Naoya Masumori M.D., Department of Urology, Sapporo Medical University School of Medicine, S1, W16, Chuo-ku, Sapporo 060-8543, Japan. Email: firstname.lastname@example.org
An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as gender identity disorder. In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called male-to-female and female-to-male gender identity disorder, respectively. Although the precise pathogenesis of gender identity disorder remains unclear, the prevalence of gender identity disorder is quite high, with the rates calculated for male-to-female to be 1:25 000 and female-to-male to be 1:12 000 in Hokkaido, Japan. The diagnosis and treatment of gender identity disorder in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition. Although gender identity disorder was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and sex reassignment surgery are considered. However, there are very few institutions that routinely carry out sex reassignment surgery in Japan, even though it is mandatory for changing sex on the census register at the present time. Sex reassignment surgery for male-to-female and female-to-male patients includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty, and hysterectomy, ovariectomy, metoidioplasty and phalloplasty, respectively. To provide accurate information about physical treatment for patients with gender identity disorder, even urologists who are not actively involved in the diagnosis and treatment of gender identity disorder should understand the fundamental aspects and contemporary problems of gender identity disorder.
Diagnostic and Statistical Manual of Mental Disorders
gender identity disorder
gonadotropin releasing hormone
International Classification of Diseases-10
insulin-like growth factor
interstitial nucleus of the anterior hypothalamus
Japanese Urological Association
polycystic ovary syndrome
sex reassignment surgery
An incongruence between one's physiological sex and the gender identity that is one's basic sense of self as a man or a woman is known as GID.1–4 In general, the conditions of physiological men having female gender identity and physiological women having male gender identity are called MtF and FtM GID, respectively. Although the nomenclature indicating such incongruence was changed from transsexual,5,6 gender dysphoria syndrome7 to transsexualism in the DSM-III in 19808 and the ICD-10 in 1990,9 the term GID was introduced in the DSM-IV in 1994,10 although the nomenclature might be changed in the upcoming DSM-V.11 According to the DSM-IV TR in 2000,1 GID is defined by the following: (i) a strong and persistent cross-sex identification (not merely a desire for any perceived cultural advantages of being the other sex); (ii) a persistent discomfort with his or her sex, or a sense of inappropriateness in the gender role of that sex; (iii) the disturbance is not concurrent with a physical intersex condition; and (iv) the disturbance causes clinically significant distress or impairment in social, occupational or other important areas of functioning. Although GID was previously thought to be a psychiatric condition, it is extremely difficult to assign gender identity to physiological sex by psychiatric and psychological treatments. To adapt the figure of the body to the native gender identity, physical treatments such as administration of cross-sex steroids and SRS are considered.2–4,6
Thus, GID should be managed by appropriate medical interventions to relieve the incongruence and suffering. However, since the 1975 conviction of a gynecologist, based on the Eugenic Protection Act, for carrying out SRS on three GID patients without sufficient preoperative examinations and informed consent,3 physical treatments for GID have been officially avoided in Japan as an untouchable issue, because SRS is generally misunderstood to be an illegal surgical procedure. This problem was partly overcome by the publication of the Report and Recommendations for Gender Identity Disorder12 (now designated the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 1st edition) proposed by the Japanese Society of Psychiatry and Neurology in 1997, after which the first official SRS was carried out for a GID patient in Saitama Medical Center in 1998. The official performance of SRS based on sufficient deliberation by ethical committees gradually expanded to Okayama University Hospital in 2001, followed by Sapporo Medical University Hospital in 2006. The guidelines have been revised twice13,14 and the 4th edition became available in 2012.3
In the present review article, diagnostic procedures based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition,3 in Japan are briefly described, along with the etiology and epidemiology of GID. In addition, physical treatments, especially the details of surgical procedures and outcomes of SRS at Sapporo Medical University, Sapporo, Japan, are introduced. Finally, clinical problems of physical treatment of GID in Japan are discussed.
Etiology of gender identity disorder
The precise pathogenesis of GID remains unclear. Although both psychological/sociological and biological etiologies are hypothesized,15 it is likely that the latter is mainly involved in the development of GID.
