Introduction There are several techniques for creation of a neovagina. However, rectosigmoid segment presents the most natural substitute for vaginal tissue. Aim To evaluate the anatomical and functional results of sigmoid vaginoplasty and long-term sexual and psychological outcomes in 86 patients with vaginal absence. Methods Between April 2000 and February 2009, 86 patients, aged 18 to 57 years (mean 22) underwent rectosigmoid vaginoplasty. Indications were vaginal agenesis (54), female transgenderism (27), and genital trauma (5). Rectosigmoid segments ranging from 8 cm to 11 cm were isolated, to avoid excessive mucus production. Preferably, it should be dissected distally first in order to check its mobility and determine the correct site for its proximal dissection. Stapling device was used for the colorectal anastomosis as the safest procedure. Creation of perineal cavity for vaginal replacement was performed using a simultaneous approach through the abdomen and perineum. Perineal skin flaps were designed for anastomosis with rectosigmoid vagina for the prevention of postoperative introital stenosis. Main Outcome Measures Sexual and psychosocial outcomes assessment was based on the Female Sexual Function Index, Beck Depression Inventory, and standardized questionnaires. Results Follow-up ranged from 8 to 114 months (mean 47 months). Good aesthetic result was achieved in 77 cases. Neovaginal prolapse (7) and deformity of the introitus (9) were repaired by minor surgery. There was no excessive mucus production, vaginal pain, or diversion colitis. Satisfactory sexual and psychosocial outcome was achieved in 69 patients (80.23%). Conclusions Rectosigmoid colon presents a good choice for vaginoplasty. According to our results, sexual function and psychosocial status of patients who underwent rectosigmoid vaginoplasty were not affected in general, and patients attained complete recovery.

Transsexualism is a complex condition in which the person experiences the inconsistency between the desired gender and their biological gender. Absence of the vagina is devastating in male to female transsexuals. Creation of the neovagina is the main surgical problem in these patients. Historically, beginnings of the neovaginal creation have their roots in the treatment of Mayer-Rokitansky syndrome and conditions such as cloacal anomalies, certain intersex disorders, vaginal malignancies, or severe vaginal trauma, but have more recently found great purpose in male to female sex reassignment surgery. Many operative procedures have been described but none is ideal. Therefore, the search for new, improved solutions continues. In neovaginoplasty reconstruction of the vulvovaginal complex is performed in its entity. The gold standard in neovaginal reconstruction in male to female sex reassignment surgery is penile skin inversion technique with or without scrotal flaps, which enables adequate sensation of the neovagina, good neovaginal depth, good erotic sensitivity of the neclitoris, and esthetically acceptable labia minora and maiora.

Introduction Metoidioplasty presents one of the variants of phalloplasty in female transsexuals. Urethral lengthening is the most difficult part in this surgery and poses many challenges. Aim We evaluated 207 patients who underwent metoidioplasty, aiming to compare two different surgical techniques of urethral lengthening, postoperative results, and complications. Methods The study encompassed a total of 207 patients, aged from 18 to 62 years, who underwent single stage metoidioplasty between September 2002 and July 2011. The procedure included lengthening and straightening of the clitoris, urethral reconstruction, and scrotoplasty with implantation of testicular prostheses. Buccal mucosa graft was used in all cases for dorsal urethral plate formation and joined with one of the two different flaps: I—longitudinal dorsal clitoral skin flap (49 patients) and II—labia minora flap (158 patients). Main Outcome Measurement Results were analyzed using Z-test to evaluate the statistical difference between the two approaches. Also, postoperative questionnaire was used, which included questions on functioning and esthetical appearance of participating subjects as well as overall satisfaction. Results The median follow-up was 39 months (ranged 12–116 months). The total length of reconstructed urethra was measured during surgery in both groups. It ranged from 9.1 to 12.3 cm (median 9.5) in group I and from 9.4 to 14.2 cm (median 10.8) in group II. Voiding while standing was significantly better in group II (93%) than in group I (87.82%) (P < 0.05). Urethral fistula occurred in 16 patients in both groups (7.72%). There was statistically significant difference between the groups, with lower incidence in group II (5.69%) vs. group I (14.30%) (P < 0.05). Overall satisfaction was noted in 193 patients. Conclusion Comparison of the two methods for urethral lengthening confirmed combined buccal mucosa graft and labia minora flap as a method of choice for urethroplasty in metoidioplasty, minimizing postoperative complications.

