One of the decisions for guys assigned
female at birth is lower surgery or no lower
surgery. There is no right or wrong answer, we
are men regardless of the content of our pants
(I have a dream ...where they will not be judged
by the content of their shorts but by the
content of their character. - apologies to
Dr. Martin Luther King, Jr).
Unlike women assigned male at birth, the
choices for us with regard to lower surgery are
less clear and involve higher risk and cost.
Some guys won’t require lower surgery,
others will be wary of the risks involved, some
of us will require surgery to feel whole and /
or avoid medical problems. Each guy’s
decision is his own.
The following annotated bibliography is a
summary of the current academic literature on
the surgical aspects of FtM reassignment. It may
help some men and their partners / families make
an informed decision about surgical options. The
surgical teams listed therein are not endorsed
by the author or FTMAustralia.
Several sites such as Transster (http://www.transster.com/)
and several Yahoo
Groups exist to discuss and compare surgical
results. Anyone considering lower surgery is
encouraged to seek out these peer support /
information sources.
Matt
A.
Perovic, S. V. and Djordjevic, M. L;
"Metoidioplasty: a variant of phalloplasty in
female transsexuals"; BJU International;
92; 981-985; (2003)
The authors report on a series of 22
patients undertaking metoidioplasty. 13 had
simultaneous hysterectomy and oophrectomy. The
technique of the authors is a heavy modification
of the original Lebovic and Laub, relying on
their experience with extreme hypospadias
repair. They report a 5/22 complication rate
(two stenoses, three fistulae). The clitoris is
degloved and both dorsal and ventral ligaments
are releases The Urethroplasty uses skin from
the labia minora and anterior vaginal wall. 5
patients underwent subsequent phalloplasty.
* http://www.ftmaustralia.org/surgical/metoidioplasty.html
uses photos and diagrams from this paper in
their explanation of metoidioplasty.
Monstrey, S.; Hoebeke, P.; Dhont, M.;
Selvaggi, G.; Hamdi, M.; Van Landuyt, K. and
Blondeel, Ph.; "Radial forearm phalloplasty: a
review of 81 cases"; Eur. J. Plast Surg;
28; 206-212; (2005)
The authors report on a series of 81 patients
undertaking forearm free-flap phalloplasty with
their team over the period 1992-2000. For their
"all-in-one" (hysterectomy,oophrectomy,
vaginectomy, phalloplasty) procedure, they
report a 42% urinary complication rate and 19%
anastomotic re-exploration rate. Testicular
implants are placed after six months and penile
implant after 12. Of 25 patients with penile
implants, 18 were successful.
Hage, J. J. and Van Turnhout, A. W. M;
"Long-term outcome of metaidioplasty in 70
female-to-male transsexuals"; Annals of
Plastic Surgery; 57; 312-316; (2006)
The second author reviews the operative notes
from the first author. 20 of the 70 patients
underwent scrotoplasty as a secondary procedure,
when it was felt that the labia majora were not
of sufficient size to allow tension-free closing
over the implants. 3 patients did not undergo
scrotoplasty. 8 patients suffered no
complications, 22 patients suffered one
complication and 19 patients suffered two
complications. An average of 2.6 additional
procedures per patient were required to deal
with all post-operative complications.
Colpectomy was eventually performed in 4
patients to resolve repeated urethrovaginal
fistulas. 17 patients underwent subsequent
phalloplasty.
Hage, J. J.; "Metaidoioplasty: An
Alternative Phalloplasty Technique in
Transsexuals"; Plastic and Reconstructive
Surgery; 97; 161-167; (1996)
The author reports on the first 20 of 32
patients to undergo metaidioplasty (Amsterdam GD
team)from 1991-1994. The urethra is constructed
from an anterior vaginal wall flap. The vagina
is narrowed once this flap is stitched up, but
is not removed. In this early series, two
haematomas were observed, leading to flap loss
in one case. Strictures and / or fistulae
occurred in 9 patients.
Berglund, R. K.; Vasavada, S.; Angermeier,
K .and Rackley, R.; "Buccal Mucosa Graft
Urethroplasty for recurrent stricture of female
urethra"; Urology; 67; 1069-1071;
(2006)
The authors report on two cases where women
underwent urethroplasty surgery to repair
urethral stricture that had not been resolved by
dilation. In both cases, there was insufficient
healthy vaginal tissue to use for a graft and so
ventral buccal mucosa was used. One patient
developed a stenosis five months
post-operatively, which was believed to be due
to the illness that caused the first stricture.
There were no other complications observed up to
30 month follow-up.
Bettocchi, C.; Ralph, D. J. and Pryor, J.