It remains unknown whether gender identity is precociously fixed between the ages of 2 and 4 years-of-age, or is not fixed and continues to remain ambiguous throughout development. Men who were raised as girls from birth because of ambiguous genitalia as a result of type 2 5α-reductase deficiency have shown male identity after puberty.16 In addition, it has been reported that a biologically normal boy whose penis was accidentally ablated during a circumcision by electrocautery at 7 months finally failed to develop female gender identity at 14 years, even though the child was raised as a girl from 17 months-of-age followed by castration and genital reconstruction at 21 months.17,18 Although another report showed a conflicting result in which female gender differentiation was successfully achieved at 26 years-of-age in a boy raised as a girl because of SRS carried out at 7 months-of-age as his penis was accidentally ablated at 2 month-of-age,19 no data strongly support the involvement of psychological/sociological factors, such as exposure to certain family dynamics or rearing as a member of the opposite sex.20
There are no abnormalities in sex chromosomes observed in persons with GID.21 In contrast, it is likely that sex hormonal factors are involved in the pathogenesis of GID as a biological factor. It was reported that there were differences in a CAG repeat sequence in the first exon of the AR, a tetranucleotide repeat polymorphism in intron 4 of the aromatase gene and a CA repeat polymorphism in intron 5 of the estrogen receptor-beta gene between 29 Caucasian MtF patients and 229 healthy male controls in Sweden.22 Hare et al. also reported that the CAG repeat in the AR gene was longer in 112 MtF patients than in 258 control males (P = 0.04),23 showing that androgen signaling through AR might be less effective in MtF patients. This concept might be supported, as gender identity is designated as female in patients with complete androgen insensitivity syndrome lacking androgenic signaling as a result of AR gene mutation regardless of the 46XY karyotype and a normal/elevated level of serum testosterone,24 whereas it is designated as male in patients with type 2 5α-reductase deficiency in which androgenic signaling stimulated by testosterone is maintained.16 In terms of FtM, Baba et al. at Sapporo Medical University Hospital reported that in 40 (58%) of 69 Japanese FtM patients, their condition was associated with PCOS characterized by chronic anovulation, polycystic ovarian morphology and/or biological signs of hyperandrogenism.25 Of the 69 FtM patients, 27 (39%) showed elevated serum levels of at least total testosterone, free testosterone, androstenedione or dehydroepiandrosterone. Although there were no control subjects in the study, the incidences of PCOS and hyperandrogenemia seemed to be high in the FtM patients. Bosinski et al. also reported higher levels of serum testosterone and androstenedione in 12 FtM patients than in 15 healthy women.26 In addition, females having congenital adrenal hyperplasia showing high levels of adrenal androgens as a result of 21-hydroxylase or 11β-hydroxylase deficiency might have a higher probability to develop male gender identity.27 Thus, development of gender identity might be partly mediated by functions of androgens and/or estrogens, although the results of previous reports are still not sufficient to draw solid conclusions.
Recently, there have been several reports showing that GID might be a sexual differentiation disorder affecting the brain. Autopsy studies showed that the BSTc, essential for sexual behavior, was always larger in men than in women.28,29 However, the volume of the BSTc and the number of somatostatin neurons in the BSTc of the MtF subjects were comparable with those of reference women, whereas a FtM subject had a BSTc volume in the male range, although only one FtM subject was analyzed in the study. Hormonal treatment in adulthood did not influence the volume of the BSTc or the number of neurons. Similar results were obtained for the INAH 3, which is part of the uncinate nucleus and related to sexual orientation. The volume of INAH 3 and the number of neurons of the MtF subjects were similar to those of control females. Thus, it is speculated that morphological and functional changes in the BSTc and INAH 3 might induce the opposite sexual differentiation between the brain and physiological sex.30
Epidemiology of gender identity disorder
Several reports investigated the prevalence of GID, although it varied depending on the country.15 For example, in the Netherlands, the calculated prevalence of adult GID was one in 11 900 men and one in 30 400 women between 1975 and 1992.31 In Germany between 1981 and 1990, the prevalence of MtF and FtM was estimated to be 1:42 000 and 1:104 000, respectively.32 The DSM-IV regrouped these results and reported an average prevalence of 1:30 000 for men and 1:100 000 for women.10 Most studies have reported that MtF is more common than FtM, with ratios of 8:1 to 2.3:1, with an average of 3:1,15 whereas even or opposite ratios were observed in Serbia, Poland and Japan.33–36 Although the precise reasons why there are differences in the ratios of MtF and FtM among countries remain unknown, differences in social and cultural backgrounds among countries might be involved. As effeminate boys are less “accepted” than masculine girls in European society, such boys might have a higher chance of visiting clinics to obtain a diagnosis of MtF than masculine girls.36 In contrast, in Japan, men having gender incongruence might tend to hide the condition because of fear of segregation, as GID has not been well recognized and understood in Japanese society.
