SEXUAL REASIGNMENT SURGERY

By Danni Hawkins

Number 3 in a series of articles
on M. to F. S.R.S. techniques for the assignment of inappropriately gendered
persons to their correct gender.

(Ed. note: As Danni points out in her introduction she is NOT a medical doctor with specialized training in this area, but rather a scientist who is writing these articles to illuminate and inform)

Penile and Scrotal Inversion Surgery - The Basics

Introduction

This surgical technique remains a common choice as a primary method of vaginoplasty by many surgeons today. Like all techniques there are a number of variations on a common theme, I will deal with those in a later series of articles. In this article I am going to provide information relating to the basic operation using a paper submitted by van Noort et al(Plast Reconstr. Surg. 91:1308,1992) as the primary source of information.

This technique was developed in order to cope with width problems, which are common with neovaginas created by penile inversion, by utilisising scrotal skin as well as penile skin. This method provides an average mean width of some 40 mm as compared to a mean width of some 20 to 30 mm (for penile inversion) and a mean depth of 10 cm (approx the same as for penile inversion). As with the penile inversions method regular sexual intercourse must be carried out or the vagina must be manually dilated in order to maintain its width and depth. A failure to observe these prerequisites will almost certainly lead to stenosis (narrowing or constriction) of the vagina. Statistically the occurence of stenosis would seem to be much less in the van Noort study when penile and scrotal inversions is utilised (6% for p&s and 36% in p).

The Operation

Before I get into the actual operation it is important to understand the anatomy of the penis, the following labelled diagram gives its morphology and should help with the nomenclature used later in this section.

The operation is performed under general anaesthetic with the patient in the lithotomy position (similar to that used in childbirth, on your back, buttocks raised, legs spread). An inverted "T" shaped incision is made with the vertical line from the base of the scrotum to the tip of the penis and the transverse incision at the base of the scrotum giving two skin flaps.

After bilateral orchidectomy (removal of the testicles and resection of the spermatic chords up to the external inguinal ring) the penis is degloved by dissection of the penile skin. The urethra and spongious bodied are transected after amputation of the cavernous bodies at the pubic arch. A cavity is created by blunt dissection between the urethra, prostate, seminal vesicles and the rectum. The penile and scrotal skin flaps are sutured to each other distally and laterally forming a tube and inverted into the cavity.

The urethra an d spongious body are pulled through an incision in the penile skin, shortened and sutured to the surrounding tissue. The residual scrotal skin is used to form the labia. The now inverted skin flaps are immobilised for 5 days by means of a vaginal stent.

Complications and Comments

Vaginal Stenosis

Perhaps the most common complication, provided that the surgery was carried out correctly, is that of vaginal stenosis. This complication would seem to be minimised for those who have this method of SRS. Most surgeons, at least those who publish, tend to lay the blame for this squarely on the patient's inadequate or lack of post-operative dilation.

Necroses

As with penile inversion not all skin flaps used in this operation may remain vascularised. Some tissue may die. The causes of these necroses may relate to surgical technique (damage by stitching, kinking of pedicles etc.) or more commonly post-operative use of a hard stent restricting blood supply t o the tissue. Any necrosis of the neovagina will require further surgery.

Rectovaginal Fistula

As explained in my previous article all girls undergoing SRS may suffer from this problem. For those of you who missed the last article, here is a repost. A fistula is a narrow passage or duct formed by disease or injury, normally the formation of an abscess, which subsequently joins the vagina and the rectum. This is not an uncommon occurrence in patients who have undergone SRS, it can and does happen during the recovery stage of initial hospitalisation or may occur at a later stage. It requires surgical intervention. It is difficult to find, at least in the literature, a comment on the initial cause of this complication, however it is related to clinical hygiene. With regard to those that form after leaving hospital, it is not difficult to imagine that the constant use of a dilator over a long period may, if hygiene is not clinically perfect, leading to bacterial infection and the formation of an abscess.

Specific problems r elated to this technique

Hair growth related to the utilisation of scrotal skin within the vaginal cavity would seem to be the major drawback with this method of SRS. Many surgeons look upon this as a minor problem however interviews with girls who have had SRS would seem to suggest otherwise, to them it is a major problem. It has been suggested that changes in the epithelium and friction caused by intercourse may cause a spontaneous remission of vaginal hair growth after about 1 year. If however you are considering using a surgeon who favours this method of SRS you may wish to seriously consider preoperative electrolysis of the scrotal hair.

The advantages of this technique

This technique is surgically relatively simple and not so invasive as rectosigmoidal techniques ( see a later article).
The cosmetic results are good but probably not as good as penile inversion in the formation of an externally correct female genitalia ( once again a lot depends upon the surgeon).
The risk of stenosis of the vagina is reduced.
A greater vaginal width is achieved.
The rate of orgasm achieved is statistically highest of all techniques ( this is a difficult one to get an unbiased opinion on).
Functionallity of the neovagina is excellent.

Some more politics - you still don't have to agree with me

My main reason for writing these articles is that I feel that the more informed we are the more we can influence, within the realms of physical possibility, future surgical techniques. I know that for each of us, going through the preamble of having our bodies changed into those which fit our minds, the choice of a suitable surgeon is something that may be considered well after we have started hormone therapy, RLT, coped with traumatised families etc. I maintain that if we want to save ourselves considerable money, pain and disappointment we should consider the capabilities of the surgeon and the surgical technique which may be employed at an early stage. We have to be aware of our options, the capabilities of individual surgeons, possible complications and costs. A valid quote from my good friend Liberty:" I know that if I had been a little more aware of things when I had surgery I'd have saved myself a bundle of problems." but she also adds, "do it again? Absolutely, no question."

We must work together as a community and let our voice be heard!

Please note I am not a surgeon nor do I have any medical training. This article, a laywoman's view, is for the information of other T* girls who, like me, are considering SRS

Hugs to you all,

Danni.