CHAPTER 104

Gender Reassignment Surgery

Transsexualism is a bona fide psychosexual disorder in which a dissociation exists between the individual’s morphologic sex and the brain’s innate perception of that person’s gender identity. Over the past 50 years, attempts to correct the central nervous system abnormality have been totally unsuccessful; thus surgery designed to change the morphologic sex has been performed to correct the paradox. This surgery typically is done within centers that specialize in these unusual sexual disorders. No operative procedure should ever be performed without proper screening, including thorough psychological, psychiatric, and sociologic testing followed by medical evaluation and hormonal therapy (Fig. 104–1). Additionally, and most important, every surgical candidate must successfully complete at least a year’s trial of living and dressing in the desired sex of choice. At the end of the 1-year test period, the candidate again is thoroughly evaluated by a multidisciplinary team, which must unanimously agree that surgery is the appropriate therapy for that individual. Finally, the patient must be given an extensive and detailed informed consent, which explains that the surgery once performed is irreversible. Other persons (e.g., hermaphrodites) may undergo similar types of surgery. As in the case of transsexuals, the screening and evaluation process should be similarly stringent. Before surgery is conducted, as with transsexuals, a multidisciplinary committee, including the patient and the patient’s immediate family, should be included in the informed decision to perform gender reassignment surgery. The type of surgery in which the gynecologist will be involved is the male-to-female reassignment procedure. All patients will have been feminized by more than 12 months’ treatment with injections of estradiol (Fig. 104–2). Every patient also undergoes bowel preparation.

The surgery is performed with the patient in the lithotomy position (Fig. 104–3). However, before positioning, a split-thickness graft is obtained utilizing a drum-type dermatome (Fig. 104–4). The full-drum graft is obtained from the buttock or thigh (Fig. 104–5). The donor site is then covered with a polyurethane-type dressing (Opsite). The external genitalia and abdomen are completely shaved of hair, and a Foley catheter is placed via the penile urethra into the urinary bladder. A hemispheric incision is made into the mons at the junction of the penile root and the mons. This is carried down to the upper lateral portion of the scrotum (Fig. 104–6). The incision alternatively may comprise a short vertical incision into the scrotum and ventral surface of the penile skin (Fig. 104–7). The incision is carried down to Colles’ fascia. By careful, nontraumatic sharp and blunt dissection, the penile skin is separated from the entire penile shaft to the level of the glans (Fig. 104–8A, B). The testes are dissected free from the scrotal skin (Fig. 104–9). The spermatic cords are doubly clamped, cut, and suture-ligated with 0 Vicryl, and the testes removed (Fig. 104–10A, B). The penile shaft proximal to the glans is clamped with a straight Zeppelin clamp, and the glans, together with the penile skin, is separated from the shaft (Fig. 104–11A, B). The urethra is recatheterized and is dissected from the bulb and shaft of the penis (Fig. 104–12A through C). On either side, the corpora cavernosa penis is isolated close to the pubic and ischial rami, clamped with two Zeppelin clamps, cut, and suture-ligated with 0 Vicryl or polydioxanone (PDS) (Fig. 104–13A, B). The entire corpora cavernosa penis is removed after it is sharply dissected from the urethral bulb (Fig. 104–14A, B). Next, a transverse incision is made between the base of the urethral bulb and the rectum (Fig. 104–15). By very careful dissection, a space is developed between the aforementioned structures and deeper internally between the prostate gland and the rectum. The space must accommodate the width of the operator’s index and center fingers loosely and must extend to a depth of 7 cm. Frequent rectal exams are performed during the critical tunneling phase. The full-thickness penile skin pedicle graft is inverted into the space, creating a full-thickness neovagina (Fig. 104–16A, B). The glans penis will be located at the vault and creates a pseudocervix (Fig. 104–16C). The urethra is shortened to approximately 3 to 4 cm and is recatheterized (Fig. 104–17A, B

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