MALE TO FEMALE

Orchiectomy

An orchiectomy is surgery in which one or more testicles are removed.

The testicles, which are male reproductive organs that produce sperm, sit in a sac, called the scrotum. The scrotum is just below the penis. There are two common orchiectomy procedures for transgender women: bilateral orchiectomy and simple orchiectomy. In a bilateral orchiectomy, the surgeon removes both testicles. During a simple orchiectomy, the surgeon could remove either one or both testicles.

Bilateral orchiectomy is the more common type of orchiectomy for transgender women. An orchiectomy is a relatively inexpensive surgery with a short recovery time.

The procedure may be a first step if you’re heading toward vaginoplasty. In some cases, you may be able to have the orchiectomy at the same time you have a vaginoplasty. You can also schedule them as independent procedures.

Orchiectomy may also be a good option for people who don’t react well to feminizing hormones or want to reduce the health risks and side effects from these medications. That’s because once the procedure is complete, your body will usually produce less endogenous testosterone, which can lead to lower doses of feminizing hormones.

Orchiectomy may also be a good option for people who don’t react well to feminizing hormones or want to reduce the health risks and side effects from these medications. That’s because once the procedure is complete, your body will usually produce less endogenous testosterone, which can lead to lower doses of feminizing hormones.

Vaginoplasty – penile inversion technique

Vaginoplasty (neovaginoplasty) is a reconstructive surgical procedure for creating a neovagina. Male to female transgenderism is among the principal indications for vaginoplasty.

Treatment
Great variety of operative techniques for creation of neovagina is reported. There are two substantial tissues for vaginal replacement: skin and bowel. For transgender patients penile inverted skin flap presents the best option.

Penile inversion technique includes creation of fully sensate neovagina from an inverted pedicled island penile skin flap and vascularized urethral flap. The important advance in this technique is complete penile disassembly, which ideally enables the use of all penile components (except the corpora cavernosa) in the construction of the new vulva, clitoris and vagina. Ordinarily, procedure is started with bilateral orchidectomy. The penis is dissected into its anatomical components and corpora cavernosa are completely removed. Glans is reduced and fashioned to create a conically shaped clitoris, with fully preserved neurovascular bundle. The skin of the penis is inverted, as a pedicled flap preserving blood and nerve supplies to form a fully sensate vagina. The urethra is then spatulated and used to create the mucosal part of the neovagina that provides additional sensitivity and wetting. Fixation of the vagina to the sacrospinous ligament is performed to achieve deep placement of the neovagina in the perineal cavity and to prevent prolapse. Clitoral hood, labia minora, and labia majora is finally created by fashioning remaining penile and scrotal tissue. Postoperative vaginal stenting and periodic dilatation is necessary. This way fully sensate and sufficient vagina is created, enabling regular sexual intercourses with erogenous sensation.

Vaginoplasty – peritoneal pull through

Reconstruction of the neovagina is of utmost importance in transfemales. It is sometimes the first, but sometimes the last surgery performed in an individual’s transition.

The ideal neovagina should be of an appropriate length and that requires minimal, if any, dilatation. It should not scar, stenose or contract and should provide a satisfactory cosmetic result.

So far, the gold standard in neovaginal creation for transfemales is considered penile inversion vaginoplasty with long-term very good and satisfying results in many centers around the world. Bowel vaginoplasty was considered in cases where penile and scrotal skin were inadequate for satisfying vulvovaginal complex reconstruction or for cases of RE-DO surgeries.

In last couple of years, an old technique, introduced by Russian gynecologist Davydov, came into light in gender affirming surgeries as another possibility for vaginal lining.

The surgery can be offered as a primary vagioplasty in transwomen, or if possible for RE-DO cases. The surgery is performed in general anesthesia. The patient is positioned in an exaggerated lithotomy position. Complete penectomy is performed until the attachments of the corpora cavernosa to the pubic bones, bilateral orchiectomy in known fashion, and cavity, between the urethra, bladder and rectum is created for vaginal lining. Using 3 ports and pneumoperitoneum, camera is introduced into the cavity, and mobilization of the peritoneal flaps is performed from the bladder and urethra above, and from rectum below, and anastomosis with the skin flaps is made inside the channel. In this way additional depth of the vagina is secured as well as natural lubrication (at certain level).

