Kontakt
Praxis für UrologieDr. med. Aref El-Seweifi
Forum Zehlendorf
Teltower Dam 35
D-14169 Berlin
Deutschland
Tel.: +49 30 804 90 950
Fax: +49 30 804 90 951
info@masculine.de
| Transsexual surgery |
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The development of flaps techniques and advance of surgery enabled to perfect the cosmetic results of plastic sexual surgery. The meticulous dissection and understanding of the psychological conflict of the patient are very important prerequisites to reach the wished cosmetic result. The conflicting life inside the body of the other sex gained interest since the beginning of this century. The feeling to belong to the opposite sex has been first described by many authors since 1910. This surgery aims at the conversion of a man genially and morphologically so to say from the external appearance to a woman. The secondary characters are changed through hormonal manipulations and plastic reconstructive surgery. The pschycological behaviour is changed through the settings carried out by a psychologist. The genetical identity does not change.
Who is qualified for the operation ? The definition of Trans sexuality is that persons that have no psychotic, genetic or hormonal disturbance feel to belong to the other sex in spite of the intact genetic information. This means men feel themselves to belong to the other sex. This feeling starts usually in the early childhood. The transsexual affinity is classified into many forms which are graduated according to the affinity and the need of treatment. Patients who wish to be transformed from a man to a woman have a psychological problem. They must live at least two years in the role of the wished sex. They should fulfil the legal and psychological and social requirements stated in law to have the surgery done. These are to have their name changed through the court and through the pschycological treatment to evaluate their new identification and to prepare them for their new role. Patients are then treated with oestrogen until they have the oestrogen serum level of the female and maintain it before the operation is performed. How to prepare for the operation ? The patient will be examined for his tolerability for anesthesia to avoid any risk during the long operation. This include a laboratory investigations, internal medical and radiological examination. The examination includes the exclusion of cardiopulmonary, liver and renal disease and renal insufficiency, Diabetes mellitus and infectious disease as for example tuberculosis, hepatitis, lues, Hb-s-antigens and HIV virus should also be excluded or pretreated. ECG, and electrolytes (serum sodium, potassium and chlorides) must be controlled. The coagulation factors (quick, partial thromboplastine, AT-III, factor V, thrombocytes, fibrinogen) should be perfect. The prostate specific antigen PSA and the free PSA are measured for patients as old as 40 years. Radiological examination of the kidneys and bladder with and without contrast dye is very important to manage any eventual complication that may some times result after the operation. Mammography is done before breast augmentation. The patient is physically examined to study any anatomical deviations that may require modification in the operative technique intra operatively. I usually receive the patient 2 days before the operation on in patient basis. She is given a bowel wash through the mouth. The meal is reduced to a thin fluid like food. The hair is removed from the umbilicus to the knee either by shaving it or by using an epilatory cream. The heparin is started at the night before the operation to protect against thrombo-embolism. The anaesthesist visits the patient on the ward at the night of the operation for a final discussion and to prescribe sleep medications if necessary. The operation must be explained in minute details during the late preparations for the operation and one day before the operation. The consent for transformation is done in written separately in a very clear and strict form and that for the operation is a separate issue that has to be signed by the patient at least 24 hours before the operation. How does the operation work ? The male and female organs develop from the same embryological elements and hence the reduction of the male elements easily results in the reconstruction of the female phenotype with very good and reproducible results. The basic steps for this are the excision of the testicles, the straightening of the urethra and its shortening similar to that of the female, complete resection of the erectile bodies, the transformation of the glans penis (the head of the penis) to a clitoris with preservation of the nerves and blood supply of the structure, the formation of the vagina out of the skin of the penis and pushing it in the space between the rectum and the bladder and prostate, and lastly the formation of the vulva out of the skin of the testicular bag (the scrotum). The normal relationship and texture of the skin of the penis allow the construction of a new vagina that possesses the function of a natural one with the possibility of cohabitation and orgasm. The patient will be lying in the supine position with the legs spread wide apart and the legs everted and semiflexed at the knees. Every effort must be made to let her lie comfortably, to avoid thrombo-embolism through the use of electro compression sheets wrapped around the legs and thighs and to avoid injury to the nerve plexus and nerve structures of the arms, which are semiflexed at the elbow and supported by a sheet across the chest. A strict disinfection must be done to avoid any risk of infection. The operation is done under a combination of intubation and peridural anesthesia. The rectum will be tamponated with gauze soaked in polividon ointment. A 18 Charr. (diameter of the catheter) Balloon catheter will drain your bladder. The eyes will be protected with