing further surgery after primary gender reassignment, because surplus corpus spongiosum caused difficulties during sexual activities.

The creation of labia majora is possible by using skin from the scrotal folds. Generally the labia are too large after the first operation because the tissue is oedematous at the end of surgery, so deciding how much tissue can be resected should be postponed. However, it is better to have surplus tissue in case of wound infection. Cosmetic corrections and the creation of labia minora can be undertaken during the second procedure, according to the patient's wishes. The posterior vaginal vault is also incised at this time, to allow for a functional vaginal orifice. It is advantageous after the first operation to have a high posterior vault to hold the obturator in position. Finally, the mons pubis is created; the neovagina has then developed an additional blood supply, which makes a suprapubic incision less dangerous.

Although excellent results are obtained in male-to-female transsexual surgery, there are particular complications. The first critical step is the preparation of the neurovascular bundle. Injury to the arteries or nerves results in an impaired blood supply or reduced sensation of the clitoris. There were three such patients with these complications, although during surgery there was no obvious injury to the neurovascular bundle. Two of these patients might have had an altered blood supply after a transverse lesion of the spinal cord; one also developed necrosis of the distal urethra. There might also have been a vascular spasm during preparation, or the blood flow could have been restricted by an unfavourable placement of the neurovascular bundle. Rehman and Melman [10] also reported two of 10 patients with necrosis of the neoclitoris.

The most critical step during surgery is the preparation of the vaginal cavity between the urethra and the bladder on the ventral side, and the rectum on the dorsal side. During this procedure all these structures can be injured. Therefore blunt preparation is used after incising the centrum tendineum. One of the present patients had a lesion of the external urethral sphincter, which was sutured; the patient only had urge symptoms for ≈4 weeks with no incontinence, possibly because of the additional internal sphincter within the male urogenital system. A rectal lesion occurred in three patients, closed in with no temporary colostomy. The lesion recurred, resulting in vaginal infection and retraction, and thus a temporary colostomy appears to be mandatory for rectal lesions.

A common complication in the present patients was meatal stenosis, possibly caused as the urethra is shortened to its final length and sutured to the skin when the phallic cylinder is already inserted into its cavity. Because of the urethral position within the introitus, suturing the urethral mucosa to the skin can be difficult, but the accurate adaptation of the urethral mucosa to the skin is most important to prevent meatal stenosis.

One patient developed an intralabial urethral fistula, caused by a haemostatic suture after resecting the tissue of the corpus spongiosum. Such a resection is necessary to prevent swelling of the corpus during sexual stimulation, which will lead to stenosis of the introitus. Therefore, these sutures should be placed carefully without compromising the mucosa of the urethra. Hage et al.[11] described such fistulae as the second most common cause of labial masses after vaginoplasty.

The main reason for vaginal shrinkage is postoperative infection resulting in wound healing problems, but instructing the patient in dilatation of the neovagina is important. For the first 6 months we recommend an inflatable stent, like that inserted during the operation. Afterwards the patient can use a rigid stent or have regular intercourse for dilatation.

If there is stenosis between the phallic cylinder and a free skin graft, augmented primarily because of a shortage of penile skin or severe vaginal contraction, we currently remove all the vaginal tissue and rebuild the vagina using a free skin mesh graft, as described by Laub and Fisk [5]. In three of five patients with vaginal stenosis we reconstructed the vagina with a pedicled ileal segment. Although sigmoid or rectum are the preferred segments for augmentation [12,13] we found ileum to be comparable, with the advantage of avoiding large bowel surgery. Nevertheless, augmenting the non-stenotic part of the vagina does not prevent another stenosis at the suture line and thus we rebuild all the vagina using a free skin graft.

The results from the questionnaire confirmed that patients were satisfied with the surgical results, appearance of the external genitalia, and function of the vagina and clitoris. No patients regretted their decision to undergo gender-transforming surgery. Comparable results were reported by others for 17 patients [14] and 28 patients [15]. The physical and functional results of surgery were judged to be good, with few patients requiring additional corrective surgery and none of the patients regretting having had surgery [14,15]. In contrast, Lindemalm et al.[16] evaluated 13 transsexuals with a follow-up of 6–25 years, reporting a disappointing surgical outcome, with only a third of the patients having a functional vagina. Orgasm was reported by only half of these patients. For the psychological results, only a third reported an acceptable sexual adjustment; four considered gender reassignment retrospectively to have been a mistake. Eldh et al.[17] indicated that personal and social instability before surgery, unsuitable body image and age > 30 years at operation correlated with unsatisfactory results. These results differ from those in the present study; there were no differences in patient satisfaction with age or social situation. The main basis for success in male-to-female gender reassignment seems to be a careful psychological evaluation to confirm the indication for transforming surgery, a ‘simple’ surgical technique as described here, and empathy for the patient.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

I thank Dr Christiane Spehr for instruction in performing the described method of transsexual surgery.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Patients and methods
  5. Results
  6. Discussion
  7. Acknowledgements
  8. References
  9. Appendix

The questionnaire completed by the patients.

1. Are you satisfied with the aspects of your external genitalia?

yes  no

If not, why? _______________________

2. Are you satisfied with the depth of your vagina?

yes  no

3. Can you have sexual intercourse with no problems?

yes  no

4. Do you have clitoral sensations/orgasm?

yes  no

5. Did you have other problems since surgery, which were related to the operation?

6. Do you regret your decision to have undergone gender transforming surgery?

yes  no