Sapporo Medical University Hospital is located in Hokkaido prefecture, which has a population of approximately 5 500 000 and is separated from the other prefectures in Japan by the sea. The hospital has been operating a GID clinic composed of psychiatrists, urologists, gynecologists and plastic surgeons since December 2003 to comprehensively diagnose and treat patients with GID by administration of cross-sex steroids and performance of SRS. As the clinic is the only GID clinic in Hokkaido prefecture, it is speculated that almost all GID patients who seek medical care in the prefecture visit the clinic. There were 104 MtF and 238 FtM patients who visited the GID clinic between December 2003 and January 2010.36 All were residents of Hokkaido prefecture. Based on the population statistics in Hokkaido, the prevalence rates of MtF and FtM were calculated to be at least 3.97 and 8.20 per 100 000 people, respectively (MtF 1:25 000 and FtM 1:12 000). The age at the first visit for MtF was widely distributed, ranging from 16 to 56 years; with an average of 31 years, whereas that for FtM was 24 years, ranging from 13 to 46 years. The proportions of patients aged 40 years and older were 2.1% (5/238) for FtM patients and 27.9% (29/104) for MtF patients. The gender clinic in Okayama University in Japan reported that MtF patients were more heterogeneous than FtM patients in terms of age at onset, sexual attraction, marital status and having children.35 Thus, the predominance of FtM in Japan might also be due to FtM patients having inflexible gender incongruence from childhood and being more likely to willingly visit a GID clinic to seek medical care.
Diagnostic procedure for gender identity disorder in Japan
The diagnosis and treatment of GID in Japan are based on the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition.3 A medical care team composed of experts who have an understanding of and interest in diagnosis and treatment of GID in various fields, such as psychiatrists, plastic surgeons, urologists and gynecologists (and, if necessary, endocrinologists, pediatricians, psychologists and social workers as well), should be organized to discuss the issues related to the diagnosis and treatment of GID.
To determine gender identity, after a detailed interview regarding the histories of nurture, lifestyle and sexual behavior, the actual status of gender dysphoria, such as a discomfort and disgust with one's sex, a strong and persistent cross-sex identification and requirement for a cross-gender role, are investigated according to the DSM-IV-TR1 and ICD-10.9 Although there is no decided period, examination continues until sufficient information is obtained. Determination of the physiological sex of MtF and FtM patients is essentially carried out by urologists and gynecologists, respectively. The internal and external genital organs are examined, and chromosomal and hormonal examinations are also carried out to check for intersex and chromosomal abnormalities. If the patients suffer from psychiatric disorders, such as schizophrenia, the diagnosis of GID should be carefully made. In addition, those who hope to change to the opposite sex to evade cultural and/or social gender roles or gain occasional benefits should be excluded from the diagnosis of GID.
If there is an obvious incongruence between physiological sex and gender identity based on comprehensive consideration of these findings, the diagnosis of GID is made, even if a patient shows chromosomal and/or sex hormone abnormalities. To confirm GID, the diagnosis should be made independently by two psychiatrists who have an adequate understanding and experience with GID.
Treatment strategies for gender identity disorder in Japan
Treatment of GID is divided into treatment in the psychiatric field and physical treatment.3 Treatment in the psychiatric field consists of psychological support (taking a history of present illnesses, empathy and acceptance), preparation for coming out to family, friends and co-workers, and real-life experience. Real-life experience is a trial in which the patients are required to live as their desired sex in everyday activity to assess whether such a situation is acceptable in daily life and if it is possible to overcome problems and/or difficulties in daily life as the opposite sex, if there are any. It is mandatory to confirm whether the patient can calmly deal with the various situations. In the guidelines, there is no minimal requirement for the duration of treatment in the psychiatric field, though usually more than 12 months of real-life experience is necessary to consider the start of physical treatment. Treatment in the psychiatric field is continued during and even after physical treatment.
