Male-to-Female

Surgical Genital Reassignment

Lena McEwan, Simon Ceber and Joyce Daws

History

The surgical treatment of gender dysphoria is a relatively recent development, with Abraham's report in 1931 being the first to describe surgical procedures used in the management of transsexualism.

Although this was followed l by sporadic attempts to treat the condition, mainly in Europe, very little attention was paid to it until 1953 when Hamburger et al. reported a comprehensive study the role of surgery in treatment of the transsexual. By and large, this consisted of psychotherapy, hormonally-induced creation with occasional gonadal castration (removal of testicles), and penectomy (removal of the penis). Construction of a vagina was rarely attempted. Among Hamburger's patients was the famous Christine Jorgensen. In 1964 Benjamin reported on ninety-one transsexuals, thirty-one of whom had undergone surgery and, of these, twenty-five had had a vagina constructed. Of the 100 transsexuals reported on by Pauly in 1965, eleven of the forty who had undergone surgery had had a vagina constructed.

In women, construction of the vagina was pioneered by Dupuytren in 1817. Split skin grafts for lining the vagina were introduced by Heppner in 1872, Abbe in l892, and Mclndoe and Counsellor, both in 1937. Baldwin used a free graft of intestine in l907. Local pedicle flaps of labial and thigh skin were described by Graves in 1921 and Frank in 1927, while in 1935 Kanter and Wells allowed the dissected vaginal cavity to heal by secondary epithelialization.

For vaginal construction in males, Gillies and Millard in 1957 suggested the use of penile skin as a pedicle flap to line the neo-vagina. Several modifications of this technique have since emerged. These include the use of an open (filleted) or tubed penile skin flap, and a choice of anteriorly- or posteriorly-based pedicles.

In some cases, to provide for sufficient vaginal depth, a split-thickness skin graft and/or scrotal tissue have been utilized together with a pedicle graft of penile skin for lining the vagina. When the group at Johns Hopkins Hospital, Baltimore, began to treat male-to-female transsexuals, Jones et al. developed an operative technique whereby the newly-formed vaginal cavity was lined with a flap of penile skin anteriorly, and a perineal skin flap posteriorly. In 1970 Edgerton and Bull reported the use of a posteriorly-based penile tube pedicle flap for lining the vagina. At a second-stage operation three to four weeks later, the posterior pedicle was partially divided and scrotal tissue was used to form labia (lips) surrounding the vaginal opening.

Although Laub and Fiske, at Stanford University in 1974, advocated a free split skin graft, Fogh-Anderson, in Denmark in 1969, used full-thickness penile skin as a free graft for lining of the vagina.

In 1971 Stuteville et al. described a vaginal reconstruction technique using an anteriorly-based inverted penile tube, and it is this which has formed the basis of the operation used at the Queen Victoria Medical Centre in Melbourne.

Operative technique

The patient is admitted to hospital three days before the operation. The bowel is prepared with twice daily enemas and a Neomycin washout is given on the evening before operation. A low-residue diet is commenced and the perineum is thoroughly shaved. Neomycin IG orally twice daily and Metronidazole 200 mg thrice daily are also given to reduce the potential risk of infection spreading from the rectum to the surrounding tissues.

At the time of anaesthetic pre-medication, the patient is given 5000 international units of Sodium Heparin subcutaneously, and electrical stimulators are applied to the calf muscles, when the patient is placed in the lithotomy position at the beginning of the operation, to prevent deep venous thrombosis. A 14 or 16-gauge catheter is inserted into the bladder.

Using the diathermy knife, a vertical incision is made, splitting the lower half of the scrotum and extending posteriorly to within 2 cm of the anus (Fig. 1). This incision is deepened until the corpus spongiosum of the penis is displayed. A plane between Buck's fascia and the dartos fascia is developed by blunt dissection up to the penile coronal sulcus. A circumcoronal incision then allows the penis to be pulled out of its skin tube (Fig. 2). The penile suspensory ligaments are divided, freeing the corpora from the pubic symphysis. Each testis is exposed and the corresponding spermatic cord is followed to the external inguinal ring where it is ligated with No.1 chromic catgut, divided, and allowed to retract into the inguinal canal. Several No. 1 chromic catgut sutures are used to close the external inguinal ring.

