The laparoscopic management of intersex patients: the preferred approach

Abstract

In the world's largest series of patients with intersex treated by laparoscopy, authors from Sao Paulo found that this technique allowed easy identification and removal of gonads. They also found that other organs could be removed and genitoplasty performed. OBJECTIVE To present possibly the largest series of the use of laparoscopy for treating intersex patients. PATIENTS AND METHODS Fifty intersex patients (34 with male and two with female pseudohermaphroditism, nine with gonadal dysgenesis, four with true hermaphroditism, and one with complex hypospadias), aged 0.5–46 years (mean 18.3), underwent laparoscopy to remove gonads and/or ductal structures incompatible with the social gender, or for gonadal tumour or a potential risk for malignancy. When necessary, genitoplasty was performed concomitantly. RESULTS At the laparoscopic evaluation, 10 gonads of six patients were absent, while four were identified as ‘vanishing’; 72 gonads (46 dysgenetic, 17 normal testes, one normal ovary, one ovotestis, seven gonadoblastomas or dysgerminomas) were removed; two ovotestes were replaced in the scrotum after removing the ovarian segment, as was one normal testis. Twelve patients with a urogenital sinus had its vaginal component removed, 11 including a hysterectomy. Three of these patients had a combined perineal approach to complete its removal, together with masculinizing genitoplasty. There were no intraoperative complications or conversions; two patients had complications after surgery. CONCLUSIONS Laparoscopy allows the straightforward identification and removal of gonads. All abnormal ductal structures must be removed, as this increases the chance of resecting unidentified gonads. Removing the uterus and vaginal component of the urogenital sinus in patients with male social sex is feasible, with low morbidity. Genitoplasty, according to the social sex, can be performed in the same procedure.

46,XY disorders of sex development (DSD)

“…4,5 For those 46,XY DSD children assigned female, laparoscopy is the ideal method for performing gonadectomy and for resection of internal organs if appropriate. 89 Feminizing genitoplasty should provide an adequate vaginal opening into the perineum, create a normal-looking vaginal introitus, fully separate the urethral from the vaginal orifice, remove phallic erectile tissue preserving glandular enervation and blood supply, and prevent urinary tract complications. 90 The most reasonable procedure for clitoroplasty is based on the concept of maintaining the clitoral glans and sensory input, which facilitates orgasm.…”

Laparoscopic gonadectomy of streak gonads within the inguinal canals in a patient with XY partial gonadal dysgenesis

“…As long as the distal margin of the streak gonad is identifi ed, excision of the vas deferens distal to the gonad is not diffi cult. Identifying dysgenetic gonads is not always easy [9]. When gonads cannot be found in the abdominopelvic cavity, after peritoneal incision along the gonadal vessels, dissection in the direction of the inguinal canal is of help to fi nd dysgenetic gonads.…”

Complete androgen insensitivity syndrome: Review of four cases

“…Although it is known that the patients over 30 are at the greatest risk for malignancy development [10][11][12] in recent literature malignant alteration of retained testicles has been reported in both prepubertal and in adult patients [13,14]. Today the laparoscopical method is a "gold standard" as a diagnostic and surgical approach [15].…”