Physical treatments, such as administration of cross-sex steroids, mastectomy for FtM and SRS, are considered if the patients desire it. The medical team has to inform the patients of the benefits and risks of physical treatment to facilitate their self-determination. The patients can select any type of physical treatment with any order based on their self-responsibility. The indication for physical treatment must be comprehensively deliberated on by the medical team and the ethical committee. A persistence of incongruence between physiological sex and gender identity with strong suffering even after treatment in the psychiatric field, sufficient preparation for psychological, family and social difficulties according to the change in physical appearance, and coping ability with unpredictable events are also necessary conditions to transit to physical treatment.
Administration of cross-sex steroids
To adapt the figure of the body to the native gender identity, administration of cross-sex steroids is considered.2,4,15,37 Androgens and estrogens/gestagens are given for FtM and MtF, respectively. Although various drugs, dosages, frequencies of administration and delivery routes are reported, the optimal procedures have not been determined because of the lack of randomized controlled trials for both the FtM and MtF. In Japan, intramuscular injection of 125–250 mg of testosterone enanthate (3-oxoandrost-4-en-17β-yl heptanate) every 2–3 weeks is a standard procedure for FtM patients. Oral administration of methyltestosterone having methylation of position 17α to delay metabolism in the liver, should be avoided because of the possibility of hepatotoxicity.38 In contrast, numerous procedures are clinically considered for MtF patients. The following drugs are solely or adjunctively given with various dosages: conjugated estrogens, ethinylestradiol, estriol, mestranol, medroxyprogesterone acetate, chlormadinone acetate, allyelstrenol and spironolactone are given orally; estradiol valerate, estradiol dipropionate, hydroxyprogesterone caproate are injected intramuscularly; and estradiol is given transdermally.
When cross-sex steroids are given, several adverse events will occur.2,4,15,37 The adverse effects are categorized into desired (favorable, wanted, positive) and undesired (unfavorable, unwanted, negative) effects (Table 1). For example, although androgen administration produces virilization, including enlargement of the clitoris, deepening of the voice, growth of facial and body hair, and increased muscle mass, as well as cessation of menstruation, symptoms and conditions such as stubborn acne, androgenic alopecia and obesity sometimes annoy FtM patients. In addition, abnormalities in laboratory values, such as an increased number of red blood cells, elevation of the hemoglobin value, elevation of liver enzymes and abnormal lipid and glucose metabolism, might induce critical clinical problems. For MtF patients, gynecomastia, decreased erectile function, reduction in testicular volume, redistribution of body fat as in females and reduction in growth of facial/body hair are desirable adverse effects, whereas venous thrombosis and depression might occur. To treat patients with GID, lifelong administration of cross-sex steroids is generally required, even after SRS. Not only before administration of cross-sex steroids, but also during the follow up, patients should be under appropriate medical supervision as indicated in the guidelines.2,3
Table 1. Desired and undesired adverse effects of cross-sex steroids
Constructed from Michel et al.15 and Moore et al.37
Increased subjective well-being
Abnormally increased libido
Increased blood testosterone
Erythrocytosis and increased hematocrit
Decreased blood estradiol and progesterone
Elevated liver enzymes and bilirubin
Decreased HDL cholesterol
Decreased bone mineral density after gonadectomy
Decreased insulin sensitivity
Decreased FSH and LH
Cessation of menses
Weight increase >10%
Hemorrhagic liver cysts
Android fat deposit
Increased muscular mass and strength
Breast atrophy, histological
According to the Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People, 7th version,2 GnRH analogs are considered to suspend development of secondary sex characteristics for juvenile patients with gender dysphoria as a reversible intervention. Although the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 3rd edition, in Japan, did not allow hormonal treatment for GID patients younger than 18 years-of-age,14 GnRH analogs are indicated to adolescents for puberty suppression in the latest guideline, the 4th edition.3
For FtM patients, mastectomy is considered, as the volume reduction of the mammary gland by hormonal treatment is limited. Removal of the mammary gland, the adipose tissue and excess skin is carried out according to the original breast volume.39,40 As the position and size of the nipple and areola are crucial to achieve a male-like chest, several methods to transpose and contour the nipple and areola have been proposed. Necrosis of the nipple is one of the serious complications.
Breast augmentation using prostheses or adipose tissue is considered for MtF patients who do not achieve satisfactory breast size with hormonal treatment. However, there are diverse opinions as to whether the breast augmentation should be reconstructive or purely cosmetic, because there are a variety of breast sizes in females.2 In the Diagnostic and Therapeutic Guidelines for Patients with Gender Identity Disorder, 4th edition, in Japan,3 breast augmentation, facial feminization surgery, voice surgery, thyroid cartilage reduction and hair removal are not included as physical treatments for MtF patients. Thus, the decision for their performance is based on self-responsibility.