The plane between the penile corpus spongiosum and corpora cavernosa is identified near the urethral bulb and is developed distally on to the penile shaft. The urethra is divided and the corpora are clamped temporarily while the urethral bulb is freed from the underside of the pubic symphysis (Fig. 3). Each corpus is then clamped at its base parallel to the inferior pubic ramus, divided, and the stump oversewn with No. I chromic catgut (Fig. 4).

The central tendon of the perineum, extending from the bulbospongiosus to the sphincter ani externus muscles, is divided (Fig. 5), and, with one finger in the rectum, a plane is developed by blunt dissection between the prostate and Denonvilliers' prerectal fascia anteriorly and the rectum posteriorly. Dissection is continued to the level of the pelvic peritoneum. The cavity is checked carefully for communication with the rectum and any major bleeding is controlled. A 5 cm vaginal ribbon-gauze pack is inserted into the cavity

The open distal end of the penile skin tube is oversewn with two layers of 4/0 Dexon: one layer is in the skin and the other in the dartos fascia. The tube is then inverted and packed with 5 cm vase-line ribbon-gauze. The site where the urethra will come through the skin flap is chosen as posteriorly as possible and incised vertically in diamond shape (Fig. 6).

The lower anterior abdominal wall skin and subcutaneous tissue are undermined for a short distance and tension sutures of No. 1 nylon are placed to hold the distally advanced abdominal wall skin to the periosteum over the pubic tuberde and to the origin of the adductor muscle tendons. The urethra is fed through the prepared aperture in the skin flap and the tension sutures are tied firmly over plastic foam bolsters.

The pack is removed from the new vaginal cavity which is inspected again to ensure that all bleeding has ceased. The packed penile skin tube is then inserted into this cavity. If a shortage of penile skin limits the advancement of the tube, several centimetres can be gained by vertically sectioning the dartos muscle and fascia in the mid-line at the base of the skin tube.

The excessive scrotal remains are split vertically until the apex of the split can be sutured comfortably under slight tension to the lower end of the original skin incision. The redundant skin and scrotal contents left on each side are trimmed to form labia (Fig. 7), and sutured with 3/0 Dexon after corrugated drains have been placed along each side of the vaginal skin tube.

The urethra is shortened and sutured to the skin with 4/0 interrupted Dexon sutures (Fig. 8). The wound is dressed with tulle-gras gauze and combine padding held in place by tight 7.5 cm elastoplast strapping applied from the buttock around to the opposite anterior abdominal wall on each side.

On the seventh post-operative day, the patient is returned to the theatre. l~he vaginal pack is removed and the cavity inspected. If the posterior skin fold is too far anterior, which is often the case it is divided vertically and re-sutured transversely. A condom filled with foam rubber is then placed in the neovaginal cavity.

After returning to her bed, the patient is taught how to remove, make, and replace the condom pack. She is instructed to keep it in place except when removal is necessary for micturition or det aecation. The catheter is removed from the bladder on the tenth day and the patient allowed home on the fourteenth day after initial surgery.

At approximately four weeks post-operatively the patient is given a rigid vaginal dilator to use for fifteen minutes twice daily. Sexual intercourse may commence six weeks after the patient has left hospital.

Results

From November 1976 to October 1982 sixty-eight patients underwent male-to-female genital reassignment surgery at the Queen Victoria Medical Centre, Melbourne. Follow-up data were available for fifty-seven of these patients. Thirty-eight (55 per cent) had been followed up for over twelve months and twenty-three of these had completed a detailed questionnaire and undergone a physical examination. These twenty-three patients will be referred to as the ‘core group’.

