feminizing genitoplasty

1. Feminizing Genitoplasty
where we are now?
Ahmed Oshiba
Assistant Lecturer, Pediatric Surgery and Urology Department, Alexandria, Egypt

4. When to operate?

7. Early repair
(early infancy,
1st six months
of life)……
why??
Easy exposure.
Thicker, more
vascular skin,
easier dissection
of the clitoris
and paravaginal
tissues.
Psychological
benefit for the
parents.
Earlier self
acceptance of
the child gender
identity.

8. Late repair
(post-
pubertal)
why??
1. The patient is able to take the decision and
to provide the informed consent.
2. Easily vaginal dilatation if needed post
vaginoplasty. (psychic trauma ????)
3. Clitoral insensitivity complication is easily
diagnosed.

9. One stage Vs
Multistage

10. One Stage
(within 1st 6
months of
life).
• Discarded flaps from the UGS and the
prepuce, therefor would no longer available
tissues for reconstruction especially in high
UGS and small vagina.

11. Multistage
(delayed
vaginoplasty
till puberty).
• Inclusion of the patients in the informed
consent.
• Assurance of cooperation for vaginal
dilatation if needed.
• Higher estrogen levels helps in vaginal
manipulation.

12. How to approach this
patient?

13. Team Approach
Pediatric
endocrinologist.
Pediatric
genetics.
Neonatologist.
Pediatric
urologist.
Pediatric
psychiatrist.
Medical ethics

14. History and
Physical
Examination
• Maternal history of alcohol, androgenic drugs.
• Family history of previous cases, neonatal deaths,
infertility, genital ambiguity.
• General examination: well being.
• Blood pressure examination: 11-β-hydroxylase
deficiency.
• Abdominal examination: distended bladder, vagina.
• Gonadal examination: testis, ovotestis.
• Careful inspection of vaginal introitus, UGS.

15. Laboratory Investigations
• Genetic karyotyping.
• Serum electrolytes (Na, K).
• Serum cortisol level.
• Serum testosterone.
• B HCG stimulation test.
• 17- hydroxyprogesterone
level.

16. Radiographic
Evaluation

17. Ultrasound abdomen
and pelvis

18. Contrast Genitography.

22. PVE
classification
Phallic size (P).
The true location of vaginal
confluence in relation to both the
bladder neck and perineal meatus
(V).
External genital appearance (E).

23. MRI pelvis

30. Endoscopic
Evaluation
Same or Separate
session.

34. Gonadal biopsy Open or laparoscopic.

35. How to prepare for surgery?

36. • Bowel preparation: clear fluids for 2 days, enema, polyethylene glycol-electrolyte
solution.
• Perioperative oral antibiotics.
• Preoperative steroids in CAH.
• Dorsal lithotomy position.
• ASTRA is another option.
• Posterior sagittal approach.
• Two Foley catheters in the bladder and vagina.
• Full lower body preparation from nipples to toes, front and back.

40. Gonadectomy
early or late

42. Feminizing
Genitoplasty

43. •Clitorplasty.
•Vaginoplasty.
•Labioplasty.

45. Clitorplasty

46. • Clitoral amputation.
• Clitoral recession or concealment.
• Complete excision of the corpora with neurovascular preservation.
• Subtunical excision with preservation of posterior tunica with
neurovascular preservation (kogan technique).
• Ventral glanular wedge reduction if needed.

50. Labioplasty

52. Vaginoplasty

53. Low confluence
• Cutback vaginoplasty.
• Flap vaginoplasty (Fortunoff
flap): midline incision in the
posterior wall of the vagina.

55. High confluence

56. Vaginal pull through
Vaginal dissection, Passerini–Glazel

59. Total UGS mobilization

61. • In 1997, Pena described in cloacal anomalies.
• Cutting the pubo-urethral ligaments (urogenital diaphragm).
• Easier dissection.
• Less operative time.
• Improved cosmesis.
• Less risk of vaginal stenosis and urethrovaginal fistula.
• Poor voiding and stress incontinence (difficult to be treated).

62. Partial UGS mobilization

63. • Rink and Kaefer described this technique as alternative to TUM.
• Minimal dissection anteriorly till the level of PULs.
• Minimal vaginal mobilization laterally.

66. Vaginal Replacement

67. • Grafts: skin grafts, buccal mucosa, Abbe–McIndoe technique (12cm X2 cm).
• Flaps: Gracilis myocutaneous flaps, pudendal thigh flaps, labia minora flaps.
• Bowel substitution: natural lubricants, less dyspareunia, less contracture
and stenosis. Sigmoid is the best option, ileum is another alternative.

70. Long Term Results
After Genitoplasty

71. Clitoral and
Genital
Sensitivity
Questionnaires.
Genitosensory analyzer (2
probes to assess thermal
and vibratory sensitivity).

74. Cosmetic
Results
Residual labial fusion
(14%).
Labial Scrotalization (30 %).
Needs for labial revision.

75. Vaginoplasties
Vaginal Stenosis ????
Revision Surgery
Vaginoplasty.
UGS Mobilization.

76. Psychosexual
Problems.
Infrequent Intercourse.
Difficult Penetration.

77. Urological Problems
Stress Incontinence
mostly related to
Total UGS
mobilization.