Sex reassignment surgery for MtF
SRS for MtF subjects includes orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty.41–51 Although these procedures are usually completed in a single session, orchiectomy only or vulvoplasty without vaginoplasty is sometimes carried out based on self-responsibility.
There are several SRS methods for MtF patients, especially for clitoroplasty and vaginoplasty. For example, vaginoplasty is categorized into five methods: pedicled intestinal transplants, free penile skin grafts, penoscrotal skin flaps, non-genital skin flaps and non-genital skin grafts.42 Pedicled intestinal transplants using the sigmoid colon or ileum are beneficial to create a neovagina with functional depth and lubrication, but its invasiveness is clinically problematic. In Japan, inversion of penoscrotal skin flaps is usually considered.46,48,50,51 In this article, the surgical technique used for SRS at Sapporo Medical University Hospital is presented step-by-step below.50,51 A video presentation with Japanese narration is also available in the Audio-Visual Journal of the JUA.51
Hormonal treatment is halted 2–4 weeks before surgery. Bowel preparation is carried out using a cathartic and enema to delay postoperative contamination of the surgical wound by the stool. If an excessive amount of pubic hair is observed on the scheduled skin flaps, preliminary laser hair removal is recommended.
The patient is placed in an exaggerated lithotomy position. Although we previously used the Lavitator (Mizuho, Tokyo, Japan), a few patients developed muscular and nerve injuries of the lower legs. Thus, we currently secure the ankles using the Leg Holder (MAQUET, Rastatt, Germany) with devices to fix the thigh to prevent excessive external rotation of the hip joints (Fig. 1). To prevent deep venous thrombosis, intermittent pneumatic compression is used on the lower legs. First-generation cephem antibiotics are given 30 min before surgery, every 3 h until the end of surgery, then twice a day on days 1–3.
Preparation of penile and scrotal flaps
An incision is made on the penile and scrotal skin as shown in Figure 2a. A triangular-shaped preputial flap is harvested to create the prepuce of the clitoris. If the penile size is large enough, it is possible to use a 1.5-cm width of the subcoronal preputial skin for creation of the labia minora. The penile flap is harvested by dissection between the superficial penile fascia and Buck's fascia. The superficial penile arteries branching from the external pudendal arteries and the superficial penile veins draining into the external pudendal veins, as well as the superficial penile nerves, are included in the penile flap.
The design of the scrotal flap is crucial to create a neovagina. At Sapporo Medical University Hospital, a rectangular-shaped scrotal flap (3.5–4.0 cm × 7.0–8.0 cm) originating from 3 cm above the anus is harvested. The scrotal flap must contain the dartos muscle. In Okayama University, a wide basic M-shaped perineoscrotal flap is harvested to create a skin roll for lining the neovaginal wall.46 In general, harvesting too much of a scrotal flap results in a shortage of scrotal skin for construction of the labia majora.
The testis with the tunica vaginalis is extruded and the spermatic cord is exposed until the level of the external inguinal ring (Fig. 2b). The vas deference is divided, then double ligations are carried out on the testicular arteries and veins, and the testis and the epididymis are removed.
The urethra is separated from the corpus cavernosum and divided at the junction of the penile and bulbar urethras. Although separation of the urethra with the bulbocavernous muscle proceeds proximally, care should be taken not to injure the deep dorsal vein near the junction of the bilateral crus.
Penectomy and clitoroplasty
The suspensory ligament is dissected using an electric cautery and scissors, and the corpus cavernosum is separated from the pubic bone. Care is taken not to injure the deep dorsal vein, dorsal arteries and dorsal nerves during the procedure. Sometimes the dorsal artery is located more laterally than the dorsal nerve near the pubic arch. The crus is dissected as close to its attachment to the pubic arch as possible (Fig. 2c).
Blood flowing into the corpus cavernosum through the cavernous arteries is shut off by clamping the root of the penis using a 10-Fr Nelaton catheter. To construct the neoclitoris, a wedge incision is placed in the glans penis (Fig. 2a). To avoid damage to the neurovascular bundle, which is responsible for blood supply and sensation of the neoclitoris, a longitudinal incision reaching the corpus cavernosum through Buck's fascia and the tunica albuginea is bilaterally placed along the lateral side of the dorsal nerve to create a wedge-shaped flap in cross-section. The incision proceeds to the medial side of the crus and the penis is removed except for the neoclitoris with the neurovascular bundle (Fig. 2d).