Length of hospitalization

This varied from two to six weeks. When patients had an uncomplicated post-operative course, the average length of stay in hospital was fourteen days.

Complications

The significant operative complications that occurred are shown in Table 10.1. There were no deaths and no major medical complications such as pulmonary emboli or myocardial infarction.

Table 10.1 Complications of male-to-female genital gender reassignment surgery in sixty-eight male transsexuals

Early in the series, two patients had rectal injuries requiring temporary colostomies. One injury was noted at operation and immediate colostomy was performed, while the other was noted at the examination under anaesthesia one week after the initial operation. Once again, a colostomy was performed immediately. Following these problems, it was decided to prepare the bowel of all patients pre-operatively so that any rectal injury noted at the time of operation could be immediately repaired. This occurred on two further occasions and there were no untoward consequences. One patient presented with a high rectovaginal fistula six weeks after operation. This was repaired three months later and has remained closed. However, because of scarring the vagina is short.

Post-operative bleeding within the newly formed vaginal cavity and from the urethral mucosa-to-skin suture line was troublesome early in the series. Two patients developed a prolapse of some of the neovaginal skin due to haemonrrhage and four patents had to be taken to theatre for control or haemorrhage from the urethral muscosa-to-skin suture line. Since the introduction of the pressure dressing technique there have been no major post-operative haemorrhages.

Four patients had necrosis (death) of a significant portion of the vaginal skin tube. This was noted at the examination under anaesthesia. Subsequently all of them were found to have short vaginas.

External genitalia

The overall appearance of the external genitalia was regarded as satisfactory in every patient within the core group and a typical result is illustrated (Figs 9,10). One patient required reduction in the size of the labia. More detailed results of surgery on the external genitalia have been as follows.

Urethra

Although the urethral opening is placed well posterior at operation it tends to migrate forward during the postoperative period due to tissue tension and contraction of scar tissue. The opening was in a satisfactory position in thirteen patients or the core group and too anterior in nine. One patient required revisional surgery of the urethral orifice for a stricture. Seven patients have had the urethra shortened to place the opening more posteriorly.

In some patients the urethral bulb is large and surrounded by dense musculature. These patients tend to develop a lump which appears in the vaginal introitus during sexual arousal and may obstruct thc vaginal cavity. Two patients have undergone further surgery to reduce the size of the urethral hulb with a satisfactory result

Posterior vaginal fold

A fold of skin is present at the posterior margin of the vaginal opening, at the point of inversion of the skin, which was previous]y at the ventral aspect of the base of the penis. This fold is initially useful in helping to retain the intravaginal packing. It is often divided at the time of the first dressing to allow better access to the vagina. In some patients the fold has persisted, leading to painful intercourse, or collection of urine in the vagina. Six patients required revisional surgery of thc skin fold.

Vagina

Table 10.2 shows the length and breadth of the vaginal cavity obtained in fifty-six patients. Thirty-six patients (65 per cent) had vaginas which were adequate for sexual intercourse, that is, greater than 10cm deep and at least 35 mm or two finger-breadths wide. In the core group 78 per cent of patients with adequate vaginas were having vaginal intercourse and surprisingly, eight or nine patients with inadequate vaginas were also having vaginal intercourse.

Table 10.2 Vaginal dimensions in male transsexuals reassigned as females

Orgasmic Junction

Within thc core group, sixteen of the eighteen patients having vaginal intercourse reported having orgasm. Three of the five patients not having intercourse could obtain orgasm by masturbation. Overall, 83 per cent of the group bad the capacity to reach orgasm.