P.; "Pedicled pubic phalloplasty in females with
gender dysphoria"; BJU International; 95;
120-124; (2005)
The authors report on a series of 85 patients
undergoing pubic pedicled phalloplasty with
their team over the period 1989 – 2000. In
32 patients this was undertaken as a one stage
procedure, but due to a high (94%) fistula rate,
a two stage procedure was adopted, lowering the
fistula rate to 29%, which has since been
lowered further by incorporation of the Martius
fat pad beneath the join. Of 65 (15 waiting for
procedure, 5 not undertaking procedure) patients
that had the neourethra fashioned, 24 were able
to void successfully, 16 were able to void with
minor difficulty. The remaining men had ongoing
problems requiring surgical intervention. Three
patients suffered complete loss of the
phallus.
16 men were able to engage in penetrative
sexual intercourse without penile prosthesis as
the scar tissue provided sufficient rigidity.
Almost half of the malleable prostheses
inserted, later eroded (no numbers provided),
thus in the later part of the series, the
authors used a hydraulic prosthesis, which
reduces the risk of tissue ischaemia (pressure
necrosis).
Rohrmann, D. and Jakse, G.; "Urethroplasty
in Female-to Male Transsexuals"; European
Urology; 44; 611-614; (2003)
The authors report on 25 patients who
underwent forearm free flap phalloplasty.
Vaginectomy and urethroplasty were combined in a
one stage procedure. 16 patients had the urethra
fashioned from a vaginal flap, in 9 patients the
labia minora were used and in the remaining four
patients the urethral plate was used. Urethral
complications occurred in 11 of the vaginal
flaps and in 3 of the labia minor flaps for a
total of 14 (58%) urethral complications.
Primary closure, staged urethroplasty with local
pedicle flaps and buccal mucosal grafts were
used to repair these complications.
Bhargava, S. and Chapple, C. R.; "Buccal
mucosal urethroplasty: it it the new gold
standard?"; BJU International; 93;
1191-1193; (2004)
The authors summarise a of number of studies
where buccal mucosal grafts were used to repair
the male urethra. Buccal mucosal grafts can be
placed ventrally, dorsally or as a tube graft
with average success rates of 85, 96 and 81%
respectively (mean follow-up of 38 months). Tube
grafts are problematic because of a lack of
supporting vascularised tissue. Donor site
complications were reported as infequent, the
most frequent being transient parasthesia.
Hoebeke, P.; Selvaggi, G.; Ceulemans, P.;
De Cuypere, G; T'Sjoen, G.; Weyers, S.;
Decaestecker, K.; and Monstrey, S.; "Impact of
Sex Reassignment Surgery on Lower Urinary Tract
Function"; European Urology; 47; 398-402;
(2005)
Authors report on questionnaire data from 24
FtM and 31 MtF Dutch speaking patients.
Uro-flowmetry data from 92 FtM patients was
reviewed. The peak flow was reduced from 16 mL/s
to 14mL/s. This difference was not statistically
significant (Wilcoxon matched pair test). Some
degree of post-voiding incontinence was noted in
79 % of FtM patients, though only 48% of
patients considered it significant. Much of this
problem was considered to be due to the fact
that the constructed neourethra is a
non-collapsible structure that can trap urine
and the construction also creates a "u-bend" in
the neourethra, which effectively constitutes a
siphon. Patients can alleviate this problem by
applying upward pressure to the base of the
scrotum. The authors have also modified their
technique to wrap the perineal muscles around
the urethra, some patients with this technique
are able to use those muscles to empty that part
of the urethra.
Kruijver, F. P. M; Zhou, J-N; Pool, C. W.;
Hofman, M. A.; Gooren, L. J. G; and Swaab, D.
F.; "Male-to-Female Transsexuals Have Female
Neuron Numbers in a Limbic Nucleus"; Journal
of Clinical Endocrinology & Metabolism;
85; 2034-2041; (2000)
The long-awaited follow-up study on non HIV
patients. Sample included 1 FtM. Regardless of
sexual orientation, males have approximately
double the neuron count in the BSTc than women.
The number of neurons in the BSTc of MtF
patients was similar to that of natal females.
The FtM patient had a neuron number in the male
range. Hormone treatment in adulthood was not
see to affect neuron count.
Weyers, S.; Selvaggi, G.; Monstrey, S.;
Dhont, M.; Van den Broecke, R.; De Sutter, P.;
De Cuypere, G; T'Sjoen, G. and Hoebeke, P.;
"Two-stage versus one-stage sex reassignment
surgery in female-to-male transsexual
individuals"; Gynecological Surgery; 3;
190-194; (2006)
Authors compare a
hysterectomy-vaginectomy-phalloplasty procedure
(one-stage, 69 patients) vs. a
vaginectomy-phalloplasty procedure (two stage,
36 patients). A greater number of one-stage
patients required blood transfusion (34.7%) vs.
16.7% of two-stage patients. The authors
rationalise this as largely due to arteries of
the uterus, which are still present in patients
who have not undergone a prior hysterectomy
causing more bleeding. There were no other
statistically significant differences in
complications between the two groups.