Dissection of the lower abdominal skin
Dissection between the anterior rectus sheath and the adipose tissue proceeds to the level of the umbilicus. Sufficient mobilization of the lower abdominal skin contributes to the advancement of the penile flap in the caudal direction and makes it easy to create the anterior wall of the neovagina without tension. The anterior rectus sheath and the adipose tissue are fixed with several sutures using a 0-PDS to create the arcuate line on the suprapubic skin (Fig. 3a).
A space between the prostate and the rectum is created according to the Young approach (Fig. 2d). After dissection of the central tendon, the perineal body is divided. The rectourethralis and the levators ani are transversely divided taking caution not to injure the branches of the internal pudendal arteries, and then Denonvilliers' fascia is exposed. Dissection between the prostate and the rectum is bluntly extended to the peritoneum to create a 10 to 12-cm deep and 3-cm wide space. Care should be taken to avoid rectal injury in patients with adhesion between the prostate and the rectum as a result of long-term hormonal treatment.
The bulbocavernous muscle is removed. On the ventral side of the urethra, a 4 to 5-cm length of spatulation is given and the redundant urethra is trimmed. The cut end of the corpus spongiosum is circumferentially sutured using 4-0 Vicryl for hemostasis. The spatulated urethra is comparable with the vestibule of the vagina in females.
To decide the design for vulvoplasty, the penile flap is temporarily fixed with the scrotal flap (Fig. 2e). A vertical incision is placed in the middle of the penile flap. The prepuce is fixed on the upper edge of the incised skin and the neoclitoris is fixed on the distal end of the urethra. The lateral wall of the urethra is sutured to the lateral edge of the incised skin. The penile flap is really sutured with the scrotal flap using 3-0 Vicryl to create a skin roll. It is inverted into the space between the prostate and the rectum. Sump drains are bilaterally indwelled behind the neovaginal wall. After the trimming of the scrotal skin and the adipose tissue, the labia majora is constructed (Fig. 2f). A vaginal device is inserted and fixed using tapes so that it does not dislocate.
The patient is kept on bed rest for 2 days. Walking and eating are allowed on day 3. The drainage tube is removed when the amount of discharge per day is 5 cc or less. The vaginal device is removed on day 5. The neovagina is dilated by the index finger of an operating surgeon once a day until day 7, then self-dilation is started using appropriately sized dilators for 15 min twice a day. The urethral catheter is removed on day 7.
From 2006, 12 MtF patients underwent SRS consisting of orchiectomy, penectomy, clitoroplasty, vaginoplasty and vulvoplasty. Their average age and duration of hormonal treatment were 38.1 years (22–54 years) and 3.1 years (0–7 years), respectively. Average operative time and estimated blood loss were 5.8 h (5.0–7.0 h) and 674 cc (240–1530 cc), respectively. No patients required blood transfusion. Neither rectal injury nor necrosis of the neoclitoris developed. Although surgical site infection was observed in all patients, all recovered with conservative management. There were two patients who developed muscular and nerve injuries of the lower legs. However, such complications were not observed after the change in the leg-fixation method. Although it was difficult to create sufficient depth of the neovagina in two early cases because of adhesion between the prostate and the rectum, it was possible to make an appropriately sized neovagina by establishment of the surgical procedure. However, the neovagina became shallow and narrow with time, despite the self-dilation. In contrast, no obvious difference in voiding function was observed between before and after surgery. Figure 3b shows the appearance of the external genitalia three months after SRS.
Sex reassignment surgery for FtM
SRS for the FtM patients includes hysterectomy, ovariectomy, metoidioplasty (metaidoioplasty) and phalloplasty.49,51–56 Although hysterectomy and ovariectomy are usually carried out by an open procedure using midline or horizontal skin incision of the lower abdomen, a laparoscopic technique was recently introduced to minimize the invasiveness and the wound scar.57,58 There are two methods of phallic construction, metoidioplasty and phalloplasty. Although it is technically possible to entirely remove the vaginal mucosa, it is usually avoided because of the invasiveness and great amount of bleeding. In metoidioplasty, the enlarged clitoris induced by hormonal treatment is used to create a microphallus. Reconstruction of the urethra up to the base of the clitoris is necessary. There are various methods of phalloplasty: using a free flap, a pedicled flap, such as the extended groin flap and anterolateral thigh flap, and their combination. The free radial forearm flap is the most common material for phalloplasty. The radial artery and the cutaneous nerve are microscopically anastomosed to the inferior epigastric artery and the clitoral nerve, respectively. Sexual intercourse and standing voiding are two important purposes of the neophallus. The microphallus created by metoidioplasty is in general too short to achieve vaginal penetration. In addition, the microphallus does not always assure standing voiding, because initial and terminal dribbling of urine bothers the patients. To achieve sufficient hardness for vaginal penetration, a prosthesis is necessary in the reconstructed phallus. Scrotal construction with insertion of a testicular prosthesis might be considered for selected patients as a second-stage operation.