Patient satisfaction

Patients in the core group were requested to grade various aspects of the genital and sociological results of their Operation on a scale of 1 to 4. The results are set out in Table 10.3. These figures confirm that most patients were satisfied with the results of operation in most areas. The greatest area of dissatisfaction was related to inadequate vaginal depth which interfered with sexual activity

Table 10.3 The degree of satisfaction experienced by male transsexuals after reassignment as females

I : Poor or worse; II : Fair or unchanged; III : Satisfactory or some improvement; IV : Good to excellent

One patient (not in the core group) committed suicide six months after a technically successful operation. This appeared to be related to loss of her job, boyfriend, and self-esteem. Shortly before her suicide she stated she had no regrets whatsoever about having had the operation.

Secondary surgery

Table 10.4 summarizes the secondary operations that were carried out up to October 1982 in the core group of patients.

Table 10.4 The frequency and nature of secondary surgical procedures in 23 male transsexuals reassigned as females

The most challenging technical problem has been that of the short vagina, one of the commonest complications of gender reassignment procedures. However, abdomino-perinteal vaginoplasty, a technique utilizing a combined abdominal and perineal approach, has allowed a safe lengthening of the organ. The two-way approach has been used to lessen the risk of trauma to the bladder or rectum which may result in troublesome fistula formation resulting in passage of urine or faeces from the vagina.

The patient is admitted two days before the operation for mechanical cleansing of the bowel by the use of enemata and bowel wash-outs. A low-residue diet is given. The night before operation 1 gm Neomycin antibiotic is given orally, and this dose is repeated with the premedication for anaesthesia.

Under general anaesthesia a split skin graft is taken from the thigh. This skin is subsequently prepared for use by stretching it over a mould which is fashioned by the packing of a condom (Fig. 11).

The patient is placed in a modified lithotomy position using Lloyd-Davies stirrups with a pad under the pelvis. A Foley urinary catheter is inserted into the bladder, which is emptied. A transverse skin incision is made within the pubic hair line (Fig. 12). This is deepened through the rectus muscle sheath and beyond its lateral margin: the rectus abdominus muscles are separated vertically and the peritoneal cavity is opened transversely (Fig. 13).

At this point in the operation, a moderate degree of head-down Trendelenburg tilt of the operating table is helpful to assist in displacing the small intestine, which is then packed Out of the surgical field. A self-retaining retractor is inserted to facilitate exposure of the pelvic cavity. The position of the bladder is identified by palpation of the balloon of the Foley catheter and an incision is made in the peritoneum, lateral to the bladder and medial to the vas deferens (Fig. 14). A space is developed beside the bladder and deepened towards its base by blunt dissection. Meanwhile the perineal operator has incised the scarred vagina and dissects upwards towards the fingers of the abdominal operator. If concern is felt about the proximity of the rectum, an assistant can insert a finger into it via the anal canal to provide guidance.

Once a meeting has occurred between the operators within the curve of the stretched levatores ani muscles laterally, the space is developed, haemostasis is secured, and the mould with overlying skin graft inserted. The visceral peritoneum is closed over the mould and the parietal peritoneum is closed with continuous No.1 Dexon sutures after any abdominal packs have been removed. The muscles are approximated with interrupted Dexon, and subcutaneous and subcuticular sutures of Dexon are used to complete wound closure.

The perineal operator inserts the condom and closes the perineal incisions (Fig. 15). The urinary catheter is left in the bladder until the first dressing is done eight to ten days later.

Soon after this time the catheter is removed and the patient can take showers or baths and can be instructed to insert the condom herself. Most patients can leave hospital after ten days. Six weeks later, sexual intercourse may be commenced.

A neovaginal condom mould is worn continuously (except for purposes of toilet and intercourse) for six months until the tendency for the skin-grafted vagina to shrink is overcome. A glass dilator is then used intermittently if regular intercourse is not occurring.

Conclusion

The results confirm that the decision by the transsexual to undergo sex-change surgery must be based on the patient's acceptance that the results may not be perfect or even ideal. The complication rate is significant and the final results are unsatisfactory with regard to vaginal adequacy in 35 per cent of cases. However, a significant proportion of these patients’ vaginal inadequacy can be corrected by further surgery of the abdomino-perineal type.

Last Update: 29 Dec. 1997