Vulvoplasty (clitoris, labia and urethra) is done like in penile inversion vaginoplasty. The vaginal packing is placed inside the vagina with antibiotic ointment for 7 days and urinary catheter as well for 12 days postoperatively. The dilation of the neovagina is commenced after vaginal packing removal, according to the instructions given by the therapist and should be performed for at least 12 months in regular fashion (twice a day for 45 minutes) Vaginal flushing is advised in terms of removal of the lubricant gel from the neovagina.

Sigmoid colon technique

Neovaginal reconstruction is necessarily performed in male transgender patients. The ideal reconstructive procedure should provide a vagina that has an appropriate length and that requires minimal, if any, dilatation. It should not scar, stenose or contract and should provide a satisfactory cosmetic result. Reconstructing the vagina using intestinal segments creates an aesthetically pleasing vagina, which seems to be more compatible with sexual activity.

After penile inversion skin flap, sigmoid colon technique presents the method of choice in transsexual surgery. Advantages of this procedure include adequate vaginal length, natural lubrication, early intercourse and a low rate of shrinkage. Sigmoid colon is particularly useful because it is anatomically similar to the perineum, with sufficient length and mobility of the segment that allows it to be easily brought into the perineum.

Treatment
The patient is placed in an extended lithotomy position as for a synchronous combined abdominoperineal approach. Through a Pfannenstiel incision, the sigmoid colon is mobilized from its lateral retroperitoneal attachment, as far as possible. Before making the final selection of the sigmoid colon segment, the length of the sigmoid and its mesentery should be assessed to determine whether it can reach the perineum easily. Isolated segment of rectosigmoid should be from 8 to 11 cm long, in order to avoid excessive mucus production as well as postoperative vaginal prolapse. Rectosigmoid is harvested with its blood supply originating from sigmoidal arteries and/or superior hemorrhoidal vessels. Stapling devices are used for the colorectal anastomosis as the safest procedure. Creation of the perineal cavity for vaginal replacement is performed using simultaneous approach through abdomen and perineum. Very precise dissection must be done to avoid injury of rectum, bladder and urethra. Introital or perineal skin flaps are designed for anastomosis with rectosigmoid vagina. Circumferential anastomosis is avoided to prevent purse string scarring with subsequent vaginal stenosis.

The neovagina was packed for 7 days, and an indwelling Foley catheter was left in place for 4 days. At discharge from hospital, patients were instructed to irrigate the neovagina once a day for 2 months and weekly thereafter and to dilate the introitus of the neovagina on a daily basis with a vaginal dilator. Reconstructing the vagina using sigmoid colon creates an aesthetically pleasing vagina, which seems to be more compatible with sexual activity.

FEMALE TO MALE

Metoidioplasty

Metoidioplasty one of the variants of phalloplasty in female to male transsexuals. It presents reconstruction of the penis from hormonally hypertrophied clitoris, with the main goal to give the patient “male looking genitalia” and possibility to void in standing position. Metoidioplasty with urethral lengthening can be performed simultaneously with hysterectomy, bilateral oophorectomy and bilateral mastectomy, as a one-stage female-to-male gender confirmaton surgery, with satisfactory results. The patients should be treated hormonally for a period of one-year minimum prior to urgery. Clitoris is preoperatively enlarged using dihydrotestosterone as a topical gel locally, applied twice a day during three months preoperatively, combined with the use of vacuum device.

Operative technique
The current operative technique comprises the following steps: vaginectomy, maximal straightening and lengthening of the clitoris, urethral lengthening by combining buccal mucosa graft and genital flaps, and scrotoplasty with insertion of testicular implants. Vaginectomy is performed by total removal of vaginal mucosa (colpocleisis), except the part of anterior vaginal wall that will be used afterwards for urethral lengthening. Internal female genital organs can be removed in the same stage (hysterectomy – removal of uterus, oophorectomy – removal of ovaries) using vaginal or laparoscopic approach. It is very important to prevent any transabdominal approach in order to preserve anterior abdominal wall for possible abdominal phalloplasty in the future.