The surgical technique of metoidioplasty for FtM at Sapporo Medical University Hospital is explained step-by-step below. A video presentation with Japanese narration is also available in the Audio-Visual Journal of the JUA.51 Preoperative preparation is the same as with the SRS for MtF patients.
Hysterectomy and ovariectomy
Simple hysterectomy and bilateral ovariectomy are carried out through an open or laparoscopic procedure in the supine position. A cystostomy using a 12 to 16-Fr silicon catheter is created to drain urine in the bladder for 3–4 weeks after surgery. After the completion of the procedures, the patient is placed in an exaggerated lithotomy position.
Preparation of flaps for urethral elongation
The urethra must be elongated 4–6 cm in length from the original external urethral meatus to the base of the glans clitoris. The elongated urethra is constructed by the combination of two flaps, the labia minora/vestibulum and the anterior vaginal wall flaps, which form distal and proximal urethral rolls, respectively (Fig. 4a). After hydrodissection using 0.8 million-fold epinephrine solution, the labia minora/vestibulum flap is harvested. The labia minora should be separated just in the middle so as not to injure the medial (flap) and lateral (remaining skin) surfaces of the labium. Several horizontal incisions are made on the chordee to release the clitoral shaft and correct for ventral curvature. The lateral subcutaneous tissue of the corpus cavernosum of the clitoris is adequately dissected.
Next, an anterior vaginal wall flap is harvested. If a viable labia minora/vestibulum flap of adequate size to create the distal urethral roll is not obtained, a longer anterior vaginal wall flap will be necessary. During the separation, care should be taken not to injure the bladder and urethra. In addition, excessive traction of the flap using Allis forceps should be avoided, because the edge of the flap is sometimes fragile. Furthermore, care should be taken not to disturb the blood supply to the flap near the original urethral meatus.
Formation of proximal urethral roll
A proximal urethral roll is formed from the anterior vaginal wall flap around a 16-Fr silicon catheter as the core. Using 6-0 Monocryl, the mucosa and submucosal tissues are sutured by the interrupted Gambee technique, and interrupted sutures are carried out on the submucosal tissues as a second layer (Fig. 4b). A leak test is necessary to confirm whether watertight alignment is achieved.
Narrowing the vagina
The anterior vaginal wall is separated for reconstruction. Most of the time, a considerable amount of bleeding is observed from the vaginal wall and the branches of pudendal vessels. Using 3-0 Vicryl horizontal mattress sutures, the vagina is narrowed (Fig. 4c). The new orifice of the vagina created narrower than 1 cm contributes to draining the vaginal discharge. A 12-Fr Nelaton drainage tube is inserted into the vaginal cavity.
Formation of a distal urethral roll and elongation of the urethra
The labia minora/vestibulum flap is anastomosed to the proximal urethral roll by two-layer interrupted sutures (Fig. 4c). Then the labia minora/vestibulum flap is tubularized by the interrupted Gambee technique with interrupted sutures as a second layer. Tubularization proceeds up to the base of the glans clitoris. If leakage is observed in the leak test, additional suturing is carried out. Thus, tension-free two-layer suturing is fundamental to avoid development of a urethral fistula.
Closure of the skin
Sump drains are bilaterally indwelled behind the vaginal wall. Using 6-0 Monocryl vertical mattress sutures, both sides of the skin are closed (Fig. 4d). By suturing between the upper edge of the skin and distal end of the distal urethral roll, a neomeatus is created at the base of the glans clitoris.
