Male-to-Female Genital Reassignment Surgery: A Retrospective Review

Mauricio Raigosa MD; Stefano Avvedimento MD; Tai Sik Yoon MD, PhD; Juan Cruz-Gimeno MD; Guillermo Rodriguez MD; and Joan Fontdevila MD, PhD

ONLINE: July 2, 2015 – The Journal of Sexual Medicine

DOI: 10.1111/jsm.12936


Introduction

The prevalence of gender dysphoria has been increasing over time. In Spain, requests for genital reassignment surgery (GRS) have also been increasing. Between 2000 and 2009, over 300 procedures were done.

Management of patients with male-to-female gender dysphoria involves a variety of considerations, including diagnosis and assessment, real-life experience, psychotherapy, hormone therapy, and GRS. The goal of GRS is to create a feminine perineogenital complex that functions well for intercourse and orgasm.

This study examined the experiences of 60 patients who underwent vaginoplasty from 2008 to 2013.

Patients and Methods

The 60 participants were followed for a minimum of one year.

Patients were required to meet these eligibility criteria for surgery:

• Diagnosis of gender dysphoria made by at least two mental health professionals

• Age 18 or older

• Psychotherapy, along with two years of real-life experience as the desired gender

• One year of hormonal treatment

• Ruled out alternative but similar disorders

Surgical Technique

The same technique was used by the same surgeon for each patient:

• A vaginal dilator was placed in the rectum as a point of reference during the dissection of the neo-vaginal cavity.

• The neo-vaginal cavity was bluntly dissected between the rectum and the prostate.

• The testes were ligated and removed.

• A penile skin flap was created.

• The penis was disassembled.

• The glans was reshaped to become a neoclitoris, which was then placed in the appropriate area.

• The penile urethra was cut, spatulated, and positioned.

• Labia majora were created.

In general, patients stayed in the hospital for about a week and had a catheter maintained for two weeks. Vaginal dilation began about six days after surgery and was continued for six months.  Hormonal replacement treatment re-started three weeks after surgery.

Results

• The patients ranged in age from 19 to 50 years (mean 28 years), and mean follow-up was 24 months.

Thirteen patients required aesthetic secondary revisions, such as a reduction of the clitoris. Five had urethral stenosis and four experienced wound dehiscence. Other complications included hematoma, neovaginal stricture, recto-vaginal fistula, minor bleeding, and intraop rectal lesion.

Acceptable vaginal depth and sensation of clitoris to reach orgasm were achieved in all patients. Eighty-six participants had regular sexual intercourse and none regretted having GRS.

Discussion

There have been several approaches to GRS, but the five major steps are typically the following:

• Orchiectomy
• Penile disassembly
• Creation of a new vaginal cavity
• Reconstruction of a female urethral meatus and clitoral reconstruction
• Creation of labia majora

In addition, there are five types of techniques to line the neovagina:

• Application of nongenital skin grafts
• Penile skin grafts
• Penile-scrotal skin flaps
• Nongenital skip flaps
• Pedicled intestinal flaps

The study’s authors recommend selected techniques to optimize outcomes.

Conclusion

This approach to vaginoplasty is simple and reduces complications. However, even if it is carefully implemented, secondary procedures are not uncommon and patients should be aware of this possibility.