After complete degloving, the clitoral ligaments are divided to advance the clitoris. Ventrally, the urethral plate is dissected from the clitoral bodies. Dissection includes bulbar part of the plate around the native orifice to enable its good mobility for urethral reconstruction. Since the urethral plate is always short causing the ventral clitoral curvature, it is divided at the level of the glanular corona. In this way, complete straightening and lengthening of the clitoris are achieved. The bulbar part of urethra is created by joining the flap harvested from anterior vaginal wall and remaining part of divided urethral plate.

Additional urethral reconstruction is performed using buccal mucosa graft and vascularized genital skin flaps. The buccal mucosa graft is harvested from the inner cheek using a standard technique. The length of the graft depends on the distance between the tip of the glans and the urethral meatus. Then, graft is fixed and quilted to the corporeal bodies starting from the advanced urethral meatus to the tip of the glans. In this way, half of the urethra covering corporal bodies is created. Urethral covering can be achieved using either labia minora flap or dorsal clitoral skin flap. Inner part of labia minora is dissected to create a flap with appropriate dimensions without detachment from the outer labial surface. This way, excellent vascularization of the flap is enabled. Flap is joined with buccal mucosa graft over a 12 to 14-Fr stent to create neourethra without tension. Only in cases of poorly developed labia minora, a well-vascularized longitudinal island flap is harvested from dorsal clitoral skin.

The penile body is reconstructed using the remaining clitoral and labia minora skin. The labia majora are joined in midline to create the scrotum. Silicone testicular implants (small or medium size) are inserted through the bilateral incisions placed at the top of labia majora. A self-adherent dressing is used for the neophallus. Suprapubic urinary drainage is placed in all cases for 3-4 weeks. The urethral stent is removed 7-9 days after surgery. Vacuum device is recommended for six months period in order to prevent postoperative shortening of the neophallus.

Advantages
Removal of the vagina. One of the main advantages of the technique is simultaneous removal of vaginal mucosa. The flap originated from anterior vaginal wall is very useful in lengthening of female urethra. At this spot, voiding pressure is the strongest and always presents the risk of fistula formation postoperatively. Joining the clitoral bulbs over the lengthened urethra and additional covering with remaining surrounding tissue is considered to be a key to successful fistula prevention. Lengthening and straightening. Clitoris can be lengthened and straightened by division of its ligaments dorsally and short urethral plate ventrally. During this dissection, care should be taken to prevent injury of both neurovascular bundle and urethral spongiosal tissue.

Urethral reconstruction. To avoid complications described after tubularized urethroplasty, we use combined buccal mucosa graft and genital skin flaps. The application of free buccal mucosa grafts for urethral reconstruction is becoming increasingly popular in certain clinical settings. They are tough, resilient, easy to harvest and handle, and leave no visible donor site. Their histological composition makes them good grafting material. Covering of the graft can be performed with longitudinal dorsal clitoral skin flap button-holed ventrally, or flap harvested from inner surface of the labia minora. In both, good vascularized tissue completely covers all suture lines preventing fistula formation in majority of cases.

Penile shaft reconstruction. Normal appearance of the external genitalia is achieved by creation of the penoscrotal angle as a male. Penile body is covered with remaining clitoral and labia minora skin. Labia majora are joined in midline to form the scrotum, in which testicular implants can be placed.

