Gender Reassignment Surgery : PENILE INVERSION SURGERY
The penile inversion surgery consist of utilizing the penile skin to
form the vaginal cavity, and is the most popular surgery worldwide. One of the
authors has performed more than 1000 of these procedures with good results and
a relatively early, complication-free recovery. The procedure was practiced
previously by Dr. Jorges Burou of Casablanca, Morocco, in more than 1000
cases.
An incision is made in the longitudinal direction in the midline of the
perineum from the scrotum to just posterior to the perineal body, and is
deepened by dissecting through the central point of the perineum. The
dissection then goes in the superior direction up to and around the base of
the penis. The penis is denuded of skin; that is, the corpora cavernosus penis
is separated from the skin and fascia without increasing the skin
longitudinally. By dissecting below the dartos fascia, or possibly even below
Buck's fascia as well, the more proximal portion of the penis skin will be
well vascularized. If the distal tissue is not viable as a pedicle, it is
"defatted" and debulked with a scissors in a manner of preparation of a full
thickness skin graft. It is possible that this penile skin has an anatomic
peculiarity in that, even with such thinning, an interdermal plexus of small
vessels ( visible with magnification ) remains and sustains circulation for
viability as a flap rather than as a free full-thickness graft. The tissue
probably takes as a pedicle rather than as a skin graft. The thinning
"releases" the tissue so that it relaxes and spreads and enlarges to make a
surprisingly large vagina from a smaller penis. The testes are isolated and
then removed with a double ligation of the spermatic cord at a high level.
Beware of inguinal hernia. Much of the contents of the scrotum are excised at
this time in order that the postoperative deformity of excessive labia majora
is not produced.
The corpora spongiosum and its contained urethra is separated "sharply"
away from the two corpora cavernosus peni up to the posterior aspect of the
pubic symphysis, from which the urethra is freed in order to allow the urinary
channel to drop posteriorly. Thus, the urinary stream is directed into the
toilet in the female micturition posture (rather than out anteriorly). The
blood supply to the spongiosum is longitudinal, and bleeding from the spongy
erectile tissue is not controlled by electrocauterization. A hemostatic
running over and over locked suture closes the erectile tissue of the corpus
spongiosum. A suture ligature placed in the area of the arteries running
longitudinally in the ventral aspect of this tubular structure will eliminate
this most common etiology for postoperative bleeding. The mucosa of the distal
segment of the male penile urethra may be fashioned into the clitoris or into
the central tissue of the perineum (the tissue that corresponds to the
internal aspect of the labia minora). The corpora cavernosa is amputated at
approximately the level of its decussation into the two crura, with oversewing
and ligating done with large-size absorbable suture material. The arterial and
venous supply from the internal pudendal arteries is located on the dorsal
surface of the tunica albuginea right at the anterior pubic symphysis.
From below, the subcutaneous tissue of the lower abdominal wall is
undermined in a superior direction, occasionally as far as the perforating
arteries near the umbilicus. The circulatory system suprajacent to the
Scarpa's facia is preserved. The connections from the superficial inferior
pudendal artery, and superficial circumflex iliac systems are preserved. The
soon-to-be-inverted penis is migrated on this advancement flap in the inferior
and posterior direction approximately 5 to 7 cm, allowing the penis flap to
arrive at the anatomic position of the vagina. The abdominal flap is fixed
with an external through-the-skin bolster suture, attaching the midflap to the
fascia of the pubic symphysis.
The vaginal cavity is dissected with the assistant's index finger of the
right hand in the rectum and with the surgeon's left index and middle fingers
grasping the central point of the perineum and the superficial transverse
perineal muscle. Sharp dissection, for example, with Metzenbaum scissors, is
made through the rectourethralis musculature, up to the external Denonvillers'
layer of fascia, which should be incised (not spread). Bluntly spreading will
only cause separation of the longitudinal rectal muscle or of the musculature
housing the very proximal urethra and base of the bladder. The prostate is
seldom visualized, but knowing that the rectum begins to upturn in an anterior
direction in this area, and feeling the assistant's finger in the rectum
posteriorly and feeling the urethral catherater in place anteriorly, a
dissection is made through the area below the male prostate. Soon a very easy
dissection field is perceived as the retrobladder preperitoneal space is
entered. Here the dissection can be easily accomplished with a spreading
technique, perhaps utilizing finger dissection and extension with ovum forceps
and sponge or the Yankauer (tonsil) suction tip, proceeding up to the level of
the peritoneum. At this point, the techniques of penile inversion and sigmoid
vaginostomy differ. In the penile skin vaginostomy, the inverted penis is
fixed up to the prostatic pedicles with sutures such as 2-0 chromic. The
vaginal cavity is gently packed.
The perineal body is located between the rectum and the vagina, and may
be reconstructed after the perineal dissection. Sutures may be placed from one
ischiorectal fossa area to the opposite in order to reappose the tissues and
to build up some semblance of musculature if this is necessary. The formation
of a posterior vaginal fourchette with overlap of the labia majora flaps
posterior to the vagina is helpful in preventing a direct and unnatural
looking view directly into the vaginal cavity. The glans penis may be
preserved if it is appropriately thinned to "survive by microcirculation" or
by full-thickness skin graft. The glans may be placed into the position of the
cervix uteri.