Considering the vaginectomy procedure alone,
the authors report a 5.7% complication rate (6
out of 105). They compare this figure to a
previously published (VALUE study) rate of
complications for total hysterectomy of 3.6% and
conclude that vaginectomy is therefore a safe
procedure.
Perovic, S. V.; Byun, J-S., Scheplev, P.
Djordjevic, M. L.; Kim, J-H.; Bubanj, T.; "New
Perspectives of Penile Enhancement Surgery:
Tissue Engineering with Biodegradable
Scaffolds"; European Urology; 49;
139-147; (2006)
Authors report on 84 (from 204) randomly
selected patients who underwent surgery for
penile girth enhancement at Yeonsei-plus
Urologic clinic in Seoul, Presidential Hospital
of Russia and University Hospital in Belgrade.
59 patients presented with primary penile
dysmorphic disorder, while 25 patients had
previous failed penile enhancement surgery.
Fibroblast (connective tissue) cells were
biopsied and grown in cell culture medium and
serum until 2 x 107 cells were present (3-5
weeks). Polylacti-co-glycolic acid scaffolds
were hydrated, washed then seeded with 2 x
107fibroblast cells and incubated at 37oC for 24
hours. Scaffolds could be inserted either
between dartos and Buck's fascia or under the
neurovascular bundle in the case of
non-compliant skin. Degradation of scaffold was
observed between 6 and 16 weeks Mean gain in
girth (flaccid) was 3.15 cm. Complications
observed were temporary seroms in siex patients
who began sexual intercourse before the
recommended time, would infection in two
patients and partial pressure necrosis in two
patients who had undergone previous failed
surgery. Patients appraised results on a scale
of 1 (very dissatisfactory) to 5 (very good),
giving a mean score of 4.25.
Djordjevic, M. L.; Perovic, S. V. and
Vukadinovic, V. M.; "Dorsal dartos flap for
preventing fistula in the Snodgrass hypospadias
repair"; BJU International; 95(9):1303-9;
(2005)
Authors report on a series of 67 children
(1-11 years) who underwent hypospadias repair
between 1998 and 2003. At a mean of 21 months
follow-up (6-65 months), no fistula or stenosis
was observed. The authors report that great care
must be taken not to damage the blood supply of
the dorsal flap, but that it is a good choice
for covering of the neourethra.
Djordjevic, M. L.; Perovic, S. V.;
Slavkovic, Z. and Djakovic, N.; "Longitudinal
dorsal dartos flap for preventing fistula after
a Snodgrass Hypospadias Procedure"; European
Urology; 50; 53-57; (2006)
Same as above, but 126 patients (10 months to
16 years) from 1998 to 2005. Complications were
six strictures which were treated by dilation.
No fistulae occurred.
Michel, A.; Mormont, C. and Legros, J. J.;
"A psycho-endocrinological overview of
transexualism"; European Journal of
Endrocrinology; 145; 365-376; (2001)
In this review article the authors discuss
the endocrinological interventions in both MtF
and FtM transexual patients, their side effects
and contraindications. They state this it is
"important to inform FM patients that androgen
therapy often leads to endometrial hypertrophy,
a putitatively precancerous state; this renders
hysterectomy nearly mandatory once the real-life
test phase has been completed."
Despite the great difficulty in obtaining
long-term follow-up of postoperative
transsexuals, studies quoted report only a
3-9.7% rate of dissatisfaction after FtM
reassignment surgery vs. 8-13% after MtF
reassignment surgery, depending on the criteria
used.
Rachlin, K; "Factors Which Influence
Individual’s Decisions When Considering
Female-To-Male Genital Reconstructive Surgery";
International Journal of Transgenderism;
3; 3; (1999)
The author reports on a small sample (27, 23%
response rate) of FtM patients who responded to
a survey offered at a peer-support group in New
York and at an FtM conference in San Francisco.
The most influential sources of surgical
information were TG/TS peers and photos of
surgery. Some 58% of respondents had rejected
phalloplasty as too risky/ costly, though 53%
were considering metoidioplasty. The strongest
factors influencing the decision to have surgery
were financial, dissatisfaction with available
options and seeing photos of surgery.
Futterweit, W. and Deligdisch, L;
"Histopathological Effects of Exogenously
Andminstered Testosterone in 19 Female to Male
Transsexuals"; Journal of Clinical
Endocrinology and Metabolism; 62; 16-21;
(1986)
The authors present data the ovaries of 19
female-to-male transsexual patients, treated
with exogenous testosterone (mean 3.1 years),
compared to 12 age matched controls who
underwent surgery for nonendocrine reasons. 13
out of 19 FtM patients met the diagnostic
criteria for PCOS (3 out of 4; multiple cystic
follicules, diffuse avarian stromal hyperplasia,
collagenisation of the outer cortex,
luteinisation of stromal cells). None of the 12
controls met the criteria for PCOS.
