As Published in TGForum

GRS and SRS in the Male Transsexual

There comes a time in the life of a male transsexual when the dream of a lifetime is about to come true. After living successfully as a woman for a year or two under the care of a mental health specialist who agrees that your goal of changing your sexual anatomy is both healthy and reasonable, the reality of undergoing gender transforming surgery (GRS) through sex reassignment surgery (SRS) is upon you. The desire to obtain a functional vagina and a sensate clitoris with the appearance of female labia is the goal of your surgery. Before describing the surgical procedure which may be repugnant to some of our readers, I can only say that as a physician my job is to help my patients achieve realistic goals which will improve their life. So to that end I advise everyone seeking this procedure to find an institution where a gender team is in place for long term follow-up.  While I have never performed SRS nor have I been part of such an experienced team consisting of a Urologist, Plastic Surgeon, Gynecologist, Endocrinologist and Mental Health Care Specialist in the field of Gender Dysphoria, I have performed all of the individual parts of the procedure many times and I am aware of the late complications which require revision in later years.  I have read, with interest and incredulity, the anecdotal stories of people who have traveled to Thailand, Morocco and small towns in the USA that have gained prominence in this field through word of mouth. But I am unable to find any follow up of their outcomes as reported by the Dutch, the Swedes, the Germans and a few American University affiliated hospitals. It seems to me that we may spend more time and money to buy a new car than we do to insure our future well being.

The surgical procedure of SRS may be undertaken in one lengthy session of about 3 1/2 to 4 hours with general anesthesia, but is best done in two or three parts. Estrogen therapy should be discontinued one month preoperatively to decrease the possibility of blood clotting while the legs are elevated and bent during the procedure. Following the procedure estrogens will be decreased since the testes have been removed. Orchiectomy or removal of the testes may be done in advance of SRS by making a small incision along the midline of the scrotum and isolating the spermatic cords on each side of the body at the external inguinal ring as they exit the abdomen. Control of bleeding is carefully assessed and now we can proceed to the formation of the Clitoris and Urethra. Assessment of penile length is very important because the penile skin and foreskin will be carefully preserved to line the neovagina. A minimum skin length of 10 to 12 cm is required or additional skin grafting will be necessary. A stricture may occur at the place where the skin graft is attached to the penile skin.  A circular incision below the glans penis will permit the penis to be degloved of skin exposing the body of the penis. Carefully the glans will be dissected with the Urethra contained within while preserving the nerve and blood supply, which runs along the top of the penis in the midline. The two corporal cavernosal bodies will then be amputated below the pubic bone. See my Viagra article for the penile anatomy. The handling of the glans penis which should be well vascularized at this point requires that the Urethra, which runs along the bottom, be removed with a small amount of the body of the Corpora Spongiosum to a point just below the pubic bone where it is splayed open, fixed and directed downward. A urinary catheter is left in place for a few days. The most common early complication is stricture or closure of this opening which can be easily recut to reopen it and allow easy urination while sitting. The glans may then be buried under a slit in the penile skin below the pubis exposing a portion as the clitoris but leaving the residual deeper. On occasion when the glans was trimmed to look like a protruding clitoris it was devascularized and died. This placement 1 cm above the Urethra requires experience so as not to kink the blood supply. On occasion swelling of the glans has interfered with intercourse.

Now attention is turned to the Neovaginoplasty. The most common method today for creating a new vagina has been to use the inverted penile skin as a flap with its original connection to the body.  An inverted Y or U - shaped incision is performed below the penis splitting the scrotum in two which will become the labia. Beneath this incision the central tendon of the perineum is opened and with blunt dissection a cavity is formed between the prostate, bladder and rectum. One must be very careful with this dissection not to enter the rectum or bladder, all of which has happened infrequently in any large series.  The resulting unrecognized complication is called a fistula or connection between the urethra or rectum and vagina. This accidental complication may necessitate a temporary colostomy or abdominal bladder drainage tube.  Now we are talking serious post-operative care.  With the successful formation of the vaginal cavity, the full thickness penile skin flap is placed on a plastic form, closed on its end and inserted to a depth of at least 12 cm. This may be fixed in place with sutures or surgical adhesive. The form may then be replaced with stiff gauze packing or an inflatable balloon for dilation. The vaginal opening is widely sutured to the scrotal skin. The most serious complication of this procedure is vaginal stenosis or narrowing where the blood supply is inadequate and the entire vagina must be replaced with a piece of large bowel. This does not become obvious until many months post-op and requires major abdominal surgery to correct.

The final procedure, the labioplasty with the creation of labia minora and majora from the scrotal skin, is performed about 6 months post-op. This is cosmetic plastic surgery where skin is moved from the pubic area and attached to the remnants of the scrotum which had been reduced at the original operation. This can be so convincing that only your surgeon knows the truth. The main complications are only swelling and local infection.

 In conclusion, a survey of completed surgeries showed that the most common complaint was lack of vaginal depth and painful intercourse in about one-quarter of the patients, requiring additional surgery in one half of these patients. The vast majority obtain orgasm and some minor lubrication. None of the patients regretted or had doubts about having undergone SRS.

Best of Luck in Your New Future,
Cerise Richards, M.D.