ointment and covered with opticlud. The testis and its seminal cord and vessels are prepared free as far as possible under the abdominal coverings to the hernial ports and are excised through a scrotal incision. The muscle and fat contents of the scrotum are preserved to cover to be used later on in the building of the labia majora. The skin and subcutaneous tissue of the abdomen are undermined to the level of the umbilicus, while securing the vessels to the penile skin, enabling the root of the penis to be advanced to the level of the vaginal entry and facilitates the invagination of the penile skin into the vaginal space. The free abdominal skin is then pulled down and fixed to the sham bone to furtherly advance the skin of the penis to the vaginal orifice and to prevent stretch of the skin and blood supply of the area. This permits the development of a very good feminine appearance of the sham area if there is enough subcutaneous fat available. The penis will then be freed from its skin on the basis of the shaft proceeding to the head of the penis where the skin is circularly cut to separate it from the head of the penis (glans). Meticulous care is taken to preserve the skin vascularity running under the skin. The foreskin is then unfolded to gain more skin to the vagina. The end of the tube is then closed by a continuous suture. The vaginal envelop is then enlarged through multiple long incision in the subcutaneous tissue again with preserving the vascularity of the skin. The urethra is separated from the glans. The glans together with the neurovascular bundle are prepared free from erectile bodies and. It is of utmost importance to understand the spread out and fanning of the nerve structures and its anatomic relationship to the glans to avoid its injury and to be able to dissect it with preservation of the sensation of the glans which will function as a clitoris later on. The clitoris is built from the whole glans volume which gives optimal functional and sensational results. To perform this I remove the superficial thin covering of the glans except for the central area that is exposed as a clitoris. The nerves and vessels are buried smoothly in a gentle curve under the sham bones. The radical excision of the roots of the erectile bodies permits the development of the female entroitus. The urethra must be straightened to run smoothly under the symphesis pubis. The space which receives the vaginal tube is developed beginning from the central facial condensation of the peritoneum. I develop the depth of the space to reach the peritoneal fold and as wide as possible. The end of the last step is considered as the completion of the preparatory part of the operation and the beginning of the transformation plasty from a male to female genitalia. The free prepared skin of the abdomen is pulled down and fixed with the stitches to the symphesis to reduce any pull on the skin and blood vessels of the new vagina. The mere pull on this skin from outside inwards i.e. from outside inwards, builds up the mons pubis. In this stage drainage of the wound and labia is secured. The vaginal dilator will then be inserted into the inverted skin of the penis. Any circularly running fibers or narrowing rings at the base of the penis are cut in the middle line. The exit of the urethra and clitoris are defined in the skin in the usual anatomical place and relationship taking care not to injure the major blood vessels of the new vagina. Both the urethra and clitoris are fixed in their places using separate fine stitches. The stented new vagina is then inserted into the prepared space and fixed there using fibrin spray. The labia majors will now be formed from the lateral parts of the scrotal skin. The skin structures, folds, urethra and clitoris are fixed in place using fibrin sprayed through fine tubes put around the circumference of the entroitus. The wounds are closed very carefully and meticulously by subcutaneous stitches which play the major role in the final cosmetic appearance of the female genital structures. The skin is closed through metal clips which co apt the skin together. If the skin of the penis is too small to build the vagina, I increase the circumference of the vaginal pouch using a strip of skin taken from the middle of the skin of the scrotum. If the this part is hairy, it is substituted with a free skin graft. The graft is taken from the inside part of the upper arm or the lower abdomen of a fatty patient. The cosmetic results can be perfected in a second setting few months later. This is done through the incision of an anion shaped piece of skin over the area of the clitoris. The fat of the subcutaneous tissue is mobilized bilaterally and united together with stitches to elevate the venous hump. The perineum must be shortened and in some few cases the labia major should be equalized on both sides. The skin at the area of the clitoris is closed by fine vicryl and the skin in the sham area is closed by metal clips. This maneuver let the clitoris be best hidden and the labia majors co apt together. This allows also the development of ring like skin cap (prepetium) around the clitoris and if the skin of the entrance of the vagina in abundance, labia minora will be folded as well Healing: I advise our patients to wear the stent few hours per day for four months, Wash the new vagina and stent daily, use estrogen ointment to keep the smooth tens texture of the tissues and abstain from sexual contact for six weeks. There is slight pain in the first post operative days. The patient must be cooperative and learn how to remove the stent, le the vagina be washed and re put the stent. The healing of the wounds is similar to any other procedure. The hospital stay is between 14-20 days. How to prepare for the operation: Please see the chapter on preparation of the patient Frequently asked questions (FAQ): --
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