Walking and eating are allowed on day 1 and day 3, respectively. The drainage tube is removed when the amount of discharge per day is 5 cc or less. The urethral catheter is removed on day 4. Urination is managed by cystostomy until resolution of the edema and completion of wound healing, usually for 3–4 weeks after surgery. After confirmation that the patient can spontaneously void through the neomeatus, the cystostomy is removed.
From 2006, 20 FtM patients underwent SRS consisting of hysterectomy, ovariectomy and metoidioplasty. The average age and duration of hormonal treatment were 32.2 years (22–42 years) and 4.5 years (1.4–13 years), respectively. The average operative time and estimated blood loss were 6.6 h (5.8–7.3 h) and 946 cc (300–1860 cc), respectively. No patients required blood transfusion. Two early patients developed muscular and nerve injuries of the lower legs. One patient who developed urethral stricture at the anastomotic site between the proximal and distal urethral rolls required surgical revision of the distal urethral roll at 13 months after metoidioplasty. Although one other patient required reinsertion of the cystostomy for acute urinary retention 1 week after removal of the cystostomy tube, the voiding condition spontaneously improved and the cystostomy was removed 18 days later. Urethral fistulae were observed in three early patients. In one patient, after entire revision of the elongated urethra, phalloplasty using a combination of a free radial forearm flap and a pedicled extended groin flap was carried out. In the remaining two patients, the urethral fistulae were successfully closed using the Martius flap59 at 5 and 10 months after metoidioplasty, respectively. In general, the peak urinary flow rate was decreased after metoidioplasty, probably as a result of increased urethral resistance induced by the elongated urethra. Figure 5 shows the appearance of the external genitalia 3 months after metoidioplasty.
If the patient desires a neophallus, phalloplasty is usually considered 6 months after metoidioplasty. In brief, a rice-paddle-shaped free radial forearm flap with the radial artery, vein and the cutaneous nerve is harvested to construct the penile urethra and glans penis. The defect of the donor site is covered by a full-thickness skin graft from the lower abdomen. A skin roll is formed from part of a shaft of the forearm flap around a 16-Fr silicon catheter as the core. The paddle of the forearm flap will be constructed as the glans penis at the second-stage surgery. An inguinal incision is carried out to expose the circumflex iliac artery and vein. The radial artery and vein of the forearm flap are microscopically anastomosed to the circumflex iliac artery and vein, respectively. The microphallus constructed by metoidioplasty is amputated to expose the clitoral nerve and the elongated urethra. The clitoral nerve and the urethra are anastomosed to the cutaneous nerve and the proximal end of the skin roll of the forearm flap, respectively. A pedicled, extended groin flap is harvested and rolled up the urethral skin roll of the forearm flap to create the shaft of the neophallus. When the neovascularization is completed, usually 2 weeks after the first-stage surgery, the pedicle of the groin flap is dissected and the glans penis is constructed. The urethral catheter is removed 2 weeks after the second-stage surgery. Figure 6 shows the appearance of the neophallus.
Clinical problems of physical treatments for gender identity disorder in Japan
For GID, as aforementioned, physical treatments, such as administration of cross-sex steroids and SRS, are applied to adapt the body to the native gender identity. At the present time, performance of SRS is mandatory for changing sex on the census register of Japan. In addition to legal problems, such as the application of health insurance for treatment of GID and other conditions required to change sex on the census register, there are several problems with physical treatments deriving from both medical professionals and patients with GID. Although GID is gradually being recognized in Japanese society, the number of medical clinics/hospitals that are involved in physical treatment for the condition is still insufficient. In addition, there are very few institutions that routinely carry out SRS. As a long time with intensive review is required to receive approval for physical treatment, it is mandatory to expand the number of institutions involved in comprehensive treatments for GID, including SRS. Furthermore, as information about the techniques of SRS, and the incidence and management of complications is insufficient, it is necessary to horizontally enhance the relationship among the institutions.
In contrast, as a problem derived from GID patients, it is not rare for them to use cross-sex steroids based on their own judgement without authorized approval and/or to go abroad to receive SRS. As they are not under appropriate medical supervision, patients often suffer from adverse reactions to cross-sex steroids and there are those who do not receive appropriate medical management for complications induced by SRS. It is likely that some patients have excessive expectations of SRS and do not always understand the risks of invasive surgery. Furthermore, unpaid fees for medical treatment might interfere with operation of the GID clinic. To provide accurate information about physical treatments for GID patients, even urologists who are not actively involved in the diagnosis and treatment of GID should understand the fundamental aspects and contemporary problems of GID.