Phalloplasty represents the latest step in female-to-male transitioning and still remains a great challenge for transgender surgeons. Since we have two options in this transitioning-metoidioplasty and total phalloplasty-the transgender surgeon has to fully inform the individual about all aspects such as surgical steps, outcomes, advantages and disadvantages, possible complications, and expectations. Total phalloplasty with the creation of a neophallus of a similar volume to that in genetic males, is a complex and multi-staged procedure. Many different tissues (i.e., flaps) can be used, and the ideal procedure is still not established. In contrast to the above complexities involved in total phalloplasty, metoidioplasty presents a simple and one-stage procedure for the creation of a neophallus from a hormonally enlarged clitoris. This technique is very promising for individuals who desire gender-affirmation surgery without having to undergo the difficult and multistage creation of a male-sized neophallus. Also, this technique prevents scarring to the extragenital region, making the final results more acceptable for transgender individuals. Our goal is to objectively present the techniques for metoidioplasty and to define their value based on postoperative results.

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Background Female-to-male gender-confirmation surgery (GCS) includes removal of breasts and female genitalia and complete genital and urethral reconstruction. With a multidisciplinary approach, these procedures can be performed in one stage, avoiding multistage operations. Aim To present our results of one-stage sex-reassignment surgery in female-to-male transsexuals and to emphasize the advantages of single-stage over multistage surgery. Methods During a period of 9 years (2007–2016), 473 patients (mean age = 31.5 years) underwent metoidioplasty. Of these, 137 (29%) underwent simultaneous hysterectomy, and 79 (16.7%) underwent one-stage GCS consisting of chest masculinization, total transvaginal hysterectomy with bilateral adnexectomy, vaginectomy, metoidioplasty, urethral lengthening, scrotoplasty, and implantation of bilateral testicular prostheses. All surgeries were performed simultaneously by teams of experienced gynecologic and gender surgeons. Outcomes Primary outcome measurements were surgical time, length of hospital stay, and complication and reoperation rates compared with other published data and in relation to the number of stages needed to complete GCS. Results Mean follow-up was 44 months (range = 10–92). Mean surgery time was 270 minutes (range = 215–325). Postoperative hospital stay was 3 to 6 days (mean = 4). Complications occurred in 20 patients (25.3%). Six patients (7.6%) had complications related to mastectomy, and one patient underwent revision surgery because of a breast hematoma. Two patients underwent conversion of transvaginal hysterectomy to an abdominal approach, and subcutaneous perineal cyst, as a consequence of colpocleisis, occurred in nine patients. There were eight complications (10%) from urethroplasty, including four fistulas, three strictures, and one diverticulum. Testicular implant rejection occurred in two patients and testicular implant displacement occurred in one patient. Clinical Implications Female-to-male transsexuals can undergo complete GCS, including mastectomy, hysterectomy, oophorectomy, vaginectomy, and metoidioplasty with urethral reconstruction as a one-stage procedure without increased surgical risks and complication rates. Strengths and Limitations To our knowledge, this is the largest cohort on this topic so far, with good surgical outcomes. Limitations include lack of selection or exclusion criteria and lack of other studies with a simple approach. For this reason, the technique should be studied further and compared with other techniques for female-to-male surgery before it can be recommended as an alternative procedure. Conclusions Through a multidisciplinary approach of experienced teams, one-stage GCS presents a safe, viable, and time- and cost-saving procedure. Complication rates do not differ from reported rates in multistage surgeries.

Introduction Metoidioplasty represents one of the variants of phalloplasty in female transsexuals. Its main characteristic is that it is a one-stage procedure. It involves lengthening and straightening of hypertrophied clitoris to create a neophallus, urethral lengthening to enable voiding while standing, and scrotal reconstruction with insertion of testicle prostheses. Aim Our aim is to describe our technique and highlight its advantages. Methods Between September 2002 and April 2007, 82 female transsexuals, aged 18–54 years (mean age 31) underwent one-stage metoidioplasty. Clitoris is lengthened and straightened by division of clitoral ligaments and short urethral plate. Urethroplasty is done with combined buccal mucosa graft and genital skin flaps. Scrotum is created from labia majora in which two testicle prostheses are inserted. Simultaneously, female genitalia are removed. Main Outcome Measures Patients’ personal satisfaction about sensitivity and length of neophallus, possibility to void in standing position, real length of reconstructed urethra as well as complication rate comparing to other published data. Results The median follow-up was 32 months (range 14–69). The mean neophallic length was 5.7 cm (range 4–10). Voiding in standing position was reported in all patients, while dribbling and spraying were noticed in 23 cases and solved spontaneously. There were two urethral strictures and seven fistulas that required secondary minor revision. All patients reported preserved sensation and normal postoperative erection. Testicle prostheses rejection was not observed in any of the patients. Conclusions Metoidioplasty is a single-stage and time-saving procedure. It could be an alternative to total phalloplasty in female transsexuals who do not wish to have sexual intercourse. Also, it represents a first step in cases where additional augmentation phalloplasty is required.

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