Reconstruction of the Female External Genitalia

A Case of Clitoral Hypertrophy of Unknown Origin

Clitoral hypertrophy is caused by disorders of sex development and it is observed from birth in most cases. We encountered a patient in whom normal morphology at birth may have acquired deformity and hypertrophy. The patient was a 10-year-old girl with a chief complaint of pudendal deformity. The clitoral hood was enlarged and the clitoris size was 8 x 5 mm on the first examination. Various tests were performed. Sex chromosome or hormonal abnormalities and tumorous lesions were not detected, and the ovaries, uterus, and vagina were normal, indicating that disorders of mullerian development were negative. In surgery, reconstruction of the vulva was performed following the Marberger method. The present case may have been a very rare case of acquired hypertrophy of unknown origin.

Long-term functional outcomes of female genital reconstruction in childhood

There are two very interesting paediatric urology papers; in the first, authors from London describe the long-term functional outcomes of female genital reconstruction in childhood, and in the second, authors from Italy present a morphological and manometric study of VUR.

Pediatric management of ambiguous and traumatized genitalia

PURPOSE

The present standard of practice in the management of ambiguous and traumatized genitalia was evaluated.

MATERIALS AND METHODS

Published cases of intersexuality and protocols for the management of traumatized genitalia were reviewed with consideration of the input of intersexual individuals. Independent research on different types of intersexuality is also presented.

RESULTS

The present standard pediatric recommendations and precepts for the management of ambiguous or traumatized genitalia are wanting. Followup studies on which to base treatment decisions are needed. Evidence based principles of medical management are proposed.

CONCLUSIONS

A moratorium on sex reassignment cosmetic surgery is recommended. Also recommended are that followup studies should be instituted on past cases, and honesty and counseling should be the core of initial and subsequent treatment.

Pediatric management of ambiguous and traumatized genitalia

PURPOSE

The present standard of practice in the management of ambiguous and traumatized genitalia was evaluated.

MATERIALS AND METHODS

Published cases of intersexuality and protocols for the management of traumatized genitalia were reviewed with consideration of the input of intersexual individuals. Independent research on different types of intersexuality is also presented.

RESULTS

The present standard pediatric recommendations and precepts for the management of ambiguous or traumatized genitalia are wanting. Followup studies on which to base treatment decisions are needed. Evidence based principles of medical management are proposed.

CONCLUSIONS

A moratorium on sex reassignment cosmetic surgery is recommended. Also recommended are that followup studies should be instituted on past cases, and honesty and counseling should be the core of initial and subsequent treatment.

Vaginal reconstruction after initial construction of the external genitalia in girls with salt-wasting adrenal hyperplasia

A total of 28 patients with salt-wasting adrenal hyperplasia who underwent revision of the external genitalia at an early age (mean age 21.4 months) has been followed for 12 to 20 years (mean 16.3 years). The age at initial surgery ranged from 3 weeks to 5 years. Twenty-five patients had a low and 3 had a high takeoff of the vagina from the urogenital sinus. Of these children 22 (78.5%) required further vaginal reconstructive procedures to achieve a normal vaginal outlet. Of the 22 patients requiring further repair 18 have undergone vaginal reconstructive procedures with an initial success rate of 72.2%. These long-term data suggest that if vaginal reconstructive surgery is performed in infancy details, such as placement of the perineal flap well into the vagina and careful followup of the vaginal outlet, are mandatory for success. If there is evidence of outlet narrowing, periodic dilation will be needed to prevent vaginal stenosis and further vaginal surgery.

Transanorectal approach for the treatment of urogenital sinus: preliminary report

The treatment of the urogenital sinus with normal rectum still represents a challenge. A perineal approach with or without a skin flap seems to be effective for those patients with a low implantation of the vagina. However, in patients with a high vaginal implantation, this treatment frequently fails to provide a good, functional vagina due to a narrow, strictured vaginal opening. Based on previous experience in the treatment of more than 80 patients with a persistent cloaca, a posterior sagittal transanorectal approach with a protective colostomy was performed in three patients with urogenital sinus and normal rectum. The pelvis was approached through a midsagittal posterior incision; the coccyx was split and the entire anorectal sphincteric mechanism was divided in the midline. The rectum was bivalved in the midline including both posterior and anterior rectal walls. This provided excellent exposure to the urogenital sinus. The vagina was then fully separated from the urogenital sinus (as described in cases of persistent cloacas), and then mobilized and sutured to the perineum. The rectum and sphincteric mechanism were meticulously reconstructed. A midline incision assures the preservation of anorectal innervation, and provides excellent exposure to the pelvis. Anal dilatations are not necessary to maintain a patent and supple anorectal opening because the rectum has two suture lines, one in front of the other. After the colostomy was closed, all patients had appropriate bowel control for their age; two of them are fully continent for urine and the third one still has a suprapubic cystostomy tube waiting for a repair of an additional urethral malformation.

A unified approach to early reconstructive surgery of the child with ambiguous genitalia

Gender assignment in the newborn with ambiguous genitalia poses a dilemma for the parents and physician, even if the infant has a normal 46XX or 46XY karyotype. In general, female pseudohermaphrodites are reared as female subjects, since they can undergo reconstruction to appear as phenotypic female subjects and they may even be able to bear children. Male pseudohermaphrodites, patients with mixed gonadal dysgenesis and male patients with a micropenis may not be so straightforward, and proper gender assignment in these infants may be difficult. A unified surgical approach to early reconstruction of the external genitalia in these patients, who are to be reared as female subjects, has been developed. Essential to this perineal reconstruction are phallic reduction and recession in which erectile tissue is removed with preservation of the neurovascular bundles and glans, creation of labia minora from flaps of phallic skin and foreskin, a labioscrotal Y-V plasty to produce normal-appearing labia majora and construction of a neovagina with a perineal flap. If the patient is a male pseudohermaphrodite or an infant with a micropenis creation of the vagina is deferred until late adolescence or young adulthood. In other patients in whom the vagina enters the urethra or urogenital sinus proximal to the external sphincter a pullthrough vaginoplasty is performed when the child is 2 to 3 years old. If the vaginal entry is distal to the external urinary sphincter a flap vaginoplasty is performed at the same time as the phallic reduction, and creation of the labia minora and labia majora during infancy. Ten patients (4 with the adrenogenital syndrome, 2 male pseudohermaphrodites, 2 genetic male patients with a micropenis, 1 with mixed gonadal dysgenesis and 1 true hermaphrodite) have undergone reconstruction with this composite procedure. All 10 patients have had a successful cosmetic and early functional result.

Feminizing genitoplasty: a synthesis

The female child with the adrenogenital syndrome is subject to a variable degree of masculinization. Surgery should be directed to 3 goals: 1) removing the corpora and preserving the glans with its innervation to create a clitoris with normal sensation, 2) creating a normal-appearing introitus by fashioning labia minora from phallic skin and foreskin, and 3) vaginoplasty to provide an adequate opening for the vagina onto the perineum. The entire repair may be completed before the age of 6 months unless the vagina enters the urogenital sinus at a high level in which case vaginoplasty should be delayed until the child is older. The evolution of this operative approach is described and the details of the operative technique are presented.