ONE STAGE REPAIR. All of our patients are managed with a single operation. Minor complications, mostly related to urethroplasty, occur in less than 10% of cases, and are solved by simple procedure. Additional cosmetic corrections are always possible as a minor procedure. Most patients are satisfied with the final outcome of metoidioplasty, since male genitalia appearance is achieved as well as voiding in standing position. Last but not least, neophallus is functionally though not fully adequate, as it is too small to allow sexual intercourse in most of patients. Additional augmentation phalloplasty is possible, according to patient’s preferences. Recommendations and key points:
• Metoidioplasty, as a one-stage gender confirmation procedure, presents a good and safe option for female-to-male transsexuals who want to avoid complex and multistaged phalloplasty
• The main goals of metoidioplasty are good cosmetic, voiding while standing with preservation and/or enhancement of sexual function
• Advanced urethroplasty using a combined buccal mucosa graft and labia minora flap offers a good result with low complication rate
• The length of the neophallus may not be adequate for penetration during sexual intercourse
• Most patients are satisfied with the final outcome of metoidioplasty as a consequence of achieving male appearing genitalia with the ability to void while standing in addition to preservation of sexual function

Phalloplasty

Neophalloplasty is one of the most difficult surgical procedures in genital reconstructive surgery. It is indicated in men when the penis is missing due to either congenital or acquired reasons, as well as in transmen. Many different tissues have been applied such as local vascularized flaps or microvascular free transfer grafts. The main goal of the neophalloplasty is to construct the functional and cosmetically acceptable penis. Urethral reconstruction in neophalloplasty presents a great challenge for surgeons who manage genital reconstruction. Different flaps (penile skin, scrotal skin, abdominal skin, labial skin, vaginal flaps, etc.) or grafts (skin, bladder, buccal mucosa) have been suggested for urethral lengthening. Although serious complications were reported in the past, new techniques and modifications for primary and secondary neophallus urethroplasty seem to be safe in experienced hands.

Several surgical techniques for neophallic reconstruction have been reported using either available local vascularized tissue or microvascular tissue transfer. However, none of them satisfy all the goals of modern penile construction, i.e. reproducibility, tactile and erogenous sensation, a competent neourethra with a meatus at the top of the neophallus, large size that enables safe insertion of penile implants, satisfactory cosmetic appearance with hairless and normally colored skin. Normal penis has some unique characteristics and restoring its psychosexual function in both the flaccid and erectile state, and the possibility of sexual intercourse with full erogenous sensations, is almost impossible. Surgical indications are expanded to many other disorders such as penile agenesis, micropenis, disorder of sexual development (intersex conditions), failed epispadias or hypospadias repair, penile cancer, as well as female transsexuals.

The most widely used flap for total neophalloplasty is the radial forearm flap. However, it has many drawbacks, e.g. an unsightly donor site scar, very frequent urethral complications, and small sized penis that does not allow the safe insertion of penile prosthesis in majority of cases. This was the main reason for us to develop a new technique using the musculocutaneous latissimus dorsi free transfer flap, which mostly satisfies the requirements noted above. Due to its workable size, ease to identification, long neurovascular pedicle and minimal functional loss after removal, the latissimus dorsi flap has been used for a variety of reconstructions. It has a reliable and suitable anatomy to meet the esthetic and functional needs for phallic reconstruction. It can also be used successfully in children. Phallic retraction with muscle based grafts seems less likely to occur than with use of fasciocutaneous forearm flap, since denervated well-vascularized muscle is less prone than connective tissue to contract.

Operative technique
We perform phalloplasty in female transsexuals in two or three stages and it includes several procedures:

FIRST STAGE (7-9 hours, three surgical teams)
1. Removal of internal (uterus, Fallopian tubes, ovaries – transvaginal, laparoscopic or abdominal approach) and external female genitalia (vagina, vulva).
2. Lengthening of the urethra using all available vascularized hairless genital skin.
3. Scrotoplasty with insertion of testicular implants.
4. Musculocutaneous latissimus dorsi free transfer phalloplasty.

