Perovic, S. V., Stanojevic, D. S. and Djordjevic, M. L. J. (2000). Vaginoplasty in male transsexuals using penile skin and a urethral flap. Bju International . 86 : 843-850.
Objectives To describe and present the results of a one-stage vaginoplasty in male-to-female sex reassignment surgery. Patients and methods The present technique is based on penile disassembly and the use of all penile components for vaginoplasty (except the corpora cavernosa). The neovagina consists of two parts; a long vascularized urethral flap and a pedicled island tube skin flap created from the penile skin. The urethral flap is embedded into the skin tube. The tube, consisting of skin and the urethral flap, is inverted, thus forming the neovagina. The new vagina is inserted into the previously prepared perineal cavity between the urethra, bladder and rectum. The neovagina is then fixed to the sacrospinous ligament. The labia minora and majora are formed from remaining penile and scrotal skin. The new method was used in 89 patients (mean age 28 years, range 18-56) with a mean (range) follow-up of 4.6 (0.25-6) years. Results Good cosmetic and functional results were obtained in 77 of the 89 patients (87%). Importantly, the neovagina produced in most patients was of satisfactory depth and width. There was only one major complication, a rectovaginal fistula caused by intraoperative injury to the rectum. Conclusions The technique produces a vagina with more normal anatomical and physiological characteristics than those produced by other methods, as all the penile components are used (except for the corpora cavernosa) to form almost normal external female genitalia. Vaginoplasty using pedicled penile skin with a urethral flap is a good alternative to other methods of vaginoplasty in male-to- female sex reassignment surgery.
Perovic, S. V. (1998). Vaginoplasty in male transsexuals using pedicled penile skin and the urethral flap. Journal of Urology . 159 : V48.
Krstic, Z., Perovic, S., Radmanovic, S., Necic, S., Smoljanic, Z. and Jevtic, P. (1995). Surgical-Treatment of Intersex Disorders. Journal of Pediatric Surgery . 30 : 1273-1281.
Despite the progress made in understanding the factors regulating sexual differentiation, infants born with ambiguous genitalia face significant problems, The authors reviewed a group of 84 children with ambiguous genitalia managed surgically between 1986 and 1993. The most frequent condition was male pseudohermaphroditism (PM) (58%); 31% had female pseudohermaphroditism. Fifty-seven percent of patients were raised as males and 43% as females. In each group of patients, feminine and masculine reconstructive operations were performed. In only 31% of PM and 60% of PF cases was the diagnosis made within the first 2 months of life. In 41% of PF and 40% of PM patients, treatment was begun before the second year of life, which we consider an acceptable time. The timing and type of vaginoplasty were determined by the point of entry of the vagina into the urogenital sinus. Of the 29 patients reared as females, 22 required perineal vaginoplasty, had pull through vaginoplasty, and 2 had colovaginoplasty. Since 1986, we have applied Mollard's clitoroplasty, which preserves the neurovascular bundle and is important for experiencing orgasm. Seventeen percent of patients with feminization procedures experienced complications. The optimal time for masculinization procedures is 2 years of age, after obligatory testosterone treatment. If there is utriculus prostaticus (UP) type II or III, it is removed before urethroplasty. This is not done for UP types 0 and 1. In PM cases, the number of feminization and masculinization operations was 2.1 and 4.05 per patient, respectively. It is easier to make a vagina than a phallus, not taking into consideration dimensions, aesthetics, or capability of erection of the phallus. The basis of surgical treatment of intersex disorders is not to coordinate the phenotype and the genotype, but rather to form the external genital organs which will be of the appropriate appearance and which will allow functional sexuality. It is much easier to create a vagina as a passive organ than an erectile phallus with sufficient dimension. Therefore, the authors suggest that most such infants be reared as females. Copyright (C) 1995 by W.B. Saunders Company.
Perovic, S. (1995). Phalloplasty in Children and Adolescents Using the Extended Pedicle Island Groin Flap. Journal of Urology . 154 : 848-853.
An operative procedure for phalloplasty is reported that uses an extended pedicle island groin flap. Forming a combined groin and lower abdominal flap based on the superficial iliac and epigastric vessels is the main characteristic of this technique. The flap consists of 3 parts: 1) the lateral narrow hairless part for the neourethra, 2) the medial wide part for neophallus shaft reconstruction and 3) the base of the flap on which a flap pedicle is formed and lengthened by de- epithelializing the skin. The pedicle includes subcutaneous tissue with blood and lymph vessels. The neourethra and neophallus shaft are reconstructed using a tube-within-tube technique. The size of the flap depends on patient build. The flap is transferred to the recipient area, that is to the level of the lower margin of symphysis. Anastomosis of the new and native urethra may be done simultaneously or during the second stage of the procedure. The donor site skin defect is closed by direct approximation. During 3 years (1991 to 1993) this flap technique was performed on 24 patients (age 12 to 18 years). There were 2 main indications for treatment: 1) complete absence of the penis, and so total reconstruction of the phallus was done and 2) small dimensions of the penis or just a penile stump, and so augmentation of the penis was done. Specific indications were female transsexualism in 4 patients, penile amputation in 2 and a small disabled penis in 18 (the exstrophy-epispadias complex, intersex and micropenis). Followup ranged from 6 to 42 months (average 29). A new phallus of satisfactory dimensions was achieved in all cases. Complications included partial necrosis of the flap in 2 patients, fistulas in 2 and stenosis of the urethral anastomosis in 1. These complications were successfully resolved by corrective surgery. The method is simple and timesaving with a minor complication rate. This technique is the available alternative to the most commonly used procedure, that is microsurgical free tissue phalloplasty.
Perovic, S. (1993). Male to Female Surgery - a New Contribution to Operative Technique. Plastic and Reconstructive Surgery . 91 : 703-711.
From january of 1989 to November of 1991, 25 patients, aged from 19 to 39 years, have been treated using one-stage male to female sex reassignment surgery. The operative technique involved orchiectomy, penectomy, clitoroplasty, urethroplasty, vaginoplasty, pseudocervicoplasty, and vulvoplasty. The main and original procedure of the technique presents formation of a vagina. The new vagina consists of two segments, the vascularized urethral flap and vascularized island tube skin flap, formed from the penile body skin. The urethral segment of the vagina provides moisture to the new vagina. Complications are minimized by such operative technique. Satisfactory anatomic and functional results were achieved in 20(80 percent) of the patients.