SECOND STAGE (6 months later, 2.5 – 3.5 hours)
1. Reconstruction of the neophallic urethra using buccal mucosa graft.
2. Glans reconstruction.
3. Implantation of the semirigid or inflatible penile prosthesis.
THIRD STAGE (if necessary, 2 hours)
1. Urethral tubularisation.
2. Additional correction of all esthetic deformities.
Musculocutaneous latissimus dorsi phalloplasty

A latissimus dorsi musculocutaneous flap of the non-dominant side is designed and harvested with thoracodorsal artery, vein and nerve. The surface of the flap is templated in two parts: (1) a rectangular part for neophallic shaft to be approxiamtely 15-17 x 12-14 cm and (2) additional, circular or semilunar component for glans reconstruction. The flap is tubularized in the midline and the neoglans formed by folding over and approximating to the penile shaft. The new constructed phallus is detached from the axilla after clamping dividing neurovascular pedicle with aim to achieve maximal pedicle length. The donor site defect is closed by direct skin approximation. If it is impossible, remaining donor site defect is grafted with split-thickness skin graft. Incision is made in the pubic area and a wide tunnel toward the femoral region is created to place the flap pedicle. The neophallus is transferred to the recipient area and microsurgical anastomoses are created between thoracodorsal and femoral artery, thoracodorsal and saphenous vein and thoracodorsal and ilioinguinal nerve. Specially constructed dressing is used to keep the neophallus in an elevated position for approximately two weeks.

Second stage includes implantation of penile prosthesis either maleable or inflatible, further urethral lengthening and glans reconstruction. Cylinders are covered with vascular PTFE or Dacron graft that imitate tunica albuginea and additionally fixed to the periostium of the inferior pubic rami. Glans is reconstructed using Norfolk technique.

Urethral reconstruction
Urethral reconstruction presents the main problem in this type of sex reassignment surgery and includes creation of a very long neourethra, since the native urethral meatus in females is positioned too far from the tip of the glans. Lengthening of the native urethra presents a great challenge, especially the first part that should be the bridge between native meatus and neophallic urethra. Neophallic urethral reconstruction is followed in the second stage and includes complete urethral lengthening (if possible) or placement of the buccal mucosa graft on the ventral side of the neophallus, and later tubularisation (third stage).

Reconstruction of the neourethra starts with reconstruction of its bulbar part. A vaginal flap is harvested from the anterior vaginal wall with the base close to the female urethral meatus. This flap is joined with the remaining part of the divided urethral plate forming the bulbar part of the neourethra. Additional urethral lengthening is performed using all available vascularized hairless tissue to lengthen the neourethra, maximally preventing the postoperative complications. For this reason, both labia minora and available clitoral skin are used for urethral tubularization. This way, the new urethral opening is placed in first half of neophallus, minimizing the requests for longer neophallus urethroplasty. It is always done in the first stage of total phalloplasty.

The most promising technique for the further lengthening of the neophallus urethra is based on two-staged procedure. The first stage includes creation of the new “urethral plate” using buccal mucosa graft. The use of buccal mucosa graft that was first described seven decades ago, has been the gold standard for urethral reconstruction. It is tough, elastic, simple to harvest, easy to handle and leaves no noticeable scar at the donor site. Buccal mucosa grafts (either pairs or single, depending on the width and length of neourethra needed) are placed on the ventral side of the penis. When the healed grafts are ready for final stage tubularization and closure, it is important to incise the underlying tissue that will support the neourethra and avoid ischemia at the neourethral suture line. It is recommended to create second layer from surrounding tissue to cover and support the new created urethra. The key for successful repair is waiting long enough until the skin is supple. The classic mistake is to perform second stage too early.

Second stage should be performed when the “urethral plate” has matured enough to be supple and thus more easily mobilized for a tubularization. If it is necessary, additional buccal mucosa grafts can be used for urethral plate augmentation and easier tubularization.

Complications and secondary repair
Most of the urethral problems can be corrected with secondary procedures. Our experience so far has showed that more than half of urethral fistulas and strictures are solved conservatively, while less than half complications need an additional surgical procedure. At least, there is still no ideal technique for phalloplasty resulting in excellent esthetic and functional outcomes. There are still problems with the neourethral reconstruction, but the incidence of complications has been reduced with new refinements of one stage repair or by using a staged procedure